Update: BOAST Guidance
If a patient with a #NoF (or other fragility fracture requiring admission) has received a head injury requiring CT a CT Neck should also be performed. A #NoF is a fragility fracture hence this patient is at high risk of also sustain C-Spine injury. Also the pain is likely distracting and the patient is often over 65yrs old so Canadian C-Spine rules will not apply.
Hx/Exam
- Why did They Fall? – was this a collapse?
- Are they sick? – Co-morbidity/illness is common in this group and must be recognised
- Anticoagulants? – This affects treatment
- On Warfarin – If INR >1.5 (or unavailable) Vit-K 5mg
- Other injuries? – >65’s the most common mechanism of TARN major trauma is fall <2m
- Typically – Pain hip/buttock, shortened, externally rotated
- Atypical – Few signs (can they lift their leg & is rotation at the hip painful)
Investigations
- X-ray (Hip, pelvis, CXR)
- X-ray femur if pathological
- Bloods: FBC, Clotting, Group/Save, U&E, Bone profile
- ECG
- CT Head & Neck: if the patient requires CT Head, a CT Neck should also be performed [BOAST Guidelines]. #NoF is a fragility fracture and painful, hence not only is the patient at a high risk of C-Spine fracture if they receive a head injury but also has a distracting injury
On EPR all required investigations can be found on the: Adult NoF order set
Analgesia
These are generally frail elderly patients, and OPIATES have been show to both significantly INCREASE MORTALITY & TIME TO RECOVERY
- IV Paracetamol should be first line
- Use Opiates sparingly
- Perform Femoral Nerve Block (FNB)
FNB, can reduce pain for the patient for many hours and often upto the point of operation. It reduces opiate requirements, and aids recovery.
Femoral Nerve Block
- Trained operator
- Ultrasound guided
- Aseptic
- Use Nerve block needle
- Recommended mix:(patients prefer this to levobupivacaine only)
- 10ml 2% Lidocaine & 10ml 0.25% Levobupivacaine
- Adjust dose to weight
- Document – ADHOC > ED procedure
- Post-Block
- Obs. every 5min (for 15min)
- 3 Lead ECG
- BP
- SaO2
- Symptoms of Toxicity – Use LA-toxicity Guide
Nerve block for Kids
- Consent child and parent as appropriate
- Nasal Diamorph – they will need it and it removes the need for lidocaine in the block (as long as done within 30min)
- Nerve block mix – MAX: 1ml/kg 0.25% Levobupivicaine (i.e 2.5mg/kg) – however only need to flush around nerve as adult.
