Immediate life-saving interventions
›Limb-threatening ischemia pathway
›If pulseless foot, then immediate reduction of deformity
›Splint in reduced position
›Immediate ortho and vascular involvement
›If persistent pulse deficit after reduction, then emergent vascular imaging and transfer
›CTA lower extremity consideration
›Continuous perfusion monitoring
›Open fracture pathway
›Sterile saline-moistened dressing
›Avoid probing
›Avoid aggressive ED debridement
›If open suspected, then antibiotics and tetanus prior to transfer when feasible
›Timing within 60 minutes target
Immobilization and Splinting
›Splint selection
›Posterior short leg splint
›Neutral ankle position
›Swelling accommodation
›Stirrup splint
›Coronal plane stability
›Added to posterior short leg for unstable ankle
›Application principles
›Avoid circumferential cast in acute swelling phase
›Compartment risk
›Skin compromise risk
›Post-splint checks
›Motor
›Sensory
›Pulses
›Pain trend
›Indications
›Fracture-dislocation
›Talar displacement
›Skin tenting
›Neurovascular compromise
›Absent pulses
›Progressive neurologic deficit
›Analgesia and anesthesia
›Multimodal analgesia
›Acetaminophen PO 1000 mg
›Maximum 4000 mg per 24 hours
›Maximum 3000 mg per 24 hours in chronic alcohol use or liver disease
›Ibuprofen PO 400-600 mg
›Every 6-8 hours as needed
›Avoid in significant renal disease or active GI bleed
›Opioid titration for severe pain
›Hydromorphone IV 0.2-0.5 mg
›Re-dose every 10-15 minutes to effect
›Monitor sedation and ventilation
›Procedural sedation when required
›Monitoring and safety
›Cardiac monitor
›Continuous ECG
›Continuous SpO2
›Capnography
›Continuous ETCO2
›Early hypoventilation detection
›Airway readiness
›Suction
›BVM and airway adjuncts
›Ketamine IV 1 mg/kg
›Additional 0.5 mg/kg IV as needed
›Emergence reaction mitigation with quiet environment
›Technique principles
›Traction and countertraction
›Gentle sustained traction
›Reverse mechanism
›Post-reduction steps
›Immediate neurovascular re-check
›Post-reduction radiographs
›Re-splint in stable position
›Failed reduction pathway
›If irreducible, then urgent orthopedics
›NPO status consideration
›Transfer if specialist not available
Open fracture medications and timing
›Antibiotics
›Cefazolin IV 2 g
›Every 8 hours
›Early administration priority
›If severe beta-lactam allergy, then clindamycin IV 900 mg
›Every 8 hours
›MRSA risk consideration per local policy
›If gross contamination or farm injury, then add gentamicin IV 5 mg/kg
›Once daily dosing
›Renal function review
›Tetanus prophylaxis
›If unknown or incomplete immunization, then Tdap
›IM single dose
›If dirty wound and immunization incomplete, then tetanus immune globulin
›IM per product dosing
DVT prophylaxis when relevant
›Risk assessment for lower-limb immobilization
›High-risk features
›Prior VTE
›Active cancer
›Estrogen therapy
›If high risk and prolonged non-weight-bearing, then prophylaxis per local protocol
›Low molecular weight heparin typical option
›Contraindications review