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Trauma CT reporting Pro Forma

Acute Primary Assessment Report for Paediatric CT

with Major Trauma

 

Patient Name

 

Patient Number

 

Date of Scan

 

 

To guide initial management only. A formal report will follow. The trauma team will be notified of any major alterations to this primary assessment

 

Primary Assessment Trauma Plain Films (for stable children)

Cervical Spine    

Normal

No CT C-spine indicated

Abnormal / Clinical suspicion

CT C-spine required

                                   

Chest X-Ray

Normal

No CT chest indicated

Proceed to CT abdo/pelvis if needed

Abnormal / Clinical suspicion

CT TAP required

 

           

CT Scanning Preliminary Review

Airway:

ET placement

N/A

Satisfactory

Unsatisfactory

Airway obstruction

Yes

No

 

Breathing:

Contusion

Yes

No

Laceration

Yes

No

Pneumothorax

Yes

No

Chest drain placement

N/A

Satisfactory

Unsatisfactory

       

 

Circulation (bleeding):

Pericardial effusion

Yes

No

Thoracic injury

Yes

No

Abdominal injury

retroperitoneal

Yes

No

 

visceral

Yes

No

Pelvic injury

Yes

No

Soft tissue

Yes

No

 

Disability:

Intracranial bleed/oedema

Yes

No

Major spinal injury (cord compromise)

Yes

No

 

Comments:

 

 

 

 

 

 

Radiologist Name

 

Time