Vehicle extrication is the process of removing a patient from a vehicle which has been involved in a motor vehicle collision. [1] Patients who have not already exited a crashed vehicle may be medically (cannot exit a vehicle due to their injuries) or physically trapped, [2] and may be pinned by wreckage, or unable to exit the vehicle because a door will not open.
Once an incident scene is protected, extrication can commence. Vehicle extrication can be considered in six phases. These phases are: [3] [4] [1]
Once a scene is protected, for example from other moving traffic, the fire service commander will complete a rapid assessment to identify any significant hazards [5] that may present immediate risks to emergency service workers, members of the public or the patient or patients. This may include fire, hazardous substances, the risk of falling from a height, or being electrocuted or injured by falling masonry from a damaged building. Steps are then taken to mitigate these risks.
Phase 1 is rapid stabilisation, these are simple methods to improve vehicle stability:
Phase 2 is stabilisation achieved using chocks and wedges under and around the vehicle.
Phase 3 is the use of additional equipment to stabilise a vehicle. This may be more complex and include:
Glass management involves controlling the risk posed by the windows of the vehicle. [6] This is not just the removal of the vehicle’s windows: it must also include the control of any glass fragments which may pose a risk to the patient and attending emergency service personnel, or which could damage equipment, especially hydraulic hoses.[ citation needed ]
The space creation step starts with a structural assessment of the involved vehicle to determine which vehicle components could be simply opened, moved, or manipulated by utilising a vehicle’s natural design features. [3] This would include opening doors, windows or sunroofs and moving/removing seats or headrests. Beyond that, an extrication plan will be formulated which details which vehicle body parts will need to be removed, displaced or reformed to allow access to the patient or patients. [7] A number of specific techniques can be utilised and these are discussed later.
Consideration should also be given to moving the vehicle involved in the incident if that will aid space creation. [8] [9] Moving vehicles with patients still inside is permissible if deemed safe. Relocation of crashed vehicles may:
Full access aims to ensure that there is enough space to meet and exceed a patient's clinical requirements and to meet the needs of emergency service personnel. [1] Space creation should allow access for medically trained responders to reach the patient. They can assess the patient and if required undertake medical interventions: for example, stopping bleeding, opening obstructed airways, providing medications such as oxygen or tranexamic acid.[ citation needed ]
It used to be thought that individuals involved in road traffic collisions needed extremely careful handling, including the use of cervical spine collars and spinal immobilisation boards. This is not however supported by the available evidence base. [10] [11] Patients should be encouraged or assisted to self-extricate from the crashed vehicle as a first-line extrication plan, unless: [12] [13]
If extrication is required, patients should not be transported on a rigid extrication (spinal) board, [14] as this can cause pressure injuries, and false positives on later examination of the back. [15] [16] [17] Cervical collars do not adequately protect the neck, [18] but they raise intracranial pressure, [19] [20] impede airway management [21] and cause pressure ulcers, [22] [23] [24] and their routine use is not advised in the developed world, [25] [26] and if used they should be loosened at the earliest opportunity. [27]
Rescue personnel may use a number of powered rescue tools to extricate victims. There are three main types of powered rescue tools including:
Stabilization tools include:
Other equipment that can be used during a vehicle extrication include but are not limited to:
These include: [7]
A roof flap can be undertaken forwards, backwards or sideways. The technique is similar for all three, but the direct the roof is "folded" differs. The steps to perform this technique (forwards) would include: [32]
Removal of the B-post or B-Pillar of a vehicle to allow improved access. The B-pillar is located between a vehicle's front and rear side glass, where it serves as a structural support of its roof, its removal leaves the side of a car wide open.[ citation needed ]
Third door creation (or conversion) provides additional access to patients in 2 door cars. [33]
The dashboard and steering column can intrude into the passenger compartment and crush a patient or restrict their movement. A dash roll, or dash relocation aims to create space by moving the dashboard away from the patient. [34]
Active systems such as airbags make cutting into a vehicle more complicated: when they are not set off during the crash (e.g. in a vehicle struck from the rear or a rollover), extrication operations may set them off. This can cause additional trauma to the victim or to the rescuers.[ citation needed ] Airbags can remain active anywhere from 5 seconds to 20 minutes after being disconnected from the car's battery.[ citation needed ] This is one of the reasons rescuers disconnect the vehicle's battery and wait before cutting into a vehicle.[ citation needed ]
Hood hinge struts can pose a great amount of danger to rescuers who are extricating a victim from a car that had any significant heat in the engine compartment. According to the strut manufacturers, these sealed and pressurized struts are designed to operate at temperatures ranging from 40 degrees Fahrenheit to 284 degrees Fahrenheit.[ citation needed ] No manufacturer could provide any evidence that any testing at temperatures above 284 degrees Fahrenheit had ever been conducted. During a vehicle fire, especially an engine compartment fire, the two hood hinge struts will be exposed to high heat levels. Since there is no pressure relief "valve" on any of these sealed and pressurized struts, the units can fail violently when overheated.[ citation needed ] Unfortunately for firefighters, this failure can actually "launch" the entire strut or just one part of the unit a significant distance off the vehicle like an unguided missile. It is the launching of the heated strut that in several incidents across the United States, has caused serious injury to firefighters. [35]
New hybrid technologies also include additional high voltage batteries, or batteries located in unusual places. These can expose occupants and rescuers to shock, acid or fire hazards if not dealt with correctly.[ citation needed ]
Some vehicles have an additional autogas (LPG) tank. As the system was not built in, there is a risk of damaging the pipe which is often under the car, releasing the pressurized fuel. The risk of this is minimized by locating the line in a protected position during installation. Modern installations also have a shutoff solenoid at the tank so that rupture will only release the fuel in the line rather than allowing fuel to come out of the tank.[ citation needed ]
Car manufacturers are increasingly using ultra-high-strength steel (UHSS) to the crash safety ratings of their vehicles. UHSS is used in areas of the vehicle such as the A-pillar, B-pillar, rockers, side impact beams, and roof beams. This steel is difficult to cut with the standard extrication tools.[ citation needed ]
Carbon fibre poses unique challenges when used to manufacture vehicles. It is light and strong and can be difficult to cut. In addition cutting this material can produce particulates which are harmful to health, and breathing protection is required for rescuers and the casualty. [36]
Tetraplegia, also known as quadriplegia, is defined as the dysfunction or loss of motor and/or sensory function in the cervical area of the spinal cord. A loss of motor function can present as either weakness or paralysis leading to partial or total loss of function in the arms, legs, trunk, and pelvis. The paralysis may be flaccid or spastic. A loss of sensory function can present as an impairment or complete inability to sense light touch, pressure, heat, pinprick/pain, and proprioception. In these types of spinal cord injury, it is common to have a loss of both sensation and motor control.
Whiplash, whose formal term is whiplash associated disorders (WAD), is a range of injuries to the neck caused by or related to a sudden distortion of the neck associated with extension, although the exact injury mechanisms remain unknown. The term "whiplash" is a colloquialism. "Cervical acceleration–deceleration" (CAD) describes the mechanism of the injury, while WAD describes the subsequent injuries and symptoms.
Hydraulic rescue tools, also known as jaws of life, are used by emergency rescue personnel to assist in the extrication of victims involved in vehicle accidents, as well as other rescues in small spaces. These tools include cutters, spreaders, and rams. Such devices were first used in 1963 as a tool to free race car drivers from their vehicles after crashes.
Rescue comprises responsive operations that usually involve the saving of life, removal from danger, liberation from restraint, or the urgent treatment of injuries after an incident. It may be facilitated by a range of tools and equipment necessary to deal with the specific circumstances.
Airway management includes a set of maneuvers and medical procedures performed to prevent and relieve airway obstruction. This ensures an open pathway for gas exchange between a patient's lungs and the atmosphere. This is accomplished by either clearing a previously obstructed airway; or by preventing airway obstruction in cases such as anaphylaxis, the obtunded patient, or medical sedation. Airway obstruction can be caused by the tongue, foreign objects, the tissues of the airway itself, and bodily fluids such as blood and gastric contents (aspiration).
Major trauma is any injury that has the potential to cause prolonged disability or death. There are many causes of major trauma, blunt and penetrating, including falls, motor vehicle collisions, stabbing wounds, and gunshot wounds. Depending on the severity of injury, quickness of management, and transportation to an appropriate medical facility may be necessary to prevent loss of life or limb. The initial assessment is critical, and involves a physical evaluation and also may include the use of imaging tools to determine the types of injuries accurately and to formulate a course of treatment.
Clearing the cervical spine is the process by which medical professionals determine whether cervical spine injuries exist, mainly regarding cervical fracture. It is generally performed in cases of major trauma. This process can take place in the emergency department or in the field by appropriately trained EMS personnel.
A spinal board, is a patient handling device used primarily in pre-hospital trauma care. It is designed to provide rigid support during movement of a person with suspected spinal or limb injuries. They are most commonly used by ambulance staff, as well as lifeguards and ski patrollers. Historically, backboards were also used in an attempt to "improve the posture" of young people, especially girls.
A vacuum mattress, or vacmat, is a medical device used for the immobilisation of patients, especially in case of a vertebra, pelvis or limb trauma. It is also used for manual transportation of patients for short distances. It was invented by Loed and Haederlé, who called it "shell" mattress.
A spinal cord injury (SCI) is damage to the spinal cord that causes temporary or permanent changes in its function. It is a destructive neurological and pathological state that causes major motor, sensory and autonomic dysfunctions.
A cervical collar, also known as a neck brace, is a medical device used to support and immobilize a person's neck. It is also applied by emergency personnel to those who have had traumatic head or neck injuries, although they should not be routinely used in prehospital care. They can also be used to treat chronic medical conditions.
A Kendrick extrication device (KED) is a device used in extrication of victims of traffic collisions from motor vehicles. Commonly carried on ambulances, a KED is typically used by an emergency medical technician, paramedic, or another first responder. It was originally designed for extrication of race car drivers. Typically used in conjunction with a cervical collar, a KED is a semi-rigid brace that secures the head, neck and torso in an anatomically neutral position. Its use is claimed to reduce the possibility of additional injuries to these regions during extrication, although its value has been questioned, as there is a lack of evidence to support its use. The original KED was designed by Richard Kendrick in 1978.
A cervical fracture, commonly called a broken neck, is a fracture of any of the seven cervical vertebrae in the neck. Examples of common causes in humans are traffic collisions and diving into shallow water. Abnormal movement of neck bones or pieces of bone can cause a spinal cord injury, resulting in loss of sensation, paralysis, or usually death soon thereafter, primarily via compromising neurological supply to the respiratory muscles and innervation to the heart.
Stabilization is a process to help prevent a sick or injured person from having their medical condition deteriorate further so that they can be treated. Examples include while the person is waiting for medical treatment and in the intensive care unit.
A disc herniation or spinal disc herniation is an injury to the intervertebral disc between two vertebrae, usually caused by excessive strain or trauma to the spine. It may result in back pain, pain or sensation in different parts of the body, and physical disability. The most conclusive diagnostic tool for disc herniation is MRI, and treatments may range from painkillers to surgery. Protection from disc herniation is best provided by core strength and an awareness of body mechanics including good posture.
Grady straps are a specific strapping configuration used in full body spinal immobilization.
In sports medicine, helmet removal is the practice of removing the helmet of someone who has just experienced a sports injury in order to better facilitate first aid. Obvious causes include head and neck injury, or both, with no immediate means of excluding neck injury in the athlete who may be unable to give a history.
Spinal precautions, also known as spinal immobilization and spinal motion restriction, are efforts to prevent movement of the bones of the spine in those with a risk of a spine injury. This is done as an effort to prevent injury to the spinal cord in unstable spinal fractures. About 0.5-3% of people with blunt trauma will have a spine injury, with 42-50% of injuries due to motor vehicle accidents, 27-43% from falls or work injuries, and the rest due to sports injuries (9%) or assault (11%). The majority of spinal cord injuries are to the cervical spine, followed by the thoracic and lumbar spine. Cervical spinal cord injuries can result in tetraplegia or paraplegia, depending on severity. Of spine injuries, only 0.01% are unstable and require intervention.
Basic airway management is a concept and set of medical procedures performed to prevent and treat airway obstruction and allow for adequate ventilation to a patient's lungs. This is accomplished by clearing or preventing obstructions of airways. Airway obstructions can occur in both conscious and unconscious individuals. They can also be partial or complete. Airway obstruction is commonly caused by the tongue, the airways itself, foreign bodies or materials from the body itself, such as blood or vomit. Contrary to advanced airway management, basic airway management technique do not rely on the use of invasive medical equipment and can be performed with less training. Medical equipment commonly used includes oropharyngeal airway, nasopharyngeal airway, bag valve mask, and pocket mask. Airway management is a primary consideration in cardiopulmonary resuscitation, anaesthesia, emergency medicine, intensive care medicine and first aid.
Cervicocranial syndrome or is a combination of symptoms that are caused by an abnormality in the cervical vertebrae leading to improper function of cervical spinal nerves. Cervicocranial syndrome is either congenital or acquired. Cervicocranial syndrome may be caused by Chiari disease, Klippel-Feil malformation, osteoarthritis, and physical trauma. Treatment options include neck braces, pain medication and surgery. The quality of life for individuals suffering from Cervicocranial syndrome can improve through surgery.
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