What are the essential steps to take before reporting a trauma case?

Essential Steps Before Reporting a Trauma Case

Before reporting any trauma case, you must systematically collect core data elements including patient demographics, injury mechanism and severity, vital signs and physiologic parameters, time intervals from injury to treatment, system factors (trauma team composition, facility capabilities), and outcome measures—all structured according to the Utstein-style uniform reporting template. 1

Core Data Collection Requirements

Patient-Specific Information

• Age, gender, body dimensions, and pre-existing co-morbidity status (graded ordinally from 1=healthy to 4=systemic illness posing constant threat to life) 1
• Mechanism of injury details: blunt versus penetrating, fall height, motor vehicle crash specifics, velocity of impact 1
• Injury severity scoring: Document using standardized systems like the Abbreviated Injury Score (AIS) or Injury Severity Score (ISS) 1

Physiologic Parameters at Presentation

• Vital signs: Blood pressure, heart rate, respiratory rate, oxygen saturation 1
• Level of consciousness: Glasgow Coma Scale score 1
• Evidence of shock: Serum lactate levels and base deficit should be obtained to estimate and monitor extent of bleeding and shock 1
• Hemodynamic status: Document response to initial resuscitation (rapid responder, transient responder, or non-responder) 1

Time Documentation

The Utstein template emphasizes precise temporal data using multiple "process clocks" 1:

• Time of injury occurrence
• Time of EMS dispatch and arrival at scene
• Time of departure from scene
• Time of arrival at receiving facility
• Time of definitive intervention (surgery, angiography, etc.)

System and Facility Factors

Trauma Team Composition

• Document the trauma team membership and their respective experience levels at the time of patient arrival 1
• Facility capabilities during the 24-hour period: Available surgical specialties, blood bank resources, imaging capabilities, ICU beds 1

Transfer Information

• Pre-hospital care provided: Interventions performed, fluids administered, airway management 1
• Inter-hospital transfer details if applicable: Reason for transfer, mode of transport, condition during transfer 1

Anatomic Injury Documentation

Specific Injury Patterns Requiring Urgent Notation

• Penetrating injuries, flail chest, two or more proximal long-bone fractures, crushed or mangled extremities, amputations, pelvic fractures, open or depressed skull fractures, and paralysis all require urgent review and documentation 2
• Intrusion measurements: Document vehicle intrusion including roof intrusion in motor vehicle crashes 1
• Ejection status: Partial or complete ejection from vehicle (complete ejection carries 27.4% risk of ISS >15) 1

High-Risk Patient Identifiers

Medical History Red Flags

• Anticoagulation therapy status: Patients on anticoagulation with trauma require urgent evaluation 2
• Pregnancy status: Pregnant patients >20 weeks with trauma need specialized assessment 2, 3
• Severe baseline cognitive impairment, advanced untreatable neuromuscular disease, metastatic malignancy, advanced immunocompromised conditions, severe irreversible neurologic conditions, or end-stage organ failure 2

Outcome Measures to Document

Mortality Data

• Time, date, and location of death 1
• Place of death confirmation 1
• Cause of death and adverse contributing factors 1

Morbidity Indicators

• All non-fatal problems leading from impairment to disability (both reversible and irreversible) 1
• ICU admission requirement 2
• Need for non-orthopedic surgery within 24 hours 1

Special Circumstances Requiring Additional Documentation

Pediatric Trauma Cases

• Screen for potential child abuse: Use protocols or screening tools to detect abuse and neglect, and be aware of state reporting requirements 1
• Document developmental stage and age-appropriate functional status 1

Violence-Related Trauma

• Screen specifically for domestic or intimate partner violence in all trauma cases 3
• Document fetal well-being carefully in cases involving violence, especially for legal purposes 3

Suspected Bioterrorism or Chemical Exposure

• Rapid identification of the offending agent 2
• Decontamination status 2
• Combined physical trauma and chemical intoxication details 2

Common Pitfalls to Avoid

• Never delay reporting to obtain "complete" data: Core data should always be obtained, but optional data collection should not delay clinical care or reporting 1
• Do not rely on single hematocrit measurements as an isolated laboratory marker for bleeding 1
• Avoid incomplete mechanism documentation: The mechanism of injury is a critical screening tool that must include specific details like fall height (>6 feet is critical), crash velocity, and direction of impact 1
• Never omit time intervals: Temporal data is essential for quality improvement and system evaluation 1