The Acute Medical Management of Patients with Fractures
The Acute Medical Management of Patients with Fractures
Dr Gary Heyburn
Introduction
The modern day management of fracture patients involves close liaison with a variety of specialities especially medicine and anaesthesia. Almost half the patients are over the age of 65 years and are plagued by the twin problems of polypharmacy and significant co –morbities. Intense medical involvement is often required to ensure patients receive optimal treatment. This manual highlights common perioperative problems. I hope it will be of some use to junior doctors, medical students and nursing staff.
CONTENTS
1. Introduction
2. Ward Routine
3. Rota
4. Management of hip fracture patients
5. Hip fracture: optimization for surgery
6. The Older Patient with a Hip Fracture : The Medical Perspective
7. Pain Management in the Hip Fracture Patient
8. Pulmonary embolism
9. Fat Embolism
10. Alcohol withdrawal
11. Amiodarone Protocol
12. Protocol for the Prophylaxis of Venous Thromboembolism for the Trauma Unit
13. Management of the patient admitted on warfarin
14. Current antibiotic guideline
15. Transfusion thresholds
16. Acute Orthogeriatric Care in the Perioperative period
17. Informing the Coroner
18. Model death certificate and covering letter
19. Delirium check list
20. Analgesia for the older patient with a fracture
21. Management of diabetic patients during orthopaedic surgery
22. Management of metastatic bone disease from unknown primary
23. Osteoporosis Management
24. The Renal dialysis patient
25. Transferring an older patient with a fracture
Ward Routine
• The working day starts at 8am sharp
• The Foundation 1 doctors attend the Hospital at Night handover at 8am
• The F1s then attend the daily fracture unit X ray meeting in the Seminar room in Fracture clinic.
• After the x ray meeting there is a team meeting with the Physicians
• During this meeting all the inpatients in the fracture service are discussed
• The Physicians are particularly interested in patients with hypoxia, hypotension, cardiac arrhythmias(AF) and reduced urinary outputs
• After this meeting doctors should rapidly go to their wards (not to the canteen !) as the early morning period can be extremely busy.
• Junior doctors should ensure they get regular breaks throughout the working day and should leave promptly when their shifts are over.
• The doctor should ensure that tasks such as writing up routine fluids and warfarin prescriptions are done by the end of the day shift.
• The ward Physician should be informed at the earliest opportunity about any planned leave or unexpected illness involving the ward doctors
• Remember to review all blood results at the end of the working day and act on any abnormalities detected- this is especially true at weekends
• Punctuality is essential
• Endeavour at all times to be a team player and remember the wealth of experience that many of your nursing colleagues possess
Insert sample rota:
Points to remember in the management of hip fracture patients
• Take a careful history particularly with regard to the fall. Does the patient fall often? How many falls in the last year? Does the patient blackout? Was the fall witnessed? Was there a postural element?
• Ensure the patient’s medications are prescribed promptly. Nursing Homes / GPs and other appropriate sources should be contacted as soon as possible to verify drugs and drug doses.
• Sedatives and psychotropic medications are associated with falls whilst diuretics and antihypertensives can exacerbate postural hypotension
• Ensure mini mental scores are recorded on admission. This essential element of the admission can facilitate delirium management or the detection of subdural haematomas.
• Investigate systolic murmurs by echocardiography ( it is especially important to identify aortic stenosis as this condition can impact on anaesthetic technique)
• Ensure bloods are done as soon as possible to enable early surgical intervention- older patients will not go to theatre unless the basics have been done
• Remember to erect intravenous fluids on all the older patients with a hip fracture (unless a contraindication exists)
• Anaesthetists expect ECGs and (when appropriate) CXRs to be available in the immediate preoperative period
• Many patients are now on warfarin and the management of their anticoagulation will depend on the indication for taking this medication. Normally surgery can proceed when the INR is less than 1.5. In the preoperative period surgery can rarely proceed if more than enoxaparin 40mg sc bd is used.
• Older patients with a hip fracture are at risk of thromboembolism and should be prescribed enoxaparin 40 mg sc nocte unless a contraindication exists
• Ensure all patients are prescribed appropriate analgesia and AVOID ALL NSAIDS AND COX2 INHIBITORS IN THE PERIOPERATIVE PERIOD
• Patients who require inhalers should also be prescribed nebulisers in the perioperative period.
• Remember alcohol abuse as a cause of falls. Help to confirm the diagnosis with LFTS and remember to check the coagulation screen and platelet count. Prescribe chlordiazepoxide.
• Clopidogrel (Plavix) is being increasingly used in cardiovascular disease. It is mandatory to determine why the patient is on plavix. If the patient has had cardiac stents inserted in the last year then cardiology should be contacted prior to stopping the plavix;. Elective patients should if possible be off this medication for 7-10 days. Emergency patients cannot wait this long and currently our hips go to theatre after 72 hours have elapsed.
• Implantable Cardioverter Defibrillators (ICDs) are being used more commonly. These devices often have to be turned off during surgery. Contact Cardiology when patients are admitted with these devices. Do not assume that all subcutaneous devices on the anterior chest wall are just pacemakers – they just might be an ICD as well.
• Many patients are admitted who are being treated with aspirin. If the condition for which they are taking this medication is stable the aspirin can usually safely be held and enoxaparin substituted
HIP FRACTURE: OPTIMIZATION FOR SURGERY
Is the patient optimized for theatre?
The following parameters can be helpful in reaching this conclusion when the orthogeriatrician is unavailable:
1. Oxygen saturations greater than 90 % either off oxygen or on low dose oxygen (28%).
2. Absence of a tachycardia.
3. Satisfactory blood pressure (systolic greater than 90 mmHg)
4. Optimised Haemoglobin
5. Optimised urea + electrolytes.
6. Absence of a significant pyrexia.
7. Does the patient need an ECHO?
8. Are there any anticoagulation problems (INR should be1.5 or less) /is the platelet count satisfactory( remember the effect of drugs such as plavix)?
The Older Patient with a Hip Fracture : The Medical Perspective
The following has been adapted from the following articles with full references :
Heyburn G, T Beringer.Hip fracture 1 .Preoperative management GERIATRIC MEDICINE VOL 31 NUMBER 9 SEPTEMBER 2001 PAGES 17-21
Heyburn G, T Beringer.Hip fracture 2. Peri- and post-operative management. GERIATRIC MEDICINE VOL 31 NUMBER 10 OCTOBER 2001 PAGES 37-42
INTRODUCTION
A recent paper in the BMJ suggested that elderly females would rather die than suffer a hip fracture that resulted in loss of independence and admission to a nursing home.1 Are hip fractures that bad?
EPIDEMIOLOGY
There were 66 000 hip fracture admissions in England and Wales in 1997/982 and this corresponds to an incidence of greater than 1:1000 of the general population. The numbers are rising (see Fig 1) with the majority of patients being female and over the age of 75 years.
The lifetime risk of a hip fracture is 16-18% in women and 5-6% in men. At the age of 80 years one in five females has had a hip fracture rising to one in two at 90 years of age.3
[pic]
Fig. 1. Estimated numbers of hip fractures in people aged over 60 in United Kingdom, 1996-2066, based on rates from 1983 and 1956 4
HISTORY AND EXAMINATION
As hip fracture patients tend to be elderly and frail , a full history and examination is essential. Although falls are commonly listed as being “simple” this is rarely the case and they are usually multifactorial. If the fall has been witnessed the aetiology is easier to ascertain as patients’ recollection of preceding events may be incorrect. Low velocity falls indoors account for most of the injuries. Despite the difficulty in taking an accurate history some attempt should be made to find the cause of the fall.
Risk factors for hip fractures are a combination of the risk factors for falls and those for osteoporosis.
Risk Factors for hip fracture5
|Female sex |
|Maternal history of hip fracture |
|Excess alcohol |
|Excess caffeine |
|Physical inactivity |
|Low body weight |
|Previous hip fracture |
|Tall stature |
|Certain psychotropic medications |
|Residence in an institution |
|Visual impairment |
|Dementia |
Postural hypotension is often an aetiological factor in the fall ,exacerbated by medications such as diuretics and sedatives. The Parkinsonian patient is at particular risk due to postural instability and L dopa induced postural hypotension. The diabetic patient is also prone to falls due to poor vision, hypoglycaemic episodes, peripheral and autonomic neuropathy.
A full alcohol history may explain the fall and the presence of osteoporosis.
Not all fractures are due to osteoporosis and sometimes hip fracture may be the first presentation of metastatic bone disease . A history of the bone “snapping” before the fall could be an indicator of this. Five cancers that commonly metastasise to bone are those from the bronchus, breast, kidney, thyroid and prostate. Haematological malignancies also occur such as multiple myeloma and lymphomas.
Medications should be assessed on admission and appropriate changes considered. An elderly pre-operative hip fracture patient is unlikely to be able to use an inhaler and therefore should be changed over to nebulisers for the peri-operative period. Non- steroidals are best avoided especially due to their detrimental effect on renal function and bone healing. Patients taking warfarin are a special problem and surgery is deferred until the INR is less than 1.5.
A full social history with information on activities of daily living , type of dwelling and other family members at home, as well as the use of outside support agencies, helps to give a fuller picture of the patient. Previous level of mobility should be enquired into and the use of walking aids documented.
Abbreviated mini-mental scores help in deciding if a patient can sign their own consent form and for monitoring perioperative confusion which is endemic amongst elderly fracture patients.
On examination the classic appearance of a fractured hip is that of a shortened and externally rotated lower limb. However not all presentations are classical, and in the case of an impacted subcapital fracture some patients can actually walk despite their injury. Examination of the cardiovascular system may detect the presence of atrial fibrillation or a murmur. Neurological examination is essential as falls can lead to head injuries that are easily missed. Respiratory examination may detect a chest infection. Examination of the abdomen is important as this group of patients are at risk of developing pseudo-obstruction.
INVESTIGATIONS
The hip fracture is usually diagnosed by standard radiographs and a chest X ray should be obtained at that time. In more difficult cases where the clinical picture suggests a fracture but the X rays do not, a bone scan can aid diagnosis. However this investigation takes a number of days to become positive. In the future MRI scans may be helpful as they can accurately detect a fracture within 24 hours of injury.
A full blood picture , blood group and hold and urea and electrolytes are mandatory. The fracture often results in blood loss and the patient may need transfusion perioperatively. The platelet count should be scrutinised as a low count is a contra-indication to spinal anaesthesia , the commonest mode of anaesthesia used in elderly hip fracture patients.
An electrocardiogram will help to detect arrhythmias and recent infarcts that may have precipitated a fall.
The presence of systolic murmurs in the elderly are common6 but create a special problem in the elderly fracture patient. Aortic stenosis, which can present as syncope, is a contra-indication to spinal anaesthesia. The difficulty arises in clinically distinguishing benign murmurs from more dangerous ones. Echocardiograms are therefore being increasing used to help in the diagnosis of murmurs and to assess cardiovascular function in the pre-operative period.
CLINICAL MANAGEMENT
ANALGESIA
Analgesia is extremely important in the management of hip fracture . Poorly controlled pain will delay early mobilisation and result in the usual complications of prolonged bed rest as well as precipitating perioperative delirium7. Repeated studies show that demented patients or the cognitively impaired receive less analgesia than their non cognitively impaired counterparts.8 This is generally because nursing and medical staff rely on self reporting of pain and rarely consider behavioural ( moaning , sighing, guarded posture) or physiological ( tachycardia, high blood pressure) pointers to the presence of pain.
New anaesthetic techniques have added to the tools available in the perioperative period. Intrathecal opioid analgesia involves injection of a small amount of opioid analgesia into the cerebrospinal fluid via the subarachnoid space. This can give prolonged pain relief lasting for between 12 to 24 hours but care is required in the management of breakthrough pain. Local nerve blocks can also be used either separately or in combination with other anaesthetic techniques.
Patient controlled analgesia involves the intravenous injection of a small bolus of morphine controlled by the patient , helping to more accurately titrate the analgesia required to obtain optimum pain relief. This type of analgesia is best avoided in the confused patient.
Many units now have a dedicated pain team led by a consultant anaesthetist to aid in the management of difficult cases.
Remember intravenous paracetamol is a very useful analgesic agent for use in older patients with a fracture. It is far more potent than oral paracetamol and is equivalent to several mg of iv morphine sulphate. It is an attractive agent as it is:
• Non sedating
• Non constipating
• Does not cause respiratory depression
• Can be safely used in renal impairment
THROMBOPROPHYLAXIS
Elderly bed bound hip fracture patients are at high risk for developing thromboembolic events. There are several different types of thromboprophylactic measures available that can be used singly or in combination . These include low molecular weight heparin, intermittent pneumatic leg compression, oral anticoagulants, aspirin and thromboembolic stockings. The optimal regime is unknown due to the relatively small number of trials involving hip fracture patients9.
Early surgery, early mobilization and lack of transfusion are also important aspects of an thromboprophylaxis strategy.
NUTRITION / HYDRATION / PRESSURE SORE PREVENTION
Hydration , nutrition and pressure sore prevention are all closely interlinked. Most patients require intravenous fluid supplementation to maintain fluid balance and satisfactory renal function particularly as hip fracture operations can be repeatedly cancelled at short notice resulting in long periods of fasting.
Malnutrition is common in both elderly and orthopaedic patients11 and is associated with increased morbidity and mortality leading to longer hospital stays, higher infection rates and increased costs.12However it is unclear whether nutritional supplementation either orally or by nasogastric tube feeding improves outcomes.13 .
Pressure sore prevention should be considered at the earliest opportunity.Lying on a hard surface, such as a hospital trolley, for as short a time as 30 minutes can result in the development of a pressure sore14. Special pressure relieving mattresses, heel pads and regular movement should be employed immediately. Early mobilization in the postoperative period will also aid in pressure sore prophylaxis.
SURGERY
The vast majority of patients are operated on as conservative treatment involves prolonged bed rest and its subsequent complications.
The aims of surgery are to control pain and aid early mobilization. Ideally surgery should occur within 24 hours of injury if the patient is medically fit. Spinal anaesthesia is normally used as it is associated with less thromboembolic complications and reduced perioperative mortality15.
Hip fractures may be simply divided into two categories, intracapsular and extracapsular. The main blood supply to the femoral head is via the capsule and interruption of this can lead to avascular necrosis. Intracapsular fractures can be fixed by insertion of a hemiarthroplasty or by reduction and internal fixation(ie with a dynamic hip screw).
Antibiotics are given at the time of surgery to reduce wound, urine and chest infections.
Providing there have been no complications the patient can sit out the day after the operation.
COMPLICATIONS
The major complications specific to the surgery are:
Non union of the fracture
Avascular necrosis of the femoral head
Dislocation of a hemiarthroplasty
Subsequent fractures that occur beneath a prosthesis can be extremely difficult to rectify. Increasing numbers of such fractures mean that there is a need for orthopaedic surgeons skilled in their management.
Other perioperative complications include
Urinary tract infection
Pressure sores
Chest infection
Thrombo-embolism
Sepsis
Pseudo-obstruction
REHABILITATION
After a hip fracture operation a variety of options are available for the further care of the patient. Some patients may be suitable for early discharge to their home with appropriate support services,16 others may be discharged back to their nursing homes.
Selected patients may benefit from a further period in a rehabilitation unit with early involvement of a multidisciplinary team including medical staff, nursing staff, occupational therapists, physiotherapists, social workers, patients and their families
Patients with a good pre-fracture level of mobility and lack of mental impairment tend to benefit most from rehabilitation schemes.17 The period in rehabilitation obviously depends on the individual but can be in excess of 30 days.
Specialised units have been shown to improve outcomes in stroke but more studies are required to assess the effectiveness of co-ordinated multidisciplinary inpatient rehabilitation for elderly hip fracture patients.18,19
PREVENTION
Prevention is best considered in two ways: prevention of osteoporosis and prevention of the fall.
Prevention of osteoporosis is best started as early as possible by adopting an active lifestyle. Exercise has been shown to increase bone mass, density and strength and is best started in childhood or early adolescence20.
Exercise in later life helps to preserve bone rather than adding to it but also has a dual protective function in the elderly by helping to reduce falls21. This probably is as a result of improved gait, balance, co-ordination and muscle strength. It appears from the literature that you are never too old to exercise.
Bisphosphonates inhibit bone resorption and have been shown to reduce fracture rates at the hip and spine. Various agents are available but the regimes used can be complex or associated with unwelcome side effects such as oesophagitis ( alendronate).
Strontium is a relatively new agent which can be used in patients intolerant of bisphosphonates.
Selective Estrogen Receptor Modulators ( SERMS) have a role in the prevention of vertebral osteoporosis in postmenopausal women.
Calcium and vitamin D have been shown to reduce hip fracture rates in elderly women living in residential accommodation.23
Lifestyle factors such as smoking and alcohol can also have a detrimental effect on bone. Smoking may be responsible for as many as one hip fracture in eight amongst women.24
The impact of a fall may be cushioned by the use of hip protectors25 but larger trials are required to properly assess this intervention. Compliance can be a problem and the evidence base is insufficient to support their current use.
Preventing falls is possible by a number of interventions , such as removing environmental hazards, assessing medications, exercise programs and visual assessment. The evidence base supports the package of interventions but not the individual elements.
OUTCOMES
One of the most important functional outcomes is the patient’s ability to walk as this will have implications on future placement. Between 50-65% of patients regain their previous level of mobility, 10-15% do not recover the ability to walk outside the home and up to 20% become immobile.5
More than half will have returned to their original residence , 30% are more dependent on walking aids and most will have slight or occasional pain in their hip.27
One year after a hip fracture between 12-37% of patients have died and this can rise to almost 50% in patients with significant dementia.
Predictive factors for mortality include:
Age
Reduced mental status
Male sex
Active medical problems
Reduced Barthel score / reduced mobility pre-fracture
To give some idea of a patient’s medical fitness for surgery , anaesthetists often use the American Society of Anaesthetists( ASA ) grade :
1. Completely fit and healthy.
2. Some illness but this has no effect on normal daily activity, that is an asymptomatic condition such as hypertension.
3. Symptomatic illness present, but minimal restriction on life.
4. Symptomatic illness causing severe restriction on life.
5. Moribund.
Most elderly hip fracture patients are labeled as Grade 3 ASA
CONCLUSION
A hip fracture can be a catastrophe for an elderly person with major implications for their physical, psychological and social well being. Numbers are increasing and represent a major socio-economic burden on the health service. Well organized acute and rehabilitative care has the potential to benefit large numbers of elderly patients hopefully improving outcomes and independence.
As in all aspects of medicine, prevention is better than cure, especially when preventative strategies are available.
Pain Management in the Elderly Hip Fracture Patient
Introduction
Elderly patients probably occupy at least half the beds in our central fracture service and hip fracture operations alone account for between 20-25% of theatre cases.
The number of hip fracture cases could possibly double in the next 50 years1 which would have huge implications for an already over burdened health service.
The vast majority of hip fracture patients are operated on despite many being very frail and elderly.
The two major principles of surgery are to control the patient’s pain and to aid early mobilisation. Without surgery the patient is at risk of developing the complications of prolonged bed rest such as chest and urinary infections, thromboembolism, pressure sores and pseudo –obstruction.
Early mobilisation in the post operative period is dependent upon effective analgesia and is therefore one of the major mainstays in the management of the elderly fracture patient.2
The Effects of Pain
There is no consensus in the literature concerning decreased perception of pain with aging . However the effects of pain on an elderly patient’s physical, psychological and social well being can be immense.
If pain is not treated promptly this can lead to pain sensitisation where pain is experienced at lower thresholds than usual.
Delirium is a common perioperative complication of hip fracture surgery and can be caused by both pain and its treatment. Multifactorial interventions by both nurses3 and doctors4 which include effective pain management can reduce the levels of this distressing complication.
Acute pain together with the stress response to surgery can have multi-system consequences. Tachycardia, hypertension and increased peripheral resistance are common changes in the cardiovascular system. A fall that has resulted in bruised ribs as well as a hip fracture can result in respiratory complications such as hypoxia and an inability to deep breathe. Pain and its treatment can lead to pseudo-obstruction especially when combined with bed rest. The immune response is also modified due to a reduction in both humeral and cellular immunity5
Psychologically , depression and anxiety together with social isolation can result if pain is not adequately treated.
Pharmacokinectics and Pharmacodynamics in the Elderly
It is important to understand the physiological changes associated with aging and their consequent effects on drug handling. Adverse drug reactions are more common in the elderly normally due to a combination of polypharmacy and multiple co- morbidities superimposed on the normal changes associated with aging.
Adsorption
There is no major reduction in drug absorption with rising age6 despite reductions in intestinal epithelium, gut motility, splanchnic blood flow and possibly gastric acid secretion7
Distribution
The volume of distribution of many drugs is reduced due to reduced lean body mass, reduced total and percentage body water and increased percentage body fat. Serum albumin levels are also reduced which can result in adverse effects with highly protein bound drugs such as diazepam
Metabolism
There is a reduction in size and liver blood flow with age and the ability of the liver to recover from injury (ischaemia/ congestive heart failure). The reduction in first pass metabolism can result in higher bioavailability of certain drugs such as opiates.
Excretion
The most important pharmacokinectic change associated with aging is the reduction in glomerular filtration rate and creatinine clearance which can result in tissue concentrations of some drugs being increased by 50%8
Pharmacodynamics
Pharmacodynamics may be altered in the elderly largely due to a reduction in the number and response of receptors. In the case of opioids this can mean an increase in their anaesthetic, sedative and analgesic effects as well as making adverse effects such as respiratory depression more pronounced6
Pain Assessment
Under-recognised and unrelieved pain in elderly patients is a major problem mainly due to a lack of systematic assessment and documentation9 .Elderly patients tend to receive less analgesia than younger patients and cognitively impaired adults receive less analgesia than their cognitively intact colleagues10 . Perioperative hip fracture patients have been noted to experience unacceptable levels of pain.11
Pain can be detected by three major means:
1. Self report
2. Behavioural characteristics
3. Physiological response
Self report is probably the commonest way medical and nursing staff detect and treat pain but this method is unsatisfactory when used in isolation.Some patients may be reluctant to report pain for cultural or social reasons In particular demented patients who are normally agitated and vocal may become quiet and withdrawn.
In the cognitively impaired patient behavioural characteristics , both verbal and non verbal , can be used. Moaning , groaning , crying and sighing are common verbal responses to pain. Clutching and rubbing affected areas together with guarded postures and reluctance to move are useful non verbal clues.
The physiological response to pain may be manifested by a rise in blood pressure and respiratory rate or the development of a tachycardia. Obviously these changes are non specific.
Various tools are available to help in pain assessment including visual analogue scores and verbal descriptor scales . Other tools include using pictures of facial responses to pain which patients then point at to indicate their personal level of discomfort.12
These tools can be difficult for the elderly to use as a result of visual or hearing impairment together with musculoskeletal or cerebrovascular disease.
The absence of pain behaviour does not rule out the presence of pain13
More research is required into pain assessment especially in the cognitively impaired. Lessons could be learned from are Paediatric colleagues where there appears to be an abundance of assessment tools for a group of patients with similar problems at the other extreme of life.
Analgesic agents and Techniques
A long bone fracture normally results in severe pain and it is a priority that effective analgesia is given at the earliest opportunity which usually means in the Accident and Emergency department.
Strong analgesics such as morphine sulphate should not be denied to elderly patients due to inappropriate fears of addiction or over emphasis on side effects such as respiratory depression. It should be remembered that there are a variety of ways of effectively delivering these drugs:
• Oral
• Intramuscular
• Intravenous
• Intrathecal
• Subcutaneous
• Transdermal
• Rectal*
*The rectal bioavailability of morphine is similar to its oral bioavailability14
The gold standard is probably morphine sulphate given intravenously at a dose of 1mg/min titrated for effect. Patient controlled analgesia involves morphine sulphate being given as an intravenous bolus on demand. This type of analgesia may be appropriate for a highly select group of cognitively intact elderly patients but the high prevalence of perioperative delirium makes its use limited. More commonly morphine sulphate is given intramuscularly at a dose of 5-10mg in the perioperative period.
In recent years anaesthetic techniques have become more sophisticated. Spinal anaesthesia is being use increasingly as it is meant to reduce perioperative mortality and morbidity.15. Epidural analgesia involves a continuous infusion of analgesia continued into the postoperative period or it can be given as a single bolus. Intrathecal analgesia uses lower doses of opioids and involves the injection of a small amount of opioid into the subarachnoid space at the time of surgery. It can produce prolonged pain relief lasting up to 24 hours but respiratory depression can develop. Nerve blocks involve the infiltration of local anaesthetic usually to the femoral nerve and can be use in combination with other techniques such as general anaethesia.
Paradoxically pain may increase after a hip fracture is fixed as patients begin to mobilise and sit out. Postoperatively sevredol (an oral morphine derivative) can be used. Pain should be anticipated and analgesia given in advance of expected painful episodes ( such as sitting out or walking practice).
In the days following surgery analgesia should be appropriately assessed and step down analgesia used. Tramadol is an opioid used for moderate to severe pain and can be given orally, intramuscularly or intravenously. It is said to be less constipating and to cause less respiratory depression than other opioids but psychiatric reactions have been reported.
Paracetamol can be used for mild pain either alone or in combination with codeine.
Remember intravenous paracetamol is a very useful analgesic agent for use in older patients with a fracture. It is far more potent than oral paracetamol and is equivalent to several mg of iv morphine sulphate. It is an attractive agent as it is:
• Non sedating
• Non constipating
• Does not cause respiratory depression
• Can be safely used in renal impairment
Most of the analgesics employed can cause constipation and nausea and both these side effects should be anticipated and appropriate measures undertaken.
Non Steroidal Anti-inflammatory Drugs are very effective agents for controlling bone pain but their side effect profile means they should be avoided or used with great caution in the peri-operative period. Those patients at increased risk of nephrotoxicity16 are:
• The elderly
• Pre-existing renal impairment
• Volume contraction
- diuretics
- cardiac failure
- cirrhosis
- hypertension
- perioperative
The cox 2 inhibitors cause less gastro-intestinal side effects but nephrotoxicity remains a problem.
Non pharmacological pain management should not be forgotten and can range from massage or stretching exercises for muscle spasm to relaxation or distraction techniques for decreasing pain perception .
Conclusion
Pain management is of paramount importance in the elderly fracture patient. More research is required to develop better pain assessment tools for the elderly ( especially the cognitively impaired) to ensure their smooth passage through the peri-operative period into rehabilitation. All members of the multi –disciplinary team should be involved in pain management from its early detection to its successful treatment. The 10 principles of pain management stated by Ferrell in 199117 should be borne in mind:
1. Always ask elderly patients about pain.
2. Accept the patient’s word about pain and its intensity.
3. Never underestimate the potential effects of chronic pain on a patient’s overall condition and quality of life.
4. Be compulsive in the assessment of pain. An accurate diagnosis will lead to the most effective treatment.
5. Treat pain to facilitate diagnostic procedures. Don’t wait for a diagnosis to relieve suffering.
6. Use a combined approach of drug and non-drug strategies when possible.
7. Mobilize patients physically and psych-socially. Involve patients in their therapy.
8. Use analgesic drugs correctly. Start doses low and increase slowly. Achieve adequate doses and anticipate side effects.
9. Anticipate and attend to anxiety and depression.
10. Reassess responses to treatment. Alter therapy to maximize functional status and quality of life.
Points on the management of suspected pulmonary embolism
• A pulmonary embolism is not an uncommon event in fracture patients
• All patients should have their thromboembolic risk assessed on admission
• Presentation will depend on the extent of the embolism. A small clot might just cause transient breathlessness whilst a huge clot can cause a cardiorespiratory arrest
• Symptoms to look out for include shortness of breath, pleuritic chest pain (pain worse on inspiration- sharp “like a knife”) and coughing up blood (haemoptysis)
• Signs can be few and may be manifested solely by the presence of a tachycardia
• If suspected the following tests should be done:
- ECG
- CXR
- Arterial blood gas
• Remember that fractures are associated with bleeding and blood clotting. A d Dimer is therefore unhelpful in this setting
• Treatment should be commenced with enoxaparin either 1 mg per Kg bd or 11/2 mg/KG once daily
• Spinal patients need special consideration and treatment in the early post injury/surgery period should involve close liaison with a spinal surgeon
• In the absence of lung disease a V/Q scan can aid diagnosis.
• If a V/Q Scan is not appropriate (or comes back with an indeterminate result) then a CTPA should be ordered.
• Interventional radiology can help in difficult cases by inserting vena caval filters or by actually helping to physically remove the clot
Fat Embolism Syndrome
• Fat embolism is usually asymptomatic and develops in nearly all patients with bone fractures
• Fat embolism syndrome(FES) develops in the minority of patients and is associated with dysfunction of the lungs, skin and brain
• FES most commonly occurs in closed long bone and pelvic fractures
• Incidence after long bone fractures varies from 1-20%
• FES usually occurs 24-72 hours after the initial insult
• The classic triad is
- hypoxaemia
- neurological abnormalities
- petechial rash
• Respiratory manisfestations can vary from mild dyspnoea through to ARDS
• Neurological abnormalities consist of altered levels of consciousness, seizures or focal deficits
• The petechial rash is usually observed on the head, neck, anterior thorax, subconjunctiva and axillae
• Aetiology is uncertain and opinions vary that FES is caused by direct entry of fat globules from disrupted tissue into the bloodstream or the production of toxic intermediaries
• No test is diagnostic and the diagnosis of fat embolism remains a clinical one.
Adapted from an Editorial in CHEST : Georgopoulos :2003 vol:123 iss:4 pg:982
ALCOHOL WITHDRAWAL
Alcohol is a major cause of morbidity and mortality on the acute fracture ward.It has been implicated as a contributing factor in:
40 % of road traffic accidents
30% of fatal road traffic accidents
20-30% of all hospital admissions
It is not always apparent that a patient abuses alcohol and problems may not develop until after an expensive operative procedure has been carried out. If full blown delirium tremens develops then the potential cost in extra nursing / medical intervention can be huge. Preventiion is better than cure!
1. All patients admitted to the fracture ward should have an alcohol history documented. Safe weekly limits are 14 units for females and 21 units for males.Remember that alcohol abuse is not limited to the young.
2. History and examination may detect signs and symptoms of alcohol withdrawal:
anxiety , tremor , tachycardia , hypertension , agitation , anorexia , nausea , hyper-reflexia , insomnia , nightmares , sweating , hyperthermia , disorientation , seizures , hallucinations , delirium .
3. Simple blood investigations such as a raised gamma GT and a MCV (greater than 100) can detect as many as 75% of problem drinkers. Other less sensitive markers that may be a pointer to alcohol abuse include a low urea and low platelet count.
4.The liver is the centre for the manufacture of some clotting factors (2,7,9 AND 10) and if damaged coagulation times may be dangerously deranged. Therefore it is worthwhile doing a coagulation screen as a baseline investigation.
5. Delirium Tremens is a potentially dangerous complication of alcohol withdrawal due to the development of fits, hypothermia, dehydration, electrolyte imbalance, shock and chest infection. Mortality can approach 10%.
6.If alcohol abuse is suspected commence chlordiazepoxide- the dose can vary and is made on an individual assessment. A typical starting dose would be 30mg t.i.d. Lower doses may be needed if the patient has respiratory disease.The dose is then tapered off over the following seven days.
7. Deficiency of thiamine ( vit B1 ) can lead to syndromes such as Wernicke's Encephalopathy and Korsakoff's Syndrome. These may be prevented by giving thiamine. If this is given orally the usual dose is 200mg daily for about a month.
8.High risk patients may need parenteral thiamine-this comes as Pabrinex. Treatment may need to last for 3-6 days. Due to the risk of anaphylaxis it should be given slowly over 10 minutes.Intravenous dextrose should not be given before parenteral thiamine because of the risk of precipitating Wernicke's Encephalopathy.
Amiodarone
Baseline;
1. Clinical history & physical examination
2. Diagnostic investigation (12 – lead ECG, U&E, Ca, Mg, LFTs, TFTs, CXR, Echocardiogram, PFTs if considering long-term usage)
3. Look for common predisposing or precipitating factors, e.g;
| |Primary Cardiac causes | |Other causes |
|1. |IHD, acute coronary syndromes, previous MI |1. |Alcohol |
|2. |Congestive heart failure |2. |Hyperthyroidism |
|3. |Cardiomyopathy |3. |Electrolyte disturbance |
|4. |Congenital heart disease e.g. atrial septal defect |4. |Certain drugs (antiarrhythmic, stimulants) |
|5. |Valvular disease |5. |COPD |
|6. |Accessory pathway |6. |Fever, chest infection |
|7. |Hypertension | | |
4. Management with amiodarone
[pic]
Changeover from IV amiodarone to oral dosing
• As soon as adequate response is obtained, oral therapy can be initiated concomitantly with IV therapy (the IV amiodarone can be phased out gradually) at usual loading dose i.e. 200mg tid for one week, 200mg bd for one week then 200mg od.
• If long-term therapy is indicated, refer to monitoring requirements / patient information in Amiodarone Trust Policy (N.B. patients started on IV amiodarone for control of ventricular response to AF during acute illness often do not need to remain on amiodarone long-term – please check with cardiology staff).
5. Monitoring requirements - Perform hourly pump checks, BP, HR and venflon site. The patient needs to be on an ECG monitor during period of amiodarone infusion.
[pic]
6. Amiodarone interactions: - for full list see BNF;
1. Digoxin level doubled
2. Flecainide level doubled
3. Warfarin - INR increased
4. Phenytoin level increased
Protocol for the Prophylaxis of Venous Thromboembolism for the Trauma Unit
Redrafted: 25/06/09
This protocol has been developed as required by the new trust policy on the prevention of venous thromboembolism.. There is some disagreement between the producers of the major set of guidelines in this area as to the most effective and efficacious treatment. This has not been resolved by the publication of guidelines by NICE in 2007. The protocol has purposely been kept simple (using one main chemical thromboprophylaxis agent, given at one particular time) to aid implementation and compliance.
Objective
To reduce the incidence of venous thromboembolism in patients admitted to the trauma unit
• Every patient admitted to the trauma unit should have their thromboembolic risk assessed on admission. (See Appendix 1 + 2)
• Methods to reduce thromboembolism may involve the use of chemical agents (such as low molecular weight heparin), mechanical agents (graduated elastic compression stockings) or patient lifestyle measures ( early mobilisation, leg exercises, adequate hydration). These measures may be used singly or in combination.
• All fracture patients with a medium to high risk of venous thromboembolism should be commenced on enoxaparin 40mg given subcutaneously at 10pm unless a contraindication exists (see Appendix 3)
• The half life of enoxaparin is 10-12 hours and its peak effect occurs at 4-6 hours post administration. This should not interfere with spinal anaesthesia if given at 10pm the night before surgery.
• Doctors should be aware of heparin associated thrombocytopenia (HAT). This usually occurs between 5-10 days (up to 20 days) after initiation of heparin. HAT should be considered in any patient whose platelet count falls by 50% or more.
• If the patient is admitted on other drugs( such as aspirin or clopidogrel) which could increase the risk of bleeding perioperatively, these should be with-held in the perioperative period depending on the clinical picture.If the patient has had a cardiac stent in the last year cardiology should be consulted regarding discontinuation of the clopidogrel - -in this case aspirin can be continued
• NICE recommends mechanical methods of thromboprophylaxis such as graduated elastic compression stockings should be used in conjunction with chemical prophylaxis. The use of this intervention should be clearly documented in the nursing or medical notes.( for cautions and contraindications see Appendix 4)
• If the patient is admitted on warfarin , the protocol in appendix 5 should be consulted. If urgent reversal of the anticoagulation is required vitamin K can be used. Vitamin K takes 6-8 hours to work. Any further advice needed can be obtained from the ward based orthogeriatric team. In certain circumstances prothrombinase complex (Octaplex) can be given to rapidly reverse the effects of warfarin – this should always be discussed with a Consultant Haematologist
• If a venous thromboembolic event occurs prompt investigation and treatment should occur. Care should be taken when trying to interpret d dimmer results when trauma or surgery has occurred(as the d dimmer will be elevated by the associated blood clotting). This test should rarely be ordered in the setting of the acute trauma ward in the perioperative period.
• The use of interventional radiology should not be forgotten in the management of difficult cases (ie the insertion of vena caval filters in the actively bleeding patient with diagnosed thromboembolic disease).Vascular surgery should also be involved in any discussions about vena caval filters
• In those patients whose thromboembolic risk remains high at discharge, arrangements should be put in place with the General Practitioner to ensure the continuation of thromboprophylaxis for the appropriate period. Examples of when to use extended thromboprophylaxis for 6 weeks include post:
- pelvic surgery
- bilateral lower limb injury
- polytrauma
- traumatic spine injury
• With regard to hip fracture surgery, patients going back to their home environment should be considered for extended thromboprophylaxis for 35 days post fracture.
• Care needs to be used when dealing with spinal patients because of the risk of spinal haematoma. Elective spinal patients should have their thromboembolic risk assessed as per other admissions. In general graduated elastic compression stockings should be used preoperatively and enoxaparin commenced 24 hours posoperatively unless otherwise stated.
• Acute spinal cord injury patients have one of the highest incidences of DVT among hospitalised groups. Enoxaparin at the 40mg dose should be commenced when primary haemostasis is evident (after 24 hours). Graduated elastic compression stockings can be used initially until this time frame has elapsed. If there is going to be a prolonged preoperative delay enoxaparin can be used after 24 hours but should be omitted the night before surgery.
• Put simply in spinal patients, enoxaparin should be commenced 24 hours after injury, stopped the night before surgery and recommenced 24 hours after surgery
• This protocol will be discussed at each induction of the new house officers and they will be given their own personal copy of the instructions.
USEFUL REFERENCES
1.The Prevention of Venous Thromboembolism in Hospitalised Patients. House of Commons Health Committee. Second Report of Session 2004-05. Feb 2005. parliament.uk/parliamentary_committees/health_committee.cfm
2. Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery. NICE Guidance:
APPENDICES
Appendix 1 : Example of risk Categorisation
Appendix 2 : Risk factors for venous thromboembolism
Appendix 3 : Contraindications and cautions for aspirin and heparins in prophylaxis of venous thromboembolism
Appendix 4 : Contraindications and cautions for use of graduated elastic compression stockings
Appendix 5 : Management of the patient admitted on warfarin
Appendix 1
Example of Risk Categorisation1
Low risk
• Minor surgery ( 30 min), age 40 yrs or other risk factor
• Major medical illness or malignancy
• Major trauma or burn
• Minor surgery, trauma or illness in patients with previous DVT, PE or
thrombophilia
High risk
• Fracture or major orthopaedic surgery of pelvis, hip or lower limb
• Major pelvic or abdominal surgery for cancer
• Major surgery, trauma or illness in patient with previous DVT, PE or
thrombophilia
• Major lower limb amputation
1. The Prevention of Venous Thromboembolism in Hospitalised Patients .House of Commons Health Committee. Page 16
2. i.e. surgery lasting less than 30 minutes.
Appendix 2
Table 1: Risk factors for venous thromboembolism 1
|Age |Exponential increase in risk with age. In the general population: |
| |< 40 years - annual risk 1/10,000 |
| |60-69 years - annual risk 1/1,000 |
| |> 80 years - annual risk 1/100 |
| |May reflect immobility and coagulation activation |
|Obesity |3 x risk if obese (body mass index >= 30 kg/m2) |
| |May reflect immobility and coagulation activation |
|Varicose veins |1.5 x risk after major general / orthopaedic surgery |
| |But low risk after varicose vein surgery |
|Previous VTE |Recurrence rate 5% / year, increased by surgery |
|Thrombophilias |Low coagulation inhibitors (antithrombin, protein C or S) |
| |Activated protein C resistance (e.g. factor V Leiden) |
| |High coagulation factors (I, II, VIII, IX, XI) |
| |Antiphospholipid syndrome |
| |High homocysteine |
|Other thrombotic states |Malignancy 7 x risk in the general population |
| |Heart failure |
| |Recent myocardial infarction / stroke |
| |Severe infection |
| |Inflammatory bowel disease, nephrotic syndrome |
| |Polycythaemia, paraproteinaemia |
| |Bechet’s disease, paroxysmal nocturnal haemoglobinuria |
|Hormone therapy |Oral combined contraceptives, HRT, raloxifene, tamoxifen 3 x risk |
| |High-dose progestogens 6 x risk |
|Pregnancy, puerperium |10 x risk |
|Immobility |Bedrest > 3 days, plaster cast, paralysis, 10 x risk; increases with duration |
|Prolonged travel | |
|Hospitalisation |Acute trauma, acute illness, surgery 10 x risk |
|Anaesthesia |2 x general vs spinal / epidural |
Appendix 3
Table 1 : Contraindications and cautions for aspirin and heparins in prophylaxis of VTE 1*
|CONTRAINDICATIONS |CAUTIONS |
|Uncorrected bleeding disorders, e.g. |Asthma (aspirin) |
|haemophilias |Severe liver impairment, alcoholism |
|oral anticoagulants |Severe kidney impairment |
|platelet count ................
................
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