Gender |
Male, Female |
Age (in years at time of admission) |
… (option for ‘Unknown’) |
Mechanism of injury |
-
-
Road traffic collision (Pedestrian, Cyclist, Motorcyclist, Motorcyclist – passenger, Car – driver, Car – passenger, other type of vehicle – driver, other type of vehicle – passenger
-
-
Fall (standing height, from height)
-
-
Assault (without a weapon, blunt instrument, knife, firearm)
-
-
Other (Self Harm, Animal attack, Explosion, Sport/recreational activity, Industrial accident – that does not fit into the categories listed above, Other violence, Unknown, Other)
|
Date / time of injury |
… (option for ‘Unknown’) |
Date / time of admission to hospital where surgery is taking place |
… |
Was the patient directly transferred from the accident scene to the hospital where surgery is taking place? |
Yes, No |
Method of transport to the hospital where surgery is taking place |
Helicopter - air ambulance, Land ambulance - staffed by paramedics, Land ambulance - not staffed by paramedics. Police, Private vehicle, By foot, Other - specify |
American Society of Anaesthesiologists (ASA) Physical Status Classification |
I, II, III, IV, V |
Glasgow Coma Score on admission (or last documented GCS off sedation if sedated on admission) |
Total and Eyes, Verbal (‘T’ if intubated/tracheostomy), Motor (option for ‘Unknown’) |
|
Left |
Right |
Fixed and dilated pupil at any time point pre-operatively? |
|
|
Unreactive pupil at any point pre-operatively? |
|
|
Did the patient have an episode of hypoxia at any point prior to surgery? |
Yes, No, Not measured prior to surgery |
Did the patient have an episode of hypotension (systolic BP < 90 mmHg*) at any point prior to surgery? |
Yes, No, Not measured prior to surgery |
* Note that the lower limit of systolic BP differs for children with age according to the formula 90 + (2 × age in years) |
|
Major extra-cranial injury (defined as requiring hospital admission in its own right)? |
Yes, No |
Was a CT Head performed before the operation? |
Yes, No |