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The Standard Trauma Survey. Written in the negative to minimize the amount of editing required. Strongly recommended to BOLD AND ALL CAPS POSITIVE FINDINGS to make it stand out from the copypasted negatives. Consider a tertiary survey (repeated secondary survey) for more high mechanism patients in 12-24 hours.

Focused Trauma History
Allergies / ADT:
Medications:
Past MHx:
Last ate/drank:
Etiology / Mechanism:

A cervical collar was/wasn’t applied.

Primary Survey
A: intact. Maintaining airway. No stridor. No abnormal upper airway sounds.
B: Nil SOB / WOB. Speaking full sentences. Saturating well on room air.
C: Warm and well perfused. Maintaining MAP > 70. Not tachycardic or hypotensive.
D: Compos Mentis. E4V5M6. Cooperative with examination.
E: No significant environmental exposure. Not hypothermic/hyperthermic.

Log Roll:
Neck examined with manual stabilization by RN _________
No bruises or penetrating injuries to back.
No midline tenderness.
No paravertebral tenderness.
Sensation intact and equal to sacral dermatomes / perianal region.
Normal voluntary anal contraction.

Secondary Survey
Head:
No haematomas. No breaks in skin
No focal bony tenderness on head / face.
Battle’s sign negative. No subconjunctival haemorrhage. No periorbital ecchymosis.
No discharge from nose. No septal haematoma.
No otorrhoea.
No acute injury to oral cavity / dentitian noted.
PEARL
Patient reports normal vision. Able to read small font text with each eye uneventfully.
No diplopia or pathological nystagmus.
No facial droop.

Abdomen soft to all four quadrants.

Chest:
Equal AE bilaterally to apices and bases posterolaterally (examined supine)
Not tender on rib spring. Denies pleuritic CP on deep inspiration.

Limbs
No pain on hip roll.
Normal ROM in UL and LL bilaterally. Denies pain on movement.
No joint line tenderness in UL or LL.

Pelvis:
No pain on pelvic spring.
Hip/groin not tender.

Special Tests:

eFAST:
No pericardial, pleural, abdominal free fluid.
No PTx

Canadian CT Brain Decision Rule:
Confirmed No high risk reatures for neurological intervention
— Alert after injury (not GCS < 15 2h afterwards)
— No suspected open or depressed skull fracture
— No signs BOS # (periorbital ecchymosis, haemotympanium, battle’s sing, CSF otorrhea/rhinorrhea)
— No vomiting more than once.
— Age < 65yo
Confirmed No medium risk features:
— No retrograde amnesia > 30 mins
— no dangerous mechanism (ped vs car. fall > 3 ft. ejected from vehicle)

Confirmed Canadian CT Head Rule is applicable
— Patient involved in head trauma: YES
— GCS 14-15: YES
— Age > 16: YES
— Not on anticoagulation. No bleeding disorders
— No obvious open skull fracture

Canadian CT Neck Decision Rule:
Rule is applicable as pt is GCS 15 and >16yo, and pt does not have exclusion criteria: neck surgery / ankylosing spondylitis / previous neck injury

1. There were no high risk factors that mandate imaging.
   — It was not a high mechanism injury
   — — (>100km/h, fall > 3ft or 5 stairs, axial loading, rollover or ejection, motorized recreational vehicle)
   — Patient is < 65yo
   — No altered sensation or parasthesias in any limb.
2. In addition to the above, at least one of the following low risk factors are present:
   — Simple rear-end MVA
   — Ambulatory at any time at the scene
   — No neck pain at the scene
   — No midline c-spine tenderness.
3. As both above criteria were met, voluntary movement was assessed.
   — Patient is able to voluntarily actively rotate 45 degrees left and right when requested