Name

No:
Area code:

DOB

SEX: M

Hospital:

Chief
complain/s
(CC):

V/S:
RR:

pulse:

U/S Doppler

No

Yes:

Investigation result: Blood group: A

HB

BP:

Temp:

Result: Neg.
B

AB

pos.
O

Neg.

pos.

Antibiotic prophylactic:
No of blood units transferred:

No of FFP transferred:

Patient's status before surgery:

Stable
Unstable W /out intubation
Unstable W/ intubation
Injured Vessel
Neck/ C. Carotid Rt.

Lt

Repair

Neck/ I. Carotid Rt.

Lt

Repair

Neck/ E. Carotid Rt.

Lt

Repair

Neck/ I. Jugular Rt.

Lt
Neck/ E. Jugular Rt.
Lt
Neck/Subclavian A Rt.
Lt
Neck/Subclavian V Rt.

Repair

Lt

UL/Axillary A Rt.

Lt

Repair

UL/Axillary V Rt.
UL/Brachial A Rt.

Lt
Lt

Repair
Repair

UL/Radial A Rt.
UL/Ulnar A Rt.
TX/A. Aorta

Lt
Lt

Repair
Repair
Repair

TX/D. Aorta

Repair

TX/SVC

Repair

TX/IVC

Repair

TX/Pulmonary A

Repair

Code

Procedure
/ R W Patch / R W vein graft
Graft
/ R W Patch / R W vein graft
Graft
/ R W Patch / R W vein graft
Graft /Ligation
Repair / ligation
Ligation
/ R W Patch / R W vein graft
Graft
Repair / ligation
/ R W Patch

Code
/ R W Pro.
/ R W Pro.
/ R W Pro.

/ R W Pro.

/ R W vein graft / R W Pro.

Graft
/ R W Patch / R W vein graft / ligation
/ R W Patch / R W vein graft / R W Pro.
Graft
/ R W Patch / R W vein graft / ligation
/ R W Patch / R W vein graft / ligation
/ R W Patch / R W vein graft / R W Pro.
Graft
/ R W Patch / R W vein graft / R W Pro.
Graft
/ R W Patch / R W vein graft / R W Pro.
Graft
/ R W Patch / R W vein graft / R W Pro.
Graft /ligation
/ R W Patch / R W vein graft / R W Pro.

Graft
TX/Pulmonary V
Abd/Portal vein

Repair

Abd/IVC

Repair

Abd/Aorta

Repair

Abd/Mesentery
Abd/C. Iliac A Rt

-Lt

Repair

Abd/E. Iliac A Rt

-Lt

Repair

Abd/I. Iliac A Rt -Lt

Abd/C. Iliac V Rt - Lt
Abd/E.Iliac V Rt -Lt
Abd/I.Iliac V Rt -Lt
LL/C. Femoral A Rt.
Lt

Repair

LL/C. Femoral V Rt.

LL/E. Femoral A Rt.

Repair
Repair

Lt.
Lt

LL/E. Femoral V Rt.

Lt
LL/Profunda Femoris Rt.
Lt
LL/Profunda Femoris V Rt.
Lt
LL/Popliteal A Rt.
Lt
LL/Tibialis Ant. Rt.
LL/ C. Peroneal Rt.

Lt
Lt

Repair
Repair

Repair

/ R W Patch

/ R W vein graft
Graft
/ R W Patch / R W vein graft
Graft
/ R W Patch / R W vein graft
Graft
ligation

/ R W Pro.
/ R W Pro.
/ R W Pro.

/ R W Patch / R W vein graft / R W Pro.

Graft /ligation
/ R W Patch / R W vein graft / R W Pro.
Graft
Repair / ligation
Repair / R W Patch / ligation
Repair / R W Patch / ligation
Repair / R W Patch / ligation
/ R W Patch / R W vein graft / R W Pro.
Graft
/ R W Patch / R W vein graft / ligation
/ R W Patch / R W vein graft / R W Pro.
Graft
/ R W Patch / R W vein graft / ligation
/ R W Patch / R W vein graft / R W Pro.
Graft
Repair / R W Patch / ligation
/ R W Patch

/ R W vein graft
Graft

/ R W Pro.