PE: T 37.9 c, Pulse 110/min, BP 100/80 mmHg, RR 22/min.

Oxygen saturation 94%

on room air.

Primary Survey:
A- no airway obstruction, no foreign body in the mouth, no facial deformity,
no hoarseness, no evidence of laryngeal fracture.
B- self breathing without difficulty.
Evidence of life-threatening conditions?:
Tension pneumothorax: trachea in midline, equal breath sounds,
equal chest movement, no hyperresonance on
percussion.
Open pneumothorax: no open wound of thorax.
Massive haemothorax: no dullness on auscultation.
Flail chest and pulmonary contusion: no paradoxical movement.
Cardiac tamponade: no engorged neck vein, no muffled heart
sounds.
C- no external bleeding.
D- E4M6V5 (GCS score 15), pupils 2 mm BRTL, no gross neurologic deficits, no
bleeding per ears, no bleeding per nostrils, no otorrhea, no rhinorrhea.
E-

Resuscitation:
A- maintain airway and protect his cervical spine with semi-rigid collar.
B-
C- large-bored intravenous catheter with LRS infusion.
D-
E- warm blanket to prevent hypothermia.

Adjuncts to primary survey and resuscitation:

Pulse oxymeter:
ECG:
NG-tube:
Urinary catheter:
 ABG:
Blood component requirement:
Films:
Lateral cross-table cervical spine:
Portable CXR:
Pelvis AP:

Secondary Survey:
Allergies:
Medicines currently used:
Past history/Pregnancy:
Last meal:
Event/Environment:

PE: T 37.9 c, Pulse 110/min, BP 100/80 mmHg, RR 22/min. Oxygen saturation 94%
on room air.
Head: no scalp lesion, no deformity of his face, no bleeding per nostrils, ears and
mouth. No burn in his mouth, no singed eyebrow nor nostril hair, no hoarseness.
Eyes: no gross hyphema, no subconjunctival haemorrhage.
Neck: no neck pain, no limitation of active neck movement, no laryngeal deformity, no
subcutaneous emphysema, trachea in midline.
Chest: self breathing without difficulty, equal breath sounds, equal chest movement,
no paradoxical movement. No chest wall pain, no open wound. Stable on chest
compression test.
CVS: regular rhythm, no muffled heart sounds.
Abdomen: no distension, soft, not tender, no rebound tenderness, audible bowel
sounds.
Pelvis: stable on pelvic compression test, no pain.
Perineum: no bleeding per urethral meatus, no perineal haematoma.
PR: no bleeding per rectum, no high ridding prostate gland, normal sphincter tone.
Back: no tenderness around the spine, no deformity.
CVA: not tender on percussion.
Extremities: no deformity.
Neurologic examination: E4M6V5 (GCS 15), pupils 2 mm BRTL, no gross
neurologic deficits.
Sensory examination: grossly intact
Motor examination: no weakness

Adjuncts to secondary survey:

Films:
Ultrasounds:
CT-Brain:
CT-Chest:
CT-Abdomen:

Post resuscitation monitoring and re-evaluation:

Definite care: