Make sure to list each injury by system. Review the injury list and confirm it matches the final imaging reads. Add each injury to the appropriate system assessment and plan and ensure that all injuries are consulted/dispo’d.
Ensure that home comorbidities are listed in the appropriate system and managed. Complete the admission medicine reconciliation.
Always obtain full set of labs and CXR on admission to the TICU.
In general ensure patients are resuscitated.
Start diet or tube feeds as soon as possible.
Start DVT ppx as soon as possible, it is only held for significant bleeding concerns, intracranial hemorrhage, neurosurgical or spine procedures. \

This is a $AGE year old $GENDER who presents on $DATE as a $ACTIVATION after $MECHANISM.
Trauma bay course remarkable for $COURSE

Injuries (by system)
Head:
Spine:
Chest:
Intraperitoneal:
Retroperitoneal:
MSK:

Consults:

Neuro
GCS in trauma bay:
GCS on arrival:

# Sedation
gtt:
sch:
prns:

# Pain
gtt:
sch:
prns:

Cardiovascular
MAP:
HR:
Pressors:
Trops:
EKG:
ECHO:

Respiratory
Vent settings:
ABG:
CXR:

GI/Nutrition
Diet:
NGT/OGT:
Bowel reg: Miralax BID

Renal
Fluids in trauma bay:
Monitor UOP
Foley:
Lactate:
BMP:
Mg/Phos:
Fluid status:
IVF:

Hematology
Tranfusions in trauma bay:
Hgb:
Platelets:

Infectious
Temp:
WBC:
Antibiotics:

Endocrine
BG on arrival:
Insulin:
POC BG Schedule:

MSK
PT/OT

PPx
DVT:
GI:

Access

Disposition
TICU