Joondalup Health Campus wishes to acknowledge the Health Department of Western Australia and The Alfred Hospital for their valued advice and support with regards to the creation of this Clinical Practice Guideline
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Scope Outcomes
Nurse Practitioner • Wrist/forearm injury, pain, swelling or deformity Identify patients suitable for NP (Emergency) CPG
Medical Practitioner +/-Nurse Practitioner
• Compound # / obvious fracture dislocation/ dislocation • Neurovascular compromise
• Multiple injuries
• Altered conscious state including effects of drugs / alcohol
• History consistent with collapse
Identify patients not suitable for
NP(Emergency) CPG and redirect Management to usual ED care with NP (Emergency) part of the ED team.
Initial assessment and interventions Outcomes History • Mechanism of injuries sustained
• Time and Date of injury • Treatment - given pre-hospital • Past medical history
• Medications
• Allergies / immunisations • Last food / fluids
Exclusion criteria identified → exit CPG. Referral to EP
Focused clinical assessment
• Look - deformity, swelling, bruising
• Feel - bony tenderness, ligaments, tendons • Move - range of movement
• Snuff box tenderness, scaphoid tubercle tenderness, axial loading on thumb [1, 2]
Determine need for wrist / scaphoid /elbow x-ray.
Identify patients for hand / elbow injury CPG Neurovascular assessment • Colour • Warmth • Movement • Sensation • Capillary refill • Peripheral pulses Neurovascular compromise → exit CPG. Referral to EP.
Pain assessment Pain scale Determine need for and type of analgesia
Analgesia/First Aid • First aid - rest
- ice / immobilisation - compression - elevation
• Administration of analgesia (see medications)
Reduction / relief of pain
Minimise / prevent swelling
Working Diagnosis and Investigations Outcomes Imaging • Imaging may not be required if
-Trivial injury
-patient has full range of motion -no bony tenderness
• Wrist x-ray - include request for Scaphoid view if bony tenderness at anatomical snuff box, scaphoid tubercle or on axial loading[1, 2]
• X-ray of joint above and below injury indicated in decreased range of motion, pain, tenderness [1]
Identify specific injury and determine patient management
Joondalup Health Campus wishes to acknowledge the Health Department of Western Australia and The Alfred Hospital for their valued advice and support with regards to the creation of this Clinical Practice Guideline
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Pathology Not routinely indicated but consider• Pre operative investigations may include FBP, U&E, Group and Hold and INR as discussed with admitting medical officer.
Interpretation of results (Diagnostic Features) and management decisions Outcomes PAEDIATRIC CAVEATS
All patients under the age of 15 presenting with injury to wrist or forearm
with localised pain, require x-ray whether bony tenderness is present or not. Fracture may be present without bony tenderness.
Growth Plate tenderness
If no fracture/dislocation seen but open growth plate on x-ray and tenderness over growth plate, manage as fracture with immobilisation and follow up at GP or trauma clinic in 10 days for clinical reassessment + further immobilisation.
No fracture seen, no bony
tenderness and full function
NP (Emergency) review with view to discharge patient • Apply conforming tubular bandage for comfort and
support • High Arm Sling
• Patient education / health promotion • follow-up appointment with GP if required
Patient identified as suitable for NP (Emergency) CPG and discharged safely. No fracture seen but suspect fracture/ ligament injury[1]
NP (Emergency) review with view to discharge patient • Apply appropriate POP back slab
• Appointment with Orthopedic Trauma Clinic 7 - 10 days.
• Plaster check GP if appropriate • High arm sling
• Patient education / health promotion
• Continuing analgesia for the patient to take following discharge from the ED until review
• Consider Orthopedic review if suspect instability.
Patient identified as suitable for NP
(Emergency) CPG and discharged safely with follow up in Orthopedic Trauma clinic.
Patient discharged after consultation with Orthopedic Registrar Undisplaced, non comminuted, Non intra-articular Fracture [1, 2]
NP (Emergency) review with view to discharge patient
• Wrist: Below elbow POP backslab and High Arm sling • Forearm: Above elbow POP backslab and Broad Arm
sling
• Appointment with Orthopedic Trauma Clinic 7 days. • Plaster check GP if appropriate
• Patient education / health promotion
• Continuing analgesia for the patient to take following discharge from the ED until review
Patient identified as suitable for NP
(Emergency) CPG and discharged safely with follow up in
Orthopaedic Trauma clinic.
Joondalup Health Campus wishes to acknowledge the Health Department of Western Australia and The Alfred Hospital for their valued advice and support with regards to the creation of this Clinical Practice Guideline
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Fracture or dislocation identified- Comminuted / Angulated / Intra-articular / Displaced [1, 2]NP (Emergency) review and consultation with Orthopedics • Maintain Rest Ice Elevation
• Review and maintain analgesia • Maintain Nil by Mouth
• consider application POP backslab if unstable or for pain management
• patient education / health promotion
Patient referred to Orthopedic Registrar for opinion + admission
Associated Care • Consider ECG/CXR for patients who require surgical
intervention
• Consider IV fluids for patients who require fasting for surgical intervention Acute Referral • Referral to +/- physiotherapy +/- interpreter +/- Allied health etc
Patient discharge education Outcomes When to return to ED • Verbal instructions from NP (Emergency)
• ED written patient information Patient understands problem, treatment, follow-up and is safe for discharge
Follow up appointments
• Verbal instructions from NP (Emergency)
• Written instructions for GP / Orthopedic Trauma Clinic
Medication instructions
• Verbal instructions from NP (Emergency) • Contact ED Pharmacist to provide medication
education for patient if applicable.
POP care • Verbal instructions from NP (Emergency)
• ED written patient information
Safety • Appropriate assessment of ability to perform ADL’s
• Patients > 60 yrs of age, consider referral to Coordinated Care Team
Certificates • Absence from work certificates
• WC certificate
Medications Outcomes
Joondalup Health Campus wishes to acknowledge the Health Department of Western Australia and The Alfred Hospital for their valued advice and support with regards to the creation of this Clinical Practice Guideline
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Simple analgesia [5]S2
Mild
Paracetamol 500mg: 1 or 2 tablets 4-6/24, not to exceed 8
tablets in 24 hrs.
Children:
Paracetamol: 15 mg/kg 4 hourly up to 4 times a day. Not to
exceed 4 doses in 24 hours
OR add to paracetamol;
Ibuprofen: 400 mg orally 6 – 8 hourly to maximum of 1600
mg in 24 hours (with food).
Children;
Ibuprofen: 10 mg/kg 3-4 times daily (over 3 months of age) NSAIDS [5]
S4
Moderate
Instead of Paracetamol, Panadeine Forte: 1 -2 tablets 4 to 6 hourly, not to exceed 8 tablets in 24 hrs.
Painstop Day: 0.6 – 0.8 mls/kg (over 1 yr old) 4 to 6 hourly.
Not to exceed 4 doses in 24 hours
OR
Naproxen: Adults; 500 mg initially then 250 mg 6 – 8 hourly
to maximum 1250 mg in 24 hours (with food)
If NSAIDS contraindicated, Adults and Children > 12 years
Contraindicated in epilepsy, SSRI use
Caution in the Elderly – Maximum 300 mg daily Tramadol Oral: 50-100mg QID, maximum 400mg over 24
hours OR
Tramadol Intravenous: 50-100mg QID, maximum 600mg over
24 hours
Patients given analgesia appropriate to allergies, current medications and past medical history.
Analgesia requirements determined by ongoing assessment of pain and adequate analgesia Provided.
Patients with excessive pain or pain unrelieved by analgesia need review by EP
Narcotic Analgesia [5] S8
Severe
ADD to Paracetamol + NSAID if still in pain
Currently NPs require Medical Prescription for Schedule 8 medication
Oxycodone: Adults only; Oral: 5mg every 4 hours
OR
Morphine
Adults; Intramuscular / intravenous: 2.5mg then incremental doses to a maximum total dose of 10mg (given over period of 30 minutes)
Children; IM – 0.1 - 0.2 mg / kg IV: 0.05 mg / kg given in
titrated doses as guided by EP.
IF PAIN NOT CONTROLLED WITH ALL 3 AGENTS, REFER TO ED CONSULTANT
Joondalup Health Campus wishes to acknowledge the Health Department of Western Australia and The Alfred Hospital for their valued advice and support with regards to the creation of this Clinical Practice Guideline
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Anti-emetic [5] PRNS4 Adults only
(Contraindicated in Parkinson’s Disease)
Metoclopromide hydrochloride: Oral/IM/IV:10mg 8/24 Max
30 mg in 24 hours
Prochlorperazine: Oral 5-10mg 8-12/24,
IM deep 12.5 mg 8/24
Children: Discuss with EP
Intravenous fluids 0.9% Sodium Chloride Intravenous fluid: Infusion titrated to
patients requirements
Children: Discuss with EP
Evaluative strategies Missed fractures Emergency Department x-ray review
References
1. Hoynak, B., Fracture, Wrist [eMedicine] 2009 Aug 13 [cited May 3 2010]; Available from:
http://emedicine.medscape.com/article/828746
2. Khaldun, J & Gore, R. Fracture, Forearm. [eMedicine] 2009 Mar 31 [cited May 3 2010]; Available from http://emedicine.medscape.com/article/824949.
3. Hunter, D., Diagnosis and management of scaphoid fractures: a literature review: Davis Hunter examines how a review of literature can help inform emergency nurses. Emergency Nurse, 2005. 13(7): p. 22- 26.
4. JHC Medication Storage and Administration Policy. Available via Hospital Intranet
5. eMIMS 2010 [cited 2010 Dec 16]; Available via Hospital Intranet
Key to terms
CPG- Clinical Practice Guideline DVA- Department of Veteran Affairs EP- Emergency Physician
GP – General Practitioner
MVIT – Motor Vehicle Insurance Trust
NP (Emergency)- Nurse Practitioner – Emergency
Services
OP- Outpatients PS- Pain Score
S1-S4- Schedule of the drug administration act WC- Workers Compensation
Written: Sept 2006 Reviewed: Jun 2011
Review date: Jun 2014
Joondalup Health Campus wishes to acknowledge the Health Department of Western Australia and The Alfred Hospital for their valued advice and support with regards to the creation of this Clinical Practice Guideline
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