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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

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