The most common source of entrapment and entanglement in most locales is the motor vehicle collision. Other potential sources include industrial accidents and agricultural incidents. It is imperative that medical providers have a standardized approach to these situations, have basic familiarity with safety issues and extrication concepts, and understand that the medical approach to these situations is unique.

• 
  

  Describe motor vehicle, industrial, and agricultural-related causes of entrapment and entanglement.

  
  
• 
  

  List key nonmedical personnel and bystanders who are present on the scene, and may serve as a vital asset during these operations.

  
  
• 
  

  Describe the initial approach to the entrapped and/or entangled victim.

  
  
• 
  

  Provide a basic description of tools utilized by fire/rescue personnel during extrication operations.

  
  
• 
  

  Describe the dangers associated with medical operations within a motor vehicle during extrication operations.

  
  
• 
  

  Discuss unique challenges to airway management in a motor vehicle.

  
  
• 
  

  Discuss management of hypotension and hemorrhage in the entrapped and/or entangled victim.

  
  
• 
  

  Discuss the criteria associated with the consideration of field amputation.

  
  
• 
  

  List other resources and personnel that may be helpful during this unique type of call.

The initial approach to any scene should always be the same but special attention is necessary when arriving first. Scene safety begins with the call going out/dispatch notification. Activate all possible resources early; it is always better to turn away resources when they are not needed than to need them and be delayed because they are not on scene. Access point and direction should be considered for any potential hazardous materials involvement. Likewise, flow of traffic and positioning of vehicles should be considered during the initial approach. Medical vehicles should generally be close to the patient without jeopardizing contamination or damage to the ambulance. Positioning of medical vehicles should be in such a way as to be protected by larger vehicles such as fire apparatus. The path to and from the vehicle should be out of traffic—in many extended operations there will be multiple trips to and from the vehicle for equipment or supplies; the more trips through or close to passing traffic, the more likely there is to be a secondary incident. Vehicles should be parked so as not to impede the loading of a patient into the ambulance and so as not to block the ambulance in at the scene. Upon arrival, there should be a visual scan for any downed lines or electrocution hazard.

If you are the first rescuer on scene an appropriate size-up should be made and conveyed to the communication center and other responders via radio in most cases. Basic information includes number and general acuity of patients and whether additional or fewer resources are needed and the response mode required on other incoming providers. Advise other responders of hazards to expect. In the common situation of an MVC with reported entrapment an appropriate size-up might be: “Fire Control, MD-1 arriving on scene. We have a single midsize vehicle into the center divider on the westbound side of the interstate, east of the Main Street on-ramp. There is major front-end damage with two victims apparently trapped. No fire or other hazards noted. Please continue all responders Code 3, start Heavy Rescue and launch the closest available helicopter. We will also need additional law enforcement for traffic control. I will be initiating care.”

The proper protective equipment should be put on before exiting the vehicle and worn at all times. Physicians should never be on scene of an active rescue wearing scrubs without any proper protective equipment. Extrication gear with proper reflective/identification markings, helmet, eye protection, gloves, and heavy boots should be worn during the extrication.¹

Many additional resources should be considered when on scene of an entrapped or entangled patient, particularly when they occur in the industrial or agricultural setting. On scene safety personnel from the industry are often intimately familiar with the operating systems and potential hazards of industrial machinery. Foremen, superintendents, or supervisors may also prove helpful in the direction of how to deactivate or cut power to machinery or devices posing dangers to the rescuers or patient (or causing the entrapment). Likewise, heavy equipment and machinery operators are beneficial in assisting with rescues that may involve the use of cranes, tractors, or heavy machinery. Engineers, linesman, electricians, and gas company personnel may also prove invaluable at the scene of an entrapped or entangled patient. Finally, coworkers of the trapped patient may be of assistance in determining the mechanism of entrapment and thus how to free the patient. Furthermore, coworkers often have emergency contact information for family, which in some rare cases may be needed if the patient is not expected to survive removal from the entrapment. In these thankfully rare cases, every effort should be made to safely allow for the family and patient to speak and be with one and other as the patient passes.

Medical responders must remember to balance extrication with patient care. Do no delay extrication for unneeded medical procedures or treatment—sometimes simpler is better. Medical responders should not delay active extrication in order to perform unnecessary procedures in the field. The need for monitoring equipment versus space and safety considerations should also be considered. Monitors utilized in confined space should be considered inert and proven to pose no threat of fire or explosion in highly volatile environments. Establish early incident command on scene and follow the structure. Prehospital scenes become much more chaotic when extended operations, extrications, and rescues are involved. Make every attempt to control the chaos and follow standard incident command guidelines and practices.

Some of the most common maneuvers in extrication from vehicles include simple door pops, roof flaps, roof removals, dash rolls, pedal pulls, airbag lifts, and the combination of any of these techniques. Many departments train with various techniques to accomplish each of these, but most have the same general technique or principles. Many of the principles such as spreading, pushing, cutting, rolling, or lifting utilized in vehicle extrication can be translated into other types of extrications; however, many more variables often exist independent of the extrication itself. This may include a broad approach to securing the scene, stabilizing debris/structures (structural collapse/disaster response), or multiple rescue types such as high-angle, confined space, and technical rescue in disaster, industrial, or agricultural incidents. Furthermore, in events of man-made disaster or incidents such as bombings or acts of terror there are often evidence preservation and law enforcement concerns to take into account as well.

Many different types of tools or brands of rescue tools are available for extrication, but most incorporate the same general principles and mechanisms of action. Some of the tools used to accomplish extrication are hydraulic spreaders, hydraulic cutters, winches, RAMS, airbags, gas cutters, power cutters/saws, and manual tools such as axes, rams, bolt cutters, and Halligan/Hooligan tools (Box 52-1; Figure 52-1).

The medical evaluation of a prehospital trauma patient on scene is much different than that of the medical evaluation of that same patient in a trauma center. The same basic principles should exist; however, one must remember that at times, good medicine can lead to bad outcomes. In other words, sometimes simpler is better. Scene times should be minimized as much as possible to properly and safely treat the patient. Furthermore, safety concerns should be taken into consideration when attempting or planning complicated medical procedures that put rescuers at risk in an unstable scene.²

One major difference in prehospital medicine that is emerging from the battlefield is now the transition from the ABC mnemonic to the MARCH mnemonic. Prehospital data show that in most traumatic injuries, particularly battlefield injuries, massive hemorrhage is considerably more fatal than airway compromise. Therefore, the mnemonic MARCH was established for the order of assessment for prehospital patients in the tactical field. This can be translated to severely wounded patients entrapped or entangled on any scene (Box 52-2).

An additional approach to assessing patients in a prehospital setting may involve a remote assessment. This may be necessary if rescuers cannot safely approach a trapped patient and a quick assessment is needed to determine the risk versus benefit of immediate or delayed rescue. For example, if a patient is in an MVC involving a hazardous material and downed power lines, a remote assessment should be performed while an incident plan is being put together. If the patient has obvious injuries incompatible with life, then putting more lives at risk during an emergent and hasty rescue would not be prudent. Likewise, if the patient has only minor injuries and is trapped in a vehicle with a powerline lying over the top of it, one would not want to immediately rush in and risk electrocution for an injury that is not life threatening to begin with. All rescuers must remember that injured rescuers only complicate the rescue and will almost guarantee assets being diverted from the patient to the injured rescuer, thus making the initial rescue even more complicated and prolonged.

AIRWAY CONTROL