Trauma Surgery Consult Note (ED/Inpatient)

Date/Time of Evaluation: [Date and time of trauma surgery evaluation]

Location: [ED / trauma bay / ICU / floor]

Requesting Service and Clinician: [Requesting service] — [Clinician name and role]

Patient Identifiers: [Age], [Sex], [Weight in kg] (Include weight if pediatric.)

Mechanism Category: [blunt / penetrating / burn / blast / other]

Trauma Activation Status: [None / consult only / Level I / Level II / Level III], arrival time [time] (Include arrival time only if activation occurred.)

Reason for Consult

[Single-sentence statement naming the requester, the specific consult question, and the urgency level: routine/urgent/emergent.]

History of Present Illness

[Narrative HPI of 3–8 sentences summarizing mechanism, time of injury, current physiologic condition, chief complaints, and immediate life threats addressed.] (If history is limited due to intubation, sedation, or altered mental status, explicitly state the limitation and list collateral sources used: EMS, family, outside hospital records, or chart review.)

Mechanism of Injury

(Include only elements relevant to the described mechanism; omit non-applicable items.)

• Time/Date of Injury: [Time and date]
• Scene Details: [Pertinent scene context and environment]
• MVC-specific: [Approximate speed], [intrusion], [ejection/rollover], [restraint status], [airbag deployment], [extrication required], [vehicle type]
• Fall-specific: [Height], [landing surface], [head strike], [loss of consciousness]
• Penetrating-specific: [Weapon type if known], [number of wounds], [estimated range]
• Burn-specific: [Enclosed space exposure], [inhalation concern], [chemical involvement]
• Protective Equipment: [Helmet / seatbelt / body armor / none / unknown]

Prehospital Care

• Vitals and Trends: [Prehospital vital signs and trends]
• Interventions: [Tourniquet, needle decompression, airway management, pelvic binder, TXA, fluids/blood products, other]
• Neurologic Status: [Loss of consciousness], [seizures], [reported GCS]

AMPLE History

(Use placeholder text such as "Unknown" or "Unobtainable" if information is unavailable.)

• Allergies: [Drug/food/environmental allergies or "Unknown" or "NKDA"]
• Medications: [Current medications] (Explicitly note anticoagulants, antiplatelets, insulin, chronic opioids if present.)
• Past Medical/Surgical History: [Relevant conditions and prior surgeries] (Emphasize bleeding risk, cardiopulmonary risk, prior abdominal surgery.)
• Last Oral Intake: [Time of last PO intake]
• LMP/Pregnancy: [LMP date or pregnancy status] (Include when relevant.)
• Events/Environment: [Events surrounding injury]

Focused Review of Systems

[Trauma-relevant symptoms: headache, neck pain, chest pain, shortness of breath, abdominal pain, pelvic pain, extremity pain, numbness, weakness] (Include only if obtained from patient; if unobtainable, state reason and omit symptom list.)

Objective

Vital Signs

• Initial Vitals: [BP], [HR], [RR], [SpO2], [Temp]
• Current Vitals: [Current values with trends if unstable]
• Oxygen Support: [Room air / nasal cannula / face mask / HFNC / mechanical ventilation with settings]
• Hypothermia Risk: [Temperature status and warming measures if applicable]

Primary Survey (ABCDE)

• Airway & C-spine: [Airway patency], [adjuncts], [intubation status], [cervical collar]
• Breathing: [Work of breathing], [breath sounds bilaterally], [chest wall stability], [SpO2]
• Circulation: [Pulse quality/rate], [skin perfusion], [active bleeding sites], [hemorrhage control measures], [response to resuscitation]
• Disability: GCS [score] (E[x]V[x]M[x]), pupils [size/reactivity], [gross focal deficits]
• Exposure: [Full exposure completed], [hypothermia prevention measures]

Secondary Survey

(If abbreviated due to instability or emergent OR, explicitly document what was deferred and why.)

• Head/Face: [Findings]
• Neck: [Findings]
• Chest: [Findings]
• Abdomen/Flanks: [Findings]
• Pelvis: [Findings and stability]
• Back/Spine: [Findings] (Note if logroll performed.)
• Extremities: [Each limb: deformity, tenderness, neurovascular status]
• Neurologic: [Motor and sensory exam]
• Wounds: [Location with laterality], [size], [depth], [contamination], [bleeding status] (Describe each wound separately using anatomic landmarks.)

Lines, Tubes, and Devices

[ETT size/depth], [NGT/OGT], [chest tube(s) with side and output], [Foley with urine character], [vascular access with locations], [pelvic binder], [splints] (Include only devices present; omit section if none.)

Diagnostics

(Document key results informing management. Distinguish "my interpretation" from "radiology interpretation" when independently reviewed. For outside hospital imaging, state whether images or only reports were reviewed.)

• FAST/eFAST: [Results by window: RUQ, LUQ, pelvis, pericardial, thoracic] [Technical limitations if any]
• Labs: [Hemoglobin], [lactate], [base deficit], [coagulation studies], [type and screen], [trends] (Include brief interpretation of abnormal values.)
• Imaging: [Modality], [key findings], [management implications]

Assessment

[One-sentence trauma summary: mechanism + key injuries + physiologic status + current trajectory]

(List injuries and problems in order of severity: immediate life threats first, then time-sensitive operative injuries, then limb/organ threats, then remaining issues.)

1. [Problem 1]: [Working diagnosis] — [Key supporting evidence] — [stable / unstable], [improving / worsening]
2. [Problem 2]: [Working diagnosis] — [Key supporting evidence] — [Status]
3. [Problem 3]: [Continue for all injuries and supportive care issues]

Plan

Global Trauma Management

• Resuscitation: [Strategy], MTP [activated / not indicated], [TXA/calcium if applicable]
• Monitoring: [Level of care: ICU / stepdown / floor], [hemodynamic monitoring]
• Airway/Ventilation: [Airway plan and ventilator recommendations if applicable]
• Serial Examinations: [Abdominal / neurologic / compartment checks] q[frequency]
• Temperature: [Warming measures and targets]
• Spine Clearance: [Clinical vs imaging pathway and current status]

Injury-Specific Plans

(For each injury from Assessment, document disposition and recommendations. Omit subsections that do not apply.)

[Injury/Problem 1]

• Disposition: [Operative / IR / Nonoperative] — [Rationale tied to hemodynamics, imaging, exam, comorbidities]
• Recommendations: [NPO status], [antibiotics with agent/indication/duration], [DVT prophylaxis: start / hold with reasoning], [activity/weight-bearing], [follow-up imaging with timing and triggers], [consults with specific questions], [pain management], [wound care]
• If Operative: [Proposed procedure], [indication and urgency], consent [obtained / emergency / surrogate needed], [preoperative optimization: reversal agents, antibiotics, tetanus, warming]
• If Nonoperative: [Monitoring location], [escalation triggers: vital sign thresholds, transfusion triggers, exam changes], [reassessment schedule], [discharge criteria]

[Injury/Problem 2]

• [Plan as above]

Tertiary Survey

[Plan for tertiary survey completion with timing; note if repeat assessment needed when patient becomes reliable] (Include only if trauma surgery is admitting or following the patient.)

Communication

• Recipients: [Names and services informed of recommendations]
• Method: [In person / phone / EHR message]
• Response: [Acknowledgment and acceptance of plan]
• Pending Items: [Awaiting radiology final read], [repeat labs at specified time], [serial exams], [other pending tasks with responsible party]

(When information is unavailable, include placeholder text indicating the limitation rather than omitting the section. Do not infer mechanism details, intoxication status, or circumstances not directly documented. Reflect degree of certainty when documenting clinical interpretation. Omit entire sections that do not apply to the specific consult.)