Chapter 29. Patient immobilisation and extrication
It is crucial that decisions about stabilisation, extrication and subsequent evacuation are taken early on in the rescue. The techniques used for stabilisation must not be viewed in isolation, but should be part of the total rescue activity and should complement the other treatments used.
Principles of immobilisation
In the prehospital setting, the principles of skeletal management are to:
• Prevent further injury
• Ensure neurovascular supply
• Make the patient comfortable.
The overriding importance of managing the airway with cervical spine protection, breathing and circulation (ABC) is fundamental to the treatment of any injury.
With the exception of cervical spine care, fracture management and extrication follow the primary survey unless a ‘snatch rescue’ is necessary.
The principles of definitive fracture management are:
• Reduction
• Immobilisation
• Preservation of function.
Every piece of equipment will cover or hide the patient to a greater or lesser extent, it is essential that any immediate local treatment and observations are carried out before the immobilisation device is applied.
Wounds should wherever possible be photographed and appropriately dressed before immobilisation.
The benefits of immobilisation are:
• Pain relief
• Reduction of blood loss
• Prevention of neurovascular damage
• Prevention of fat embolism.
Remembering the ABC principles, splinting or extrication devices should never produce any airway, breathing or circulation compromise.
The patient should always feel more comfortable after the splint or device has been applied, so that handling becomes easier.
Always check the pulses distal to an injury before starting treatment
Forms of splintage
Box splints
Box splints are simple in design and are useful for some arm, lower leg and ankle injuries and are carried by every front-line ambulance.
The splint forms an oblong box, open along one side with the other three sides able to be folded in such a way as to form a gutter. There may be a foot support at one end. Box splints are available in adult and child sizes.
Application
• Expose the injured leg
• Remove footwear (occasionally, footwear may provide support and should be left in place)
• Apply dressings to any wounds
• Straighten the ankle and check the peripheral pulses
• Raise the leg and pass the splint passed underneath it
• Fold the two sides of the splint so they fit closely against the leg, place the foot support
• Secure with the Velcro straps
• If any strap passes near to an injury, care should be taken that it does not cause pain; if it does, it should be left loose
• Once the splint is applied, the patient should be rechecked – specifically, the pulses in the limb and the distal sensation must be noted and recorded
• Mark the position of a palpable dorsalis pedis pulse with pen once a splint has been applied to the leg.
Traction splints
The primary function of a traction splint is to immobilise the fracture (of a lower limb) in a reduced position
• Following a fracture of the shaft of the femur the muscles of the thigh will shorten the leg, causing the bone ends to override. This increases the radius of the thigh so that it becomes more spherical: this shape has a larger internal volume than a cylinder and so presents a larger space into which blood can fill
• Application of traction will restore the cylindrical shape of the thigh, reducing its volume and reducing the overall blood loss
• Three types of traction splint are found in prehospital care: the Hare® or Trac-3® splint, the Sager® splint and the Donway® splint
• There may be other more life-threatening injuries which must take priority. Patients are far less likely to die from a fracture of the lower limb than they are from a blocked airway
• All compound fractures will need to be explored and cleaned. Therefore the receiving hospital must know that a fracture was compound and if possible a photograph should be taken.
Indications for traction splintage
• Closed (simple) fractures of the femoral shaft
• Closed (simple) fractures of the proximal two-thirds of the tibia and fibula
• Compound fractures of the femur, and the proximal two-thirds of the tibia and fibula.
Contraindications to traction splintage
• Fractures around the knee
• Dislocation of the hip
• Fracture dislocation of the knee
• Ankle injuries
• Simple undisplaced fracture of the lower third of the tibia and fibula (better immobilised with a box splint)
• Fractures of the pelvis.
Complications of traction splintage
• Damage to the neurovascular supply to the leg. This can be prevented by careful examination of the distal limb function
• Absence or change in distal function must be reported to the Emergency Department. If it is found that the distal pulses diminish or are absent after traction has been applied then traction must be gently reduced until the pulse returns
• The pulse oximeter can be used to detect alterations in the blood flow if the probe is placed on one of the toes of the fractured leg.
Hare® or Trac-3® traction splint
This splint can be used with traction to maintain a reduced fracture of the lower limb and can also be used without traction simply for support.
Application
• The splint requires two people to apply it correctly and analgesia should be given as required before manipulating the fracture
• The splint should be set-up as follows:
• The fracture site is exposed (clothes should be cut if necessary). Motorcycle leathers should not be removed as these can be dramatically effective in the control of lower limb and pelvic fracture bleeding
• The limb should be examined thoroughly and the footwear removed
• The pulses distal to the fracture together with the colour and warmth of the limb and sensation and motor function distal to the fracture should also be assessed (the neurovascular examination)
• Wounds are dressed if required
• The splint is prepared
• Select the appropriate ankle hitch
• The splint is placed by the good leg, measured for length and adjusted accordingly, then laid by the injured leg
• All the straps are checked; these should be open and placed at the correct intervals down the splint
• Some of the traction strap should be unwound
• The foot is straightened and the ankle hitch placed well under the ankle
• The side straps are then tightly folded over the ankle (not around the foot) and the rings brought together below the foot
• Finally the strap at the bottom of the foot is firmly grasped: traction must be applied along the longitudinal axis of the femur, not over the dorsum of the foot, which can cause permanent damage to the limb
• Manual traction is started with one hand while the other hand supports the leg
• The splint is then put in the correct position. The best method is to roll the patient away from the splint while a colleague slides the splint under the leg
• The top padded ring must fit under the ischial tuberosity. The patient is then rolled back onto the splint. If the position is still not correct then the patient can be moved down slightly so that he is sitting on the padded ring. Manual traction MUST be maintained THROUGHOUT this procedure
• The top strap is done up and padding applied if required. The external genitalia should be avoided in males. If correctly positioned, this strap will lie parallel to the crease of the groin
• The traction hook is then put through the ‘D’ rings and traction taken up, ensuring that manual traction is not released before the splint’s mechanical traction is tightened
• Traction is applied until the limb is comfortable (to a maximum of 7 kg in adults)
• The neurovascular examination is repeated and the oximeter reading rechecked
• The leg is elevated by raising the foot stand
• The Velcro straps are positioned and tightened to support the site of the fracture
• The leg is covered to keep it warm.
En route to hospital
The neurovascular examination should be repeated every 5–10 minutes. The straps should be checked and loosened if required – the leg may swell.
The tension of traction should be checked; as a result of reduced spasm in the muscles, tension can be lost.
To release traction
The two splints (Hare® and Trac-3®) have slightly different release mechanisms
Manual traction is taken up and then the mechanical traction is released after all the supporting Velcro straps have been removed
The Hare® splint has a pull ring which releases the traction suddenly, whereas the Trac-3® has a knob which has to be unwound to release the traction (which is less likely to be accidentally released).
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