Forensic chain of custody considerations per local protocol dependent
Behavioral and mental status
Behavioral and mental status
Orientation
Affect
Intoxication signs
Immediate safety concerns
Lab Studies
Core trauma and bleeding risk labs
Core trauma and bleeding risk labs
CBC
Anemia suggests bleeding
Leukocytosis nonspecific
Electrolytes and creatinine
Kidney function for contrast decisions
Baseline for medication dosing
Coagulation studies when indicated
INR for warfarin
aPTT when heparin exposure suspected
Type and screen when significant bleeding risk
Pregnancy and sexual assault related labs
Pregnancy and sexual assault related labs
Urine pregnancy test
Guides imaging and medications
Emergency contraception eligibility timing
Baseline STI testing per protocol dependent
NAAT for gonorrhea
NAAT for chlamydia
HIV testing baseline with consent
Hepatitis B and C testing baseline with consent
Muscle injury and metabolic labs when indicated
Muscle injury and metabolic labs when indicated
CK
Consider if prolonged immobilization
Consider if extensive soft tissue trauma
Urinalysis
Hematuria suggests GU trauma
Myoglobinuria suggests rhabdomyolysis
Toxicology and intoxication evaluation
Toxicology and intoxication evaluation
Point of care glucose
Hypoglycemia mimic of intoxication
Hyperglycemia in diabetics
Blood alcohol level when clinically needed
Urine drug screen limitations
Does not exclude ingestion
False positives possible
Imaging
Scoring Systems
Scoring Systems
Canadian CT Head Rule
Adult minor head injury criteria
Not for anticoagulated patients in some protocols
New Orleans Criteria
Alternative for minor head injury
Higher imaging rates than Canadian CT Head Rule
NEXUS C spine criteria
Low risk rule out criteria
Not reliable with intoxication or distracting injury
Canadian C Spine Rule
High sensitivity in alert stable adults
Not for non trauma neck pain
Ottawa Ankle Rules
Reduces unnecessary ankle imaging
Not for intoxicated or unreliable exam
MRI
MRI
Brain MRI
Persistent focal deficits with negative CT
Suspected diffuse axonal injury
Cervical spine MRI
Neurologic symptoms with normal CT
Ligamentous injury concern
Contraindications
Non MRI compatible device
Metallic foreign body risk
CT
CT
CT head without contrast
Concerning head injury features
Anticoagulation with head trauma often lowers threshold per local protocol dependent
CT cervical spine without contrast
Neck pain with concerning mechanism
Neuro deficits or midline tenderness
CT angiography head and neck
Strangulation with neurologic symptoms
Expanding neck hematoma
Carotid bruit after neck trauma
CT chest abdomen pelvis with contrast
Concern for internal injury
Abnormal vitals or exam
Contrast cautions
Reduced kidney function
Prior contrast reaction
Ultrasound
Ultrasound
eFAST
Free fluid assessment
Pneumothorax assessment
OB ultrasound
Pregnancy with abdominal pain or bleeding
Dating for pregnancy risk counseling
Soft tissue ultrasound
Abscess versus hematoma
Foreign body detection limitations
Special Tests
Bedside maneuvers and functional tests
Bedside maneuvers and functional tests
Neurocognitive screen for concussion
Symptom checklist
Balance assessment if safe
ABI for lower extremity vascular injury
ABI less than 0.9 suggests vascular injury risk
Normal ABI does not exclude all injury
Ocular bedside evaluation when indicated
Fluorescein staining for corneal abrasion
Tonometry contraindicated if globe rupture concern
Forensic and safeguarding processes
Forensic and safeguarding processes
Sexual assault evidence kit timing per local protocol dependent
Forensic photography per consent and policy
Documentation standards
Patient quoted statements when possible
Injury description without speculation
Mandatory reporting triggers
Child abuse
Vulnerable adult abuse
ECG
Indications and high risk patterns
Indications and high risk patterns
Chest trauma with pain or dyspnea
Syncope or near syncope
Stimulant use
Known cardiac disease
QT prolongation risk with medications
New ischemic changes
New arrhythmia
Assessment
Problem list and severity
Problem list and severity
Injury burden summary
Head injury severity
Neck injury severity
Chest and abdominal injury severity
Extremity injury severity
Strangulation risk stratification
High risk features present
Imaging and observation need
Sexual assault care needs
Prophylaxis eligibility
Evidence collection preference
Safety assessment
Safety assessment
Safe discharge destination available
Ongoing threat from assailant
Dependents safety addressed
Need for social work involvement
Need for law enforcement involvement per patient preference and local laws
Diagnostic uncertainty and alternatives
Diagnostic uncertainty and alternatives
Occult internal injury despite benign exam
Delayed airway edema after neck compression
Delayed concussion symptoms
Plan
First 5 minutes workflow
First 5 minutes workflow
Cardiac monitor if unstable or concerning mechanism
SpO2 monitoring
IV access criteria
Two large bore IV if hypotension or major trauma concern
IO access if unable to obtain IV in shock
Oxygen criteria
SpO2 less than 92 percent
Respiratory distress
Immediate hemorrhage control
Direct pressure
Tourniquet for life threatening extremity bleeding per local protocol dependent
Early airway planning for neck compression red flags
Diagnostic sequencing
Diagnostic sequencing
Head and neck imaging based on decision tools and red flags
FAST or eFAST in unstable patient
Serial exams for abdominal injury concern
Pregnancy testing before teratogenic medications or radiation when feasible
Therapeutics and procedures
Therapeutics and procedures
Analgesia
Acetaminophen PO 1000 mg once
Ibuprofen PO 400 mg once
Avoid NSAIDs if active bleeding or high bleeding risk
Wound care
Irrigation volume adequate for contamination
Closure decision based on contamination and
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.