Asociación Ayuda Enfermo Neuroquirúrgico (AAEN)

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Informant:

Mode of Arrival:

Mode of Arrival Other:

Education:

Occupational Status:

Income:

Marital Status:

Injury Details

Date of Injury:

Time of Injury:

Injury Duration:

History of Major Injury

History of Major Injury Specify:

Mass Casuality

Mass Casuality Specify:

Time Elapsed Hospital Admission:

Reason For Delay:

Reason For Delay Other:

Air Bag

Seat Belt

Driving License

Helmet Use

Helmet Fastening

Helmet Make:

Cause of Injury:

Cause of Injury Other:

Type of Vehicle:

Vehicle Crash Pattern:

Incident Victim:

Incident Victim Other:

Dominant Type of Injury:

Dominant Type of Injury Other:

Mechanism of Injury:

Injury Examination

External Bleeding

Body Regions Involved:

Body Regions Involved Other:

Any Life Threatening Injuries:

Any Life Threatening Injuries Other:

Minor Injury:

Moderate Injury:

Serious Injury:

Severe Injury:

Critical Injury:

Maximum Injury:

Blood Investigations

Hemoglobin:

Total Leukocyte Count:

Blood Sugar Random:

Blood Sugar Fasting:

Blood Sugar PP (Postprandial):

Hematocrit:

Platelets:

Blood Group:

Sodium:

Potassium:

Creatinine:

BUN (Blood Urea Nitrogen):

pH:

HCO3 (Bicarbonate):

pCO2 (Partial Pressure of Carbon Dioxide):

pO2 (Partial Pressure of Oxygen):

Arterial Base Excess:

Lactate:

Urine Pregnancy Test:

Prothrombin Time:

INR:

Troponin C:

ECG

Date of ECG:

Time of ECG:

ECG 12 Leads

ECG Results:

Rhythm:

Conduction:

Conduction Other:

QRS ST Complex:

QRS ST Complex Other:

QT Interval:

ECG Impression:

Echocardiography

Ejection Fraction:

Regional Wall Motion Abnormality:

Pre-hospital Care

Resuscitation

Arrive From Injury Site

Protective Equipment:

Highest Level Pre-hospital Care:

Highest Level In-hospital Care:

Mortality:

Emergency Management

Arrival Time ER:

Left Time ER:

Time To ER:

Time In ER:

Date of Admission:

Time of Admission:

Date of Discharge:

Hospital Stay:

Attempt To Control Bleeding

Method Used To Control Bleeding:

Basic Life Support Given

Brought Dead

Pre-hospital Cardiac Arrest

Prehospital Airway Management

Fluids At Scene

Activation Of Trauma Team

Trauma Team Activated:

Airway:

Breathing:

Circulation:

Airway Management:

Discharge Destination ER:

Discharge Destination ER Other:

Disposition From Emergency:

Disposition From Emergency Other:

Conservative Management

Conservative Management:

Days on Ventilator:

Surgical Management

Date of Surgery:

ICP Monitoring

Intracranial Surgery

Extracranial Surgery

Any Re-Surgery

Cranial Surgical Intervention:

Cranial Surgical Intervention Other:

Extracranial Surgical Intervention:

Extracranial Surgical Intervention Other:

Hypotension Episode

Hypoxia Episode

Infections

Deep Vein Thrombosis

Other Organ Damage

Other Organ Damage Specify:

Diagnosis and Outcome

ICD-10:

ICD-10 Other:

Outcome at Discharge

Survival Status at Discharge:

Discharge Destination (Hospital):

Discharge Destination (Hospital) Other:

Follow Up

Disability Eye Opening (Discharge):

Disability Eye Opening (3 Months):

Disability Eye Opening (6 Months):

Disability Communication (Discharge):

Disability Communication (3 Months):

Disability Communication (6 Months):

Disability Motor Response (Discharge):

Disability Motor Response (3 Months):

Disability Motor Response (6 Months):

Disability Feeding (Discharge):

Disability Feeding (3 Months):

Disability Feeding (6 Months):

Disability Toileting (Discharge):

Disability Toileting (3 Months):

Disability Toileting (6 Months):

Disability Grooming (Discharge):

Disability Grooming (3 Months):

Disability Grooming (6 Months):

Disability Level Functioning (Discharge):

Disability Level Functioning (3 Months):

Disability Level Functioning (6 Months):

Disability Employability (Discharge):

Disability Employability (3 Months):

Disability Employability (6 Months):

Neurotrauma Data Form

Neurotrauma Data Form

Services

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