APPENDIX 6

APPENDIX

Sample Trauma Flow Sheet

Advanced Trauma Life Support

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 APPENDIX 6
SAMPLE TRAUMA FLOW SHEET*

Chief Complaint:

Name:
Date:
Arrival time:

MECHANISM OF INJURY

PREHOSPITAL TRANSPORT INFORMATION

Scene

Ambulance

Helicopter

Police

Private vehicle

Ambulatory

Wheelchair

Other _____________________________

Referring doctor ______________________________________

Referring hospital _____________________________________
Other information _____________________________________
________________________________________________________
________________________________________________________

MCV:

Driver Passenger
Seat belt on

MCC:

Driver Passenger
Helmet on Protective clothing worn

Pedestrian vs vehicle

Front
Back
Air bag inflated

Vehicle vs bicycle

Vehicle speed _______________ mph/kph

Fall ________________________ feet/meters
GSW
Assault

PROCEDURES BEFORE ARRIVAL

Stab
Hypothermia

Crush
Other

Burn/Cold

AMPLE HISTORY

Oral airway

Nasal airway

EOA/PTL

Allergies: _______________________________________________

ETT #______

NTT #______

RSI

________________________________________________________

Cric #______

O2 @__________L/min via___________

Medications: ____________________________________________

Breath sounds:

L ________________ R ________________

________________________________________________________

IVs #______

Peripheral Central

IV fluids: 1 2 3 4 5 6

Blood: 1 2 3 4 5

CPR

PASG:

Urinary cath

Gastric tube

Chest tube:

C-spine/spine protection

Intraosseous

Legs

Abdomen

Past illnesses: ___________________________________________

________________________________________________________
Last meal:__________________ Last tetanus: ________________
Events: _________________________________________________

Both

Time on: _________________

________________________________________________________
Pregnant?

Yes No

LMP _________________________

Splints: Type _________________________________________

Spine protection device removed @ ________________________

Medications:__________________________________________

Other: __________________________________________________

________________________________________________________

________________________________________________________

Other procedures: _____________________________________

________________________________________________________

________________________________________________________

________________________________________________________

OTHER SERVICES CONTACTED (Time called/arrived)

Service
Name
Called
Arrived

PERSONNEL RESPONSE (Time called/arrived)

Service
Name
Called
Arrived
ED doctor
Trauma surgeon
Neurosurgery
Orthopaedics
Anesthesia
Pediatrics
ENT/OMFS
Plastics/burns
Urology
Nurse
Nurse
Other

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American College of Surgeons

APPENDIX 6
SAMPLE TRAUMA FLOW SHEET*

INITIAL ASSESSMENT

IDENTIFY INJURY SITE BY NUMBER

AIRWAY/BREATHING
Patent

Obstructed

Symmetrical

Asymmetrical

Unlabored

Labored

Trachea midline?

Yes

No

Breath Sounds:

Present:

Right

Left

Clear:

Right

Left

Decreased

Right

Left

Absent

Right

Left

Rales/rhonchi

Right

Left

Yes

No

Crepitus?

CIRCULATION
Skin/mucous:

Pink

Pale

Membrane color:

Flushed

Jaundiced

Ashen

Cyanotic

Pulses:

Normal, Site __________________

Bounding, Site ________________
Weak, Site____________________
Absent, Site __________________

Rate:________/minute

Rhythm ___________________

Skin temp:

Warm

Hot

Cool/cold

Skin moisture:

WNL

Dry

Moist

1.
2.
3.
4.
5.

Laceration
Abrasion
Hematoma
Contusion
Deformity

6.
7.
8.
9.
10.

Open fracture
GSW
Stab
Burn
Cold

11.
12.
13.
14.

Edema
Amputation
Avulsion
Pain

Head: __________________________________________________
________________________________________________________
________________________________________________________
Maxillofacial:____________________________________________
________________________________________________________
________________________________________________________
C-spine/neck: ___________________________________________

DISABILITY
Eye opening

________

________________________________________________________

Verbal

________

________________________________________________________

Best motor

________

TOTAL GCS SCORE

________

GCS Score:

Revised Trauma

Respiratory

________

Score (RTS)

Systolic BP

________

GCS

________

TOTAL RTS

Chest: __________________________________________________
________________________________________________________
________________________________________________________
Abdomen: ______________________________________________

_________

________________________________________________________

OS Size

OD Size

________________________________________________________

Brisk

______ mm

______ mm

Constricted

______ mm

______ mm

Sluggish

______ mm

______ mm

Dilated

______ mm

______ mm

Nonreactive

______ mm

______ mm

Pupil Reaction:

Perineum: ______________________________________________
________________________________________________________
________________________________________________________
Musculoskeletal:_________________________________________
________________________________________________________
________________________________________________________

Advanced Trauma Life Support

347

 APPENDIX 6
SAMPLE TRAUMA FLOW SHEET*

TRAUMA RESUSCITATION ORDERS

Time

Laboratory
Type/cross #
Type/hold
CBC Screen
ETOH
Drug screen
PT/PTT
ABGs
Urinalysis
DPL fluid
Pregnancy test
HIV

Time
units

Other:

X-rays
Chest
Pelvis
Lateral c-spine
Swimmers
Thoracic spine
Lumbar spine
Skull
Facial series
Mandible
Abdomen
Extremity: LUE/RUE
Extremity: LLE/RLE

Time

IVP
Cystogram
Urethrogram
Arteriogram/Aorto
CT head
CT chest
CT abdomen
CT pelvis
Helical CT

FLUID INTAKE/OUTPUT
Intake
Ouput
Total fluids prehospital______mL
Urine _______ mL
ED Total fluids_______mL
Gastric ______ mL
Total blood prehospital_______mL Blood _______ mL
ED Total PRBCs_________mL
TOTAL _____ mL
FFP Total_________mL
Platelets__________mL
Other:

Procedures
O2 @
L/min via
ETT #
by:
NTT #
by:
Cric #
by:
Needle thoracostomy by:
Chest tube#
by:
R return:
L return:
ED thoracotomy by:
Autotransfuser
R IV site:
size:
R IV site:
size:
L IV site:
size:
L IV site:
size:
C IV site:
size:
CVP site:
size:
Pericardiocentesis by:
ECG
Gastric tube#
by:
Return
Color
Rectal tone:
Urinary cath#
by:
Urine dip
Spontaneous void dip
DPL
FAST
by:
Results
Suturing by:
Restraints:
UE
LE

O2 LPM

pH

Med
Tetanus

Dose

ABGs
PCO2

PO2

MEDICATIONS
By
Route/Site

Time

Time

TOTAL__________________________mL

348

American College of Surgeons

APPENDIX 6
SAMPLE TRAUMA FLOW SHEET*

TIME
Cuff BP
Pulse
Rhythm
Respirations
Temperature
MAP line
O2/Hgb Sat
Carboximetry
CVP
Urinary output
Blood output

GCS SCORE
1. Eye opening
2. Verbal
3. Best motor
TOTAL (1+2+3)
R pupil size and reaction
L pupil size and reaction
TIME

NOTES

DISPOSITION:

Alive: Time out: _________am/pm

To: ___________________________

Dead: Time out: _________am/pm

To: ___________________________

Operative permit signed

Family notified

Pastoral service notified

Service: ____________________

Social services notified

Valuables/clothing: __________________________________________________________________________________________________
Forensic evidence: ___________________________________________________________________________________________________
Doctors Signature:___________________________________________________________________________________________________

*NOTE: This flow sheet is only an example of information that may be required. All institutions that receive trauma patients should develop a form
that meets the needs of the institution.
Advanced Trauma Life Support

349

 APPENDIX 6
SAMPLE TRAUMA FLOW SHEET*

350

American College of Surgeons