Chapter

Prehospital Care for Orthopedic

Trauma: The Developed
Countries Perspective

3
INTRODUCTION
Trauma is the leading cause of death in people younger than
45 years of age and fourth leading cause of death for all
ages. Approximately 5 million people died worldwide as a
result of injury in 1990 and this is expected to rise to 8.4
million by 2020. Though blunt trauma due to road traffic
accidents is the leading cause of death in Europe, penetrating
injuries such as gunshot and stab injuries have become the
main cause of death in some states of USA.
Two people will be killed, 350 will have a disabling injury
and approximately 78,00,0000 dollars will be spent on the
unintentionally injured patients in the USA in the time taken
for one to finish reading this chapter. Approximately 60
million injuries occur annually in the USA. Trauma related
dollar costs exceed 400 billion dollars annually.
One-third of prehospital deaths may be preventable by
providing appropriate prehospital trauma care. But the
quality of care provided is highly variable and there is often
a controversy about what is optimum care. The average
prehospital time taken by the paramedics in UK is 45 to 50
minutes. The so called Golden Hour after injury is a
prehospital event and the prehospital trauma care should
be considered as the start of a continuum of care. The Golden
Hour is an unproven concept but is a good yardstick by
which resuscitative measures can be assessed.
The main aim of prehospital trauma care is to promote
functioning of vital organs and preservation of blood clot,
while transporting the injured patient quickly to the nearest

K Vivek Pannikar, Srinivas Samsani

trauma facility to provide definitive care. The priorities in

preoperative trauma care are the same as that in the hospital.
A quick primary survey is performed. The conditions that
might cause deterioration or death during extrication or
transport such as airway obstruction, hypoxia or tension
pneumothorax must be identified. Prehospital care doctors
place less emphasis on full examination, auscultation and
equipment but more on mechanism of injury and clinical
assessment of physiology. When a patient is trapped, oxygen
is administered, the cervical spine is stabilized, analgesia is
administered and basic monitoring (pulse oximeter) is setup before extrication starts.
The package used for transport of the patient should
include hard cervical collar, head blocks, limb splints if
required and a body splint such as scoop stretcher or vacuum
mattress. Spinal immobilization on a spinal board is a
standard procedure. Time to definitive treatment is an
important determinant to outcome in some patients.
Communication with the receiving hospital is also a key
element of prehospital care. Patient should be rapidly
transported to the nearest appropriate hospital depending
on possible medical requirements of the patient. Road
transport is commonly used, however, helicopter transport
may be used to cover large distances or to a multispecialty
hospital far away.
The basic principles of the prehospital trauma care are
airway protection, oxygenation, control of hemorrhage and
volume replacement, spinal immobilization, pain control
and rapid transport to the nearest hospital.

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First Aid and Emergency Management in Orthopedic Injuries

BASIC PRINCIPLES OF PREHOSPITAL CARE

Airway protection and management
Oxygenation
z
Control of hemorrhage and volume replacement
z
Spinal immobilization
z
Pain control.
In the transition from prehospital phase to primary
survey, the handover is a very important step. Successfully
done it sets the stage for the resuscitation: controlled, orderly,
quiet. Prehospital details can be transferred to the trauma
team under the headings MISTmechanism of injury,
suspected injuries, vital signs and treatment given. This
report should be delivered before the patient is transferred
to the resuscitation bed and should be listened to by all the
members of the receiving team and should be concluded in
approximately a minute.
z
z

Providers and Type of Prehospital Care

The prehospital care for trauma patients in the industrialized countries is provided by the Emergency Medical
Systems (EMSs). These systems are predominantly
paramedic based in UK and USA (the Anglo-American
system), whereas in continental Europe and Scandinavia,
physicians become an important member of the prehospital
trauma care team (Franco-German system).1,2
The method of providing prehospital care took a more
organized form after the introduction of the Advanced
Trauma and Life Support Course, the first of which was
held in 1978. The stimulus to set-up this type of organized
system was the tragedy that befell an Orthopedic Surgeon
while piloting his own plane in February 1976. The surgeon
crashed in a rural Nebraska cornfield sustaining serious
injuries himself. In addition, three of his children suffered
critical injuries, his wife died instantly and one child suffered
minor injuries. The surgeon in spite of his injuries is reported
to have provided and given the instructions for the initial
resuscitation of his family in the cornfield.
The surgeon commented that, When I can provide
better care in the field with limited resources than what my
children and I received at the primary care facility, there is
something wrong with the system and the system has to be
changed.
In the aftermath of this tragedy, a group of surgeons and
physicians in Nebraska, the Lincoln Medical Education
Foundation, Lincoln Area Mobile Heart Team Nurses along

with the University of Nebraska and the South East Nebraska

Emergency Medical Services combined to form the
prototype of the ATLS courses.
The type of prehospital trauma care provided also varies
from place to place and system to system. The FrancoGerman physician-based EMSs tend to provide the
prehospital trauma care using Advanced Life Support (ALS)
techniques, whilst the paramedic based Anglo-American
system provide either Advanced Life Support (ALS) or Basic
Life Support (BLS) techniques. The BLS based prehospital
care, also called the Scoop and Run approach, provides
care employing non-invasive techniques such as oxygenation,
noninvasive cardiopulmonary resuscitation, wound dressing,
immobilization and splinting of fractures.3 Whereas the ALS
based care uses the Stay and stabilize approach utilizing
both BLS techniques as well as invasive procedures such as
intubation, IV access and fluid replacement, administration
of drugs, and application of pneumatic antishock garments
(PAGs). Traditionally, the BLS (Scoop and run approach)
has been used in the prehospital care trauma patients but
recently the ALS (Stay and stabilize approach) is being
commonly used. The argument for using the ALS in
prehospital trauma care is to optimize the physiologic and
hemodynamic condition of the patient before arrival at the
trauma center and thereby improving the outcomes.
However, the main drawback of this approach is the
increased time spent at the site and thereby delaying
definitive care. However, there is no definitive evidence
available in literature that ALS skills in prehospital setting
improve the outcomes.2-4 Paramedics with their enormous
experience in prehospital trauma care may be in a better
position to take urgent decisions and provide optimum care
with the limited resources. In addition, they are also more
familiar with the influences of hazardous conditions,
communicable diseases and hostile people. On the other
hand, physicians are more successful in performing invasive
procedures such as endotracheal intubation, venous access,
sedation and pain control. At present, there is no evidence
to support the viewpoint that the physicians involvement
in prehospital trauma care improves the outcome in
polytrauma patients.
Paramedic Based EMSs: Advantages
z
z
z

Extensive experience
Better adapted to prehospital care
Optimum care with limited resources

Prehospital Care for Orthopedic Trauma: The Developed Countries Perspective

z

Familiarity with hazardous conditions, communicable

diseases and hostile people.

Physician Based EMSs: Advantages

Skills due to special education and training

z
More successful in performing invasive procedures such
as intubation, venous access, sedation and pain control.
Death due to injury has a trimodal distribution. The
first peak within the first few seconds and minutes post
injury is usually due to lacerations to the brain stem, brain,
heart, aorta and other large blood vessels. Very few of these
patients can be salvaged and this is only in large urban areas
where prehospital care is optimal. Only preventative
measures can reduce the number of deaths that occur in
this group.
The second peak occurs within minutes to several hours
after injury and is the group where the mortality can be
affected the greatest by optimal prehospital care.
The third peak of death occurs several days to weeks
after the injury and is usually due to sepsis and multiorgan
system failure. Care during the previous phases has a
significant bearing on the outcome of patients who reach
this phase.
z

AMBULANCE SERVICES IN THE UK AND USA

Ambulance services in the UK are under the control of the
regional Ambulance care trusts which are part of the
National Health Service. There are centrally prescribed
response times and these targets are monitored at regular
intervals. There are 34 Ambulance Service trusts which cover
the whole of the UK and in addition there are 14 Air
Ambulance services which are called upon less often. An
average Ambulance trust serves a population of about 2.6
million and covers an area of about 2,700 miles. On average,
there are a total of 250,000 calls to each regional ambulance
trust while the helicopters are called out approximately three
times a day. Unlike in the USA, ambulance crew in the UK
do not double up as firefighters and if patients need
extrication from a crash scene usually the fire crews need to
be summoned too. The present target for Emergency calls
are for them to be attended within 9 minutes in urban areas
and 14 minutes in the rural areas (on average). The National
targets are for 75% of all such calls to be responded to within
this period of time. These ambulances are state of the art
and have two fully trained staff, one of whom accompanies

17

the patient in the back of the vehicle. These vehicles are

provided with facilities for intubations, cannulation,
insertion of chest drains, defibrillation, blood transfusion,
spinal boards, pneumatic antishock garments, etc. These
services are free at the point of provision. In the USA,
however, the provision of these services are often by private
providers, 75 percent of whom are members of the American
Ambulance Association. Emergency personnel in the USA
often double up as ambulance and firefighting personnel.

PREHOSPITAL MEDICAL MANAGEMENT

Management of Airway

Airway obstruction is the quickest killer in a polytrauma

patient and is a major cause of preventable death in these
patients.2,5 That is why airway management is widely
considered the highest priority in the management of
critically injured patient. The skills to assess a patient for
obstructed airway, to establish and maintain a patent airway,
and to ensure adequate ventilation and oxygenation, are
therefore essential. Patent airway should be maintained by
whatever, means possible until the patient arrives in the
emergency room. Dirt, broken teeth and clotted blood
should be removed to prevent obstruction and aspiration
into the lung. The tongue can fall back and can cause
obstruction. This can be prevented by chin lift or jaw thrust
maneuvers and then the airway is maintained using
nasopharyngeal or oropharyngeal airways. Alternatively
patency of the airway can be maintained by endotracheal
intubation or surgical airway (tracheostomy or cricothyroidotomy). Surgical airway is seldom required in the
prehospital setting.
Measures to Maintain Airway

Remove dirt, broken teeth, and suction of secretions and

clotted blood
z
Chin lift/Jaw thrust maneuvers to prevent obstruction
by the tongue
z
Airways (nasopharyngeal or oropharyngeal)
z
Endotracheal intubation
z
Surgical airway (rarely used in prehospital setting)
The rationale for onsite endotracheal intubation is that
it maintains airway patency to allow oxygenation and
protects the patients from aspiration. The argument against
onsite intubation is that it delays the transfer and definitive
treatment. However, onsite intubation is recommended in
z

18

First Aid and Emergency Management in Orthopedic Injuries

some situations with compromised airway such as

unconsciousness (GCS < 8), severe maxillofacial injuries,
and in patients with increased risk of aspiration and upper
airway obstruction. Intubation performed by the basic
emergency staff has been questioned due to a result of serious
complications. The factors that increase the risk of failure
of intubation are inadequate sedation, patient combativeness, lack of practice and the need for concomitant cervical
spine immobilization. It is generally performed by the
emergency physicians in the European continent but in UK
and certain states of USA, this is done by the paramedics.1,2,6
Intubation by the emergency staff without drugs can result
in serious complications such as rise in intracranial pressure,
vomiting with associated risk of aspiration, and the fatal
risk of unrecognized esophageal intubation. In addition,
intubation at the accident scene has not shown to improve
the outcomes. Preferably the intubation should be performed
by a skilled person (such as the emergency physician) with
the use of sedation and neuromuscular blockade to prevent
the risk of failed intubation and other serious complications.
Ability to intubate a trauma patient without sedation or
neuromuscular blockade is a reflection of initial severity of
injury and is a strong predictor of poor outcome.
Intubation in trauma patients without the use of sedation
and muscle relaxants can be very difficult and can lead to
increased intracranial pressure which should be avoided in
head injury patients. Restless or agitated patients due to
hypoxia, lack of continuous practice, and the need for
concomitant cervical immobilization from suspected cervical
spine fracture can complicate a successful intubation and
airway maintenance. Rapid sequence induction (RSI) with
sedative agent such as thiopentone, ketamine or etomidate
and followed by neuromuscular blockade with rapid acting
drug such as succinylcholine to induce sedation and muscle
relaxation should be used and is the gold standard for
emergency endotracheal intubation. 2,5 It requires a
combination of skills and thorough knowledge of drugs and
therefore should be undertaken by the professionals such as
anesthetists. Hypovolemia necessitates reduction of the dose
of sedative drugs and internal abdominal bleeding may
prevent the use of muscle relaxants to prevent profound
hypotension due to loss of abdominal muscle tone.
Preoxygenation is essential and prolonged attempts at the
procedure should be avoided. Cricoid pressure, awareness
of drug kinetics and pharmacokinetics in hypovolemic

patients and reliable assessment of tube position are essential.

Considering all these factors, endotracheal intubation using
RSI technique is a safe procedure for the physician based
Emergency Medical Systems. However, for paramedic based
systems, Bag-Valve-Mask ventilation or noninvasive device
such as laryngeal mask may be safe alternatives.
Tension pneumothorax is a clinical condition which, may
need to be addressed in the prehospital setting, as it can
interfere with ventilation and kill the patient very quickly.
Clinically, it is diagnosed by respiratory distress, persistent
hypotension, and low oxygen saturation levels. It may also
be associated with deviation of trachea to opposite side and
a tympanic note on percussion of the chest. Once diagnosis
is made, tension pneumothorax prompt action is required.
This is temporarily treated by insertion of a wide bore needle
into the second intercostal space in the mid-clavicular line
on the affected side. This usually results in sudden gush of
air through the needle and decompression of chest until
patient arrives to the hospital. Definitive treatment for
tension pneumothorax is a chest drain insertion and should
be performed in the hospital. Presence of a sucking chest
wound must be recognized and promptly treated with a
three-way dressing.
Key Points for Endotracheal Intubation in Trauma Patient

Endotracheal intubation in trauma patient can be very

difficult
Endotracheal intubation should be performed by a physician
who has the skills, and thorough knowledge of drugs
Should be performed with Rapid Sequence Induction (RSI)
Preoxygenation essential and prolonged attempts must be
avoided
Caution should be exercised in patients with hypovolemia
and intra-abdominal bleeding
Assessment of correct positioning of tube is essential.

In UK, where the endotracheal intubation is commonly

performed by paramedics, a review study from UK,
involving 486 trauma patients intubated without anesthesia
and muscle relaxants, resulted in only one survival (0.2%).7
The role of endotracheal intubation for obstructed airway
in a prehospital setting is a controversial issue. The general
consensus is that variables such as conditions, skills and
performance may affect the outcome rather than the
endotracheal intervention per se.

Prehospital Care for Orthopedic Trauma: The Developed Countries Perspective

Oxygenation

Oxygenation is important principle in the prehospital care

of trauma patient. Every trauma patient should receive
supplemental oxygen and saturation levels must be
maintained above 95%. The basic aim of the administration
of oxygen is to correct or prevent hypoxia, thereby preventing
tissue anoxia and secondary organ damage. Hypoxia along
with hypotension should be avoided to prevent secondary
brain injury and spinal cord injury. 100% oxygen at a flow
rate of 10 to 12 liters per minute is generally given via nasal
specs, facemask or endotracheal tube. A patent airway must
be established before giving oxygen. Simultaneous correction
of hypovolemia improves tissue perfusion and oxygenation.
Management of Hemorrhage and Fluid Resuscitation

There is general agreement regarding the procedures to stop

the external bleeding in prehospital setting. Rapid external
bleeding is controlled by direct manual pressure on the
wound. Pneumatic transparent splinting devices may be
useful. Tourniquets are not recommended to control external
hemorrhage except in case of traumatic amputations of
extremity. Use of hemostats is not generally recommended
as they can cause extensive damage to surrounding
structures. An important aspect of the management of
external bleeding is rapid transport of the patient to the
hospital as most of them need surgical intervention.
The role of onsite IV access and fluid replacement in
prehospital trauma care is controversial and continuously
evolving. The rationale for employing the prehospital fluid
resuscitation is to prevent possible physiologic and
hemodynamic deterioration. However, some authors believe
that the amount of fluid infused cannot compensate for the
severe blood loss in these patients and surgery is usually the
definitive treatment.
The three areas of fluid resuscitation in the prehospital
setting that continues to be subject of intense research and
debate are gaining IV access, the choice of fluid and the
quantity of fluid given.
Early venous access in trauma patients has been believed
to be very useful. It allows administration of IV fluids, pain
killers, resuscitation or anesthetic agents as and when
necessary. In addition, placement of the IV cannula is
technically easier in the early phases of shock than in the
later stages where the compensatory mechanism causes
intense peripheral vasoconstriction making the procedure
difficult. While an early cannulation saves time when the

19

patient arrives in the hospital, a failed attempt at cannulation

also causes significant delay in transfer of patient. Transfer
time to the hospital is an important predictor of outcome in
the trauma patients and delays in transfer due to onsite
cannulation therefore should be avoided. The best way to
gain the benefits of early cannulation while preventing delays
in transfer is to obtain the IV access en route. However onsite IV access is generally indicated in situation such as
entrapment in a vehicle, buildings, etc. as it allows administration of pain killers, fluids and rarely the resuscitation
agents.
Fluid resuscitation depends on severity of hemorrhage
and mechanism of injury. Patients with a controllable
hemorrhage such as an extremity injury or superficial soft
tissue wounds of the trunk, fluid resuscitation can be
administered if the patient shows clinical signs of shock.
However, in case of uncontrollable hemorrhage, the fluid
resuscitation depends on mechanism of injury. In patients
with penetrating trauma and presumed uncontrollable
hemorrhage who show some signs of shock but not in
imminent circulatory arrest, the amount of fluid
administered should be limited (to keep the veins open). In
moribund patients due to penetrating injuries it may be
reasonable to provide immediate fluid resuscitation just to
maintain vital organ perfusion. The fluid administration in
patients with blunt trauma should be more liberal based on
clinical condition but they should still receive just enough
fluid to maintain perfusion.
Regarding the choice of fluid administered in the
prehospital care of the trauma, several options are available:
crystalloids (isotonic or hypertonic), colloids (gelatines or
starch solutions) or oxygen carrying solutions (blood and
blood substitutes). Crystalloid such as 5% dextrose should
not be used in the fluid resuscitation of trauma patient.
Several factors influence the selection of fluid for
administration in prehospital setting such as heomydynamic
and hemostatic effects, oxygen carriage, pH buffering,
distribution in the body and capillary endothelial leak,
method of elimination, safety, practicality and cost. The
main aim of the fluid resuscitation is to restore the perfusion
of vital organs and tissue oxygenation. Fluids increase the
blood pressure by increasing the circulating intravascular
volume and subsequently the cardiac output. Seriously ill
patients exhibit increased capillary permeability leading to
extravasation of water and proteins. Molecular size is the
main factor whether the fluid will remain in intravascular
compartment or is distributed widely in the extracellular

20

First Aid and Emergency Management in Orthopedic Injuries

compartment. Low molecular weight fluids such as

crystalloids generally diffuse out through vascular
endothelium into the extravascular compartment.
Crystalloids are popular fluids for prehospital fluid
administration in UK and USA. The traditional teaching
concerning crystalloid infusion has been the 3:1 rule,
whereby 1 liter of crystalloid remains in the vascular
compartment for every 3 liters infused. On the other hand,
the high molecular weight fluids such as colloids tend to
remain in the intravascular space and causes intracellular
dehydration by osmotic diffusion of water into the
intravascular compartment. Generally, fluid resuscitation is
associated with a tendency to increase bleeding by dislodging
the thrombus plug from vessel, causing vasodilatation,
decreasing the blood viscosity and diluting the clotting
factors and the hypothermia induced coagulopathy. Ideal
resuscitation fluid must be safe to administer in all patients,
cheap with long shelf life. They should be easy to store and
to warm when required. However, there is no ideal
resuscitation fluid available at present that can be given in
all circumstances.
Crystalloids such as normal saline and Ringers lactate
solution are the most popular solutions commonly
administered in the prehospital trauma fluid resuscitation.
Other crystalloid solutions such as hypertonic saline are
rarely used and may have a role in the treatment of
hypotensive patient with severe head injury. Colloids such
as gelatine and starch solutions are rarely used. Prehospital
administration of blood and blood products is rarely
practicable. General consensus at present is that isotonic
saline is the first line fluid in the resuscitation of hypovolemic
trauma patient in the prehospital setting.8,9
The amount of the fluid that can be safely administered
remains a controversial issue and continues to be the focus
of intense discussions and debates. Too little fluid transfused
is unlikely to be effective in preventing hypovolemia and
organ ischemia, on the other hand, liberal administration
of fluids can increase the risk of rebleeding and increased
blood loss. Generally fluid can be administered in boluses
at a time to prevent the risk of excessive fluid administration.
In the prehospital setting, the need for fluid administration
is based on assessment of clinical signs of hypovolemia and
shock. Presence of a radial pulse indicates a systolic blood
pressure of 80 to 90 mm Hg or above. A palpable brachial
pulse corresponds to 70 to 80 mm Hg and a palpable central
(femoral or carotid) pulse indicates 60 to 70 mm Hg.
Different subgroups tolerate hypotension differently

depending on the compensatory mechanisms. Patients with

head injury may require high blood pressure to maintain
cerebral perfusion and reduce secondary brain injury.
Patients with penetrating torso injuries require lower
pressures and elderly patients tolerate hypotension poorly.
Not all the trauma patients need prehospital fluid
administration. If the radial pulse is palpable, fluid administration is not required. If the radial pulse is not palpable,
judicious aliquots of 250 ml should be given and response
is observed. If the radial pulse returns, fluid resuscitation is
stopped and the situation is monitored. In penetrating torso
injuries, presence of a central pulse is regarded as adequate.
In the penetrating injuries of torso, however, there is evidence
that suggests aggressive fluid resuscitation is detrimental to
outcome by increasing the mortality. Patients perfusion and
metabolic status can be monitored using clinical parameters
such as pulse, blood pressure, mental status, etc. However,
clinical monitoring may be difficult and unreliable in
patients with severe circulatory compromise. Under these
circumstances, measurement of end tidal carbon dioxide
measurements (ETCO2) may be a very useful adjunct, to
monitor perfusion especially in those who are already
intubated. ETCO2 measurements provide reliable noninvasive indicator of correct positioning of tube and changes
in cardiac output and tissue perfusion.
Key Points in Prehospital Fluid Administration of
Trauma Patients

IV Access should be performed en route where possible

Only two attempts at IV access should be made
Transfer should be delayed due to attempts to gain IV access
Entrapped patients require cannulation at the scene
Normal saline is recommended as a preferred fluid for
administration
Boluses of 250 ml may be titrated against the presence or
absence of radial pulse (caveats: penetrating torso injury,
head injury, infants).

In addition, attempts at gaining onsite IV access may

delay the transfer to trauma center and thereby delaying the
definitive treatment. A Cochrane review of randomized
controlled trials performed recently showed no evidence to
support the use of early or large-volume intravenous fluid
replacement in patients with uncontrolled hemorrhage.10
Most of the current literature indicates that measures
employed to normalize the blood pressure in hemodynamically unstable patients can be counterproductive. Not

Prehospital Care for Orthopedic Trauma: The Developed Countries Perspective

all the trauma patients require volume replacement in the

prehospital setting. Certain groups of patients may benefit
from volume replacement at the scene of injury such as
prolonged extrication procedures, elderly with coexisting
cardiac problems. The need for prehospital fluid resuscitation
is determined by the injuries with ongoing hemorrhage
rather the mechanism of injury per se.
Management of Spinal Injuries

The incidence of spinal cord injuries is about 40 to 50 cases

per million people per year. Spinal cord trauma due to acute
injury is responsible for 3 percent of all trauma admissions
and half of these injuries involve cervical spine with risk of
quadriplegia. About 5 percent of the cervical spine injuries
are reported to have either missed or delayed diagnosis.
15 percent of patients with injury to the body above the
level of clavicle are associated with cervical spine injury.
Approximately 50 percent spinal fractures occur in cervical
spine and the remainder in thoracolumbar spine. Spinal
injury should be suspected in every trauma patient and
excluded by clinical and radiological assessment. The risk
of missing a cervical spine injury is more in patients with
multiple injuries and altered level of consciousness.
The aim of prehospital spinal immobilization in the
prehospital setting is to restrict the mobility of the spine to
prevent secondary spinal cord injury during extrication,
resuscitation, transport and assessment of the trauma patient
with potential spinal injury. Prehospital spinal
immobilization should be employed in all patients with
suspected spinal injury; rigid cervical collar and sand bags
for cervical spine and spinal board for thoracic and lumbar
spine. Patient should be immobilized in the supine position
and neutral alignment, avoiding any rotation or bending of
the spine. Restless or violent patients with a suspected spinal
injury may require use of a sedative or short acting paralytic
agent to prevent any further damage to the spine. However,
spinal immobilization is not without any complications.
Rigid cervical collars are known to cause complications such
as increased intracranial pressure, risk of aspiration, restricted
respiration, dysphagia and pressure sores. Prolonged
immobilization on spinal boards for suspected thoracic and
lumbar spine injuries is painful and can cause severe
decubitus ulcers commonly at occiput and sacrum.
Therefore, spinal boards should be used only for
transportation of patient and should be removed as quickly
as possible after assessment by the specialist. It is advised to
not leave the patient longer than two hours on spinal boards

21

to prevent decubitus ulcers. The ATLS principle of Airway

and Cervical spine control should also be applied in the
prehospital setting. However, in the presence of suspected
cervical spine injury, endotracheal intubation should be
carefully performed by a competent person, while
maintaining in-line stabilization, to prevent any secondary
spinal cord injury.
Oxygenation is another important aspect in the
prehospital trauma care of spinal injury. Oxygenation helps
to prevent hypoxia and secondary spinal cord injury. Oxygen
could be delivered by mask or endotracheal tube if the patient
is already intubated. It is also important to prevent hypoxia
from hypovolemia for the same reason. Despite widespread
use of spinal immobilization, its role in prehospital setting
has been questioned. However, a WHO committee on
prehospital trauma care remains uncertain about the effects
of prehospital spinal immobilization. It states because
airway obstruction is a major cause of preventable death in
trauma patients, and spinal immobilization, particularly of
cervical spine, can contribute to airway compromise, the
possibility that immobilization may increase mortality and
morbidity cannot be excluded.
Key Points for Spinal Immobilization

Spinal fracture is presumed to be present in all trauma

patients, especially those with multiple injuries and altered
level of consciousness
Cervical collar, head blocks, and tape for C-spine and long
spinal board for thoracolumbar spine are widely used
Spine should be immobilized in supine and neutral position
Beware of complications of these devices, especially the
airway compromise by the cervical collar
Patient should not be on the spinal board longer than
two hours

Pain Management

Pain relief is an important and compassionate aspect of

prehospital trauma care. Unfortunately, the pain relief in
the prehospital setting often goes unnoticed, under-treated
or both. This may be partly due to the fact that other ongoing
clinical problems take priority over the pain relief or the
paramedics may not have authority to prescribe drugs.
Isolated hip fractures in elderly are one of the most common
orthopedic emergencies encountered by the EMS personnel.
However, only a small proportion of these patients receive
prehospital analgesia for this painful condition. In a patient
with isolated extremity fracture, every effort should be made

22

First Aid and Emergency Management in Orthopedic Injuries

to provide adequate pain relief as a part of prehospital trauma

care. In a patient with multiple injuries, the main aim should
be to transfer the patient to hospital swiftly while providing
the standard prehospital care.
The strategies of prehospital pain management are; nonpharmacological and pharmacological therapies. Splinting
and immobilization is very effective form of pain relief for
long bone and spinal fractures. Rest, Ice, Compression and
Elevation (RICE) therapy may be a useful adjunct in pain
relief of musculoskeletal injuries. In the pharmacological
therapy, centrally acting opiate analgesics are commonly
used. Morphine or their derivatives are commonly employed
and are usually administered intravenously. Caution should
be exercised when opiates are used in presence of head injury
and its side effects such as respiratory depression.
Intramuscular administration of drugs is generally avoided.
Entonox gas, mixture of nitrous oxide with oxygen at a 50:50
ratio, is a safe and effective analgesic in pain management
of prehospital trauma care.

CONCLUSION
Prehospital trauma care is continuously evolving specialty.
There are no universally accepted guidelines to deliver this
care. The main aim is to promote oxygenation and
preservation of blood clot with rapid transport of the patient
to a hospital with appropriate facilities to provide definitive
care. Management of obstructed airway takes top priority
as it is the major cause of preventable death in trauma. Fluid
replacement in prehospital care continues to be a source of
controversy and should be used with great caution in patients
with head injury and penetrating injuries. Supplemental
oxygen should be given to all trauma patients and hypoxia
should be avoided by administering 100% oxygen. Spinal
immobilization is widely practiced and secondary spinal cord
injury should be avoided. Pain relief is often neglected and
undertreated and appropriate pain relief should be
administered to all trauma patients.
Overall in addition to the qualitative aspects of prehospital care coordination with the intrahospital element
of the care is essential.
Funding of trauma care is another complex issue with
the trend in recent years shifting this responsibility to
insurance companies rather than being state funded.

Obviously having a service that is free at the time of

provision with no preconditions is the ideal the complexities of healthcare funding and the lack of budgetary
funding may prove barriers that need crossing in the not
too distant future. The alternative to State funding is for
everyone to be insured which is unlikely to happen which
is then likely to lead to a division between the haves and
have nots.

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