EMS Gaining Access and Extrication

Issues of Concern

The primary concern for EMS providers on all scenes is personal safety. An injured or incapacitated EMS provider cannot assist a patient. EMS is an inherently dangerous job, and providers must prioritize safety to ensure they return home at the end of each shift.

Ensuring Safety from Dispatch to Arrival

Ensuring scene safety begins at dispatch. From the moment an EMS crew receives a call, they must remain mindful of potential dangers associated with the scene.

For example, vehicle crash scenes present significant risks, such as fires, downed electrical wires, broken glass, and passing traffic. EMS crews should park strategically to avoid traffic, use emergency lighting when stationary on a road or in a hazardous area, and wear reflective clothing to enhance visibility. Despite these precautions, MVC scenes continue to pose dangers to EMS providers, making situational awareness crucial. Additionally, airbags that fail to deploy during the initial impact may activate during extrication or patient care. While airbags save lives in crashes, their delayed deployment can lead to serious injuries or even death. EMS providers must remain vigilant to this risk as they work at accident sites.

Scenes unrelated to vehicle crashes or roadways still hold significant dangers, so EMS crews should never lower their guard. Potential threats, such as violent patients, agitated family members, or bystanders, can escalate situations. EMS providers should refrain from entering an unsecured scene or one that may involve violence until law enforcement secures the area.[4] Other hazards, including exposures to chemicals like carbon monoxide, also warrant consideration. EMS crews must recognize hazardous material placards and request specialized teams when necessary to mitigate the danger.

Mitigating Environmental Hazards in Patient Extrication

The appropriate method for gaining access and extricating patients varies depending on the scenario, but some basic principles apply across all situations. Any structure involved must be stable. For example, an overturned car requires support to prevent movement, which could endanger both the patient and the EMS crew. Various techniques and equipment are available for this purpose, from basic wood-block cribbing to pneumatic airbags and advanced strut systems. EMS personnel must be familiar with the tools used by their agency and comfortable with deploying them.

In cases involving fire, explosion, or earthquake, EMS providers should avoid entering a structure until its integrity has been verified. If the structure cannot be deemed safe to enter, EMS providers must weigh the risks and benefits. However, in situations where a patient's life is at risk, EMS personnel may choose to enter the structure regardless. In these cases, EMS providers should make every effort to maintain safety, including using appropriate personal protective equipment.

Gaining Access to Patients

After confirming that the structure is sound, EMS must gain access to assess and treat the patient, always starting with the most straightforward route. A useful phrase to remember is "try before you pry." Whether on a car or a residence, the EMS provider must verify whether the door is unlocked before resorting to force to open it. Gaining access to the patient may be as simple as turning the knob.

If the door is locked or inoperable due to damage, forceful entry becomes necessary. A variety of tools and techniques are available for this purpose. Whenever possible, law enforcement should be involved to ensure safety. The risks and benefits of forcing entry should be carefully weighed, and this step should only be taken if the patient appears to be in imminent danger.

Depending on the EMS agency and its capabilities, the task of forceful entry may fall to a mutual aid agency, such as the fire department. Hydraulic tools, like spreaders and cutters—commonly known as the "jaws of life"—are often used to access patients trapped by mangled metal, such as in a motor vehicle crash (see Image. Hydraulic Spreader). Another popular tool used by the fire service is the Halligan bar, which combines a blade, claw, and tapered pick in one versatile instrument. This tool provides significant leverage and is particularly effective for opening or breaking through locked residential doors.

While the specific procedure for forceful entry into a vehicle may vary depending on the equipment and the situation, the underlying principles remain consistent. Glass in windows should be taped in a criss-cross pattern before breaking to minimize the risk of glass shards falling into the vehicle and potentially injuring the patient. A gap can be created between the door and the frame near the handle using a Halligan bar or similar tool. Hydraulic spreaders can then be inserted into the gap and used to widen the door from the frame. If complete removal of the door is necessary, the same technique can be applied to the door's hinge after initially opening it.

Providing Medical Care During Extrication

Gaining access may only be the first step in patient care. In some cases, EMS may successfully access the patient and begin treatment. However, if the patient remains trapped, transportation to the hospital for definitive care is not possible. Extricating these patients can be complex and carries significant risks to both the patient and EMS personnel, especially in cases of severe trauma, such as major car accidents, where a large portion of the critical first hour of trauma care may be consumed.

EMS must provide any care possible to the entrapped patient, such as managing the airway or administering intravenous fluids, while ensuring the safety of both the patient and providers. Minimizing spinal movement during extrication is crucial to prevent exacerbating potential injuries. Cervical collars should be applied as soon as possible when a cervical spine injury is suspected. Long spine boards are commonly used to maintain spinal alignment during the extrication process. Short spine boards are also available for similar purposes. Although these boards are valuable tools for extrication, EMS should prioritize removing the patient from the board as soon as it can be accomplished safely.

Crush Injuries and Blood Transfusion

Early and aggressive fluid resuscitation is critical for entrapped patients, particularly those at risk for crush syndrome and shock due to fluid losses. Crush syndrome results from traumatic rhabdomyolysis, potentially leading to metabolic disturbances, fluid sequestration, and renal failure. Guidelines recommend initiating intravenous fluid administration before extrication, with alternative routes such as intraosseous or subcutaneous for delivery, if intravenous access is not possible. Normal saline should be used at an initial rate of 1 to 1.5 L/h for adults, adjusted based on urine output, with caution in patients with comorbidities. While permissive hypotension is generally avoided in these cases, fluid resuscitation must be balanced against the risk of hemorrhage and coagulopathy.

Hyperkalemia, exacerbated by acidosis, can also result from crush injuries and subsequent renal failure. An electrocardiogram should be obtained to monitor for signs of hyperkalemia, such as peaked T waves, prolonged PR interval, and widening of the QRS, as the condition is potentially fatal and requires prompt treatment. Sodium bicarbonate administration is recommended before extrication to reduce the risk of early dysrhythmias caused by hyperkalemia.[5]

Any active bleeding must be identified and immediately managed by applying direct pressure to the site. A tourniquet may be used if necessary. Blood transfusions should be initiated whenever feasible, including before or during extrication, for patients with significant blood loss and signs or symptoms of shock to improve oxygen delivery and survival. Type O negative blood products, typically packed red blood cells and plasma, are most commonly used in the prehospital setting, where blood typing and crossmatching are not possible.

Helicopter EMS most often provides prehospital blood transfusion. Thus, early activation of helicopter EMS should be considered in cases of prolonged entrapment with trauma and blood loss. Ground EMS agencies are increasingly carrying blood products, expanding their availability and improving outcomes.

EMS providers should adhere to their agency's protocols in these situations. EMS physicians directly involved in patient care will initiate treatments according to the latest recommendations. 

Vehicle Extrication Techniques

In MVCs, patients may become trapped as the dashboard collapses, pinning their legs. Delays in care occur as EMS must first gain access to the patient and then extricate them from the entrapment. Some treatment is possible after gaining access, but transport cannot proceed until extrication is complete. Hydraulic tools commonly lift the dashboard in such cases through a technique called the "dash roll." EMS providers must be well-versed in the capabilities and tools available to their agency.

In certain situations, the car’s roof may need to be removed for extrication. Rescuers must first remove the windows before cutting the metal support posts between the windows using hydraulic cutters or similar tools. Depending on the specific needs of the extrication, rescuers can cut all the posts and remove the roof entirely, or they may opt to cut the front 2 to 4 posts, then fold the roof up and backward. To facilitate easy folding, a cut at each side of the roof may be necessary at the desired folding point.

EMS providers must complete a hands-on course before performing any automotive extrication technique. The complexities of automotive extrication extend beyond the scope of this article. EMS personnel should only attempt techniques they are specifically trained to perform and should be familiar with their equipment. The National Fire Protection Agency (NFPA) provides detailed guidelines and regulations for fire industry practices that EMS teams must follow.

Industrial and Farming Accidents

Extrication may also be necessary in industrial or farming accidents. As with other incidents, the specific method of extrication depends on the situation. EMS agencies must remain aware of local hazards where such accidents are likely to occur. For instance, grain bins in farming communities pose a unique danger.[6] Entrapment in grain bins can quickly become fatal, and extricating patients from these situations is both complex and dangerous. EMS agencies in these areas should practice and plan for grain bin rescues, and specialized courses may be available to learn these techniques. An agency should not hesitate to request assistance from a mutual aid agency, such as a technical rescue squad, when its extrication needs exceed its capabilities.

Managing Impaled Objects

For patients with impaled objects, leaving the object in place is usually the safest approach, as it may tamponade internal bleeding.[7] However, the impaled object should be cut when it is part of a larger fixed structure, such as machinery, in an industrial incident. The cutting process must prioritize patient safety and minimize movement to prevent further injury. Removing impaled objects requires specialized training and tools, which are typically carried by Fire Department personnel.

Field Amputation—The Last Resort

In extreme situations, field amputation may be necessary to extricate and transport a patient for definitive care.[8] This procedure serves as a last resort when the patient faces imminent death without immediate release. Contacting medical control is essential, and EMS providers must be familiar with agency protocols governing this intervention.

Some EMS systems deploy physicians in the prehospital setting. When available, these physicians can provide advanced care to entrapped patients throughout the extrication process. EMS agencies with this resource should consider utilizing it, particularly when prolonged extrication is expected. Physicians working in the field must follow scene safety protocols and only perform extrication-related procedures within their training. In cases requiring field amputation, having a trained physician on the scene provides the optimal conditions for performing the procedure.

Considerations for Continued Patient Care After Extrication

Postextrication care for entrapped patients requires a coordinated approach that integrates medical stabilization, timely interventions, and efficient transport to definitive care. Once extrication is complete, EMS clinicians must prioritize patient monitoring and address ongoing medical needs, such as managing the airway and preventing complications like hypothermia and crush syndrome.

As airway management remains a challenge in entrapped patients, EMS clinicians should be prepared to employ advanced airway techniques, including supraglottic airways and alternative methods, if necessary. These strategies should continue into postextrication care to stabilize the patient’s respiratory status. The most experienced operator should accomplish the task.

Prolonged entrapment can lead to hypothermia, even at high ambient temperatures, due to extended exposure.[9] Hypothermia can cause coagulopathy and increase the risk of cardiac dysrhythmias. Immediate rewarming is essential. EMS clinicians must actively warm the patient using blankets, thermal kits, or forced hot air.[10]

Medications like sodium bicarbonate, calcium gluconate, and albuterol should be administered early and may continue in the postextrication phase to prevent fatal hyperkalemia from crush syndrome. Antibiotics should be given to avoid infection, as sepsis remains a significant risk.

Tourniquets may be applied to control hemorrhage during extrication, but they should be reassessed and adjusted as necessary. While tourniquets may prevent hemorrhagic shock, care must be taken to avoid complications like reperfusion injury. (INSARAG Medical Working Group)

Ongoing communication between the rescue team and the receiving hospital ensures efficient transfer to definitive care. EMS clinicians should relay key information, including the patient’s status, injuries, and interventions, to prepare the receiving team for immediate management upon arrival. Effective communication with the patient is likewise essential, as providing reassurance and explaining the care process help improve patient satisfaction.

Given the complexity of postextrication care, early involvement of EMS physicians can enhance patient outcomes. Physicians can perform advanced procedures, make critical decisions, and manage complex cases, ensuring optimal care until the patient reaches the hospital.[11]

Throughout the postrescue phase, continuous monitoring of vital signs and response to interventions is essential to ensure the patient remains stable during transport. Effective postretrieval management not only addresses immediate medical needs but also optimizes patient outcomes by preparing them for definitive care in the hospital.

Clinical Significance

Understanding the prehospital environment benefits emergency department clinicians by improving communication with EMS and enhancing patient care. The scene of a traumatic injury is often chaotic, and recognizing what a patient has endured before hospital arrival allows for more informed decision-making. Delays between the incident and hospital arrival frequently occur, and acknowledging these delays is especially important in trauma resuscitation, where time is critical. Additionally, the extrication process itself can be traumatic, potentially complicating the patient’s condition.

EMS plays a vital role in prehospital care, balancing patient treatment with personal safety. EMTs and paramedics must remain aware of time-sensitive trauma care while ensuring access and extrication are performed as quickly and efficiently as safety permits. Ultimately, without the dedication and expertise of EMS personnel, many patients would never reach the emergency department for definitive care.[12][13]