Trauma CT reporting Pro Forma
with Major Trauma
Patient Name |
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Patient Number |
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Date of Scan |
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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: |
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Radiologist Name |
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Time |
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