Mode of arrival: --------- Self Private Vehicle Ambulance/108 staff Police/Firefighters Rescuers Bystanders/Neighbours Relatives Others (Please specify)

Education: --------- Profession or Honours Graduate or Postgraduate Intermediate or post high school diploma High school certificate Middle school certificate Primary school certificate Illiterate

Occupational status: --------- Legislators, senior officials, and managers Professionals Technicians and associate professionals Clerks Skilled workers and shop and market sales workers Skilled agricultural and fishery workers Craft and related trade workers Plant and machine operators and assemblers Elementary occupation Unemployed

Income: --------- >20,482 10,241-20,481 7681-10,240 5120-7680 3072-5119 1034-3071 <1033

Marital status: --------- Married Never married Divorced

Loss of consciousness: --------- Yes No

Loss of consciousness duration: --------- Less than one minute Less than 30 minutes Less than an hour 1-24 hours 1-7 days More than 7 days

Vomiting: --------- Yes No

Nausea: --------- Yes No

Ear bleed: --------- Yes No

Nasal bleed: --------- Yes No

Oral bleed: --------- Yes No

Headache: --------- Yes No

Seizures: --------- Yes No

Rhinorrhea: --------- Yes No

Otorrhoea: --------- Yes No

Post traumatic amnesia: --------- Yes No

Lucid interval: --------- Yes No

Diabetes: --------- Yes No

Hypertension: --------- Yes No

Smoking: --------- Yes No

Tobacco smokeless: --------- Yes No

Illicit drug use: --------- Yes No

Anti platelet agents aspirin: --------- Yes No

Clopidogrel: --------- Yes No

Oral contraceptives: --------- Yes No

Sedatives: --------- Yes No

Anticonvulsants: --------- Yes No

Other history:

Post traumatic amnesia duration: --------- PTA less than 5 minutes PTA between 5-60 minutes PTA between 1-24 hours PTA between 1-7 days PTA greater than 7 days

Influence of alcohol: --------- Yes No

Breath analyser used: --------- Yes No

Blood alcohol levels done: --------- Yes No

Influence of drug: --------- Yes No

Blood levels done: --------- Yes No

Asa ps: --------- ASA-PS 1. A normal healthy patient ASA-PS 2. A patient with mild systemic disease ASA-PS 3. A patient with severe systemic disease ASA-PS 4. A patient with severe systemic disease that is a constant threat to life ASA-PS 5. A moribund patient who is not expected to survive without an operation ASA-PS 6. A declared brain-dead patient whose organs are being removed for donor purposes Unknown

Date of injury: --------- DD:MM:YYYY

Time of injury: --------- HH:MM (24 hours format)

Injury duration: --------- HH:MM (24 hours format)

History of major injury last 12 months: --------- Yes No If yes, please specify

Mass causality more than 10 persons: --------- Yes No If yes, please specify

Time elapsed from injury to hospital admission: --------- Delayed in ED Transfer from other hospital Distance to hospital from place of injury No transport facility Sought traditional treatment Other please specify

Reason for delay in admission: --------- Delayed in ED Transfer from other hospital Distance to hospital from place of injury No transport facility Sought traditional treatment Other please specify

Air bag: --------- Yes No

Seat belt: --------- Yes No

Driving license: --------- Yes No

Helmet use: --------- Yes No

Helmet fastening: --------- Yes No

Helmet make: --------- ISI Non-ISI

Cause of injury: --------- Road Traffic accident Ship accident Airplane crash Train accident Fall Assault Hanging Sports Fall of object Crush Others, please specify

Type of vehicle: --------- Bicycle Animal cart Four-wheeler car Four-wheeler bus Four-wheeler truck Motorized two-wheeler Three-wheeler

Vehicle crash pattern: --------- Vehicle skidded Hit a non-moving object Fall from vehicle Collision with animal/others

Incident victim: --------- Pillion rider Back seat passenger Driver Front seat passenger Pedestrian Others (please specify)

Dominant type of injury: --------- Abrasion Amputation Blast injury Blunt Bruise Burn Contusion Crush injury Cut Dislocation Drowning Fracture limbs Laceration Penetrating injury Sprain Others (please specify)

Mechanism of injury: --------- Animal related injury Bicycle Accident Electrocution Fall from bed Fall from Height/Building/Train/Bus Heavy substance falls on head Hit by Train Lightening Motor Vehicle Trauma: Ejected Motor Vehicle Trauma: not ejected Pedestrians Penetrating injury gunshot Penetrating injury stab Road traffic accident Self-fall/Self hit on wall or door Three-wheeler Two-wheeler Unknown

Pre hospital care: --------- Yes No

Resuscitation: --------- Yes No

Arrive from injury site: --------- Yes No

Protective equipment: --------- Immobility (spine boards/cervical collar) Any other please specify

Highest pre hospital care: --------- Level I. No Field Care Level II. Basic Life Support Level III. Advanced Life Support -No Physician Present Level IV. Advanced Life Support -Physician Field Care

Highest in hospital care: --------- Emergency Department General Ward Operation Theatre High Dependency Unit (HDU) Critical Care Unit (definition based on nurse-to-patient ratio)

Mortality: --------- Died at Scene Brought Dead Alive at admission

Date first key intervention:

Time first key intervention:

Pulse rate per minute:

Blood pressure systolic mmHg:

Blood pressure diastolic mmHg:

Temperature celsius:

Respiratory rate per minute:

Vision: --------- Normal Impaired Blind

Best eye response: --------- No eye opening Eye opening to pain Eye opening to verbal command Eyes open spontaneously

Best verbal response: --------- No verbal response Incomprehensible sounds Inappropriate words Confused Oriented

Best motor response: --------- No motor response Extension to pain Flexion to pain Withdrawal from pain Localizes to pain Obeys commands

Pupils right size:

Pupils left size:

Pupils right reaction: --------- Equal and reactive to light Equal but not reactive to light Unequal but reactive to light Unequal and not reactive to light

Pupils left reaction: --------- Equal and reactive to light Equal but not reactive to light Unequal but reactive to light Unequal and not reactive to light

Decorticate posturing: --------- Present Absent

Decerebrate posturing: --------- Present Absent

Ocuolocephalic reflex right: --------- Intact Abnormal

Ocuolocephalic reflex left: --------- Intact Abnormal

External bleeding: --------- Yes No

Body regions involved: --------- Abdomen Cervical spine Chest Face Head Lower limbs Lumbar spine Neck Pelvic cavity Pelvic girdle Thorax Thoracic spine Upper limbs Genitalia Others (please specify)

Life threatening injuries: --------- Airway Obstruction Tension pneumothorax Open pneumothorax Massive haemothorax Flail chest Cardiac tamponade Simple pneumohemothorax Aortic rupture Tracheobronchial rupture Pulmonary contusion Blunt cardiac injury Blunt splenic injury Diaphragmatic rupture Others (please specify)

Ais minor injury: --------- Minor injury Moderate injury Serious injury - not life-threatening Severe injury - life threatening, but survival probable Critical injury - survival uncertain Maximum injury - untreatable and virtually un-survivable

Ais moderate injury: --------- Minor injury Moderate injury Serious injury - not life-threatening Severe injury - life threatening, but survival probable Critical injury - survival uncertain Maximum injury - untreatable and virtually un-survivable

Ais serious injury: --------- Minor injury Moderate injury Serious injury - not life-threatening Severe injury - life threatening, but survival probable Critical injury - survival uncertain Maximum injury - untreatable and virtually un-survivable

Ais severe injury: --------- Minor injury Moderate injury Serious injury - not life-threatening Severe injury - life threatening, but survival probable Critical injury - survival uncertain Maximum injury - untreatable and virtually un-survivable

Ais critical injury: --------- Minor injury Moderate injury Serious injury - not life-threatening Severe injury - life threatening, but survival probable Critical injury - survival uncertain Maximum injury - untreatable and virtually un-survivable

Ais maximum injury: --------- Minor injury Moderate injury Serious injury - not life-threatening Severe injury - life threatening, but survival probable Critical injury - survival uncertain Maximum injury - untreatable and virtually un-survivable

Hemoglobin:

Total leucocyte count:

Blood sugar random:

Blood sugar fasting:

Blood sugar pp:

Hematocrit:

Platelets:

Blood group: --------- A+ A- B+ B- AB+ AB- O+ O-

Sodium:

Potassium:

Creatinine:

Bun:

Ph:

Hco3:

Pco2:

Po2:

Arterial base excess:

Lactate:

Urine pregnancy test: --------- Positive Negative

Prothrombin time:

Inr:

Troponin c:

Date of ecg:

Time of ecg:

Ecg 12 leads: --------- Yes No

Ecg results: --------- Normal Abnormal

Rhythm: --------- Normal sinus Sinus arrhythmia Atrial fibrillation Atrial flutter Premature ventricular contraction Other arrhythmias

Conduction: --------- Normal LBBB RBBB AV block Others (please specify)

Qrs st complex: --------- Normal Non-specific ST changes Old MI Myocardial ischemia Acute myocardial infarction Others (please specify)

Qt interval:

Ecg impression:

Echocardiography: --------- Yes No

Ejection fraction:

Regional wall motion abnormality: --------- 0 = None 1+ = Hypokinesis 2+ = Severe hypokinesis 3+ = Akinesis 4+ = Dyskinesis

Date of ct:

Time of ct:

Contrast: --------- Yes No

Extradural hemorrhage: --------- Yes No

Acute subdural hemorrhage: --------- Yes No

Chronic subdural hemorrhage: --------- Yes No

Intracerebral hemorrhage: --------- Yes No

Cerebral contusion: --------- Yes No

Subarachnoid haemorrhage: --------- Yes No

Intraventricular hemorrhage: --------- Yes No

Skull fracture: --------- Yes No

Extradural hemorrhage location: --------- Frontal Temporal Parietal Occipital Posterior fossa Basal ganglion Thalamus Cerebellum Brain stem

Acute subdural hemorrhage location: --------- Frontal Temporal Parietal Occipital Posterior fossa Basal ganglion Thalamus Cerebellum Brain stem

Chronic subdural hemorrhage location: --------- Frontal Temporal Parietal Occipital Posterior fossa Basal ganglion Thalamus Cerebellum Brain stem

Intracerebral hemorrhage location: --------- Frontal Temporal Parietal Occipital Posterior fossa Basal ganglion Thalamus Cerebellum Brain stem

Cerebral contusion location: --------- Frontal Temporal Parietal Occipital Posterior fossa Basal ganglion Thalamus Cerebellum Brain stem

Extradural hemorrhage side: --------- Right Left Bilateral

Acute subdural hemorrhage side: --------- Right Left Bilateral

Chronic subdural hemorrhage side: --------- Right Left Bilateral

Intracerebral hemorrhage side: --------- Right Left Bilateral

Cerebral contusion side: --------- Right Left Bilateral

Subarachnoid hemorrhage side: --------- Right Left Bilateral

Asdh volume ml:

Edh volume ml:

Ich volume ml:

Asdh shape: --------- Normal Abnormal

Edh shape: --------- Normal Abnormal

Ich shape: --------- Normal Abnormal

Skull fracture type: --------- Closed Compound Depressed Linear

Skull fracture location: --------- Frontal Temporal Parietal Occipital Posterior fossa

Subarachnoid hemorrhage location: --------- Basal Cortical Tentorial

Mass effect pressure: --------- Yes No

Hydrocephalus: --------- Yes No

Parenchymal lesions small shearing: --------- Yes No

Third ventricular compression: --------- Yes No

Contralateral ventricle dilated: --------- Yes No

Any herniation: --------- Yes No

Cerebral ischemia: --------- Yes No

Penetrating missile tract: --------- Yes No

Air sinus involved: --------- Yes No

Intracranial air: --------- Yes No

Midline shift: --------- Yes No

Obliteration of third ventricle: --------- Yes No

Petechial hemorrhages: --------- Yes No

Midline shift mm:

Basal cisterns: --------- Normal Compressed Absent

Ct classification category: --------- Diffuse Injury-I Diffuse Injury-II Diffuse Injury-III Diffuse Injury-IV Evacuated Mass Lesion Non-evacuated Mass Lesion

Fischers grade: --------- I. No blood detected II. Diffuse thin (<1 mm) SAH with no clots. III. Localized clots and/or layers of blood >1 mm in thickness IV. Intracerebral or intraventricular blood (+/- SAH)

Efast: --------- Normal Abnormal If abnormal findings

Chest x ray: --------- Normal Abnormal If abnormal findings

Cervical spine x ray: --------- Normal Abnormal If abnormal findings

Dorsal spine x ray: --------- Normal Abnormal If abnormal findings

Lumbar spine x ray: --------- Normal Abnormal If abnormal findings

Pelvis x ray: --------- Normal Abnormal If abnormal findings

Long bone x rays: --------- Normal Abnormal If abnormal findings

Ct cervical spine: --------- Normal Abnormal If abnormal findings

Ct chest: --------- Normal Abnormal If abnormal findings

Ct abdomen: --------- Normal Abnormal If abnormal findings

Ct pelvis: --------- Normal Abnormal If abnormal findings

Mri brain: --------- Normal Abnormal If abnormal findings

Mri spine: --------- Normal Abnormal If abnormal findings

Dsa: --------- Normal Abnormal If abnormal findings

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: --------- Yes No

Method used to control bleeding: --------- Direct pressure Tourniquet Any Other

Basic life support given: --------- Yes No

Brought dead: --------- Yes No

Pre hospital cardiac arrest: --------- Yes No

Prehospital airway management: --------- Yes No

Fluids at scene or on way to hospital: --------- Yes No

Activation of trauma team: --------- Yes No

Airway: --------- Clear Obstructed Adjunctive airway Intubated

Breathing: --------- Spontaneous, adequate Spontaneous, insufficient Manual support with bag, valve, mask Mechanical ventilation

Circulation: --------- No specific treatment IV fluids Crystalloids Hypertonic saline Colloids Blood Vasopressors CPR

Airway management: --------- No specific treatment Supplemental oxygen via nasal tube or mask Adjunctive airway Temporary support with bag, valve, mask (for example ambubag) Intubation Mechanical ventilation

Discharge destination from er: --------- Admitted Ward Admitted ICU OT LAMA Dead Discharged Others

Disposition from emergency: --------- Trauma surgery Medicine Orthopaedics Neurology Neurosurgery Burn ENT Ophthalmology Paediatrics Paediatric surgery Cardiology Anaesthesia Plastic surgery Others

Bed rest: --------- Yes No

Blood transfusion: --------- Yes No

Central line: --------- Yes No

Cervical collar: --------- Yes No

Cervical traction: --------- Yes No

Chest tube: --------- Yes No

Colloid: --------- Yes No

Crystalloid: --------- Yes No

Hyperventilation therapy: --------- Yes No

Hypothermia therapy: --------- Yes No

Intubation: --------- Yes No

Mannitol: --------- Yes No

Nasogastric tube: --------- Yes No

Nutrition replacement: --------- Yes No

Seizure prophylaxis: --------- Yes No

Steroids: --------- Yes No

Tetanus toxoid: --------- Yes No

Urinary catheter: --------- Yes No

Ventilation: --------- Yes No

Total days on ventilator:

Date of surgery:

Icp monitoring: --------- Yes No

Intracranial surgery: --------- Yes No

Extracranial surgery: --------- Yes No

Any re surgery: --------- Yes No

Cra surg int acute sdh: --------- Yes No

Cra surg int contusion: --------- Yes No

Cra surg int craniofacial surgery: --------- Yes No

Cra surg int csf shunt: --------- Yes No

Cra surg int chronic sdh: --------- Yes No

Cra surg int decompressive craniectomy: --------- Yes No

Cra surg int depressed skull fracture: --------- Yes No

Cra surg int epidural hematoma: --------- Yes No

Cra surg int intracerebral hematoma: --------- Yes No

Cra surg int infection: --------- Yes No

Cra surg int optic nerve decompression: --------- Yes No

Cra surg int posterior fossa surgery: --------- Yes No

Cra surg int external ventricular drainage: --------- Yes No

Cra surg int wound debridement: --------- Yes No

Cra surg int foreign body removal: --------- Yes No

Cra surg int bone flap replacement: --------- Yes No

Cra surg int cranioplasty: --------- Yes No

Cra surg int others specify: --------- Yes No

Extracra surg int maxillofacial intervention: --------- Yes No

Extracra surg int lower limb fracture internal fixation: --------- Yes No

Extracra surg int lower limb fracture external fixation: --------- Yes No

Extracra surg int upper limb fracture internal fixation: --------- Yes No

Extracra surg int upper limb fracture external fixation: --------- Yes No

Extracra surg int laparotomy: --------- Yes No

Extracra surg int pelvic fracture internal fixation: --------- Yes No

Extracra surg int pelvic fracture external fixation: --------- Yes No

Extracra surg int spinal stabilization cervical: --------- Yes No

Extracra surg int spinal stabilization thoracic: --------- Yes No

Extracra surg int spinal stabilization lumbar: --------- Yes No

Extracra surg int thoracotomy: --------- Yes No

Extracra surg int tracheostomy in er: --------- Yes No

Extracra surg int tracheostomy in icu: --------- Yes No

Extracra surg int hypotension episode: --------- Yes No

Extracra surg int hypoxia episode: --------- Yes No

Extracra surg int infections: --------- Yes No

Extracra surg int deep vein thrombosis: --------- Yes No

Extracra surg int other organ damage secondary brain injury: --------- Yes No

Extracra surg int others specify: --------- Yes No

S02.0 Fracture of vault of skull: --------- Yes No

S02.1 Fracture of base of skull: --------- Yes No

S02.3 Fracture of the orbital floor: --------- Yes No

S02.7 Multiple fractures involving skull and facial bones: --------- Yes No

S02.8 Fractures of Others skull and facial bones: --------- Yes No

S02.9 Fracture of skull and facial bones, part unspecified: --------- Yes No

S06.0 Concussion: --------- Yes No

S06.1 Traumatic cerebral edema: --------- Yes No

S06.2 Diffuse brain injury: --------- Yes No

S06.3 Focal brain injury: --------- Yes No

S06.4 Epidural hemorrhage: --------- Yes No

S06.5 Traumatic subdural hemorrhage: --------- Yes No

S06.6 Traumatic subarachnoid hemorrhage: --------- Yes No

S06.7 Intracranial injury with prolonged coma: --------- Yes No

S06.8 Others intracranial injuries: --------- Yes No

S06.9 Intracranial injury, unspecified: --------- Yes No

S07.1 Crushing injury of skull: --------- Yes No

Others (Please specify): --------- Yes No

Survival status: --------- Dead Alive

Discharge destination: --------- Admitted Ward Admitted ICU OT LAMA Dead Discharged Others

Disability rating scale at discharge:

Disability rating scale at three months:

Disability rating scale at six months:

A. Eye opening: --------- Spontaneous To Speech To Pain None

B. Communication ability: --------- Oriented Confused Inappropriate Incomprehensible None

C. Motor response: --------- Obeying Localizing Withdrawing Flexing Extending None

D. Feeding (Cognitive ability only): --------- Complete Partial Minimal None

E. Toileting (Cognitive ability only): --------- Complete Partial Minimal None

F. Grooming (Cognitive ability only): --------- Complete Partial Minimal None

G. Level of functioning (Physical, mental, emotional, or social function): --------- Completely Independent Independent in special environment Mildly Dependent-Limited assistance (non-residential helper) Moderately Dependent-moderate assist (person in home) Dependent-assist all major activities, all times Totally dependent-24-hour nursing care

H. 'Employability' (As a full-time worker, homemaker, or student): --------- Not Restricted Selected jobs, competitive Sheltered workshop, Non-competitive Not Employable