I85PREP
⌘ K
NREMT EMR study materials
NREMT EMR study resources

The Helmet, the Vomit, and the Patient Who Wants to Sit Up

NREMT EMR · Put your knowledge to work in context.

All case studies

The Helmet, the Vomit, and the Patient Who Wants to Sit Up

At 10 pm you are dispatched to a single-vehicle bicycle crash on a paved trail. A 28-year-old man was found by a passerby lying on his side, his full-face helmet still on and cracked at the chin bar. He is confused, repeatedly asking where he is, and he vomits once while on his side. He has a large abrasion on his right forearm, and his right pupil appears slightly larger than the left. He complains of neck pain and cannot recall the crash. His respirations are 22, radial pulse 96 and regular. He does not want to be strapped down and tries to sit up. You are 20 minutes from the hospital, with a paramedic intercept available in 8 minutes.

1. He is confused, vomiting, and fighting immobilization. How do you sequence airway management against spinal motion restriction?

Read the worked answer

Airway first. Spinal motion restriction is a technique, not a higher priority than breathing.

Reasoning:

  • He is vomiting and confused. Vomit plus an unprotected airway is an immediate, certain threat; a theoretical movement injury is a risk.
  • Confusion after head trauma also means he cannot be trusted to protect his own airway or cooperate.

Sequence:

  1. Manual stabilization of the head and neck with both hands - that is continuous, low-cost, and does not require strapping anyone down.
  2. Keep him on his side. A side-lying position protects the airway from vomit and is compatible with manual stabilization.
  3. Suction as needed; have it in hand, not in the truck.
  4. Do not fight him into full immobilization. A combative patient who is thrashing against straps is at more risk from the struggle, and the airway is harder to manage. Talk him down, keep him still and side-lying, and move.
  5. Oxygen by nonrebreather if tolerated; assist ventilations if his breathing becomes inadequate.
  6. Reassess mental status and pupils repeatedly.

Explain to him what you are doing and why, in short sentences. Cooperation is a clinical tool.

2. Should you take the full-face helmet off? Explain your reasoning and, if removal is needed, how it should be done.

Read the worked answer

Do not remove a helmet reflexively, but this helmet has to come off or be opened up.

Reasoning both ways:

  • General rule: a snug helmet that fits well actually splints the head. Removing it moves the neck, and with one rescuer it is easy to make things worse.
  • Reasons to remove here: it is a full-face helmet with a cracked chin bar, which blocks your view of the mouth, blocks suctioning, and would block a BVM seal if he stops breathing. He has already vomited inside it.

The judgment:

  • If the face can be cleared and suctioned without removal, and he is breathing adequately, leave it on and let the receiving facility decide.
  • If the chin bar or face shield blocks your access to the airway - which is the case here - remove it with two rescuers: one holds manual stabilization from below, the other opens or cuts the straps and slides the helmet off in line, without lifting or rotating the head.
  • Never twist or lever the helmet; spread it apart at the sides as you slide it.
  • If you cannot remove it safely and he needs ventilation, ventilate around the helmet or via a mask you can seal - the airway always wins.

Document what you did and why.

3. Which findings push this from a routine transport to a time-critical one, and how does that change your plan?

Read the worked answer

The neuro findings are the trigger:

  • Confusion and inability to recall the crash - altered mental status after head trauma is not a benign finding.
  • Unequal pupils - suggests pressure building on one side of the brain. This is the finding that changes everything.
  • Vomiting - common with rising intracranial pressure and a direct airway threat.
  • Neck pain plus a mechanism that can injure the spine.

Plan changes:

  1. Request the ALS intercept and state the neuro findings explicitly - unequal pupils and a falling level of consciousness get a different response than a generic bike crash.
  2. Do not wait 8 minutes on scene for the intercept if transport is ready. Move toward the hospital and meet ALS en route - time to a CT scanner matters more than time to a paramedic.
  3. Reassess mental status, pupils, and breathing frequently and record times. Deterioration in the back of the ambulance is common in these patients.
  4. Keep the airway protected - side-lying or suction-ready at all times.
  5. Watch for inadequate breathing, which is the terminal event in a worsening head injury. Be ready to assist ventilations.