Handing over to rescue personnel
Name:
Date of birth/CPR:
Date:
Ship's name:
Port call at:
Name of examiner:
Takes medicine – name:
Hypersensitivity to medicine/which:
Name of relative:
Tel. no.:
Informed □
Not informed □
What has happened – describe the situation
A: Airway
Action
Guidelines
Secure free airways
Give oxygen
Head fixation
Neck support provided □
Neck/back
No symptoms □
6 l/min □
9 l/min □
If unconscious – tongue depressor □
Pains □
Lesion □
* See reverse side
B: Respiration
Action
Guidelines
Respiratory rate
Normal □
Laboured □
Superficial □
None □
Chest
No symptoms □
Pains □
Lesion □
* See reverse side
Yes □
Yes □
No □
No □
On the neck
Yes □ No □
Used cardiopulmonary resuscitation:
Used defibrillator:
Action in case of heart failure:
Start at: __________
C: Circulation
Action
Guidelines
Pulse
The pulse can be felt on the wrist
Yes □ No □
Pulse quality
Fast
□
Slow
□
Regular
□
Irregular
□
Skin colour
Normal
□
Pale
□
Bluish
□
Reddish
□
Skin feels
Warm and dry □
Cool and dry
□
Warm and moist
□
Cool and moist
□
Capillary response
Reacts in less than 2 seconds
□
Reacts after more than 2 seconds
Bleeding control
Stopped bleeding
□
Where? * See page 2
Inserted cannula – yes □ no □
□
Administered NaCl. □ at __________ hours no □
D: Disability
Action
Guidelines
□
Level of consciousness
Awake
Reacts to speech
Control over pupillary reflex
Normal reaction to light
Action
□
Reacts to pain
□
□
Abnormal: Describe
No reaction
Examine for other injuries
Belly
No symptoms
□
Pains:
□
Lesion:
□
* See reverse side
Pelvis
No symptoms
□
Pains:
□
Lesion:
□
* See reverse side
Arms/legs
No symptoms
□
Pains:
□
Lesion:
□
* See reverse side
Centre for Maritime Health Service
□
Patient's actual values
Hour
Hour
Hour
Respiration frequency/minutes
Pulse per minute
Capillary response > 2 seconds
Level of consciousness
Oxygen saturation
Blood pressure
Oxygen l/min.
Infusion NaCl. dr./min.
Administered medicine – yes □ no □
Which medicine:
____________________ quantity: __________
____________________ quantity: __________
____________________ quantity: __________
Insert any injuries here:
How: tablets □ im □ sc □ iv □
How: tablets □ im □ sc □ iv □
How: tablets □ im □ sc □ iv □
at: __________ hours
at: __________ hours
at: __________ hours
Normal body values
Respiration frequency
Age
Respiration frequency per min.
0-6 weeks
30-50
7 weeks-6 years
20-30
6-13 years
12-30
13-16 years
12-20
Older than 16 years
12-16
Oxygen saturation Children/aduts
> 95 per cent
Pulse
Age
Pulse
0-6 weeks
120-160
7 weeks-1 year
80-120
1-16 years
60-120
Older than 16 years
60-80
Blood pressure
0-6 years
75-100/50-70
6-16 years
105-125/65-80
Older than 16 years
120-140/60-80
Centre for Maritime Health Service