By Rommie L. Duckworth
出色的车辆解脱涉及救援与紧急医务人员之间的合作，目的是提供有效的创伤护理，而不仅仅是尽可能快地打开车辆。对于最佳的解脱团队，这项合作延伸到所有人，从事件指挥官（IC），救援老板和精心的技术人员到初级保健提供者和支持人员。1, 2
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The Pillars of Vehicle Rescue: The Mindset and The Technique
即使是经验丰富的救援人员也可能过于专注于“工具和任务”，这是一种隧道愿景的形式，可能会导致完美执行的削减，推送，分布和卷，同时将患者护理留给EMS人员可以在救援团队中工作的任何方式。一种协调的方法可以将“工具和任务”的决定留给专家救援技术人员，但确保这些技术人员从患者护理方面的专家那里获得所需的信息。换句话说，何时（快速 /谨慎），（选择工具 /技术的选择）以及为什么（战略目标 /目标）在救援方面被WHO（WHO）（什么患者）告知了什么（他们是什么问题））以及从EMS一侧（受伤的地方）。
一个Four-Step Approach
协调的解释包括四步方法。
•到达 - 现场。一个s you approach and arrive on scene, you know that a good size-up can determine how well the rest of the call goes.3一个lthough they may not relay it over the radio, every responder should perform a personal size-up to identify dangers on scene as well as the best way to integrate their roles in the extrication operation.4这是情境意识和机组人员资源管理概念的本质。5
There are many mnemonics for extrication size-up. One that is easy to use on virtually any scene is “U-CAN”:
√你nit: Who are you (what is your role)?
√COnDitions：您看到的第一件事是什么？
√一个ctions：您将要做什么？
√needs: What do you need to do it?
√dangers: What hazards might stop you from doing it?
This simple mnemonic can aid responders in identifying what is going on on scene and what they are going to do about it.
The next step is to establish or integrate with command-and-control on scene.6他们可能不总是直观地定义为锥,flares, or scene tape, but even basic extrications will have Hot, Warm, and Cold zones. Just as with hazardous materials incidents, extrication Hot, Warm, and Cold zones define the level of hazards in an area as well as the training and protective equipment responders will need to operate there.
•一个ccess–Putting EMS personnel in contact with the patient.It can be tempting to “jump in” right away, but the responder gaining access should accomplish or verify the following general tasks:
√在车辆周围检查720+（360外圈调查，360内圆调查，以及在车辆上方和下方），并减轻立即危害。
√稳定悬架，然后堵塞/设置制动器。
√Put power doors, seats, windows, steering wheels, and so on in the optimal position.
√杀死车辆点火并卸下钥匙。
√Turn the headlights off and the hazards on.
√disconnect the battery and, in the cases of EV or hybrid vehicles, shut off the HV disconnect or pull the fuse as appropriate.
Once these initial actions have been completed, the Inside EMS provider(s) will make initial contact with the patient or patients inside the vehicle, communicates with him; protects him from further injury; assesses the injuries; provides immediate life-saving treatment; and, if possible, stays with the patient throughout transport.4
Immediate life threats such asmassive hemorrhage,一个irway difficulties,respiratory emergencies,Circulation problems, andHead Injury (MARCH) will necessitate immediate patient removal; assessment findings such as patient paralysis, significant neck or back pain, severe angulation of an extremity, impalement, significant crush injury, or the need for pain management or other medication administration will require a slow and careful removal.7
一个s with every other aspect of fireground operations, clear and concise communications are the key to effective action. One way the Inside EMS provider can quickly relay key information on the patient is with CAN reports —Condition， 这一个ctions内部EMS提供商正在尝试，内部EMS提供商将会needto accomplish these actions.8
一个ction: Initial Emergency Care
The rescue boss’s extrication plan (insert your local designation for the person assigning extrication strategy/tactics here) must include immediate medical priorities. The immediate medical priorities can be summarized by the phrase “MARCH Forward to the Emergency Department!” This plan often can be rapidly implemented by responders with EMS training, regardless of agency or advanced life support (ALS) responder status as long as they are trained and equipped to operate in the Hot Zone.
行进
一个responder’s first priority must be to deal with the problems that are most threatening to a patient’s life. These conditions can kill a patient quickly, but first responders can deal with virtually all of them in the first few moments of patient contact.9
massive Hemorrhage
To control excessive bleeding, responders must follow the “5 Ds”:detect(find the source);direct pressure(compress the bleeding site);devices(use equipment such as tourniquets, clotting gauze, pressure bandages, and clamps to free responders’ hands); anddon’t Dilute（如果您能获得静脉注射，请不要浇水患者的血液）。
一个irway Difficulties
management of airway emergencies during extrication should begin with basic life support (BLS) oral or nasal airways and suction and proceed to devices such as supraglottic airways, endotracheal intubation, and cricothyrotomy, as needed and as a provider’s certification / licensure allows.10
respiratory Emergencies
management of immediately life-threatening respiratory emergencies may include assisting a patient’s breathing with bag-valve mask (BVM) ventilation; dealing with a flail chest; sealing a sucking chest wound; and, for ALS providers, decompressing a tension pneumothorax.10
Circulation Problems
而大出血集中管理n first stopping bleeding, circulation focuses on keeping the blood perfusing the body. Considerations include obtaining IV or IO vascular access, administering only enough fluid to maintain a minimum blood pressure without diluting the blood, coordinating careful movement of the patient so as not to dislodge any internal blood clots that have formed, and possible pain management or patient sedation to help rescuers remove the victim more quickly. In some advanced systems, this may also include administration of blood products or medications such as tranexamic acid to minimize internal bleeding.9, 11-13
Head Injury
management of life-threatening head injuries require a provider to avoid the four “H-Bombs” that kill brain: hypoxia (keep the patient’s oxygen saturation above 90%), hyperventilation (don’t ventilate faster than 10/min), hypotension (keep BP >90 mm/Hg systolic), and hypoglycemia (keep blood sugar above 70 mg/dl).
向前
While immediate patient care and extrication efforts continue, Outside EMS providers and support personnel can begin to prepare to move the patient out of the vehicle and into the ambulance. Using a concept from rapid intervention teams, providers should “harden the egress” by ensuring that belts are cut, glass is fully removed, sharp edges are covered, and hoses and equipment are cleared along the path of the patient’s exit path.14
创伤护理
这里的想法不仅仅是将患者运送到急诊室，而是要将他带到适当的创伤护理水平，并确保创伤团队已准备好患者的到来。对于严重伤害的患者，这将意味着与指定的创伤设施进行协调并运输。15为了使创伤团队做好准备，它通常必须尽早获得受害者的预知。
一个fter: Follow-Up and Preparation for the Next Call
在最后一名患者被从车辆中删除并正在确定护理的路上后，仍有许多EMS方面有待处理。
Pictures
一个lthough there is no doubt that video and photographs of real extrication incidents can contribute to responders’ training and education, the guidelines for who should take them (and who should not) as well as how they are handled and who owns and has the right to distribute them (and who does not) should be well defined and clear to every responder. Most often, the best policy is one that makes it clear to responders what rights the public has and what ethical, if not legal, obligations responders have to sometimes obstruct public views of incidents to protect the privacy and dignity of the patients involved without coming in direct conflict with the photographer.
Pain/Pathogens
responder safety from physical and pathogen hazards should be evaluated after each incident: Are all of the responders safe? Were there any near misses? What could we have done to improvesafety? These questions should be asked after each call.4
Post-Traumatic Stress Disorder
Some incidents, especially those involving large numbers of victims, young children, or fellow emergency responders can have a significant psychological and emotional impact on those who respond. Just as we evaluate the potential for physical injury for our responders, we have to keep in mind their psychological well-being as well.
Preview/Review
departments should learn from every incident. Formal or informal after-action reviews are the times to evaluate not only what occurred but also how the response team(s) can improve each aspect of their response to better prepare for the next call.
Practice
review and self-reflection are the beginning, but great extrication teams put words into action by practicing and performing hands-on skills they have identified as those that will get them from good to great.
***
In the end, all fires eventually go out, all bleeding eventually stops, and all patients eventually get freed from their vehicles. Yet, with consideration of and coordination with the EMS aspects of extrication, rescuers eacharriveto do their own size-up and know their own roles and zones. They know that the vehicle is safe so that they can使用权the patient rapidly to assess what the patient needs from the extrication team. They don’t wait for ALS providers to perform life-saving BLS动作，但是当需要ALS技能时，护理人员准备好使用工具和培训来完成这项工作。最好的救援队回顾一下后each call and ask What can we improve? This is how integrating EMS aspects into the heart of your training and operations makes a good crew into a truly great extrication team.
BIO
Rommie L. Duckworthis a career captain/paramedic EMS coordinator and past volunteer chief officer. He is the co-founder and director of The New England Center for Rescue and Emergency Medicine, the editorial director for RescueDigest.com, and executive director of the First Few Moments nonprofit emergency services education corporation. As a dedicated emergency responder and an award-winning educator with more than 25 years of experience working in career and volunteer fire departments, public and private emergency services, and hospital healthcare systems, he is a frequent speaker at national conferences and a contributor to research, magazines, and textbooks on operations, leadership, and emergency services education.
references
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8。Kastros, A, “Mastering Fireground Command,”fireengineering.com, 2011.
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