Trauma (Generic Charting) – © MedTx, LLC 2017

CC: Trauma

(Instructions: click on the checkbox to expand the decision tree and suggested options below. Click on the submit button a chart will be generated below in the text box). *Has yet to be sufficiently peer reviewed for clinical purposes.

  • CC: year old with PMH/PSH of presents with
  • chief compliant:
    • Poly Blunt Trauma,
    • Isolated Head Trauma,
    • Assault,
    • MVC,
    • Peds v Auto,
    • Motorcycle accident,
    • Fall from height,
    • Penetrating trauma,
    • Reported GSW (per paramedic report),
    • Reported stab wound (per paramedic report),
    • Burn,
  • Level of activation:
    • Trauma activation level
      • 1
      • 2
    • Trauma service kindly at bedside to concurrently evaluate/treat patient.
  • HPI:
    • Attempted AMBPLE history though unable to be obtained.
    • Abbreviated hx per paramedics, full hx unable to be obtained 2/2 acuity of patient.
    • Pt transferred from outside hospital. Reviewed chart accompanying patient for additional information.
    • Allergies:
      • NKDA
    • Pertinent Medical Problems/Surgeries/Medications
      • None pertinent
      • No blood thinners
      • Unable to access given pt’s condition
    •  Pain at location:
        • pt unable to indicate
    • Events surrounding traumatic incident (hx via collateral with help of paramedics on scene):
      • Mechanism of trauma
        • MVC
        • Motorcycle accident
        • Peds v Auto
        • Pedaling bike v auto accident
        • Fall from height
        • Assault
        • GSW (per report by paramedics)
          • Reported 1 GSW
          • Reported 2 GSWs
        • Stab wound (per report by paramedics)
      • Estimated time prior to ED trauma occurred:
        • no prolonged delay prior to arrival to ED after trauma
      •  MVC
        • Estimated speed
          • moderate
        • Location of pt in car
        • Seatbelted
          • yes
        • LOC
          • yes
          • no
        • Head strike
          • no
        • Extrication
          • no
        • Ambulatory at scene
          • yes
          • no
        • Vehicle drivable after accident
          • yes
          • no
        • Roll over
          • yes
          • no
      • Peds v Motor
        • Est of speed of car
          • sidestreet
          • moderate
          • high speed
        • Head strike
          • yes
          • no
        • Ambulatory at scene
          • yes
          • no
      • Motorcycle collision
        • helmeted
          • yes
          • no
        • LOC
          • yes
          • no
        • headstrike
          • yes
          • no
      • Cycling bicycle accident
        • helmeted
          • yes
          • no
        • LOC
          • yes
          • no
        • headstrike
          • yes
          • no
      • Assault
    • Sobriety:
      • Clinically appears intoxicated
      • Clinically appears sober
    • Last tetanus:
      • Updated
      • Within 5 years
      • Unknown
  • ROS:
    • ROS unable to be obtained secondary to acuity of patient’s condition
    • 10 Point Review of System negative unless otherwise specified in the HPI
    • Able to obtain the following ROS:
      • Constitutional: no lethargy
      • Eyes: no recent changes in vision
      • Nose/Mouth/Throat: no sore throat, rhinorrhea, otalgia
      • Cardiovascular: no chest pain, no palpitations
      • Respiratory: no SOB, no new cough
      • Gastrointestinal: no n/v/d. no BRBPR/melana
      • Genitourinary: no dysuria
      • MSK: no trauma to extremities
      • Neurological: no confusion
      • Psychiatric: no disorganized thinking
  • PMH/PSH/PSFH:
    • PMH:
      • medical history pertinent to chief complaint as noted in HPI
    • PSH:
      •   surgical history pertinent to chief complaint as noted in HPI
    • Reviewed, pertinents as able to be obtained were noted in HPI.
  •   SH:
    • Tob:
      • Denies.
      • Endorses.
    •   Etoh:
      • endorses
      • suspected based upon collateral of paramedics
      • denies
    • Illicits
      • Denies
      • Endorses
      • suspected based upon collateral of paramedics
  • FH:
    • Reviewed and non-contributory to patient’s chief complaint.
  • Exam (Complaint relevant additional components of the exam)
    • VITALS (overall impression of vital signs with repeat vitals in EMR as RNs re-access patient):
      • HR:
        • normal HR.
        • tachycardic
      • BP:
        • normotensive.
        • hypertensive
          • (attempted to inform pt to advise to f/u with PMD).
        • hypotensive.
      • O2 sat:
        • no hypoxia as interpreted by me
        • hypoxic
      • RR:
        • normal RR
        • tachypnic
    • Primary Survey:
      • Airway: Patent, oropharynx clear, trachea midline
      • Breathing: Symmetric breath sounds, equal chest rise
      • Circulation: Palpable radial peripheral pulse (BP as above), IV access obtained, pt on monitor
      • Disability:
        • GCS E4 V5 M6
        • GCS:
      • Exposure: Exposed patient for full examination (subsequent to examination, pt covered in warm blanket)
    • Secondary Survey:
      •  Head:
        • Atraumatic, no scalp lacerations, no retroauricular ecchymosis
      •  Eyes: PERRL, EOMI, no orbital trauma/crepitus
      •  Face: Atraumatic (No midface signs of trauma, no tenderness/instability, no mandibular tenderness or instability, no septal hematoma)
      •   Neck: No midline TTP, no step offs, cervical collar in place.
      •   Chest: Atraumatic (no seat belt sign/ecchymosis/abrasions/no crepitus)
      •   CV: no m/g/r
      •   Resp: Lungs BLTA, symmetric,
      •   Abdomen:
        •  Atraumatic,
          •  non-tender, non-distended,
          • no ecchymosis/lacerations/penetrations,
          • no signs of blunt trauma,
          • no signs of penetrating trauma,
      •  Pelvis: Stable, no pelvic tenderness
      •  Back: Atraumatic no stepoffs, no midline TTP
      •  Extremities: No deformities, Pulses+motor+sensation intact in all 4 extremities
      •   GU: Perineum intact, no blood at ureathral meatus, able to squeeze buttock
  • ———————————————————————————
  • ED Course:
    • Per ATLS protocol, primary survey performed emergently upon pt’s arrival, any abnormalities addressed. RNs exposed pt, placed on monitor and secured IV access. Secondary survey performed. Per ATLS protocol, primary survey performed emergently upon pt’s arrival, any abnormalities addressed. RNs exposed pt, placed on monitor and secured IV access. Secondary survey performed.
    • Emergent Interventions required fkrobstsvikiprior to definitive diagnoses required given cardiopulmonary instability of patient.
      • PTX
        • presumptive diagnosed by
          • paucity of breath sounds unilaterally
          • sucking wound
          • CXR
  •   Diagnostically:
    • Utilized adjuvents to secondary survery:
      • CXR
        • Reviewed indications, applied NeXUS CDIBT to this patient to inform appropriate use of diagnostics. Not indicated given
          • age<60, no rapid dec (fall<20ft, MVC<40mph, no CP, no TTP on CW, not intox/AMS, no distracting injury
        • Interpretation (ED Prelim by me): Normal CXR. Trachea midline. No plueral effusions. No air under diagphrams. No parenchymal radio-opacities thereby less likely pneumonia or pulmonary edema. Lung markings throughout – no radiographic evidence of pneumothorax. Intepretation: No evidence of trauma sequela on CXR.
      • PXR
        • Reviewed indications, applied to this patient to inform appropriate use of diagnostics and not indicated.
        • Interpretation (ED prelim by me): No evidence of pelvic bony abnormalities.
        • Reviewed indications, applied NeXUS CDIBT to this patient to inform appropriate use of diagnostics. Not indicated given age<60, no rapid dec (fall<20ft, MVC<40mph, no CP, no TTP on CW, not intox/AMS, no distracting injury.
    • Point of Care Testing:
      • Pregnancy Test
        • negative
      • POC gluc
        • wnl
      • POC Hg
        • wnl
      • iStat
        • no base deficit
      • lactate
        • wnl
    • Laboratory Analysis:
      • Standard trauma lab panel send (type and screen, cbc, cmp, ua, coags, etoh)
    • Advanced Radiographs: Considered the following (and applied diagnostic clinical decision rules and clinical gestalt/evaluation (and shared decision making when possible) to inform appropriate use of radiographic diagnostics i.e. image as indicated, not image when risk of radiation exceeds diagnostic benefit):
      • Intracranial injury
        • CT head
        • Not indicated. Reviewed indications, applied Canadian head criteria to this patient to inform appropriate use of diagnostics.
          • Not indicated given no dangerous mechanism (PMVT, ejection, fall>3ft), GCS>=13, no coagulopathy, no open skull fxr, 1630.
      • Cervical spine injury
        • CT neck
        • Not indicated. Reviewed indications, applied Canadian head criteria to this patient to inform appropriate use of diagnostics.
          •  Not indications given GCS<15, intoxication/distracting injury, 16>age<65, parathesias, previous spine dz/surgeries, no dangerous mechanism (MVC>60mph, rollover, ejection, recreational motor vehicle, bike-MVC, then CT. If none of above, then if any low risk factors (no neck pain, simple rear end MVC, sitting position, ambulatory, delayed neck pain), then safe for ROM. No pain w/ ROM.
      • Vascular neck injury
        • CT Angio Neck
        • Not indicated. Reviewed indications, applied to eval for Blunt Cerebral Vascular Injury (BCVI) with Denver Screening Criteria and given none of the following:
          • signs/symptoms
            • focal neurological deficit
            • arterial hemorrhage
            • cervical bruit/thrill (if pt <50 y/o)
            • infarct on head CT
            • expanding neck hematoma
            • neuro exam inconsisten with head CT
          • risk factors
            • midface fractures
            • cervical spine injuries
            • basical skull fracture
            • GCS <8
            • hanging w/ anxoic brain injury
            • sealt belt abrasion WITH swelling or AMS
      • Thoracic injury
        • CXR
          • ED Prelim Interpretation by me: No evidence of traumatic sequelae on CXR. No cardiomegaly. Trachea midline. No plueral effusions. No air under diagphrams. No parenchymal radio-opacities thereby less likely pneumonia or pulmonary edema. Lung markings throughout – no radiographic evidence of pneumothorax. No obvious multiple rib fractures.
        • CT chest
        • Imaging not indicated. Employed risk stratification to inform appropriate use of diagnostics. Not indicated given no severe mechanism c/w intrathoracic injury, no signs of chest wall trauma, not extremes of age, no cardio-pulmonary distress).
      • Abdominal injury
        • CT a/p
        • Imaging. Not indicated. Reviewed indications, applied to this patient to inform appropriate use of diagnostics. Not indicated given none of the following: severe mechanism c/w intra-and injury, TTP abd, signs of intra-abd injury, un-evaluable pt with suspected abd injury.
        • and negative FAST
      • Pelvic injury
        • CT a/p
        • PXR
        • Not indicated given sufficiently low suspicion of pelvic bony/vascular injury.
      • Extremity injury
        • XRs of extremities with signs of trauma or pain obtained.
        • Not indicated to obtain XRs of extremities given constellation of no deformities, no signs of trauma, no elicitable pain bone/joint on secondary examination, pulses intact, and full ROM. Of note, pt will be re-examined and ambulated prior to discharge and if any new findings revealed, as is common practice, will pursue further diagnostics at that time.
        • CTA
          • CTA not indicated given 2+ pulses, neuro intact, cap refil <2 sec, no evidence of arterial injury.
          • CTA performed given concern for possible arterial injury
    • Laboratory Results Reviewed. Analysis/Interpretation:
      • Diagnostically:
        • trauma labs set (cbc, cmp, UA, etoh, lactate, serum etoh, coags)
      • Basic Labs:
        • CBC:
          • No significant unexpected anemia suggestive of hemorrhage.
        • BMP:
          • No significant pathologic electrolyte derangements.
        • Basic laboratory analyses does not suggest more pathologic process in patient at this time.
      • Complete Laboratory Analysis:
        • CBC:
          • No significant unexpected anemia suggestive of hemorrhage.
        • BMP:
          • No significant pathologic electrolyte derangements.
        • LFTs/lipase:
          • No laboratory evidence of hepato-biliary injury (appreciated limited sensitivity) and therefore correlated clinically.
        • UA:
          • No hematuria thereby making GU injury less likely (appreciated limited sensitivity) and therefore correlated clinically.
    • EKG Interpretation:
      • Normal EKG in eval for blunt cardiac injury):
        • EKG: NSR, regular rate, normal axis, normal intervals, no abnormal TWI, no ST elevation/depression.
        • Interpretation: No clear evidence of active ischemia on EKG
      • Normal EKG in eval for arrhythmia/syncope:
        • EKG: Normal Sinus Rhythm. No arrythmia (no PACs, no PVCs), no brugada wave, no prolonged QTc, no delta wave/no shortened PR, no episilon wave, no evidence of ischemia.
        • Interpretation: No cardiogenic etiology for syncope obvious on EKG.
      • Abnormal EKG
        • Sinus tachycardia, no abnormal TWI, no significant ST. No EKG e/o ischemia suggestive no EKG evidence of blunt cardiac injury.  elevation/depression.
        • Non-specific repolarization abnormalities. No ST elevation/depression. No EKG e/o ischemia suggestive no EKG evidence of blunt cardiac injury.
        • ST morphology concerning for blunt myocardial ischemia/infarct.
          • troponin sent
        • Potential arrhythmogenic etiology elucidated on EKG.
          • Would benefit from syncope work up, telemetric monitoring given possible non-mechanical cause to truama.
          • Hx not c/w syncope/arrhythmia and given pt is symptomatic, advised for prompt f/u with PMD.
  • Therapeutically:
    • C-collar in place, c-spine precautions
    • NPO, resuscitation with IVF
    • Hemostasis achieved with all bleeding wounds.
    • Lacerations repaired (see procedure note).
    • Emergent reduction of deformity indicated and performed with post reduction neuro-vasc-motor intact.
    • Prophylactic antibiotics.
    • Tetanus updated.
  • Medical Decision Making:
  • Suspect (most consistent with the following DIAGNOSIS)
    • DDx includes but is not limited to (Considered the following diagnoses though based upon the medical evaluation, pt does not meet reasonable likelihood for further pursuit at this time (risks/outweigh benefits of non-indicated testing). Attempted shared decision making with discussion with patient to the extent that was possible.)
  • Re-evaluation
    • On re-evaluation, after patient was observed on telemetric monitoring, patient remains hemodynamically stable, normal vital signs, with clear sensorium, repeat cardio-pulmonary-abdominal exam benign, is ambulatory, has no new develop of pain, pain is well-controlled and is amenable to discharge after observation period in the ED.
    • On re-evaluation, remains intoxicated. Hemodynamically stable. Will continue observation.
  •   Disposition:
    • Discharged from Emergent Department with prompt PMD follow up.
      • The patient understands that at this time there is no evidence for a more malignant underlying process, but the patient also understands that early in the process of an traumatic illness, an initial workup can be falsely reassuring. Routine discharge counseling was given to the patient and the patient understands that worsening, changing or persistent symptoms should prompt an immediate call or follow up with their primary physician or return to this or any ED for reevaluation. More extensive discharge instructions were given in the patient’s discharge paperwork.  Discharge Instructions included: Follow Up: Patient/family advised for prompt follow up with primary care physician. I explained the importance of follow up given the limitations of a one time emergency department visit and the importance of continued care and diagnoses that may only be elucidated by serial evaluations. Should the patient have difficulty finding primary care follow up, the patient was advised of community health resources as well as advised that they always could return to the Emergency Department for re-evaluation. Return precautions – both general and specific to the patient’s evaluation were discussed with the patient.
    • Admitted given above findings/rationale
    • Sign out at change of shift to oncoming ED team
      • pending
    • Counseling: Patient/family was counseled on the above evaluation, findings, assessment, and plan and were in agreement with plan. All questions answers. Reiterated understanding.
  • Supplemental Aspects of Care:
    • SW offered to patient
    • Hospital police informed of presence of patient with trauma given potential for pt sustaining assault and requiring safety, additional HPI withheld and per discretion of patient to reveal information to police.
    • Critical Care:
      • Critical Care Procedure Note:
      • Performed by attending physician
      • Approximate time of critical care:
        • Critical care procedure note. Performed by attending physician. Total critical care time approximately
          • 37 minutes
        • The patient required critical care given the patient’s presentation predispose the patient to significant pathology which could result in loss of life program and permanent morbidity. Emergent diagnostics and treatments were of critical important to elucidate, life-threatening pathologies and mitigate risk of imminent deteriorated. The patient required my direct emergent evaluation in obtaining a history, performing exam, interpreting vital signs including pulse oximetry, ordering and interpretation of diagnostic studies, coordinating plan , ordering emergent interventions and repeated reevaluations in order to evaluate response to the above interventions.  This part of my care the patient is exclusive of other billable procedures, specifically procedures, treating other patients, and any educational time. Please refer to the above rationale for further documentation regarding the critical nature of the patient during my care.
      • Observation Note
        • Given patient’s presentation with trauma, the patient required an observation in the ED to evaluate for potential improvement, ensure stability, or deterioration given that traumatic injuries can have delayed manifestation of symptomatology and without observation present too high of a risk and precludes safe discharge without said observation.  As such, the patient was observed in the ED on telemetric monitoring with re-evaluation of vital signs and by RN as well as more extensive re-evaluations by me.
        • Observation time began at:
        • Observation time ended at:
        • Total observation time:

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