Trauma Management: Hemorrhage Control, Splinting, and Spinal Motion Restriction

Trauma Management: Hemorrhage Control, Splinting, and Spinal Motion Restriction

Trauma remains a leading cause of preventable death in the prehospital setting. Three skills form the backbone of field trauma care: controlling life-threatening bleeding, stabilizing injured extremities, and protecting a potentially injured spine. Mastering each technique—and knowing when to use it—is required for both NREMT certification and safe patient care.

Hemorrhage Control

Why it matters. Uncontrolled external hemorrhage from an extremity can cause death within minutes. The sequence of interventions moves from least to most invasive based on severity.

Tourniquets. A commercial windlass tourniquet (such as the CAT) is the first-line intervention for life-threatening extremity bleeding that cannot be controlled by other means, or when direct pressure is impractical (multiple casualties, unsafe scene). Apply the tourniquet approximately two inches proximal (above) the wound on the limb, not over a joint. Tighten the windlass until bleeding stops—not just until tight—then lock the windlass and secure it. Write the exact time of application on the device. Never remove a tourniquet in the field once applied. Document application time and relay it during your hand-off report, because prolonged tourniquet time affects limb viability.

Wound packing. For wounds where a tourniquet cannot be placed (junctional wounds such as groin or axilla) or as an adjunct for deep cavity wounds, pack hemostatic gauze directly into the wound cavity. Use a single continuous length of gauze, packing tightly and methodically from the deepest point outward. Apply firm direct pressure with both hands for the time directed by the product or protocol—typically several minutes. Hemostatic gauze accelerates clot formation but pressure is still essential.

Pressure dressings. For moderate bleeding or after wound packing, apply a pressure dressing (such as an Israeli-style emergency bandage). Secure firmly over the wound; some designs include a built-in pressure bar. Check the dressing for saturation and re-enforce rather than replacing if it bleeds through.

Safety point. Always use body substance isolation (gloves at minimum) before contact with blood or body fluids.

Splinting Long-Bone Fractures

Splinting reduces pain, limits further soft-tissue injury, and decreases blood loss at fracture sites. Before and after every splint application, assess and document PMS: Pulse, Motor function, and Sensation distal to the injury. Any deterioration after splinting requires immediate reassessment and splint adjustment.

Traction splint (femur fractures). A suspected mid-shaft femur fracture is one of the few indications for a traction splint. The device applies gentle longitudinal traction, reducing hemorrhage into the thigh and relieving muscle spasm pain. Contraindications include injuries at or near the knee or ankle, hip fractures, and open fractures with bone protruding. Secure the proximal ischial strap, apply the ankle hitch, extend the device to apply mechanical traction until the patient reports pain relief or until the limb length approximates the uninjured side, then secure the leg straps. Recheck PMS.

SAM splint (forearm or other long-bone injuries). Mold the aluminum-core SAM splint to the natural contour of the limb in a position of function or in the position found (if the limb is severely angulated, attempt gentle longitudinal traction only if distal PMS is absent and local protocol permits). Pad bony prominences. Secure with roller bandage; do not wrap so tightly that circulation is impaired.

Improvised splints. When commercial devices are unavailable, rigid materials (boards, rolled magazines, cardboard) padded with soft material can immobilize a fracture. The principle is the same: immobilize the joint above and the joint below the fracture site.

Safety point. Never force a severely angulated fracture into alignment unless there is absent distal pulse and transport time is prolonged—follow local protocol and medical direction.

Spinal Motion Restriction (SMR)

Modern EMS practice has moved from routine spinal immobilization to selective spinal motion restriction based on mechanism-of-injury assessment and clinical criteria. You must be able to verbally clear or identify indications for SMR.

Mechanism and assessment. Indications for SMR include significant mechanism (high-speed MVC, fall from height, axial loading), midline spinal tenderness, neurological deficit, altered mental status, or distracting painful injury. If the patient is alert, oriented, has no midline tenderness, no neurological symptoms, and no distracting injury, many EMS systems allow clinical clearance without full immobilization—always follow your medical director's protocol.

Cervical collar. Measure and apply a correctly sized rigid cervical collar before moving the patient when SMR is indicated. A collar that is too large hyperextends the neck; one that is too small provides no stability.

Long backboard with log-roll. For a supine patient, a three-rescuer log-roll maintains spinal alignment while a board is positioned. One rescuer controls the head and directs the team; the others manage torso and legs. Straps are applied at the chest, hips, and legs. Pad voids (cervical, lumbar) to prevent movement.

Standing takedown. For an ambulatory patient with suspected spinal injury, three rescuers guide the patient to a supine position on the board using a controlled standing takedown, maintaining manual in-line stabilization throughout.

KED (Kendrick Extrication Device). Used for a seated patient (typically in a vehicle). Apply the cervical collar first, then insert the KED behind the patient, secure the torso flaps, then leg straps, then head straps. The KED stabilizes the thoracolumbar spine during extrication to a long backboard.

Safety point. Manual in-line stabilization must be maintained without interruption until the patient is fully secured. Never release manual stabilization to apply a collar or strap.