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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