Immediate life-saving interventions
›Time-critical actions
›Open injury pathway
›Antibiotics initiation without delay
›Tetanus prophylaxis pathway
›Limb ischemia pathway
›If pulseless or cool foot, emergent reduction and ortho consult
›Compartment syndrome pathway
›If escalating pain with tense swelling, emergent surgical evaluation
Immobilization and Splinting
›Immobilization plan
›Non-weight-bearing status
›Crutches or walker training
›Splint selection
›Posterior short leg plus stirrup splint
›Bulky Jones splint for marked swelling
›Positioning principles
›Neutral ankle position
›Avoid circumferential casting in early swelling phase
›Post-splint checks
›Neurovascular reassessment documented
›Pain trend after immobilization
›Reduction decision-making
›Indications for emergent reduction attempt
›Neurovascular compromise
›Skin tenting or threatened skin
›Gross deformity with severe pain
›Caution triggers
›Open injury with contamination
›Suspected vascular injury
›Analgesia and anesthesia options
›Oral and IV analgesia pathway
›Acetaminophen PO 1000 mg
›Maximum 4000 mg/day
›Ibuprofen PO 400 to 600 mg
›Maximum 2400 mg/day
›Hydromorphone IV 0.2 to 0.5 mg
›Repeat every 10 to 15 minutes to effect with monitoring
›Procedural sedation pathway when required
›Ketamine IV 1 mg/kg
›Additional 0.5 mg/kg every 5 to 10 minutes as needed
›Airway and monitoring readiness
›Capnography
›ACEP procedural sedation principles applied (Level B)
›Continuous monitoring until recovery criteria met
›Reduction technique principles
›Longitudinal traction and countertraction
›Gentle plantar to dorsal pressure over displaced metatarsal bases when appropriate
›Avoid repeated forceful attempts
›Post-reduction requirements
›Immediate neurovascular re-check
›Post-reduction radiographs
›Re-splint in bulky support
Open fracture medications and timing
›Open injury medications
›Antibiotic selection by contamination risk
›Cefazolin IV 2 g
›Repeat every 8 hours per protocol
›If severe beta-lactam allergy, clindamycin IV 900 mg
›Repeat every 8 hours per protocol
›If gross contamination concern, add gram-negative coverage per local protocol
›Early administration within 60 minutes target
›Tetanus prophylaxis
›Td or Tdap if immunization not up to date
›Tetanus immune globulin if high-risk wound and unknown immunization status
›Wound care
›Sterile saline-moistened dressing
›Avoid aggressive ED irrigation for grossly open joint when immediate OR planned
DVT prophylaxis when relevant
›Thrombosis risk management
›Prolonged non-weight-bearing lower limb immobilization risk assessment
›Prior VTE history
›Active malignancy
›Estrogen therapy
›Major trauma context
›Prophylaxis decisions aligned to local protocol
›Bleeding risk and contraindications documented