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Table 2 Statements achieving consensus by theme

From: A Delphi study of rescue and clinical subject matter experts on the extrication of patients following a motor vehicle collision

Theme and Relevant Publications Statement Number of SME opt outs
Terminology
[14,15,16,17,18,19,20,21,22]
A Multi-Professional Standardised Terminology (MPST) should be developed and adopted to describe different extrication approaches and their variants 0
The term "patient" is used to refer to the (potentially) injured person post motor vehicle collision regardless of entrapment status 0
A MPST should be adopted to describe risks and hazards at a scene of an entrapped patient 0
A MPST should be adopted to described how badly injured and or time-critical entrapped patients are 0
A MPST should be developed and adopted to describe the entrapment status of patients (e.g. medically trapped, physically trapped) 0
A MPST should be developed and adopted to describe different extrication techniques as per Joint Emergency Services Interoperability Principles (JESIP) 0
A MPST should be developed and adopted to describe how rapidly a patient needs to be extricated 0
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)
Time critical hazard (Time critical due to a hazard such as fire)
0
Extrication goals and approach
[14,15,16,17,18,19,20,21,22]
The historical focus on absolute movement minimisation is no longer justified given information on rarity of spinal injury and frequency of other time critical injuries 0
The rescuer goal in consideration of patient movement should be “Gentle patient handling” 1
Minimising entrapment time should be a multi-professional goal for all entrapped patients 0
Self-extrication or minimally assisted extrication should be the standard ‘first line’ extrication for entrapped patients who are conscious and likely to be able to stand with assistance 0
Extrication routes (other than self-extrication) appear to be bio-mechanically similar, so it is reasonable to choose the quickest deliverable route given the specific circumstances of the incident 0
Unconscious patients have high risk of significant injuries and should have an expedited extrication undertaken using ‘gentle patient handling’ techniques 0
Extrication goals and approach should be similar regardless of the sex or gender of a patient 1
Patients with acute neurological deficit (e.g. pins and needles in arms) may have time dependent pathology. They should be handled “gently” throughout and entrapment time should be minimised 2
FRS and clinicians should work together (as per JESIP principles) to plan and deliver a patient and rescuer centred extrication strategy 0
When environmental conditions permit, FRS personnel should be trained and empowered to plan and complete extrication when clinicians are not available 0
Self-extrication
[7, 23,24,25,26,27,28,29,30,31]
All patients should be assessed to see if they are suitable for self-extrication as the primary method of extrication 0
Patients with neck and / or spinal pain should be considered for self-extrication 3
Patients with lower limb injuries should be considered for assisted self-extrication 1
Patients regardless of their injuries should be assessed for suitability for (assisted) self-extrication 1
Patients with evidence of neurological injury (e.g. pins and needles in arms) may have a spinal cord injury. Patients in this group that can self-extricate, with or without assistance should be encouraged to do so (as this method is associated with smallest movement and shortest entrapment time) 4
FRS should be trained and empowered to assess patient suitability for self-extrication and assist with this if required 2
Patients of all ages who are normally mobile should be considered for self-extrication 1
Patients of all ages should be assessed for actual and potential injuries and a bespoke extrication strategy planned and delivered 1
Patients with suspected open book pelvic injuries SHOULD NOT be considered for (assisted) self-extrication 5
Contraindications to self-extrication include: i) an inability to understand or follow instructions, ii) injuries or baseline function that prevents standing on at least one leg, (specific injuries include: unstable pelvic fracture, impalement, bilateral leg fracture) 4
Patients without contraindications can be considered for self-extrication 3
Considering statements that define suitability for self-extrication, further consideration of specific pelvic related contraindications are not required 6
Disentanglement
[3, 5, 7, 16, 19, 26, 32,33,34,35,36,37,38]
Patients who are physically entrapped as a result of intrusion have a high likelihood of significant injuries and as such should be considered time critical 1
Disentanglement should be followed by the quickest appropriate extrication type 2
Disentanglement should be followed by the quickest appropriate extrication type including self-extrication 2
Collisions where patients require disentanglement should trigger a senior FRS extrication response 12
Collisions where patients require disentanglement should trigger an ‘enhanced’ clinical care response1 3
Collisions where patients require disentanglement should trigger a ‘critical-care’ clinical response2 4
Entrapped patients with evidence of energy transfer (injury) should be considered to have time-dependent injuries and entrapment time should be minimised 2
Collisions where patients require disentanglement are associated with significant injuries to patients, as such FRS should provide an enhanced* response to such incidents. *Accepting that this term and the response will require definition 3
Post-extrication patients who were entrapped should be carefully and comprehensively assessed, and where appropriate, transferred preferentially to a major trauma centre 1
Clinical procedures such as intubation and thoracostomy should ideally be delayed until a patient has been extricated 2
Clinical care
[16, 17, 39,40,41,42,43,44]
Clinical care should be limited to necessary critical interventions to expedite safe extrication 3
Rescuers should be aware that clinical observations may prolong entrapment time and as such should be kept to the minimum required 2
Following clinical assessment, if a patients 'in-vehicle' needs can be met by FRS personnel then clinicians are recommended to withdraw from the vehicle to enable an efficient extrication 0
FRS training in clinical care for entrapped patients should be standardised 0
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 0
Within an appropriate system of training and governance, FRS personnel should be enabled to deliver in-vehicle clinical interventions that assist with extrication and mitigate avoidable patient harm 2
Appropriate in-car interventions for the trapped patient include control of compressible haemorrhage 4
Appropriate in-car interventions for the trapped patient include oxygen 3
Appropriate in-car interventions for the trapped patient include decompression of tension pneumothorax 10
Appropriate in-car interventions for the trapped patient include analgesia 3
Appropriate in-car interventions for the trapped patient include tranexamic acid  
Patients who require volume (fluid or blood product) resuscitation are likely to have time critical injuries and their removal from the vehicle should be prioritised. In the small number of patients who cannot be released quickly then ‘in vehicle’ fluids and /or blood products may be required 3
The choice of blood product (where available) and IV fluids should be led by the available evidence 5
Immobilisation
[9, 17, 28,29,30, 39, 45,46,47,48,49,50,51]
Kendrick Extrication Devices prolong extrication time and their use should be minimised 5
Cervical collars should be loosened or removed following extrication as dictated by clinical assessment 1
Long boards are an extrication device and are not suitable for patient carriage beyond the immediate extrication phase 1
Pelvic slings should not be applied to patients until they have been extricated 5
During the initial call to emergency services, patients, should be asked to self-extricate if they are able to do so and the environment is considered safe 0
During the initial call to emergency services, bystanders should be advised NOT to assist patients with a decreased conscious level from the vehicle unless there is an immediate threat to life 1
Call takers identifying a motor vehicle collision with suspected entrapment or patients requiring disentanglement should use an appropriately developed algorithm or call interrogation to identify the most appropriate response 3
Patient focused extrication
[3, 4]
Communication and companionship for entrapped patients should be designated to a specific staff member who, if safe to do so and not an impediment for extrication, should join the patient in the car 0
Where possible, patients should be referred to by name 0
Where possible the patient should be engaged in discussion and explanation around extrication strategy and their role in this process 0
An ‘extrication buddy’ should be assigned to explain the procedure, ensure companionship, and provide reassurance to the patient whilst entrapped 0
Communication with the patient should be clear and use accessible lay language 0
Where possible the ability of the public to photograph the vehicle and the patient should be minimised 3
Attempts should be made to minimize onlooker photography and post-accident photos on social media and news channels 3
Rescuers and their affiliated organizations should not post extrication related photos on their social media channels or websites 0
Patients should be reassured (when true) that their co-occupants are safe (including animals) 0
If conscious, patients should be allowed to communicate with their family members (including remotely using their phones) 0
The potential harmful effects of social media interaction should be notified to the public / onlookers (see QR code campaign) 0
Emergency Services Call and Triage
[34, 52,53,54,55,56,57]
On initial emergency services call attempts should be made to clarify entrapment status 0
Consideration should be given for call back, video from scene and other modalities to enhance the fidelity of triage response 0
Collisions identified during emergency services call as potentially requiring disentanglement should trigger a senior FRS extrication response 10
Collisions identified at emergency services call as potentially requiring disentanglement should trigger an expert FRS extrication response 9
Collisions identified at emergency services call as potentially requiring disentanglement should trigger an ‘enhanced’1 clinical care response 3
MVC with suspected entrapment should warrant an immediate response triage category for prehospital medical services 4
A standard multi-agency MVC trauma message should be developed to ensure the correct resources are deployed 3
MVC with suspected entrapment should warrant an immediate response triage category for prehospital medical services 3
Audit standards and Research
[2, 32]
Audit standards should be developed with patient and public engagement 4
Multi-Professional (MP) datasets should be developed to enable research and audit 0
MP datasets should include patient entrapment status 0
MP datasets should include how badly injured and or time-critical entrapped patients are 0
MP datasets should include different extrication approaches and their variants 0
MP datasets should include entrapment time 0
MP datasets should include in-car patient care and its timing 0
MP audit standards should be developed to improve quality of patient care and extrication practice 0
Rejected statements The rescuer goal in consideration of patient movement should be “Absolute movement minimisation and mitigation” (REJECTED) 0
Cervical collars should be used where available on all patients as a movement minimisation tool (REJECTED) 3
  1. 1 Enhanced care: Enhanced care is a term used in the UK to describe a wider scope of practice above that of a non-specialist paramedic. Enhanced care may be delivered by specialist or advanced paramedics (and other clinicians) and would normally include skills such as sedation a wider choice of analgesia, enhanced decision making and other interventions
  2. 2 Critical care: Critical care is a term used in the UK to describe a wider scope of practice above that of enhanced care. Critical care is normally delivered by a team including specialist / advanced paramedics (or other appropriate background) and a doctor. The critical care skill set normally would include anaesthesia, surgical skills and access to blood product resuscitation
  3. Notes on the statements:
  4. (i) SME’s also agreed that where required to improve understanding "Where / when possible" could be added to statements
  5. (ii) Statements / principles apply to all vehicles
  6. (these contextual statements above were derived as individual statements from the Delphi process)