Incident Management

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Chapter 20
Vehicle Extrication
and Special Rescue
National EMS Education
Standard Competencies
EMS Operations
Knowledge of operational roles and
responsibilities to ensure patient, public, and
personnel safety.
Vehicle Extrication
• Safe vehicle extrication
• Use of simple hand tools
Introduction
• Special rescue situations include:
– Water rescue
– Diving problems
– Ice rescue
– Confined space rescue
– Farm emergencies
– Bus collisions
• You must maintain your personal safety.
Extrication (1 of 3)
• Rescuers should wear protective equipment
similar to a fire fighter’s outfit:
– Coat
– Pants
– Boots
– Helmet with face shield
– Gloves
Extrication (2 of 3)
• Basic guidelines
– Know the limitations of your training, equipment,
and skill.
– Identify any hazards.
– Control those hazards for which you are trained
and equipped.
– Gain access to the patients.
– Provide patient care and stabilization.
– Move patients only if necessary.
Extrication (3 of 3)
• As an EMR, you have two primary
extrication goals:
– To obtain safe access to the patients
– To ensure patient stabilization
Step One: Overview of the
Scene (1 of 3)
• As soon as the dispatcher tells you of the
incident, begin to anticipate and plan for
what you are likely to find on arrival.
• The dispatch information should include:
– Which types of vehicles are involved
– Whether there are injured or trapped people,
burning vehicles, or hazardous materials
present
Step One: Overview of the
Scene (2 of 3)
• As you approach the scene and before you
exit your vehicle, get an overview of the
entire incident.
– Rapidly determine the extent of the accident.
– Estimate the number of patients.
– Locate any hazards present.
– Call for any assistance needed.
Step One: Overview of the
Scene (3 of 3)
Courtesy of District Chief Chris E. Mickal/New Orleans Fire Department, Photo Unit
Step Two: Stabilization of the
Scene and Any Hazards (1 of 12)
• Infectious diseases
– Many patients involved in motor vehicle crashes
will have soft-tissue injuries and active bleeding.
– If sharp glass or metal is present, wear heavyduty leather gloves over latex gloves.
– If there is the danger of splattering blood,
consider using face protection.
Step Two: Stabilization of the
Scene and Any Hazards (2 of 12)
• Traffic hazards
– Park your vehicle so that it protects the scene
and warns oncoming traffic.
– Park so you can use your vehicle’s warning
lights to their best advantage.
– Wear an approved safety vest and other PPE.
– Ignite fusees or warning flares as soon as
possible.
– Survey the scene for other hazards.
Step Two: Stabilization of the
Scene and Any Hazards (3 of 12)
• Bystanders
– Keep bystanders away from the crash scene by
giving them specific directions.
– Use a rope or police/fire barrier tape to establish
an off-limits area.
• Spilled gasoline
– Expect to find a fuel spill if a motor vehicle has
been hit near the rear, is on its side, or is upside
down.
Step Two: Stabilization of the
Scene and Any Hazards (4 of 12)
• Spilled gasoline
(cont’d)
© Mark C. Ide
– If a fuel spill is
present, call the fire
department.
– If patients are in a
motor vehicle with a
fuel spill and the fire
department has not
arrived, consider
covering the fuel
with dirt.
Step Two: Stabilization of the
Scene and Any Hazards (5 of 12)
• Motor vehicle batteries
– Turn off the vehicle’s ignition.
– Do not attempt to disconnect the battery unless
you have been trained to do so.
– Hybrid vehicles and electric vehicles have large
quantities of batteries.
Step Two: Stabilization of the
Scene and Any Hazards (6 of 12)
• Downed electrical wires
– May be caused by high winds, ice buildup, or a
vehicle hitting a utility pole
– Locate the wires but avoid contact with them.
– If a vehicle has a downed wire across it and
passengers are trapped inside, instruct them to
stay inside the car and call the utility company
and fire department for assistance.
Step Two: Stabilization of the
Scene and Any Hazards (7 of 12)
• Unstable vehicles
– Assume that every vehicle involved in a crash is
unstable, unless you have stabilized it.
– Vehicles on their wheels
• Ensure stability by chocking the front or back
of each wheel.
• If you can gain access to the inside of the
vehicle, place the transmission in park and
set the brake.
• Deflate the tires by cutting or pulling the valve
stems.
Step Two: Stabilization of the
Scene and Any Hazards (8 of 12)
Step Two: Stabilization of the
Scene and Any Hazards (9 of 12)
• Vehicles on their sides
or upside down
– Do not climb on the
vehicle.
– Break the rear window
glass and enter
through the back of the
vehicle.
Courtesy of Mark Woolcock
– The primary hazard of
an upside-down vehicle
is spilled gasoline.
Step Two: Stabilization of the
Scene and Any Hazards (10 of 12)
• Vehicle fires
– Impact fires occur when the gas tank ruptures
during the crash.
– Postimpact fires are often caused by electrical
short circuits and can be prevented by turning
off the ignition.
Step Two: Stabilization of the
Scene and Any Hazards (11 of 12)
• Emergency actions for motor vehicle fires
– Use a dry chemical fire extinguisher.
– Use the extinguisher to keep flames out of the
passenger compartment.
Step Two: Stabilization of the
Scene and Any Hazards (12 of 12)
• Emergency actions for motor vehicle fires
(cont’d)
– Do not be overly worried about discharging the
extinguisher onto the passengers.
– Immediately have someone else gather fire
extinguishers from other vehicles.
– Remove patients as quickly as possible.
– Move everyone at least 50′ away from any
vehicle that is on fire.
Step Three: Access to Patients
(1 of 4)
• Access through doors
– Try all doors first.
– Ensure that the locking mechanism is released.
– Try the outside and inside handles at the same
time.
Step Three: Access to Patients
(2 of 4)
• Access through
windows
– Do not try to break
and enter through
the windshield
because it is made
of plastic-laminated
glass.
– The side and rear
windows are made
of tempered glass
and will break easily.
Step Three: Access to Patients
(3 of 4)
• Access through
windows (cont’d)
– Carry a spring-loaded
center punch in your
EMR life support kit.
– If you must break a
window, try to break
one that is the farthest
from the patient.
– Follow the steps in
Skill Drill 20-1.
Step Three: Access to Patients
(4 of 4)
• Access through windows (cont’d)
– When you gain access to a crash vehicle, be
alert for undeployed air bags.
– If you cannot gain access to the vehicle:
• Stabilize the vehicle.
• Protect the scene until the proper equipment
arrives.
Step Four: Initial Emergency
Care (1 of 2)
• Conduct a patient assessment.
– Monitor the ABCs.
– Control bleeding.
– Treat the patient for shock.
– Stabilize the cervical spine.
– Provide psychological reassurance.
– Maintain the body’s temperature with a blanket.
Step Four: Initial Emergency
Care (2 of 2)
• Leave patients in the vehicle unless:
– The vehicle is on fire.
– The patients are otherwise in immediate
danger.
• Skill Drill 20-2 shows how to perform initial
airway management when the patient is in a
vehicle.
Step Five: Patient
Disentanglement (1 of 2)
• Usually requires
tools and specialized
equipment
• In some serious
extrication situations,
disentanglement can
take up to 30
minutes and requires
advanced training.
© Glen E. Ellman
Step Five: Patient
Disentanglement (2 of 2)
• Golden Period
– The less time you spend at the scene with a
seriously injured patient, the better.
– The patient’s chance for survival increases if
rescuers can get the patient to a trauma center
as soon as possible.
Step Six: Preparation for
Patient Removal
• As disentanglement proceeds, dressings,
bandages, and splints are applied and the
patient’s head and spine are immobilized.
• The access route used to care for the
patient may not be adequate as an
extrication route.
– The extrication route must be large enough to
permit the safe removal of the packaged
patient.
Step Seven: Patient Removal
• Once the patient is packaged, he or she is
removed from the vehicle and placed onto a
stretcher.
• Although EMRs are directly involved in only
the first four steps, you should be aware of
the entire operation.
Review of the Extrication
Process (1 of 2)
• Call for extrication help.
• Specify the types of vehicles involved.
• Do not stand idly by while waiting for help.
– Identify and contain hazards.
– Park your vehicle appropriately.
– Clear a working area around the crash site.
– Use your head!
Review of the Extrication
Process (2 of 2)
• Do not stand idly by while waiting for help.
(cont’d)
– Try opening the doors first, rather than breaking
windows.
– Once you gain access to the patients, assess
and monitor their conditions.
– Above all, remain calm.
Water Rescue (1 of 4)
• Reach
– Use any readily available object.
– If the person is close to shore, a branch, pole,
oar, or paddle may be long enough.
• Throw
– At a swimming pool, dock, or supervised beach,
a flotation device may be available.
– Throw a life buoy if one is available.
Water Rescue (2 of 4)
• Throw (cont’d)
– Some public safety departments carry a rescue
throw bag that contains a rope.
– If these devices are not available, improvise.
• Row
– Row out to the drowning person if a small boat
or canoe is available.
– Wear an approved personal flotation device.
Water Rescue (3 of 4)
• Go
– As a last resort, you may have to go into the
water to save the person.
– Enter the water only if you are a capable
swimmer trained in lifesaving techniques.
– Remove encumbering clothing before entering
the water.
– Take a flotation device with you.
Water Rescue (4 of 4)
Initial Treatment of a Person in
the Water (1 of 5)
• If you are involved in a water rescue, your
primary concerns must be to:
– Open the airway.
– Establish breathing and circulation.
– Stabilize spinal cord injuries.
• Skill Drill 20-3 describes how to turn
patients who are face down in the water
face up.
Initial Treatment of a Person in
the Water (2 of 5)
• Use the jaw-thrust maneuver.
• Look, listen, and feel for signs of breathing.
• If the patient is not breathing, start rescue
breathing in the water.
Initial Treatment of a Person in
the Water (3 of 5)
• If the patient has experienced cardiac
arrest:
– Quickly stabilize the patient’s head and neck.
– Remove the patient from the water.
– Place the patient on a hard surface.
– Begin CPR.
• Treat a patient who is unconscious in the
water as if a spinal cord injury is present.
Initial Treatment of a Person in
the Water (4 of 5)
• Assume the presence of a spinal cord injury
if a conscious patient in the water:
– Reports numbness or tingling in the arms or
legs
– Is unable to move the extremities
– Reports neck pain
Initial Treatment of a Person in
the Water (5 of 5)
• Strap the patient to a backboard, stabilize
the head and neck, and remove the patient
from the water.
Diving Injuries (1 of 3)
• Most recreational divers use self-contained
underwater breathing apparatus (scuba).
• Scuba consists of:
– An air tank
– A regulator
– A mouthpiece
– A face mask
Diving Injuries (2 of 3)
• Diving accidents can cause trauma, near
drowning, or specialized injuries.
• Specialized injuries associated with diving
include air embolism and decompression
sickness (bends).
– Both are caused by air bubbles released in the
body as a result of pressure changes while
diving.
Diving Injuries (3 of 3)
• Treatment
– Maintain the patient’s ABCs and normal body
temperature.
– Administer oxygen.
– Some physicians recommend placing the
patient on his or her left side with the head
slightly lowered.
– Patients may need to be transported to a
hospital with a hyperbaric chamber.
Ice Rescue (1 of 4)
• No ice is truly safe.
• Visually mark the location where the person
was last seen.
• The basic rules of ice rescue are the same
as water rescue: reach–throw–row–go.
– Reach for the victim using anything that will
extend your natural stretch.
– Throw a flotation device, throw rope, etc.
Ice Rescue (2 of 4)
• Reach–throw–row–
go (cont’d)
– Row or propel a small
boat to the victim, or
use a toboggan to get
across the ice.
© Chris Rush, Bartlesville Examiner-Enterprise/AP Photos
– If you must go, secure
yourself to shore with a
rope around your waist,
lie on your stomach,
and proceed across the
ice.
Ice Rescue (3 of 4)
• A motor vehicle on the ice presents a risky
situation.
– Instruct the occupants to avoid unnecessary
movement.
– If the vehicle has not gone through the ice,
instruct the occupants to open the doors.
– If the doors cannot open, instruct the occupants
to roll down the windows.
Ice Rescue (4 of 4)
• Both the persons on the ice or in the water
and the rescuers are at risk for
hypothermia.
– Keep all rescuers as warm as possible.
– Rescue persons should be stripped of wet
clothing, dried, and warmed.
– If the patient has no pulse, start CPR and
continue until the patient has been transported
to a hospital and warmed.
Confined Space Rescue (1 of 4)
• Confined spaces are structures designed to
keep something in or out.
• Below-ground confined spaces
– Manholes
– Below-ground utility vaults or storage tanks
– Old mines
– Cisterns
– Wells
Confined Space Rescue (2 of 4)
• Ground-level confined spaces
– Industrial tanks
– Farm storage silos
• Elevated confined spaces
– Water towers
– Storage tanks
Confined Space Rescue (3 of 4)
• Rescue situations involving confined spaces
have two deadly hazards.
– The confined space may have insufficient
oxygen to support life or a poisonous gas may
be present.
– There is also the danger of collapse.
• Call for additional assistance and do not
enter the space until help arrives.
Confined Space Rescue (4 of 4)
© Harris Shiffman/ShutterStock, Inc.
© Joe Gough/ShutterStock, Inc.
Farm Rescue (1 of 4)
• Farm accidents pose many challenges.
– Reporting of an emergency may be delayed if
the farmer works alone.
– There may be a lengthy response.
– It may be hard to pinpoint the exact location of
the emergency.
– Poor roads, nonexistent roads, and muddy soil
may require you to leave your vehicle behind.
Farm Rescue (2 of 4)
• Farm hazards
– Animals
– Hazardous
chemicals including
pesticides,
herbicides, and
fertilizers
– Electrically powered
machinery
– Tall barns and silos
© Nancy Hixson/ShutterStock, Inc.
Farm Rescue (3 of 4)
• Farm hazards (cont’d)
– Below-grade manure
storage pits
– Accidents with farm
machinery
Courtesy of Lynn Betts/NRCS USDA
• Rollovers of farm
tractors
• Entrapment in
machinery
• Severing of body
tissue by sharp
objects
Farm Rescue (4 of 4)
• Your role in farm rescues
– Stabilize the scene and provide initial medical
care for the patient.
– Follow the seven steps of extrication.
Bus Rescue (1 of 2)
• Crashes involving buses are considered
multiple-casualty events.
• Your role in bus rescues
– Perform a scene size-up.
– Call for adequate police, fire, and EMS
resources.
– Establish an incident command system if
multiple casualties are present.
Bus Rescue (2 of 2)
• Your role in bus
rescues (cont’d)
– Set up a one-way
traffic pattern for
responding
vehicles.
© Dena Libner, The Conway Daily Sun/AP Photos
– With a large
number of patients,
triage the patients
using the START
triage system.
Summary (1 of 3)
• You should be able to perform the first four
steps in the extrication process and assist
other rescuers with the remaining steps.
• Ice rescue, water rescue, underwater diving
accidents, confined space rescue, farm
rescue, and bus crashes are situations that
require extensive skills and special training.
Summary (2 of 3)
• In water and ice rescue situations, you can
take some simple steps to help the person
without endangering yourself, including
reaching out to the person with an object,
throwing a flotation device to the person, or
rowing to the person in a boat.
Summary (3 of 3)
• In confined space rescue, your primary
goals are to call for additional assistance
and prevent other people, including
yourself, from becoming victims.
• Farm emergencies and bus crashes are
complex rescue situations.
Review
1. Which of the following would NOT be
considered a special rescue situation?
A. a school bus collision
B. a hiker who has fallen through thin ice
C. a diver who is discovered unconscious on the
surface
D. an elderly man with chest pain at the park
Review
Answer:
D. an elderly man with chest pain at the
park
Review
2. As an EMR, your primary goal in extrication
is to:
A. use specialized equipment to access patients.
B. access patients safely and stabilize them.
C. reach patients as quickly as possible to
administer pain medications.
D. dismantle the vehicle or machinery.
Review
Answer:
B. access patients safely and stabilize
them.
Review
3. Once you have access to the patient, you
should:
A. perform an assessment.
B. rapidly extricate the patient.
C. administer oxygen.
D. immediately begin treating injuries you see.
Review
Answer:
A. perform an assessment.
Credits
• Opener: © Glen E. Ellman
• Background slide image (ambulance): ©
Comstock Images/Alamy Images
• Background slide images (non-ambulance):
© Jones & Bartlett Learning. Courtesy of
MIEMSS.
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