Primary care management for isolated limb injury: referral to orthopedic surgery in a trauma center (original) (raw)
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Canadian family physician Médecin de famille canadien, 2009
To describe referral mechanisms for referral to orthopedic surgery for isolated limb injuries in a public health care system and to identify factors affecting access. Cross-sectional survey. Orthopedic surgery service in a level 1 trauma centre in Montreal, Que. We conducted a prospective study of 166 consecutive adults (mean age 48 years) referred to orthopedic surgery for isolated limb injuries during a 4-month period. Self-reported data on the nature of the trauma, the elapsed time between injury and orthopedic consultation, the number and type of previous primary care consultations, sociodemographic characteristics, and the level of satisfaction with care. Average time between the injury and orthopedic consultation was 89 hours (range 3 to 642), with an average of 68 hours (range 0 to 642) for delay between primary care consultation and orthopedic consultation. A total of 36% of patients with time-sensitive diagnoses had unacceptable delays to orthopedic consultation according t...
Orthopedic Trauma: Office Management of Major Joint Injury
Medical Clinics of North America, 2006
Patients presenting with musculoskeletal pain and injury challenge the office internist with extensive differential diagnoses and management considerations. The acutely traumatized patient should be rapidly evaluated for the presence of life-or limb-threatening injuries. Any evidence of significant head, spinal, chest, abdominal, or pelvic injuries should precipitate rapid transfer to the closest emergency department. Similarly, patients who have open musculoskeletal trauma, obvious extremity deformity, or severe pain and those who are nonambulatory are better served in the emergency department than in the office.
Low-value injury care in the adult orthopaedic trauma population: a protocol for a rapid review
BMJ Open
IntroductionOrthopaedic injuries affect almost 90% of trauma patients. A previous scoping review and expert consultation survey identified 15 potential low-value intra-hospital practices in the adult orthopaedic trauma population. Limiting the frequency of such practices could reduce adverse events, improve clinical outcomes and free up resources. The aim of this study is to synthesise the evidence on intra-hospital practices for orthopaedic injuries, previously identified as potentially of low value.Methods and analysisWe will search Medline, Excerpta Medica Database (EMBASE), the Cochrane Central Register of Controlled Trials and Epistemonikos to identify systematic reviews, randomised controlled trials (RCTs), quasi-RCTs, cohort studies and case–control studies that evaluate selected practices according to a priori PICOS statements (Population–Intervention–Comparator–Outcome–Study design) . We will evaluate the methodological quality for systematic reviews using the Measurement T...
Guidelines for the acute care of severe limb trauma patients
Anaesth Crit Care Pain Med, 2021
Goal: To provide healthcare professionals with comprehensive multidisciplinary expert recommenda- tions for the acute care of severe limb trauma patients, both during the prehospital phase and after admission to a Trauma Centre. Design: A consensus committee of 21 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e., pharmaceutical, medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE1) system to guide assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations remained non-graded. Methods: The committee addressed eleven questions relevant to the patient suffering severe limb trauma: 1) What are the key findings derived from medical history and clinical examination which lead to the patient’s prompt referral to a Level 1 or Level 2 Trauma Centre? 2) What are the medical devices that must be implemented in the prehospital setting to reduce blood loss? 3) Which are the clinical findings prompting the performance of injected X-ray examinations? 4) What are the ideal timing and modalities for performing fracture fixation? 5) What are the clinical and operative findings which steer the surgical approach in case of vascular compromise and/or major musculoskeletal attrition? 6) How to best prevent infection? 7) How to best prevent thromboembolic complications? 8) What is the best strategy to precociously detect and treat limb compartment syndrome? 9) How to best and precociously detect post-traumatic rhabdomyolysis and prevent rhabdomyolysis-induced acute kidney injury? 10) What is the best strategy to reduce the incidence of fat emboli syndrome and post-traumatic systemic inflammatory response? 11) What is the best therapeutic strategy to treat acute trauma-induced pain? Every question was formulated in a PICO (Patient Intervention Comparison Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE1 methodology. Results: The experts’ synthesis work and the application of the GRADE method resulted in 19 recommendations. Among the formalised recommendations, 4 had a high level of evidence (GRADE 1+/) and 12 had a low level of evidence (GRADE 2+/). For 3 recommendations, the GRADE method could not be applied, resulting in an expert advice. After two rounds of scoring and one amendment, strong agreement was reached on all the recommendations. Conclusions: There was significant agreement among experts on strong recommendations to improve practices for severe limb trauma patients.
Journal of Pain Research
To examine 1) pain management strategies within the care trajectory of orthopaedic trauma patients and patients' perception of their effectiveness, 2) adverse effects (AEs) associated with pharmacological treatments, particularly opioids and cannabis, and 3) patients' perceptions of strategies that should be applied after an orthopaedic trauma and support that they should obtain from health professionals for their use. Patients and Methods: This study was conducted with orthopaedic trauma patients in a level 1 trauma center. A convergent mixedmethods design was used. Data on pain experience, pain management strategies used and AEs were collected with self-administered questionnaires at hospital discharge (T1) and at 3 months after injury (T2). Patients' preferences about the pain management strategies used, the required support and AEs were further examined through semi-structured individual interviews at the same time measures. Descriptive statistics and thematic analyses were performed. Results: Seventy-one patients were recruited and 30 individual interviews were undertaken. Pharmacological pain management strategies used at T1 and T2 were mainly opioids (95.8%; 20.8%) and acetaminophen (91.5%; 37.5%). The most frequently applied non-pharmacological strategies were sleep (95.6%) and physical positioning (89.7%) at T1 and massage (46.3%) and relaxation (32.5%) at T2. Findings from quantitative and qualitative analyses highlighted that non-pharmacological strategies, such as comfort, massage, distraction, and physical therapy, were perceived as the most effective by participants. Most common AEs related to opioids were dry mouth (78.8%) and fatigue (66.1%) at T1 and insomnia (30.0%) and fatigue (20.0%) at T2. Dry mouth (28.6%) and drowsiness (14.3%) were the most reported AEs by patients using recreational cannabis. An important need for information at hospital discharge and for a personalized follow-up was identified by participants during interviews. Conclusion: Despite its AEs, we found that opioids are still the leading pain management strategy after an orthopaedic trauma and that more efforts are needed to implement non-pharmacological strategies. Cannabis was taken for recreational purposes but patients also used it for pain relief. Support from health professionals is needed to promote the adequate use of these strategies.
Background Acute pain is one of the most commonly cited reasons for attendance to the Emergency Department (ED): it is estimated that 7 out of 10 people present to the ED because they are in pain. The Royal College of Emergency Medicine (RCEM) Best Practice Guideline (2014) acknowledged that the current management of acute pain in UK EDs is inadequate and has a poor evidence base. Methods The Prescription Of analgesia in Emergency Medicine (POEM) study is a cross-sectional observational study of consecutive patients presenting to 12 NHS EDs with limb fracture and/or dislocation in England and Scotland and was carried out between 2015 and 2017. The primary outcome was to assess the adequacy of pain management in the ED against the recommendations in the RCEM Best Practice Guidelines. Results 8346 patients were identified as attending the ED with a limb fracture and/or dislocation but adherence to RCEM guidelines could only be evaluated for the 4160 (49.8%) patients with a recorded pain score. Of these, 2409/4160 (57.9%) patients received appropriate pain relief, but only 1347 patients were also assessed within 20 minutes of their arrival in the ED. Therefore, according to the RCEM guidelines only 16.1% (1347/8346) of all patients in the study were assessed and had satisfactory pain management in the ED. Conclusions The POEM study has identified that pain relief for patients in the UK with an isolated limb fracture remains inadequate when strictly compared to the RCEM Best Practice Guidelines. However, we have found that some patients receive analgesia despite having no pain score recorded, while other analgesic modalities are provided that are not currently encompassed by the Best Practice Guidelines. Future iterations of these guidelines may wish to encompass the breadth of available modalities of pain relief and the whole patient journey. In addition more work is needed to improve timely and repeated assessment of pain and its recording, which has been achieved better in some EDs than others. Subsequent analysis of secondary outcome measures may provide insight into the reasons why variability exists.
Clinical and experimental emergency medicine, 2018
The aim of this study was to investigate the effectiveness of a quality improvement activity for pain management in patients with extremity injury in the emergency department (ED). This was a retrospective interventional study. The patient group consisted of those at least 19 years of age who visited the ED and were diagnosed with International Classification of Diseases codes S40-S99 (extremity injuries). The quality improvement activity consisted of three measures: a survey regarding activities, education, and the triage nurse's pain assessment, including change of pain documentation on electronic medical records. The intervention was conducted from January to April in 2014 and outcome was compared between May and August in 2013 and 2014. The primary outcome was the rate of analgesic prescription, and the secondary outcome was the time to analgesic prescription. A total of 1,739 patients were included, and 20.3% of 867 patients in the pre-intervention period, and 28.8% of 872 ...
Patient-Reported Pain Outcomes for Children Attending an Emergency Department With Limb Injury
Pediatric emergency care, 2017
The aim of this study was to describe patient-reported pain outcomes at various stages of an emergency department (ED) visit for pediatric limb injury. This prospective cohort consisted of 905 patients aged 4 to 17 years with acute limb injury and a minimum initial pain score of 4/10. Patients reported pain scores and treatments offered and received at each stage of their ED visit. Multiple logistic regression was used to identify predictors for severe pain on initial assessment and moderate or severe pain at ED discharge. The initial median pain score was 6/10 (interquartile range, 4-6) and decreased at discharge to 4/10 (interquartile range, 2-6). Stages of the ED visit where the highest proportion of patients reported severe pain (score, ≥8 of 10) were fracture reduction (26.0% [19/73]; 95% confidence interval [CI], 17.1%-37.5%), intravenous insertion (24.4% [11/45]; 95% CI, 13.8%-39.6%), and x-ray (23.7% [158/668]; 95% CI, 20.6%-27.0%). Predictors of severe pain at initial asses...
Painful discrimination: The differential use of analgesia in isolated lower limb injuries
The American Journal of Emergency Medicine, 2002
Our primary objective was to compare use of analgesia for patients with and without fracture as a result of isolated lower extremity trauma, in the emergency department (ED). Our secondary objective was to compare the analgesic practices of emergency physicians (EPs) with that of physician assistants (PAs). We performed a prospective, blinded cohort study with the presence of fracture as the risk factor and provision of any pain medication while in the ED as the primary outcome. Included in the study were all patients who presented to a 90,000 visit suburban teaching hospital with an isolated lower extremity injury who received a radiograph of the foot or ankle over a 9-week period. We excluded patients without trauma, with multiple trauma, admitted, or seen by one of the investigators. Patients admitted and those with multiple trauma were excluded because these patients had contacts with multiple physicians and it is unlikely they would be able to differentiate which physician prescribed medication and if they were emergency personnel. We defined analgesia as any pain medication at any dose. One investigator preformed follow-up interviews using a standardized questionnaire 3 days after the visit. Patients expressed their recollection of their degree of pain using a verbal analog scale of 1 to 10. We report crude and adjusted odds ratios (OR). Of 516 consecutive patients, 111 met exclusion criteria and 3 had incomplete data. Of the remaining 405, we contacted 384 (95%) in an average of 3 ؎ 1 days. Patients with and without fractures recalled their initial degree of pain similarly, with the mean initial pain scores on the verbal analog scale of 6.6 ؎ 2.5 versus 6.8 ؎ 2.1 respectively. Patients with a fracture were more likely to receive pain medication while in the ED (23% v 15% P ؍ .047, OR 1.75 (CI 95% 1.02, 2.99). EPs gave some form of ED analgesia to 29% of patients, as compared with 10% of patients seen by PAs (OR ؍ 3.58 CI 95% 2.05, 6.24). EPs provided a prescription to 44% of patients versus 21% of patients seen by PAs (OR ؍ 2.91 CI 95% 1.85, 4.57). Our estimated adjusted ORs for providing analgesia in the ED were: fracture ؍ 2.0 (CI 95% 1.13, 3.58); EP: 3.52 (CI 95% 1.98, 2.99); and for every additional point on the verbal pain scale: 1.28 (CI 95% 1.11, 1.48). Patients with fracture were more likely to receive pain, despite reporting identical degree of pain. EPs were more likely to provide analgesia than PAs. (Am J Emerg Med 2002;20:502-505.