Do entrapment, injuries, outcomes and potential for self-extrication vary with age? A pre-specified analysis of the UK trauma registry (TARN)

Extrication following a motor vehicle collision: a consensus statement on behalf of The Faculty of Pre-hospital Care, Royal College of Surgeons of Edinburgh

BACKGROUND

Road traffic injury is the leading cause of death among young people globally, with motor vehicle collisions often resulting in severe injuries and entrapment. Traditional extrication techniques focus on limiting movement to prevent spinal cord injuries, but recent findings from the EXIT project challenge this approach. This paper presents updated recommendations from the Faculty of Pre-Hospital Care (FPHC) that reflect the latest evidence on extrication practices.

METHODS

A systematic scoping review identified 170 relevant articles from 7083 records. Findings, together with EXIT project data, informed the development of 12 core and supplemental statements on extrication. In April 2024, 43 subject matter experts from diverse backgrounds participated in a consensus process. Statements were discussed, voted on, and synthesised into the updated statement, ratified by FPHC.

RESULTS

Consensus was achieved for all 12 statements, emphasising self-extrication as a preferred, primary approach, reducing extrication time, and moving away from absolute movement minimisation. The U-STEP OUT algorithm was endorsed as a decision-making tool. Key themes included interdisciplinary collaboration, use of operational and clinical decision aids, and enhanced training.

CONCLUSIONS

This consensus statement marks a paradigm shift in extrication practice, moving away from traditional movement minimisation to a focus on time-sensitive, patient-centred care. The findings advocate for empowering both clinical and non-clinical responders and improving interdisciplinary training and communication. Further research is needed to assess the broader implementation of this statement and to explore the psychological impacts of entrapment and extrication on patients.

Derivation and validation of the simplified BleedingAudit Triage Trauma (sBATT) score: a simplified trauma score for major trauma patients injured in motor vehicle collisions

OBJECTIVES

To develop and validate a simplified Bleeding Audit Triage Trauma (sBATT) score for use by lay persons, or in areas and environments where physiological monitoring equipment may be unavailable or inappropriate.

DESIGN

The sBATT was derived from the original BATT, which included prehospital systolic blood pressure (SBP), heart rate, respiratory rate, Glasgow Coma Scale (GCS), age and trauma mechanism. Variables suitable for lay interpretation without monitoring equipment were included (age, level of consciousness, absence of radial pulse, tachycardia and trapped status). The sBATT was validated using data from the UK Trauma Audit Research Network (TARN) registry.

SETTING

Data sourced from prehospital observations from multiple trauma systems in the UK.

PARTICIPANTS

70 027 motor vehicle collision (MVC) patients from the TARN registry (2012-2019). Participants included were those involved in MVCs, with exclusion criteria being incomplete data or non-trauma-related admissions.

INTERVENTIONS

Not applicable.

PRIMARY AND SECONDARY OUTCOME MEASURES

Death within 24 hours of MVC. Secondary: need for trauma intervention.

RESULTS

In a cohort of 70 027 MVC patients, 1976 (3%) died within 24 hours. The sBATT showed an area under receiver operating characteristic curve of 0.90 (95% CI: 0.90 to 0.91) for predicting 24-hour mortality, surpassing other trauma scores such as the Shock Index and Assessment of Blood Consumption score. Sensitivity was 96% and specificity 72%, with a negative likelihood ratio below 0.1, indicating strong rule-out capability. Sensitivity analyses confirmed consistent performance across varying SBP and GCS thresholds. The sBATT was equally effective across sexes with no significant predictive discrepancies.

CONCLUSIONS

The sBATT is a novel, simplified tool that performs well at predicting early death in the TARN dataset. It demonstrates high predictive accuracy for 24-hour mortality and need for trauma intervention. Further research should validate sBATT in diverse populations and real-world scenarios to confirm its utility and applicability.

Prehospital Trauma Compendium: Management of the Entrapped Patient - a Position Statement and Resource Document of NAEMSP

Entrapped patients may be simply entombed or experiencing crush injury or entanglement. Patients with trauma who are entrapped are at higher risk of significant injury than patients not entrapped. Limited access and prolonged scene times further complicate patient management. Although patient entrapment is a significant focus of specialty teams, such as urban search & rescue (US&R) teams that operate as local, regional, and/or national resources in response to complex scenes and disaster scenarios, entrapment is a regular occurrence in routine EMS response. Therefore, all EMS clinicians must have the training and skills to manage entrapped patients and to support medically-directed rescue throughout the extrication process. NAEMSP RECOMMENDSEMS clinicians must perform a timely and thorough primary and secondary assessment and reassessments in parallel with dynamic extrication planning; the environment may require adaption of standard assessment techniques and devices.EMS clinicians should establish early, clear, and ongoing communications with rescue personnel to ensure a coordinated patient-centered medically directed approach to extrication. Communication with the patient should be frequent, clear, and reassuring.EMS clinicians should immediately take measures to effectively prevent and manage hypothermia.EMS clinicians should recognize airway management in the entrapped patient is always challenging. When required, advanced airway placement should be performed by the most experienced operator with proficiency in multiple modalities and alternative techniques in limited access situations.In entrapped patients who are experiencing or are at risk for crush syndrome, EMS clinicians should initiate large-volume (i.e., 1-1.5 L/h for adults and 20 mL/kg/h for pediatric patients for the initial 3-4 h) fluid resuscitation with crystalloid, preferably normal saline, as early as possible and prior to extrication.In entrapped patients who are experiencing or are at risk for crush syndrome, EMS clinicians should administer medications to mitigate risks of hyperkalemia, infection, and renal failure, early and prior to extrication.Tourniquet application should be considered in the setting of the crushed extremity as a potential adjunct to medical optimization before extrication of some patients.Patients with prolonged entrapment with the potential for severe injuries require complex resuscitation and may benefit from EMS physician management on scene. EMS systems should consider an early EMS physician response to entrapped patients.

A data-driven algorithm to support the clinical decision-making of patient extrication following a road traffic collision

BACKGROUND

Some patients involved in a road traffic collision (RTC) are physically entrapped and extrication is required to provide critical interventions. This can be performed either in an expedited way, or in a more controlled manner. In this study we aimed to derive a data-driven extrication algorithm intended to be used as a decision-support tool by on scene emergency service providers to decide on the optimal method of patient extrication from the vehicle.

METHODS

A retrospective observational study was performed of all trauma patients trapped after an RTC who were attended by a Helicopter Emergency Medical Service (HEMS) in the United Kingdom between March 2013 and December 2021. Variables were identified that were associated with the need for HEMS interventions (as a surrogate for the need for expedited extrication), based on which a practical extrication algorithm was devised.

RESULTS

During the study period 12,931 patients were attended, of which 920 were physically trapped. Patients who scored an "A" on the AVPU score (n = 531) rarely required HEMS interventions (3%). Those who did were characterised by a shorter than average (29 vs. 37 min) 999/112 emergency call to HEMS on-scene arrival interval. A third of all patients responding to voice required HEMS interventions. Absence of a patent airway (OR 6.98 [1.74-28.03] p < .001) and the absence of palpable radial pulses (OR 9.99 [2.48-40.18] p < .001) were independently associated with the need for (one or more) HEMS interventions in this group. Patients only responding to pain and unresponsive patients almost invariably needed HEMS interventions post extrication (90% and 86% respectively). Based on these findings, a practical and easy to remember algorithm "APEX" was derived.

CONCLUSION

A simple, data-driven algorithm, remembered by the acronym "APEX", may help emergency service providers on scene to determine the preferred method of extrication for patients who are trapped after a road traffic collision. This has the potential to facilitate earlier recognition of a 'sick' critical patient trapped in an RTC, decrease entrapment and extrication time, and may contribute to an improved outcome for these patients.

A biomechanical study to compare spinal movement in a healthy volunteer during extrication between 'chain cabling' and 'roof off' methods of extrication

INTRODUCTION

Following a motor vehicle collision some patients will remain trapped. Traditional extrication methods are time consuming and focus on movement minimisation and mitigation. 'Chain cabling' is an alternative method of extrication used in some countries. The optimal extrication strategy and the effect of extrication methods on spinal movement is unknown. This study compares 'chain cabling' to the established roof removal method of extrication on spinal movement.

METHODS

Biomechanical data were collected using Inertial Measurement Units on a single healthy volunteer during multiple experiments. The extrication types examined were chain cabling and roof removal. Measurements were recorded at the cervical and lumbar spine, and in the anteroposterior (AP) and lateral (LR) planes. Total movement (travel), maximal movement, mean, standard deviation and confidence intervals are reported.

RESULTS

Eight experiments were performed using each technique. The smallest mean overall movements were recorded during roof-off extrication (cervical spine 0.6 mm for AP and LR, lumbar spine 3.9 mm AP and 0.3 mm LR). The largest overall mean movements were seen with chain cabling extrication (cervical spine AP 5.3 mm. LR 6.1 mm and lumbar spine 6.8 mm AP and 6.3 mm LR).

CONCLUSION

In this study of a healthy volunteer, roof-off extrication was associated with less movement than chain cabling. The movement associated with chain cabling extrication was similar to that previously collected for other extrication types.

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

BACKGROUND

Approximately 1.3 million people die each year globally as a direct result of motor vehicle collisions (MVCs). Following an MVC some patients will remain trapped in their vehicle; these patients have worse outcomes and may require extrication. Following new evidence, updated multidisciplinary guidance for extrication is needed.

METHODS

This Delphi study has been developed, conducted and reported to CREDES standards. A literature review identified areas of expertise and appropriate individuals were recruited to a Steering Group. The Steering Group formulated initial statements for consideration. Stakeholder organisations were invited to identify subject matter experts (SMEs) from a rescue and clinical background (total 60). SMEs participated over three rounds via an online platform. Consensus for agreement / disagreement was set at 70%. At each stage SMEs could offer feedback on, or modification to the statements considered which was reviewed and incorporated into new statements or new supporting information for the following rounds. Stakeholders agreed a set of principles based on the consensus statements on which future guidance should be based.

RESULTS

Sixty SMEs completed Round 1, 53 Round 2 (88%) and 49 Round 3 (82%). Consensus was reached on 91 statements (89 agree, 2 disagree) covering a broad range of domains related to: extrication terminology, extrication goals and approach, self-extrication, disentanglement, clinical care, immobilisation, patient-focused extrication, emergency services call and triage, and audit and research standards. Thirty-three statements did not reach consensus.

CONCLUSION

This study has demonstrated consensus across a large panel of multidisciplinary SMEs on many key areas of extrication and related practice that will provide a key foundation in the development of evidence-based guidance for this subject area.

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)

OBJECTIVES

To identify the differences between women and men in the probability of entrapment, frequency of injury and outcomes following a motor vehicle collision. Publishing sex-disaggregated data, understanding differential patterns and exploring the reasons for these will assist with ensuring equity of outcomes especially in respect to triage, rescue and treatment of all patients.

DESIGN

We examined data from the Trauma Audit and Research Network (TARN) registry to explore sex differences in entrapment, injuries and outcomes. We explored the relationship between age, sex and trapped status using multivariate logistical regression.

SETTING

TARN is a UK-based trauma registry covering England and Wales.

PARTICIPANTS

We examined data for 450 357 patients submitted to TARN during the study period (2012-2019), of which 70 027 met the inclusion criteria. There were 18 175 (26%) female and 51 852 (74%) male patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

We report difference in entrapment status, injury and outcome between female and male patients. For trapped patients, we examined the effect of sex and age on death from any cause.

RESULTS

Female patients were more frequently trapped than male patients (female patients (F) 15.8%, male patients (M) 9.4%; p<0.0001). Trapped male patients more frequently suffered head (M 1318 (27.0%), F 578 (20.1%)), face, (M 46 (0.9%), F 6 (0.2%)), thoracic (M 2721 (55.8%), F 1438 (49.9%)) and limb injuries (M 1744 (35.8%), F 778 (27.0%); all p<0.0001). Female patients had more injuries to the pelvis (F 420 (14.6%), M 475 (9.7%); p<0.0001) and spine (F 359 (12.5%), M 485 (9.9%); p=0.001). Following adjustment for the interaction between age and sex, injury severity score, Glasgow Coma Scale and the Charlson Comorbidity Index, no difference in mortality was found between female and male patients.

CONCLUSIONS

There are significant differences between female and male patients in the frequency at which patients are trapped and the injuries these patients sustain. This sex-disaggregated data may help vehicle manufacturers, road safety organisations and emergency services to tailor responses with the aim of equitable outcomes by targeting equal performance of safety measures and reducing excessive risk to one sex or gender.