Author: embeds

#NoF – Fractured Neck of Femur

BOAST Guidance

  • #NoF patients (or other fragility fracture) who requiring CT Head (for head injury) also be performed a CT Neck
    • Fragility fractures indicate the 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)

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Lower Back Pain: Red & Yellow Flags

Each year 1:15 of the adult population will seek medical help for Lower Back Pain, that is 2.6 million patients in the UK. Most Lower Back Pain is not serious and will revolve within 8 weeks, with analgesia and self physio.

However, this is not the case for some. This may be due to serious underlying pathology ‘RED Flags‘, or psychological factors that indicate chronicity ‘Yellow Flags‘.

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Hypomagnesaemia

Classification

  • Normal: 1.1-0.7
  • Mild: 0.69-0.5
  • Moderate: 0.49-0.4
  • Severe: <0.4

Signs/Symps (normally <0.5)

  • MSK: Muscle Twitch, Tremor, Tetany, Cramps
  • CNS: Apathy, Depression, Hallucination, Agitation, Confusion, Seizure
  • CVS: Tachycardia, Hypertension, Arrhythmia, Digoxin Toxicity
  • BioChem: Hypokalaemia, Hypocalcaemia, Hypophosphataemia, Hyponatraemia

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Hypothermia

Remove COLD, Add WARM, Don’t SHAKE

  • 32-35ºC [Mild] – Shivering, Tachycardia, Tachypnoeic, Vasoconstriction
  • 30-32ºC [Moderate] – Shivering stops, Pale/Cyanosed, Hypotensive, Confused, Lethargic
  • <30ºC [Severe] – Low GCS, Bradycardia/pnoeic, Hypotensive, Arrhythmias, Cardiac Arrest

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Silver Trauma

The population is ageing and thus our ‘typical’ trauma patient is also changing. In 2017 the TARN report “Major injury in older people” highlighted the following issues:

  • The typical major trauma patient: has changed from a young and male to being an older patient.
  • Older Major Trauma Patients (ISS>15): A fall of <2m is the commonest mechanism of injury
  • Triage/Recognition of ‘Silver Trauma’ is POOR
    • Pre-hospital: Not identified hence taken to TU’s (Here) not MTC’s (Leeds).
    • The ED: Often seen by Junior Staff and endure significant treatment delays.
    • Hospital: Much less likely to be transferred to specialist care.
    • Outcomes: More likely to die, but those who survive have similar levels of disability to younger people.

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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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Acidosis & VBG’s

We are frequently asked to check the lactate on Venous Blood Gases (VBG’s), by the nursing staff. However, remember to look at the first result (pH) it is the most important.

Acidosis: Unless you have a good reason (e.g. you know its due to DKA) you should be investigating and performing an Arterial Blood Gas (ABG)

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