Trauma Proforma

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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:	No CT chest indicated Proceed to CT abdo/pelvis if needed
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
Thoracic 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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Trauma CT reporting Pro Forma