ED nurse initiated Mx of isolated limb injuries

see also:

• EM nursing
• nurse initiated ED treatment
• ED nurse initiated analgesia
• Western Health policies (intranet only):
  • Nurse initiated procedures
  • Nurse Initiated X-rays
  • Nurse Initiated Intravenous Opioid Analgesia Standing Orders

• the following is a suggested framework for ED's who have nurses accredited to undertake ED nurse initiated treatment including the ordering of x-rays.

• see also: basic nursing assessment common to all pathways
• mechanism of injury
• could it be non-accidental (eg. children or the elderly at risk in particular)
• time of injury
• last ate and drank (keep nil orally if likely to need anaesthetics)
• if open wound, last tetanus injection
• if possible fracture, is the wound open, if so, cleanse and dress and inform medical team as will likely need operative Mx and iv antibiotics, plus tetanus prophylaxis
• neurovascular assessment
• if ankle injury, is the ankle deformed - this would manadate IMMEDIATE (within 10-20minutes) reduction by medical staff PRIOR to Xrays to reduce risk of skin necrosis
• check that a ED major trauma call is not required

• suspected compound fracture
• possible neurovascular compromise present
• dislocations or fractures requiring urgent reduction or opioid analgesia
• suspected non-accidental injury in children
• the pregnant patient
• multiple trauma

• simple closed injuries distal to and including the elbow and suspected clavicular fractures.
• simple closed injuries distal to and including the knee
• injuries that exhibit signs of a fracture:
  • deformity
  • bony tenderness
  • pain
  • swelling
  • loss of function
  • NB. it is not necessary to test for crepitus
• consider use of recognised “rules” for need for X-rays
  • Ottawa ankle rules

• triage 1 or 2 category
• workload is such that an ED doctor will be able to assess patient in a timely manner
• minor injuries that do not need x-rays as per x-ray “rules”
• probable pulled elbow in children
• non-accidental injuries in children
• pregnancy
• comparative or stress views
• CT scans or MRI scans