Trauma Call: Thoughts on extracation, other methods

[OVeractiveBrain]

The scenario is quite simple. An officer was pursuing a perp down a dark side of a building at full sprint, jumped 3 stairs, landed in gravel and rolled. He ended about 10 yards from the stairs. We found him propped up on his arm, sitting, his left leg rotated inward with Left leg pain. PMS is present in all extremities, no neck head or back pain. To keep the report simple, assume this is an isolated injury and that the patient is completely stable.

The Volley crew on scene reported that he had proximal femoral pain. At this point I was thinking dislocation (he weighed about 100kg and had on about 10kilos of gear and armor) and agreed with the volley's decision to board him, thus immobilizing the joint above and below.

The Medic preceptor decided that was unnecessary and used a scoop to transfer him to the stretcher without immobilization. As the assessment continued it was determined that the pain was not proximal, but mid-shaft. Rotation inward and mid shaft pain (without crepitus) and grossly swollen is indicative of femoral fracture.

Now, PHTLS i believe would have us traction-splint the femur and secure to a long board. Perhaps the long board is unnecessary. If it were a dislocation, I believe the long board would be indicated. In the end, everything seemed to work out - the patient was seated in a position of comfort, received morphine for pain management, and he had no complaints. He received an activated trauma by triage which was downgraded by the trauma physician. I had no followup with this patient, though he seemed to be doing well (besides his leg being swollen to three times the size of his other).

The question i leave open for you is: what would your trauma protocols say to do? how would you immobilize this patient? is it ok to NOT immobilize an isolated injury if the patient is able to tolerate the pain as is?

This is important for I have heard similar stories (a geriatric hip dislocation standing from the toilet, slunking back to a seated position) coming under reprimand for a failure to secure the patient to a long board. However, once the trauma docs saw the patient they denied the request for a c-collar or board (coming from the nurses, who assumed it was indeed a full trauma). So a different call (though frighteningly similar) received reprimand from no-boarding and another it seemed to be the right conclusion. I must admit I am confused, and am open to response.

[nsmedic393]

We have a c-spine clearance protocol. Basically it says if any of these conditions ie. fall greater than 6 feet, high speed/roll over mvc, significant MOI...to name a few, you must secure c-spine. Like anything else it comes down to common sense. Go where your assesment leads you and be ready to justify your actions.

[whit72]

I am not sure I get the gist of your question, are you asking should the injured extremity be immobilized or the pt receive full c-spine immobilization?

[vs-eh?]

Honestly (and I know people will preach to the high heavens), people probably board way to many patients than those that actually need to have spinal immobilization. PHTLS/BTLS/ITLS/whatever....aside...

Spare me the lecture.

I think that your treatment was correct, and it is what I would have done. Buddy jumped, landed wrong, a bad twist and turn here, boom - query femur fracture.

Scoop, splint, position of comfort, and analgesia. That is how I have treated all of my suspected femur fractures...

That being said...

There is an argument that can be made for traction splinting. Generally speaking (though I have never actually done it) it probably is more beneficial. It is just tough seeing a patient in a POC, pain being managed, and "comfortable" and say "Ummm, we have to do something else, it's gonna hurt". I think it is a fear of potentially being wrong, regardless of clinical presentation, in applying the traction (in the face of apparent comfort) and causing the patient (pontentially) more discomfort and applying it to an non-fractured femur. I fall into this too, after all, the hospital does xrays first too...

The next time I come across a query femur fracture based on clinical assessment and even if the above criteria are met, I will do the following.

- Sedate the patient (via midazolam) +/- further analgesia and apply the traction split. Generally speaking based on sound clinical assessment it is the right thing to do. Based on multiple physiological things...

- Keep in mind I would have to call a doctor to do this, and he/she would have to allow it (i.e. sedate and traction given the patient that you had).

We have no specific trauma "protocols", it is always left to our discretion.

[1EMT-P]

As I understand it the officer was chasing after the suspect prior to his injury, so yes I would have immobilized this patient based on his H & P & MOI.

[1EMT-P]

Vs-eh, Let me get this straight your telling us that you would sedate the patient, instead of giving them pain medication :?:What's your rationale?

[BushyFromOz]

Vs-eh, Let me get this straight your telling us that you would sedate the patient, instead of giving them pain medication :?:What's your rationale?

You would give both

Besides the obvious reduction in pain by the conjunctional use of narcs, sedation gives a nice little amnesic effect, so even if they do squirm (the CSN is still going to feel it and respond, though the pain perception may be reduced by the narcs) they are not going to remember just how much it hurt.

[vs-eh?]

Vs-eh, Let me get this straight your telling us that you would sedate the patient, instead of giving them pain medication :?:What's your rationale?

- Sedate the patient (via midazolam) +/- further analgesia and apply the traction split.

I'm saying after initial comfort measures (including analgesia), do the above...

[whit72]

overactivebrian wrote:

full sprint, jumped 3 stairs, landed in gravel and rolled. He ended about 10 yards from the stairs.

How fast was this guy running if after he fell he rolled for 30 ft? I agree if you do not immobilize, be ready to justify it.

[OzMedic]

The one thing that has not really been looked at in this post is the failure to apply a traction splint to the affected limb. There are varying thoughts on the utilisation of this procedure and because I am in a lazy mood today I will just post 2 contrasting opinions and a link to a JEMS article that looks at this issue.

"Traction Splinting in Limb Fracture - A Vital Manoeuvre" Article from: Trauma Grapevine – Volume 1 No.7 April – June 1997 The aim of this short paper is to highlight the need for early application of traction splints in the management of femoral shaft fractures. Over the last four weeks I have been consulted as a Vascular Surgeon, to review three patients with femoral shaft fractures, in whom absent pulses have been noted below the groin. The first patient reviewed in the Emergency Department of a tertiary referral hospital had sustained a combination of chest, abdominal and right leg injuries. The acute management of the patient had been appropriate but during the secondary survey, the obviously angulated and externally rotated pulseless right leg, caused a lot of consternation in the attending staff, who asked for a vascular surgical review. Prompt application of a Hare traction splint resulted in brisk restoration of popliteal and pedal pulses. Failure of both Ambulance and Emergency Department staff to identify the need for this device in the management of a simple femoral shaft fracture was interesting. Two further cases presented within a week to Liverpool Hospital Emergency Department. In the first instance, a male motorcyclist had sustained a simple transverse fracture of the femoral shaft at the junction of the middle and distal third. This had resulted in leg shortening and external rotation of the distal leg. Emergency Department staff, concerned at the absence of pulses, were arranging for radiography and Doppler studies. A consultation to the Vascular Surgical Service was also requested. Prompt application of a Hare traction splint was all that was necessary to realign the femoral shaft and restore the pulses, avoiding unnecessary radiography or vascular studies. The final case again involved a male motorcyclist who had sustained a transverse fracture of the distal left femur with slight comminution. A transverse laceration of the popliteal fossa had resulted in degloving to the level of the gastrocnemius muscle of the distal portion of the wound. The leg was obviously deformed, the thigh shortened and grossly swollen. Two x-rays were performed to confirm the bony injury which was quite clinically apparent. Nothing had been done to restore the pulse deficit below the left groin. In this case, again, the application of a Hare traction splint resulted in prompt restoration of pulses during the interval prior to placement of a Denham tibial pin in the Operating Theatre. In all three scenarios, staff with at least moderated exposure to general principles of trauma management, failed to identify the need for application of a traction splint to restore pulses in the presence of a femoral shaft fracture. In part, their concerns related to the pain that movement of the leg would produce. Systemic analgesia with intravenous Morphine or inhaled nitrous oxide and reassurance and explanation, will usually allow the placement of traction splints. Patients usually experience significant relief from pain promptly after the leg is restored to normal alignment. The decision to x-ray prior to realignment, was made on one occasion in this trio of patients. In some ways this is analogous to x-raying a tension Pneumothorax or dislocated ankle before treating these life or limb threatening conditions. The need for application of the traction splint has higher priority than the need to image the bony deformity, which can be done with greater patient comfort and less threat to the limb, after application of the traction splint. The final observation was of the lack of familiarity of attending medical staff from two teaching hospitals with the traction devices which are available to them in their respective emergency departments. These three cases highlight the need for general awareness of first aid principles in the management of femoral shaft fractures and of the need for attending staff to be practised in the application of simple traction splints. John Crozier, Vascular Surgeon, Lecturer in Surgery Liverpool Hospital, LIVERPOOL

or there was this study from Am J Emerg Med. 2001 Mar;19(2):137-40.

Prehospital midthigh trauma and traction splint use: recommendations for treatment protocols.

Abarbanell NR.

Department of Emergency Medicine, Baptist Medical Center, Jacksonville, FL 32207, USA.

The present study was completed to establish an epidemiologic database defining the prehospital occurrence of midthigh trauma/suspected femoral shaft fractures, and the use of/need for traction splints (TS) in hope of developing recommendations for further treatment protocols. On review of 4,513 paramedic run reports for the 12-month period from January 1999 through December 1999, from a low-volume urban emergency medical services (EMS) system, 16 persons (0.35% total patients) presented with midthigh injuries. Data collected included patient chief complaint/injury, mechanism of injury, clinical findings, splint application, additional interventions, iatrogenic complications, patient age, and ambulance field time. Paramedics noted injuries suspicious for femoral shaft fractures in 5 patients (31.25% study patients, 0.11% total patients). TSs were applied successfully only twice (12.50% study patients, 0.04% total patients). Fourteen patients (87.50% study patients) were managed with long backboard immobilization, rigid splinting, and/or patient transportation in a position of comfort. No sequelae as a result of such care occurred. No inappropriate use, point estimate (PE) [(0)/(16) (0.00% to 20.60%)] or unmet need, PE [(0)/(4), 497) (0.00% to 0.08%)] of care was noted. The data presented in this study suggest that given similar EMS system characteristics, prehospital midthigh injuries/suspected femoral shaft fractures occur on an extremely rare basis, and treatment with long backboard immobilization, rigid splinting, and/or patient transportation in a position of comfort may constitute an acceptable course of care. Including TSs as essential ambulance equipment may be unnecessary.

and the link....... http://www.swissrescue.ch/dossier/traction...splint_angl.pdf

I think in this case the fact that the patients leg was described as grossly swollen might indicate the need for some traction for haemorrhage control if nothing else. In response to the original question, I am a big fan of C-spine clearance and use it often, however, if this patient has suffered a mechanism then his C-spine cannot really be cleared due to the distracting nature of his other injury. Just my thoughts