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ED nurse initiated Mx of isolated limb injuries


  • 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.

specific history and examination

  • 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

nurse initiated X-rays

BEFORE ordering xrays, document pregnancy status and if pregnant, ensure Xray has been approved by an ED doctor and radiology staff are aware so they can shield the foetus.

discuss with ED doctor if

  • 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

indications for nurse initiated x-ray

  • 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

exclusions for nurse initiated x-rays

  • 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
nursing/limb_trauma.txt · Last modified: 2012/07/19 14:24 (external edit)