“Medic 7, Rescue 1, Engine 45, respond to an accident with entrapment.” Medic 7 arrives, establishes command and sizes up the scene. It’s a two-car head-on collision with one unresponsive driver entrapped by a jammed door. The driver of the other vehicle is walking around and appears uninjured. There’s heavy damage to both vehicles, but most of the vehicle doors open and their side-curtain and front-end air bags have deployed. Both patients are triaged. The unresponsive driver is triaged “red” and the walking driver is triaged “green.”
A second ambulance is requested for the “green” patient and the first crew’s efforts are focused on the “red” patient. The inside medic rapidly assesses the driver, stabilizes the C-spine and controls the airway. An oropharyngeal airway is inserted and oxygen is administered. The patient is unresponsive, tachycardic, normotensive, pale, sweaty and has no obvious trauma. Due to the patient condition, the inside medic communicates with the rescue officer that immediate extrication is required as soon as the door is open. The patient is rapidly extricated to a long spine board, quickly immobilized and moved to Medic 7 for transport. Medic 2 has arrived and is caring for the “green” patient. En route to the hospital, venous access is obtained and a routine blood glucose test is conducted. The blood sugar is measured at 40 mg/dL, and 25 grams of 50% dextrose is administered. The patient regains consciousness. Subsequent evaluation in the emergency department (ED) is unremarkable and the patient is discharged.
THEN AND NOW
Experienced rescuers have noticed a significant change in the type and acuity of motor vehicle crashes (MVCs) being managed today compared to 20 years ago; road and auto safety design features have significantly decreased injuries and fatalities. In the ’90s most high-energy collisions resulted in serious injuries and entrapment. Today, occupants often self extricate and are ambulatory following high-energy collisions that previously would have resulted in fatalities. Although serious crashes do occur, they don’t seem to happen with the same frequency. The result is safer highways. For rescuers, this equates to fewer encounters with extrication incidents. Today, both medical and mechanical rescuers must work harder to maintain proficiency in extrication.
In studying our system over the past 15 years, a consistent trend has emerged; we tend to repeat variations of the same extrication. In our community of more than 80,000 residents, there are roughly:
>> 4,000 accident reports taken by police;
>> 800–900 reported personal injury crashes;
>> 60 reports of entrapment; and
>> 12–15 actual extrications.
Of these extrications,
>> Two thirds of the patients require a simple “door pop” for release; and
>> One-third require multiple maneuvers for release.(1)
There are also basic extrication trends and operations that we execute. The basic operations to gain proficiency in, beyond vehicle stabilization and scene safety, are the:
>> Simple door pop;
>> Door pop-roof flap;
>> Door pop-roof flap-dash roll; and
>> Rapid release of a patient pinned under vehicle.
Before we dive into the strategy of extrication, let’s discuss five simple tips every provider should know. Remember your vehicle ABCs. When it comes to entrapped patients, simple and basic is better than unnecessary advanced skills. There are some critical questions providers must answer about the patient: Is their airway open? Can they protect their own airway? Are they oxygenating adequately? Are they ventilating adequately? Is there obvious external bleeding? Is there occult bleeding? What is the anticipated clinical course of the patient?
Find balance. Part of finding balance means don’t use tools just because you have them. As human beings, we love to use our tools, be they medical or mechanical. Because we can do medical procedures, we often do them more frequently than indicated. Sometimes really good medical care means using different tactics, resulting in a slower extrication. Other times, perfect extrication tactics can mean costly delays and poor medical outcomes. Hence, the need for balance. The extrication goal for entrapped patients is 10 minutes or less on scene. Extrication time for the “red” patient must be kept to an absolute minimum. That means just enough tool work to allow disentanglement, release and safe extrication and nothing more. Make sure you find your balance.
Wear the right gear. If you watch the news coverage of a rescue incident, you might see firefighters working an extrication in full personal protective equipment (PPE) and EMS personnel with partial (or absent) PPE. EMS personnel should wear the same level of PPE as other workers at an incident. In order to fully participate in a rescue effort, EMS personnel should have such equipment as a helmet, protective eye wear, gloves, safety shoes/boots, ANSI Class II safety vests and turnout coats, and pants or extrication coveralls.
Less is more. Travel light, gain rapid access, accomplish the task and get out quickly. If it seems like it will be a short extrication, avoid adding ECG, NIBP, SpO2 and other monitoring devices because unnecessary wires and tubes will only impede patient removal. Use a manual blood pressure cuff, and take a pulse. Ask yourself if the patient truly needs an IV immediately or if it could wait until you are en route to the hospital.
It’s important to set up your scene with inner and outer circles so that personnel can easily provide care. The inner circle is the area of the crashed vehicle and its immediate surroundings. Often, this area becomes so crowded that it can be difficult to get anything done. A good rule of thumb is to put a medical rescuer either inside the car with the patient or immediately next to them. The EMS personnel in the inner circle must provide medical care, but avoid getting in the way and slowing things down. Any EMS personnel not immediately needed should be positioned “on deck” with their equipment in the outer circle. The outer circle is the area outside the immediate extrication zone that’s still close enough for personnel to move in quickly. Communication and cooperation between the medic in the car and the extrication officer is critical to discuss strategy and tactics. They must both share a common goal: Gain access, disentangle and extricate the patient while optimizing the potential outcome.
Most entrapped patients are hemodynamically stable enough to allow for sedation and analgesia before movement. It’s simply a humane thing to do. Never underestimate the value of talking to a patient (verbal distraction) as a pain-management tool, along with basic splinting. You can always splint by attaching an injured extremity to the torso or to another extremity. However, for patients with severe injuries or entrapment, distraction and basic splinting won’t be enough. Disentanglement and extrication will place severe stress on broken bones and injured muscles. This will cause intense pain.
There are multiple medical options for patient management during the disentanglement and extrication. Weigh the risk/benefit ratio for each medication prior to use. Consider using an antiemetic even if the patient is not yet nauseous, and follow the rule of titrating the medication to the effect you’re looking for—in most cases you can always add more.
Opiates are the key to EMS pain management. Morphine offers long-lasting pain relief, but a slow onset of action and significant histamine release. This creates the potential for hypotension when given in the setting of hypovolemia. It also frequently causes nausea.
Fentanyl, however, has a rapid onset of action, a short half-life and limited histamine release. It can also cause hypotension, but much less so than morphine. Fentanyl offers another interesting benefit, because it can be given intranasally. Note that the volume of medication needed for intranasal administration precludes this as a useful adjunct in adults over 50 kg.
Benzodiazepines, midazolam (Versed) in particular, can be key for humane extrication. Midazolam has a reputation for causing amnesia to the events surrounding to its administration; although the patients who get the medication don’t always report that. It’s a big help in facilitating pain management in conjunction with an opiate as well. But be careful with midazolam because the combined effect of an opiate and a benzodiazepine can cause apnea. Lorazepam and diazepam are also used in EMS, but because of their long half-life and more significant hemodymanic effects, they’re rarely indicated in extrication or disentanglement.
Two anesthetic agents have reportedly been used in extrication with great success. One, etomidate (Amidate), is a sedative hypnotic with very little hemodynamic effect. It’s not a controlled substance and successfully achieves sedation, but frequently causes apnea at low doses. Etomidate also requires a very high level of monitoring to ensure patient safety.
Ketamine is a dissociative anesthetic agent available for EMS use in 11 states. It’s a controlled substance that causes vivid dreams and sometimes nightmares. It generally doesn’t cause respiratory depression. It can also increase blood pressure and heart rate, relieve bronchospasm and offer pain relief and anesthesia for significantly painful procedures. It should be used with caution in the elderly and those with cardiac conditions and shouldn’t be used in the head injury patient or with eye trauma. Ketamine can be used intramuscularly as well as via IV.
The most valuable part of patient removal is the planning prior to any movement. For safe removal, all members of the team should have a clear understanding of their assignments yet remain flexible to adjust if events change. The team leader should stay away from the patient to ensure all participants are safe and to observe inordinate movement of the patient. There are two basic removal strategies: laterally through the doorway or vertically after the roof is removed. Lateral extrication is generally well understood by most rescuers. The patient is pivoted and moved to a long spine board. The vertical method is valuable in many situations because the roof is removed and the patient can be rapidly extricated, however, most providers aren’t familiar with this method. Essentially, the steps for vertical extrication are as follows:
1. The patient is collared, and one rescuer holds the head/neck securely;
2. A long board is gently placed between the seat and the patient;
3. Two to three rescuers slide the patient onto the board in unison, careful to support the legs as well;
4. The long board straps and head blocks are applied; and
5. The patient is positioned and fully secured to the transferring stretcher.
Once the patient is removed from the vehicle, they should be moved to the ambulance, and any additional care should occur en route to the hospital. If you need to utilize HEMS resources, call them early on rather than waiting for the resource to arrive. Ideally, HEMS should be on scene before the patient is extricated.
A successful extrication can be measured by minimal scene time, ABCs and packaging, as well as by the humane management of pain and absence of injury to rescuers. For a successful extrication, apply the same focus and effort as you would to managing any cardiac arrest patient. Good extrication care is an excellent illustration of your EMS system’s level of sophistication. It’s easy to manage the ABCs of an arrest. It’s much harder to deal with multi-agency cooperation and the dynamics of incident management of a difficult extrication. However, modern EMS care has always been about bringing good care to bad places. Not having highly qualified medical responders at the patient’s side due to lack of equipment, training or preparation is unacceptable. Remember, rescue must be driven by the medical needs of the patient. No patient, no rescue! Are you up for the challenge? JEMS
1. Funk D, Politis J, McEarlean M, et al. Necessity of fire department response to the scene of motor vehicle crashes. Am J Emerg Med. 2002;20:580–582.