Immediate life-saving interventions
›Immediate life-saving interventions
›If hemorrhagic shock physiology, resuscitation per trauma protocol
›If pulseless limb, immediate reduction of gross deformity and emergent consultation
›If open fracture suspected, antibiotics and tetanus pathway
Immobilization and Splinting
›Immobilization and splinting
›Lower extremity immobilization options
›Knee immobilizer
›Use for isolated proximal fibula fracture when associated injuries excluded
›Posterior long leg splint
›Use when pain severe or concern for associated injury
›Immobilization principles
›Avoid circumferential cast in swelling phase
›Neurovascular re-check after immobilization
›Joint above and below coverage for long bone injury
›Practical conservative management option
›Knee immobilizer or bulky dressing with weight bearing as tolerated when isolated injury confirmed
›Reduction
›Indications for reduction
›Fracture-dislocation pattern
›Threatened skin
›Neurovascular compromise
›Contraindications or caution triggers
›Suspected vascular injury requiring immediate specialist involvement
›Suspected physeal injury requiring gentle technique
›Open fracture requiring antibiotics and tetanus pathway first when feasible
›Analgesia and anesthesia
›Non-opioid analgesia
›Acetaminophen PO 1000 mg every 6-8 hours
›Maximum 3000 mg per 24 hours in older adults or liver disease risk
›Ibuprofen PO 400 mg every 6-8 hours
›Maximum 2400 mg per 24 hours
›Opioid analgesia for severe pain
›Morphine IV 0.05 mg/kg
›Titration 0.02-0.03 mg/kg every 10-15 minutes to effect
›Hydromorphone IV 0.01 mg/kg
›Titration 0.005 mg/kg every 10-15 minutes to effect
›Procedural sedation when required
›ACEP procedural sedation capnography recommendation
›Capnography adjunct for earlier hypoventilation detection
›ACEP Level B recommendation
›ACEP fasting recommendation
›Do not delay procedural sedation based on fasting time
›ACEP Level B recommendation
›Medication options
›Ketamine IV 1 mg/kg
›Supplemental 0.25-0.5 mg/kg every 5-10 minutes
›Propofol IV 0.5-1 mg/kg
›Supplemental 0.25-0.5 mg/kg every 2-3 minutes
›Post-reduction requirements
›Immediate neurovascular re-check
›Post-reduction imaging
›Immobilization in position of stability
›Failed reduction pathway
›Persistent neurovascular deficit triggers immediate escalation
›Irreducible deformity triggers urgent orthopedics
Open fracture medications and timing
›Open fracture medications and timing
›Antibiotics
›Cefazolin IV 2 g
›Repeat every 8 hours until definitive management per local protocol
›If severe beta-lactam allergy
›Clindamycin IV 900 mg
›Repeat every 8 hours per local protocol
›If farm or heavy contamination concern
›Add gram-negative coverage per local protocol
›Tetanus prophylaxis
›Td or Tdap if immunization incomplete or unknown
›Tetanus immune globulin if high-risk wound and unimmunized
›Wound care
›Sterile moist dressing
›Gross debris removal without deep probing
DVT prophylaxis when relevant
›DVT prophylaxis when relevant
›Lower limb immobilisation VTE risk assessment
›NICE Quality Standard recommendation for VTE risk assessment at discharge with lower limb immobilisation
›Shared decision-making on pharmacologic prophylaxis when risk outweighs bleeding risk
›Definition relevant to ED discharge
›Immobilisation includes prevention of normal weight-bearing or normal limb use
›If pharmacologic prophylaxis indicated by local protocol
›Low molecular weight heparin dosing per local protocol
›Renal dosing adjustment for reduced creatinine clearance