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CE ARTICLE Table II: Shock Classes and Estimated Blood Loss1 CLASS I Up to 750 Blood loss (mL) Pulse rate Blood pressure Pulse pressure Respiratory rate Mental status CLASS II 750-1500 <100 Normal Normal or high 14-20 Fluid replacement Crystalloid en route to the hospital to improve patient comfort and reduce soft tissue injury. The American College of Surgeons Committee on Trauma believes musculoskel- etal injuries cannot be ignored for treatment at a later time.1 Foregoing splint application causes patients to experi- ence increased pain because the loose bone ends continue to move freely against soft tissues, which increases the damage to these tissues. This can cause increased blood loss, damage to the neuro- vascular bundles and trigger a fatty embolism.3 Improperly applied splints tend to either be too large or too small, too loose or too tight. Applying too large of a splint, or one that is not adequately secured, provides ineffective splinting and has the same effect as no splint at all and the bone ends continue to move rela- tively freely as no support or protection is provided. Splints that are too small or too tight can cause ischemia distal to the splint which increases the patient's pain and can cause a buildup of acids in ischemic tissues. Assessment Evaluating a musculosk- eletal injury is important. Any life-threatening For More Information Circle 61 on Reader Service Card 38 FEBRUARY 2012 | EMSWORLD.com 100-120 Normal Decreased 20-30 Slightly anxious Mildly anxious Crystalloid CLASS III 1500-2000 120-140 Decreased Decreased 30-40 Anxious/ confused Crystalloid & blood hemorrhage present should have been managed in a primary assessment; severe hemor- rhages are best controlled with well-aimed direct pressure and take priority over injury stabiliza- tion. Begin assessing a muscu- loskeletal injury visually, looking for debris such as dirt, stick frag- ments, broken glass or stones that may have become embedded in the skin at the time of impact. Brush off these objects prior to applying a splint so they aren't ground deeper into the body from the splint's compressive effects. During this time also remove any clothing or jewelry on the injured extremity; folds and seams in clothing can rub against the skin if left inside of a splint, causing tissue breakdown and increasing opportunities for infection. Take note of any angulation or defor- mity. Table III identifi es common deformities seen in joint injuries. Next palpate the injury site for FAST FACT The goal of IO insertion is to place the distal tip in the bone marrow. Both red and yellow marrow can absorb fl uids and medications with equal effi cacy. crepitus. Crepitus is the sensation felt when bone ends grind together. Many clinicians do avoid palpating obviously fractured bones to avoid additional discomfort, and only touch the limb to realign it and apply a splint. Document any swelling that is observed as well. Rapidly progressing swelling is typically associ- ated with capillary or small vessel bleeding while swelling that develops over the course