PHEM curriculum unit 4.3 · Theme 4: Supporting Rescue and Extrication
The DipIMC is blueprinted against phase 1 of the UK Pre-hospital Emergency Medicine (PHEM) curriculum. This page covers unit 4.3, Support extrication.
Below are 3 free practice questions from the DipIMC.Ninja bank, in the Part A single best answer format. Every answer names the textbook page, guideline or statute it was written from, so you can check it rather than take it on trust. The bank holds 24 questions on this unit.
Question 1 · Paediatrics & Obstetrics · Moderate
A car carrying a 9-month-old girl in a rear-facing infant car seat has been struck on its side at moderate speed. The car seat is undamaged and still correctly fitted. The baby is alert, crying and moving all four limbs, with normal observations for her age and no other injuries found. Because of the mechanism, the attending paramedic wants to protect her spine during the journey to hospital. Which statement about her spinal care is correct?
AShe should travel in the intact car seat, padded and taped
BAn adult long board is the right device for a baby of her age
CA semi-rigid collar gives her the most reliable protection
DHer neck should be slightly flexed to protect her airway
EA pillow under her head will bring her neck into neutral
Show answer
Answer: A
She should travel in the intact car seat, padded and taped
A stable infant who is already restrained in an intact car seat can be conveyed in it. The Oxford Handbook of Pre-Hospital Care says an infant in a car seat who may have a spinal injury should be transported in the seat, with a blanket roll and tape to immobilise the cervical spine; the ABC of Prehospital Emergency Medicine gives the same advice for a stable child (with extra head padding and tape); and NICE NG41 lists keeping infants in their car seat, if possible, among the measures to consider for children. Adult spinal boards are unsuitable for small children, and NG41 says a longboard is an extrication device only, not a means of transport. Collars may be ill-fitting in small children and, if not properly applied, can compress the soft tissues of the neck and compromise the airway. An infant's large occiput already pushes the neck into flexion, which risks airway obstruction, so a pillow under the head makes this worse — if a baby has to be laid flat, padding goes under the shoulders to achieve neutral alignment. If the child becomes unstable or needs airway intervention, she comes out of the seat.
Where this comes from
Oxford Handbook of Pre-Hospital Care
Ch. 8 Child health · Trauma in children: Cervical spine control“transported to hospital in the seat using a blanket roll and tape”
Ch. 8 Child health · Trauma in children: Cervical spine control“Adult spinal boards are unsuitable for small children.”
Ch. 8 Child health · Trauma in children: Cervical spine control“Flexion of the neck risks airway obstruction in small babies.”
ABC of Prehospital Emergency Medicine
Ch. 29 Care of Special Groups: The Paediatric Patient · Tips from the field · p. 164“leave them in it for onward transportation”
Ch. 29 Care of Special Groups: The Paediatric Patient · Anatomy and physiology: Airway · p. 160“The larger occiput of a newborn may force the neck into flexion”
Oxford Handbook of Pre-Hospital CareCh. 8 Child health · Trauma in children: Cervical spine control“Collars may be ill-fitting and, if not properly applied, can produce airway compromise”
ABC of Prehospital Emergency Medicinep. 163Ch. 29 Care of Special Groups: The Paediatric Patient · Management of paediatric trauma emergencies: Head and neck injury“it may be necessary to pad the shoulders to obtain neutral alignment”
Fire and rescue crews have lifted a 2-year-old girl out of a crashed car on an adult spinal board, which is being used only to extricate her before she is moved onto a scoop stretcher. She is alert and crying, and spinal injury has not been excluded. As she lies supine on the board, the paramedic notices that her head is pushed forward so that her neck is flexed. What is the most appropriate way to bring her head and neck into neutral alignment?
APlace a folded towel beneath the back of her head
BFit a smaller collar and tighten it under her chin
CPlace padding beneath her shoulders and upper back
DTape her forehead down firmly against the board
ETilt the whole board about 15 degrees head-down
Show answer
Answer: C
Place padding beneath her shoulders and upper back
A small child's relatively large occiput pushes the head forward on a flat surface, flexing the neck. The ABC of Prehospital Emergency Medicine notes that the larger occiput of a newborn may force the neck into flexion and, for children generally, advises that when a child is immobilised on a spinal board it may be necessary to pad the shoulders to obtain neutral alignment of the head and neck, unless a paediatric board is used.
A towel under the head raises the occiput further and adds to the flexion. A collar, tape across the forehead or tilting the whole board does nothing about the cause, which is the size of the occiput relative to the shoulders. NICE NG41 adds that a longboard is an extrication device only, which is why she will be moved to a scoop.
Where this comes from
ABC of Prehospital Emergency Medicine
Ch. 29 Care of Special Groups: The Paediatric Patient · Management of paediatric trauma emergencies — Head and neck injury · p. 163“pad the shoulders to obtain neutral alignment of the head and neck”
Ch. 29 Care of Special Groups: The Paediatric Patient · Anatomy and physiology — Airway · p. 160“The larger occiput of a newborn may force the neck into flexion”
Ch. 29 Care of Special Groups: The Paediatric Patient · Anatomy and physiology — Airway · p. 159“prone to compression in both excessive flexion (large occiput)”
Question 3 · Scene Safety & Extrication · Moderate
Which statement best reflects the FPHC EXIT consensus (2024) on extrication from road traffic collisions?
ARescuer-led extrication on a long board with full immobilisation should be the default
BMovement-minimising techniques reliably limit spinal movement and should be routine
CSelf-extrication or minimally assisted exit is first line unless contraindicated
DThe extrication mode should wait for a clinician to decide, whoever reaches scene first
EPatients with neck pain should not self-extricate but await full spinal immobilisation
Show answer
Answer: C
Self-extrication or minimally assisted exit is first line unless contraindicated
The Faculty of Pre-Hospital Care consensus (November 2024), built on the EXIT project, reverses the old default of absolute movement minimisation. Its first recommendation is that all patients with injury should be considered time dependent, with operational and clinical teams building a patient-centred plan focused on minimising entrapment time. Its third is that self-extrication or minimally assisted extrication should be the standard first line for all patients without contraindications, because self-extrication is associated with the least spinal movement and the shortest extrication times; the contraindications are an inability to understand or follow instructions, or injuries or baseline function that prevent standing on at least one leg. The consensus states that self-extrication is appropriate for patients experiencing neck or back pain, a point on which NICE NG41 (2016) differs. Biomechanical analysis shows that techniques aimed at minimising patient movement do not achieve that aim, and absolute movement minimisation takes time and delays release. Non-clinicians are empowered to decide on the extrication mode and deliver it before the clinical team arrives, and extrication should not be delayed to await clinicians. NICE NG41 reserves the longboard for extrication only, not for immobilised transport.
Where this comes from
Extrication following a motor vehicle collision: consensus statementRoyal College of Surgeons of Edinburgh, Faculty of Pre-Hospital Care, November 2024 (Nutbeam, Fenwick, Haldane, Leech, Foote, Todd, Lockey)·Recommendation 1: all patients with injury are time dependent“All patients with injury should be considered time dependent.”Open PDF at page 6
Extrication following a motor vehicle collision: consensus statementRoyal College of Surgeons of Edinburgh, Faculty of Pre-Hospital Care, November 2024 (Nutbeam, Fenwick, Haldane, Leech, Foote, Todd, Lockey)·Recommendation 1: movement-minimising techniques“techniques aimed at minimising patient movement do not achieve this aim”Open PDF at page 6
Extrication following a motor vehicle collision: consensus statementRoyal College of Surgeons of Edinburgh, Faculty of Pre-Hospital Care, November 2024 (Nutbeam, Fenwick, Haldane, Leech, Foote, Todd, Lockey)·Recommendation 2: non-clinicians decide the extrication mode“Extrication should not be delayed in order to await the arrival of clinicians.”Open PDF at page 6
Extrication following a motor vehicle collision: consensus statementRoyal College of Surgeons of Edinburgh, Faculty of Pre-Hospital Care, November 2024 (Nutbeam, Fenwick, Haldane, Leech, Foote, Todd, Lockey)·Recommendation 3: self-extrication first line“Self-extrication is associated with the least spinal movement and the shortest extrication times”Open PDF at page 7