Evaluation of Pediatric Trauma (Initial and Follow-up Survey) Template

Primary Survey  
The Primary Survey is conducted to swiftly identify and address life-threatening conditions. Key priorities include:
- Catastrophic Hemorrhage  
- Airway (with cervical spine control)  
- Breathing  
- Circulation  
- Disability (Neurological Status)  
- Exposure / Environment Control  
Pre-Arrival Preparation  
- Trauma Team Activation: The trauma team was mobilized based on the injury mechanism and the patient's unstable vital signs.  
- Pre-Arrival Briefing: The team was informed about the patient's condition, roles were assigned, and equipment was prepared.  
- Medication & Equipment Preparation: Weight-based drug doses were verified, and all necessary equipment was ready.  
- Protective Measures: Personal protective equipment and radiation protection were employed.  
On Arrival  
- Handover: The I-MIST-AMBO handover from paramedics included the mechanism of injury, injuries sustained, signs, treatment given, allergies, medications, background, and other pertinent information.  
- Parental Communication: Additional history was gathered from the parents, including the child's medical history and allergies.  
- Support for Family: Emotional support was provided to the family, and they were kept informed of the child's condition.  
Airway and Cervical Spine  
Life Threat: Airway Obstruction  
- Assessment: Airway was clear with no obstructions noted. No facial fractures or signs of burns were present.  
- Neck Examination: No tracheal deviation or other airway threats were identified.  
- Airway Management: The airway was maintained with positioning and suction.  
- Cervical Spine Management: Spinal precautions were confirmed with a cervical collar applied.  
Breathing  
Life Threats: Tension Pneumothorax, Open Pneumothorax, Massive Hemothorax, Flail Chest  
- Assessment: The patient showed increased work of breathing and decreased chest expansion on the right side.  
- Examination: Decreased breath sounds on the right side were noted on auscultation.  
- Management: Oxygen was administered, and a chest drain was inserted on the right side.  
Circulation  
Life Threat: Hemorrhagic Shock  
- Assessment: Heart rate was elevated, capillary refill time was prolonged, and blood pressure was low.  
- Sites of Bleeding: No external bleeding was noted; internal bleeding suspected in the abdomen.  
- Interventions: Fluid resuscitation was initiated, and blood products were prepared for transfusion.  
Disability (Neurological Status)  
Life Threat: Traumatic Brain Injury  
- Neurological Assessment: GCS score was 13, indicating mild head injury.  
- Pupillary Exam: Pupils were equal and reactive to light.  
- Motor Function: Limb movements were symmetrical with no deficits.  
- Blood Glucose: Capillary blood glucose was within normal range.  
- Neuroprotection Strategies: Head elevation and normothermia were maintained.  
Exposure and Environmental Control  
- Full Body Inspection: No additional life-threatening injuries were identified.  
- Hypothermia Prevention: Warm blankets and a warming device were used to maintain normothermia.  
Radiology and Imaging  
- Imaging Ordered: Chest X-ray and abdominal CT scan were ordered.  
- Findings: Chest X-ray showed right-sided pneumothorax; abdominal CT scan was pending.  
Secondary Survey  
The Secondary Survey is conducted once the patient is stable, and all immediate life threats are addressed.  
Preparation  
- Communication and Reassurance: The patient was reassured, and parents were involved in the care process.  
- Positioning and Comfort: Pain management was provided with analgesics.  
Head and Face  
- Inspection and Palpation: No scalp lacerations or skull fractures were noted.  
- Eyes: No eye trauma or visual impairment was observed.  
- Ears and Nose: No bleeding or CSF leaks were present.  
- Mouth and Jaw: No oral trauma or dental injuries were found.  
Neck  
- Inspection: No neck bruising or tracheal deviation was observed.  
- Palpation: No vertebral tenderness was noted.  
Chest  
- Inspection and Palpation: No seat belt injuries or paradoxical movement were observed.  
- Auscultation: Breath sounds were decreased on the right side.  
Abdomen  
- Inspection and Palpation: No bruising or distension was noted; tenderness was present over the right upper quadrant.  
- Genitourinary Examination: No signs of trauma were observed.  
Pelvis  
- Inspection and Palpation: No pelvic instability or tenderness was noted.  
Limbs  
- Inspection and Palpation: No fractures or soft tissue injuries were observed.  
- Range of Motion: Full range of motion was present in all joints.  
Back  
- Log Roll Assessment: No tenderness or deformities were noted along the vertebral column.  
- Spinal Palpation: No abnormalities were detected.  
Urinalysis  
- Test Results: Urine dipstick was negative for blood.  
Disposition Planning  
- Ongoing Management: Abdominal CT scan results pending; surgical consultation requested.  
- Pain Management: Analgesia was administered with good patient response.  
- Surgical Consideration: Possible surgical intervention pending CT results.  
- Definitive Care Plan: Plan for ICU transfer for close monitoring.  
- Handover Details: The ICU team was briefed, and a formal handover was completed.