In the Emergency Department (ED) lower leg immobilisation after injury is a necessary treatment but is also a known risk factor for the development of venous thromboembolism (VTE). This accounts for approximately 2% of all VTE cases which are potentially preventable with early pharmacological thromboprophylaxis.
We now have ORAL prophylaxis available!!
Penthrox is an inhaled, patient controlled analgesic for use with moderate to severe acute pain associated with trauma. Not to be used in atraumatic pain, chronic pain, children or pregnancy.
Rapid onset of analgesia lasting 25-60 minutes depending on rate and depth of inhalation. Wears off 10 minutes after last inhalation.
| Injury | ED Treatment | Discharge Pathway | |
|---|---|---|---|
| Clavicle | Adult – Undisplaced | Polysling/BAS | VFC |
| Adult – Displaced | Polysling/BAS | VFC | |
| Paediatric – Undisplaced | Polysling/BAS | Discharge sling for 2 weeks then Mobilise as pain allows Advice Sheet: HERE |
|
| Paediatric – Displaced | Polysling/BAS | Discharge | |
| Open #/threatened skin/Floating shoulder | Polysling/BAS | Ortho On Call | |
| Proximal Humerus # | Paediatric – Undisplaced/minimal displacement/angulation | Collar & Cuff | Discharge C&C for 2 weeks, mobilise as pain allows |
| Paediatric – Significant Displacement /angulation | Collar & Cuff | VFC | |
| Adult | Collar & Cuff | VFC | |
| Shoulder Dislocation-NO #! | First time & Recurrent | Reduce ED + Polysling | MSK shoulder Physio Clinic |
| Unreducible | Ortho On-Call | ||
| Fracture Dislocation | Greater Tuberosity # | ED Reduction- Polysling | VFC |
| Unreducible / Multi-fragmentary | Polysling for comfort | Ortho On-Call | |
| ACJ Dislocation | All Grades | Polysling /BAS | MSK shoulder Physio Clinic |
| Open Injury / Threatened skin | Polysling /BAS | Ortho On-Call | |
| Rotator Cuff Injury | Polysling/ BAS | MSK shoulder Physio Clinic | |
| Humeral Shaft (documentation of Radial Nerve function pre/post application of brace) | No Nerve Injury | Humeral Brace with Check XR | VFC |
| Radial Nerve Injury | Humeral Brace with Check XR | Ortho On-Call | |
| Injury | ED Treatment | Discharge Pathway | |
|---|---|---|---|
| Elbow dislocation | Reduce ED, Above Elbow Backslab | VFC | |
| Supracondylar # Distal Humerus (Paediatric) | Undisplaced | Above Elbow Backslab (>90 Degrees Flexion) Check XR in cast | VFC |
| Displaced | Above Elbow Backslab (Comfortable position) | Ortho On Call | |
| Paediatric Epi/condylar # | Undisplaced | Above Elbow Backslab | VFC |
| Displaced | Above Elbow Backslab | Ortho On Call | |
| Radial Head/Neck | Undisplaced / Minimally displaced | Collar & Cuff | Discharge |
| Comminuted/significantly displaced | Collar & Cuff (Above Elbow Backslab if pain ++) | VFC | |
| Paediatric Radial Head Subluxation (with Ulna Plastic deformation) | Above Elbow Backslab | VFC | |
| Olecranon | Undisplaced | Above Elbow Backslab | VFC |
| Displaced | Above Elbow Backslab | Ortho On-Call | |
| Fat Pad +ve Elbow | Collar & Cuff | Discharge – Encourage ROM, discard C&C as comfort allows |
|
| Injury | ED Treatment | Discharge Pathway | |
|---|---|---|---|
| Fingertip | Crush # Terminal Phalanx | ? Mallet splint to protect | Discharge |
| Nailbed | Wound Management | GP Practice Nurse Wound review | |
| Significant Soft Tissue Injury/? terminalisation | Plastics | ||
| Mallet Finger | Ext Tendon (No Bony Injury) | Well-fitting Mallet splint (Ensure allows PIPJ Flexion) 8/52 then 4/52 at night | Discharge |
| Avulsion # <50% Joint Surface | 6/52 then 4-6/52 night (XR in splint to ensure joint congruence) | Discharge | |
| Avulsion # >50% Joint Surface | 6/52 then 4-6/52 night (XR in splint to ensure joint congruence) | VFC | |
| Undisplaced Phalangeal # / Metacarpal # | Stable | Neighbour strapping 2/52 +/- Splint | Discharge |
| Concern over stability | Neighbour strapping 2/52 +/- Splint | VFC | |
| Displaced phalangeal # | ED Reduction N/S +/- Volar Slab (check Rotation) | VFC | |
| IP Dislocation | Extensor Mechanism - Intact (post reduction) | ED Reduction & NS | Discharge |
| Extensor Mechanism - Disrupted (post reduction) | ED Reduction & Capner Splint | VFC | |
| Metacarpal Neck # | Neighbour strap | Discharge | |
| Bennett’s/ 1st MC Basal # | Bennett’s Slab (Ensure IPJ Mobile) | VFC | |
| Scaphoid | Fracture Identified | Scaphoid Slab | VFC |
| Query Fracture | Scaphoid Slab/Splint | Face-Face # Clinic 2/52 post injury |
|
| Thumb MCPJ Injury | Stable | Splint | VFC |
| ? Unstable | Backslab | Face-Face # Clinic | |
| Volar Plate Injury (+/- Avulsion #) | Neighbour Strap 2/52 | Discharge Advice Sheet-HERE | |
| Minor Trauma Evidence of OA No # | Symptomatic Treatment ? Splint 2/52 | Discharge | |
| Paediatric Torus # Distal Radius | Futura splint 3-4/52 | Discharge Advice Sheet-HERE | |
| Paediatric Radius /Ulna | Undisplacd | AE backslab | VFC |
| Displaced/Angulated | AE backslab | Ortho On-Call | |
| Injury | ED Treatment | Discharge Pathway | |
|---|---|---|---|
| No Trauma | Symptomatic Treatment | Discharge | |
| OA | Symptomatic Treatment | Discharge | |
| Atraumatic Acute swollen Knee | Bloods Aspirate(Ortho) | Ortho On Call | |
| Tibial Plateau/ Femoral Condlye # | Immobilise | Ortho On Call | |
| Patella Dislocation | First Time – no OC# | Knee Splint WBAT | MSK Lower Limb Physio Clinic |
| First Time – OC# | Knee Splint | VFC | |
| Recurrent | Knee Splint WBAT | MSK Lower Limb Physio Clinic | |
| Patella Tendon/ Quads Tendon Rupture | Knee Splint | Ortho On Call | |
| ?Meniscal, ?Ligament Injury | Knee Splint | MSK Lower Limb Physio Clinic | |
| Injury | ED Treatment | Discharge Pathway | |
|---|---|---|---|
| Isolated avulsion # tip of lateral/medial malleolus | Treat as sprain WBAT, RICE Ankle Brace/Walker boot if necessary | Discharge | |
| Isolated Weber A distal fibula #s | Treat as sprain WBAT, RICE Ankle Brace/Walker boot | Discharge Advice to contact VFC if symptoms > 3/12 |
|
| Isolated Weber B Lateral Malleolar # (Documentation must include: Is there medial swelling? Yes/No Is there medial tenderness? Yes/No Is there medial bruising? Yes/No) | Talar shift/displacement - Present | Backslab | Ortho On-Call |
| Talar shift/displacement - NONE | Walker Boot WBAT | VFC | |
| Isolated Weber C fibula # (Also Need Assessment for medial injury& syndesmotic injury) | Displaced | Backslab | Ortho On-Call |
| Undisplaced | Walker Boot WBAT | VFC | |
| Bimalleolar/ Trimalleolar | Backslab | Ortho On-Call | |
| Tarsal fractures - Small avulsions without disruption of tarsal alignment | Treat as sprain -Walker boot, analgesia, WBAT | Discharge | |
| If Unsure | Treat as sprain -Walker boot, analgesia, WBAT | VFC | |
| Tarsal or cuneiform # | Walker boot, analgesia, WBAT | VFC | |
| Metatarsal # | Intra-articular/basal # ? Lis Franc | Walker boot, analgesia, WBAT | VFC |
| Definite Lis Franc/ Significant displacement | Backslab | Ortho On-Call | |
| Metatarsal Neck & Shaft #s | Minor Trauma/Minimally displaced/stress # | Walker boot /flat post op shoe WBAT | Discharge Advice Sheet-HERE |
| High Energy/ Multiple / Significant displacement | Backslab | Ortho On-Call | |
| Isolated 5th Metatarsal Base (diagram below) | Zone 1 | Walker boot /flat post op shoe WBAT | Discharge |
| Zone 2/3 | Walker boot | VFC | |
| Lesser Toe Injuries #’s/dislocations | ED reduction (if needed) Neighbour Strap WBAT flat shoe/ Normal footwear | Discharge Advice Sheet-HERE | |
| Achilles Tendon Rupture | Equinous Slab, NWB, VTE prophylaxis | Face-Face # Clinic | |
| Talus Neck/Body # | Backslab | Ortho On-Call | |
| Calcaneal # | Walker boot NWB | Ortho On-Call | |
| Tongue Type # | Equinous Slab NWB (Keep NBM) | Ortho On-Call | |
Studies suggest around 1% of hip fractures are missed on plain X-ray. So as usual you must combine clinical and radiological findings. Read more
We are regularly doing femoral blocks next to major vessels. So warn the patient of the symptoms, & keep them monitored(at least 15 min).
Symptoms of local anaesthetic toxicity
Intralipid – in antidote cupboard (Green Majors treatment room)
Propofol is not a suitable substitute for lipid emulsion
Use conventional therapies to treat:
PDF:la_tox
Recent Incident: Bat contact was not recognized (effectively touching a bat without gloves means treatment is recommended)
Rabies is an acute viral encephalomyelitis caused by members of the lyssavirus genus. The UK has been declared “Rabies-Free”. However, it is known that even in “Rabies-Free” counties the bat population posse a risk.
In the UK the only bat to carry rabies is the Daubenton’s Bat [Picture on the Left] and this is not a common bat in the UK. The UK and Ireland are Classified as “low-risk” for bat exposure. Despite our “low-risk” status in 2002 a man died from rabies caught in the UK from bat exposure.
Although rabies is rare it is fatal so we must treat appropriately, Public Health England – Green book details this.
To establish patients risk and thus treatment you need to establish the Exposure Category and Country Risk [Link to Country Risk]
Obviously patients with wounds will need appropriate wound care and cleaning, specifics for rabies are below.
If in ANY doubt, or you feel you need advice about treatment contact: On-Call Microbiologist (who will contact PHE or Virology advice)
You will likely need to liaise with the duty pharmacist to obtain vaccine or HRIG – which may need to be sent from a different hospital. [it is probably worth trying to obtain the 1st weeks treatment if possible, to avoid treatment delays]
Rabies and Immunoglobulin Service (RIgS), National Infection Service, Public Health England, Colindale (PHE Colindale Duty Doctor out of hours): 0208 327 6204 or 0208 200 4400
C-spine injury ranges from the obvious fracture-dislocation to the less obvious ligamentous injury, affecting about 2.5% of blunt trauma patients. However, ALL of them are serious and can lead to life changing injuries, that we obviously don’t want to miss. Unfortunately reported miss rates range from 4-30%. [IJO 2007]
Warning:
Working out what your patient might have been vaccinated for can be tricky, and more so if they were raised outside of the UK. Luckily there are a couple of tools online you can use to make this easier.
