Working in the rescue environment: DipIMC practice questions
PHEM curriculum unit 4.1 · 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 4.1, Work within the rescue environment.
Below are 2 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 12 questions on this unit.
Question 1 · Scene Safety & Extrication · Moderate
A controlled extrication is under way with the roof of the car partly cut. The trapped driver suddenly develops noisy, obstructed breathing that you cannot manage in the seat. What should you do?
AContinue the controlled plan and manage the airway in the vehicle meanwhile
BHave the fire service finish the roof fast, then extricate along a board
CLoudly announce the switch to the B-plan and extricate within 1–2 minutes
DPerform rapid sequence induction in the vehicle before any further movement
EHold the extrication until the ambulance commander authorises a plan change
Show answer
Answer: C
Loudly announce the switch to the B-plan and extricate within 1–2 minutes
The B-plan is identified and communicated at the outset precisely so that it can be instituted the moment the patient deteriorates; an unmanageable airway problem in the vehicle is one of the stated reasons for a rapid release. A sudden change from the A-plan to the B-plan must be communicated loudly and clearly, usually demands a degree of physical leadership from the clinician, and an effective B-plan should be carried out in less than 1 to 2 minutes. The recorded failure mode is that B-plans are carried out too slowly even when there is an immediate threat to life. Finishing the roof and extricating along a board is still the controlled A-plan, only hurried. There is no place for intubation within the confines of a damaged vehicle; in-vehicle airway care is limited to simple adjuncts and suction, and exceptionally a supraglottic device or surgical airway. The decision belongs to the team at the vehicle, not a commander elsewhere on scene. NICE NG41 agrees that when there is an immediate threat to life and rapid extrication is needed, spinal movement is limited without delaying treatment.
Where this comes from
ABC of Prehospital Emergency Medicine
Ch. 21 Trauma: Extrication of the Trapped Patient · Planning: B-plan considerations · p. 112“A sudden change from A-plan to B-plan must be communicated loudly and clearly”
Ch. 21 Trauma: Extrication of the Trapped Patient · Planning: B-plan considerations · p. 112“An effective B-plan should be carried out in less than 1–2 minutes.”
Ch. 21 Trauma: Extrication of the Trapped Patient · Planning: tricks of the trade · p. 112“B-plan rescues are often carried out too slowly”
Ch. 21 Trauma: Extrication of the Trapped Patient · Treatment and monitoring in the vehicle · p. 112“there is no place for intubation within the confines of a damaged vehicle”
A window cleaner has hung motionless in a fall-arrest harness for about 25 minutes. He is drowsy but rousable. The rope rescue team can bring him to the ground within a few minutes. What is the correct approach once he reaches the ground?
AKeep him semi-recumbent for 30 minutes to stagger the reperfusion
BLay him horizontal in the recovery position and resuscitate him
CKeep him suspended in the harness until intravenous access has been gained
DSit him upright against a wall until his conscious level improves
ELay him flat and run in Hartmann's solution rapidly to restore volume
Show answer
Answer: B
Lay him horizontal in the recovery position and resuscitate him
Suspension syncope results from motionless vertical suspension with orthostatic pooling of blood in the legs; it is the inability to regain a horizontal position, and the resulting cerebral hypoperfusion, that leads to syncope and, if uncorrected, death. The ABC's management is to rescue the casualty as soon as is safely possible and place him in the horizontal recovery position if consciousness is impaired, as it is here. There is no evidence to support rescue in the semi-recumbent position, so the older teaching of keeping him semi-recumbent or sitting upright to stagger reperfusion should not be followed, and keeping him suspended while access is gained prolongs exactly the process that is harming him. When the circulation is resuscitated, potassium-containing solutions such as Hartmann's must be strictly avoided in the field, to avoid hyperkalaemia; 0.9% saline is the fluid the ABC uses. Arterial tourniquets just proximal to a harness are a considered option to prevent rescue cardioplegia on release, but if rescue has been completed without one and the patient remains stable, delayed application is not required because washout will already have occurred.
Where this comes from
ABC of Prehospital Emergency Medicine
Ch. 19 Trauma: Suspension and Crush · Introduction: suspension syncope · p. 98“orthostatic pooling of blood in the lower extremities”
Ch. 19 Trauma: Suspension and Crush · Introduction: suspension syncope, horizontal position · p. 98“The inability to regain a horizontal position”
Ch. 19 Trauma: Suspension and Crush · Management: isolate and move to a place of safety · p. 100“placed in the horizontal recovery position if consciousness is impaired”
Ch. 19 Trauma: Suspension and Crush · Management: no evidence for semi-recumbent rescue · p. 100“There is no evidence to support rescue in the semi-recumbent position.”
Ch. 19 Trauma: Suspension and Crush · Management: delayed tourniquet application · p. 100“delayed application of a tourniquet is not required”
Ch. 19 Trauma: Suspension and Crush · Resuscitate the system: avoid potassium-containing fluids · p. 100“Administration of potassium-containing solutions (e.g. Hartmann’s) must be strictly avoided in the field”
scene-049 · Scene Safety & Extrication · Extrication · Hard · v3