Reference Card for WHO Emergency Unit Form Trauma


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REFERENCE CARD FOR WHO EMERGENCY UNIT FORM: TRAUMA

DATES/TIMES: Do not leave dates/times blank. Where unknown, write UNK

MASS CASUALTY: Check box if patient part of a mass casualty event

AGE: If age unknown, circle category: IN (infant) if appears <1 year of age, CH (child) if 1-18 years, or AD (adult)

OCCUPATION: Be as specific as possible (eg. farm laborer or farm manager instead of farming)

PATIENT RESIDENCE: Note if homeless, migrant worker, other

CHIEF COMPLAINT: Always in the patient’s own words

DEAD ON ARRIVAL: Use ONLY if NO signs of life on arrival

NORMAL VITAL SIGNS – FOR ALL: SpO2 >92% on RA, Temp 36˚C - 38˚C Paediatric:

*Record O2 saturation and amount/route of O2, eg. 94% on 2L by NC

Adult: Pulse 60-100 bpm, RR 10-20, SPB >90mmHg Pain score: Ask the patient to choose the face that best represents the pain they are experiencing.

TREATING PROVIDER ASSESSMENT Date and time of first assessment of patient by medical provider at current facility

Primary Survey

Airway: Normal (NML) •Patent (if they can speak normally) •NO signs of obstruction, stridor, angioedema or burns

•OPA/NPA=oro-/naso-pharyngeal airway •LMA=laryngeal mask airway •BVM=bag valve mask •ETT=endotracheal tube •TTP=tenderness to palpation

Breathing: NML • Effort normal • Sounds clear

Abnormal •Decreased breath sounds •Crepitation •Rhonchi •Wheezing •Enter N/A for spontaneous RR if sedated, paralyzed or on ventilator

Supplemental Oxygen: •NC=nasal cannula •NRB=non-rebreather mask •BVM=bag valve mask •CPAP/BiPAP=continuous or bi-level positive airway pressure •For ventilator: enter mode (eg. SIMV, AC, etc.)

Circulation: NML •Skin warm & dry •Pulse strong & symmetric (upper & lower extremities)

Abnormal •JVD (jugular venous distention) •Prolonged capillary refill (>3 sec)

Access: Document location (loc) and size •IO=intraosseous •IV=peripheral intravenous •CVL=central venous line IVF (intravenous fluids): •NS=normal saline •LR=Lactated Ringer’s •Other (write name)

Disability: NML

Abnormal

•Alert (A)

•Responds only to Verbal (V), Pain

•Oriented to person/place/time

(P), or is Unconscious (U)

•No focal neuro deficit

•Motor or sensory deficit

•Blood glucose: >3.5 mmol/L

• Blood glucose: <3.5 mmol/L

•Pupils: Enter size then reactivity.

•Large, pinpoint or unequal. Fixed,

NML/brisk, slow or nonreactive (NR) slow or nonreactive (NR)

Exposure: Detail ALL injuries (in space provided for physical exam) including

•tenderness •bony deformity •dislocation •amputation •crush injury

•ecchymosis/contusion •haematoma •vascular injury •laceration •abrasion

•burns •pulse deficit •oedema •motor or sensory deficit •foreign body

GCS Eye Opening 4 – Spontaneously 3 – To verbal command 2 – To pain 1 – No response GCS Verbal 5 – Talking and oriented 4 – Confused 3 – Inappropriate words 2 – Incomprehensible sounds 1 – No response

GCS Motor 6 – Obeys commands 5 – Localizes pain 4 – Withdraws to pain 3 – Flexes to pain 2 – Extends to pain 1— No response *Qualified GCS: Check box if patient sedated, intubated, or vision obstructed

MEDICAL HISTORY

Past Medical History: •DM •COPD •HTN •Psych •Renal disease •Other (list conditions not noted, eg. heart disease, stroke, asthma, sickle cell, active cancer, HIV/AIDS) Medication: include anticoagulants, traditional medicines, herbs, supplements

Tetanus status: Ask if up to date. Review card if available. Safe at home: Ask about violence in the home

HISTORY OF PRESENT ILLNESS

Place of injury: Note type of location where injury occurred, eg. home, school, highway, nursing home, restaurant, farm, factory, sports field Activity at time of injury: Note activity time of injury, eg. sports, leisure, working, attending school, in transit, sleeping First care sought: First source of care for this injury/illness, eg. clinic, traditional healer, etc. Prehospital care: Mark if care was provided at the scene of injury or prior to arrival at current facility; note any procedures performed Assaulted by (relationship between patient and assaulter): •Spouse or partner •Parent •Other relative •Unrelated caregiver • Friend or acquaintance(s) •Stranger(s) •Other Mechanism of injury (may use multiple mechanisms): If road traffic incident: Vehicle: •Cycles (bicycle, etc) •Motorised 2- or 3-wheeler •Other non-motorised vehicles •Car •Minibus (<10 seater), pick-up truck, van •Bus (≥10 seater) •Heavy transport vehicle (eg. truck, lorry) •Other
Hit by/crashed with: •Pedestrian •Animal •Cycles •Motorised 2- or 3-wheeler •Other non-motorised vehicle •Car •Train or railway vehicle •Minibus, pick-up truck, van •Bus, heavy cargo truck or lorry •Fixed or stationary object •Non-collision transport incident •Other When relevant, note: fall height, drowning with or without intent of being in the water, cause of burn (eg. electric, thermal, chemical), route of toxic exposure (ingestion, inhalation, cutaneous). “Other” mechanisms include: transport incident without road traffic (eg. boat, railway, air), animal bite/scratch, snake bite, electric/lightning injury, radiation exposure, explosive blast, exposure to nature, etc.

***NOTE: if more than one calendar is used in your setting by clinical providers and recorded as such on this form, all dates must be converted to Gregorian calendar and times converted to 24-hour format by data clerk before it is entered into registry.***

To be used as a reference for completing the trauma form.
www.who/int/emergencycare

NORMAL EXAM (Do NOT mark “NML” unless all elements below are normal)
General: Well-developed, well-nourished, awake, alert Neuro/Psychiatric: Oriented x3, cranial nerves (CN) intact, no focal weakness or sensory deficits HEENT: Normocephalic, atraumatic, pupils equal and reactive, ocular movements intact, conjunctivae normal Neck/C-spine: Trachea midline, neck supple, range of motion (ROM) nml Respiratory: Nml effort, nml breath sounds, nml expansion, atraumatic Cardiac: Nml rate and rhythm, strong pulses, nml sounds Abdominal: Soft and non-tender, bowel sounds nml Pelvis: Stable, no pain to palpation GU/Rectal: External genitalia nml, no blood at meatus, nml urine color, atraumatic, rectal tone, no rectal bleeding MSK: Range of motion nml, no deformities Skin: Warm, capillary refill < 3 sec, atraumatic
ABNORMAL EXAM FINDINGS (specify RIGHT or LEFT when needed, draw arrow from injury on diagram to descriptive text)

General: Distressed, malnourished, diaphoretic, uncooperative, sedated, lethargic Neuro/Psychiatric: Disoriented, cranial nerve deficit, sensory or motor deficit (RUE, LUE, RLE, LLE), abnormal gait or coordination, reflexes hypo or hyperactive, saddle anesthesia, no rectal tone HEENT: Unequal pupils, eye injury, bleeding from ears, skull fracture (open or closed), penetrating head/face injury, scalp haematoma, scalp/face laceration, signs of basilar skull fracture (Raccoon eyes/Battle’s sign, cerebrospinal fluid leak) Neck/C-spine: C-spine tenderness, palpable deformity/step off, haematoma, limited ROM, neck crepitation, active bleeding, penetrating injury, superficial injury Respiratory: Respiratory rate low or high, absent breath sounds, decreased breath sounds, crackles, wheezes, crepitation, transmitted upper airway sounds, paradoxical chest wall movement, sucking chest wound, penetrating injury, palpable rib fracture, superficial injury Cardiac: Distant heart sounds, systolic or diastolic murmur, abnormal pulse, S3 or S4 gallop, irregular heartbeat, bradycardia, tachycardia, asymmetric pulses Abdominal: Distension, tenderness, rebound, tense/guarding, evisceration, mass, penetrating abdominal injury, abnormal bowel sounds, superficial injury If pregnant - no fetal heart rate Pelvis: Unstable, pain with palpation, superficial injury, penetrating injury GU/Rectal: Vaginal laceration, vaginal bleeding, penile laceration, priapism, blood at urethral meatus, high riding prostate, rectal bleeding, superficial injury, penetrating injury MSK: Joint swelling, joint dislocation, sprain or muscle/tendon injury, decreased ROM or strength, extremity deformity/closed fracture, open fracture, crush injury, compartment syndrome, amputation Skin: Superficial laceration, deep laceration, ecchymosis, abrasion, burn, foreign body, overlying infection if presentation delayed

DIAGNOSTIC TESTS: UPT (urine pregnancy test), Hgb (hemoglobin), Blood type •Other: list lab study (eg. PT/INR, PTT, CK, lactate, electrolytes, lipase) and write result •List imaging studies done with results (or use tick boxes). If study needed but not available, write this in other.

INTERVENTIONS (if no interventions, write NONE) Fluids/Medications: list Blood product type (eg. PRBC, platelets) and number of units, write medication name/dose in appropriate category if applicable (eg. Opioid Analgesia: Morphine 4 mg) •Other: Vasopressors, post-intubation gtt, etc. Procedures: list number of attempts, location, and outcome for each procedure, if applicable •Other: Diagnostic peritoneal lavage, regional block, central line placement (if not noted in “Circulation” section), suprapubic catheterization, cricothyroidotomy, foreign body removal, etc.

ASSESSMENT & PLAN: include summary & differential diagnosis, plan for further imaging, pain meds, consults REASSESSMENT: Time, vital signs, and clinical condition at the time of disposition

DISPOSITION: Write date and time of ED departure, updated vital signs (VS), check box for destination Checklist Completed: Use WHO trauma checklist to verify tasks have been completed

DIAGNOSIS: List ALL injuries including sprains, fractures, lacerations, burns, contusions, etc. Include shock, respiratory failure, AMS if relevant

Number of serious injuries as judged by provider: Circle number (0, 1, ≥2)

Admit or Transfer: Write the name of the accepting provider for all handovers.

Discharge: Confirm if plan was discussed with patient including follow-up care

Death: Specify cause of death, but DO NOT WRITE cardiac or respiratory failure/arrest. Instead, use precise terms such as “external haemorrhage secondary to road traffic accident” or “drowning” or “suicide.”

Document all providers engaged in the patient’s care including through shift handovers.

***NOTE: if more than one calendar is used in your setting by clinical providers and recorded as such on this form, all dates must be converted to Gregorian calendar and times converted to 24-hour format by data clerk before it is entered into registry.***

To be used as a reference for completing the trauma form.
www.who/int/emergencycare

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Reference Card for WHO Emergency Unit Form Trauma