Trauma Activation (Resuscitation) Note

(Trauma Activation/Resuscitation note intended to complement the nursing trauma flow sheet. Focus on clinical synthesis, decision-making, and key time-stamped events; do not duplicate granular flow sheet data. Use explicit timestamps for key events. If information is unavailable, use "Unknown" or "Unable to obtain.")

Date/Time: [Encounter date and time]

Patient: [Name, MRN, DOB] (If identity unknown, use "Unknown [male/female], estimated age [X]" and include trauma alias if assigned.)

Trauma Activation Level: [Level 1 / Level 2 / Consult / per local protocol]

Arrival Mode: [EMS / air medical / private vehicle / interfacility transfer]

Author/Role: [Author name and role] (Include supervision status if applicable.)

Pre-Arrival and Activation

• EMS/transfer notification: [Time received]
• Trauma team activated: [Time and level]
• Patient arrival: [Time to trauma bay]
• Team leader at bedside: [Time; name/role if applicable]

Activation criteria met: [Physiologic / Anatomic / Mechanism / Provider judgment] (List specific criteria. If unclear, state: "Activation criteria not documented; activation per ED/EMS communication.")

Activation level change: [Original level] → [Revised level]; [Reason] (Omit if not applicable.)

Prehospital Report

(Summarize EMS or transferring facility report. If history limited, state the reason and primary source.)

• Mechanism of injury: [Mechanism with key details relevant to injury prediction] (For MVC: speed, restraints, airbags, intrusion, ejection, extrication time. For falls: height, landing surface. For penetrating: weapon type, number/location of wounds.)
• Estimated time of injury: [Date/time or window]
• Prehospital vitals trend: [BP/HR/SpO2/RR trends; note hypotension, tachycardia, hypoxia]
• Neurologic status: [GCS components E/V/M and trend] (Note confounders: sedation, paralysis, intoxication.)
• Major exam findings: [Key findings suggesting injury or shock]
• Prehospital interventions: [Airway management; hemorrhage control (tourniquet site/time, pelvic binder, hemostatic dressings); IV/IO access and sites; fluids/blood products with volumes; medications with doses; immobilization]
• Interfacility transfer details: [Key events at referring facility; interventions performed; hemodynamic course; imaging obtained and whether available for direct review vs report only] (Include only for transfers.)

Arrival Status

[One-sentence synthesis of presentation capturing mechanism and physiologic status]

• Initial vitals: [Values with timestamp] (Or reference nursing flow sheet with location.)
• Mental status/GCS: [E/V/M components] (Note confounders.)
• Pupils: [Size/reactivity/symmetry]
• Airway status: [Patent / at risk / intubated; adjuncts in place]
• External hemorrhage: [Present/controlled/none; sites and control measures]
• Unable to assess on arrival: [Items and reasons] (Omit if all assessments completed.)

Primary Survey and Resuscitation

(Organize findings, interventions, and responses under ABCDE. Document reassessment after major interventions.)

Airway/C-spine

• Findings: [Airway patency; protective reflexes; vomitus/blood; C-spine precautions status]
• Interventions: [Airway maneuvers/suction/adjuncts/intubation] (If intubation performed: indication, method, medications, confirmation with capnography, ETT size/depth, complications.)
• Response: [Post-intervention status] (Include rationale if airway intervention deferred.)

Breathing

• Findings: [Work of breathing; chest rise symmetry; breath sounds; tracheal position; SpO2 trend]
• Interventions: [Oxygen/ventilation; needle decompression; chest tube with side/size/time]
• Ventilation (if intubated): [Mode/FiO2/PEEP; ETCO2]
• Response: [Physiologic/clinical response]

Circulation

• Findings: [Perfusion (pulses/skin); BP/HR trends; signs of shock]
• Access: [IV/IO/central line type, site, time]
• Resuscitation: [Crystalloid/blood products with units and times] (Note use of uncrossmatched blood.)
• MTP (if activated): [Activation time]; [Trigger]; [Products by type]; [Termination time/reason]
• FAST/eFAST: [Windows obtained]; [Interpretation]; [Limitations]
• Pelvis/long bones: [Pelvic stability; binder status]; [Long bone deformities; splinting; pulses/compartments]
• Response: [Hemodynamic response to interventions]

Disability

• GCS: [E/V/M] (Note confounders: sedation/paralysis/intoxication.)
• Pupils: [Size/reactivity/symmetry]
• Lateralizing signs: [Present/absent]
• Glucose: [POC value/time if indicated]

Exposure

• Exposure/log roll: [Fully exposed; log roll performed] (If not performed, state reason.)
• Temperature: [Value/time]; [Hypothermia prevention measures]
• Injuries identified: [Findings on exposure]

Reassessment: [Key reassessments after major interventions and outcomes]

Secondary Survey

(If deferred for OR/ongoing resuscitation, document what was assessed, reason for deferral, and plan for tertiary survey.)

• AMPLE history:
  • Allergies: [Listed / Unknown] (State source; never infer.)
  • Medications: [Listed / Unknown] (Emphasize anticoagulants/antiplatelets; state source.)
  • Past medical history: [Relevant conditions / Unknown]
  • Last meal: [Time / Unknown]
  • Events: [Circumstances surrounding injury / Unknown]
• Head/Face: [Findings / Not assessed]
• Neck: [Findings / Not assessed] (Tracheal alignment, wounds, tenderness.)
• Chest: [Findings / Not assessed]
• Abdomen: [Findings / Not assessed]
• Pelvis: [Stability/tenderness; binder status]
• Perineum/GU: [Blood at meatus; perineal hematoma; gross hematuria / Not assessed]
• Back/Spine: [Log-roll findings / Not assessed]
• Extremities: [Deformities; pulses; compartments; motor/sensory]
• Neurologic: [Focal deficits; overall assessment] (Note confounders.)
• Deferred elements: [Items deferred; reason; plan for completion] (Omit if survey complete.)

Procedures

(For each procedure performed in trauma bay. Reference separately documented procedure notes when applicable.)

• [Procedure]; [Indication]; [Time]; [Operator/supervision]; [Technique summary]; [Confirmation of success]; [Complications or "none"]; [Time-out performed / Emergent—time-out not feasible]

Labs and Imaging

• Critical labs: [VBG/ABG with lactate, base deficit]; [Hemoglobin]; [Coags: INR, fibrinogen, platelets]; [TEG/ROTEM if used]; [Type & screen status] (Include timestamps. Toxicology only if clinically relevant.)
• Imaging: [Modality/regions]; [Key actionable findings]; [Preliminary vs final] (If deferred, state reason. For transfers, note direct image review vs report only.)
• Pending: [Studies pending and responsible clinician for follow-up]

Trauma Bay Course

(Chronological summary of significant events, reassessments, and escalations.)

• [HH:MM]—[Event/intervention and response]
• [HH:MM]—[Reassessment/vitals change/exam change]
• [HH:MM]—[Imaging result/consultant input]
• [HH:MM]—[Escalation: MTP/OR/IR activation]

Assessment

(List injuries in order of physiologic threat. Avoid overclaiming certainty when imaging incomplete.)

• Confirmed: [Injury] (basis)
• Suspected: [Injury] (rationale; pending confirmation)
• Rule-out: [Injury] (mechanism-based concern; plan to exclude)

Severity statement: [Why high acuity: hemorrhagic shock/airway compromise/TBI concern/polytrauma]

Plan

(Organize by problem. Assign responsibility and timing for pending items.)

• Immediate destination: [OR / IR / CT / ICU] (Rationale.)
• Hemorrhage control: [Operative/IR/external measures; MTP plan]
• Ventilation/sedation: [Airway plan; ventilator settings; sedation strategy]
• Neuroprotection: [BP/SpO2 targets; head-of-bed; hyperosmolar therapy; seizure prophylaxis] (Include if TBI suspected.)
• Antibiotics/tetanus: [Indications and agents] (Include if indicated.)
• VTE prophylaxis: [Mechanical/chemical; timing]
• Consults: [Services; purpose; urgency]
• Imaging follow-up: [Pending studies; responsible clinician]

Consultations

• [Service]; [Time contacted]; [Responder]; [Key recommendations]
• Family notification: [Who contacted; when; information provided]
• Law enforcement/forensics: [Involvement and time] (If applicable; document without non-medical speculation.)

Disposition

• Destination: [OR / IR / CT / ICU / floor / transfer]
• Accepting service/attending: [Service; attending name]
• Level of care: [ICU / stepdown / floor]
• Condition at departure: [Hemodynamics; airway status; ongoing interventions]
• Departure time: [Time]
• Handoff: [Recipient name/role]
• Transfer details: [Receiving facility; transfer mode; stabilization performed] (Include only for transfers.)

Critical Care Time

(Include when critical care provided or required by local policy.)

• Total critical care time: [Minutes] (Exclude separately billable procedure time.)
• Justification: [Life-threatening condition requiring continuous re-evaluation]
• Attestation: [Attending presence and involvement] (Include for teaching encounters.)

(When exam elements are deferred, document what was assessed, reason for deferral, and plan for later completion. Omit sections entirely only if they clearly did not occur.)