What should be included in the ER notes for a patient with a head injury from a road traffic accident?

Comprehensive ER Notes for Head Injury from Road Traffic Accident

ER notes for a patient with head injury from a road traffic accident should include detailed documentation of the primary and secondary assessments, diagnostic findings, interventions, and monitoring parameters to ensure optimal patient outcomes and reduce mortality and morbidity.

Initial Assessment and Documentation

Patient Demographics and Mechanism of Injury

• Patient identification information
• Date and time of arrival
• Mechanism of injury (specific details of the road traffic accident)
• Pre-hospital care provided
• Time of injury

Primary Survey Documentation

• Airway assessment and interventions 1

  • Airway patency status
  • Interventions performed (oral airway, intubation)
  • Cervical spine immobilization status

• Breathing assessment 1, 2

  • Respiratory rate and pattern
  • Oxygen saturation
  • End-tidal CO₂ measurements if intubated
  • Ventilator settings if applicable (target PaO₂ ≥ 13 kPa, PaCO₂ 4.5-5.0 kPa)

• Circulation assessment 1, 2

  • Blood pressure readings (target SBP >110 mmHg, MAP >80 mmHg)
  • Heart rate and rhythm
  • Peripheral perfusion status
  • IV access established (type, size, location)
  • Fluid resuscitation details
  • Vasopressor use if applicable

• Disability (Neurological) assessment 1

  • Glasgow Coma Scale score (detailed components)
  • Pupillary size, symmetry, and reactivity
  • Motor responses in all extremities
  • Focal neurological deficits
  • Seizure activity if present

• Exposure/Environmental control

  • Temperature measurement
  • Complete secondary survey findings
  • Evidence of other injuries

Secondary Assessment Documentation

Detailed Neurological Examination

• Serial GCS assessments with timestamps 1
• Cranial nerve examination findings
• Motor and sensory examination
• Reflexes
• Signs of basilar skull fracture (hemotympanum, Battle's sign, raccoon eyes, CSF rhinorrhea/otorrhea)

Associated Injuries

• Other traumatic injuries identified
• Vital signs trending
• Fluid balance (input/output)

Diagnostic Studies Documentation

Imaging Results

• CT brain and cervical spine findings 1, 2

  • Presence of intracranial hemorrhage (epidural, subdural, subarachnoid, intraparenchymal)
  • Skull fractures
  • Midline shift
  • Cerebral edema
  • Cervical spine injuries

• Additional imaging results if performed

  • CT angiography findings
  • Chest/abdominal CT findings in polytrauma

Laboratory Results

• Complete blood count
• Coagulation profile
• Electrolytes
• Blood gas analysis
• Toxicology screen if indicated
• Blood alcohol level if indicated

Interventions and Management

Airway Management

• Details of intubation if performed (medications used, grade of view)
• Ventilation parameters 1
• Head elevation status (20-30° head-up tilt)

Medication Administration

• Sedation and analgesia details 1

  • Agents used (propofol, fentanyl, etc.)
  • Dosages and timing

• Neuromuscular blockade if used 1

• Anticonvulsant therapy if administered

• Mannitol or hypertonic saline administration for suspected raised ICP

Hemodynamic Management

• Fluid therapy details
• Vasopressor/inotrope use and titration
• Blood product administration if applicable

Monitoring and Ongoing Assessment

Vital Signs Monitoring

• Frequency of vital sign checks
• Trends in vital parameters
• Response to interventions

Neurological Monitoring

• Serial neurological assessments
• Transcranial Doppler findings if performed 1
• Signs of increased intracranial pressure

Disposition Planning

Consultation Documentation

• Neurosurgical consultation details and recommendations
• Other specialist consultations

Transfer Information (if applicable)

• Reason for transfer to neurosurgical center 1
• Mode of transport
• Accompanying personnel
• Receiving facility information
• Pre-transfer stabilization measures

Admission Details

• Admitting service
• Level of care (ICU, ward)
• Key concerns for ongoing management

Treatment Plan and Orders

Immediate Orders

• Medications (analgesics, anticonvulsants, antibiotics if indicated)
• Fluid orders
• Monitoring parameters
• Nursing instructions
• Neurosurgical intervention plan if needed

Prevention of Secondary Injury

• DVT prophylaxis plan
• Stress ulcer prophylaxis
• Seizure prophylaxis if indicated
• Normothermia maintenance plan
• Glycemic control measures

Common Pitfalls to Avoid in Documentation

• Failure to document serial GCS assessments
• Incomplete documentation of pupillary responses
• Missing documentation of secondary insults (hypoxia, hypotension)
• Inadequate documentation of timing of events and interventions
• Failure to document neurosurgical consultation and recommendations
• Incomplete documentation of pre-hospital events and care

Follow-up Plan

• Frequency of neurological reassessments
• Timing of repeat imaging
• Criteria for neurosurgical intervention
• Family notification status

By including all these elements in ER notes for head injury patients from road traffic accidents, healthcare providers ensure comprehensive documentation that facilitates optimal patient care, appropriate decision-making, and continuity of care across the treatment team 1, 2.