EMT Chapter 30


1. Slide 1

Advance Preparation

Review local protocols on the management of musculoskeletal trauma.

Bring examples of several different types of splints to class. (See slide 42.)

Consult with your medical director for assistance in obtaining radiographs of orthopedic injuries. (See slide 19.)

Schedule assistant instructors for supervised lab practice of splinting skills. A ratio of one instructor for every four students is recommended.


2. Slide 2

The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.


3. Slide 3

The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.


4. Slide 4

The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.


5. Slide 5

The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.


6. Slide 6

The objectives for this chapter meet and exceed the National EMS Education Standards. Briefly introduce these objectives to your students so they get a feel for what’s ahead in the upcoming lesson and can anticipate the emphasis points of your presentation.


7. Slide 7

These videos appear later in the presentation; you may want to preview them prior to class to ensure they load and play properly. Click on the links above in slideshow view to go directly to the slides.


8. Slide 8

Planning Your Time

Plan 120 to 130 minutes for this chapter as follows:

Musculoskeletal System Review (30 minutes)

Injuries to Bones and Joints (45 minutes)

Basics of Splinting (45 minutes)

Note: The total teaching time recommended is only a guideline.


9. Slide 9

Case Study Discussion

The following case study is intended to challenge your students to think about caring for a high school football player-the quarterback-who suffered a leg injury after being tackled hard while playing the game.

Present the case in a way that your students will imagine being on the call and feel challenged by the circumstances of the incident. 

If appropriate, briefly relate a personal experience you’ve had running a similar call and how you managed it.


10. Slide 10

Case Study Discussion, continued

You and your partner are staffing Medic One this afternoon.

Dispatch requests that you respond to the Peninsula High School football field.

A 17-year-old male patient is down on the field complaining of leg pain.

Time out is 1634 hours.


11. Slide 11

Case Study Discussion, continued

Upon arrival, you are met by the football coach. He tells you his quarterback was tackled very hard.

The patient cries out in pain, “My leg, my leg!”


12. Slide 12

Case Study Discussion, continued

What are the patient management priorities in this situation?

Describe how you will proceed with this patient.


13. Slide 13

Teaching Time

30 minutes

Point to Emphasize

The musculoskeletal system provides protection and movement, gives the body shape, stores minerals, and produces red blood cells.

Teaching Tip

Since this section is review material, rely more heavily on questioning students than on providing information.


14. Slide 14

Talking Points

The functions of the musculoskeletal system are to:

Give the body shape

Protect the internal organs

Provide for movement

Store salts and other materials needed for metabolism

Produce red blood cells necessary for oxygen transport

Class Activity

Assign groups of students to prepare presentations to review the musculoskeletal system. Divide the following topics among the groups: Skeletal Muscle, Axial Skeleton, Shoulder Girdle and Upper Extremities, Pelvis and Lower Extremities, and Types of Joint Movements. Give students 20 minutes to prepare before reporting back to the class.


15. Slide 15

Talking Points

The three kinds of muscles are voluntary, involuntary, and cardiac:

Voluntary (skeletal) muscle is most pertinent to the topic of musculoskeletal injuries and is primarily discussed on the upcoming slides.

Involuntary (smooth) muscle is found in the walls of organs and helps move food through the digestive system.

Cardiac muscle is found only in the walls of the heart.

Point to Emphasize

Skeletal muscle is under voluntary control.

Discussion Question

What happens to the shape of muscles when they contract?


16. Slide 16

Talking Points

Voluntary muscles are those that are under the control of a person’s will. They make possible all deliberate acts, such as walking, chewing, swallowing, smiling, frowning, talking, or moving the eyeballs. Often referred to as skeletal muscles, most voluntary muscles are generally attached at one or both ends to the skeleton.

Voluntary muscles form the major muscle mass of the body. Movements of the body are the result of work performed by the muscles. What enables muscle tissue to work is its ability to contract-to become shorter and thicker-when stimulated by a nerve impulse. In addition to enabling us to move, muscles help give our bodies their distinctive shapes.

Muscles can be injured in many ways. Overexerting a muscle may break fibers, and muscles subjected to trauma can be bruised, crushed, cut, torn, or otherwise injured, even if the skin is not broken. Muscles injured in any way tend to become swollen, tender, painful, or weak.


17. Slide 17

Point to Emphasize

Tendons connect muscles to bones. Ligaments connect bones to bones.


18. Slide 18

Talking Points

Tendons and ligaments are composed of specialized connective tissue. They are the “glue” that holds the body together.

Ligaments connect bone to bone.

Tendons connect muscle to bone.

Tendons and ligaments, like muscles, can be bruised, crushed, cut, or torn, and are included in the category of musculoskeletal injuries.


19. Slide 19

Discussion Question

What is the function of cartilage?


20. Slide 20

Talking Points

Cartilage is an extension of the bone end and is comprised of connective tissue.

It is a strong, smooth, flexible, compressible, and slippery substance found at the point of articulation of two bones.

Cartilage allows the bones to ride over each other during movement with relatively little friction.

Cartilage also acts somewhat as a shock absorber between the bone surfaces. Cartilage can be injured, leading to joint pain.

Knowledge Application

Students should be able to use the information in this section to assess and describe musculoskeletal injuries.


21. Slide 21

Talking Points

As the body’s structural framework, the skeleton must be strong to provide support and protection, jointed to permit motion, and flexible to withstand stress.

The skeletal system has six basic components: the skull, spinal column, thorax, pelvis, lower extremities, and upper extremities.

The skeletal system is often subdivided into the axial and appendicular skeleton:

The axial skeletal system is comprised of the head, thorax, and vertebral column.

The appendicular skeletal system is made up of the bones in the extremities, to include the shoulder girdle and the pelvis, and can be divided into bones of the upper extremity and bones of the lower extremity.

Discussion Questions

What are the components of the appendicular skeleton?

What are abduction and adduction?


22. Slide 22

Talking Points

A major element in motion is the body’s joints, or places where bones meet. Joints allow for several different types of motion:

Flexion: Bending motion that moves the extremity toward the body

Extension: Bending motion that moves the extremity away from the body

Adduction: Movement of a body part toward the midline of the body

Abduction: Movement of a body part away from the midline of the body

Rotation: Turning along the axis of the bone or joint

Circumduction: Movement through an arc of a circle or in a circular motion from a central point


23. Slide 23

Teaching Time

45 minutes

Teaching Tip

Obtain and show a variety of radiographs of orthopedic injuries.


24. Slide 24

Talking Points

A fracture is a break in the continuity of a bone.

Fractures occur as a result of a variety of mechanisms of injury, including direct force, indirect force, and twisting force.

A fracture is generally categorized as open or closed.

Points to Emphasize

The displaced ends from a fracture can cause damage to surrounding tissues, nerves, and blood vessels.

Osteoporosis and other bone diseases can weaken the bone, leading to pathologic fractures.


25. Slide 25

Talking Points

An open fracture is associated with an open wound, which may have been caused by the bone end punching through the muscle, soft tissue, and skin or by the force that caused the fracture, such as a bullet. A closed fracture is a fracture with no break in the skin.

Signs and symptoms of a fracture may include pain; deformity; discoloration; paresthesia or anesthesia distal to the fracture site; paresis or paralysis; inability to move the extremity indicating damaged muscle or tendon; decreased pulse amplitude; increased capillary refill time, and pale, cool skin distal to the fracture site.

Complications from a fracture include hemorrhage from the bone itself; instability of the extremity leading to an increased incidence of tissue, nerve, or vessel damage; surrounding tissue damage; infection associated with an open fracture; and interruption of distal blood supply.

Osteoporosis is a degenerative bone disorder associated with an accelerated loss of minerals, primarily calcium, from the bone. This condition dramatically weakens the bones and makes them very susceptible to fracture. Geriatric patients are especially prone to fractures because of osteoporosis.


26. Slide 26

Video Clip

Information about Osteoporosis

What causes osteoporosis?

What contributing factors are associated with osteoporosis?

Who is most likely to be diagnosed with osteoporosis?

Describe what happens to the bones in patients with osteoporosis.

Discuss ways to help prevent osteoporosis.


27. Slide 27

Points to Emphasize

A sprain is an injury to the joint capsule with damage to the connective tissue.

Dislocations are significant injuries.

All musculoskeletal injuries present with similar signs and symptoms: pain, swelling, and/or deformity.

Discussion Questions

Which joints are more commonly dislocated?

Why are dislocations considered significant injuries?


28. Slide 28

Talking Points

A strain is an injury to a muscle or a muscle and tendon, possibly caused by overextension or overstretching. Overstretching tears muscle fibers and causes pain that typically increases with the muscle use. Because there is no bleeding, the injury does not present with edema or discoloration.

A sprain is an injury to a joint capsule, with damage to or tearing of the connective tissue, and usually involves ligaments. The shoulder, knee, and ankle are the joints most vulnerable to sprains. The patient typically experiences immediate pain and tenderness at the joint upon injury. The joint then becomes inflamed and swollen. Discoloration usually occurs over time but not for several hours after the injury.

A dislocation is the displacement of a bone from its normal position in a joint. The joint is usually in an abnormal position with obvious deformity and swelling. The patient may complain of pain and tenderness at the site of dislocation and typically be unable to move the extremity.

All of these injuries present with similar signs and symptoms: swelling, pain, deformity. Some of these injuries may present with discoloration.


29. Slide 29

Video Clip

Information about Joint Injuries

What happens to the ligaments in a dislocation?

Why is it important for an EMT to splint a joint injury?

Identify joints that are commonly injured or dislocated.


30. Slide 30

Talking Points

As you approach a patient with an injured extremity, you can get a good idea of how much damage may have occurred by determining the mechanism of injury.

The forces that may cause bone and joint injury include direct force, indirect force, and twisting force.

Discussion Questions

What is an example of direct force applied to a bone?

What is an example of indirect force applied to a bone?


31. Slide 31

Talking Points

The injury from direct force, or a direct blow, occurs at the point of impact. For example, a man in an automobile accident who is not wearing a seat belt is thrust forward, the knees hitting the dashboard. As a result, the patella may be fractured.

With indirect force, the force impacts on one end of a limb, causing injury some distance away from the point of impact. For instance, a woman is thrown from a horse and lands on two outstretched hands. One arm sustains a fractured wrist while the clavicle (collarbone) at the end of the other arm is fractured.

In twisting force, one part of the extremity remains stationary while the rest twists. Take the case of the child running across a field who steps into a hole. The child’s foot is rammed snugly into the hole and stays stationary while his leg twists, fracturing the tibia and/or fibula. Bone and joint injuries from twisting force occur commonly in football or skiing accidents.


32. Slide 32

Talking Points

Most fractures are not considered critical injuries and can be managed with standard splinting procedures. However, two specific fractures are associated with a high incidence of serious bleeding and the potential for the patient to develop shock.

A fracture to the femur or pelvis is a critical injury and must be managed not only to immobilize the bones but also to reduce the associated bleeding.

Point to Emphasize

Femur and pelvis fractures can be associated with enough blood loss to cause hypovolemic shock.


33. Slide 33

Talking Points

The bones of both the femur and the pelvis contain a large blood supply. When fractured, the bones themselves have a tendency to bleed heavily.

When the femur fractures, the bone bleeds heavily. A patient can easily lose approximately 1,500 mL or 1.5 liters of blood around each femur. Also, because muscle tension in the thigh is lost, the diameter of the thigh increases and allows even more blood to leak into the thigh, promoting bleeding. Traction splints accomplish two goals:

The bone ends realign to prevent further injury and reduce pain.

The diameter of the thigh decreases to allow less blood to accumulate and to pressure indirectly the bleeding bone ends.

The pelvis also has a very rich blood supply and if fractured, two liters of blood can be lost within the pelvic cavity. Applying the PASG not only stabilizes the fracture but also decrease the size of the compartment into which the pelvis can bleed, which may tamponade the bleeding pelvis.


34. Slide 34

Point to Emphasize

Assess the pulse and motor and sensory function distal to the suspected injury.

Class Activity

Divide the class into small groups to practice assessment of musculoskeletal injuries.


35. Slide 35

Talking Points 

As you approach the patient with a possible bone or joint injury, take appropriate Standard Precautions and consider the mechanism of injury. During your scene size-up, ask questions of bystanders, family, and the patient. Is the cause of the injury a fall, ejection from a vehicle, high-speed collision, or some other traumatic force?

During the primary assessment, your general impression of the patient’s injury helps determine the priority of care and whether or not your patient has a life-threatening emergency. Joint and bone injuries are often dramatic but rarely life threatening. However, you should check for obvious signs of severe hemorrhage and treat for shock.

Check pulses in injured extremities. Pulselessness or cyanosis distal to an injured extremity is a serious condition. If this is apparent, transport the patient after immobilizing the injury immediately following your secondary assessment.


36. Slide 36

Talking Points

If the patient is unresponsive, you suspect multiple injuries, or the mechanism of injury is significant, conduct a rapid secondary assessment.

If the patient is responsive and oriented, multiple injuries are not suspected, and the mechanism of injury is not significant, conduct a modified secondary assessment, inspecting and gently palpating the injured bone or joint.

Be sure to assess the joints above and below any bone injury or the bones above and below any joint injury.

As you examine the patient, be gentle and reassuring because musculoskeletal injuries can be very frightening for the patient. Check for deformity, contusions, tenderness, swelling, discoloration, and open wounds at the injury site.

Assess the skin temperature, color, and condition; pulse amplitude; and capillary refill time distal to the site of injury.


37. Slide 37

Talking Points

Assess the baseline vitals, and obtain a history from the patient.

The signs and symptoms of bone and joint injury may include deformity or angulation, pain and tenderness, grating, or crepitus, swelling, severe weakness and loss of function, bruising, and exposed bone ends.

When assessing for fracture or dislocation, evaluate for the “Six Ps”:

- Pain on palpation, with movement or without movement

- Pallor or pale color to the skin distal to the injury site and delayed capillary refill

- Paralysis and inability to move the extremity from nerve, muscle, tendon, or ligament damage.

- Paresthesia, a numbness or a tingling sensation indicating nerve damage

- Pressure, a sensation in the extremity associated with swelling

- Pulses distal to the injury that are absent or have a decrease in amplitude, indicating damage to an arterial vessel


38. Slide 38

Talking Points

In some cases, the bone injury is the chief complaint.

If the patient has a life-threatening condition caused by or directly related to the extremity injury, such as a femur or pelvic fracture, immobilize the injured extremity during your primary assessment.

If the patient has a life-threatening condition not directly related to the extremity injury, initiate transport and immobilize the extremity en route if time and critical patient care permit.

Point to Emphasize

Manage life-threatening conditions before musculoskeletal injuries, but remember the contribution of musculoskeletal injuries to hemorrhage.


39. Slide 39

Talking Points

Perform the following steps to immobilize a suspected fracture:

Use proper Standard Precautions, such as disposable gloves.

Administer oxygen, as indicated.

Maintain in-line spine stabilization if you suspect spine injury.

Splint bone and joint injuries. Be sure to check the patient’s distal pulses, motor function, and sensation both before and after splinting. Document your findings in the prehospital care report.

Apply cold packs to the painful, swollen, or deformed extremity to reduce pain and swelling.

Elevate the extremity (if spine injury is not suspected) and keep it elevated throughout transport.

Transport.


40. Slide 40


41. Slide 41

Talking Points

Perform the reassessment, including a recheck of the patient’s vital signs and interventions.

Assess whether or not the injured extremity is properly immobilized.

Make sure that the patient’s distal pulses, motor function, and sensation have improved or have not deteriorated as a result of immobilization.

Knowledge Application

Students should be able to recognize a painful, swollen, deformed extremity, as well as other indications of musculoskeletal injury.

Critical Thinking Discussion

How can you balance the need for immediate transport of a patient in shock with the need to immobilize major fractures to prevent further bleeding, tissue damage, and pain?


42. Slide 42

Teaching Time

45 minutes

Talking Points

Any device used to immobilize a body part is a splint.

A splint can be soft or rigid.

A splint can be commercially manufactured or improvised from virtually any object that can provide stability.

Point to Emphasize

Splinting is necessary to prevent further injury, reduce pain, and minimize complications.


43. Slide 43

Talking Points

There are several reasons for splinting a bone or joint injury. Splinting prevents movement of any bone fragments, bone ends, or dislocated joints, reducing the chance for further injury. Splints usually reduce pain and help to minimize complications from bone and joint injuries.

Splinting helps minimize some of the common complications from bone and joint injuries. These complications include:

- Damage to muscles, nerves, or blood vessels caused by movement of bone fragments or bone ends

- Conversion of a closed fracture to an open fracture (by breaking the skin)

- Restriction of blood flow as a result of bone ends or dislocations compressing blood vessels

- Excessive bleeding from tissue damage caused by movement of bone ends

- Increased pain associated with movement of bone ends or dislocated bones

- Paralysis of the extremities resulting from a damaged spine


44. Slide 44

Discussion Question

What are the general rules of splinting?

Points to Emphasize

You must assess distal pulses and motor and sensory function before and after splinting.

Immobilize the joints above and below a fracture. Immobilize the bones above and below a joint injury.

Attempt to align an injured extremity only if there is a severe deformity or distal circulation is impaired.

Teaching Tip

Provide students with adequate time to practice splinting under supervision.


45. Slide 45

Talking Points

Regardless of where you apply the splint, follow these general rules:

Both before and after you apply the splint, assess the pulse, motor function, and sensation distal to the injury. Keep in mind the mnemonic “PMS” for pulse, motor function, and sensation as you manage a fracture. Reassess every 15 minutes after applying the splint.

Immobilize the joints both above and below a long bone injury.

Remove or cut away all clothing around the injury site. Remove all jewelry, especially distally, because it may become entrapped by swelling.

Cover all wounds, including open fractures, with sterile dressings.

If a patient has a severe deformity or an extremity that is cyanotic or lacks pulses, align the injured limb with gentle manual traction before splinting. Make one attempt to align the extremity and if pain, resistance, or crepitus increase, stop.

Never intentionally replace protruding bones or push them back.

If the patient shows signs of shock, align the patient in the normal anatomical position. Treat for shock and transport immediately without taking the time to apply a splint.


46. Slide 46

Talking Point

Some splints are more suitable to certain types of injuries than others, but many are interchangeable. Follow your local protocol in such cases.

Point to Emphasize

General types of splints are rigid, traction, pressure, and improvised splints. A sling and swathe can be used to splint the upper extremity.

Teaching Tip

Show examples of each type of splint as you talk about it.

Class Activity

Have a contest to see which group of students can come up with the best improvised splint.


47. Slide 47

Talking Points

Rigid splints are designed in specific shapes for arms and legs and equipped with Velcro closures.

Pressure splints, sometimes known as air or pneumatic splints, are soft and pliable before being inflated but rigid once they are applied and filled with air.

Traction splints provide a counterpull, alleviating pain, reducing blood loss, and minimizing further injury.

Formable splints are malleable enough to form to a deformed or angulated extremity.

Vacuum splints are soft, pliable splints that become extremely rigid when the air is sucked out, causing them to hold their position of placement.

A sling and swathe is often used to provide stability to a painful and tender shoulder, elbow, or upper humerus injury.

A long spine board is considered a full body splint. In the case of a critical injury when extremity fractures cannot be splinted at the scene, placing the patient on a long spine board provides some stabilization through the limitation of movement.


48. Slide 48

Talking Points

You may be forced to improvise at the scene.

Improvised splints can be made from a cardboard box, cane, ironing board, rolled-up magazine, umbrella, broom handle, catcher’s shin guard, or any other similar object.

An ordinary bed pillow or blanket roll can be a very effective improvised splint when wrapped around the area and secured with several cravats.

In order to be effective, an improvised splint must be:

- Light in weight but firm and rigid

- As wide as the thickest part of the fractured limb

- Long enough to extend past the joints and prevent movement on either side of the fracture

- Padded well so the inner surfaces are not in contact with the skin


49. Slide 49

Point to Emphasize

For all of the obvious benefits to the patient with a bone or joint injury, splints can also cause complications if they are applied in the wrong manner.


50. Slide 50

Talking Points

Improper splinting can:

Compress the nerves, tissues, and blood vessels under the splint, aggravating the existing injury and causing new injury.

Delay the transport of a patient who has a life-threatening injury.

Reduce distal circulation, compromising the viability of the extremity.

Aggravate the bone or joint injury by allowing movement of the bone fragments or bone ends or by forcing bone ends beneath the skin surface.

Cause or aggravate damage to the tissues, nerves, blood vessels, or muscles from excessive bone or joint movement.


51. Slide 51

Talking Points

Take special considerations into account when splinting long bones or joints.

Remember that some long bone injuries may lead to serious internal bleeding.


52. Slide 52

Talking Points

As you assess, look for the following signs and symptoms of long bone injury:

Exposed bone ends

Joints locked in position

Paresthesia, a pricking or tingling feeling that indicates some loss of sensation

Paralysis

Pallor of the injury site

Assess the motor and sensory function and pulses below the injury site:

- If the injury involves an upper extremity, motor function is intact if the patient can make a fist; undo the fist; spread the fingers; and make a hitchhiking sign with the thumb. If the injury involves a lower extremity, motor function is intact if the patient can tighten the kneecap and move the foot up and down as if pumping an automobile accelerator.

- Sensory function is intact if the patient can tell you, without looking, which finger or toe you are touching and can feel painful stimuli.

- Assess the radial pulse for an upper extremity. Assess the dorsal pedal or posterior tibial pulse for a lower extremity.


53. Slide 53

Video Clip

Information about Long Bone Injuries and Splints

What are signs and symptoms of a long bone fracture or dislocation?

Discuss characteristics of an effective splint.

What are some types of splints that can be used on a long bone injury?

When are traction splints used?


54. Slide 54


55. Slide 55

Talking Points

In a dislocation, the ligaments holding the bones in proper position are often stretched and sometimes torn loose. Dislocations cause serious pain because the joint surfaces are rich in nerves.

The principal signs and symptoms of any type of joint injury are pain, swelling, deformity, and possible rigidity and loss of function.

As with long bone injuries, assess the pulse and motor and sensory function below the injury site.

Look for paresthesia or paralysis. If the distal extremity is cyanotic or lacks pulses, align the joint with gentle traction. If pain or crepitus increases, stop.

Remember not to spend time trying to differentiate a joint injury from a bone injury since it may be difficult to distinguish between the two; you will need to splint and transport for both types of injury.


56. Slide 56

Talking Points

Successfully immobilize femur fractures with a traction splint.

A fractured femur is complicated because of the amount of bleeding that can occur from the fractured bone.

A fractured femur is also complicated because the large muscle mass of the thigh contracts and pulls the fractured femur ends so that they override, or pass each other. This allows the thigh to increase in diameter, permitting more blood loss to occur within the thigh and causing great pain in addition to a lot of internal soft tissue injury.

Discussion Question

What is the mechanism by which traction splinting works?


57. Slide 57

Talking Points

Use traction splinting with femur fractures to relieve muscle spasms and reduce bleeding.

Traction splinting functions to reduce the diameter of the thigh, decrease the space in which bleeding can occur, and realign the fractured femur. This helps to tamponade the bleeding, relieve pain, and reduce the incidence of internal injuries that would occur if the patient were transported without immobilization.

If the thigh is painful, swollen, or deformed, treat as if the femur is fractured.

In general, a traction splint is contraindicated when:

- The injury is within one to two inches of the knee or ankle.

- The knee, hip, or pelvis has been injured.

- A partial amputation or avulsion with bone separation has occurred, and the distal limb is connected only by marginal tissue.


58. Slide 58

Video Clip

Application of a Sager Splint

Explain the steps in applying a Sager Splint.

Discuss when a Sager Splint should be applied.

Why is it important to check the pulse and motor and sensory function before and after applying a splint?


59. Slide 59


60. Slide 60

Talking Points

Apply special techniques when splinting suspected bone and joint injuries for specific sites.

Splinting techniques for the shoulder are illustrated in EMT Skill 30-7.

Splinting techniques are illustrated in EMT Skill 30-8 for the upper arm, elbow, forearm, wrist, hand, fingers, pelvis, hip, thigh, knee, lower leg, ankle, and foot.

Knowledge Application

Given a series of scenarios, students should be able to assess musculoskeletal injuries, assign injuries proper priority in the overall management of the patient, and demonstrate proper splinting techniques.


61. Slide 61

Points to Emphasize

Pelvic fractures may be associated with significant pain and bleeding.

Stabilize pelvic fractures with a PASG, a commercial pelvic splint, or an improvised pelvic wrap.


62. Slide 62

Talking Points

You can use a pneumatic antishock garment (PASG) to splint the pelvis and decrease the compartment size to reduce bleeding.

You can also use a commercial pelvic splint to stabilize the fracture and tamponade the bleeding.

If a PASG or commercial pelvic splint is not available, apply an improvised pelvic wrap. To apply an improvised pelvic wrap:

- Fold a sheet lengthwise to approximately an eight-inch width.

- Slide it under the small of the back and down under the pelvis until it is centered and the ends of the sheet are of equal length on both sides of the patient.

- Cross the tail ends over the patient and twist the ends until the sheet is tightly secured around the pelvis.

- Tuck the sheet ends under the patient or tie the ends into a square knot.

- Place the patient on a backboard or rigid device.


63. Slide 63

Talking Points

Compartment syndrome may occur when a fracture or injury to an extremity has occurred. Compartment syndrome may also occur in the buttocks and abdomen of the body.

When an injury occurs, swelling and bleeding in the space between the tissues is usually present. If the pressure in the space around the capillaries exceeds the pressure needed to perfuse the tissues, the blood flow is cut off and the cells become hypoxic, leading to compartment syndrome.

The hypoxic cells release chemicals that cause the capillaries to leak, leading to further swelling. If the pressure continues, the cells eventually die, resulting in the loss of muscle, nerves, and vessels in the affected area.

Point to Emphasize

Compartment syndrome is a complication of extremity injuries that results in decreased perfusion distal to the injury due to swelling.


64. Slide 64

Talking Points

Compartment syndrome usually develops over time as edema around an injured area increases, so it may not be seen at the initial stages of injury. It is commonly associated with fractures, arterial and venous bleeding from penetrating or blunt trauma, crush injuries, and high-energy trauma.

Signs and symptoms include:

- Severe pain or burning sensation

- Decreased strength in the extremity

- Paralysis of the extremity

- Pain with movement

- Extremity feeling hard to palpation

- Distal pulses and motor and sensory function possibly normal

Emergency medical care focuses on treating any life-threatening injuries first. Immobilize and splint the affected extremity. Elevate the extremity and apply a cold pack or ice. Transport the patient since he may lose the limb if the compartment syndrome is not treated quickly and effectively.


65. Slide 65

Case Study Follow-Up Discussion

This case study is continued from the beginning of the presentation.

Briefly remind students that they are just arriving on the scene at the local high school for a 17-year-old male football player down on the field after being tackled hard.

The patient is complaining of leg pain.


66. Slide 66

Case Study Follow-Up Discussion, continued

As you wheel the stretcher onto the field, you are met by the football coach who tells you his quarterback, Tom Cvitanovic, was tackled. “He can’t move his right leg. He got tackled pretty hard.” The coach’s remarks lead you to believe the mechanism of injury may mean a fracture caused by direct force. You approach Tom and introduce yourself. Your partner asks, “What happened, and where is the pain?”

Tom complains of severe right leg pain and says his right arm hurts too. Because he is talking clearly, you assume his airway is open. His breathing is adequate; his radial pulse is strong and 103 per minute.

You do not believe he has a life-threatening condition.

Tom then lets out a groan, and says, “Oh, man, can’t you do anything for the pain?”

He seems frightened, so you reassure him that he’ll get care quickly. Your partner is at Tom’s head maintaining manual in-line spine stabilization.


67. Slide 67

Case Study Follow-Up Discussion, continued

He is alert and oriented and is exhibiting no signs of respiratory distress or hypoxia.

He has no complaints of shortness of breath.

His SpO2 reading is 99 percent on room air, so you decide not to place him on oxygen.


68. Slide 68

Case Study Follow-Up Discussion, continued

While your partner continues spine stabilization, you perform a secondary assessment and assess for signs of injury.

Tom denies any neck pain. However, because of the mechanism of injury, you apply a cervical spine immobilization collar as your partner continues to maintain manual stabilization.

You find that Tom’s right arm is tender and swollen.

Approximately six inches below Tom’s right knee, you see bone ends protruding through a fracture site.

Pulse and motor and sensory function are good below both injury sites.


69. Slide 69

Case Study Follow-Up Discussion, continued

You apply a cold pack to Tom’s right arm and then take his baseline vital signs. His blood pressure is 140/70 mmHg; respirations are 20 per minute; pulse is 120 per minute; skin is warm and slightly sweaty. Skin color is normal.

You obtain a history and learn that Tom denies any further pain or injury. He says he is allergic to aspirin and doesn’t take any medication. He tells you that three years ago he broke the same leg and was hospitalized for almost a week. He had his last meal at noon. Then he describes how he was tackled by two, maybe three, other football players.

Following your local protocols, you decide to apply a vacuum splint to Tom’s right arm. You cover the protruding bone ends below the knee with a trauma pad and note very little bleeding. Following local protocols and with your partner’s assistance, you apply padded board splints to Tom’s right leg. You recheck pulse and motor and sensory function of Tom’s injured arm and leg. You note no change. Once Tom is fully immobilized to a backboard, you load him into the ambulance for transport.

Case Study Follow-Up Discussion Question

Do you agree with the choice of splints? Why or why not?


70. Slide 70

Case Study Follow-Up Discussion, continued

You perform a reassessment and find that Tom remains alert and oriented. His airway, breathing, and circulation remain adequate.

You reassess vital signs, then recheck your medical interventions. The vacuum splint is rigid, and the padded board splints are secure. You reassess pulses, motor function, and sensation to Tom’s right arm and leg.

You radio your report to the emergency department, continue your reassessment, and reassure Tom that you are only five minutes away from the hospital.

A few weeks later, when you are reading the sports page, you spot a picture of Tom on the team bench with crutches propped up beside him. The season is nearly over, but Tom is only a junior and is expected to quarterback the team again next year.


71. Slide 71

Critical Thinking Discussion

This critical thinking scenario is intended to challenge your students to think about managing a multitrauma victim with an unstable pelvis amongst other possible fractures.

The scenario continues on the next slide.


72. Slide 72

Critical Thinking Discussion, continued

Ask students to briefly discuss the scenario before moving on to the series of questions on the next slide.


73. Slide 73

Critical Thinking Discussion, continued

Answers:

Immediately establish and maintain manual in-line spine stabilization. The patient’s airway is open and the respirations are adequate, so provide oxygen via a nonrebreather mask at 15 lpm.

Based on the assessment findings and the patient’s complaint of pain, this patient has likely suffered a fractured pelvis. She also has a possible fractured right tibia and fibula evident by the deformity.

Quickly stabilize the pelvic fracture with a pelvic wrap or the pneumatic antishock garment (PASG). Due to the apparent onset of shock and the need for rapid transport, initially immobilize the lower leg injury with the long spine board. If there is an opportunity during transport, splint the lower leg with a vacuum, board, pneumatic, or other acceptable rigid splint.

Pelvic fractures are associated with severe bleeding. The pelvis often fractures in more than one place, and the bone itself may bleed profusely along with lacerated or disrupted vessels in close proximity to the fractured bone. The lower leg fracture could result in reduced distal circulation and muscle, vessel, nerve, and other tissue damage from the fractured bone ends.


74. Slide 74

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