Category: MSK

Unsuspected NoF

We have seen multiple incidence where clinicians of ALL grades have assessed patients with falls and examined hips and even mobilised patients

Evidence shows (and reflected in the incidents) this predominantly effects patients with:

  • Communication difficulties: inc. Delirium, dementia, learning difficulties
  • Live in Supported accommodation
  • Normally require help mobilising

If a patient presents with ANY of these and a fall – X-ray Pelvis

 

Major Trauma: STOP>SORT>GO

YAS crews may on occasions (rarely) bring us a Major Trauma patient that meets the criteria for bypass to the MTC because they have a problem that the crew cannot manage, or they won’t survive to LGI e.g. an unmanageable airway/ incompressible haemorrhage. In these instances we will get a pre-alert either from the crew or more likely the Major Trauma Triage Co-ordinator in EOC with some information but primarily the reason the patient is coming to us.

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Tetanus – Wounds

Tetanus prone and High Risk definitions

Immunisation schedule

  • Primary: 2, 3 & 4 months old
  • Boosters: 3½ – 5yrs and 13-15yrs

Warning:

  • Immunisation only started nationwide in the UK in 1961 (people born before 1961 are unlikely to have completed a primary course)
  • Immunocompromised patients are unlikely to produce adequate antibodies
  • Immediate reinforcing dose of vaccine – these patients are expected to have a rapid response to vaccine dose conferring protection

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VTE prophylaxis in lower limb Immobilisation (ED – 2023)

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.

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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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VFC/Orthopedic – Trust Treatment & Follow-Up

Select the appropriate body area for guidance table

No Spinal injuries, back pain, Cauda Equina, foot drop etc to be referred to VFC
 

Patients that will not be suitable & need a “face-to-face” as below

  • Homeless patients
  • Prisoners
  • Non English Speaking Patients
  • Inpatients
  • Patients with Hearing Difficulties
  • Phoneless Patients
  • Injuries Associated with Domestic or Child Abuse
  • Children under 2 Years of Age
Upper Limb

Lower Limb

5th MT zones

LA – Toxicity

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

  • Circumoral and/or tongue numbness
  • Metallic taste
  • Lightheadedness/Dizziness
  • Visual/Auditory disturbances (blurred vision/tinnitus)
  • Confused/Drowsiness/Fitting
  • Arrhythmia
  • Cardio-Resp Arrest

Remember – Do basics WELL

Intralipid – in antidote cupboard (Green Majors treatment room)

    1. Bolus – 1.5ml/kg 20% lipid solution over 1min
    2. Then start Infusion – 15ml/kg/hr 20% lipid solution
    3. 5 mins reassess if Cardiac instability/deterioration
      • Rpt Bolus 1.5ml/kg over 1min (max 3 boluses inc. initial)
      • Increase infusion rate – up to 30ml/kg/hr
      • Total Max dose 12ml/kg

Propofol is not a suitable substitute for lipid emulsion

Without Cardio-Resp Arrest

Use conventional therapies to treat:

  • Seizures
  • Hypotension
  • Bradycardia
  • Tachyarrhythmia (Lidocaine should not be used as an anti-arrhythmic therapy)

In Cardio-Resp Arrest

  • CPR – using standard protocols (Continue CPR throughout treatment with lipid emulsion)
  • Manage arrhythmias – using standard protocols
  • Consider the use of cardiopulmonary bypass if available
  • Recovery from LA-induced cardiac arrest may take >1 h
  • Lidocaine should not be used as an anti-arrhythmic therapy

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