TRAUMA ASSESSMENT

Patient: [Name or trauma alias, age, sex]
Record number and date: [Chart or record number, date]
Clock used: [Wall clock, monitor, or recorder's sheet]

ACTIVATION AND ARRIVAL
Time of injury: [Time, stated or estimated, and where it came from]
Trauma team activation: [Level, time paged, and the criteria met]
Arrival: [Time and mode: ground ambulance, helicopter, private vehicle, or transfer from another hospital]
Team: [Leader with time at the bedside; airway, procedures, nursing, recorder, and others, with arrival times]

PREHOSPITAL REPORT
Handover: [Who gave it, the time, and the format, such as MIST]
Mechanism: [What happened: speed, restraint, airbags, intrusion, ejection, height of a fall, weapon, extrication time]
Injuries found or suspected: [What the crew found]
Signs: [First and last prehospital vital signs and GCS with E, V, M, each with its time]
Treatment given: [Airway, oxygen, access, fluids, blood, tranexamic acid with time, tourniquet with time applied, splints, pain relief]

PRIMARY SURVEY
Catastrophic hemorrhage: [External bleeding, and how it was stopped: pressure, packing, or tourniquet with time]
Airway with cervical spine protection: [Patent, at risk, or secured; device, size, and how it was confirmed; collar or manual stabilization]
Breathing: [Rate, SpO2 and oxygen, chest movement, breath sounds, trachea, chest wall, and any decompression or chest tube with time]
Circulation: [Heart rate, blood pressure, skin and capillary refill, bleeding sources, pelvic binder, and access]
Disability: [GCS as E, V, M and total, pupil size and reaction, limb movement, glucose]
Exposure: [Fully exposed, temperature, and warming measures]
Reassessed: [Times the survey was repeated, and what changed]

ADJUNCTS
eFAST: [Time, operator, and each view: right upper quadrant, left upper quadrant, pelvis, pericardium, both lungs]
Chest and pelvis X-rays: [Times and findings, or skipped and why]
Monitoring and tubes: [ECG rhythm, end-tidal CO2, urinary catheter, gastric tube]
Bloods sent: [Group and crossmatch, CBC, coagulation, fibrinogen, blood gas with lactate and base deficit, ionized calcium, pregnancy test, alcohol]

RESUSCITATION
Massive transfusion protocol: [Activated or not, the time, and the trigger]
Blood products: [Red cells, plasma, platelets, and fibrinogen or cryoprecipitate: units and times]
Tranexamic acid: [Dose, start time, minutes since injury, and the second dose]
Calcium and warming: [Ionized calcium, the dose given and time, and warming measures]
Blood pressure target: [The target and the reason]
Anticoagulant reversal: [Drug, last dose time, reversal agent, dose, and time given]
Response: [Vital signs after each step: responder, transient responder, or non-responder]

SECONDARY SURVEY
Head, face, and neck: [Scalp, skull, eyes, ears, nose, facial bones, mouth; collar, midline tenderness, trachea]
Chest and abdomen: [Chest wall, breath and heart sounds; bruising, tenderness, distension, seatbelt sign]
Pelvis and perineum: [Bruising, blood at the urethral meatus, perineal wounds]
Spine and back: [Log roll with in-line stabilization: bruising, step-off, midline tenderness]
Limbs: [Deformity, wounds, pulses, sensation, movement, compartments]
Neurological: [Repeat GCS as E, V, M, pupils, focal deficits]
Deferred: [What was not examined, why, and who will finish it]

AMPLE HISTORY
Allergies: [Drug and other allergies, with the reaction]
Medications: [Current medicines, with any anticoagulant or antiplatelet and the time of the last dose]
Past history: [Conditions, surgery, and pregnancy status when relevant]
Last meal: [Time and what]
Events: [What led to the injury, and anything before it, such as a faint, seizure, or chest pain]
Source: [Patient, family, paramedics, or records]

RESULTS AND CONSULTS
Labs: [Key results with the time drawn]
CT: [Studies, time scanned, and findings, marked preliminary or final, with who read them]
Other imaging: [Limb X-rays, angiography, or none]
Consultations: [Service, consultant's name, time called, time they replied or arrived, and their advice]

INJURY LIST AND PLAN
Injuries: [Each injury, confirmed or suspected, one per line]
Plan: [Operation, interventional radiology, admission, observation, repeat imaging, or transfer, for each injury]
Tetanus: [Given, up to date, or not needed]
Tertiary survey: [When it is due, and who will do it]

DISPOSITION AND TIMES
Disposition: [Operating room, interventional radiology, ICU, ward, transfer, or home, with the time]
Family and goals of care: [Who was told, by whom, and when; goals of care confirmed, when relevant]
Key times: [Injury, arrival, activation, first blood, CT, decisions, and departure from the trauma bay]

Signed: [Team leader name, credentials, date and time]