Nurse Practitioner Medical Practitioner +/- Nurse Practitioner Scope All open wound injuries Identify patients suitable for NP CPG Wound requiring specialist suture technique Identify patients not suitable Uncontrolled haemorrhage for NP CPG and redirect to Compensable status MVIT/WC (all assessment and GP +/- NP in team documentation must be completed by a GP) Initial Assessment and Interventions Primary Survey Airway Breathing Circulation History MIST: Mechanism: Injuries sustained; Signs vitals Treatment given/pre hospital management/time Range of movement/ability to weight bear Deformity Past medical history/medications Allergies/immunisations/tetanus status Focussed Clinical Assessment Neurovascular Assessment Last food/fluids Assess size and location of wound Classify by: - Severity Superficial/Penetrating Degree of Contamination clean/contaminated/infected Tidy/untidy straight edges vs. jagged edges Depth epidermis/dermis/subcutaneous/muscle fascia/bone Cause intentional/unintentional NB: Clenched fist/animal or human bite preference is wound healing by secondary intention Description cut/laceration/abrasion/contusion/ incision/puncture Consider referral for: o Facial wounds o Wounds overlying a joint o Wounds in young children o Injuries involving tendons o Nerve damage o Contaminated wounds o Untidy wounds (see acute referrals) After anesthetising wound: Thoroughly explore wound for any underlying structures i.e. tendon injury If bony tenderness or suspicion of foreign body see appropriate CPG Colour Warmth Movement Abnormal primary survey identified exit CPG Identify patients not suitable for NP CPG exit CPG Determine method of closure and additional management required D/W GP re need for referral for specialist consult/management (as appropriate). Identify patients not suitable for NP CPG exit CPG 1
Pain Assessment Analgesia / First Aid Management Sensation complete sensory loss partial sensory loss/hypoesthesia Capillary refill Peripheral pulse Nerves/tendons (a thorough understanding of colour, anatomy and function of the injured limb is essential for proper management) Pain score Determine need for and type of analgesia First Aid Reduction/relief of pain. o Rest o Ice/immobilisation o Compression o Elevation Administration of analgesia (see medications) Consider early application of Local Anaesthetic after thorough assessment and documentation of neurovascular function Working diagnosis and Investigations Imaging No imaging required where there is no suspicion of bony injury or foreign body X-ray required if: Pathology o Pain and localised tenderness suggestive of bony injury o Suspicion of foreign body Ultrasound in addition to X-ray may be required if non radio opaque foreign body is suspected Not routinely indicated but consider: Wound swab if moderate or severe infection, especially where there is: Cellulitis Signs and symptoms of systemic infection Delayed presentation Insert cannula if required If surgical repair required, pre operative investigations may include FBP, U&E, Group & Hold, and INR as discussed with admitting medical officer / specialist Minimise or prevention of complications Detect foreign body or determine joint involvement Ongoing assessment of need for intravenous access Referral to acute care facility identifies need for preoperative investigations performed as requested Diagnosis Clean wound appears clean, no evidence of contamination, healthy tissue present, good opposition of wound edges evident Tidy/untidy straight edges vs. jagged edges see acute referral Contaminated wound see acute referral Nerve damage see acute referral Patient identified as suitable for NP CPG and discharged safely Correct diagnosis made and patient management carried out and/or referred to acute 2
Tendon damage see acute referral Other Need for antibiotics and or tetanus immunoprophylaxis will depend on patient MIST, wound examination findings and whether delayed presentation as per therapeutics guidelines. Interpretation of results (diagnostic features) & Management decisions Cleaning of Wounds Management Associated Care Acute Referral Wound irrigation: A 30ml syringe attached to 19g cannula without the stylet should be used to vigorously irrigate with 0.9% NaCl Wound cleansing Chlorhexidine solution soaked gauze used to topically clean wound Contaminated wounds 1% Povidine Iodine applied for 3 5 minutes then washed off a. Tissue Adhesive Simple wounds <3cm in length ensure good wound edge approximation Consider for wounds in children b. Steri-strip May be adequate in simple wounds in areas with little skin tension i.e. not over joints requires patient compliance, keep dry for 72hrs, minimal movement etc. c. Suture Select appropriate suture material absorbable/nonabsorbable Wound usually requires infiltration with local anaesthetic which allows for thorough wound examination/cleaning d. Dressing Dressing will be required for closure of wounds. Select appropriate dressing according to need. Consider: - Absorption of blood/ exudate Wound immobilisation/pain relief Application of pressure Occlusion from dirt, bacteria and inquisitive fingers Aesthetic covering Consider: ECG for patients > 65yrs who require surgical intervention Consider need for acute referral for: Facial wounds requiring Plastics/Surgical specialty review Wounds overlying a joint requiring Surgical/Orthopaedic specialty review Wounds in young children Tendon damage evidence of peripheral tendon damage after focussed clinical examination and direct visualisation of wound may require specialty unit review (dependant on injury sustained and location) care facility / specialist consult for management +/- admission (see acute referral) Selection of appropriate closure material will ensure good wound healing and cosmesis Correct diagnosis made D/W GP to identify +/- need for referral to acute care facility or specialist consult for management +/- admission 3
Contaminated wounds evidence of contamination and presence of debris in wound, devitalisation of wound edges o Extent of contamination of the wound will determine whether referral to Plastics unit is required as the wound may require surgical debridement in an operating theatre if extensive. Jagged edges may require debridement or specialist suture technique Patient discharge education When to return Verbal/written instructions from NP Written patient education information Follow up appointment Medication instructions POP care (where appropriate) Safety Assessment i.e. crutches Ensure patient understands problem, treatment, follow up Verbal/written instructions from NP Ensure patient understands Verbal/written instructions from NP/GP Ensure patient understands Verbal/written instructions from NP Written patient education Refer patient for crutches as appropriate Patients > 60 yrs of age consider referrals Other Referrals Consider referrals for specific patient problems as required: Social Work Physiotherapy SW Community Drug Service Team Aboriginal Liaison Officer SW 24 / SW Mental Health Service Interpreter Silver Chain Hospital @ Home Certificates Absence from work certificates Certificate of attendance Ensure patient understands Ensure patient understands Ensure patient understands Ensure appropriate documentation completed Refer to GP for relevant WC and MVIT documentation Letter Copy of notes to specialist or acute care facility Ensure continuity of care and referral to health care team GP to complete BDH Patient Admission Pack 4
Medications All medications will be stored, labelled and dispensed in accordance with hospital policy and relevant legislation MILD PAIN S2 S4 Simple analgesia On initial assessment of mild pain: ADULTS: Paracetamol: 500mg 1g 4-6 hourly PO/PR, not to exceed 4g in 24hr Paracetamol 500mg/Codeine 8mg per tablet: 1 or 2 tablets PO 4 6 hourly, not to exceed 8 tablets in 24hrs. CHILDREN Paracetamol: 15mg/kg/dose 4 hourly PO/PR up to 4 times/day. Not to exceed 4 doses in 24hrs Painstop Day: 0.6 0.8ml/kg PO 4 6 hourly. Not to exceed 4 doses in 24hrs. Painstop Night: 6 8 hourly PO: Max 3 doses in 24hrs Age: 2yrs: 4-5ml; 3-4yrs: 6-7ml; 5-6yrs: 7-8ml; 7-8yrs: 9-10ml Total daily maximum of paracetamol 60mg/kg/24hrs for the first 48hrs, thereafter 60mg/kg/24hrs. CAUTION: PAINSTOP NIGHT When dosing at maximum level of paracetamol: dose will deliver a larger than recommended promethazine dose and may give a higher than necessary codeine dose leading to an increase in sedation. Patients given analgesia appropriate to allergies, current medications and past medical history Analgesia requirements are determined by ongoing assessment of pain and the provision of adequate analgesia Patients with excessive pain or pain unrelieved by analgesia review by GP MODERATE PAIN S2 S4 On initial assessment of moderate pain or failure to relieve mild pain: ADULTS: Paracetamol 500mg/Codeine 30mg per tablet: 1 or 2 tablets PO 4 6 hourly, not to exceed 8 tablets in 24hrs AND/ Naproxen: 500mg PO initially then 250mg 6 8 hourly Ibuprofen:400mg PO 3 4 times daily CHILDREN Ibuprofen: 10mg/kg PO 3 4 times daily to maximum of 600mg in 24hrs Failure to control moderate pain Discuss further management with GP If NSAIDS contraindicated: Tramadol (adults and children>12yrs) o Oral: 50-100mg QID, maximum 400mg over 5
SEVERE reassess Narcotic Analgesia S8 Anti-emetic S4 PRN Local Analgesia (LA) S4 Antibiotics S4 24hrs o IM: 50-100mg QID, maximum 600mg over 24hrs Special Note: TRAMADOL: Contraindicated in epilepsy and SSRI use. Caution must be used in the elderly maximum dose 300mg daily NOTE: Currently NP s require medical prescription for S8 medications ADULTS (only) Morphine: IM: 5 10mg single dose CHILDREN Morphine: IM: 0.2mg/kg single dose Consider need for: Metoclopramide hydrochloride: PO/IM/IV o Adult > 60kg: 10mg 3 times per day o 30-59kg: 5mg 3 times per day o 20-29kg: 2.5mg 3 times per day o 15-19kg: 2mg 2-3 times per day o 10-14kg: 1mg 2-3 times per day o <10kg: 0.1mg/kg (maximum 1mg) twice daily Total daily dose should not normally exceed 0.5mg/kg, especially in children and young adults. Procholperazine: ADULT Oral - Initially 20mg, then 10mg 2 hours later; if still needed, 5-10mg 3 times daily IM/IV 12.5mg 8 hourly as needed Rectal 25mg followed by oral medication (if possible) 6 hours later CHILDREN > 2YRS Oral 250micrograms/kg 2-3 times daily Lignocaine 1% (plain) Lignocaine 1% with adrenaline 1:100,000 *Administration via infiltration techniques: Lignocaine (plain): MAX dose 3mg/kg Lignocaine (with adrenaline): MAX 7mg/kg *Consider need for digital nerve block **Preparations containing ADRENALINE are not to be used on digits, nose, ears, penis or contaminated wounds. - The use and appropriateness of antibiotic therapy in the treatment of potentially infected/infected wounds depends on the cause, condition, and likely microbial organisms to be treated. - Refer to the Antibiotic Therapeutic Guidelines for appropriate antibiotic drug administration. Initial assessment of severe pain discuss further management with GP CLEAN WOUNDS 6
LOW RISK: Not Routinely used for clean wounds not involving tendons or joints that can be adequately debrided and irrigate and are seen within 8 hours HIGH RISK/ESTABLISHED INFECTION including delayed presentation or difficult debridement Di/flucloxacillin: 500mg (child: 12.5mg/kg up to 500mg) PO 6 hourly for 5 days Metronidazole: 400mg (child:10mg/kg up to 400mg) PO 12 hourly for 5 days Alternatively use: Amoxycillin + clavulanate: 875 + 125mg (child: 22.5 + 3.2mg/kg up to 875 + 125mg) PO 12 hourly for 5 days *Patients with penicillin hypersensitivity: Cephalexin: 500mg (child: 12.5mg/kg up to 500mg) 6 hourly for 5 days Metronidazole: 400mg (child: 10mg/kg up to 400mg) PO 12 hourly 5 days CONTAMINATED WOUNDS Di/flucloxacillin: 2g (child: 50mg/kg up to 2g) IV 6 hourly Gentamicin: 4-6mg/kg (child: <10yrs 7.5mg/kg; > 10 years: 6mg/kg) IV daily (adjust dose for renal function) Metronidazole: 500mg (child: 12.5mg/kg up to 500mg) IV 12 hourly *Patients with penicillin hypersensitivity: Metronidazole: 500mg (child: 12.5mg/kg up to 500mg) IV 12 hourly Cephazolin:2g (child: 50mg/kg up to 2g) IV 8 hourly Cephalothin: 2g (child: 50mg/kg up to 2g) IV 6 hourly NOTE: Duration of treatment should be at least 5 days. Correct diagnosis made D/W GP to identify +/- need for referral to acute care facility or specialist consult for management +/- admission CLENCHED FIST/ANIMAL and HUMAN BITES HIGH RISK: o Delayed presentation o Puncture/difficult debridement o Wounds on hands/feet/face o Involving underlying structures eg joints/tendons Amoxycillin + Clavulanate: 875 + 125mg (child: 22.5 + 3.2mg/kg up to 875 + 125mg) PO 12 hourly for 5 days 7
Vaccine/ Immunisation S4 Unexpected representation NP Clinical Practice NP Nurse Practitioner GP General Practitioner S1 S4; S8 Schedule of the drug administration act Procaine penicillin: 1.5g (child 50mg/kg up to 1.5g) IM single dose (if commencement of above delayed) followed by above. ESTABLISHMENT INFECTION &/ SEVERE PRENETRATING INJURY Metronidazole: 400mg (child: 10mg/kg up to 400mg) PO 12 hourly (consider initial IV dose) Cefotaxime: 1g (child 25mg/kg up to 1g) IV 8 hourly Ceftriaxone: 1g (child: 25mg/kg up to 1g) IV daily Alternatively use: Ticarcillin + Clavulanate (Timentin): 3 + 1.0g (child: 50+ 1.7mg/kg up to 3+ 1.0g) IV 6 hourly *Patients with penicillin hypersensitivity: Metronidazole:400mg (child: 10mg/kg up to 400mg) PO 12 hourly EITHER Doxycycline: 200mg (child >8yrs 5mg/kg up to 200mg) PO for 1 st dose, then 100mg (child 2.5mg.kg up to 100mg) PO daily Trimethoprim + sulfamethoxazole: 160 + 800 mg (child 4 + 20mg/kg up to 160 + 800 mg) PO 12 hourly Ciprofloxacin: (authority prescription) 500mg (child:10mg/kg up to 500mg) PO 12 hourly days NOTE: A low threshold should exist for discussing these patients with a Specialist Consultant/Infectious Disease for appropriate therapy and management regimes *Consider tetanus immuno-prophylaxis in tetanus prone wounds Refer to Australian Immunisation Handbook 9 th Edition section on Immunisation for tetanus prone wounds for dosage regimen (dependent upon previous immunisation status and type of exposure) Evaluative strategies Review Patient Notes NP Clinical Practice/Medical Report Audit Correct diagnosis made and D/W GP to identify +/- need for referral to acute care facility or specialist consult for management +/- admission Key Terms CPG Clinical Practice Guideline WC Worker s Compensation MVIT Motor Vehicle Insurance Trust 8
References and existing CPG s Naturaliste Medical Group Nurse Practitioner Clinical Practice Guideline: Authorship and Endorsement This guideline was written by: Lisa Scholes - Nurse Practitioner Broadwater Medical Practice & Dunsborough Medical Practice Reviewed and authorised by: Dr Andrew Lill - General Practitioner Broadwater Medical Practice & Dunsborough Medical Practice Dr Mostyn Hamdorf -General Practitioner Broadwater Medical Practice & Dunsborough Medical Practice GP Down South: Chair Dr Scott McGregor - General Practitioner Broadwater Medical Practice & Dunsborough Medical Practice Jarred Smith - Pharmacist West Busselton Pharmacy Date written: June 2010 Review Date: June 2011 9