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Trauma diagnoses
Select one or more diagnoses
Polytrauma
Hemorrhagic shock
Thorax
Ribs/flail
Ptx/Htx
Abdomen
Pelvis
Long bone
TBI
Spine
Burns
🆔
Patient
▼
Medical ICU
Surgical ICU
Bed
♂
♀
Last name initial
First name initial
🏷️
Diagnoses
▼
Medical ICU
Sepsis/Shock
ARDS
Resp. failure
Pneumonia/VAP
Cardiogenic shock
Post-arrest
AKI
GI bleed
Pancreatitis
DKA/HHS
PE
Liver failure
Neurosurgical / Neuro ICU
TBI
SAH
ICH
Ischemic stroke
SDH
EDH
Post-craniotomy
Tumor/edema
Hydro/EVD
SCI
Trauma
No trauma diagnosis selected
📚
Past medical history
▼
No
Unknown
Known
Functional status
Bedridden
🧠
Neuro
▼
RASS
+4
+3
+2
+1
0
−1
−2
−3
−4
−5
GCS
Pupils
PERRL
Sluggish
Anisocoric
Non-reactive
Sedation
Propofol
Midazolam
Dexmedetomidine
Ketamine
Analgesia
Fentanyl
Sufentanil
Morphine
Remifentanil
🫁
Respiratory
▼
Airway
RA
NC
Mask
HFNC
NIV
ET
Trach
%
/min
ABG
mmHg
mmHg
mmol/L
mmol/L
Auscultation
Clear
Crackles
Wheeze
↓ L
↓ R
Secretions
Minimal
Moderate
Copious
Purulent
❤️
CVS
▼
/min
/
mmHg
mmHg
Rhythm
Sinus
S. tachy
AFib
A. flutter
Paced
Other
Catecholamines
No
Yes
Trend
↓ Weaning
→ Stable
↑ Escalating
Perfusion
Warm
Cool
Mottled
↑ CRT
Leg oedema
🍽️
GI / Nutrition
▼
Abdomen
Soft
Distended
Rigid
Tenderness
None
RUQ
LUQ
RLQ
LLQ
Diffuse
Bowel sounds
Normal
Hypoactive
Absent
Hyperactive
Stool
Passing
Constipated
Diarrhea
Melena
Nutrition
NPO
Enteral
TPN
Oral
Tolerating feeds
Yes
No
mL
Enteral access
NG
PEG
PEJ
💧
Renal / Fluids
▼
mL
mL/kg/h
mL/24h
mmol/L
mg/dL
mmol/L
AKI
No
Stage 1
Stage 2
Stage 3
🦠
Infectious Disease
▼
°C
×10⁹/L
mg/L
ng/mL
Infection trend
↓ Improving
→ Stable
↑ Worsening
Suspected source
Pneumonia
VAP
Urinary
Bloodstream
CLABSI
Intra-abd
Skin/STI
CNS
Microbiological results
Multiplex
Culture & sensitivity
🩸
Hematology
▼
g/dL
×10⁹/L
s
Anticoagulation
Prophylactic
Therap. heparin
Therap. LMWH
DOAC
Held
Transfusion (last 24h)
PRBC
FFP
Plt
Cryo
🧬
Endocrine
▼
mmol/L
Glycemic control
In range
Hyper
Hypo
Labile
Insulin
None
Sliding scale
Infusion
Other
Hydrocortisone
Thyroid Rx
DKA
🩹
Skin
▼
Skin condition
Intact
Pressure injury
Surgical wound
Rash
Edema
Jaundice
Mobilization
Bed rest
Passive ROM
Sitting up
Bed-to-chair
Ambulating
🔌
Lines & Devices
▼
📋
Plan
▼
Trajectory
↓ Improving
→ Stable
↑ Deteriorating
Today's plan