Care of the Entrapped Patient Including Crush Injuries

1

Why is scene safety so important?

There are a variety of scenarios to which EMS providers will be called. When discussing patient extrications, the majority will be from severe motor vehicle accidents. There are also many possible industrial and agricultural accidents, as well as the rare but catastrophic natural disasters and acts of terrorism. Extreme caution must be used to avoid secondary injury to first responders—having a keen awareness of potential chemical leaks and the structural integrity of buildings after a fire, bombing, tornado, hurricane, or earthquake. With the increase in mass shootings, first responders must be aware of the possibility of a secondary shooter targeting EMS responders. As an EMS responder, you are no good to the patient if you become injured or incapacitated.

2

How can I protect myself when responding to an emergency?

Situational awareness (understanding your surroundings) is paramount to ensuring your own safety. Personal protective gear such as gloves, helmet, and a high-visibility reflective vest should always be used along with emergency lighting when parked on a road or other potentially dangerous scene. Larger vehicles such as fire engines should be parked diagonally across the roadway ahead of the accident as an impact barrier to keep the primary accident scene safe. EMS providers must be cognizant of potential fuel or other hazardous material spills and wait for fire/hazmat to clear the scene. Medical vehicles should be close to the patient for quick access to supplies and ease of transport.

3

What are the components of a systematic approach to rescue trapped patients?

• a.

  Scene assessment: Approximately 10% of motor vehicle accident patients are trapped for more than 30 minutes prior to extrication. The incident commander must assess the scene and rapidly identify immediate hazards, the number of victims, and possible rescue strategies. It is important to activate all possible resources in a timely manner; it is better to turn away resources than to delay care because they are not on scene.

• b.

  Hazard management: The key components are donning personal protective equipment and controlling traffic flow.

• c.

  Gaining initial access: This allows initial triage of the involved patients and prioritization of resources. Glass in windows can be taped in a crisscross pattern before it is broken to minimize the pieces that fall into the car onto the patient. A fire blanket can provide soft protection.

• d.

  Creating space: This is staging for patient extrication. Perform immediate medical care (ABCs)—supplemental oxygen, cardiac monitoring, maintaining c-spine precautions, and establishing intravenous (IV)/intraosseous (IO) access or administration of intramuscular (IM) or intranasal medications. Without a clear egress pathway, extrication may result in further injury to the patient. Providing rapid, aggressive treatment prior to extrication may make the difference between life and death.

• e.

  Getting full access: It is important to shield both the patient and rescuers from falling objects, glass fragments, rescue tools, bare metal edges, and noise as to not further injure the patient by efforts of the rescue team.

• f.

  Patient extrication: Appropriate analgesia and sedation will often facilitate an extrication. During the process of extrication, care should be taken to minimize movement of the spine to prevent worsening of any possible injuries. Caution should be used to maximize patient immobilization and prevent dislodgement of fractures, hematomas, and existing lines and tubes. The Kendrick Extrication Device (KED) may be helpful in safely moving the patient to a long board for easier transport.

4

What types of tools might be used to extricate a patient?

In the event of a fire, explosion, or earthquake, EMS providers should not enter a structure until its integrity can be verified. Any structure involved should be stabilized. A variety of methods may be used, including wood block cribbing, pneumatic airbags, and strut systems. EMS personnel must be familiar with the equipment used by their agency and be comfortable with deploying it. Wide full access is achieved by systematic dismantling the object or vehicle around the patient. The Halligan bar, which combines a blade, claw, and tapered pick, along with hydraulic tools, such as spreaders and cutters, commonly referred to as the “jaws of life,” is often used. A gap can be created between the door and frame near the handle with a Halligan bar or other similar tool. Hydraulic spreaders can then be inserted into the gap and used to spread the door from the frame.

5

What are some important mechanical considerations when extricating a patient from a vehicle?

One of the first steps is to disconnect the battery. Airbags that have not deployed with the initial impact may deploy during the extrication attempt, causing severe injury to the patient or providers. A rescuer should never place themselves between a loaded airbag and the patient. Front seats can be reclined or moved backward to maximize space. In some situations, a car may need to be disassembled to extricate a patient. This is performed in a stepwise manner. The windows are first removed, starting away from the patient to allow immediate access to cover the patient before breaking windows close to them. Next, the metal support posts between the windows are cut. If necessary for roof removal, the front and rear posts can then be cut and the roof lifted off the car. Alternately, the front two to four posts can be cut, and the roof can be folded up and backward.

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