# Not arm-chair answers: industrio-agro entrapment



## mycrofft (Feb 15, 2014)

You are first on scene at (your pick):


1. A paper recycler factory where a worker got his fingers into a cold (not heated) drying roller up to the elbow.






*OR*​
2. A corn auger, the victim got off the seat and tried to kick a jammed load through, pulled foot into the machine to mid-calf.




Pt is trapped in the machine with the engine just idling, in tremendous pain, conscious, alert, little to no active bleeding but moderate amount of blood in vicinity, maybe more in the machine. VS accelerated but not shocky. Healthy 24 y/o, no meds, no drugs, no alcohol. If you want, throw in some tobacco use. 

1. What are your immediate actions upon arrival?
2. What if any extrication do you perform?
3. Any special considerations for these types (crushing with stretching) injuries?

If you will, please use your company or department's actual protocols for us so we can discuss them. If you are going to "arm-chair" this, say so. (Any discussions of anatomy, physiology or meds will be assumed to be arm- chaired unless otherwise stated).

OK, GO.


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## mycrofft (Feb 15, 2014)

dupe post


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## mycrofft (Feb 15, 2014)

BTW, the website about the corn augur:


http://www.public-health.uiowa.edu/face/Reports/REPORT-016.html

And a NIH article on augers

http://www.ncbi.nlm.nih.gov/pubmed/7053516

And one on paper rollers not from NIH 
http://www.justicenewsflash.com/2010/07/30/nh-industrial-accident-worker-pulled_201007305136.html


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## Angel (Feb 16, 2014)

oh boy im going to chose the #2,

 first things going through my head would be, who, if anyone can cut the machine OFF. In our system fire is either already there or coming at the same time so its a 5 person crew (including me). 
1 gets vitals (RR, BP, P)

what are skin signs, based on the amount of blood lost Im just going to go for 15 NRB so another guy is going to put him on o2, pain level! pending v/s he's a candidate for morphine (we don't have fentanyl yet).

and the other guys are either figuring out how to get the machine off or get him out of it. (Knowing nothing about augers I'm assuming the gears will move back and forwards so well reverse that foot out the same way it went in)

Im going to ask questions of him and/or the bystanders of how long has he been there, and what all happened . depending on how he answers will also help me determine LOC/GCS

Ill wait for the numbers to come back on v/s but hes getting at least 1 IV. Hes going to fall under the trauma protocol (based on my discretion). I'll assess the leg as best I can for DCAPBTLS, I'm especially concerned about CSM 
 however we don't have a crush injury protocol :unsure:


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## mycrofft (Feb 16, 2014)

Stretch and crush.


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## mycrofft (Feb 16, 2014)

Normal vital signs except accelerated pulse and resp due to pain and consternation.

The entrapment is imposing mechanical haemostasis.

Also, stretch-crush injury can affect major vessels so they will tend to stretch, tear, then snap back and close up.


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## mycrofft (Feb 17, 2014)

ok call the code


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## Household6 (Feb 17, 2014)

I'll the first one, it's an unfamiliar machine to me and makes for a continuous scene hazard because of it's complexity. Let's assume this is a rescue and not a recovery? <_< I'll take the role of Incident Commander, since I'm a bossy old hag.

Approaching assessment on that machine, I would need to assemble three teams. A hazard team, a medical team and an extrication team. Gather witness statements

Hazard include potential/stored energy --how is the machine powered, and by how many sources.. Are their pneumatic parts that will move or fall on power down? Are their pieces being held in place by hydraulics? Under pressure? Hazard team is also responsible for continuous evaluation of hazards during the extrication. Recon and protection, their job doesn't end until the scene is completely cleared by extrication team.

Medical team.. Treat for shock. Skin signs, blood loss, heat loss, vitals.. Consider dual peripheral IVs during rescue. Keeping the pt awake is vital here. Assess, treat what's treatable, and package for transport.

Extrication assessment.. The plant manager and the plant service personnel are vital, since they know the machine. Unfortunate, but I hope they can grow some and think straight enough to guide and inform. Large machinery needs to disassembled correctly so it can be done as quickly as possible. So they get assigned to cutting, dis-assembly, and lifting/moving.


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## DrParasite (Feb 17, 2014)

either one (but I'm going with #2):

1) shut the machine off.  completely powered off.
2) this is a rescue assignment more than an EMS one.  Until he's freed, it's rescue's show (hopefully an EMS rescue crew or a Fire/Rescue crew who is EMS trained)
3) remove the machine from around the entrapped limb
4) monitor for compartment syndrome
5) transport to trauma center, giving them a good report


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## mycrofft (Feb 18, 2014)

*They sound good to me.*

I'd forgotten about stored energy. 

Oh: "Keeping the pt awake is vital here".

Why?


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## Household6 (Feb 18, 2014)

mycrofft said:


> I'd forgotten about stored energy.
> 
> Oh: "Keeping the pt awake is vital here".
> 
> Why?



Ya you never know if powering down the electricity is going to make solenoids de-actuate, causing pneumatic cylinders to extend or retract. It could be either. 

JMO, but that's why you can't go in all gung ho with your jaws of life on a machine.. A complex machine is different than prying open a car door.

The patient is at high risk for hypovolemic and neurogenic shock, and losing consciousness.. Ideally, I'd like for them to maintain their own airway. It makes it easier to determine if there are changes to their condition, and they can possible pinpoint where other injuries are..

I like my patients either alive and screaming, or asystole and quiet.


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## Handsome Robb (Feb 18, 2014)

I'm going with number two. 

1. The machine needs to be locked out and tagged out. Find out if we have someone who knows it well or if we can get someone on the phone that does to make sure it's not going to release a bunch of stored energy, how to get it apart, can we reverse it so on and so forth. 

2. Depending on what bleeding I can visualize and trends in his vitals I might go straight to a TQ on that leg.

3. Get a line, fluids TKO just aiming to keep his MAP >65, O2 PRN, lets get some fentanyl onboard, I might consider going intranasal immediately upon my arrival to get the poor guy some relief. I don't know how big he is, fent is 0.5-2 mcg/kg, I'm generally on the heavyweight end of the dose if I'm comfortable with the patient. I'm going to be on the phone with OLMD as well asking for permission to switch from fentanyl to morphine if we're going to have an extended extrication time. I'd prefer to stay with fentanyl for this patient though due to it's hemodynamic profile. Also, I'm going to ask they remove my max dose on fentanyl (300 mcg) and allow me to titrate it to effect. The majority of physicians here would give me those orders. 

4. Once we are ready to extricate I'm going to have a CAT in place if it isn't already - removing the compression that the machine is causing is going to result in bleeding. This is assuming he's got extensive soft tissue damage with probable vascular involvement. If that's the case I'm not going to doink around pretending that I can control the bleeding with pressure. I'm also going to put some O2 on if it's not already there, sidestream capnography monitoring then going to give 1 mg of versed and 1 mcg/kg of fentanyl. I can repeat q5 mins so if the first go round doesn't do it for him I'll repeat it. My max on versed is 5 mg, fentanyl is 300 but I'm hoping my max doses were removed when I called for orders. The second dose is going to depend on his sedation score and how much he's received thus far. I'm aiming for a bloomsbury sedation score of -1 to -2 for this extrication. I can give all these combinations on standing orders, the only thing I need OLMD for is to remove maxes and to use fentanyl and morphine but like I said I'd like to stay with fent for this guy if at all possible. We're going to remove him from the machine and go straight to the gurney then take a nice smooth ride to the ER. 

My biggest concern with this guy besides hemorrhagic shock and pain is crush syndrome/rhabdomyolysis. That's going to depend on the length of entrapment and the amount of extremity entrapped. The longer he's entrapped the more worried I am. If we get upwards of 4 hours I'd be considering calling for more orders for bicarb. The TQ is going to keep all that nasty potassium, lactic acid and myoglobin out of systemic circulation. 

Compartment syndrome is something to consider as well depending on the type of injury. If it is a true crush without penetration of the skin then I'm going to be more worried about it but again it's not something that's super concerning unless you're looking at *hours* to definitive care. 


I *LOVE* it. Can we do more scenarios please I miss the field


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## mycrofft (Feb 18, 2014)

Here's a note.

With this sort of accidents, when the victim is able to disentangle him or herself and the trauma is not just cutting or crushing but also stretching, the victims have been known to get up and walk away (or drive a tractor) for help.

In the old days (Korea), and ??nowadays, in the field a medic would take a hemostat to a big bleeder and squish and stretch the visible end.:censored: Sometimes it would retract and stop bleeding enough for packing and pressure to work. Sometimes it just retracted and kept bleeding.


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## Household6 (Feb 20, 2014)

mycrofft said:


> Here's a note.
> 
> With this sort of accidents, when the victim is able to disentangle him or herself and the trauma is not just cutting or crushing but also stretching, the victims have been known to get up and walk away (or drive a tractor) for help.
> 
> In the old days (Korea), and ??nowadays, in the field a medic would take a hemostat to a big bleeder and squish and stretch the visible end.:censored: Sometimes it would retract and stop bleeding enough for packing and pressure to work. Sometimes it just retracted and kept bleeding.



That's why they stopped teaching IV/fluids in CLS.. Troopies would try to help their buddies by pushing saline, and they'd end up blowing their clots out.. Troops were bleeding to death. Retraction is nature's way.

We didn't push fluids in my buddy I told you about, crofty.. We waited until we got to the ER, and dropped a central line in his jugular and gave him 3 pints at our level 3, and he took two more in the nine line to the level one.


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## mycrofft (Feb 21, 2014)

Household6 said:


> That's why they stopped teaching IV/fluids in CLS.. Troopies would try to help their buddies by pushing saline, and they'd end up blowing their clots out.. Troops were bleeding to death. Retraction is nature's way.
> 
> We didn't push fluids in my buddy I told you about, crofty.. We waited until we got to the ER, and dropped a central line in his jugular and gave him 3 pints at our level 3, and he took two more in the nine line to the level one.



Pints of what? Blood or a colloid or NS or Jack Daniels?
Wait, Starbucks, its a vasopressor.


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## Handsome Robb (Feb 21, 2014)

They need to stop teaching target systolic pressures and start teaching target MAP.


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