iPhoneIcon_BigCar accidents with trapped victims can be incredibly frustrating. There is often very little one can do until the rescue services achieve extrication. Sometimes, because of limited patient access, all you can achieve during extrication is some very basic airway management, pain relief through a crap IV and ‘neck stabilisation’ while waiting for the firemen to fully extricate. Everyone on scene knows how every minute counts, and it feels like it is taking forever. A British study in EMJ looks at how long the various stages of extrication takes.

The authors define some necessary steps that need to be performed in order to achieve extrication.
1. Scene assessment and safety: Rescuers assess scene safety. Other traffic needs to be controlled, airbags secured, chemical spills managed etc.
2. Stabilisation: The car is stabilised so it wont move during extrication. Air is released from tires, pneumatic stabilisers applied ect.
3. Glass management: Glass from windshields must be managed, it is important to remember that the car can have a Windshield Replacement done, what’s most important in this case is to keep the victim alive. A windshield under stress may explode and shower the victim with fragments causing cuts or even inhalational injury. Often an anti-shatter film is applied before the windshield is lifted out.
4. Initial access: The phase where ambulance or firemen have limited access to the patient and can make a rough assessment of what medical management is required. If the victim is in a critical condition the clincians can call for a rapid extrication without immobilising the victim.
5. Full access: Enough internal and external space has been created so that rescuers can provide somewhat effective treatment. The victim is ready to be extricated.
6.  Final extrication: the victim is extricated, often immobilised on a spineboard, to an prepared area where full medical stabilisation happens.

The study
The authors calculate the average time each step takes after identifying 158 incidents with trapped victims requiring fire crew extrication. Time-points were collected by listening to emergency services’ two-way radio.

Stabilisation and glass management took on average 4 minutes each, meaning initial access was achieved after 8 minutes. Achieving full access required another 12 minutes. Finally, extrication took on average 7 minutes. Median time to full extrication, after which full medical management can begin, was 30 minutes.

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Take-home message
On average it takes 30 minutes to achieve full extrication. After setting up the stretcher, setting up for intubation, for immobilisation and what not, it seems to take an eternity for the firemen to extricate. Often, all you can do is just watch. Still, im often surprised when I see the actual timings after delivering the patient to the hospitals. Most of the time, extrication happens a lot quicker than I expected. I guess it’s the intensity of car crash scenes that’s screwing up my perception of time.

Study lives here:
Emerg Med J. 2014 Dec;31(12):1006-8. doi: 10.1136/emermed-2013-202668. Epub 2013 Sep 4. The stages of extrication: a prospective study.Nutbeam T1, Fenwick R2, Hobson C3, Holland V4, Palmer M5.

Also, I found an excellent, but a bit dated, review describing some of the basic principles of extrication:
Emerg Med J. 2005 Nov;22(11):817-21. Extrication of the seriously injured road crash victim. Calland.
Also I recommend you to read this driving safety blog post from Hornsby, Watson & Hornsby.

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  1. Nice summary – time does seem to drag on and the above post describes nicely the reasons for clinicians feeling edgy whilst scene is made safe and patient extricated – dont underestimate the value of verbal reassurance, simple monitoring (finger on pulse…or one of those small handheld monitors with SpO2 and ETCO2 capabilities)

    I’d put in a plug for Ian Dunbar’s excellent book on vehicle extrication techniques – see

    …and as always, use time taken to extricate to get all kit ready, stretcher inline, vac mat and pelvic binder ready…and have a plan for rapid extrication if clinical deterioration or expediency (car on fire)

    Safety – self, scene, survivors…in that order!

  2. Excellent post. Access is hardly addressed in most of the medical articles that are written today.

    I would recommend on initial Scene Assessment. Looking at things like slope and wind direction and access for larger fire apparatus. Keeping access routes for follow on responders clear. Police tend to “pile on” at incidents.
    I would also recommend during vehicle stabilization that the battery cables should be cut. This will disable the airbags. Some modern cars have up to 22 airbags in them. Just a footnote some of the airbag struts are in the A B or C post, so be careful cutting through those to gain access.

  3. Ian Dunbar says:

    Excellent debate here.

    Tim, thanks for the shameless plug. Cheque is in the post!

    I would like to add that more multi disciplinary training would breed a relationship that would greatly reduce the time taken to achieve safe initial patient contact.

    If the technical crew are aware of the need for patient access (which lets face it, with the massive advent of trauma care within fire and rescue services, they are!) then they will endeavor to create medic access as soon as possible. This will often be done before stabilisation or glass management where the necessity exists!

  4. Andrew Rork says:

    I would like to point out that the process by which European, in this case British, emergency services do extrication is different than here in the United States. It is apparent they tend to be slower and with more emphasis on protecting the patient from harm during the “extrication” than quickly getting the patient out for transport. In the USA there is more emphasis on the time component of extrication and treatmenting while in transport to a major trauma hospital (MVC or any trauma) than staying on scene. If you want to see this for yourselves I recommend watching episodes of the show “Trauma Doctors” featuring London HEMS!

  5. Marshall says:

    My eldest Son and two other occupants of a supposive speeding car lost control.Not allowed much info. Just want to know my son had an IV in forearm 3 EKG tabs and board?____.Would it not been advisable to keep him calm.No fire car pretty bad shape .Hit a wall.No pther cars involved???????.Son had cardiac arrest two actually.about 48 minutes after impact.Why as his Mother i am puzzled at why it took so long to remove car door and take him out.Fire will not share with me.Authorities will not share.Son dead all dead brought to station. Then bodily handlers and fire removed bodies then taken to Morgue 12 hours after single speeding MVA. Is this a normal procedure as it was a busy road or so I was told.

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