Emergency Services Trauma Flow Sheet

Hospital Logo

Example

Patient Sticker

Date:

Patient Arrival Time:

N/A Pre-Hospital Treatment

Transporting Ambulance_____________________________________________________________________________________
O2 @ ______L/min/ IV: Needle size______________ Backboard
NC
NRB
Ambu
LR _________________
Long Short Ked
Airway
Medications ________________
Scoop
Oral
Nasal
Other _____________________________ Bilateral Head Supports
ET tube # _____ @ _____cm C-Collar o n: Yes____ No ____ Splint on _________________
Ice on __________________
CPR started @ (time)______________
Dressing ________________
Other __________________
Date of Injury: ________________ ___ Time of Injury: _ _________ Pre-hospital trauma team alert notification:
Yes
No
Hospital Trauma Team Activ atio n Yes____ No____ Time of Trauma Team Activation: _______________
Trauma Team Members
Type of Vehicle
Team members notified: Time Called Time Arrived Car
Nurses x _________________
Truck ATV
Physician / CNP / PA
Moto rcycle Boat
Bicycle
Lab
X-ray
Other_____________________________________
Other ____________________

Pedestrian

Mechanism of Injury
Restraint Devices
Speed of vehicle ________ MPH Rollover Lap belt Airbag deployed
Ejected Shoulder belt Helmet
Number of vehicles
1 2
3
>3
Rearend Car seat Unrestrained
Steering wheel deformity T-Bone
Starred windshield
Head on
Fall Penetrating Blunt Thermal Other
Fell from: GSW Assault Burn Hanging
Stabbing
Height____________ ft. Other

Crush

Heat exposure Near drowning

Other
Cold exposure Animal related

Emergency Services Trauma Flow Sheet

Example

Initial Assessment
AIRWAY
DISABILITY
Patent
Suctioning
Glasgow Coma Score Initial Disch
Oral Airway Bag Mask
Eye Opening
Nasal Airway O2 __________________ L. Spontaneously 4
ET ________________ Commen ts
To Speech (Shout) 3
Trach
To Pain 2 ______ ______
Crico
_____________________________________ No Response 1
BREATHING
Verbal Response
Spontaneous Respiratory Effort Oriented (Coos, Babbles) 5

RL
Normal Agonal
Confused
4
(Consolable, Cry)
Lung sounds Shallow Nasal flaring
Clear Stridor Tachypnea
Inappropriate Words
3
(Persistent Cries, Screams)
Rales Dyspnea Grunting
Rhonchi/Wheezes Retracting Absent
2
Incomprehensible
Words (Grunts, Restless)
Decreased In tercostal Paradoxical
Absent Substernal Cough No Responses 1 ______ ______
Motor
Smoker
Yes
No
Unk
CIRCULATION
Obeys (Spontaneous) 6
Capillary Refill: None Delayed (> 2 sec) Normal (< 2 sec) Localized Pain 5
Pulses Present: Carotid Femoral Radial Pedal Withdrawal to Pain 4
Flexion to Pain
3
Palpated Pulse Regular Irregular
(Decorticate)
Heart tones Audible Absent
Jugular Vein Distension No
Yes
Extension to Pain 2

Bleeding Controlled Uncontrolled NA No Response to Pain 1 ______ ______

Skin Color Pink Pallor
Dusky
Cyanotic Total GCS Score ______ ______
Flushed Mottled

Area of Injury
Allergies
:
Tetanus: ________ LMP:_________ Wt: ___________
Procedures
Time Procedure
Results
ET Tube _____ Combitube ____
Size ______________________
Secured @ ______________cm
FiO2 ___________________ %
Central Line/ IV
Size ____________________ Fr
Site _______________________
Solution___________________
Warming Measures
Fluids
Mechanical
Bair Hugger
Blankets
NG Tube
Size _____________________
Color____________________
OW = Open
Foley / Quick Cath
Size ____________________ A = Abrasion Fc = Closed
Fracture
Wound
Color____________________
B = Burns Fd = Dislocation P = Paralysis
Neck immobilization
CMS:
C = Crepitus Fo = Open Fracture S = Edema
C-Collar Applied: ___________ Before___________________
After
____________________
D
=
Deformity
L = Laceration Ta = Total
__________________________
Splinting ___________ ___ ___ Location:__________________ E = Ecchymosis Na = Near
_________________________

Amputation
Amputation

Emergency Services Trauma Flow Sheet

Example

Secondary Assessment

Input
Output
Head/Scalp
Eyes
Mouth
Ears
Source
Prior
to
Arrival
ED
Total
Source
Prior
to
Arrival
ED
Total
Intact Rash PEARL
Intact No drainage
IVLaceration
Fluids Burns Urine
Raccoon eyes Teeth Drainage
Abrasions Pain EOMSEmesis
follows Missing teeth
Right
Left
Chest Tube
Bruising Battle
Visual Acuity OD ____/____
Dentures intact
Clear
Clear
Signs Other
OS ____/____
Comments_________
Blood
Clear
Neck
Chest
Heart Sounds
Blood
Intact C-Collar Symmetrical Chest Pain Present
Fresh
Frozen Pain
PlasmaAsymmetrical
Swelling
Location_______________ Distant
Trachea midline Paradoxical movement
Time of onset ___________ Absent
Trachea deviated
Location _____________
Activ ity @ onset ________
Sub-q emphysema Crepitus Flail
chest
Personal Belongings
Difficulty
Location_____________ Other _________________
Clothes swallo win g
Abdomen / Pelvis / GU
Purse
Abdomen
Bowel Sounds Pelvis
Wallet
Soft Distended Last Intake: Present Intact
Jewelry
____________________________________________________________________
Nontender
Rigid
Food ________________ Absent Pain ______________________
Given
to:
Tender
Liquid
_______________
Hyperactive ____________________________
Name ________________________________________________________________________
Hypoactive Blood at meatus ____________
Comments:
Relationship __________________________________________________________________
Blood at rectum ____________
Nursing Staff __________________________________________________________________
Instability _________________
Posterior
Extremities
Nurse
IntactNotes:
Intact
Deformity
Fracture
Pain
Pain
Comments _________________________________________ Deformity
____________________________________________________ Comments _________________________________________
____________________________________________________ ____________________________________________________
____________________________________________________ ____________________________________________________
Pupil Reaction Pain Scale
Comments
Time Tem

/
/
/
/
/
/
/
/
/
/
/
/

p P R BP SaO2 O2

L/min

S-slow
U-unequal
0-10
B-brisk
D-dilated
Pain
F-fixed
= - Equal
C-closed by swelling Scale Type

Right Left

Medication

Medications Given
Dose Route Time Given Initials

RN Signature: ______________________________________________________________________________
Q/trauma2/trauma/trsystemdevelopment/sdtaskford/flowsheetdraft/09-09