CRASH2 Protocol Outcome Form

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	OUTCOME FORM COMPLETE AT DISCHARGE, DEATH IN HOSPITAL OR 28 DAYS AFTER INJURY, WHICHEVER OCCURS FIRST			Attach treatment pack sticker here
1. HOSPITAL	(hospital name or code)
2. PATIENT
Patient initials		Hospital ID	Sex	M - F
Date of Birth		(YEAR / MONTH / DAY)
3. OUTCOME
3.1 DEATH IN HOSPITAL Date of death (YEAR / MONTH / DAY) CAUSE OF DEATH [ ] Bleeding [ ] Head injury [ ] Myocardial Infarction [ ] Stroke [ ] Pulmonary Embolism [ ] Multi organ failure [ ] Other - describe		3.2 PATIENT ALIVE [ ] Discharged - Date of discharge (YEAR / MONTH / DAY) [ ] Still in this hospital now (28 days after injury) - Date (YEAR / MONTH / DAY)
		3.3 IF ALIVE TICK ONE BOX THAT BEST DESCRIBES THE PATIENT'S CONDITION (at 28 days or prior discharge) [ ] No symptoms [ ] Minor symptoms [ ] Some restriction in lifestyle but independent [ ] Dependent, but not requiring constant attention [ ] Fully dependent, requiring attention day and night
4. MANAGEMENT		7. TRANSFUSION
a) Days in Intensive Care Unit (if not admitted to ICU, write '0' here) b) Significant head injury YES / NO c) Operation site - Tick one box on every line Neurosurgical Chest Abdomen Pelvis		a) Blood products transfusion YES / NO b) Units transfused in 28 days Red cell products - units Fresh frozen plasma - units Platelets - units Cryoprecipitate - units Recombinant Factor VIIa YES / NO
5. COMPLICATIONS		8. PERSON COMPLETING FORM
TICK ONE BOX ON EVERY LINE YES / NO Pulmonary Embolism Deep Vein Thrombosis Stroke Operation for bleeding Myocardial Infarction Gastrointestinal bleeding		Name Position Date
		NOW SEND THIS FORM TO THE CO-ORDINATING CENTRE IN ONE OF THE FOLLOWING WAYS: Secure website Electronic data forms / email Fax +44 (0)20 7299 4663 SEE INSTRUCTIONS IN YOUR SITE FILE
6. TRIAL TREATMENT
a) Complete loading dose given YES / NO b) Complete maintenance dose given YES / NO

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