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Trauma History & Physical
Initial trauma H&P for trauma bay and emergency department evaluation.
On this page
On this page
- Date/Time:*
- Attending:*
- Consulting service:*
- Disposition destination:*
Mechanism of Injury
Mechanism: (MVC, fall, GSW, assault, industrial, other) • MVC: Speed, restraints, airbag, ejection, fatality at scene, extrication...Section
Mechanism of Injury
Mechanism: (MVC, fall, GSW, assault, industrial, other) • MVC: Speed, restraints, airbag, ejection, fatality at scene, extrication...- Date/time of injury:
- Mechanism: (MVC, fall, GSW, assault, industrial, other)
- Details:
- MVC: Speed, restraints, airbag, ejection, fatality at scene, extrication
- Fall: Height, surface, LOC
- Penetrating: Weapon type, estimated number of wounds
- Pre-hospital: (EMS, flight, LOC, vitals at scene)
- GCS at scene: ___ GCS on arrival: __
Primary Survey
Airway patent: (yes/no) • Intervention: (none / BVM / OPA / NPA / ETT / surgical airway) • C-spine: (cleared / collar in place)Section
Primary Survey
Airway patent: (yes/no) • Intervention: (none / BVM / OPA / NPA / ETT / surgical airway) • C-spine: (cleared / collar in place)A — Airway
- Airway patent: (yes/no)
- Intervention: (none / BVM / OPA / NPA / ETT / surgical airway)
- C-spine: (cleared / collar in place)
B — Breathing
- Respiratory rate: ___ breaths/min
- O₂ saturation: ___% on __
- Breath sounds: (bilateral / decreased on L/R)
- Intervention: (none / needle decompression / chest tube — side, size)
- CXR: (clear / PTX / HTX / mediastinal)
C — Circulation
- HR: ___ BP: ___/___ (MAP: ___)
- Skin: (warm/dry / cool/clammy / pale / diaphoretic)
- IV access: (G IVs × ___)
- Blood products: (given / yes/no; pRBC: ___ FFP: ___ Plt: ___)
- Hemorrhage control: (tourniquet / packing / direct pressure — site)
- FAST exam: (positive / negative / indeterminate — views)
D — Disability
- GCS: E___ V___ M___ = __
- Pupils: R: ___ mm / ___ L: ___ mm / __
- Motor exam: (intact / deficit — side, grade)
- Sensation:
- Spinal precautions: (yes / cleared)
E — Exposure / Environment
- Temperature: ___°C
- Significant findings on undressing:
- Warming measures: (warm blankets, fluid warmer, other)
Secondary Survey (Head to Toe)
(Log roll findings)Section
Secondary Survey (Head to Toe)
(Log roll findings)Vital Signs on Arrival
Parameter • Value • TempSection
Vital Signs on Arrival
Parameter • Value • Temp| Parameter | Value |
|---|---|
| Temp | |
| HR | |
| BP | |
| RR | |
| SpO₂ | |
| GCS |
Imaging
FAST: (positive / negative — pericardial, RUQ, LUQ, pelvic)Section
Imaging
FAST: (positive / negative — pericardial, RUQ, LUQ, pelvic)- FAST: (positive / negative — pericardial, RUQ, LUQ, pelvic)
- CXR:
- Pelvis XR:
- CT Head:
- CT C-spine:
- CT Chest/Abd/Pelvis:
- Extremity XRs:
Labs
BMP: Na ___ K ___ Cl ___ CO₂ ___ BUN ___ Cr ___ Glucose __ • Coags: PT/INR ___ PTT _Section
Labs
BMP: Na ___ K ___ Cl ___ CO₂ ___ BUN ___ Cr ___ Glucose __ • Coags: PT/INR ___ PTT _- Type & Screen:
- CBC: WBC ___ Hgb ___ Plt __
- BMP: Na ___ K ___ Cl ___ CO₂ ___ BUN ___ Cr ___ Glucose __
- LFTs:
- Lipase:
- Coags: PT/INR ___ PTT __
- Lactate:
- Base deficit:
- ETOH:
- Urine toxicology:
- Pregnancy test (if applicable):
- ABG:
Injuries Identified
1. 2. 3. 4.Section
Injuries Identified
1. 2. 3. 4.1. 2. 3. 4.
Assessment & Plan
Primary diagnosis:*Section
Assessment & Plan
Primary diagnosis:*- Primary diagnosis:*
- ISS (Injury Severity Score):* (calculate when able)
- Immediate plan:*
- Airway:
- Hemorrhage control:
- Imaging:
- Surgical intervention: (yes / no — OR, IR)
- Admission destination: (Trauma bay → SICU / SDU / floor)
- Consultations:
- Admission plan:*
- Monitoring:
- DVT prophylaxis:
- Activity:
- Diet:
- Follow-up imaging:
- Attending attestation:*
- I have reviewed and agree with the above note. [Any modifications noted below.]*