Simulated Patient Scenario

Scenario Details

MDT Information

• Urgent Response - Industrial Accident / Trapped Person
• Male worker trapped by collapsed shelving in warehouse
• Reported leg entrapment, duration unknown
• Patient conscious
• Fire & Rescue responding for extrication
• Location: Industrial Warehouse

On Arrival

You arrive at a large warehouse. Co-workers direct you to an aisle where heavy metal shelving has collapsed. The patient, a 50-year-old male, is lying supine on the concrete floor, pinned from the mid-thighs down by several fallen shelves laden with boxes. He is conscious, grimacing in pain, and appears anxious. Fire & Rescue crews are assessing the stability of the remaining structure and planning extrication.

Scene Safety Note: Liaise with Fire & Rescue regarding scene safety, structural stability, and extrication plan before approaching patient closely. Wear appropriate PPE (helmet, safety glasses).

Initial Impression and Primary Survey

Secondary Survey and Simulation Progression

History (obtained from patient and co-worker)

Vital Signs/Assessment (Pre-Extrication)

Physical Examination

• General Appearance: Alert, anxious, significant pain, trapped by lower limbs.
• Lower Limbs (Distal to entrapment - if accessible): Skin may appear pale, mottled, cool. Pulses likely absent. Sensation may be reduced/absent. Motor function absent. Compartments feel tense/swollen (assessment limited by entrapment).
• Proximal Assessment: Assess abdomen, pelvis, chest, head/neck for associated injuries. Pelvis stable. Abdomen soft. Chest clear. No obvious head/neck injury.
• Neurological: GCS 15. Moves upper limbs well. Complains of numbness/paraesthesia in legs.

Assessment and Treatment

Appropriate Management Focus

• Safety & Coordination: Confirm scene safe with FRS. Liaise closely regarding extrication plan and timing. Request critical care/medical team backup if available/indicated.
• Airway/Breathing: Apply oxygen via NRB mask. Monitor respiratory status.
• Circulation - Pre-Extrication Management (CRITICAL):
  • IV Access: Establish large-bore IV access (x2 if possible) in upper limbs prior to extrication.
  • Fluid Resuscitation: Commence aggressive IV fluid resuscitation (Sodium Chloride 0.9%) before the crushing weight is released, if safe and feasible. Aim for 1-1.5 Litres in the hour prior to extrication (or as per local protocol). This helps mitigate systemic effects of reperfusion (crush syndrome).
  • ECG Monitoring: Apply ECG monitor before extrication and monitor continuously for signs of hyperkalaemia (peaked T waves, wide QRS, arrhythmias).
• Pain Management: Provide aggressive IV opioid analgesia (e.g., Fentanyl or Morphine titrated doses) before extrication. Consider Ketamine if available/protocol allows for severe pain or sedation during extrication.
• Consider Pre-Extrication Medications (Protocol Dependent):
  • Sodium Bicarbonate IV may be considered pre-release to counter acidosis (follow local guidelines).
  • Calcium Chloride/Gluconate IV should be readily available to administer immediately if ECG changes of hyperkalaemia appear, especially upon release.
  • High-dose nebulised Salbutamol may be considered pre-release for potential hyperkalaemia (protocol dependent).
• Extrication Phase: Coordinate closely with FRS. Monitor patient closely during lifting/release. Be prepared for rapid deterioration (hypotension, arrhythmias) due to reperfusion/crush syndrome. Administer Calcium immediately if hyperkalaemic ECG changes occur. Consider further fluid bolus upon release.
• Post-Extrication Management:
  • Reassess ABCDE rapidly.
  • Continue aggressive fluid resuscitation.
  • Continue ECG monitoring. Treat hyperkalaemia aggressively if present (Calcium, Salbutamol, Bicarbonate per protocol).
  • Immobilise potential fractures. Splint limbs.
  • Reassess neurovascular status of limbs frequently (risk of compartment syndrome).
  • Maintain body temperature (prevent hypothermia).
  • Continue analgesia as needed.
• Transport: Urgent transport to a Major Trauma Centre with capabilities for managing crush syndrome (e.g., dialysis). Pre-notify early and comprehensively (Mechanism, entrapment time >60min, suspected crush injury/syndrome, pre-extrication treatment, post-extrication status, ECG findings, fluids given).
• Teamwork & Communication: Essential for coordination with FRS, backup resources, and hospital. Clear documentation of times (entrapment, extrication, treatments).

Debrief Focus Points

• Recognizing crush injury mechanism and potential for crush syndrome (especially with entrapment > 1 hour).
• Pathophysiology of crush syndrome (reperfusion injury, release of toxins, hyperkalaemia, AKI).
• Importance of scene safety and interagency collaboration (FRS).
• Critical pre-extrication management: IV access, aggressive fluid loading, ECG monitoring, analgesia.
• Rationale and potential use of pre-extrication medications (Fluids, Bicarbonate, Salbutamol, Calcium preparedness).
• Monitoring for and immediate management of hyperkalaemia (ECG interpretation, Calcium administration).
• Post-extrication priorities: ongoing resuscitation, monitoring, fracture/compartment syndrome management, preventing hypothermia.
• Importance of transport to a specialist centre and detailed pre-notification.