2019 EMT Refresher Instructor Manual

C.4.B - 2

Situation: 55-year-old, unconscious in driver’s seat

Head Injury

Scene Size-up: Safety:

Safe (workshop)

BSI:

Gloves

Patients: 1 Mechanism/Nature: MOI – serious MVA Resources: ALS

Laceration with crepitus

Primary Assessment: General Impression: Man lying in car – no seat belt Mental Status: Unresponsive Airway: Gurgling Breathing: 8 per minute shallow Circulation:

Palpable at pulse at wrist, Warm, dry skin, light bleeding from head head

Rapid Scan: Head: Desired Response: Primary then Rapid scan. Transport - Vitals, full body scan enroute. Full Body Scan Exam: Head: 2” laceration with light bleeding. Crepitus. 2” laceration with light bleeding. Crepitus.

Neck:

Unremarkable

Neck:

Unremarkable

Chest :

Unremarkable

Chest :

Unremarkable

Abdomen:

Unremarkable

Abdomen:

Unremarkable

Pelvis:

Unremarkable

Pelvis:

Unremarkable

Extremities:

Unremarkable

Extremities:

Unremarkable

Posterior :

Unremarkable

Posterior :

Unremarkable

Vitals: 1 Pulse: 60

2

3

OPQRST: O:

SAMPLE: S:

58

54

N/A N/A N/A N/A N/A N/A

Unobtainable Unobtainable Unobtainable Unobtainable Unobtainable Unobtainable

P: Q: R:

A:

BP:

182/102

190/110

204/118

M:

P: L: E:

Resp: 8

8

8

S: T:

SPO2: 92 86 (improve the SPO2 if the patient is being bagged) 88

OTHER: