I am sure most A&E clinicians would agree that the safest thing to do with
an angulated, deformed long bone # is gently to restore axial alignment, and
in the case of the femur, traction also. In almost all cases this will
restore lost pulses. Reduction of dislocated ankles is a priority, and I
usually achieve this with a combination of morphine and midazolam (small
dose - for the purists!). Remember though that a talar # with medial
displacement can look just like a dislocated ankle, and these are very hard
to reduce.
----- Original Message -----
From: "JMTesco" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, December 13, 2000 3:41 PM
Subject: Prehospital reduction & Sedation
> Have found the discussions on reduction helpful. From A&E days, I have
> understood that reduction where skin necrosis is a real threat should take
> place as soon as possible. I recall some early experiences using entonox
and
> a lot of shouting by the patient with say ankle # dislocation.
>
> I have been in the situation twice where I decided I must reduce an ankle
#
> dislocation, due to risk of skin necrosis, and haemorrhage control (very
> difficult to compress a compound wound with damage to ant tibial artery -
as
> this injury requires splintage, and normal anatomy to apply adequate
> compression or oozes rapidly).
>
> So I used a mixture of ketamine and hypnoval - patients usually have 25mg
at
> least ketamine on board prior to extrication, then 2 mg hypnoval is
usually
> enough to provide light enough sedation to safely reduce the injury.
>
> I have usually had a paramedic in charge of airway, and managed to reduce
> the limb with little stress within 5 minutes.
>
> This has meant a comfortable, atraumatic journey for the patient ( I've
used
> this where journey times have been prolongued), haemorrhage was easy to
> control, and they are awake and alert by the time they arrive at A&E.
>
> So - in the light of this discussion....am I being a little cavalier??
>
> Also, a few weeks ago, I attended a motorcycle pillion passenger who had a
> compound # femur. When I arrived, the patient was already boarded to go -
> but the # limb was at 180 degrees...though circulation good with pulse
oxim,
> pulses and cap refill.
>
> Instinct would have tempted me to try to achieve better anatomical
> alignment, but there was no point in delaying transport.
>
> With talk of on table arteriograms etc, is this a thought that should
never
> have entered my head?
>
> I have done this once, when someone carelessly messed with a huge wood
> grinding auger in a silo, and I was sure the limb would be lost, as
> extrication took more than an hour. However, once an attempt was made to
> align the limb anatomically, the pulses returned and he's still walking
> around today! (minus an arm unfortunately).
>
> The motorcycist case was also interesting, as on arrival in hospital,
there
> wasn't a senior orthopod to be had, and this patient lay there for more
than
> 30 minutes having regular shots of morphine and the leg splinted upside
down
> (but with regular checks on circulation)...so I wondered more than ever if
I
> could have avoided all that trouble.
>
> Sorry this is a bit longwinded....but would be grateful for info. Clearly,
> if you wouldn't attempt it in A&E, perhaps we shouldn't in the field??
>
> Jeremy (GP/ SIMCAS/ BASICS)
>
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