EMT: Soft-Tissue and Musculoskeletal Trauma

In depth

The one-page summary above is what the PDF prints. These sections go further.

Bleeding control: why the order matters

The ACS Stop the Bleed program teaches three basic actions because bleeding is the leading preventable cause of death after injury. NASEMSO starts every trauma assessment with massive hemorrhage (the M of MARCH) and sweeps the back as well as the front. Direct pressure and a pressure dressing come first. A commercial windlass, ratcheting or pneumatic tourniquet follows when pressure fails or cannot be held, for example with several patients or a long carry. Narrow elastic or bungee devices do not reliably stop arterial flow, and an improvised tourniquet is used only when no commercial device is available; if a bystander placed one, a commercial tourniquet goes on above it.

A tourniquet applied too loosely can block veins without stopping arterial flow, and the 2025 scoping review lists venous occlusion and worse bleeding among the problems of misapplied devices; NASEMSO therefore has it tightened until the bleeding stops and the distal pulse is gone. A properly tight tourniquet hurts: treat the pain (Paramedic analgesia), never by loosening. Packing is for junctional wounds (groin, axilla) and for limb wounds still bleeding after pressure or tourniquets. Gauze goes to the bottom of the wound, around any bone fragments or foreign bodies, and pressure is held on top; packing is not pulled out to look. Arterial pressure points may slow bleeding while a tourniquet is readied but do not control it reliably.

Mark the time on the patient and in the report, keep the tourniquet visible, tell every clinician who takes over, and recheck for blood soaking through or bleeding below the tourniquet at each move. Converting or removing a tourniquet is not an EMT field task. A 2023 proposal from a mixed military and civilian author group (not a consensus statement) would aim to convert within 2 hours where other means can control the bleeding, attempt conversion when the tourniquet has been on under 6 hours, and leave it in place beyond 6 hours or while the patient remains in shock. NASEMSO says not to release a properly applied tourniquet until the patient reaches definitive care. A 2025 scoping review found nerve palsy, compartment syndrome and amputation after tourniquet use, with longer and tighter use linked to more complications; amputation tracked injury severity more than the tourniquet itself.

Children: commercial tourniquets work on most children over 2 years; direct pressure and packing may suit infants better, and a small blood volume makes early control critical. Paramedic: TXA within 3 hours of injury for hemorrhagic shock, fluids and blood are on the Trauma: Primary and Secondary Survey page.

Wounds: types and dressing

Closed injuries keep the skin intact: contusions (bruises), hematomas (pooled blood under the skin or in muscle) and crush injuries. Open injuries break it: abrasions, lacerations, avulsions (a flap torn loose), punctures and amputations. A dressing covers the wound and a bandage holds it; dressings are sterile and bandages snug but not constricting. Wet or blood-soaked clothing is removed and the patient kept warm.

Classic teaching: an avulsed flap that is still attached is laid back in its normal position, covered and pressed; a degloved sheet of skin is preserved, laid back and kept moist; a partial amputation is splinted in anatomic position and never completed in the field. NASEMSO adds that torn ear and nose cartilage gets a moist sterile dressing, while completely avulsed ear or nose tissue travels in dry sterile gauze in a plastic bag on ice.

Amputated part: NASEMSO says cool but dry, in a plastic bag placed on ice in a second bag, never touching the ice, and always transported with the patient. Some protocols lightly moisten the gauze with saline; follow local protocol, but never submerge the part in water or saline or put it straight on ice. Label it with the patient and time.

High-pressure injection (paint, grease, hydraulic fluid): pressures often exceed 100 psi through a pinpoint, sometimes almost invisible, wound. Early pain and swelling can be mild, so patients and clinicians underestimate it. Amputation rates of 30–48% are reported, up to 80% with oil-based paint, and outcomes are best with diagnosis and surgery within about 6 hours. Splint, elevate, and send the patient now to a center with hand surgery, with the product name.

Impaled objects, eviscerations and open chest wounds

An impaled object may be tamponading the vessel it tore, so it stays in. Bulky dressings around it stop it moving; long objects are shortened only by rescue crews with the embedded part held still. Classic exceptions: an object through the cheek that blocks the airway (removed, then the cheek packed inside and pressed outside) and an object that prevents chest compressions.

Eviscerated bowel is covered with sterile dressings moistened with saline, then an occlusive layer to hold moisture and heat. Nothing is pushed back. Classic teaching: if the spine allows, flexing the hips and knees eases tension on the abdominal wall. Treat for shock and transport rapidly.

NASEMSO calls for a semi-occlusive dressing over an open chest wound. A sealed wound can still develop tension: worsening breathing, falling SpO2 and shock after a seal mean burp the dressing and call for decompression. The signs and interventions are on Trauma: Primary and Secondary Survey.

Face, eye and mouth

NASEMSO puts the airway first in facial trauma: an unstable midface or mandible, loose teeth and blood can all block it, and teeth not found on scene may be in the airway. A patient with an unstable jaw cannot spit or swallow well; if spinal-care criteria are absent, transport sitting up with suction and an emesis basin. Avoid nasal airways with facial injuries.

Eye: any significant eye injury gets a rigid shield. A penetrating object is left in place and stabilized, and the uninjured eye is covered (or kept closed) because the eyes move together. An avulsed globe is not pushed back; the socket gets moist saline dressings and a shield. Nausea and vomiting raise eye pressure, so Paramedics consider an antiemetic.

Nose: squeeze the soft part continuously for 10–15 minutes with the patient sitting and leaning forward, not lying down or tilting back. After a nasal fracture, bleeding may be posterior, run down the throat and not respond to pressure. Teeth: pick up by the crown, do not wipe the root, rinse under cold water for 10 seconds if dirty, and store in milk or saline; an alert, cooperative patient can hold it in the mouth.

Splinting in depth

Merck: splint moderate to severe or unstable fractures promptly to reduce pain and further soft-tissue damage, immobilizing the joints above and below; splinting long-bone fractures may help prevent fat embolism. Splints are not circumferential, so they allow ice and some swelling. NASEMSO asks for vascular status (pallor, pulse, capillary refill, skin temperature) and neurologic status (light touch, movement) before and after any manipulation or splinting, and documentation of both.

Splint as found unless distal circulation is compromised; then one gentle attempt to restore normal anatomic position, followed by a perfusion check. Stop if resistance or pain increases (classic teaching). If a hand turns pale and pulseless after splinting, the splint is too tight or the position pinches the vessels: loosen, readjust, recheck. Classic splint choices: sling and swathe for shoulder, clavicle and upper arm; rigid splints for forearm and lower leg; pillow splints for ankle and foot; a vacuum splint or mattress conforms to angulated limbs.

Cold packs limit swelling (Merck: 15–20 minutes at a time over the first 24–48 hours, never on bare skin), and NASEMSO elevates extremity fractures above the heart when possible. A limb with suspected compartment syndrome is the exception: reviews (Donaldson 2014, Sonawane 2022, Rossie 2026) keep it level with the heart and not raised, because elevation lowers arterial inflow and narrows the arterial-venous pressure gradient. Routine fracture elevation is fine; heart level applies once compartment syndrome is suspected. Paramedics strongly consider analgesia before moving a suspected fracture.

Open fractures: control bleeding with pressure around the bone, cover with saline-moistened gauze, and splint. Classic teaching: bone that slips back under the skin during realignment is reported, because the wound is contaminated. In hospital (Merck): tetanus prophylaxis, early IV antibiotics (for example within 1 hour of emergency department arrival) and surgical irrigation and debridement.

Dislocations by joint

Merck: a deformity the patient or bystanders describe that is gone on arrival is assumed to be a dislocation that reduced on its own. Dislocations, especially if not reduced quickly, carry more vascular and nerve risk than fractures, and knee and hip dislocations can cause distal ischemia that stays clinically hidden for hours. Field care is splinting as found with repeated distal checks; reduction happens in hospital unless protocol allows one attempt for a pulseless limb with a long transport.

Knee: popliteal artery injury is suspected whether or not ischemia is evident, and normal pulses cannot exclude it; the peroneal nerve is the nerve most often hurt. Compare pulses, color, temperature and capillary refill in both feet. Hip: most dislocations are posterior, from the knee striking the dashboard with hip and knee flexed; the leg is shortened, adducted and internally rotated; the sciatic nerve is at risk, and reduction preferably within 6 hours lowers the risk of femoral head necrosis. Anterior hip dislocation holds the leg abducted and externally rotated. Shoulder: at least 95% are anterior; the arm is held slightly out from the side, and decreased sensation over the deltoid suggests axillary nerve injury.

Classic teaching: an older adult with a hip fracture after a fall often has a shortened, externally rotated leg; pad and immobilize as found (pillows or a scoop), no traction splint, and look for the medical cause of the fall.

Traction splints and pelvic binders: evidence

StatPearls recommends traction splints for midshaft femur fractures; they are thought to relieve pain, limit damage from bone ends and shrink the space the thigh can bleed into, though a 2020 cohort could not confirm outcome benefits and found that injuries complicating or contraindicating their use are common in multisystem trauma. No open guideline or review found gave a contraindication list (the 2020 cohort says only that coexisting injuries that complicate or contraindicate use are common). The classic list is therefore labeled as such. A 2009 JEMS article names suspected pelvic or hip fracture, avulsion or amputation of the ankle or foot, and knee fractures, and advises against traction near any open fracture or within a short distance of a joint. Because traction pulls through the hip, knee and ankle, services also commonly rule out a same-side lower leg injury and partial amputation (the EMT item emt-tra-14 lists these as well), but that part is reasoning and local protocol, not a cited guideline. Distal pulse, motor and sensation are checked before and after. NASEMSO asks for medical direction before traction splinting a young child.

Pelvic compression devices are applied on suspicion (mechanism, pain, bruising, instability, shock) because examination is unreliable. A 2020 rapid review found biomechanical benefit and some cohorts with less transfusion, but no high-level evidence of lower mortality, and it warned that springing the pelvis can dislodge clots. NASEMSO palpates once with gentle medial pressure on the iliac crests and binds an unstable pelvis with a binder or sheet. Correct level is over the greater trochanters (see Trauma: Primary and Secondary Survey).

Compartment syndrome and crush injury

Compartment syndrome: pressure inside a closed fascial space rises until it stops capillary flow. Causes include fractures, contusions, crush, reperfusion, tight casts and bandages, and prolonged compression of a limb in a patient lying unconscious (overdose, intoxication). The first symptom is pain out of proportion to the injury, worse on passive stretch; the compartment feels tense; paresthesia follows. Pallor, paralysis and pulselessness are late, and perfusion fails long before the pulse goes, so a palpable pulse does not exclude it. Remove anything constricting and transport for fasciotomy, a surgical emergency.

Crush injury: prolonged compression of a large muscle mass. The patient may look well while trapped. Release can cause reperfusion syndrome: sudden hypovolemia, hyperkalemia and lethal arrhythmia, then kidney injury later. Dark, red or cola-colored urine signals rhabdomyolysis. EMT (classic teaching, matching the EMT items; NASEMSO writes the fluid step for IV-capable clinicians): control bleeding, oxygen, warmth, call ALS early and, when the scene is stable, time release for their arrival. Paramedic (NASEMSO): IV normal saline 1 L before release (avoid lactated Ringer, which contains potassium), cardiac monitor and 12-lead before and after release, then fluids and hyperkalemia treatment per protocol.

Mechanism of injury and field triage

Classic kinematics: every crash has three impacts (vehicle into object, occupant into vehicle, organs into the body wall). Frontal, down-and-under: the knees strike the dash (patella, femur, posterior hip dislocation, knee dislocation). Frontal, up-and-over: head into windshield, chest and abdomen into the steering wheel. Side impact: near-side chest, abdomen, pelvis and lateral neck flexion, with little door protection. Rear impact: the head lags into hyperextension then flexes; note the headrest position. Feet-first fall: force travels up through heels, legs, hips and lumbar spine. Deformed steering wheel, starred windshield and dash damage predict injuries before the exam finds them.

Gunshot wounds: kinetic energy is half the mass times velocity squared, so speed raises energy fastest, and Baum describes the extent of damage from the temporary cavity as determined primarily by velocity and the tensile properties of the tissue; the same review finds classing bullets as high or low energy more useful than velocity alone, and says wounding depends on the structures hit. High-energy projectiles can open a temporary cavity 10–30 times the permanent track; fragments and bone splinters extend injury. Wound size misleads, and entry and exit sites are often misclassified, so count and describe wounds without labeling entry or exit.

Blast: primary injury is the pressure wave, which damages air-filled organs (the lungs most dangerously, and the eardrums; bowel in classic teaching), secondary is fragments, tertiary is the body thrown, and quaternary covers burns, crush and toxins. Blast lung symptoms can be significantly delayed, a 2011 review suggests enclosed-space explosions may explain the more severe lung injury seen in civilian blasts, and NASEMSO tells EMS to keep reassessing for blast lung and to prefer a trauma center. Eardrum rupture and deafness complicate the neuro exam. Watch for secondary devices.

2021 National Guideline for the Field Triage of Injured Patients, red criteria (highest-level trauma center) relevant here: penetrating injury to the head, neck, torso or proximal extremities; chest wall instability; suspected pelvic fracture; suspected fracture of two or more proximal long bones; crushed, degloved, mangled or pulseless extremity; amputation proximal to the wrist or ankle; active bleeding needing a tourniquet or wound packing with continuous pressure. Yellow criteria (trauma center): intrusion over 12 in at the occupant site or over 18 in at any site, extrication, partial or complete ejection, death in the same compartment, fall over 10 ft, pedestrian or cyclist thrown, run over or hit with significant impact, rider separated from a motorcycle or similar vehicle. The 2011 version used 20 ft for adult falls and speed thresholds.

Abdomen and closed injuries

In blunt trauma the spleen is the organ most often injured, then the liver. Left upper quadrant pain referred to the left shoulder points to splenic bleeding, and a splenic hematoma can rupture hours to months later. Solid organ injury typically bleeds; hollow organ injury (bowel, bladder) typically spills contents and causes peritonitis, though either can bleed. A chest wound below the fourth intercostal space (nipple line) is treated as a possible abdominal wound because the abdominal organs sit inside the chest during part of each breath. The EMT treats for shock and does not delay transport for a diagnosis.

Exam pearls

• Bleeding: pressure, then tourniquet, then packing for junctional wounds; time written, never loosened
• Impaled objects stay in; eviscerated organs stay out, moist and covered
• Amputated part: dry gauze, bag, bag on ice; never directly on ice
• Check pulse, motor and sensation before and after every splint
• Joints above and below a fracture; splint dislocations as found
• Traction splint: isolated midshaft femur only
• Pain on passive stretch with a pulse present can still be compartment syndrome
• Crush: release with ALS ready; the patient may look fine
• Read the mechanism, not the size of the wound