Medical Directive Title: Suspected Ortho Injury Suspecte… · Medical Directive Title: Suspected Ortho Injury Lead Contact Person: Christina Scerbo, Clinical Educator & Alyson Wilson,

EMG-2015-002

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Medical Directive Title: Suspected Ortho Injury

Lead Contact Person: Christina Scerbo, Clinical Educator & Alyson Wilson, Registered Nurse

Physician Lead: Rod Lim, Paediatric Site Chief, Emergency Department

Program: Children’s Emergency Medicine

Approval By: Medical Advisory Committee Original Effective Date: Revised Date: Reviewed Date:

This Medical Directive Applies to the following sites:

All LHSC sites LHSC-UH LHSC-VH LRCP LHSC-SSA BFMC VFMC

Other:

This Medical Directive Applies to the following patient population

In-Patients Out-Patients Adults Paediatrics Neonates

Order: Registered Nurses (RN) within the Children’s Emergency Services Program may administer analgesic and order x-ray in patients with a history of direct trauma or injury to an extremity / joint, greater than 1 year up to and including 17 yrs of age.

Dosing as follows: Ibuprofen 10 mg/kg/dose oral q6h PRN, max single dose 400 mg; or Acetaminophen 15 mg/kg/dose oral q4h PRN, max dose 65mg/kg/day or 4gm/day whichever is less

Appendix Attached? Yes No Recipient Patients: Patients with a history of direct trauma or injury to an extremity / joint, excluding those with: • Open fracture• Instability• Severe pain• Abnormal Neurovascular Assessment

Authorized Implementers: • Identify individuals or groups of individuals by position and qualifications who will be involved in implementing

the medical directive

Position / Title Qualifications / Certifications

Registered Nurse (RN) RN registration with College of Nurses of

Ontario practicing in Children’s Emergency Department (VH/UH)

June 23, 2016 June 23, 2016 June 23, 2019

EMG-2015-002

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Indications & Contraindications: Indications:

• Musculoskeletal injury +/- pain

Contraindications: • Less than 1 yr of age• Confirmed or suspected pregnancy• Patient or Substitute Decision Maker (SDM) (i.e. caregiver) refusal to provide consent for x-ray• Allergy to acetaminophen and/or ibuprofen• Unstable vital signs• Severe pain• Severe dehydration• Renal problems• Evidence of neurovascular compromise to affected limb (i.e. diminished sensation & distal

pulses, prolonged capillary refill, suspected nerve entrapment)• Suspected additional musculoskeletal injury / injuries outside RN’s discretion or jurisdiction to

request radiographic examination (i.e. falling outside the parameters of this medical directive)• Do not give additional acetaminophen within 4 hours or ibuprofen within 6 hours of a previous

dose (e.g. at home or other health care institution) without physician orderMedication / Drug Table: Please identify all medications/drugs, using the chart below, which are included under this medical directive by listing the AHFS classification and then identifying which drugs are INCLUDED and specific to your practice.

Note: medical directives for medication orders excludes: non-formulary medications, special access program medications/investigational drugs, off-label use medications, and narcotics, controlled drugs, and benzodiazepines (definition of practitioner as defined under CDSA and Narcotic Regs restricts prescribers).

For any off-label use of a specific medication to be included, the actual drug and indication must be listed individually and not in the AHFS classification section (e.g. Gabapentin for pain).

Drug Name (GENERIC) LIST INCLUSIONS

Indications Route of Administration Special Consideration (e.g. monitoring, lab tests)

Ibuprofen 10 mg/kg/dose, max single dose 400 mg

pain PO q6-8h

Acetaminophen 15 mg/kg/dose, max 65 mg/kg/day or 4 g whichever is less

pain PO q4h

(for formulary listings see - http://appserver.lhsc.on.ca/Formulary1.0/public/advancedsearch.php)

Consent Verbal consent obtained from patient or SDM by RN initiating Directive. Educational Requirements • Emergency department orientation reviewed during Triage course (triage course only offered after 2

years’ experience in the Children’s Emergency Department) • Completion of educational self-learning package demonstrated by a passing grade of 80% on the test

included in the package. • Yearly review of Medical Directive

Appendix attached? Yes No

http://appserver.lhsc.on.ca/Formulary1.0/public/advancedsearch.php

EMG-2015-002

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Documentation & Communication Medical Directive initiation noted on Emergency Department Assessment and Intervention Flow Sheet, or electronic Triage Assessment including response to pain medication.

Review and Quality Monitoring Guideline: • If any issues arise that directly affect the patient while performing this medical directive

please notify Most Responsible Physician.• Any adverse events directly resulting from the implementation of this protocol shall be

reported through the LHSC Adverse Events Management System (AEMS) as per LHSCpolicy.

• Medical directive will be reviewed bi-annually with physicians, coordinator, manager,educator, and nurses from the Paediatric Emergency Department for alignment with bestpractices or evidence based practice guidelines.

Professional Staff Approvals (Physician, Dentist, Midwife): • Identify all Professional Staff members (less than 10 list by individual name, greater than 10 list

by title & program) responsible for patients who may receive an order or procedure under thismedical directive.

NAME DEPARTMENT / PROGRAM Physicians at LHSC-Victoria Hospital Children’s Emergency Department

Emergency Medicine / Paediatrics

EMG-2015-002

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Administrative Authorization Approval Form

Please note: signature pages are not to be signed until the medical directive has been approved. Name of Directive: Suspected Ortho Injury Lead Contact Person (s): Alyson Wilson, Paediatric Emergency Registered Nurse IMPORTANT: This template is a general document that may need modification based on the needs of the directive. Please modify appropriately. • Identify all administrative bodies, including individuals (PPL’s, managers, directors, chiefs) and other

approving bodies (i.e. Medical Advisory Committee, Drug & Therapeutics Committee) that must approve the medical directive.

Administrative Authorizations

(approved by): Signature Date

Chair, LHSC Medical Advisory Committee – Dr. Mark MacLeod

Chief Nursing Executive, Quality & Patient Safety Officer, and Professional Scholarly Practice – Dr. Vanessa Burkoski

Chair, LHSC Drug & Therapeutics Committee – Dr. Philip Jones

Integrated Director, Medical Imaging – Anthony Orfanides

Director Children’s Care – Jill Craven

Coordinator, Paediatric Emergency Medicine – Claire Martin

Site Chief, Paediatric Emergency Medicine – Dr. Rod Lim

Implemented by: (Person(s) performing initiation or

person representing a large group and responsible for notification of that

group)

Signature Date

Paed ER Educator-LHSC: Christina Scerbo

Registered Nurse – Alyson Wilson

Revised: 02/2016

APPENDIX A LHSC CHILDREN’S EMERGENCY

MEDICAL DIRECTIVE EMG ‐ 2015 ‐ 002

SUSPECTED ORTHOPEDIC INJURY PATHWAY Provide Comfort

measures Immobilize, splint, ele‐

vate, ice

Is it an open fracture?

‐ Unstable? ‐ Severe pain? ‐ Abnormal CNS

Send Pt. to a bed hand off to appropri‐ate RN & no fy MD

YES NKDA to ibu‐profen or aceta‐

minophen

RN offers oral analgesic: Ibuprofen 5‐10 mg/kg (max 400mg), or Acetaminophen 15 mg/kg, order & chart accordingly on FirstNet (if not allergic or not already given at

home offer)

NO

Is injured area easily visualized

at triage?

Triage nurse to assess injury; obtain informed consent & place X‐ray

order on Firstnet accord‐ing to direc ve

YES

Pt to a bed in a gown & primary RN to assess in‐jury; obtain informed consent & place X‐ray

order on Firstnet accord‐ing to direc ve

NO

Pt arrives to triage full hx obtained, including physical assessment, VS, Wt. & Pain

Pt to X‐ray

Revised: 05/2016 Page 1 of 6

Appendix B

LHSC Emergency Care Program MEDICAL DIRECTIVE EMG-2015-002

for SUSPECTED ORTHOPEDIC INJURY IN PAEDIATRIC PATIENTS

UPPER EXTREMITIES

Upper Extremity Common Mechanisms of Injury

Clinical Presentation Supporting Need for X-ray

Views Needed FirstNet Order

Fingers (phalanges) • Crush injuries • Digits caught in equipment • Forceful hyperextension

• Pain, tenderness, swelling over the phalanx, PIP or DIP joint

• Loss of function • Deformity, crepitus • Subungual hematoma

AP/Lat/Obl. Specify finger i.e. - index

- middle - ring - little

e.g. - Left index finger AP/Lat/Ob.

Thumb (phalanges) • Direct trauma • Impaction • Hyperextension • Varus or valgus stress

• Pain & swelling • Deformity • Decreased mobility

AP/Lat/Obl. Specify thumb e.g. Right thumb AP/Lat/Obl. Thumb and Hand AP/Lat/Obl.

Hand (metacarpals) • Crush injuries • Striking firm surface e.g. A punch with a closed fist • Direct blows

• Tenderness & swelling over the involved metacarpal

• Deformity • Decreased mobility

AP/Lat/Obl. Hand AP/Lat/Obl. e.g. Left hand AP/Lat/Obl.

If the patient has injuries to both hand and wrist, a separate radiographic series should be performed for each. Wrist (carpals) • Fall on outstretched hand

(FOOSH) • Direct blow

• Pain & swelling • Discoloration • Obvious deformity • Inability to move joint

through a normal range of motion (ROM)

AP/Lat/Obl. Wrist AP/Lat/Obl. e.g. Left wrist AP/Lat/Obl.





Scaphoid (carpal) • FOOSH • Most commonly fractured

of carpal bones

• Dorsal radial wrist pain • Limited ROM of wrist and

thumb • Tenderness upon palpation

of the anatomic snuff box

Scaphoid Wrist/Scaphoid e.g. Right wrist/scaphoid

Forearm (radius or ulna)

• Fall on extended arm • Direct blow • Forced pronation of the

forearm • Altercations • MVCs

• Pain, point tenderness • Swelling • Deformity or angulation • Shortening of forearm • All movement of the hand

will be resisted because of pain

AP/Lat Forearm AP/Lat e.g. Right forearm AP/Lat

Elbow (proximal radius & ulna)

• Fall on extended arm • Fall on flexed elbow

• Significant limitation in ROM

• Obvious deformity • Joint effusion • Significant tenderness over

any of the bony prominences or the radial head

• Severe pain

AP/Lat/Obl. Elbow AP/Lat/Obl. e.g. Left elbow AP/Lat/Obl.

Humerus • Fall on extended, outstretched arm

• Direct trauma, severe twisting of arm

• Direct blow to the arm

during a fall or MVC

• Pain • Point tenderness • Swelling • Inability or hesitance to

move arm • Severe deformity or

angulation • Bony crepitus felt in shaft

of humerus with any manipulation of the arm

AP/Lat Humerus AP/Lat e.g. Left humerus AP/Lat





Clavicle (clavicle & acronium)

• Fall on arm or shoulder • Direct trauma to shoulder

laterally

• Pain in clavicular area • Point tenderness • Refusal to raise arm • Swelling • Deformity • Ecchymosis • Crepitus

2 views of clavicle Clavicle 2V e.g. Right clavicle 2V


LOWER EXTREMITIES

Lower Extremity Common Mechanisms of Injury



Toes (phalanges) • Dropped heavy objects • Stubbing the toe

• Acute pain • Swelling • Deformity • Difficulty ambulating or

wearing shoes • Tenderness • Crepitus • Reduced ROM • Subungual hematoma

(Generally do not require x-rays unless there is a deformity needing reduction) Toe – Specify which toe by number: 1 = Great toe 2 3 4 5 = Baby toe

Toe e.g. Right 4th toe

Foot Forefoot: [phalanges] metatarsals Midfoot: cuneiforms (3) navicular cuboid Hind foot: talus calcaneus

• Crush injury • Fall from a height

(calcaneus injury) • High-energy impact

Hind foot: if the calcaneus is tender, there is a high incidence of associated spinal, tibial plateau and pelvic injuries. These are often marked by the distracting foot pain.

• Pain • Swelling • Tenderness • Crepitus • Exquisite pain with

calcaneus fractures • Unable to weight bear Ottawa Foot Rules: Any pain in midfoot zone and any of these findings: 1. Bone tenderness at base of

the 5th metatarsal; or 2. Bone tenderness at the

navicular bone; or 3. Inability to bear weight for at

least 4 steps both immediately after the injury & at the time of evaluation

AP/Lat/Obl.

Falls with direct axial compression specify calcaneus, not foot.

Foot AP/Lat/Obl. e.g. Left foot AP/Lat/Obl. Calcaneus 2V, 3+ views e.g. ® calcaneus or bilateral calcaneus


Lower Extremity Common Mechanisms of Injury



Ankle (articulation of the tibia & fibula with the talus)

• Falls on uneven surfaces • Twisting injuries • Direct trauma • Torsion/inversion/eversion

• Immediate swelling • Severe pain • Inability to weight bear

immediately after an injury • Popping sound with tearing

of the ligaments • Ecchymosis • Crepitus • Pain upon ambulation, or

altered gait Ottawa Ankle Rules: An ankle x-ray series is only required if there is any pain in the malleolar zone and any of the following findings: 1. Bone tenderness is present at

the posterior edge of the distal 6cm or the tip of the media malleolus; or

2. Bone tenderness is present in the posterior edge of the distal 6cm or the tip of the lateral malleolus; or

3. The patient is unable to weight bear for at least 4 steps both immediately after the injury and at the time of the evaluation.

Palpation over proximal fibula produces pain/tenderness. Pain over proximal end of the 5th metatarsal produces pain/tenderness.

AP/Lat/Mortise Ankle & tib/fib Ankle & foot

Ankle AP/Lat/Mortise e.g. Left ankle AP/Lat/Mortise Ankle & Tib/fib AP/Lat Ankle AP/Lat/Mortise Foot AP/Lat/Obl.


Lower Extremity Common Mechanisms of

Injury Clinical Presentation

Supporting Need for X-ray Views Needed FirstNet Order

Lower leg (tibia & fibula)

• Rotational or twisting forces • Direct trauma • Fall with compression

forces or a fixed foot

• Localized tenderness • Swelling • Deformity • Pain • Inability to weight bear

AP/Lat Tib/Fib AP/Lat e.g. Right Tib/Fib AP/Lat

Knee (articulation of the distal femur, proximal tibia, and patella)

• Rotational or hyper-flexion trauma

• Medial meniscus injury from a twisting motion

• Collateral ligament injury: medial from valgus (away from the midline) stress, and lateral from varus (toward the midline) stress.

• Anterior and posterior cruciate ligament injury from hyperextension trauma

• Swelling • Ecchymosis • Effusion • Tenderness-instability of the

joint Ottawa Knee Rules: A knee x-ray series is only required for knee injury patients with any of these findings: 1. Age 55 or older; or 2. Isolated tenderness of patella

(no bone tenderness of knee other than patella); or

3. Tenderness of head of fibula; or

4. Inability to flex to 90°; or 5. Inability to bear weight both

immediately and at the time of evaluation for at least 4 steps (unable to transfer weight twice onto each lower limb regardless of limping).

AP/Lat/ Oblique/Skyline

Tunnel views are appropriate when cruciate injuries are suspected.

Knee Routine e.g. Right Knee Routine

Revised: 05/2016

Appendix C Emergency Care Program

Suspected Isolated Orthopedic Injury Guideline

Medical Directive EMG-2015-002 Condition: Musculoskeletal injury +/- pain Circumstances: History of direct trauma or injury to an extremity/joint Procedures/Treatment/Interventions:

- Physical assessment (including neurovascular assessment) - Pain scale assessment - Vital signs - Weigh patient - Comfort measures - Administration of analgesic - Ordering x-ray

Contraindications & Risks:

- Less than 1 yr of age - Confirmed or suspected pregnancy - Patient or Substitute Decision Maker (SDM) (i.e. caregiver) refusal to provide consent for

x-ray - Allergy to acetaminophen and/or ibuprofen - Unstable vital signs - Severe pain - Evidence of neurovascular compromise of affected limb (i.e. diminished sensation and

distal pulse, prolonged capillary refill, suspected nerve entrapment) - Suspected additional musculoskeletal injury/injuries outside RN’s discretion or

jurisdiction to request radiographic examination (i.e. falling outside parameters of medical directive

- Renal problems - Severe dehydration - Not to provide acetaminophen within 4 hours or ibuprofen within 6 hours of previous

dose. Reason to seek medical consultation

- Unstable vital signs - Severe, distressing pain - Evidence of neurovascular compromise of affected limb (i.e. diminished sensation and

distal pulse, prolonged capillary refill, suspected nerve entrapment) - Suspected additional musculoskeletal injury/injuries outside RN’s discretion or

jurisdiction to request radiographic examination (i.e. falling outside parameters of medical directive

- Parent/patient prefer to await MD assessment

Revised: 02/2016

Appendix D Emergency Care Program

Suspected Isolated Orthopedic Injury

Medical Directive EMG-2015-002

Self-Directed Learning Outline

1. Self-directed learning packages

2. Review of Medical Directive I.e. condition, circumstances, procedures/treatment/interventions, etc.

3. Algorithm Review

Emphasize: a. Importance of complete history and mechanism of injury b. Pain assessment following initiation of comfort measures c. Analgesic administration d. Importance of thorough assessment on undressed patients

4. Correct & Complete Physical Assessment – Review of Appendix B

a. Fingers b. Thumb c. Hand d. Wrist/scaphoid e. Forearm f. Elbow g. Humerus h. Clavicle i. Toes j. Foot – forefoot, mid foot, hind foot k. Ankle (including assessment of proximal fibula) l. Lower leg – tibia, fibula m. Knee

5. Documentation

Subjective & objective data, therapeutics (history and physical findings, therapeutic interventions) on Flowsheet FirstNet Order

EMG-2015-002 Suspected Ortho InjurySuspected Ortho InjuryMedical Directive Title:Christina Scerbo, Clinical Educator & Alyson Wilson, Registered NurseLead Contact Person:Rod Lim, Paediatric Site Chief, Emergency DepartmentPhysician Lead:Children’s Emergency MedicineProgram:Medical Advisory CommitteeApproval By:Reviewed Date:Revised Date:Original Effective Date: This Medical Directive Applies to the following sites: All LHSC sites LHSC-UH LHSC-VH LRCP LHSC-SSA BFMC VFMC Other: This Medical Directive Applies to the following patient population Qualifications / CertificationsSignature

EMG-2015-002 APPDX AEMG-2015-002 APPDX BSUSPECTED ORTHOPEDIC INJURY IN PAEDIATRIC PATIENTSUPPER EXTREMITIES

EMG-2015-002 APPDX CEMG-2015-002 APPDX DEMG-2015-002 APPDX E

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Medical Directive Title: Suspected Ortho Injury Suspecte… · Medical Directive Title: Suspected Ortho Injury Lead Contact Person: Christina Scerbo, Clinical Educator & Alyson Wilson,