EMTs, how would you examine a concussion victim on-scene?

vagough · Dec 1, 2014

Back in March, I asked you all how to injure my main character and got many wonderful responses. Eventually, I decided to give him a concussion. (This was based in large part on the fact that a colleague at work suffered a rather severe concussion in a car accident this summer -- I had no idea how long the symptoms would persist and how long it would take to completely recover!)

Now I’m back for part two: EMT response.

Here’s my scenario: My MC is out running early in the morning on a narrow semi-rural road with few street lights (dumb, I know, but he can’t sleep for various reasons key to the plot and decides to go out earlier than usual -- I’ve seen people do this where I live, so it’s within the realm of the possible). But I digress. An SUV, driven by the Bad Guy, comes along and tries to run him down. The MC barely escapes by taking a nose dive off the side of the road down a middling-steep embankment. He’s out cold for a while. Another person is out jogging (dumbness knows no bounds) and calls 911, police arrive, then the EMTs arrive.

My question: what exactly would the EMTs do? They’d arrive in an ambulance, get out and go over to my MC.... but then what? By the time they arrive, he’s kind of semi-conscious, sort of aware of where he is but not fully. Would they... shine a light in his eyes? Check him for other injuries? What would they say to him? What would they ask him? I want them to transport him to the hospital but would they simply put him on a stretcher? Or would they also put a brace on his neck at all? The more technical details, the better. Inquiring minds want to know.

Thanks in advance!

King Neptune · Dec 1, 2014

I'm not an EMT, but I don't think they would get to the point of checking for a concussion until he was in the ambulance. They would start by checking to see if he had a broken back/neck. They wouldn't move him until they determined that it was safe to move him, and they would check for other major injuries, broken bones, etc. Then they would put him on a stretcher and put him into the ambulance. If he was groggy/semiconscious, then they would assume a concussion, but they couldn't do anything about that unless there was a skull fracture.

sdevonh · Dec 1, 2014

I'm coming at this from the perspective of an RN, rather than an EMT, but here's my experience. If he's had head trauma, they'll want him to remain immobile and then they'll assess his level of consciousness. The questions are usually, "What's your name? What day/year/month is it? Do you know where you are? Do you know who the president is?" They're determining that the patient is oriented to person, place and time. Then they'll take vitals and check his pupils with a pen light, making sure pupils are equal size and both contract when exposed to light. They'll probably stabilize his back/neck and do a quick physical assessment before transporting him.

jclarkdawe · Dec 1, 2014

Airway
Breathing
Circulation
Primary survey
Backboard and collar
Strip and secondary survey

Primary and secondary survey are head to toes. You examine everything. Leaking from ears, eyes for reaction, nose for leaking, feel for any fractures, look for bruising, look for bleeding, look for deformity.

So, yes, we'd shine a light into the eyes, holding the lids open if we have to. We'd ask if he's conscious enough to track the light, but we also want to check for pupil reaction. We'd ask what happened and check to see whether oriented in time and place. Unless you're absolutely, positively sure the spine is not compromised, you backboard and neck brace.

Major concerns would be skull deformity, ear leaking, coon's eyes (bluish-purplish color around eyes), poor pupil response, and depressed breathing. If he's at all disoriented, probably give him high flow O2.

Best of luck,

Jim Clark-Dawe

Andreas_Montoya · Dec 2, 2014

Everything that has been above. Also, I'd have him squeeze my index and middle finger with his hands, then push down against my hands with his feet, then pull up against them to check for a neural deficit. A C collar would go on immediately and he would be spider strapped to a backboard until x rays cleared his cervical spine for injuries.

asroc · Dec 2, 2014

A concussion isn’t really something you can check for as such. The signs and symptoms don’t preclude other (worse) head injuries, so it’s somewhat of a diagnosis of exclusion and it might require a CT scan to rule out other injuries. What’s especially important to find out is how long he was unconscious. A concussion would only knock you out for a very short time, if at all. A lengthy loss of consciousness is a bad sign and indicates a serious problem.

As for procedure, jclarkdawe covered it pretty well. You check your ABCs. You take vital signs. You do your physical exams, a rapid one while backboarding, if applicable, and a focused one, repeated periodically. You assess the level of conciousness with the Glasgow Coma Scale. You’d do a neurological exam (although I’m not sure if this is paramedic skill only), involving the questions the squirrel mentioned, to check if the patient is alert and oriented (around here times four = person, place, time, situation, but times three is also common), check his long- and short-term memory, assess motor and sensory systems and record anything abnormal. If the patient is not entirely conscious, oxygen is a must, also an IV and potentially an EKG, and be ready to intubate should the patient deteriorate. However with a concussion the patient should only improve.

vagough · Dec 6, 2014

Thank you so much, everyone -- your answers were fabulous and exactly what I needed to know. I've completely revamped the scene to make it more realistic and in line with your guidance.

You are wonderful!

Bolero · Dec 7, 2014

vagough said:
(This was based in large part on the fact that a colleague at work suffered a rather severe concussion in a car accident this summer -- I had no idea how long the symptoms would persist and how long it would take to completely recover!)

!

General question to the experts on here if you don't mind.

Is that all down to concussion, or does whiplash play a part?

I am just remembering someone I knew who was in a rear end shunt and their car didn't have a head rest, so head whipped backwards. They had trouble for about a year - some of it neck injury, some of it short term memory problems and some of it a tendency to fall asleep at odd times.
Would be interested to know the likely causes. (Long since lost contact with said person.)

MDSchafer · Dec 7, 2014

Bolero said:
General question to the experts on here if you don't mind.

Is that all down to concussion, or does whiplash play a part?

I am just remembering someone I knew who was in a rear end shunt and their car didn't have a head rest, so head whipped backwards. They had trouble for about a year - some of it neck injury, some of it short term memory problems and some of it a tendency to fall asleep at odd times.
Would be interested to know the likely causes. (Long since lost contact with said person.)

It's probably a bit of both. Concussions can have lingering effects. Post-concussion effects include both memory problems and post-traumatic narcolepsy isn't uncommon. Extremity weakness is one of the more common things you see with extreme whiplash injuries, but those tend to clear fairly quickly.

EMTs, how would you examine a concussion victim on-scene?

vagough

Traveling down the Query Road...

King Neptune

sdevonh

jclarkdawe

Feeling lucky, Query?

Andreas_Montoya

asroc

Alex

vagough

Traveling down the Query Road...

Bolero

MDSchafer