If we are fairly certain the patient has a femur fracture and are not too suspicious of a back injury we will generally place this splint before log-rolling the patient. Some would argue that the log roll needs to be done earlier.
Place a femoral nerve block (preferably ultrasound guided)
Give some IV analgesia as well (if not already done) eg IV fentanyl
Check pulse, sensation and power of the toes and ankle (gently!)
Insert a urinary catheter for females (males can still use a urinal with a Sagar in place)
Place the padded end into the groin on the ipsilateral side, avoiding any sensitive bits.
Place the padded strap around the ankle and ensure this is fixed to the end of the splint with no twists.
If you need to shorten the splint lift up the release (see top photo)
Pull the handle to put traction on the splint so that it reads ~ 1/10th of the patients weight, reading at the distal end of the handle.
Gently strap the leg to the brace.
Check neurovascular function again.
Video from CE Solutions https://vimeo.com/40637632
Click on the blue “Watch on Vimeo” button.
Music: The Black Trio. Sweet Loving Around. http://tvnz.co.nz/new-zealands-got-talent-2013-extras/extra-nzgt-semi-final-6-black-trio-video-5724046
Juggling patients / patient flow:
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Left bundle branch block and a paced rhythm are frequent source of confusions for new docs, paramedics, GPs and … some senior ED docs.
Some people make LBBB more confusing than it should be.
A ventricular paced heart usually produces a LBBB pattern on ECG and when it does the following points apply.
A LBBB QRS complex is more than 3 small squares wide (or the computer can tell you that the QRS duration is greater than 120ms).
The is a big fat negative deflection in V1
There is left axis deviation (QRS predominantly negative in aVF)
There is negative concordance between the QRS and the ST segments. ie if the QRS is mainly positive, there will be ST segment depression (or isoelectric), if the QRS is mainly negative, there will be ST segment elevation.
SO it is normal for there to be ST elevation in V1-3 and the inferior leads (II, III and aVF) in a ECG with LBBB
If the ST segments are the concordant with the QRS complexes there may be a STEMI (Sgarbossa criteria)
Caveat: If there is discordant ST elevation > 5mm this may indicate a STEMI (see Sgarbossa criteria)
Download audio here (right-click and save or save as) or
Music: Tennis Court by Lorde
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There’s an app (iPhone only, Android coming soon) to guide the management of bleeding while on warfarin.
(NB: this is a New Zealand app and recommendations and medications (especially available prothrombin concentrate) may vary in your country)
There is an online calculator here https://www.clinicaldata.nzblood.co.nz/resourcefolder/prothrombinex.php?dhbid=1
Of note they still recommend giving FFP for severe bleeds
This is what the haemotologists use to make their treatment decisions.
And we no longer need permission from a haematologist to use prothrombin concentrate (eg Prothrombinex TM)
And just a reminder that any patient on warfarin with a bang to the head + headache and/or vomiting and/or drowsiness = an intracranial bleed till proved otherwise … don’t wait for them to crash.
By the way the way the actual case that this post is based on cost one of our residents $50.
The patient was on warfarin, had had a headache for a few days, then collapsed in the bathroom, and came to ED with increasing headache and vomiting. He then vomited and dropped his GCS to 7.
Me: “What do you think is going on?”
Me: “Intracranial bleed”
—–> $50 donated to a fund to bring student radiographers from Fiji to New Zealand for training
A young woman presented to ED following with chest pain following a rugby injury.
Clinically and radiologically she had a rib fracture without pneumothorax (personally I don’t X-Ray for isoloated rib fractures with no signs of pneumothorax). She was very sore
The doctor looking after her was advised to perform intercostal blocks.
A few hours later when examined by another doctor she was found to have no air entry on the effected side.
A chest drain was inserted and she spent several days in hospital (you could debate whether a chest drain was required but that is another story).
A safer technique for provide analgesia for rib fractures is to do a “haematoma block”. Find the most tender point by palpation, put a finger of your non-dominant hand into the rib space above and below the fracture to clearly localize the rib, then infiltrate 3ml of long acting anaesthetic (eg bupivocaine 0.5%) over the fracture site without going into the fracture, and not going into the intercostal space.
This gives good analgesia for around 18 hours.
Prescribe lots of good analgesics.
If the patient is fit to go home, advise them they can come back for a repeat injection if needed. They very seldom need a second injection.
Advise against flying or diving for 6 weeks.
Thanks to Dr Helen Cosgrove, now Director of Emergency Medicine, Palmerston North Hospital for teaching me this technique many moons ago.
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