A couple of months ago, while walking through an emergency department (ED), I saw anEMS crew rolling a young woman in a wheelchair toward the triage desk, and I noticed how uncomfortable she was. The petite patient was scrunched down in the wheelchair, almost curled into a ball, softly crying.
As they passed by, I saw that her ankle was dangling near the ground, unsupported by the wheelchair pedal. It was obviously fractured but haphazardly immobilized with a padded disposable cardboard splint. The splint wasn't even cut to fit the bend of her ankle.
I asked one of the EMTs to place her foot on the wheelchair support pedal and immediately saw the patient's facial expression change as she experienced relief from the pain caused by the lack of support for her fracture. But having been a paramedic for 12 years and an ED nurse for four, I knew the injury wasn't the only cause of her pain. She simply wasn't being well cared for.
Later that shift, I took over care for this patient. I helped her move to a bed, shifted her ankle onto a big, soft pillow, loosened the splint and checked for pedal pulses. Her ankle had started to bruise and was markedly swollen. I applied an ice pack to her ankle, reapplied the splint and put her chart in the "to-be-seen" rack for the physician. As I left her side, she thanked me for being gentle.
When we think of splinting, we think of fracture. We should also think of the goals of splinting, which are simple: immobilize potentially broken bones, reduce the chance for further soft tissue injury that bone movement can cause and decrease the patient's pain.
Like many who've seen the statistics on prehospital pain treatment, I was stunned at the results of an Ohio study that showed only a small number of the patients had their pain addressed by EMS. Out of 1,073 people diagnosed with an extremity fracture, only 182 (17%) received ice, 268 (25%) had a splint placed and 18 (1.67%) received pharmacological treatment.
EMS, like many other facets of health care, is now moving toward evidence-based practice. This shift in thought is causing us to take a good look at what we do and how we do it. There's also an increasing trend toward refocusing on the basics, including the application of splints and pain management. Pain management comes in many forms and isn't always pharmacological. New evidence suggests that prompt, effective basic care sometimes decreases the need for more invasive treatments.
Splinting comes in many forms and, as we find with many aspects ofEMS care, there's both a science and an art to it. Like other skills, the more we splint, the better we get. We_re expected to know all about splinting, including what injuries we should splint in the field. Should we splint all fractures, sprains, strains, dislocations or soft-tissue injury sites on an extremity?
Types of injuries
Fractures: Mosby's medical dictionary defines a fracture as: "A traumatic injury to the long bone in which the continuity of the bone tissue is broken." A fracture can be classified as closed or open. Fractures that have no break in the skin are calledclosed fractures.
An open fracture occurs when the traumatic force that caused the bone to break also causes an external wound. This wound can be caused by bone edges puncturing the skin from the inside out, or by the external force compressing or shearing the skin, causing the open wound to result from the outside.
The significance of open fractures is they have a high risk for infection in the bone, calledosteomyelitis. This type of infection usually requires large doses of antibiotics and, when left untreated, can be limb or life threatening.
Fractures can also be categorized as displaced or non-displaced. In anon-displaced fracture, no gross deformity can be seen, whereas, with a displaced fracture, a deformity can be seen. An extra "joint" is often visible where there should be a straight line (see photo, p. 60). A true diagnosis of displacement must be diagnosed by X-ray. Other classifications of fracture appear in Table 1 p. 54.
Other injuries: A dislocation to a joint is the displacement of bones from their rightful place. These injuries are grossly deformed, swollen and painful. Injuries are usually sustained by a pulling or twisting force, causing the joint to displace. Supporting ligament and tendon injuries are a common complication.
A sprain is caused by the twisting or pulling of a joint beyond its normal range of motion, causing soft tissue injury to the underlying tendons, muscles and ligaments. It can often be difficult to differentiate a sprain from a fracture in the field. Astrain is an injury to the muscle only, caused by movement outside the muscle's normal range.
The first thing you should do when assessing and managing a potential fracture is ensure the blood supply to the extremity is not impaired. Check to see that CMTS is present at the distal end, especially if you'll need to reposition the extremity during splinting. Also, check for adequate sensational capillary refill distal to the effected area by blanching the nail bed (usually fewer than three seconds).
Capillary refill continues to be considered an important diagnostic technique to check the status of distal perfusion, especially useful for trending distal perfusion or comparing circulation from one limb to another. Capillary refill times that increase over time reflect a decreasing perfusion, while decreasing capillary refill times indicate increased distal perfusion.
However, research has shown that capillary refill times alone are poor indicators of a patient's circulatory status. Many chronic conditions and preexisting factorsƒlike caffeine intake, smoking, COPD and exposure to cold temperatures -- can delay refill times beyond what was previously thought to reflect normal skin perfusion distal to a fracture site. Therefore, capillary refill must be just one of your diagnostic indicators of circulatory perfusion to the distal region of an extremity. Use skin color, skin temperature, pulse oximetry and your other assessment knowledge to determine perfusion status to the injured extremity.
During your early assessment, also examine the temperature of the limb. Is it hot, cold, clammy or dusky? A cold, clammy extremity may be indicative of a circulating impairment secondary to the fracture or position of the bone. Compare the look, feel and temperature of the other limb to assist you in determining abnormal conditions. Also ask your patients if they can move the distal end of the appendage.
Once these early assessment procedures are completed, examine the injury more thoroughly. Remove all clothing and jewelry surrounding and distal to the injury, covering any open wounds with a dressing as you would do for any laceration or avulsion.
Open fractures in particular should be carefully dressed and bandaged to prevent further contamination of the wound and infection. Most bacteria are opportunistic; if an entry point is accessible, bacteria will travel through it to an area that may not be able to prevent infection.
Deformity is an obvious sign that an injury exists below the surface of the skin. As previously mentioned, this sometimes results in an extra "joint," but other times the deformity is subtle. Assuming there's no pathological defects, always compare the injured extremity to the uninjured one to reveal signs of injury. Tenderness is also a reliable indicator that an injury is present. Typically, patients can accurately localize (musculoskeletal) somatic pain.
Bruising also alerts us that an injury has occurred. Fractures often become swollen as fluid from bruised tissues leaks into the interstitial spaces and blood flow to the area is increased to promote healing.
With fractures, we can sometimes feel and hear the broken bones rub against each other. This is referred to as crepitus. Free motionƒor abnormal, loose movement where there should be none -- usually accompanies crepitus.
Use of the PQRST acronym when classifying pain and/or tenderness will help to evaluate not only the injury, but how the patient perceives the pain (see Table 2, p. 56). When a person injures an extremity, they frequently attempt to protect it from further injury by holding it against their body. This reduces movement and the subsequent pain it causes. Seen a lot in children with fractures and other injuries, this is called guarding and serves as a form of self-splinting.
When and what to splint
A good rule to follow is to splint the extremity even if you're not 100% certain it's fractured. Soft tissue injuries, such as sprains or strains, are frequently splinted in the ED because a splint provides support and protection, and prevents the injury from being jostled excessively, causing further damage and pain.
All bony prominences should be padded before placing a splint over them to prevent pressure points and keep skin healthy. This is especially true when placing splints or other spinal immobilization devices on elderly or very young patients. An elderly patient's skin is fragile, and can bruise or tear easily. Pediatric patients lack adipose and muscle that supports the skeletal frame and prevents pressure points during periods of inactivity. Placing a blanket between the patient and a splint or backboard provides some padding, as do towels in voids between the patient and the immobilization device. Pediatric patients are not "small adults" and have a different physiological structure (e.g., a large occiput); they need that extra pad on the pediatric longboard to prevent neck flexion (C-spine) and airway compromise. Special products, such as the inflatable Back Raft and vacuum splints, can add substantial support and comfort to patients with fractures.
The splint should cover the joint above and below the fracture site. This gives added support to the splint and prevents movement of the joint and extremity, and shifting of bone ends. The rule in EMS has long been to splint fractures in the position in which they're found, especially if the injury involves a joint. However, current textbooks recommend that, except for joint injuries, extremities should be splinted in their correct anatomical position unless resistance is met when attempting to do so or there's a disruption caused to the patient's circulation. If there's a noted loss of perfusion (cool, clammy, cyanotic skin tone) upon initial assessment, attempts to reestablish circulation should be made while "loading and going."
During splinting, take care not to cause sharp bone ends to move unnecessarily and re-enter the wound. This can cause further tissue or vessel damage and increased hemorrhaging. However, keep in mind that, during proper splinting, bone ends frequently do re-enter the subcutaneous area on their own as the bone segments are realigned. There's nothing you can do to prevent this. If this does occur, be sure to advise the ED staff and note it on your patient-care report so they're aware of it and manage the patient accordingly. Bone end re-entry could also happen, along with nerve damage, if you do not reposition the effected limb. Therefore, EMS personnel should defer to their agency protocols and medical director's recommendation regarding the careful repositioning of fractures.
Most orthopedic specialists feel that the anatomical position occurs when the body naturally rests to alleviate stress, exertion and pain and argue that repositioning protects against further injury and makes the patient more comfortable. However, if you meet any type of resistance during repositioning, stop the attempt and splint the extremity in the position found. The splint should be secured with the appropriate straps or fasteners and the extremity rechecked for CMTS after splinting and frequently throughout patient transfer to the hospital.
Tractions splints, love them or hate them, still work wonders at immobilizing fractured femurs and reducing associated hemorrhage and pain (see photo, p 52). It's important to remember the massive amount of kinetic energy it takes to fracture the femur and that this force frequently causes other injuries, especially to soft-tissue regions. A single femur fracture can result in the loss of 1,000 cc of blood in the thigh and result in shock.
Use of a traction splint is contraindicated when the knee joint is involved. The knee is a complicated synovial joint. Therefore, if you apply unnecessary traction to this joint, you can further tear tendons and ligaments that are already injured. Pelvic injuries are another contraindication of traction splint use, due to the pressure it places on the posterior wall of the pelvic ring.
Just like with any other splint, once a traction splint is applied, CMTS should be checked to establish that they remained intact, and hopefully improved. Follow your local protocols when using traction splints because of the potential for making undetected soft tissue injuries worse.
Pelvic slings are now being used increasingly in the prehospital environment. Preliminary research shows that using a pelvic sling in an unstable pelvic fracture in the prehospital environment is indicated and can help prevent further injury when transferring the patient during extrication and transport. These splints, like the others, decrease the patient's pain associated with their injury. Remember that the anatomy underneath this splint is very susceptible to injury. Sudden shifting of the unstable pelvic ring can cause a tear in large blood vessels, thus causing hypovolemia (hypotension and tachycardia) and death.
Because fractures are painful
Pain management is something that many EMS agencies are working to improve, particularly when dealing with fractures. EMTs and paramedics have more pain management at their disposal than they often realize. The splint itself does a good job of managing pain, when properly applied. But sometimes the patient needs more than a splint.
A good mnemonic to use in remembering some simple, but often overlooked, pain management techniques is RICE (rest, ice, compress [splint] and elevate). Ice is a frequently forgotten analgesic. It may initially cause the injury to throb a bit because it causes blood vessels to constrict, but it decreases the swelling of an injury and the pressure that swollen tissue exerts on the injury. Ice can also numb a sensitive nerve and offer your patient more pain relief.
Elevating a splinted extremity can also decrease painful throbbing and swelling. This results from a simple law of physics: Blood has a harder time flowing uphill than down. Elevating and padding the injury with a pillow also decreases the amount of movement the injury sustains as the ambulance bounces, twists and turns en route to the hospital.
Finally, along with splinting, ice, elevation and positioning, the touch of another human being has been shown to reduce the anxiety level of patients in pain and should be used in conjunction with your reassuring words. The actual medical term for this concept is "therapeutic touch." Also, simply talking with your patients and telling them you care is just as important as showing them the splinting process. These are simple ways to decrease their anxiety and consequently decrease their pain.
Pharmacological analgesics are also effective at reducing pain and are a key tool in the ALS toolbox. Morphine, Dilaudid, fentanyl and Toradol are options for pain management in many states. Morphine and, in some cases, fentanyl, is approved for use by EMT-Intermediates in some states, such as Wisconsin and New York (see MD Forum, p. 46).
Morphine, fentanyl and Toradol can all be given IM if no IV is accessible. However, it's important to remember that absorption rates may vary depending on the patient, injury and co-morbid factors. Keep in mind that starting a capped IV may decrease the time it takes to get analgesic medication to a patient once they get to the ED, even if your service can't give the actual medication. It will also greatly speed medication administration if the local services choose to intercept with an intermediate or paramedic service.
Many prehospital providers think of splinting as a "basic" skill. However, for all providers, the basic skill of splinting takes talent and experience to be performed correctly. Failure to properly splint an extremity can lead to injury that's worse than if you didn't splint it at all.
By providing appropriate care and pain relief to your patient, you're serving as the patient's advocate, which is the goal we should seek on every call. JEMS
Jennifer Cuske works in the emergency department at Aurora Sinai Medical Center in Milwaukee, Wis. She has previously worked as an EMT-P in both urban and rural settings. She continues to hold a paramedic license in addition to her nursing credentials, while providing EMS continuing educational lectures independently and for Aurora Healthcare System's ambulance services. She can be reached at Jennifer.firstname.lastname@example.org.
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