Category: Teaching

Thomas Spint – how to apply

Invented by a Welshman ‘Hugh Owen Thomas’, the introduction of this simple device in World War 1 went on to reduce the mortality of #femurs from 80% to 16%.

The Kit

  • Measuring Tape
  • Thomas splint – Adult or Paediatric (depending on size)
  • Hoop – Sizing guide can be found here
  • Slings
  • Hoop Pad
  • Skin Traction – Adult or Paediatric
  • Padding rolls x 2
  • Bandages (wide) x 2
  • Tape
  • Scissors
  • Tongue Depressors x 2

Printable application guide

Measuring

Measure the Inside Leg (unbroken leg) and add 30cm/12inch (to give room for the traction)

Adjusting Splint

Adjust length to the above measurement. ensuring the Hoop is at an angle with the lateral (outside leg) higher than the medial (inside leg).

Set up

  • Apply the hoop Pad (to reduce pressure and secure to tight)
  • Apply the 4 slings (lowest should be 40cm from base)
  • Apply padding along slings
  • Creat a small padding for behind the knee

Application

  • Ensure Adequate analgesia (this hurts) – typically Opiates and entonox
    • Femoral nerve block may be helpful (however, this is variable due to the innovation of the femur and reduces the more distal the fracture)
  • Check Genitals not trapped – by the hoop
  • Apply skin traction & and bandage from ankle to thigh
  • Secure the tight Clip – remembering to put the padding under the clip and velcro round

The Knot

1. take the strings and pass one over and one under the sides of the frame.

2. secure tightly with a Reef Knot

3. pass strings down (one over and one under) around the base, bringing them back over the Reef Knot and  back around the base. This makes a pulley system.

4. Tension the pulley system and tie-off using a bow

5. Pass the tongue depressors (2 tongue depressors tapped together), twist the tongue depressors to achieve the required tension, and lock off against the side.

 

Bandage & Elevate

  • Bandage the leg to the sling using the bandage – to keep secure
  • Place a pillow or blankets under the splint to elevate the heel – To prevent pressure sores

Dislocated Shoulder (Teaching Video)

Great review of shoulder reduction, techniques and sedation. 

Learning points:

  • Most techniques will work 80% of the time (Best results tailor the technique to the patient)
  • Kocker’s shouldn’t be used in # greater tuberosity
  • Cunningham technique looks interesting (I’m going to give this a go)
  • Traction is the what causes the most pain. Reduce the traction & Reduce the sedation required

#EuSEM2018 – Day 1

For those of you working hard on the shop-floor a quick summary of whats going on in Glasgow @ #Eusem2018

 

Sepsis

3 interesting talks from dual Emergency Med and Infectious disease specialists, from Denmark and Germany, which highlighted that we are all in the same boat, and again doing the basics right is what maters.

Antibiotic Stewardship (What we do in ED, dictates inpatient care)

  • Viral v.s. Septic – clinical differentiation is not reliable, and POCT for flu may be useful in the high prevalence of an outbreak but performs poorly the rest of the time.
  • Choosing well – we can reduce the use of broad-spectrum antibiotic usage dramatically by using our site specific antibiotics [68-85% of the time we can correctly establish site clinically i.e. without tests – if it sounds like a chest infection it is]
  • Blood cultures – really important for guiding the care of our inpatient colleges, esp. to help deescalation, [2 sets are better than 1]

Antibiotics within an hour

  • 33% mortality reduction –  more and more studies demonstrate the benefits of early antibiotic treatment

  • Delay of 2nd dose kills – with longer boarding times in ED waiting for wards we need to remember that second dose it matters.

 

Sedation

Is TCI (Target-Controlled Infusion) the way forward? Basically using an anaesthetic pump to smooth sedation instead of bolusing. Its already be used by non-anaesthetics in several areas and demonstrates lower complication rate than the RCEM sedation audit 0.05% vs approx 4%, when you look across studies.

PROTEDs group are currently doing a feasibility study into its application into the ED, early results show set up is quick, but the sedation time is slow. However, they admit that so far they have been very cautious with their dosing and are looking for optimal dosing regime.

 

Doing the basics well

There were a few pearls to take away.

  • ECG moment artefact – if you get the patient to hold their arms out forward until they are too tired to move the artefact goes away!!
  • Radiology in pregnancy
    • Doses under 50mSV are not harmful to baby
    • CXR is 0.1mSV (10 days background radiation)
    • CT abdo pelvis 20mSV
    • Once again doing the best for Mum is best for the baby
      • Use Ultrasound/MRI where we can but if X-Ray/CT is warranted use it
      • However, when multiple test are required (i.e. trauma) we need to actively monitor how that dose is increasing.