Category: Trauma

Intranasal Fentanyl

There is currently a national shortage of Intranasal Diamorphine therefore we are using Intranasal Fentanyl as a replacement.

Dose is 1.5micrograms/Kg for the initial dose and 0.75micrograms/kg 10 minutes later if required.

Drug Delivery

Draw up the appropriate dose plus 0.1ml to allow for the dead space in the Mucosal Atomizer Device

Attach the MAD to the syringe

Sit the child at 45 degrees insert MAD loosely into the nostril and press the plunger

Doses greater than 0.5ml should be split between 2 nostrils

 

Contraindications

  • Blocked nose due to upper respiratory illness or epistaxis
  • Respiratory depression
  •  Hypovolaemia
  • Altered consciousness
  • Hypersensitivity to fentanyl
  •  Children below 1 year old

Full Intranasal Fentanyl SOP

Penthrox (Methoxyflurane)

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.

Contraindications (CHECK ALLL):

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TXA – Tranexamic Acid

TXA a bleeding wonder drug!

Crash 2 Study (2010)

  • Multi-Centre RCT of the use of TXA in trauma
  • Inclusion – Adult trauma patients with ≥1 of
    • Suspicion of significant haemorrhage
    • HR ≥110bpm
    • sBP ≤90mmHg
  • Treatment – 1g TXA IV over 10min then a second 1g TXA IV over 8hrs
  • Outcome – Significant reduction in Death, bleeding with NO increase in clots(thrombotic disease)
    • Most benefit seen if given early (<3hr – NNT 53)

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Domestic Abuse

Domestic abuse can affect anyone and often its not readily disclosed on an ED admission. We must be alert to the fact some of our patients may be attending with domestic abuse. Please explore concerns and escalate if you’re unsure. Our colleagues in the Pennine Domestic Violence Group have kindly drawn this a guidance up for us.

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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