Vehicle Extrication and Special Rescue DR. MIADA MAHMOUD RADY
LECTURE 1
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Introduction Rescue : Is to deliver from danger or
imprisonment. EMS departments must be prepared to respond to a
variety of special rescue situations. Paramedics are often first on
the scene, so knowing special rescue skills and how to master use
of hand tools is important.
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Types of special rescue incidents include: a.Vehicle
extrication. b.Confined space. c. Trench. d.Water. e.Wilderness
rescue.
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Awareness All EMS providers must have some formal education or
training in rescue techniques. Education and training focus on
awareness. Awareness is Introductory-level training focused on
identifying hazards and securing the scene.
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The function of a paramedic on scene at a rescue incident
depends on the company. a.Safety is the primary concern.
b.Providers must wear personal protective equipment (PPE).
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Technical rescue incident (TRI) A technical rescue incident
(TRI ) : is a complex rescue incident that requires specially
trained personnel and special equipment, involves: 1.Vehicle
extrication.5.Structural collapse. 2.Water/ice rescue.6.High-angle
rescue. 3.Trench collapse.7.Hazardous materials incidents.
4.Confined spaces.8.Wilderness search and rescue.
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levels of TRI training Three levels : A. Awareness. B.
Operations. C. Technician.
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Awareness Introductory-level training focused on identifying
hazards and securing the scene No actual use of rescue skills
Operations More intensive training focused on working in the
immediate area surrounding the hazard (the warm zone) Teaches the
paramedic to directly assist those conducting the operation
technicians Advanced level training focused on direct involvement
in the rescue operation including use of equipment, patient care,
and incident management
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Guidelines for Rescue Operations There are several guidelines
for assisting rescue team members : 1. Be safe ; take care of
hidden hazards e.g. combustible fuels. 2. Follow orders of rescue
team, if you fail to understand specific order ask for
clarification. 3. Work as team. 4. Think, assess and continuously
reassess the scene. 5. Follow the golden rule of public safety;
patient comes first.
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Steps of Special Rescue Regardless of the rescue circumstances,
all rescuers should perform the same eight steps. Aim : to ensure
safety, effectiveness, and efficiency. 1.Preparation5.Access
2.Response6.Disentanglement 3.Arrival and scene size-up7.Removal
4.Stabilization of the scene8.Transport
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Preparation Training with fire departments and special rescue
teams allows you to: 1. Be prepared to respond to mutual aid calls.
2. Learn the skill level of other departments. 3. Communicate
better in the field. Assess the following issues before responding
to TRIs: 1. Does the department have the personnel and equipment
needed to handle a TRI? 2. Who will respond to the call, and with
what equipment? 3. Are department personnel familiar with the
hazard areas in their response area?
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Arrival and Scene Size-Up A.Information received during the
initial dispatch call is critical to the success of the rescue
operation, they may include: 1.Location and nature of the incident.
2.Condition, position of the patient and number of patients trapped
or injured. 3.Specific injuries and hazard information. 4.Name of
the person calling and number to be in contact with.
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Arrival and Scene Size-Up B.Because not all information are
available in dispatch call, responder must : 1.Identify and handle
life threatening hazards. 2.Inform the incident commander (IC) of
any specialized resources needed. 3.Determine whether the situation
is a search, rescue, or recovery. C.Scene size-up includes the
initial evaluation and establishment of a control perimeter.
D.Evaluate the situation before approaching the patient or the
accident area.
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Stabilization of the scene A. Be sure you have identified all
hazards. B.The first arriving responder assumes command. C.Three
guidelines should be followed at every rescue scene: 1. Approach
the scene cautiously. 2. Position apparatus properly. 3. Assist
specialized team members as needed.
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Stabilization of the scene D.Establish three controlled zones:
1.Hot zone : Surrounds the accident, for rescue team only. 2.Warm
zone : For properly trained and equipped persons only. 3.Cold zone
: For staging vehicles,equipment and command post.
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Stabilization of the scene E.Accountability system : 1.Tracks
personnel on the scene via their identity, location and assignment.
2.Can be used to track resources, task assignments, and ensure
personnel safety. 3.Ensures that only rescuers given a specific
task are operating in the rescue area.
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Stabilization of the scene F.Patient contact 1.TRIs can last
for hours, and patients may be alone., so establish communication
via radio, cell phone, or yelling 2. if possible, stay in
communication with the patient throughout the rescue.
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Access Once the scene is stabilized, focus on how to access the
patient : I. Simple access requires hand tools. II. Complex access
requires special tools. Gaining access depends on: I. Type of
incident II. Nature and severity of injuries
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Disentanglement Disentanglement: freeing a patient from
whatever is trapping them. Emergency medical care should begin as
soon as the patient is accessed. A team member should stay with the
patient while they are being disentangled. Unless there is an
immediate threat of danger, perform a primary assessment before
disentanglement begins.
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Removal Preparing for removal involves: 1.Controlling
life-threatening problems 2.Dressing wounds 3.Immobilizing
fractures and spinal injuries Rapid removal if patient is
deteriorating rapidly or hazards are present. Packaging: Preparing
the patient for movement as a unit.
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Transport Transport varies depending on: I.Severity of the
patients injuries II.Distance to the medical facility
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Vehicle Extrication
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Gaining access to the patient 1. First try an easy way as: a.
Through an open window. b. Opening the doors :Try all doors even if
they appear damaged and ensure the locking mechanism is released.
2. If failed, try gaining access through tempered glass Tempered
glass is glass when broken, shattered into pieces
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Gaining access to the patient Gaining an access through
tempered glass is done by following these steps : a.Side and rear
windows are made from tempered glass and break easily. b.Try to use
the window far away from the patient. c.Cover the patient with
blanket before breaking the glass. d.Wear proper PPE and give other
paramedics warning. e.Lower the window as far as possible and aim
at lower corner.
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Gaining access to the patient f. After breaking the window,
clean the remaining glass using hand tool. g. Immediately after
breaking window try to open door by releasing locking mechanism. h.
If not try to enter through the rear window. 3.If still cannot
access patient, heavier tools and more trained personnel's may be
needed.
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4. Providing initial medical care which includes a. Spine
immobilization. b. Assessment and management of the ABCs. c. Care
should occur simultaneous with extrication.
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Additional Specialized Rescue Situations
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1- Confined Spaces
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Additional Specialized Rescue Situations Confined spaces :
Location surrounded by a structure that is not designed for
continuous occupancy. Hazards ( disadvantages) : a. Have limited
openings for entrance and exit. b. Limited ventilation. c. Oxygen
deficiency and poisonous gases. d. High risk of fire and explosion
because flammable mixtures trapped. e. The potential of stored
electrical energy.
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Safe approach 1. Gathering information from bystanders while
waiting for the technical rescue team. 2. Assume an IDLH atmosphere
at any confined-space call. 3. Do not make an entry prior to
atmospheric monitoring. 4. Share with other rescuers what ever
information you have. 5. Assisting other rescuers e.g. Bringing
rescue equipment to the scene.
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2- Trenches
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Trenches Definition :collapse sites are unstable and liable to
further collapse. Hazards : 1. Patients should be dug out after
shoring has stabilized the excavation site. 2. Vibrations or
additional weight may cause secondary collapse. 3. Safe removal
requires a special rescue team.
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Safe approach 1. Stay away from the edges of the site. 2. Shut
off all heavy equipment. 3. Stop or divert nearby traffic if
needed. 4. Avoid disturbing the spoil pile. 5. Prioritize your
personal safety.
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3- Water
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water Almost all EMS departments potentially may be called to a
water rescue. Sites vary, ranging from small streams to the ocean
to a swimming pool. So the following steps should be followed 1. Be
aware of self-rescue techniques. 2. Cold water rescue. 3. Other
water rescue situations. 4. Safe approach.
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Self rescue techniques Minimum PPE includes: i.Personal
flotation device (PFD). ii.Thermal protection. iii.Helmet.
iv.Cutting device. v.Whistle. vi.Contamination protection. If
immersed in fast-moving water, adopt the self- rescue position:
i.Roll into a face up, arched position. ii.Keep feet together in
the direction of travel, arms to the side. iii.Use hands to change
direction. iv.Tuck chin to protect head, face, and lower back from
striking objects.
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Cold water rescue Water temperature of less than 98.6F (37C)
will cause hypothermia can quickly progress to loss of
consciousness and death so to maintain body tempertue : 1. keep
head and face above water, assuming the heat-escape-lessening
position (HELP) which helps keep heat to core of body 2. Victims
should minimize movement. 3. In a group, victims should huddle
together.
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In water colder than 70F (21C) patients may benefit from the
cold protective response: 1. Heat is conducted from the body to the
water and hypothermia can protect vital organs from lack of oxygen.
2. Cold water exposure can activate primitive reflexes that
preserve body functions. 3. Provide full resuscitative efforts
until the patient recovers or is pronounced dead by a
physician.
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The mammalian diving reflex : occurs when a person dives or
jumps into cold water : 1.Consists of bradycardia followed
vasoconstriction of capillaries. 2.loss of consciousness may occur.
3.Patient may survive for long periods of time under water because
of: Lowering of metabolic rate. Decreased oxygen demand and
consumption.
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Water Other water rescue situations A. Drowning in vehicle. B.
Special hazards of surface water : 1. Hydraulics created by moving
water 2. Strainers (objects such as trees or debris) 3. Dams and
hydroelectric sites
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Safe approach A. Wear appropriate PPE. 1.Approved PFD within 10
feet of water 2.Shoes with traction B. Do not exceed your level of
training. 1.Currents can challenge even trained lifeguards. 2.Keep
bystanders from attempting rescue efforts.
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Water rescue gear
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C.Use the talk reach throw row - go approach. 1.Attempt to
reach out with an object (a branch or paddle). 2.If reaching out
fails, throw an object (a rope). 3.If other means fail, row out to
the drowning person in a small boat or canoe. 4.Go into the water
to save the victim as a last resort.
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Ice rescue Specialized equipment exists for ice rescues. 1.
Ladders distribute the weight of the rescuer on ice-covered water.
2. Special flotation devices and rescue suits are available. 3. Ice
rescues require specialized training
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Ice rescue and ice rescue gear
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Recovery situations Occur when the victim is not visible in the
water upon arrival at the site. Requires trained personnel with
equipment, including: I.Snorkels II.Masks III.Scuba gear IV.A
grappling hook can be used as a last resort.
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Recovery and scuba gear
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Spinal injuries in submersion incidents Assume spinal injury
has occurred in these conditions: 1.Diving accident or fall
2.Unconscious patient with no information to rule out neck injury
3.Conscious patient reporting weakness, paralysis, or numbness in
arms and/or legs 4.You have any other reason to suspect spinal
injury. When spinal injury is suspected, the neck must be protected
while the patient is in water.
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Rope Rescue Types of rope rescue: A.Low-angle operations: slope
of the ground is less than 45. B.High-angle operations: slope of
the ground is greater than 45. Safe approach : A.Take time to set
up equipment properly. B.Protect yourself by putting distance
between you and any loose materials. C.Move bystanders out of the
way.
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Wilderness search and rescue ( SAR) Two parts to search and
rescue (SAR) : 1.Search (looking for lost persons). 2.Rescue
(removal of patient from environment). situations that initiate
SAR, including: 1.Small children wandering off and becoming lost.
2.Older adults with Alzheimer disease becoming confused and
disoriented. 3.People hiking or engaging in other outdoor
activities.
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Safe approach 1.Be aware that topography and environmental
factors will vary, and extraction time is variable. 2.Bring
drinking water, food, suitable clothing, and PPE. 3.Use a handheld
strobe light for additional visibility. 4.Be aware of your physical
limitations. 5.Call in a special wilderness rescue team if
necessary.
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Lost person search and rescue Prepare search base with an
ambulance : One of the basic steps of SAR incidents I. Prepare the
equipment in advance to waste no time once the patient is found.
II. Store the equipment inside the ambulance to protect against
weather. III. Follow the progress via radio. IV. Obtain medical
history information from victim family.
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Lost person search and rescue Safe approach : I.Once the
patient is found, distribute equipment evenly between responding
personnel. II.Keep to pace that allows personnel to stick together.
III.Consider relocating ambulance closer to the patient.
IV.Cooperation between EMS and the search team ensures safe
delivery of the patient back to the base.
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Structure fires
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Structure fire Definition: Structure fire is any fire occurring
in a building e.g. house. EMS rules ( 6 steps ): I.Determine
whether special route is needed. II.IC will determine appropriate
place for parking the ambulance which must have : Far enough from
the fire to be safe. Should not block arriving equipment (or become
blocked in). Close enough to be visible and available.
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III.Determine if there are injured patients at the scene or if
you are on standby. IV.Stay with the ambulance. V.Remain present
even after the fire is out as fire fighter may become injured
during rescue and overhaul. VI.Do not leave the scene unless you
are transporting a patient or have been released by the IC.
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Agricultural and industrial rescue
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Agricultural and industrial rescue Hazards : Tractors and other
machines used in agricultural and industrial settings, protective
shields and guards may be damaged or removed, causing hazards
Rescue personnel should visit their local farms and industrial
plants and learn about: I. Equipment that is used II. How it
operates and how an operator can become entrapped.
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Safe approach : a. It is critical to master cribbing in order
to stabilize the vehicle. b. machines made of strong steel so it
may be taken apart more easily than cut. c. Isolate the site of
injury by ensuring that parts of the machine on either sides of
patient are secured and prevents movement during extrications. d.
Determine alternative methods of disentangling the patient.
e.Assess the patient while rescue personnel plan for
disentanglement.
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f.Be aware of differences between industrial and farm settings.
Industrial Coworkers may be able to halt the machinery and begin
extrication. Farm Farmers typically work alone; there is no one to
call EMS so Lag time exists between time of injury and medical
treatment and condition is usually more sever.
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PTRU Tactical emergency medical support
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Tactical emergency medical support Law enforcement may call in
the SWAT team in tactical situations e.g. hostage situation.
Tactical emergency medical support or paramedic tactical rescue
unit ( PTRU) : are medical personnel added to tactical team.
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Tactical emergency medical support Definition : medical
personnel added to special tactical unit. Characteristics : a.
Receive special training to be able to provide medical support
under adverse and dangerous circumstances. b. They wear the same
PPE as law enforcement officers e.g. Body armor, ballistic helmet
and eye protection.
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c. Tactical EMS personnel carry a special compact medical kit
into the hot zone which contain equipment designed to handle
traumatic injuries, such as bleeding and complete set of ALS
medical gear.
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Function : The main duty is to provide immediate medical care
to persons who become injured during an incident, mostly this will
occur before the scene is declared safe. When not responding to an
incident, the tactical paramedic will be responsible for: 1.
Maintaining medical records of team members 2. Conducting basic
first aid training to team members 3. Providing suggestions for
training
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Patient Care during rescue and extraction
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Medical and trauma cases assessed during rescue Many medical
and trauma conditions are assessed during the rescue process the
usual protocol for patient care should be followed. Crush syndrome
: A. May occur in confined-space or trench incidents. B.
Pathophysiology :
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Pathophysiology of crush injury I.Large muscle groups are
compressed for a prolonged period of time (2 to 4 hours). II.When
human tissue is deprived of oxygen-enriched blood, cells metabolize
anaerobically, producing lactic acid. III.When compressed areas are
reperfused, this product is released into circulation, causing
respiratory, metabolic acidosis and renal impairment.
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Treatment of crush injury C. Treatment : I.high-flow oxygen
therapy or positive pressure ventilations. II.Administration of:
Sodium bicarbonate Calcium chloride Fluid bolus
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Pain control 1. Use non pharmacologic methods in the
prehospital environment, such as: a.Splinting b.Gentle handling
c.Talking to patients to create a distraction during assessment. 2.
Pharmacologic treatment options are controversial and require
consultation with medical directors.
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Medical Supplies
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Patient packaging Using Basket stretcher (Stokes basket). Two
types : Wire basket More suitable for water rescue and helicopter
lift situations. Allows water or air to pass through. Plastic or
fiberglass suitable for most other evacuation types. easily slides
over the top of surfaces.
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Packing precautions and obstacles 1.Patients with fractured
pelvises will be caused great pain by basket packaging: Secure the
patient to a full-body vacuum mattress to reduce pain. 2.Packaging
spine-immobilized patients in a basket stretcher : Place the
patient in a Kendrick Extrication Device (KED) instead of on a
backboard.
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3.Consider all patient needs when packaging a. Set up portable
oxygen tank. b. Maintain IV lines. c. Keep the patient warm. d.
Provide head and eye protection e. Consider using a KED or KED/SKED
combination in narrow spaces.
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summary 1. Rescue means to deliver from danger or imprisonment.
2. A technical rescue incident (TRI) is a complex rescue incident
involving vehicles, water, trench collapse, confined spaces, or
wilderness search and rescue that requires specially trained
personnel and special equipment. 3. Technical rescue training
occurs on three levels: awareness, operations, and technician.
