Operations, Patient Care, Rescue & Vehicle Extrication, Special Topics, Trauma

Entrapped Yet Conscious Patient Presents Unique Aspects to MVC

Issue 10 and Volume 40.

On Oct. 10, 2014, the lone occupant of a small sedan is driving into North Naples, Fla., when a dump truck suddenly veers into oncoming traffic and crashes into the driver’s side of the car, forcing both vehicles off the road and into a roadside canal.

The canal has about a foot of water but, fortunately, no alligators. The dispatch tones and subsequent messages from the county’s 9-1-1 communication center advise of a wreck with entrapment and a vehicle in water. A full assignment includes North Collier Fire Control and Rescue District (NCFCRD) equipment, a Collier County EMS paramedic unit and a standby for the county’s air ambulance.

First-arriving NCFCRD units find and report a small vehicle with massive damage under the front end of a high-capacity dump truck. The dump truck isn’t loaded, there’s no fire, and the severely entrapped driver of the vehicle isn’t in immediate danger of drowning.

Command is rapidly established by the battalion chief, and two portions of the operations sector are organized—one group is responsible for the extrication operation and one is responsible for medical care.

NCFCRD paramedics crawl into the water and into the remnants of the passenger side of the vehicle. Some space is also available behind the patient. Upon primary assessment, he has a Glasgow Coma Scale score below 12. The front of his vehicle and the weight of the dump truck are across his lower body and the front of his chest.

The driver’s seat is reclined backward so the patient is able to breathe and an oxygen mask is placed to improve oxygenation. There’s only a right arm available for assessment of pulse and perfusion. A single rescuer is placed in the vehicle to provide an assessment, to reassure the patient and to determine what movement of the vehicle is occurring as the extrication begins.

The extrication officer performs a six-sided assessment of the incident scene. There are minor fluid leaks from both vehicles, but no major fuel leak, and ignition sources are eliminated. The impact of the crash has pushed the A-pillar and the steering wheel into the driver, as well as the entire front end of the car. The driver’s chest is 12 inches from the front bumper of the truck. There’s no way to assess the damage to his abdomen, pelvis and lower extremities.

The auto is resting on an uncertain surface below the water. There are no obvious drop-off points around or under the car, and the surface is sandy and somewhat boggy. The weight of the dump truck is completely resting on the car, and movement of the truck may actually pull the automobile up with it.

The weight of the truck is initially secured by winches on the front of two fire engines. Command requests a heavy-duty wrecker to assist with the operation, and fortunately one is available and already en route.

The extrication will require moving the dump truck safely both vertically and horizontally off the car and the victim. In the time before the large wrecker arrives, the crews use hand tools to gain access to as much of the victim as possible and to stabilize the sedan in the water and sand.

The medics stabilize the patient with the body parts they’re able to reach. A C-collar is fitted, oxygen is provided, an IV line is placed in the right arm and fluids are started. No large hemorrhage is noted. A pulse oximeter provides adequate assessment of pulse rate and perfusion. The patient regains consciousness and is able to tell the rescuers he can feel his legs and wiggle his toes. But as minutes go by, the patient begins complaining of pain in the chest and left arm, and more intense pelvic and lower extremity discomfort.

The paramedics set up for more extensive advanced care and to mitigate the likely complications that will occur when the vehicles are lifted off the patient, such as the potential loss of vascular tone when compression is removed, with threats to airway including vomiting and aspiration. Tourniquets are prepared in case an open wound to an artery is exposed. The fluid rate is adjusted to give a bolus of about a liter prior to extrication. Pain medicines are prepared in case the extrication results in severe discomfort to the patient, which could then delay further disentanglement and ultimately cause further harm.

The county’s medical helicopter is placed in a safe landing zone for utilization when the victim is freed because ground transport to the nearest trauma center will take 45 minutes.

The 50-ton wrecker arrives and is placed in a prepared location; the extrication team has already prepared all the necessary secondary stabilization and disentanglement tools. With safe but rapid movement of the wrecker, the cables are attached and, at approximately 58 minutes into the event, the truck is lifted and slid off the car. With a few hand tool maneuvers, the victim is freed and slid onto a backboard. He’s conscious, doesn’t lose his airway, and his pain is manageable. He’s noted to have significant lower extremity wounds that aren’t bleeding. He’s loaded into the helicopter and flown to the regional trauma center. The flight crew finds no unexpected wounds on secondary assessment en route.

On arrival to the ED, the patient is conscious. The trauma service finds significant leg wounds, along with survivable chest and upper extremity injuries. He undergoes a number of surgeries, but is able to be released to a rehabilitation facility several weeks later.

DISCUSSION

There were significant challenges in patient management in this incident, involving the original crash and the secondary compression. The challenges included limited access with very limited ability to assess the patient’s injuries and the uncertain time to extrication. A cooperative patient who was perfusing adequately to provide the responders some feedback on injuries they couldn’t visualize was an unusual aspect of this incident, compared to others that are normally reported.

There’s some literature and experience that supports medical care for compression injuries.1,2 But there were uncertain compression forces on the lower body of this victim, who’s in a car and underneath a truck, with wet and sandy ground underneath. It’s much easier to consider the effect of compressive forces when you have a victim trapped with a known amount of weight (10 tons) that’s fallen a certain height (20 feet) against an immoveable surface (a concrete floor) and a known distance of compression where part of the patient is compressed (inches). These scenarios also play out in building collapse situations, such as those in earthquakes.

The scene in this case indicated the lower body and legs were being compressed, and the patient would be found to have significant injuries once extrication was completed. With uncertain timing of extrication, the victim was given supportive care and a modest fluid bolus, but very importantly, the preparations were made for life-threatening injuries once the heavy object was removed from his body.

There’s unlikely to ever be an evidence-based treatment plan that’s best for victims of compression injuries. There will be no randomized controlled study that’s going to provide exact science on these issues due to unique scene characteristics, the medical circumstances related to the crush injuries, coincidental trauma, timing of extrication, preceding volume status and likelihood of vascular collapse after release from entrapment.

The two officers responsible for the extrication process and the medical care were in constant communications and able to make second-to-second decisions. Incident command was in position to negotiate any conflicts between those two officers. These operations frequently are noisy, so some form of reliable communication must be available, even if it’s hand signals that are mutually understood.

CONCLUSION

The early decisions in this incident were made with an expectation of lengthier extrication. Fortunately, the time interval was abruptly shortened and the patient was extricated in less than an hour. This victim had a very good outcome, and the scene was managed with no injuries to rescuers.

REFERENCES

1. Augustine JJ. Priorities in extrication. Emerg Med Serv. 1994;23(6):53–61.

2. Augustine JJ. Wreck with entrapment. Preplanning and communication pay off when a serious crash leaves a woman entrapped. EMS Mag. 2007;36(6):26, 29–30, 32–33.