Extrication

PHEMCAST

Road traffic collisions are a leading cause of death and injury. Following a road traffic collision many patients will remain trapped in their vehicle. Extrication is the process by which injured or potentially injured people are removed from their vehicle by the rescue services.

Rescue service training focuses on the absolute movement minimisation of potentially injured patients’ spine and has developed extrication techniques with the focus of movement minimisation. Unfortunately these techniques take significant amounts of time (30 minutes plus); this delays access to potentially lifesaving treatments for injuries.

In this Road Safety Trust funded project, the EXIT team across nine published academic studies reconsider extrication, provide evidence of harm, demonstrate that current techniques do not minimise movement as intended and provide a framework of principles for evidence-based extrication:

Operational and clinical team members should work together to develop a bespoke patient centred extrication plan with the primary focus of minimising entrapment time

Independent of actual or suspected injuries patients should be handled gently. A focus on absolute movement minimisation is not justified

When clinicians are not available, FRSs should where necessary assess patients, deliver clinical care and make and enact extrication plans (including self-extrication)1

Self-extrication or minimally assisted extrication should be the standard ‘first line’ extrication for all patients who do not have contraindications, which are: -An inability to understand or follow instructions, -Injuries or baseline function that prevents standing on at least one leg, (specific injuries include: unstable pelvic fracture, impalement, bilateral leg fracture)

All patients with evidence of injury should be considered time-dependent and their entrapment time should be minimised

Incidents where a patient may require disentanglement are complex and associated with a high morbidity and mortality. A senior FRS and clinical response should attend such instances2

Clinical care during entrapment: -Can be delivered by FRS or clinical services1 -Should be limited to necessary critical interventions to expedite safe extrication3 -Rescuers should be aware that clinical observations may prolong entrapment time and as such should be kept to the minimum -FRS and clinical personnel should be aware of the physical and observable signs of patient deterioration and if identified should make this known to the responsible clinician

Immobilisation: -Longboards are an extrication device and should not be used beyond the extrication phase -Kedrick Extrication Devices prolong extrication time and their use should be minimised -Pelvic slings should not be applied to patients until they have been extricated -Cervical collars should only be used following assessment and should be loosened or removed following extrication

Patient focused extrication: -Build a connection with patients, explain actions, and use their name -Where appropriate, reassure patients as to the safety of their co-occupants and others involved in the incident (including animals) -Provide an ‘extrication buddy’ -Allow communication with family members or other close contacts -Rescue teams should not publish extrication related imagery to social media or other outlets -Minimise the ability of the public to view the accident, take photographs or record videos. Provide education to this effect

On initial call to Emergency Services -Attempt to clarify entrapment status -Attempt to identify patients who require disentanglement (and dispatch an appropriate priority senior2 response) -A standard multi-agency MVC trauma message should be developed to ensure the correct resources are deployed

Multi-professional datasets should be developed with patient and public engagement and should include entrapment status, entrapment time, injuries, extrication approach, clinical care

Agreed nomenclature for categories of patient Not injured, Minor injuries (evidence of energy transfer but no evidence of time-dependent injury), Major injury (currently stable but should be assumed to be time-dependent), Time critical injured (Time critical due to injury; use fastest route of extrication) m Time critical hazard (e.g. secondary to fire or other hazard)

These principles have been adopted by national level stakeholders in the UK are being incorporated into national clinical and operational guidance which will reduce entrapment time and may demonstrate morbidity and mortality reductions.

Links to papers:

1. Nutbeam T, Fenwick R, Smith JE, Bouamra O, Wallis L, Stassen W. A comparison of the demographics, injury patterns and outcome data for patients injured in motor vehicle collisions who are trapped compared to those patients who are not trapped. Scand J Trauma Resusc Emerg Medicine 29, 17 (2021).

• Nutbeam T, Kehoe A, Fenwick R, Smith JE, Bouamra O, Wallis L, Stassen W. Do entrapment, injuries, outcomes and potential for self-extrication vary with age? A pre-specified analysis of the UK trauma registry (TARN). Scand J Trauma Resusc Emerg Medicine 30, 14 (2022).

• Nutbeam T, Weekes L, Heidari S, Fenwick R, Bouamra O, Smith JE, Stassen W et al. Sex-disaggregated analysis of the injury patterns, outcome data and trapped status of major trauma patients injured in motor vehicle collisions: a prespecified analysis of the UK trauma registry (TARN). BMJ Open 2022;0:e061076. doi:10.1136/ bmjopen-2022-061076

• Nutbeam, T. Fenwick R, May B, Stassen W,Smith JE, Wallis L, Dayson M, Shippen J. The role of cervical collars and verbal instructions in minimising spinal movement during self-extrication following a motor vehicle collision – a biomechanical study using healthy volunteers. Scand J Trauma Resusc Emerg Medicine 29, 108 (2021).

• Nutbeam, T. Fenwick R, May B, Stassen W,Smith JE, Shippen J. Maximum movement and cumulative movement (travel) to inform our understanding of secondary spinal cord injury and its application to collar use in self-extrication. Scand J Trauma Resusc Emerg Medicine 30, 4 (2022).

• Nutbeam, T. Fenwick R, May B, Stassen W,Smith JE, Bowdler J, Wallis L, Shippen J. Assessing spinal movement during four extrication methods: a biomechanical study using healthy volunteers. Scand J Trauma Resusc Emerg Medicine 30, 7 (2022).

• Nutbeam, T. Fenwick R, May B, Stassen W,Smith JE, Bowdler J, Wallis L, Shippen J. Comparison of ‘chain cabling’ and ‘roof off’ extrication types, a biomechanical study in healthy volunteers. In press; Injury

• Nutbeam T, Brandling J, Wallis L, Stassen W. Understanding people’s experiences of extrication whilst being trapped in motor vehicles: a qualitative interview study. In press; BMJ Open

• Nutbeam T, Fenwick R, Smith JE, Dayson M, Carlin B, Wilson M, Wallis L, Stassen W. A Delphi Study of Rescue and Clinical Subject Matter Experts on the Extrication of Patients Following a Motor Vehicle Collision Scand J Trauma Resusc Emerg Med 30, 41 (2022). https://doi.org/10.1186/s13049-022-01029-x