Management of the Mangled Extremity
Annotation for Point C
In the patient who remains hemodynamically stable, the most important initial step is to reduce the fractured bones using either splinting or traction fixation. This will alleviate kinking of the vasculature and improve subsequent perfusion and permit better assessment of the bony and soft tissue abnormalities. Adequate analgesia is crucial to achieving good bony alignment in a humane manner. Repeat doses of fentanyl, in 25 microgram IV aliquots, may facilitate the performance of bony manipulation. When using this approach, blood pressure and respiratory status should be assessed at regular intervals to insure that cardiorespiratory depression because of narcotic use is avoided. Induction of anesthesia and endotracheal intubation may be required.
Level of Supporting Evidence: Level 4