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CE ARTICLE patient, it often is associated with an imme- diate signifi cant reduction in pain and decrease in anxiety. EMTs without rapid access to ALS providers capable of administering analgesia should not delay realignment. However, when capable, analgesia should be administered prior to realigning an extremity. Unfortunately, pediatric patients with trau- matic injuries have been found to be under- treated with analgesia in the prehospital environ- ment even though they often receive analgesia in the emergency department.4 This study found that only 21.9% of injured pediatric patients (and 26.3% of adult patients) received prehospital analgesia even though 79.4% of the patients ultimately received analgesics. the same study also found that among patients who did receive prehospital analgesia, addi- tional emergency department doses were often administered after the drug's half-life had passed. The authors concluded that prehospital analgesia is important and underutilized.4 This research is also supported by a study released at the 2012 NAEMSP assembly, which identifi es that paramedics see too many barriers toward administering analgesia to pediatric patients and encourages a cultural shift in promotion toward pediatric analgesia.5 Introducing intra- nasal atomized fentanyl has been shown to decrease paramedic discomfort with pediatric analgesia and leads to increased analgesic administration.6 Both morphine and fentanyl are accepted and commonly utilized for prehospital anal- gesia. Both drugs provide similar degrees of pain relief, though fentanyl requires a higher comparative dose than morphine.7 Fentanyl has been shown to be relatively free of side effects, and not cause hypotension, respira- tory depression, hypoxemia or sedation when administered with an initial dose of 1–2 micrograms per kilogram.8 Drs. Caroline Lee and Keith Porter published in the Journal of Emergency Medicine3 that in some cases, such as with entrapped patients, mangled extremities and complicated open fractures, a peripheral nerve block may be the analgesic of choice during prehospital care. They did acknowledge that this skill requires additional training and close monitoring; however, particu- larly for programs with extended transport times, it may be worth discussing introducing this safe and proven practice with a medical director.3 Whenever patients present with angulated Interestingly, or deformed musculoskeletal injuries, consider the administration of narcotic analgesia early during their patient care. While the routine administration of benzodiazepines for muscu- loskeletal injury care is not recommended, advanced life support providers can consider sedation when there is a need to straighten an extremely angulated fracture or dislocation.1 Sedation during extremity manipulation can provide the patient amnesia as some benzo- diazepines, such as midazolam, have amnesic properties. Benzodiazepines also help to relax spasming muscles so that straightening the extremity is easier. FAST FACT Open fractures should be realigned like any other fracture. All open fractures will have surgical debridement. Splint Construction Applying an effective splint is an essen- tial component of musculoskeletal injury management. Effective splints follow the principle of complete, compact and comfort- able. These three Cs are taught by Wilderness Medical Associates (www.wildmed.com) to fi rst responders who will not have access to any pre-made splints when they need to manage patients with musculoskeletal inju- ries. Following the 3 Cs, splints can be made of nearly any materials available, and can effectively immobilize an injury as well as any commercially made device. Complete splints are properly sized to immobilize the joints above and below frac- tured long bones and the long bone above and below injured joints. Most organiza- tions accept the joint above and below an injured long bone require immobilization. However, exactly what determines complete joint-injury immobiliza- tion is debated in some circles. One position states that splinting the long bone above and below the injured joint is acceptable and provides adequate stabi- lization. This position states it is reasonable, for example, when an elbow is injured, to allow wrist movement. However, the other position to this argument is not only do the long bones above and below the injured joint require immobilization, but that the next closest joints require immo- bilization as well. Thus this position would state when an elbow is injured, the wrist and shoulder require immobilization as well. The rationale for this position is that the associ- For More Information Circle 64 on Reader Service Card EMSWORLD.com | FEBRUARY 2012 41