You may be involved in pre-hospital care, for example, during shifts in the ambulance, as a sports physician or if a mass casualty occurs. It is therefore useful to know what is (and what is not) advised during pre-hospital care.

In pre-hospital care, stick to the XABCDE structure, as described on the Primary survey page. This is set up to save life and limb.

Initial assessment at the scene

At the scene, it is important to check your own safety first, before doing anything else. The abbreviation DRS XABCDE is often used. DRS means:

• Danger
• Responsiveness
• Shout for help

If there is more than one patient, use a triage system to see who you attend to first. You can use mass casualty triaging to do this.

Stop the bleeding

Management of external bleeding is part of the XABCDE treatment³. Depending on the severity of the bleeding, you treat it before or after making sure you have proper oxygenation.

To achieve hemostasis there are multiple options available:

Pressure & elevation 

Direct pressure to a wound can be enough to reach hemostasis. This works best when combined with elevation to reduce blood flow to the limb by means of gravity.

Packing

If pressure and elevation fails, you can pack the wound with, for example, gauzes and apply a tight bandage. If blood still soaks through this bandage, add the Windlass technique.

Windlass technique

Apply a second bandage over the wound, with the knot on top of the wound. Insert a straight strong object in the knot (e.g. a pen or wooden stick) and start twisting to tighten the bandage, in a similar fashion to a tourniquet. Check the distal arterial pulse, if the pulse disappears, loosen the bandage. If the wound starts bleeding again after loosening, this means the Windlass needs to function as a tourniquet.

Tourniquet

If the previous techniques do not work, apply a tourniquet proximal of the injury. In practice, a tourniquet is seldomly needed. Most bleedings can be stopped by direct pressure on the wound and a well placed bandage. Applying a tourniquet for too long can be dangerous as the risk of nerve injury and muscle necrosis increases significantly when kept in place for more than two hours.

Note the date and time of application of the tourniquet, since it is important for the healthcare workers in hospital to know the avascular time of the distal limb. A tourniquet can be applied for a maximum of two hours before the tissue becomes necrotic.

Reduction of the fracture

Repositioning the limb back into an anatomical position may help reducing a fracture if dislocation is present. Repositioning may help to:

• Reduce pain - Correcting the position of the limb reduces tension and results in pain relief.
• Reduce further soft-tissue injury - Persistent tension from a severely displaced limb can place significant pressure on the skin and surrounding tissues. If this persists, an initially closed fracture may progress to an open fracture. Early realignment helps limit ongoing tissue trauma.
• Reduce ongoing blood loss - Realigning of the limb may decrease bleeding from bone and soft tissues.
• Restore distal perfusion - A displaced fracture can compress a blood vessels. When distal perfusion is absent, gentle realignment may relieve this obstruction and improve blood flow.

If you notice a dislocation, always check for distal arterial pulse before reduction. Reduce the fracture and check distal vascularization again. If it was present before reduction but not after reduction, then you have to put the limb back into the dislocated position. If arterial pulsations do not return, transport to hospital quickly, because time is essential for limb survival.

Splinting 

In order to maintain the limb in an anatomical position, external support can be applied. Splinting stabilizes the reduced fracture, reduces pain, relieves pressure on the surrounding soft tissues and skin, may reduce blood loss, and can improve distal perfusion.

Traction splinting is mainly done for lower extremities, and it can only be done if there is not an accompanying ankle fracture on the ipsilateral side.¹

Thomas splint

Before splinting, you need to consider if it will prolong the prehospital time. It may sometimes be quicker to transport the patient directly to a hospital. If the travel time to a healthcare facility is long, it is better to splint before departure.⁴

If you have no splints available for lower extremities in the pre-hospital setting, it can help to tie one leg to the other for splinting support.

Analgesia

The main reason to provide analgesics is to make the patient more comfortable. If the patient is tachycardic, adequate pain control may also help lower the heart rate.

Please see the adviced pain medication schedule on the initial evaluation and management in open fractures in the ER page. Strong opiods are adviced as a first choice.

Pre-hospital antibiotics

The time between accident and the first dose of antibiotics is an indicating factor for developing a fracture-related infection later on. For Gustilo Anderson Grade 3 open fractures, administration of antibiotics within 60 minutes of injury significantly reduces the risk of developing an infection.²

We recommend to administer first generation cephalosporin antibiotics as soon as possible. However, the choice of antibiotics should follow local protocols based on local resistance patterns. For an extended explanation see Initial evaluation and management in open fractures in the ER page

Although antibiotics should be given as soon as possible, this should not delay transport to a healthcare facility. Always treat life threatening injuries first through the ABCDE system before focusing on antibiotics.