01Approach to the Critical Patient/attcp43

Immediate priorities

›Time-critical stabilization

›Airway and ventilation readiness for procedural sedation

›Hemorrhagic shock screening in high-energy trauma

›Pelvic and long-bone bleeding search with associated injuries

›Pain control prioritization to reduce sympathetic surge

›Trauma team activation for polytrauma physiology

›Limb threat priorities

›Neurovascular status before reduction

›Dorsalis pedis pulse

›Posterior tibial pulse

›Capillary refill

›Skin temperature and color

›Sciatic nerve function before reduction

›Peroneal division motor

›Ankle dorsiflexion

›Great toe extension

›Tibial division motor

›Ankle plantarflexion

›Toe flexion

›Sensory distribution

›Dorsum of foot

›Plantar foot

›Neurovascular status after reduction

›Repeat pulses and perfusion

›Repeat sciatic nerve exam documentation

›Key decision points

›Emergent reduction target within 6 hours from injury to reduce osteonecrosis risk

02History/hx33

Mechanism and timing

›Injury context

›Dashboard mechanism

›Posterior dislocation risk

›Posterior wall acetabular fracture risk

›Fall from height

›Central fracture-dislocation risk

›High-energy MVC

›Polytrauma pattern risk

›Time factors

›Time of injury

›Time since any prior reduction attempt

›Duration of dislocation state as osteonecrosis risk modifier

Symptoms and function

›Pain and mobility

›Inability to bear weight

›Mechanical block sensation

›Neuro symptoms

›Foot drop symptoms

›Dorsal foot numbness

›Plantar numbness

›Associated injury symptoms

›Knee pain and instability symptoms

›Chest pain or dyspnea in high-energy trauma

›Abdominal pain in high-energy trauma

Risks and modifiers

›Medication and bleeding risk

›Anticoagulants

03Physical Exam/exam35

Hip and limb exam

›Resting position patterns

›Posterior dislocation posture

›Hip flexion

›Hip adduction

›Hip internal rotation

›Apparent limb shortening

›Anterior dislocation posture

›Hip abduction

›Hip external rotation

›Skin and soft tissue

›Open wound over hip or groin

›Threatened skin or severe tension

›Expanding hematoma

Neurovascular exam

›Vascular status

›Distal pulses

›Capillary refill

›Doppler signal if pulses difficult

›Sciatic nerve exam

›Peroneal division

›Ankle dorsiflexion strength

›Great toe extension strength

›Dorsal foot sensation

›Tibial division

›Plantarflexion strength

›Plantar sensation

04Differential Diagnosis/ddx19

Traumatic hip pathology

›Hip joint injuries

›Traumatic hip dislocation without fracture

›ICD-10 S73.0 dislocation of hip

›Hip fracture-dislocation

›Femoral head fracture

›Acetabular fracture

›Femoral neck fracture

›Pelvic ring injuries

›Pelvic fracture with apparent hip malposition

›Proximal femur fractures

›Intertrochanteric fracture with rotation deformity

Mimics and related emergencies

›Vascular injury syndromes

›Iliac or femoral artery injury with limb ischemia

›Neurologic injury syndromes

›Lumbosacral plexus injury

›Sciatic nerve traction injury

›Nontraumatic hip dislocation contexts

›Prosthetic hip dislocation

›Pathologic dislocation from infection or malignancy

05Laboratory Tests/lt18

Baseline testing for sedation and trauma context

›Targeted labs based on physiology and pathway

›Point-of-care glucose for altered mental status

›Venous blood gas for respiratory compromise or shock physiology

›pH interpretation support

›pCO2 in mmHg

›CBC for major bleeding concern

›Electrolytes and creatinine for trauma resuscitation context

›Type and screen for operative or transfusion pathway

›Coagulation testing when indicated

›INR for warfarin exposure

›Anti-Xa when local protocol supports and DOAC concern exists

›Pregnancy testing when applicable

›Urine or serum hCG for imaging and medication planning

Complication-oriented labs

›Muscle injury and ischemia context

›Creatine kinase for crush or prolonged entrapment

›Potassium and creatinine for rhabdomyolysis risk

›Open injury context

›Lactate for shock physiology and contamination risk context

06Diagnostic Tests/dt38

Scoring Systems

›Classification and management implications

›Thompson and Epstein classification for posterior dislocation patterns

›Type I simple posterior dislocation

›Type II large posterior wall fragment

›Type III comminuted posterior wall

›Type IV acetabular fracture involving acetabular floor

›Type V femoral head fracture

›Pipkin classification for femoral head fractures

›Type I inferior to fovea capitis

›Type II superior to fovea capitis weight-bearing

›Type III with femoral neck fracture

›Type IV with acetabular fracture

›Judet and Letournel acetabular fracture patterns for operative planning

Radiographs

›Initial imaging

›AP pelvis

›Cross-table lateral hip

›Judet views for acetabulum if stable and available

›Post-reduction imaging

›AP pelvis confirmation of reduction

›Cross-table lateral hip confirmation of reduction

›Nonconcentric reduction clues

›Widened joint space

›Asymmetric femoral head position

›Suspicion for incarcerated fragment or loose body

MRI

›Indications

07Disposition/dispo19

Admission and transfer criteria

›Inpatient pathway

›Associated fracture requiring operative evaluation

›Neurovascular deficit

›Unstable or nonconcentric reduction on imaging

›Open dislocation

›Polytrauma or unreliable outpatient follow-up

›Transfer triggers

›No orthopedic surgery capability for fracture-dislocation

›Failed closed reduction in ED

›Vascular injury concern requiring higher-level resources

Discharge criteria for isolated simple dislocation

›Safe outpatient pathway prerequisites

›Concentric reduction on imaging

›Post-reduction CT without operative indication

›Pain controlled with oral regimen

›Neurovascular exam normal or stable and documented

›Reliable follow-up within 1 to 2 weeks

›Mobility plan

›Protected weight-bearing plan per orthopedics

›Crutches or walker training completion

08Treatment/t115

Immediate life-saving interventions

›Resuscitation actions when indicated

›Hemorrhage control in associated trauma

›Massive transfusion protocol activation criteria per local system

›Pelvic binder use when pelvic instability suspected

›Limb ischemia actions when indicated

›Immediate reduction attempt prioritization over nonessential testing

›Vascular surgery consultation for persistent ischemia after reduction

Immobilization and Splinting

›Post-reduction positioning

›Hip precautions aligned to dislocation direction

›Posterior dislocation precautions

›Avoid hip flexion beyond local protocol threshold

›Avoid adduction

›Avoid internal rotation

›Anterior dislocation precautions

›Avoid extension

›Avoid external rotation

›Immobilization adjuncts

›Knee immobilizer for comfort and motion control when recommended

›Abduction pillow use when available and recommended

›Reassessment after immobilization

›Repeat neurovascular exam documentation

›Pain trend after immobilization

Reduction

›Indications for emergent reduction

›Native hip dislocation as orthopedic emergency

›Time-to-reduction target within 6 hours to reduce osteonecrosis risk

›Contraindications or caution triggers

›Ipsilateral femoral neck fracture suspicion

›Avoid forceful closed reduction attempts

›Urgent orthopedic involvement

›Open dislocation

›Antibiotics and tetanus pathway without delaying life-saving reduction

›Incarcerated fragment or nonconcentric reduction suspicion

›Limited attempts

›Early operative consultation

›Analgesia and anesthesia strategy

›Local and regional options

›PENG block

›Ropivacaine 0.2% to 0.5% volume per local protocol

›Maximum local anesthetic dose by weight per local protocol

›Fascia iliaca block

›Bupivacaine 0.25% volume per local protocol

›Local anesthetic systemic toxicity monitoring plan

›Procedural sedation preparation

›Monitoring standards

›Continuous pulse oximetry

›Continuous capnography as adjunct

›ACEP Level B recommendation for capnography adjunct use

›Blood pressure interval monitoring

›ECG monitoring in higher-risk patients

›Fasting time management

›No delay based on fasting time

›ACEP Level B recommendation

›Staffing

›Dedicated monitor clinician in addition to proceduralist

›ACEP Level C recommendation

›Sedation medication options and dosing

›Ketamine

›IV 1 to 2 mg/kg

›ACEP Level A recommendation for pediatric use

›ACEP Level C recommendation for adult use

›Additional IV 0.5 mg/kg for inadequate depth

›Emergence reaction mitigation plan

›Propofol

›IV 0.5 to 1 mg/kg initial

›ACEP Level A recommendation for adult and pediatric use

›Additional IV 0.25 to 0.5 mg/kg titration doses

›Hypotension risk plan

›Etomidate

›IV 0.15 mg/kg

›ACEP Level B recommendation for adult use

›Myoclonus anticipation

›Fentanyl for analgesia supplementation

›IV 1 mcg/kg

›Chest wall rigidity risk with rapid high dosing

›Reduction techniques

›General principles

›Traction and countertraction

›Gentle sustained force

›Avoid repeated forceful attempts

›Team roles and pelvic stabilization

›Allis technique

›Supine position

›Hip and knee flexion

›Inline traction with assistant countertraction

›Stimson technique

›Prone position

›Knee flexion

›Downward traction with gravitational assist

›Captain Morgan technique

›Supine position

›Provider lever under knee with traction

›Post-reduction requirements

›Immediate neurovascular reassessment

›Post-reduction radiographs

›Post-reduction CT

›Occult fracture and loose body evaluation

›Pain reassessment and compartment concerns in associated injuries

›Failed reduction pathway

›Two to three attempts maximum depending on physiology and suspicion profile

›Urgent orthopedic escalation for irreducible hip

›Operative reduction planning

Open fracture medications and timing

›Open dislocation or open fracture-dislocation pathway

›Antibiotics without delaying time-critical reduction

›Cefazolin 2 g IV

›Redose interval per local protocol for prolonged course

›Severe beta-lactam allergy alternative per local protocol

›Tetanus prophylaxis logic

›Tdap if not up to date

›Tetanus immune globulin for unknown or incomplete immunization with dirty wound

›Sterile dressing coverage

›Early irrigation principles per trauma and ortho guidance

DVT prophylaxis when relevant

›Venous thromboembolism risk planning

›Lower limb immobilization and reduced mobility risk context

›Anticoagulation contraindications assessment

›Prophylaxis decisions aligned to orthopedic service and local protocol

09Special Populations/sp22

Pregnancy

›Maternal and fetal considerations

›Left lateral tilt positioning when feasible

›Obstetric consultation for viability gestational age context

›Imaging considerations

›Radiographs when needed with shielding considerations

›CT use when benefits outweigh risks in trauma

›Analgesia and sedation considerations

›Shared decision-making for sedation agents with maternal physiology

›Aspiration risk awareness without delaying emergency reduction

Geriatric

›Fragility and comorbidity context

›Lower physiologic reserve

›Delirium risk with sedatives and opioids

›Injury pattern considerations

›Lower-energy dislocation consideration in severe osteoporosis or prior arthroplasty contexts

›Higher threshold for admission and observation

Pediatrics

›Growth and remodeling context

›Lower sciatic nerve injury incidence compared with adults in literature

›Sedation and monitoring

›Weight-based dosing

›Ketamine safety support in ED procedural sedation

›ACEP Level A recommendation for pediatric ketamine use

›Nonaccidental trauma consideration when mechanism inconsistent with injury pattern

10Background/b24

Epidemiology

›Frequency and context

›Traumatic native hip dislocation as rare injury with high associated injury burden

›Posterior dislocation as most common traumatic direction in high-energy mechanisms

›Nerve injury frequency

›Neurologic injury incidence approximately 10% in adults

›Neurologic injury incidence approximately 5% in children

Pathophysiology

›Mechanism to pattern mapping

›Posterior dislocation

›Axial load through femur with hip flexion and adduction

›Posterior capsule disruption

›Posterior wall acetabular fracture association

›Anterior dislocation

›Abduction and external rotation force vectors

›Femoral head displacement anteriorly

›Osteonecrosis mechanism

›Femoral head perfusion compromise duration dependence

›Increased osteonecrosis risk with delayed reduction beyond 6 hours

Therapeutic Considerations

›Time dependence rationale

›Reduction within 6 hours associated with lower osteonecrosis rates in studies

›Imaging rationale

›Post-reduction CT to detect occult fractures and loose bodies missed by radiographs

›Neurologic injury expectations

›Sciatic nerve most commonly affected

›Peroneal branch commonly involved

11Patient Discharge Instructions/pdi21

Copy discharge instructions

›Discharge packet

›No driving until cleared by orthopedics and off sedating medications

›Protected weight-bearing per orthopedic plan

›Hip precautions based on dislocation direction

›Pain plan

›Acetaminophen dosing per local protocol

›NSAID use if no contraindications

›Short opioid course only if needed with constipation prevention plan

›Ice and elevation guidance for associated soft tissue swelling

›Return to ED now triggers

›Worsening pain uncontrolled with prescribed plan

›New numbness or weakness in foot or toes

›Cold, pale, or blue foot

›Increasing swelling with severe tightness

›Fever or wound drainage if open injury

›Follow-up timing

›Orthopedics within 1 to 2 weeks or sooner per imaging findings

›Repeat imaging plan per orthopedics

›Sedation aftercare

›No alcohol or sedatives for 24 hours

›Responsible adult supervision period per local policy

12References/r22

Clinical guidelines and key sources

›Source file

›:contentReference[oaicite:0]{index=0}

›Reduction timing and osteonecrosis risk

›Meta-analysis and cohort data supporting lower osteonecrosis with reduction within 6 hours

›Post-reduction CT rationale

›CT described as standard of care after closed reduction to identify occult fracture or loose bodies

›Sciatic nerve injury incidence

›Literature review reporting approximately 10% in adults and 5% in children

›Procedural sedation evidence and ACEP levels

›ACEP Clinical Policy Procedural Sedation and Analgesia in the ED

›No delay based on fasting time

›Level B recommendation

›Capnography as adjunct for earlier hypoventilation detection

›Level B recommendation

›Dedicated monitoring individual in addition to proceduralist

›Level C recommendation

›Ketamine pediatric safety

›Level A recommendation

›Propofol adult and pediatric safety

›Level A recommendation

›Etomidate adult safety

›Level B recommendation

Evidence & Review

Evidence & Review