Immediate life-saving interventions
›Hemorrhage and shock actions
›Unstable physiology pathway
›Balanced resuscitation when hemorrhage suspected
›Massive transfusion protocol trigger per local criteria
›Antifibrinolytic consideration in major trauma
›If within 3 hours of injury and significant bleeding, TXA 1 g IV over 10 minutes
›TXA infusion 1 g IV over 8 hours
›Oxygenation and ventilation support
›Hypoxia management
›Supplemental oxygen titrated to target saturation
›Escalation to noninvasive or invasive support per status
›Pain control escalation triggers
›Delirium risk mitigation
›Prefer regional block when feasible
›Avoid high-dose benzodiazepines
Immobilization and Splinting
›Positioning and movement limitation
›Comfort positioning
›Pillow between legs
›Avoid forced internal rotation
›Movement precautions
›Minimize log roll frequency
›Lift sheet transfer technique
›Traction options
›Skin traction consideration
›Temporary pain reduction
›Not definitive management
›Traction splint avoidance
›Not for proximal femur fracture patterns
›Consider only for femoral shaft fractures
›Neurovascular reassessment
›Post-positioning check
›Pulses
›Sensation
›Motor
›Reduction context
›Femoral neck fracture reduction in ED
›Not typical
›Specialist-directed
›Hip dislocation coexisting with fracture
›Emergent reduction priority
›AVN risk increases with delay
›Analgesia and anesthesia for urgent procedures
›Non-opioid base
›Acetaminophen PO or IV 1000 mg
›NSAID avoidance in CKD or high bleed risk
›Opioid titration
›Fentanyl IV 25 to 50 mcg increments
›Reassess every 5 minutes
›Regional anesthesia
›Fascia iliaca block
›Local anesthetic selection
›Ropivacaine 0.2% to 0.5%
›Bupivacaine 0.25% to 0.5%
›Volume strategy
›Typical total volume 20 to 40 mL
›Max dose per kg respected
›Monitoring
›LAST monitoring
›Lipid emulsion availability
›Procedural sedation when required
›Monitoring requirements
›Continuous pulse oximetry
›Continuous ECG
›Capnography
›Medication examples
›Ketamine IV 0.5 to 1 mg/kg
›Propofol IV 0.5 mg/kg bolus then 10 to 20 mg increments
Open fracture medications and timing
›Antibiotic coverage
›Gustilo type I to II suspicion
›Cefazolin IV 2 g
›Repeat dosing per operative timing
›Gustilo type III suspicion
›Cefazolin IV 2 g
›Gentamicin IV 5 mg/kg
›Farm or fecal contamination concern
›Add metronidazole IV 500 mg
›Alternative add penicillin G per local protocol
›Beta-lactam allergy
›Clindamycin IV 900 mg
›Add gram-negative agent if type III suspicion
›Tetanus prophylaxis
›Unknown or incomplete immunization
›Tdap
›Tetanus immune globulin for dirty wound per protocol
›Up-to-date immunization
›Tdap booster if indicated by timeline and wound class
›Wound handling
›Sterile saline-soaked dressing
›Avoid deep probing in ED
DVT prophylaxis when relevant
›Immobilization and hip fracture risk
›High VTE risk baseline
›Advanced age
›Reduced mobility
›Pharmacologic prophylaxis planning
›LMWH common standard unless contraindicated
›Timing coordinated with surgery and neuraxial anesthesia
›Contraindications
›Active bleeding
›Severe thrombocytopenia
›Recent intracranial hemorrhage
›Multimodal regimen
›Acetaminophen scheduled
›1000 mg PO q6 to q8h maximum daily dose per patient factors
›Lower max dose in liver disease
›Opioid for breakthrough
›Hydromorphone IV 0.2 to 0.5 mg increments
›Morphine IV 2 to 4 mg increments
›Regional anesthesia preference
›Fascia iliaca block early
›Repeat block strategy coordination with anesthesia
Timing and guideline signals
›Surgical timing
›Early operative management target
›Surgery within 24 to 48 hours when medically feasible
›Delay only for reversible high-risk issues
›Evidence framing
›AAOS hip fracture guideline supports early surgery when feasible
›Moderate strength recommendation labeling used by AAOS
›Class I recommendation concept
›Early ortho and anesthesia co-management in hip fracture pathway
›ACEP sedation guidance relevance
›ACEP Level B for capnography during deep sedation when available
›ACEP Level C for shared decision based on patient risk and setting