SWORBHP Ask MAC

Answer: Thanks for your question. SWORBHP was told by MOHLTC to cease distribution of the app due to their concerns surrounding the distribution of MOHLTC material via electronic platforms that they did not create themselves. We are very happy that you liked the apps especially given how much time and effort we invested into their creation! Thank you!

We have been in regular contact with MOHLTC seeking approval for the re-release of these apps and have met with recurrent delays. As soon as MOHLTC provides us with direction on this issue, we will be very pleased to provide the apps to you ASAP.

Answer: Thanks for the question. The intent of the ASKMAC website was originally to address issues that relate to the Advanced Life Support Patient Care Standards and areas that traditionally require oversight by Regional Base Hospital Programs. It is interesting that a large percentage of ASKMAC questions actually pertain to the Basic Life Support Patient Care Standards (BLS PCS). Despite this, we have endeavored to answer all questions that are brought to this forum.

As for your question relating to sager application, this is not our area of expertise similar to other devices a paramedic may utilize. As such we have reached out to our college colleagues for their advice.

Here is the answer from the manufacturer with the following contraindications:

• A fracture of the pelvis occurring with a fracture of the femur
• Supracondylar fractures of the distal end of the femur
• Compound fractures of the femur
• Fractures of the ankle and foot

Reference: (2014). Sager Emergency Fracture Response System. Retrieved April 23, 2014 from http://www.sagersplints.com/pages/home.html.

Here is the answer from Fanshawe College who provides initial education for some paramedics in the region:

During initial education we reference several sources of information for students regarding the guidelines, precautions and contraindications of this traction splint.

1. The BLS Patient Care Standards has references in several areas to traction splint in general with the recurring guideline to “weigh the application time for traction splints at the scene against the need for rapid transport.” BLS PCS Appendix 91: Trauma Care – Pearls. Clinically it makes sense to apply a traction splint to a stable patient with an isolated single femur splint on the scene. However in the setting of bilateral femur fractures or multi-system trauma the Paramedic is encouraged to apply the traction splint enroute to the lead trauma centre or appropriate local facility.

2. The MOH EHS Equipment Manual (page 93) includes the following precautions:

iv) in the event of groin injury, the splint may be applied to the outside of the leg.
v) The elderly may not tolerate traction well, especially if there is a pre-existing condition such as arthritis or joint tenderness”

3. The manufacturer’s instructor manual for the Sager Traction Splint (page 36) offers the following contraindications:

A fracture of the Pelvis occurring with a fracture of the Femur is generally a contraindication for the use of a traction splint of any type.

Supracondylar fractures of the distal end of the Femur are contraindicated because traction can cause anterior rotation of the distal bone fragment – forcing the sharp fractured bone end down into the Popliteal Artery and Nerve. These fractures should be splinted as found.

Fractures of the Ankle and Foot are also contraindicated. Pressure from the ankle harness and from traction is not therapeutic.

Compound fractures of the Femur with bone fragments sticking through the skin may be a contraindication. Guidelines by local protocol or instructions by a Medical Consultant should be followed.

Our teaching regarding compound femur fractures is to use the traction splint without applied traction to stabilize the long bone fracture if possible.

The BLSPCS Extremity Injury – Bone/Joint regarding management advises:

2 ii. Prior to splinting leave protruding bone ends as found; if ends remain visible after manipulation/in-line traction, cover ends with extra dressings and/or padding. Upon arrival, advise receiving staff that protruding bone ends were retracted during splinting (where applicable).

The SWORBHP Medical Council would advise paramedics to review their service policies as with any equipment they are supplied as well as follow the Basic Life Support Patient Care Standards from the MOHLTC.

Answer: Thanks for your question. This is very similar to another ASKMAC question posted on Sept 4, 2012.

This exact scenario was actually the focus of a live rounds discussion on MCI patient management last year.

The power point and Webinar can be found on our website here under MCI Jan 2011:
www.lhsc.on.ca/About_Us/Base_Hospital_Program/Education/archived_rounds.htm

What we would suggest is to first consider your triage scheme. In mass casualty triage, your resources are overwhelmed (10 patients and one paramedic crew). In this circumstance and triage mode, your care must be directed to the most injured patients who have the highest chance of survival (not the VSA patients initially). Once however more crews arrive, your resources will no longer be overwhelmed and you should now revert back to multiple casualty triage where your care is now directed to the patients who are most unwell.

In the scenario you describe, this would now mean that (once you have adequate resources) you attend to the patients who are VSA assuming that they do not meet the criteria for obviously dead. These patients require assessment regardless as they have not been pronounced, and the trauma TOR would most likely be the result. The alternative would be to leave three patients VSA on scene who have had no medical assessment or pronouncement and this would not seem reasonable.