Nurse Practitioner Emergency Services CLINICAL PRACTICE GUIDELINE Chest Wall Injuries
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1 Nurse Practitioner Medical Practitioner +/- Nurse Practitioner Nurse Practitioner Emergency Services Scope Chest wall injury, localised pain & or crepitus, swelling or deformity Compound Fracture / obvious fracture dislocation / dislocation Open / Penetrating Injury Suspected sternal fracture Injury resulting from significant force Sepsis Airway / Breathing / Ventilation compromise Multiple injuries Altered conscious state including effects of drugs / alcohol History consistent with collapse Identify patients suitable for NP (Emergency) CPG Identify patients not suitable for NP (Emergency) CPG and redirect Mx to usual ED care with NP (Emergency) part of the ED. Initial Assessment & Interventions The major goal is to detect the presence of underlying thoracic or abdominal injuries such as pneumothorax, haemothorax, pulmonary contusion or significant vascular trauma 1. Primary Survey Airway Cervical Spine Breathing Circulation Disability History Mechanism of injuries sustained Treatment given pre hospital management Time of injury Cause: Intentional / Unintentional / Non Accidental Injury (NAI) Chest wall deformity Past medical history, any previous pulmonary or cardiac history / medications Allergies / Immunisations Last food / fluids Compensable status MVIT / WC / DVA / Private Insurance Focused clinical assessment Chest Inspection to assess location & extent of injury Classify by: - Severity Closed / Contusion / Superficial / Penetrating / Open Degree of Contamination Clean / Contaminated / Infected Depth epidermis / dermis / subcutaneous / muscle fascia / bone Description and Location: Lac / Abrasion / Contusion / Incision / Puncture Rib / Rib level Abnormal primary survey identified exit CPG Exclusion criteria identified exit CPG. Referral to EP +/- NP (Emergency) as part of Exclusion criteria identified exit CPG. Referral to EP +/- NP (Emergency) as part of 1
2 Paradoxical motion: flail segment Surgical Emphysema Chest Palpation Chest Auscultation Chest Percussion Work of breathing Baseline observations: T, HR, BP, RR, SpO2 ECG: reviewed by Senior ED Doctor or Consultant Abdominal assessment Renal assessment & urinalysis Acute abdominal pain or significant tenderness- rev by senior ED Doctor / Consultant, +/- CT scan Pain assessment Pain scale Determine need for and type of analgesia Analgesia / First Aid Initially Rest Ice Chest wall Support during cough / deep inspiration Administration of analgesia (see medications) Reduction / relief of pain Minimise / prevent swelling Decrease dyspnoea Reduce risk of chest infection / consolidation Imaging Pathology ECG Working Diagnosis and Investigations May not be required Patient less than 65 years of age 2 with no bony tenderness, no respiratory discomfort & / or minimal force of injury CXR maybe required when Bony tenderness Deformity Pain on inspiration & / or cough Increased work of breathing Decreased breath sounds* Hyperresonant hemithorax* Not routinely indicated but consider necessity for IV access and insert cannulae if required Investigations may include VBG, FBP, U&E, Troponin, Group and Hold as discussed with Senior ED Doctor or ED Consultant. To evaluate for suspected cardiac blunt trauma +/- cardiac enzymes as discussed with ED senior Doctor/Consultant. ECG should not be required in patients less than 55 Years of age with no bony tenderness, respiratory discomfort & / or minimal force of injury & no cardiopulmonary disease risk factors in past medical history. Reviewed by Senior ED Doctor or ED consultant Patient not subjected to unnecessary investigations. Identify specific injury and determine patient management including CXR in resus* Ongoing assessment of need for intravenous access The presence of a normal ECG and cardiac markers has been demonstrated to indicate patients at low risk for cardiac contusion 1. 2
3 Interpretation of Results (diagnostic features) and Management Decisions Imaging ± clinical features No pathology seen: Fracture Space Occupying Lesion Pulmonary Contusion or Costochondral Separation Rib Fracture/Fractures Identified Space Occupying Lesion Pulmonary Contusion Costochondral Separation Chest Wall Bruising/ Contusion/ Abrasion Intercostal Strain Associated care NP (Emergency) review with view to discharge patient education / health promotion Analgesia as required: See formulary P5 Follow-up appointment with GP if required Referral to physiotherapy as required NP (Emergency) & Senior ED Doctor/Consultant review Aligned, Segmented, Fragmented, how many? Fractures ribs 8-12 carry increased risk of abdominal trauma 4 Fractures 1 st & 2 nd Rib associated with significant force injury: Risk cranial, vascular, thoracic & abdominal injuries 5 Rib fragments: Risk penetration resulting in Haemo or Pneumothorax 5 Flail: Risk of ventilatory insufficiency 5 Discuss with & Senior ED Doctor/Consultant for patient care in main dept or resuscitation area as appropriate NP (Emergency) review with view to discharge patient education / health promotion Analgesia as required: See formulary follow-up appointment with GP if required Referral to physiotherapy as required NP (Emergency) review with view to discharge patient education / health promotion Analgesia as required: See formulary follow-up appointment with GP if required Referral to physiotherapy as required Consider IV fluids for patients who require fasting for surgical intervention Patient discharged Adequate pain control, early mobilisation, and meticulous respiratory care can prevent respiratory complications in patients with rib fractures 3. Children: Consider NAI if lack of significant mechanism for multiple fractures or fractures of different healing stages. Children <2yrs with rib fractures have prevalence NAI up to 83% 5 Exclusion criteria identified exit CPG. Referral to EP +/- NP (Emergency) as part of Exclusion criteria identified exit CPG. Referral to EP +/- NP (Emergency) as part of Acute Referral Consider Referral as Required +/-Medical +/- Physiotherapy +/- Interpreter +/- Allied health. Holistic Management of Patient. 3
4 When to return Patient Discharge Education Verbal instructions from NP (Emergency) Sudden onset shortness of breath Increasing discomfort chest/abdomen Fever Productive cough Not coping at with pain Follow up appointments Medication instructions Safety assessment i.e. ability to mobilize comfortably Other Referrals Verbal instructions from NP (Emergency) Written instructions for GP & / or Community physiotherapist (if applicable) OP appointment (if applicable) Verbal instructions from NP (Emergency) Contact ED Pharmacist to provide medication education for patient when available. Written information as per the Hospital Pharmacy on medications dispensed. Ambulation instructions from NP (Emergency) / physiotherapist Avoid activities aggravate injury: Sport 6 Patients > 60 yrs of age, consider referrals Referrals may be made for specific patient problems or as required to; - social work - physiotherapy - drug and alcohol counsellor - aboriginal health officer Certificates Absence from work certificates WC certificate Certificate of attendance Appropriate documentation completed Letters Local GP letter Ensures continuity of care and referral to health care 4
5 Medication All medication will be stored, labeled and dispensed in accordance with hospital policy and relevant legislation 7 Simple analgesia Paracetamol 500mg: 2 tablets 4 to 6 hourly, not to exceed 8 S2 8 tablets in 24 hours. Mild Children: Paracetamol: 15 mg/kg 4 hourly up to 4 times a day. Not to exceed 4 doses in 24 hours OR add to Paracetamol; Ibuprofen: 400 mg orally 6 to 8 hourly to maximum of 1600 mg in 24 hours (with food). Children: Ibuprofen: 10 mg/kg 3 to 4 times daily (over 3 months of age) Patients given analgesia appropriate to allergies, current medications and past medical history Analgesia requirements determined by ongoing assessment of pain and adequate analgesia provided Patients with excessive pain or pain unrelieved by analgesia need review by EP NSAIDS S4 8 Moderate Instead of Paracetamol, Panadeine Forte: 1 to 2 tablets 4 to 6 hourly, not to exceed 8 tablets in 24 hours. Painstop Day: 0.6 to 0.8 mls/kg (over 1 year old) 4 to 6 hourly. Not to exceed 4 doses in 24 hours OR Naproxen: Adults; 500 mg initially then 250 mg 6 8 hourly to maximum 1250 mg in 24 hours (with food) If NSAIDS contraindicated, Adults and Children > 12 years Contraindicated in epilepsy, SSRI use Caution in the Elderly Maximum 300 mg daily Tramadol Oral: mg QID, maximum 400mg over 24 hours OR Tramadol Intravenous/Intramuscular: 50 to100mg QID, maximum 600mg over 24 hours Narcotic Analgesia 8 S8 Severe Reassess ADD to the above if still in pain Hyperlink to schedule 8 CPG IF PAIN NOT CONTROLLED WITH ALL 3 AGENTS, REFER TO ED CONSULTANT 5
6 Unexpected representation Missed problem Injury in children <2yrs Clinical audit evaluation strategies Emergency Department attendance register and NP (Emergency) clinical log Emergency Department x-ray review Emergency Department injury review References 1. Thoracic Trauma-rib Fractures, Clinical Evaluation (ND). 24/05/ Mancini, M.C, (2012). Blunt Chest Trauma. Medscape Reference Drugs, Disease and Procedures, 28/03/ Nadalo, L.A, (2011). Rib Fracture Imaging. Medscape Reference Drugs, Disease and Procedures, 24/05/ Bruce, J.S et al, (2005). Pain management guidelines for blunt thoracic trauma, The Journal of Trauma Injury Infection and critical care. (59) p Mahoney, L.k, (2010). Rib Fracture. Medscape Reference Drugs, Disease and Procedures, 28/03/ Victorian Government (2012). Better Health Channel Rib Injuries, 28/03/ JHC Hospital Medication Storage and Administration Policy. Available via Hospital Intranet 8. emims 2006 [cited 2006 Mar 16]; Available via Hospital Intranet 6
7 Authorship and endorsement (This Guideline has been developed in collaboration with the JHC ENP CPG Review Committee) This CPG was written by: This CPG has been reviewed and is endorsed by: Ann Hope Nurse Practitioner Emergency Services Joondalup Health Campus Dr Cameron Burrows FACEM Director of Emergency Medicine Signature: Date: Anthony Lourensen FACEM Emergency Consultant Signature: Date: Bronwyn Nicholson Nurse Practitioner Emergency Services Signature: Date: Dr Steve Ward Haematologist Head of Department of Pathology Signature: Date: Dr Martin Marshall Radiologist Perth Radiological Clinic Signature: Date: Mayli Foong Pharmacist Joondalup Health Campus Pharmacy Signature: Date: 7
8 Key to terms BD- Twice Daily BP- Blood Pressure CPG- Clinical Practice Guideline CXR- Chest X-Ray DVA- Department of Veteran Affairs ECG- Electrocardiogram ED- Emergency Department EP- Emergency Physician FBP- Full Blood Picture GP- General Practitioner HR- Heart rate Hrs- Hours IV- Intravenous Kg- Kilogram(s) Mg- Milligram(s) MVIT Motor Vehicle Insurance Trust Mx- Management NAI- Non Accidental Injury NP (Emergency) Nurse Practitioner Emergency Services OP- Outpatients QID- Four Times a day RR- Respiratory Rate SpO2- Saturation of Peripheral Oxygen SSRI- Selective Serotonin Reuptake Inhibitors S1-S4-S8- Schedule of the drug administration act T Temperature U&E- Urea & Electrolytes VBG- Venous Blood gas WC- Workers Compensation # - Fracture Written: June 2013 Reviewed: N/A Appendices Review date: 8
9 Notes for Guideline Use Statement of Intent This clinical practice guideline is intended for use by Nurse Practitioners working in the Emergency Department of Joondalup Health Campus. This clinical practice guideline is intended to serve as a guide for the Nurse Practitioner in the Management of. Standards of care are determined on the basis of clinical data available and are subject to change as scientific knowledge and technology advance and patterns of care evolve. The parameters of practice within this clinical practice guideline should be considered a guide only. Adherence to them will not ensure a successful outcome in every case, nor should they be interpreted as including all proper methods of care or excluding other acceptable methods of care aimed at the same result. The judgment regarding a clinical procedure or treatment plan must be made by the Nurse Practitioner in the light of clinical data presented combined with the best available evidence, diagnostic and treatment options available. In making clinical decisions the Nurse Practitioner should remain cognisant of their level of expertise and scope of practice and take advantage of the expertise of other clinicians for consultation and inclusion into the treating to optimize patient care and discharge. This may involve direct referral and/or consultation. 9
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