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ROCKINGHAM KWINANA DISTRICT HOSPITAL

Nurse Practitioner - Emergency Services CLINICAL PRACTICE GUIDELINE INJURY ­ WRIST / FOREARM

· · · · · · · Scope Wrist/forearm injury, pain, swelling or deformity Compound # / obvious fracture dislocation/ dislocation Neurovascular compromise Multiple injuries Altered conscious state including effects of drugs / alcohol History consistent with collapse Compensable status - MVIT/ WCA (all assessment and documentation must be completed by the attending medical officer)

No. 2

Nurse Practitioner Medical Practitioner +/Nurse Practitioner

Outcomes Identify patients suitable for NP CPG Identify patients not suitable for NP CPG and redirect to usual ED care +/- NP in team.

Initial assessment and interventions History

· · · · · · · MIST: Mechanism; Injuries sustained; Signs ­ vitals; Treatment given / pre hospital management / time Range of movement / ability to use arm Deformity Past medical history / medications Pre-hospital care including first aid and analgesia Allergies / immunisations Last food / fluids Scaphoid tenderness (eg. snuff box) [1, 2] Open wound see Open Wound CPG Bony tenderness o distal ulna o distal radius o carpus Assessment of elbow Tenderness / laxity of ulna collateral ligament (Gamekeepers thumb) ­ refer to Hand CPG Pain scale

Outcomes Exclusion criteria identified exit CPG

Focused clinical assessment

· · ·

Determine need for wrist/ scaphoid x-ray Identify patients for hand injury CPG

· ·

Pain assessment Analgesia/First Aid

· ·

Determine need for and type of analgesia Reduction / relief of pain Minimise / prevent swelling

First aid o rest o ice / immobilisation o compression o elevation Administration of analgesia (see medications) colour warmth movement sensation - complete sensory loss - partial sensory loss / hypoaesthesia capillary refill peripheral pulse nerves/tendons (a thorough understanding of colour, anatomy and function of the injured limb is essential for proper management)

·

Neurovascular assessment

· · · · · · ·

Neurovascular compromise exit CPG

Rockingham Kwinana District Hospital wishes to acknowledge the Health Department of Western Australia and the Alfred Hospital (Victoria) for their valued advice and support with regards to the creation of this Clinical Practice Guideline

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ROCKINGHAM KWINANA DISTRICT HOSPITAL

Nurse Practitioner - Emergency Services CLINICAL PRACTICE GUIDELINE INJURY ­ WRIST / FOREARM

Working Diagnosis and Investigations · No imaging required if: o no bony tenderness o full ROM o closed injury · · · · Wrist x-ray AP, Lateral and Oblique views Include Scaphoid view if bony tenderness of scaphoid eg. snuff box. [1, 2] X-ray of elbow indicated if locally tender or distal ulna # seen. Not routinely indicated but consider: o IV access and insert cannula if required o Pre operative pathology if requires surgical repair

No. 2

Imaging

Outcomes Identify specific injury and determine patient management

Identify specific injury and determine patient management

Pathology

Ongoing assessment of need for intravenous access Referral to specialty unit identifies need for pre-operative investigations ­ as requested Outcomes Patient discharged safely with appropriate LMO, OP specialty review

Interpretation of results (Diagnostic Features) and management decisions No evidence of #, no tenderness and full function · · · · · · · · · · · · · · · · · · NP review with view to discharge Patient education / health promotion Follow-up appointment with GP as required Consider compression / support bandage NP to review with view to discharge Consider application of compression bandage or POP backslab if significant pain Patient education / health promotion Follow-up appointment with GP as required NP review with view to discharge Apply appropriate POP back slab[1] Appointment with Fracture Clinic 1/52. Patient education / health promotion Broad arm sling NP review with view to discharge Apply POP backslab[1] Appointment with Fracture Clinic 10- 14 days. Patient education / health promotion Broad Arm Sling

No # seen, but tenderness and decreased ROM (except scaphoid tenderness) No fracture seen but suspect fracture/ ligamentous injury[1]

No fracture seen but suspect scaphoid fracture[1, 3]

Rockingham Kwinana District Hospital wishes to acknowledge the Health Department of Western Australia and the Alfred Hospital (Victoria) for their valued advice and support with regards to the creation of this Clinical Practice Guideline

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ROCKINGHAM KWINANA DISTRICT HOSPITAL

Nurse Practitioner - Emergency Services CLINICAL PRACTICE GUIDELINE INJURY ­ WRIST / FOREARM

Undisplaced, non comminuted, non intraarticular / single bone # (+/ulna styloid) [1] · · · · · · · · · · · · · · · · · · · · · · · NP review with view to discharge Below elbow POP backslab Appointment with Fracture Clinic 7-10 days. Broad Arm Sling to elevate hand above elbow Patient education / health promotion +/- Referral to care co-ordination NP to review D/W ED Consultant / Orthopaedic specialty Above elbow POP backslab to 90º NP to review D/W ED Consultant with view to refer to Orthopaedic specialty Maintain ice/elevation Review and maintain analgesia Maintain Nil by Mouth Consider application POP backslab Patient education / health promotion +/- Referral to care co-ordinator NP to review D/W ED Consultant with view to refer to Orthopaedic specialty Likely to require ORIF Maintain ice/elevation Review and maintain analgesia Maintain nil by mouth Not routinely indicated but consider necessity for IV access and insert cannula if required If surgical repair required, pre operative investigations may include FBP, U&E, Group & Hold, and INR as discussed with admitting medical officer.

No. 2

# distal radius and # ulna (not inc. ulna styloid) Fracture or dislocation identifiedComminuted / Angulated / Intraarticular / Displaced [1]

Correct diagnosis results in referral and ongoing management Orthopaedic specialty

"Night stick' # (isolated # of ulna 2º to direct blow)

Pathology

· ·

Ongoing assessment of need for intravenous access Referral to specialty unit identifies need for pre-operative investigations ­ performed as requested

Associated Care

Consider: · ECG for patients > 65 who require surgical intervention · IV fluids for patients who require fasting for surgical intervention

Rockingham Kwinana District Hospital wishes to acknowledge the Health Department of Western Australia and the Alfred Hospital (Victoria) for their valued advice and support with regards to the creation of this Clinical Practice Guideline

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ROCKINGHAM KWINANA DISTRICT HOSPITAL

Nurse Practitioner - Emergency Services CLINICAL PRACTICE GUIDELINE INJURY ­ WRIST / FOREARM

Acute Referral * See referral plan outlined in interpretation of results and management decisions (as above)

No. 2

Correct diagnosis made - D/W ED Consultant / SMO to identify +/- need for referral to appropriate specialty unit for intervention prior to safe discharge home or further management +/admission Outcomes Ensure patient understands problem, treatment, follow up and is safe for discharge home Ensure patient understands problem, treatment, follow up and is safe for discharge home

Patient discharge education When to return

· · Verbal / written instructions from NP ED written patient information

Follow up appointments

-

Verbal / written instructions from NP re: When to return for ED review (if applicable)

-

OPD appointment (if applicable Written information to LMO via Communik8

*Patient advised to collect X-ray prior to OPA if private clinic or X-rays not on PACS

Medication instructions

·

Verbal / written instructions from NP Written information as per Hospital Pharmacy on medications dispensed.

POP care (where appropriate)

· ·

Verbal / written instructions from NP ED written patient information

Safety assessment

· ·

Appropriate assessment of ability to perform ADL's Patients > 60 yrs of age consider referral

Ensure patient understands problem, treatment, follow up and is safe for discharge home Ensure patient understands problem, treatment, follow up and is safe for discharge home Ensure patient understands problem, treatment, follow up and is safe for discharge home

Rockingham Kwinana District Hospital wishes to acknowledge the Health Department of Western Australia and the Alfred Hospital (Victoria) for their valued advice and support with regards to the creation of this Clinical Practice Guideline

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ROCKINGHAM KWINANA DISTRICT HOSPITAL

Nurse Practitioner - Emergency Services CLINICAL PRACTICE GUIDELINE INJURY ­ WRIST / FOREARM Other Referrals

Consider referral to: · Social Work · Physiotherapy · Drug and Alcohol Counsellor · Aboriginal Liaison Officer · ED Mental Health Liaison Nurse · Allied health · Interpreter · Discharge coordinator etc · · · · Absence from work certificates Certificate of attendance LMO letter via Communik8 Copy of ED notes to Specialist or Outpatients Clinic (as appropriate)

No. 2

Ensure patient understands problem, treatment, follow up and is safe for discharge home

Certificates Letters

Ensure appropriate paperwork completed Ensures continuity of care and referral to health care team

Medications Outcomes All medications will be stored, labelled and dispensed in accordance with hospital policy and relevant legislation[4]

Simple analgesia [5] S2 ­ S4 MILD PAIN

On initial assessment of mild pain: ADULTS: Paracetamol PO / PR: - 500 mg ­ 1 gram 4 - 6 hourly, not to exceed 4 grams in 24 hrs. IV infusion: - 1 gram infused over 15 minutes. Not to exceed 4 doses in 24 hrs. Use for mild ­ mod pain or fever where PO/PR not tolerated, or patient fasting/ vomiting OR Paracetamol 500mg/Codeine 8mg per tablet - 1 or 2 tablets PO 4 ­ 6 hourly, not to exceed 8 tablets in 24 hrs

Patients given analgesia appropriate to allergies, current medications and past medical history

Rockingham Kwinana District Hospital wishes to acknowledge the Health Department of Western Australia and the Alfred Hospital (Victoria) for their valued advice and support with regards to the creation of this Clinical Practice Guideline

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ROCKINGHAM KWINANA DISTRICT HOSPITAL

Nurse Practitioner - Emergency Services CLINICAL PRACTICE GUIDELINE INJURY ­ WRIST / FOREARM Simple analgesia [5] S2 ­ S4 MILD PAIN

CHILDREN: Paracetamol: PO / PR: - 15 mg/kg/dose 4 hourly up to 4 times /day. Not to exceed 4 doses in 24 hours IV infusion: - >6 months 15 mg/kg/dose infused over 15 minutes. Not to exceed 4 doses in 24 hrs. Use for mild ­ mod pain or fever where PO/PR not tolerated, or patient fasting/ vomiting. OR Painstop Day: 0.6 ­ 0.8 mL/kg PO 4- 6 hourly. Not to exceed 4 doses in 24 hours OR Painstop Night: 6 ­ 8 hourly PO; Max 3 doses in 24 hours Age: 2 yrs: 4-5 mL 3-4 yrs: 6-7 mL 5-6 yrs: 7-8 mL 7-8 yrs: 9-10 mL Total daily maximum of paracetamol 90 mg/kg/24 hrs for the first 24 hours, thereafter 60 mg/kg/24 hrs. CAUTION: PAINSTOP NIGHT When dosing at maximum level of paracetamol; dose will deliver a larger than recommended promethazine dose and may give a higher than necessary codeine dose leading to an increase in sedation.

No. 2

MODERATE PAIN S2 ­ S4

On initial assessment of moderate pain or failure to relieve mild pain: ADULTS: Paracetamol 500mg/Codeine 30mg per tablet - 1 or 2 tablets PO 4-6 hourly, not to exceed 8 tablets in 24 hrs AND/OR Naproxen: 500 mg PO initially then 250 mg 6 ­ 8 hourly OR Ibuprofen: 400 mg PO 3 ­ 4 times daily CHILDREN: Ibuprofen: 10 mg/kg PO 3-4 times daily to maximum of 600mg in 24 hours If NSAIDS contraindicated, Tramadol (adults and children >12 years) Oral: 50-100mg QID, maximum 400mg over 24 hours OR IM / slow IV: 50-100mg QID, maximum 600mg over 24 hours

Analgesia requirements determined by ongoing assessment of pain and adequate analgesia provided Patients with excessive pain or pain unrelieved by analgesia need review by ED Consult / SMO

Rockingham Kwinana District Hospital wishes to acknowledge the Health Department of Western Australia and the Alfred Hospital (Victoria) for their valued advice and support with regards to the creation of this Clinical Practice Guideline

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ROCKINGHAM KWINANA DISTRICT HOSPITAL

Nurse Practitioner - Emergency Services CLINICAL PRACTICE GUIDELINE INJURY ­ WRIST / FOREARM

Special Note: TRAMADOL: · Contraindicated in epilepsy and SSRI use. · Caution must be used in the elderly ­ maximum dose 300mg daily FAILURE TO CONTROL MODERATE PAIN AND/OR INITIAL ASSESSMENT OF SEVERE PAIN ­ Discuss further management with ED Consultant / Senior ED Medical Officer

No. 2

MODERATE PAIN S2 ­ S4

Narcotic Analgesia

[5]

NOTE: Currently NPs require medical prescription for S8 medications ADULTS (only) Oxycodone oral : 5mg every 4 hours OR Morphine IM: 5 -10mg single dose Slow IV: 1- 2.5mg incremental doses to a maximum total dose of 10mg (given over period of 30 minutes) CHILDREN: Morphine IM: 0.2mg/kg single dose Slow IV: 0.1 - 0.2mg/kg/dose given in titrated doses up to maximum of 10mg in 30 minutes

S8 Severe

Anti-emetic [5] S4 PRN

Consider need for: Metoclopramide hydrochloride Oral/IM/IV Adults - > 20 years 10 mg ­ 20 mg 8 hourly - 16 ­ 20 yrs 5 ­ 10 mg 8 hourly Prochlorperazine Oral: Acute - 20mg initially then 5-10mg 8-12 hourly IM deep: - 12.5 mg 8 hourly NOTE: Antiemetics are not to be used in children <16 years

Intravenous fluids S4 Unexpected representation 48 hrs Missed fractures NP Clinical Practice

0.9% Sodium Chloride Intravenous fluid: IV infusion at 812hrly titrated to patients requirements Evaluative strategies Emergency Department Information System (EDIS) attendance record and NP clinical log Emergency Department x-ray review NP Clinical Practice / Medical Record Audit

Rockingham Kwinana District Hospital wishes to acknowledge the Health Department of Western Australia and the Alfred Hospital (Victoria) for their valued advice and support with regards to the creation of this Clinical Practice Guideline

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ROCKINGHAM KWINANA DISTRICT HOSPITAL

Nurse Practitioner - Emergency Services CLINICAL PRACTICE GUIDELINE INJURY ­ WRIST / FOREARM Key Terms

NP- Nurse Practitioner SMO ­ Senior Medical Officer PS- Pain Score S1-S4- Schedule of the drug administration act LMO- Local Medical Officer OPA- Outpatients Appointment ADL's ­ Activities of Daily Living

No. 2

CPG- Clinical Practice Guideline WC- Work cover MVIT- Motor vehicle insurance trust DVA- Department of Veteran Affairs WADH ­ Western Australian Department of Health ROM ­ Range of Movement

References

1. 2. 3. 4. 5. 6.

P

Forearm, wrist & hand. [National Guidelines Clearinghouse] c2004 2005 [cited 2006 Feb 17]; Available from: http://www.guidelines.gov. Hoynak, B. Fractures, Wrist. [National Guidelines Clearinghouse] 2005 2005 Jun 21 [cited 2006 Feb 24]; Available from: http://www.guidelines.gov. 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. Hospital Medication Storage and Administration Policy.Available via Hospital Intranet eMIMS ( April 2006). Accessed via Hospital Intranet RKDH Emergency Department Drug Protocol Manual.

Rockingham Kwinana District Hospital wishes to acknowledge the Health Department of Western Australia and the Alfred Hospital (Victoria) for their valued advice and support with regards to the creation of this Clinical Practice Guideline

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