Management Algorithm for Extrication and Indications for Field Amputations
The authors present a case involving a recent entrapment of an 18-month-old child in an escalator which was successfully managed by the swift actions of first responders.
We present a case of a pediatric entrapment in an escalator comb plate of an 18-month-old child. The incident necessitated field intubation of the child in a shopping mall with subsequent disassembly of the escalator and transport with the escalator comb plate attached to the finger to a Level 1 trauma center with hand/microvascular coverage. The escalator part was successfully removed in the operating room and the child went on to have full recovery and complete use of the hand.
We discuss current algorithms and recommendations for the management of limb entrapment including field amputations. We propose the early involvement of a hand microvascular specialist for upper extremity entrapment via telemedicine to assist the onsite first responders and help coordinate possible operative care once a patient is extracted.
Approximately 11,000 escalator-related injuries occur each year according to recent estimates by the United States Consumer Product Safety Commission (CPSC).1 Ninety percent of these occur due to a fall, with the remaining 10% of injuries resulting from entrapment of the foot or hand.1 As a result, in 2008, the CPSC published detailed guidelines regarding the safe use of escalators.
Approximately 6% of escalator-related accidents happen to children.4 In a large epidemiologic study performed by McGeehan et al. (2006), there was an average of 2,000 annual escalator injuries among children aged 0 to 19 years, with a mean age of 6.5 years at the time of injury.5 Case reports began to emerge in the 1960s that led to greater public awareness of potential dangers to children on escalators, as well as improved design to limit injuries.2,3 Entrapment comprised 29% of all injuries from prior reports. The leg was overall the most commonly injured limb; however, injuries to the hand were the most frequently injured body part in children younger than five. Reid (1968) reported two cases of pediatric hand injuries secondary to the children’s hands slipping between the stair edge and the sidewall, entrapping the hand as the gap closed upon final descent.2 Similarly, Kates (1968) reported a pediatric foot injury resulting from rubber boots catching in the escalator.3 These series of injuries led to preventative measures emphasizing close supervision of small children upon escalators and warning labels posted upon entry to an escalator.
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McGeehan et al.5 concluded that vigilance is necessary when monitoring children on an escalator and emphasized the need for smaller gaps between the staircase and sidewall to reduce entrapment injuries to young children. In an effort to reduce the risk of entrapment, large escalator manufacturers introduced new designs that aimed to eliminating entrapment by molding the skirt panel (the panel adjacent to the side of the steps) and the moving step into one unit. Further, the stair treads now have a 4-mm radius of curvature on the ends to decrease the risk of laceration or entrapment with the comb plate.6
Previous pediatric case reports describe a common mechanism of injury related to entrapment of the hand between the stair and the sidewall, and injury stemming from primary trauma as well as extrication-related injuries. Other cases describing entrapment of the foot in the “teeth” at the bottom or top of the escalator have been reported as well, often attributed to types of flexible, rubber shoes.7 The mechanism of the hand injury sustained by our patient presented in this case report is less commonly documented. The patient had an entrapment of the fingers between the grooved step and the “comb” (the toothed portion of an escalator comb-plate). During extrication, the comb plate was unable to be freed from the patient’s hand, as one of the comb spikes had impaled the small finger. The following case highlights the need for understanding proper extraction protocols and field procedures in these challenging scenarios through this case presentation.
An 18-month-old male presented to the emergency department at our institution after a prolonged extrication from an escalator at a local shopping mall. The child arrived intubated with the comb plate of the escalator still attached to the finger. Per the emergency medical services (EMS) report, upon descending the stair to the horizontal landing, the patient’s hand was resting on the grooved stair. As the grooved stair met the comb-plate, the small finger was entrapped between the groove of the stair and the metal combs, impaling the finger with a single metal comb. This action alerted the “comb-step impact device,” which detects when an object is caught beneath the comb-plate, thus initiating an emergency stop of the escalator. EMS arrived on the scene and were unable to extricate the hand from the comb-plate. The crew performed a field intubation and unfastened the entire comb-plate apparatus while it was still attached to the patient’s hand [Figure 1].
Upon arrival at the emergency department, the small finger appeared perfused and the patient was expedited to the operating room to attempt removal of the impaling object. Due to the attached escalator plate, no radiographic diagnostic imaging was feasible, although it appeared that the impaling comb had caused a middle phalanx fracture. The initial assessment was concerning due to the hook-shaped comb design, and it was unclear if the object could be removed without having to cut the metal comb. Fortunately, the phalangeal fracture provided enough mobility to allow careful removal of the comb using ultrasound gel as a lubricant to protect the surrounding tissues. The small finger maintained excellent perfusion and capillary refill throughout the procedure. Surgical debridement was performed. The wound was closed with 5/0 chromic sutures and placed the hand in a long arm splint. The small finger healed uneventfully [Figure 2].
Case reports in the 1960s of escalator-related hand injuries, along with detailed guidelines from the CPSC have brought greater public awareness of the potential dangers for children on escalators. Of the approximately 11,000 escalator-related injuries occurring each year, nearly 6% involve children, with a mean age of 6.5 years at the time of injury. The most common cause of entrapment in young children occurs as the child is reaching for a fallen object or sitting on the escalator step.8 While the leg is the most commonly injured body part in children 0 to 19, the hand is the most common site of injury in children younger than five. This injury pattern can likely be explained from a less well-established upright gait as well as the smaller size of the hand and resulting in a higher likelihood of entrapment in small gaps such as between the stair/sidewall and the step/comb-plate at the terminal end of an escalator.
The resulting trauma is often a combination of the initial entrapment and the attempt of extrication of the entrapped limb. In a retrospective review of nearly 6,000 escalator-related injuries in children, McGeehan et al. (2006) concluded that amputations resulting from escalator injuries, although infrequent (833/5989), primarily occurred in children younger than five years old (71.4%, 595/833).5 In addition, 86.2% (512/595) of the amputations/avulsions were results of entrapment and most, 92% (548/595), were of the hand.5 The entrapment of a child is a traumatizing event not just to the patient but to the involved family and first responders alike. It is thus important to operate using a standardized protocol to clarify decision-making and optimize outcomes.
While field amputations are rarely indicated, they can be considered in two scenarios: first in large-scale catastrophes such as an earthquake where entrapment is caused by large structural collapse, and second in isolated accidents involving a single patient such in our case. Availability of resources, accessibility of the patient, and the patient’s medical status might be vastly different between the two types of scenarios.
As is with any situation, when encountering an entrapment, it is imperative for first responders to assess the scene of the accident for risk of imminent harm to patient and personnel, such as the risk of structural collapse, fire danger, etc. From a medical perspective, stable vitals must be confirmed, and the patient must be evaluated for associated injuries. Parallel to this, respiratory support including intubation if needed, fluid resuscitation, and analgosedation is initiated as indicated by the scenario.
An indication for field amputation is given whenever the physical environment does not allow extricating the patient without severing a limb – e.g. nonremovable object, or an unstable environment necessitating rapid extrication. With regard to the patient’s condition, specific indications for a field amputation are: 1) hemodynamic instability and lack of response to resuscitation, 2) multiple failed attempts at extrication, 3) a minimally attached extremity or an extremity that is severely mangled or crushed, and 4) a deceased patient blocking access to survivors.5,9 Macintyre et al. (2012) presented a detailed summary of this and suggested a protocol for field amputations and dismemberment in scenarios of individual entrapment in collapsed structures.10 Based on current literature and our anecdotal experience, we propose an algorithm for extraction and/or field amputation in scenarios of limb entrapment from isolated accidents such as seen in our case [Table 1].
While this algorithm can be used for upper extremity and lower extremity involvement, this report focuses on upper extremity entrapments. First responders should first assess whether extraction of the entrapped limb will require prolonged efforts. If so, providers need to assess if the environment is safe and establish whether the patient has stable vitals and escalate interventions as needed. This may entail establishing airway control and intubating the patient as needed as well as placing vascular access and starting resuscitation efforts.11 Once these first steps are performed, and the patient is stable, it is important to assess the limb condition in detail: Is the limb intact and perfused? Are other resources available to facilitate extrication while preserving the limb?
As in our case, there was a stable intubated patient in a mall, who could not be extricated from an escalator due to the hook-shaped comb plate which had impaled the finger. While finger amputation would have been the next step if disassembling the escalator would have not been feasible, this step was avoided by the available expertise of the firefighters and escalator technician. If at any time during the extraction process, the patient’s hemodynamic status deteriorates, the decision to amputate may be indicated in order to remove the patient from the hazardous situation and expedite transfer to the hospital to improve survival odds.
Detailed extrication guidelines may be found in EMS field manuals. As outlined, appropriately structured extrication requires a combined collaboration between the emergency medical personnel and extrication technicians. In addition, once the decision is made to perform a field amputation, there must be a systematic approach to safely and quickly perform the amputation as well as a patient transport and care protocol in place for immediately after the amputation.
When performing a field amputation, the procedure should be directed by a team approach. The team leader should be well versed in limb anatomy and trained in performing amputations. First responding providers in an entrapment situation are usually emergency medicine physicians or trauma surgeons. While there is usually no upper extremity reconstructive surgeon available on site as part of the limb salvage team, we propose to include contact numbers of a 24/7 hand microvascular service in the emergency manual for field amputations. Ideally, the contact is via cellphone and video telemedicine, such as demonstrated in a statewide model in Arkansas12 to establish real-time audio/visual communication. A hand and upper extremity microvascular surgeon can not only provide valuable guidance for the team on-site but also facilitate access to operative specialty care once the extrication is performed.
Having access to a specialist in limb replantation and salvage may be beneficial in the decision-making process, especially in scenarios where the resources of EMS are limited. This specialist can help assess the salvageability of the limb together with first responders’ assessment of the patient’s vitals and a collaborative decision can be made to either extricate, even if the process may need extra resources, or perform a field amputation. In the current time of advanced telemedicine, electronic consultation with a surgeon may be possible even via a smartphone.12,13,14,15 Certainly, in instances where a surgical specialist is not available, the most qualified physician should be utilized, and field management should not be delayed.
While improved escalator design and increased awareness among healthcare providers and parents reduced escalator-related pediatric injuries, these tragic accidents still happen and therefore a coordinated response by first responders and limb salvage specialists is needed. We present a case of a recent entrapment of an 18-month-old child in an escalator which was successfully managed by the swift actions of first responders and present an updated algorithm for the management of limb entrapment and field amputations. When possible, we recommend the early involvement of a hand/microvascular specialist in the management of these injuries via telemedicine to facilitate on-site management and to expedite referral to an appropriate trauma center after extrication.
Written informed consent was obtained from the patient’s parent for publication.
List of Abbreviations
CPSC – United States Consumer Product Safety Commission
EMS – Emergency Medical Services
The authors declare that they have no competing interests.
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- MacIntyre A, Kramer EB, Petinaux BP, Glass T, Tate CM. Extreme measures: Field amputation on the living and dismemberment of the deceased to extricate individuals entrapped in collapsed structures. Disaster Medicine and Public Health Preparedness. 2012 December;6(4):428-435.
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- Bracey JW, Tait MA, Hollenberg SB, Wyrick TO. A Novel Telemedicine System for Care of Statewide Hand Trauma. Hand (N Y). 2021 Mar;16(2):253-257. doi: 10.1177/1558944719850633. Epub 2019 May 29. PMID: 31142147; PMCID: PMC8041423
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