Cold and hurt: Motor vehicle accidents in the winter
Cold patients and slippery scenes present very difficult decision-making for rescuers
By James J. Augustine
Winter is here in the Northern Hemisphere. Trauma season is present year round. The two together represent some of the most challenging patient care and scene management scenarios that face EMS providers.
A 44-year-old male involved in a motor vehicle accident is found by a passing trucker who barely noticed the vehicle that slid off the road. The victim is trapped in his car, and extrication equipment is slow to arrive on the interstate highway due to the awful, slippery road conditions.
On the arrival of the first EMS unit, the victim is cold and bleeding from head wounds. His airway is patent, not compromised by injury or bleeding. He has slow respirations. Skin that was not covered in clothing is cold and pale. It is too cold for the EMTs to palpate a radial pulse, and there is no reading from the attempt at pulse oximetry. No one knows how long the victim and his car may have been off the road.
Following the basic principles of managing cold patients, the first responders cover the patient with warm towels and blankets from the EMS unit and insure that nothing wet is lying against the victim. He has no active bleeding apparent, and his clothing will not be cut off to preserve his body temperature. There is a drop of fresh blood from a head woundso an instant glucose reading is done and the meter indicates the victim’s blood sugar is about 100.
Cold patients and slippery scenes present very difficult decision-making for rescuers. As the extrication equipment and fire apparatus arrives, there is an opportunity to protect the scene from any further cars sliding into the working areaand also to establish the priorities for extrication and victim care.
The extrication will involve carrying equipment down the embankment at the edge of the highway, removing the door, and raising the dash off the patient’s legs. In ongoing snow and slippery footing, this is likely to take about twice as long as the same operation in warm, dry weather conditions. So the extrication and EMS leaders plan for a 25-minute operation until the victim will be free.
EMS priorities during extrication
The paramedic in charge of patient care has assessed all parts of the patient that are not bundled in. She has kept the victim covered and warmed as best can be accomplished, and is working to place four leads from a cardiac monitor on the victim’s torsoby sliding them under the victim’s clothing.
This will be the best way to monitor the patient, since the medic’s cold fingers can’t feel peripheral pulses and the pulse oximeter could not detect a pulse on the digits. The EMTs will rotate warm towels and blankets from the ambulance to provide as much warming as possible while extrication is ongoing, even sliding some warm towels inside the man’s shirt.
The passenger compartment of the ambulance is being warmed, intravenous fluids are being warmed, and the portable oxygen cylinder is also placed in front of the heater vent to warm it. The stretcher is left in the ambulance, as the crews set up a backboard and rescue basket to haul the patient up the embankment when he is freed. Incident command has taken the responsibility to notify the regional trauma center to allow timely preparation of the trauma team, and to set up invasive re-warming treatmentif needed.
Incident command and extrication priorities
Incident command is very concerned about the safety of the crews working this incident. Traffic still moving on both sides of the interstate highway is subject to the ongoing problems that caused this accident, so Command has placed all fire/EMS vehicles strategically in an attempt to protect the working members. All members are to stay off the roadways, and law enforcement is always challenged to keep traffic flowing safely without getting run over themselves.
The vehicle is not leaking fuel, but Command has ordered a hose line on the ground in case of unexpected fire. The heavy rescue vehicle is as close to the scene as possible, but equipment will still need to be taken down the embankment.
Command orders that the transport down the hill be done on tarpsso that no member is lifting equipment and trying to carry it down a slippery hill. It will also keep the equipment as dry as possible in the ongoing precipitation, and will allow a rapid process for getting it back up the hill once extrication is complete.
Extrication will be done using twice the number of personnel make sure the working operation can be done safely. Extra cribbing material is needed to make sure the vehicle doesn’t move further. The extrication operation will be undertaken as rapidly as safely possiblesince this victim is already cold.
The rescue operation
The vehicle is stabilized, especially on the downhill side, and all needed equipment is slid down the hill on tarps. The victim is protected in the car during the cutting and bending operations involved in extrication. A backboard and tarp are brought down the hill, and the backboard is kept dry from the precipitation.
As soon as the door is opened and the dashboard rolled up, the victim is slid onto the board, and simple tape is used to secure the victim for the trip up the hill. The blankets that were used for warming are used as cervical stabilization devices. The victim is slid up the hill on the backboard and on the tarp, and then the backboard carried into the back of the warm ambulance.
Once in the ambulance, there is the first opportunity to remove the patient’s clothing in orderto complete a primary assessment. Medics cut through the clothingand peel it off, and then the paramedic does a hands-on assessment before covering the victim in warm blankets.
The victim is maintaining his own airway, so warm oxygen is administered. He is breathing slowly has no obvious chest injury and a soft abdomen. The victim’s arms are not injured, so a single intravenous line is started and warmed fluid is started with a 500 cc bolus.
After a few minutes, the pulse oximeter is able to detect a pulse, and oxygen saturation is maintained about 95 percent. When pants are cut off, it is obvious the patient has a fractured right lower leg. That area is splinted. His scalp and face have multiple lacerations, so these are covered.
He is transported to the trauma center, a slow journey for the ambulance. The trauma staff are prepared, and the patient is evaluated. With a core temperature probe, they determine his temperature is 86 degrees, so must have been off the road for some time. He requires aggressive re-warming in the Operating Room, and control of internal bleeding in his abdomen, but makes an excellent recovery.
The challenge of motor vehicle trauma and cold weather
While hypothermia is now a growing treatment option for medical patients in cardiac arrest, our best medical research indicates that cold and injured is a lethal combination. A cold body has trouble maintaining its ability to coagulate blood, and results in lethal acidosis and multiple organ failure. Victims who happen to get wet in the course of their traumatic event have more rapid progression of hypothermiaand frostbite if skin area is wet and exposed.
Treatment of the cold and injured motor vehicle accident patient includes three very important elements. The EMS provider should not allow the victim to get wet or to get colder. If extrication is required, do not strip the patient, or start cold IV fluids. Even cold oxygen will worsen the patient’s condition.
Another important issue for the patient that is injured and cold is to make sure there is no other reason for the victim to be unconscious or in shock. Hypothermia rarely occurs in isolation from another medical problem (diabetic problem, intoxication, overdose, etc). EMS protocols should allow for assessment for those problems, in addition to trauma.
Trauma treatment protocols should include warmed inhalation treatment and intravenous fluids. There are a variety of devices that now offer the ability to provide warmed and humidified oxygen and warmed intravenous fluids. Some of these products have been tested in field environments that includ Alaska. A protocol may have these elements:
Move the victim from the cold, or remove the cold from the victim. Particularly important is the removal of wet clothing. Leave warm, dry clothing in place until the environment around the patient is warmer than the patient.
Ventilation should use warmed oxygen and humidity as possible. Use of endotracheal or nasotracheal intubation to protect the airway and ventilate is beneficial if it can be performed quickly and does not move the injured victim’s cervical spine.
Intubation techniques are generally the same whether the patient is normothermic or hypothermic, although insertion can be more difficult in hypothermics.
Once warming has started, do not let the victim get cold again. If there is a likelihood of prolonged extrication, do not initiate rewarming until it is certain that warming can be continued.
Make sure packaging is ready when extrication is complete. Splinting can be done using the victim’s dry clothing and simple items like blankets, towels, and tape.
Use commercial products for warming if available. Warmed oxygen (to a maximum of 108°F (42°C)) should be administered and humidified. Heating oxygen without humidification is not an effective warming technique. IVs should be heated to approximately 104° F (40° C)when possible, and should not be administered if they are colder than the patient's core temperature. The general approach to hypothermia is to initiate fluid therapy very slowly because a cold heart cannot effectively manage large fluid boluses.
The system challenge of motor vehicle accidents in winter weather
Multiple vehicle accident incidents occurring in rapid succession, when winter road conditions are bad, may be among the most challenging situations for EMS leaders to manage. Cold and slippery roadway conditions can lead to simultaneous multiple-victim incidents.
Public safety leaders, including fire, EMS and law enforcement, must work with the media (the fourth member of the public safety team) to minimize these threats to public health. The work of the public information officer with the local media may be lifesaving. At the department level, possibly involving the local emergency management agency, there may need to be a change in operating protocols. These would include sending more fire and EMS equipment to provide more personnel and a safer work environment.
When ice is an element of the weather challenge, carrying equipment and patients becomes a risky business. When operating on icy roadways, there is every reason to use the ice as an assist device. Rescuers may need to essentially “skate” their way to the vehicles and victims, and slide equipment to avoid having to carry it.
Extrication equipment may need to be pushed or dragged on tarps to the vehicles. There should be sand or salt buckets on all responding vehicles to provide traction in critical work areas. Public works crews will be another dispatch element to sand or salt roadways or plow snow for emergency vehicle access.
Some departments even have organized snowmobile or “snow cat” vehicle approaches to major snow events. (Multiple trauma patients from downhill skiing accidents have long benefitted from rapid transport using those vehicles, and ski patrol members may offer local expertise at packaging cold trauma patients).
When faced with the likelihood of a severe winter weather event, regional EMS and emergency department leaders will need to communicate to insure the integrity of the emergency system. EMS incident action plans developed with hospitals may include the need to remove all patients to the closest emergency department (regardless of its trauma status), identify those hospitals that have active rewarming capability,and ensure that larger supplies of sheets, towels, and blankets may be needed to re-supply those used in patient care.
Hospitals should plan to address cold stress on emergency personnel with warmed blankets and beverages. In addition to motor vehicle trauma, winter weather will also change other patient loads, including more patients with carbon monoxide exposure, falls, acute cardiac events, and burns.