Initial Trauma Evaluation (Primary Survey Documentation) Template

Patient Age: 34, Patient Gender: M, BIBA, Patient was involved in a high-speed motor vehicle collision.
Pre-Arrival:
- Personal Protective Equipment (PPE): Team members wore gloves, masks, and face shields.
- EMS Notification: Patient was ejected from the vehicle, sustained blunt trauma, field vitals were BP 90/60, HR 120, RR 28, SpO2 92%, pre-arrival interventions included IV fluids and oxygen.
- Mechanism of Injury: High-speed motor vehicle collision, patient ejected, significant vehicle damage, presence of blood at the scene.
- Trauma Activation Criteria: Level I activation triggered due to high-speed collision and ejection.
Arrival:
- Time of Patient Arrival: 14:32
- Trauma Team Activation Time: 14:33
- Team Members Present: Dr. Thomas Kelly (EM physician), Dr. Sarah Lee (trauma surgeon), Nurse John Smith, RT Emily Davis
- EMS Hand-off:
- Time of Handoff Completion: 14:35
- Key Findings from EMS Report: BP 90/60, HR 120, RR 28, SpO2 92%, IV fluids and oxygen administered, blunt trauma from ejection.
- Immediate Life Threats Noted: Agonal respirations, significant external bleeding from the left leg.
Primary Survey (ABCDE Assessment):
Vital Signs:
RR: 28, SpO2: 92%, HR: 120, BP: 90/60 (MAP: 70), T: 36.5C, GCS: 10 (E: 3, V: 3, M: 4)
Central Capillary Refill Time: Delayed
Airway:
- Patent: Blood present, suctioning performed
- Verbal Response: Incoherent sounds, stridor noted
- Airway Interventions: Suctioning and intubation performed
Breathing:
- Chest Wall Examination: Bruising on the left side, crepitus noted
- Trachea Position & JVD: Trachea midline, no JVD
- Breath Sounds: Decreased breath sounds on the left
- Oxygenation/Ventilation: O2 saturation 92%, EtCO2 45 mmHg
Circulation:
- External Bleeding: Significant bleeding from left leg, tourniquet applied
- Internal Bleeding Suspicion: E-FAST positive for free fluid in the abdomen
- Blood Pressure & Pulses: BP 90/60, weak radial pulses bilaterally
- Pelvic Stability & Intervention: Pelvic binder placed due to instability
Disability (Neurologic Status & Cervical Spine Status):
- Pupil Examination: PEARL bilat
- Extremity Movement: Limited movement in lower extremities
- Cervical Spine (Status and precautions taken): In Cx Spine precautions
- Collar: Yes, rigid collar placed at 14:34
Exposure:
- Complete Undressing: Patient fully exposed for assessment
- Hypothermia Prevention: Warm blankets applied
- Log Roll for Back Assessment: No saddle anesthesia, bruising noted on the back