Volume I:
First Thirty Minutes
- Section 1
  Acute Care Algorithm/ Treatment Plans/ Acronyms
- Section 2
  Universal Approach
  - CALS Universal Approach To Emergency Advanced Life Support
- Section 3
  Steps 1-6
- Section 4
  Preliminary Impression/Focused Clinical Pathways
Volume II:
Resuscitation Procedures
Volume III:
Definitive Care

Acute Care 44: Trauma Flow Sheet

Patient Name ___________________________________________________ Date ______________________

MR#_____________________________ DOB_____________________ Band # _________________________

Date of Arrival ___________________________ Time of Arrival ____________________________________

Pre-Hospital Information

Injury _________________ Injury Time ___________________ Location of Injury ________________ Pre-Hospital Report/Information Time of Arrival at Scene Trauma Alert Called? Yes No
Method of Arrival		Prior to Arrival
Ambulance Private Care Law Enforcement Other	Ambulatory Wheelchair Stretcher Other	Airway Backboard C-Collar CPR Cardiac Monitor Extrication	Dressing Meds: ________ Oxygen _______ IV Splinting MAST Trousers

Mechanism of Injury

Blunt

Assault

ATV

Bicycle

Fall
Distance____ft
Landed on____
checkbox

Motorcycle
checkbox

MVA

Pedestrian
checkbox

Other Vehicle_____
checkbox

Other:___________
checkbox

Skiing

Snowmobile
checkbox

Sporting

Water/Boating

Penetrating
checkbox

GSW
Caliber______
Gauge_______
Range_______
checkbox

Stab Wound
checkbox

Self-Inflicted
checkbox

Other____________

Burn

Inhalation
checkbox

Explosion

Safety Restraints
checkbox

None

Seat/Safety Belt
checkbox

Airbag

Helmet

Other

Impact

Broadside

Driver's Side
checkbox

Passenger's Side
checkbox

Head-On

Single Vehicle
checkbox

Roll Over

Ejected

Driver

Passenger

Front Seat
checkbox

Back Seat

Prolonged extrication
> 20 minutes
checkbox

High Speed
checkbox

Low Speed

Other Information Relevant to Patient's Injury

Pertinent Health History

Past Medical History Unknown	Medications Unknown	Allergies Unknown	Date Last Tetanus _______________ Unknown LMP___________ N/A Last Meal_______
Initial Nursing Assessment BP____P____R___ T____ (Oral/Axillary/Tympanic/Rectal) % Sat___________

	Primary Assessment	Intervention	Notes
Airway	Patient talking if awake Obstructed Blood Vomit Foreign objects/teeth Other: ________________	Jaw Thrust/Chin Lift Suctioning Removal of foreign objects Oropharyngeal airway Intubation
C-Spine	C-Spine precautions implemented Yes, How? Manual Stabilization C-Collar Long Back Board/KED No, Why: _______________	Spinal precautions maintained C-Spine stabilization applied via _________ C-Spine X-rays ordered C-Spines Cleared Time______ By_______ C-Spines not cleared prior to transfer
Breathing	Spontaneous Breathing (record rate in VS) Breath Sounds Equal Diminished/Area_____ Absent/Side______ Respiratory Distress JVD or Tracheal Deviation Accessory Muscle Use Other (please list) ____________________	Respiration Assisted Ambu Bag Bag-Valve-Mask Oxygen @___L/min by: Mask Cannula Additional interventions (chest tube) are documented in procedures.
Circulation	Pulse Present Radial Doralis Pedis Femoral Carotid Major External Bleeding None Location _______________ Skin Assessment Warm Dry Cool Moist Hot Diaphoretic Skin Color Normal Pink Flushed Pale Cyanotic Dusky	Direct Pressure to Bleeding Sites Location _________________ IV Inserted (see below) IV Sites (2 Large Bore) Site/Gauge/Time/By R______________ R______________ L______________ L______________

Disability/
GCS

Eyes

4 Spontaneously
checkbox

3 To verbal
command
checkbox

2 To pain

1 Never OR
checkbox

1 Never-
Medically
paralyzed

Verbal

5 Oriented
checkbox

4 Confused
checkbox

3 Inappropriate
checkbox

2 Incomprehensible
sounds
checkbox

1 No response OR
checkbox

1 No response-
Intubated/Paralyzed

Motor

6 Obeys

5 Localizes pain
checkbox

4 Flexion/
Withdrawal
checkbox

3 Flexion Abnormal
checkbox

2 Extension
Abnormal
checkbox

1 No response OR
checkbox

1 No response-
Medically paralyzed

Right		Left
	Non-Reactive
	Fixed
	Dialed
	Constricted

______Size_____

Secondary Assessment

Head/Neck	WNL	Other
Chest	WNL	Other
Abdomen/Pelvis	WNL	Other
Extremities	WNL	Other
Back	WNL	Other
Neurological	WNL	Other

Physician Orders

Lab CBC UA Type & Screen Type & Cross # units_____ BHGG Other (list) ___________	X-Ray Portable cross- table lateral C-spine Chest Pelvis (after C- spine and chest) Other (list) ___________ ___________	Medication Tetanus Ancef____g IV Other (list) ____________ ____________ ____________ ____________ ____________ ____________	IV 2 large bore sites NS @_____cc/h LR @_____cc/h	Other Immobilization _________ Foley NG ECG Cardiac monitor Oxygen _____L via _____ BP and pulse q 5 min Pulse oximetry
Physician Signature Authenticating Orders:

P R O C E D U R E S	RSI Meds Dose/Route Etomidate____________ Succinylcholine_______ Vecuronium__________ Versed______________ Atropine_____________ Lidocaine____________ Fentanyl_____________	Intubation ETT NTT Size: ________	Chest Tube Right Left R size: _______ L size: _______	Foley Size ____	NG Size ____	Wound Care Cleansed Ice Dressing (specify) __________ __________	Gastric Lavage 18 Fr 34 Fr
Time
By

Monitoring Flowsheet

Time

Pulse

Resp Rate

Temp

O₂ Sat

O₂

LOC

Pain
(0/10)

Cardiac
Monitor

Warm
Blankets

Bar
Hugger

Position of
Comfort

Nurse's Notes

Time

Disposition and Destination

Admitted to: checkbox

Acute Care checkbox

ICU/ICA

Surgery

Other
Transferred to: _____________________________
Discharged to: checkbox

Home

Other ______________
Transported by: checkbox

Wheelchair checkbox

Stretcher

Ambulance (specify) ________________ checkbox

Helicopter (specify)____________
Report called to: ____________________________ By: ___________________________ Time: _______________________
Discharge Assessment:
BP ______ P_______ RR _______ GCS _______ (E) _______ (V) _______ (M) _______
Other: _________________________________________________________________________________________________
_______________________________________________________________________________________________________
Condition @ Discharge: checkbox

Stable

Guarded

Other
Time of DIscharge: _________________________________
Belongings (list):_________________________________________________________________________________________

_________________________________________________________________________________________
_________________________________________________________________________________________

Sent with patient checkbox

Cat

Given to Family checkbox

Taken by law enforcement

Family Information

Notified?

Yes Name_____________________ Time ______ Location ________ Estimated Time of Arrival ________
checkbox

No/Unable Time of Last Attempt_____ Phone Number___________Name________________

Primary Nurse______________________________ Assisting Nurse_____________________________ Anesthesia:________________________________ X-Ray_____________________________________ EMT______________________________________ EMT______________________________________	Doctor___________________________________ Assisting Nurse___________________________ Lab_____________________________________ EMT____________________________________ EMT____________________________________ Recorder_________________________________
Other________________________________________________________________________________

Acknowledgement
This form has been adapted from Mercy Hospital and Health Care Center in Moose Lake, Minnesota.

Acute Care 44: Trauma Flow Sheet

Edition 13-October 2011