Photo courtesy Adrian DeJesus
Motor vehicle crashes (MVCs) continue to be a source of severe injury and death in the United States. In 2013, the National Highway Traffic Safety Association (NHTSA) reported 32,719 fatalities and 2,313,000 injuries from MVCs.1 This is a downward trend in the fatality of the over 5 million total crashes each year. Of occupants in fatal crashes, 49% were unrestrained, and alcohol-impaired fatalities accounted for 31% of the deaths.
However, changes in personal behavior, overall health of citizens and vehicle design changes are making the rescue and treatment of survivors of MVCs more difficult for EMS.
More than one-third (78.6 million) of U.S. adults are obese.2 Obese and morbidly obese drivers have a 50% and 80% increased risk of death in an MVC, respectively.3 Survivors with advanced age, anticoagulants and complex medical conditions all make the initial triage and medical care of patients in MVCs more challenging.
Vehicle design changes and changes in emergency spinal care guidelines would appear to reduce the challenges of vehicle extrication, but in fact have created more challenges for EMS, fire and rescue teams. A vehicle occupant with a properly functioning restraint system will have a greater chance of being alive with severe but survivable injuries than they were a decade ago, but will often require a very coordinated extrication uninhibited by the complexity of a modern vehicle.
Emergency crews must work together to balance the priorities of rescuer and patient safety, utilization of resources, tactical decision-making, and patient care in the continued race to bring a patient to a trauma team as quickly as possible. Crews are encouraged to get patients to critical trauma care within the "Golden Hour"--a term credited to famous University of Maryland shock trauma surgeon R Adams Cowley, MD--which is the first 60 minutes after their injury. The Golden Hour will likely never see a randomized trial, but trauma teams across the nation continue to work to shorten the time patients experience the progressive decline toward death brought on by hemorrhagic injuries and shock.
Despite awareness of the time sensitivity of the severely injured trauma patient, barriers can still occur that add time to the clock. Rescue teams with inadequate resources and training, delays in extrication because of safety concerns, lengthening the extrication time because of needing to modify a rescue plan, lack of preparation to quickly transition from treatment to transport, and underuse of air medical resources or poor communication from rescue to transport crews can all prolong the time it takes for a patient to reach definitive surgical care and negatively impact the patient's outcome.
Damage Control Extrication
Changes in how severely injured trauma patients are treated by trauma teams can be applied to how vehicle extrication is performed by rescue teams. Over the past 20 years, trauma teams have applied the concepts of damage control to performing surgical interventions on polytrauma patients.4
Damage control surgery means trauma teams perform only the necessary maneuvers to stop bleeding and resuscitate the patient. The patient is then allowed to stabilize before undergoing additional surgery to completely repair their injuries.
The concept "damage control extrication" (DCEx) was first described by trauma surgeon Mark Gestring, MD, director of the Kessler Trauma Center at the University of Rochester.5 DCEx requires teams to assess the complexity of the rescue scenario and develop an integrated rescue and medical plan that incorporates tactics that balance the patient's injuries, time and risk to the survivor and team. The goal of DCEx is to improve survival through teamwork, effective tactics and a stronger focus on the patient than the accident.
This concept has created a framework for rescuers and emergency medical professionals to increase education, discuss common strategies and tactics, define roles and expectations and train together to improve patient care.
For responders who have the luxury of working with cross-trained rescue and medical personnel daily, this may not be a difficult challenge. But for the thousands of responders who work in isolation from their peers in the rescue services, the DCEx platform is an opportunity to come together. The DCEx process should be used when there's been a high-energy impact and inadequate use of restraint systems or failure of the patient compartment, thoracic or lower extremity trauma (including pelvis), or a complex extrication (more than three multi-step maneuvers).
Each rescue maneuver (door removal, roof removal, etc.) should take less than five minutes. After size-up, a rescue team should have a good idea of how many maneuvers it should take. Photo courtesy John Spaulding
To participate in vehicle extrication, EMTs and paramedics should have more than the obligatory extrication demonstration. To integrate into the rescue team, a provider must understand the following:
- Crash mechanics, force and velocity;
- Injury profiles;
- Restraint systems benefits and limitations;
- The team's "rescue playbook";
- Their defined role in the rescue team;
- The appropriate personal protective equipment (PPE) to wear; and
- The process to communicate with the rescue supervisor.
- When confusion and conflict occur between medical and rescue priorities, it's the patient who suffers.
Understanding injury profiles is the first step in adding value to the extrication process. The crashworthiness of vehicles is based on a detailed assessment of many factors. Translating this information into the initial and ongoing size-up for rescue teams can be intimidating. Begin by considering what the typical crashworthiness test is and make a determination if the impact the survivor compartment sustained was beyond that.
This high index of suspicion for severe injuries will lead the EMT, paramedic or first responder to consider what severe injuries may be involved. For frontal or offset collisions with a combined speed of greater than 75 miles per hour with damage and intrusion to the survivor compartment, or with failure or inadequate use of restraints, medics must consider that these patients have severe injury.6 (See Table 1 above.)
Frontal impact protection reduces head and cervical injury but significant thoracic, lumbar, pelvis and lower extremity injury can still persist.7,8 Side impact or lateral collisions offer very little space to displace or absorb the energy of the collision.
Chest wall, lung, and pelvis injuries can easily occur along with the head impacting the B post if there's no side curtain airbag. In side impact crashes, despite modern vehicle design, a 30-cm (11.8-inch) intrusion is associated with a 20-fold increase risk of pelvic fractures, and in the elderly there's a 70% increase risk of pelvic fracture.9
In rollover crashes, ejection of occupants continues to be a major risk. But belted, non-ejected occupants in rollover crashes account for 1/3 of serious spinal cord injuries and 42% of spine injuries occurred with roof intrusion of less than 5.8 cm.10
EMS units should always position their vehicles to consider routes of travel to the hospital, protection from traffic, upwind and uphill hazard separation, and allowing rescue and fire suppression equipment adequate space.
Vehicle extrications pose many hazards to rescuers and survivors. Teams should operate within the hot, warm and cold zone safety fields. Hazards from fire, electricity, jagged metal, projectiles, falls, biological contaminants and inhalation of dust and fumes are present at every crash.
The hot zone should generally be a 15-foot parameter around the vehicle, and everyone in that zone should have proper PPE that includes footwear, long pants, jackets, eye protection, gloves and respiratory protection as needed.
Emergency medical providers trained in extrication can add a great deal of value to a rescue team. The approach to a crash involves a detailed 360-degree size up, scene safety measures, ongoing vehicle stabilization, safe patient access, disentanglement of the vehicle from the patient and extrication of the patient from the vehicle. (See Table 2 above.)
Scene size-up should include looking for evidence the driver was alert and reactive at the time of the accident through steering or braking maneuvers. Gathering information about posted and observed speeds of those involved should be obtained in conversation with law enforcement.
First-arriving EMS resources that may not be able to participate in the hot zone of the rescue can provide important information to the rescuers by using gathering information about fuel, battery locations and restraint systems.
Patient protection should include both hard and soft material. Hard material such as polycarbonate (lexan) will shield the patient from impact debris and tools, and soft material such as a tarp will protect the patient from glass. If sparking tools are used, a non-flammable blanket should be used for protection. Crews should also be able to provide dust protection to the patient as needed. The stance of crews operating in the hot zone should be down in a crouch with a reduced profile,standing only to perform an extrication maneuver. This is an easy way to separate the spectators from the workers.
EMS on the Inside
Patient access should be performed as soon as the vehicle is stable and any external hazards are controlled. Consider that doors unaffected by the crash may open normally. When breaking glass is required, it should be done farthest from the patient until they're adequately protected.
The inside medic (EMT or paramedic) should be prepared with safety equipment, flashlights, hemorrhage control supplies, spinal immobilization equipment and patient lifting straps. A dedicated outside medic should stay in constant communication with the inside medic to provide any additional equipment, direct the preparation of treatment and transport equipment, and provide updates to the receiving trauma team.
The inside medic should perform an initial focused exam of the survivor and vehicle, provide psychological first aid and perform any treatment that doesn't interfere with the rescue. The inside medic should account for all occupants in the vehicle, determine seat position and function and damage to the interior compartment. They should also identify fired or unfired air bags and determine if the patient was restrained.
The presence of unfired restraint systems should be communicated with the team leader. Managing risk and providing protection to all team members and the patient are critical to permitting the rescue to proceed at an appropriate speed. If the patient has an adequate airway and ventilation, an early priority will be to determine the extent of the entrapment and communicate this in detail to the rescue team leader.
The inside medic's ability to determine and communicate the internal entrapment and possibly remove debris will improve the speed of the rescue. The extent of entrapment will vary based on impact direction, survivor characteristics and vehicle type. In many cases the lower extremities will simply disappear below the dash and their status is unknown.
If the limbs can be located and it's determined the entrapment is a focal entrapment by a pedal or floor pan wrapped around the foot, the rescue team strategy should change appropriately. A rescue group supervisor may be planning to lift the entire dash when a focal entrapment only requires a relief cut and displacing some material. In modern vehicles, the entrapment can occur from a large amount of plastic debris. Although rigid, this material can often be fractured and removed internally, freeing lower limbs.
An overweight or obese patient will also impact the strategy. The larger patient generally is entrapped by pressure in all directions and requires access from 360 degrees to allow team members adequate access to lift without risking injury.
Rescue group supervisors encountering an overweight patient should consider using a second tool team to remove opposing vehicle side walls and seats to allow proper access. Even when the patient will be removed horizontally, lifting straps or large webbing can permit adequate and safe points for rescuers.
The ongoing assessment of the trapped survivor will yield vital information that can reduce delays after extrication. Pertinent medical history of cardiac or endocrine diseases or neurological disorders are important findings to communicate to the transport team. The Centers for Disease Control and Prevention 2011 Field Triage Guidelines for Injured Patients includes patients on anticoagulants or with bleeding disorders as criteria for a trauma center.
The primary goal should be to get the patient to the definitive care of the trauma team. Good communication between the rescue supervisor and the inside medic will determine if an extended extrication may warrant escalating patient care.
Each rescue maneuver (door removal, dash removal, roof removal, etc.) should take less than five minutes. After size-up, a rescue team should have a good idea of how many maneuvers it should take.
A rescue effort lasting longer than four major maneuvers or 20 minutes should be considered an extended extrication. During extended extrications, the medical concerns for hypothermia, pain control or volume resuscitation may warrant additional management. Even mild hypothermia (34–36 degrees F) can give patients cold-induced coagulopathy, which will worsen any bleeding or shock state.11
Crews transporting multi-trauma patients should have hypothermia management kits for any patient with a delayed rescue or who may be receiving volume resuscitation. Pain control or sedation during extrication should be administered with clear communication with the rescue team and cautious titration that permits the patient to remain conscious and allows for an accurate exam to identify possible injuries. Agents like ketamine, fentanyl and midazolam have been shown to be administered safely and effectively intranasal in hospitalized patients as well as in prehospital settings.12,13
Scene size-up should include looking for evidence the driver was alert and reactive at the time of the accident through sterring or braking maneuvers. Photo courtesy Bill Hallinan
The disentanglement maneuvers used by rescue groups should have predefined names and steps known to all responding agencies. Even in the most mangled vehicle, standard steps for cutting, spreading, relief gapping and displacing material should be used.
Many disentanglement procedures can be ineffective if there aren't proper relief gaps or if the material is displaced against the suspension system of the vehicle. Another barrier to effective disentanglement is tunnel vision, which prevents teams from seeing the strong points from which material can be pushed.
Teams can lose valuable time trying to make small efforts to get "just enough room," when what may seem like a larger maneuver can displace a lot of material more quickly and provide the team greater access to extricate the survivor. In complex or extended extrications, rescue group leaders should request enough resources to operate several plans simultaneously. (See Table 3 below.)
For example, the damaged side may seem like a direct path to a patient in a side impact collision, but a full sidewall, seat and center console removal can create a faster extrication path because crews aren't working against the impact of the collision.
For rescue groups with limited equipment or manpower, knowing when to stop a plan that's struggling is a difficult challenge. Even if resources for simultaneous operations aren't available, a leader can be identified who will be working on a backup plan, monitoring the primary plan for progress and be empowered to discuss changing plans with the rescue group supervisor. The crews working on the primary plan will often continue without consideration for a change in direction.
The transition from disentanglement to extrication should be seamless. The decisions to remove a survivor horizontally or vertically will depend on the manpower available, access to the patient, suspected injuries and resources for lifting. Extrication of patients with severe limb injuries can be a painful experience for the patient and uncomfortable for the EMT or paramedic. Angulated limbs can be returned to a neutral position when the patient is extricated. Delaying extrication for a limb that's free but requires manipulation puts the patient at further risk of hypothermia, bleeding, limb ischemia and injury.
The rescue, treatment and transport groups must all understand they share the same precious field time allotted to the prehospital team. Opportunities to reduce on-scene time include the outside medic keeping transport teams updated on the progress of the rescue, transport teams being available and ready to transport the patient after extrication, and reducing repetition in patient assessments.
An effective means of producing a seamless, accurate and timely transition to transport is to keep the inside medic with the patient until handoff to the trauma team at the hospital. During handoff, accurate facts are often lost that would paint an important picture for the members of the trauma team. Transporting medical crews must be ready to receive the patient after extrication. Have ambulances well-positioned, gurneys and immobilization devices ready, infusion lines primed, and adjuncts to keep the patient warm and secure.
With proper education and training, EMS can improve outcomes for critically injured trauma patients. The integration of high-quality medical care, quick and efficient rescue plans, and timely transport can give trauma teams the time to provide definitive care.
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