Dealing with Fractured Neck of Femur Injuries in the Pre-Hospital Setting - Assignment Example

Dealing with Fractured Neck of Femur Injuries in the Pre-hospital Setting Introduction This is the case of a 78-year-old woman, otherwise fit and well, seemed to have sustained a trauma due to a suspected trivial fall in her flat, the exact scenario unknown. However, the warden of her sheltered housing complex discovered her on the floor of her second floor flat. The patient was on two medications, indomethacin, which is a nonsteroidal anti-inflammatory agent and metformin, which are prescribed to type 2 diabetic patients for control of blood sugar levels. There is no definite history in this scenario as to whether the patient is obese or a diabetic; however, from the medication history it seems likely that the patient is a diabetic with poor blood glucose control. Most likely, the patient took metformin when her blood glucose levels were low, and this could have led to hypoglycaemia and unconsciousness and a fall (Gardiner and Begg, 2006). Given her age, this fall is likely to lead to a fracture of the neck of the femur, which is the most common fracture in the osteoporotic elderly women arising from apparently trivial trauma and associated with far less pain than normal. Obviously, this clinical feature is misleading, since the pain was not more than her usual and baseline pain of arthritis. The shortening and rotation of the left leg indicates most probably, this is fracture left neck of femur. The patient's mentation is confused, although she is conscious and is able to answer questions, all these could have resulted from hypoglycaemia. The low blood pressure, both systolic and diastolic, bradycardia, bradypnoea, and unobtainable oxygen saturation all point to this and some concealed haemorrhage (Ostrum, Verghese, and Santner, 1993). Theoretical Basis of Specific Clinical Practices Fracture of the neck of left femur These can follow relatively minor trauma. This is a known high risk in the elderly, because of osteoporosis, osteomalacia and high rate of falls. Fractures are more common in peri- or post-menopausal women. These fractures can disrupt the blood supply to the femoral head, leading to avascular necrosis. As in this case, these typically follow a fall onto the lateral aspect of the hip or directly onto the bottom. Pain may radiate down towards the knee. The affected leg may be shortened and externally rotated. The care here will involve a detailed history taking of the patient and at the same time acting quickly. The pre-hospital care would involve first checking for hypothermia and dehydration, since the patient may have been lying on the floor for hours. The affected hip joint would need to be assessed, particularly the pain over the hip joint or greater trochanter, particularly on rotation. Given the patient's confusional state, it is unlikely that the patient would be able to provide a detailed history, but her posture and the orientation of the limb strongly suggests a fracture (Astrom et al., 1987). Specific Clinical Practice Given the patient's slow respiration rate and inability to record a pulse oximetry, it is likely that the patient is dehydrated and the peripheral circulation is jeopardised. While all attempts to be made to have a secure airway and breathing in a high oxygen environment is definitely required, it very important to restore the peripheral circulation. While the cause may be hypoglycaemia, before even a diagnosis and intervention, given that the patient is awake and responsive, the first step after the detailed history should be securing an intravenous line. Thus an intravenous access will be secured, and at the same time, blood will be drawn for glucose, grouping, cross matching, and full blood count. While this blood will be subjected to blood sugar estimation on spot, given this patients low or falling blood pressure, an infusion should be started immediately (Adams, Aldag, and Wolford, 1996). Today's pre-hospital testing systems are very efficient, and it will just take moments to get the report. It is suspected and can be strongly predicted that this patient will have hypoglycaemia, an infusion with 10% dextrose could be ideal. The patient will be given an intravenous analgesic in small increments until the control of the pain, since the analgesic overdosage will increase the confusion of the patient (Holstein et al., 2003) and it is highly likely that the pain response that the patient is demonstrating is the result of her previous dose of indomethacin that she had taken the night before. Moreover, since the peripheral circulation could have been compromised, the desired action of the analgesic administered through the intravenous route can be late to be achieved, and therefore, a small-dose titration of the analgesic medication could be the best course with strict monitoring of all the haemodynamic parameters. An ECG is important to assess the status of the heart, and it would reveal an arrhythmia or evidence of myocardial infarction if there is any. Haemodynamic monitoring and maintenance of circulation even in the absence of any cardiac problems detected in the ECG (Racht, 2001) is important in this case, since closed fractures of the femoral shaft, even without obvious vascular injury, may be associated with marked blood loss. Up to 1.5L of blood may be lost without visible thigh swelling. The diagnosis is usually clear on examination with deformity, shortening, external rotation, and abduction at the hip on the affected side. The fracture may be felt or even heard on movement of the lower limb. It is important to carefully check for associated pelvic, knee, or distal limb injuries or the presence of associated wounds. The sensation and pulses in the limb must be documented and re-checked frequently to document or predict worsening. The diagnostic x-rays may be taken in the hospital, but in the pre-hospital care setting, it is more important to resuscitate, exclude life-threatening injuries, replace intravenous fluids, give adequate analgesia, and splint fractures (Lee and Porter, 2005). Key Concepts of Pharmacology The patient was on two medications, metformin and indomethacin. It would be wise to examine whether these two drugs have some role to play in her current condition and whether these leads from the history help her pre-hospital management. Metformin given alone or in combination with a sulfonylurea improves glycemic control and lipid concentrations in patients who respond poorly to diet or to a sulfonylurea alone. Metformin is antihyperglycemic, not hypoglycemic. It does not cause insulin release from the pancreas and generally does not cause hypoglycemia, even in large doses. Metformin has no significant effects on the secretion of glucagon, cortisol, growth hormone, or somatostatin. Metformin reduces glucose levels primarily by decreasing hepatic glucose production and by increasing insulin action in muscle and fat. At a molecular level, these actions are mediated at least in part by activation of the cellular kinase AMP-activated protein kinase. The mechanism by which metformin reduces hepatic glucose production is controversial, but most data indicate an effect on reducing gluconeogenesis. Metformin also may decrease plasma glucose by reducing the absorption of glucose from the intestine. Metformin is absorbed mainly from the small intestine. The drug is stable, does not bind to plasma proteins, and is excreted unchanged in the urine. It has a half-life of about 2 hours. Acute side effects of metformin, which occur in up to 20% of patients, include diarrhea, abdominal discomfort, nausea, metallic taste, and anorexia. These usually can be minimized by increasing the dosage of the drug slowly and taking it with meals. Thus it is highly likely that this patient was anorexic and did not have a proper dinner. Over and above that the night dose of metformin could have precipitated an acute attack of hypoglycaemia that led to this cascade of events surrounding the fall and the fracture. It is prudent to stop metformin if a patient is undergoing a prolonged fast or is treated with a very low-calorie diet (Kirpichnikov, McFarlane, and Sowers, 2002). Indomethacin has prominent anti-inflammatory and analgesic-antipyretic properties similar to those of the salicylates. Indomethacin is a more potent inhibitor of the cyclooxygenases than is aspirin, but patient intolerance generally limits its use to short-term dosing. Indomethacin has analgesic properties distinct from its anti-inflammatory effects, and there is evidence for central and peripheral actions. Oral indomethacin has excellent bioavailability. Peak concentrations occur 1 to 2 hours after dosing. Indomethacin is 90% bound to plasma proteins and tissues. The concentration of the drug in the CSF is low, but its concentration in synovial fluid is equal to that in plasma within 5 hours of administration. Indomethacin does not directly modify the effect of warfarin, but platelet inhibition and gastric irritation increase the risk of bleeding. Indomethacin is effective for relieving joint pain, swelling, and tenderness, increasing grip strength, and decreasing the duration of morning stiffness (Rothermich, 1966). It is estimated to be approximately 20 times more potent than aspirin. Overall, about two-thirds of patients benefit from treatment with indomethacin. Like other patients, although not provided in the history, this patient might have been treated with a higher dose at night to provide better nighttime analgesia and relief from morning stiffness. Gastrointestinal complaints are common and can be serious. Diarrhea may occur and sometimes is associated with ulcerative lesions of the bowel. Underlying peptic ulcer disease is a contraindication to indomethacin use. Acute pancreatitis has been reported, as have rare, but potentially fatal, cases of hepatitis. The most frequent CNS effect and the most common side effect is severe frontal headache, occurring in 25% to 50% of patients who take the drug for long periods. Dizziness, vertigo, light-headedness, and mental confusion may occur. Thus it is possible that the light-headedness of hypoglycaemia has been compounded with that of indomethacin, and the confusion that is the patient's prime presentation has been partly contributed to by indomethacin also (Tharumaratnam, Bashford, and Khan, 2000). While different tests are necessary to establish the diagnosis, it is to be reminded that there must be adequate caution while treating elderly patients with indomethacin. Indomethacin increases the chance of bleeding, and this frail patient with a risk of fall while fractured her hip, the bleeding may be inordinate given the history of this drug. Discussion Regardless of the level of certification, licensure, training, or experience, the roles of anyone providing care to trauma patients before they reach the hospital can be summarized as (1) control the scene/triage, (2) correct immediate life threats, (3) identify the patient priority, (4) avoid secondary injury, and (5) provide transport. While each of these roles seems to be obvious and straightforward, the challenges of the out-of-hospital setting can make each an extraordinary clinical challenge (Clements and Mackenzie, 2005). Situations in which people have been injured are often highly chaotic and dangerous scenes. The very first priority of the pre-hospital care provider is to assess the scene for hazards and assure that no additional injuries occur. While it takes tremendous personal discipline not to rush into a scene to render care to an injured patient, the initially responding personnel have the primary responsibility to assure that neither they nor others are hurt in the process (van der Velden, 2008). In this case, the patient had a slower than normal respiration and pulse oximetry was not able to be recorded. The first priority therefore is to ensure a patent airway. There may also be a possibility of other associate trauma. The options of maintaining the airway may include manual positioning, suction, oral or nasal airways, endotracheal intubation depending on the case. As it appears in this case simple positioning would do the best. The goal of providing a patent airway is to ensure that ventilation can occur. It is common for such a patient to be hypoventilating either as a direct result of the injuries or secondary to mental status changes. Thus the next course of action would be to provide adequate ventilation through exhaled breath ventilation with or without a barrier device, bag-valve device, flow-restricted oxygen-powered ventilation devices, or automatic transport ventilators. The bag-valve device is the most commonly used one. As in this case internal hemorrhage is much more common, and it is more insidious. Major bleeding must be controlled in the scene. Even with relative close proximity to a hospital, most patients cannot survive without these immediate lifesaving interventions. Airway management and ventilation are the only clinical reasons for delaying transport (Hickman, 2006). The patient priority must be identified. The underlying problems here are first hypoglycaemia and then fracture neck of femur. The underlying problem in fracture neck of femur will be corrected in the hospital, but before that, in the pre-hospital level, the hypoglycaemia may be corrected adequately. A rapid trauma assessment is the second priority. The goal of this assessment must be to recognize and correct immediate life threats and identify patients who have a serious risk of rapid decompensation. This typically includes an altered level of consciousness, respiratory compromise, signs of shock, signs of internal hemorrhage, or fractures of the pelvis or femurs. Moving traumatized patients provides a risk of secondary tissue damage from fractured bone ends. This can be permanently debilitating, especially when it involves nerve damage. Decisions to immobilize the extremities have to take into consideration the mechanism of injury, assessment findings, patient condition, as well as the balancing of time vs. the benefit. After the patient is stabilized on hypoglycemia, her left lower extremity must be extremities have to take into consideration the mechanism of injury, assessment findings, patient condition, as well as the balancing of time vs. the benefit (Roberts and Smith, 2003). Prehospital care providers serve as the link between the scene of the incident and the hospital by providing transportation to patients in a manner that is most consistent with their needs. Selection of the proper destination is critical to patient survival. Rapid transportation to a facility that is not capable of immediate intervention will result in a suboptimal outcome. In some cases it is perfectly reasonable to bypass the closest hospital in order to take the patient directly to a facility that is prepared to provide immediate surgical care. In this case while transporting, the patient must be monitored continuously (Snooks, Foster, and Nicholl, 2004), and the patient would be placed on a dextrose intravenous drip with repeated monitoring of blood glucose levels. When the blood glucose is restored, then the priority would be haemodynamic monitoring and replacement of fluid loss to bring the haemodynamic parameters back to normal. Conclusion The role of the prehospital care practitioner is critical to trauma patients. It has been demonstrated that with proper education, experience, equipment, and system design, emergency medical systems can have a dramatic effect on the morbidity and mortality from traumatic injuries. By integrating out-of-hospital and in-hospital care, the prehospital care professionals can provide a continuum of service that provides the best chance for a positive outcome for all victims of trauma. As in this case, in the case of many victims, the initial responders may provide no care, but rather spend their time triaging patients, securing additional resources, and coordinating additional response. Although safety issues must be on each individual's agenda, the primary responsibility for safe operations lies with management. Selection of personnel, training, standards, procedures, quality assurance system, adequate equipment, and an open and supportive attitude have a great impact on safety. Thorough information collection, premission planning, good communication, information transfer, and cooperative teamwork are all factors that are known to enhance not just efficiency, but safety as well. Reference List Adams, J., Aldag, G., and Wolford, R., (1996). 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