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					                                     Nurse Practitioner – Emergency Services
                                       CLINICAL PRACTICE GUIDELINE
                                               INJURY - ANKLE

                                         Scope                                                              Outcomes
Nurse Practitioner               •     Ankle injury, pain, swelling or deformity                    Identify patients suitable
                                                                                                    for NP (Emergency)
                                                                                                    CPG
Medical Practitioner                   •
                              Compound # / obvious fracture                                         Identify patients not
+/-Nurse                      dislocation/ dislocation                                              suitable for NP
Practitioner              • Neurovascular compromise                                                (Emergency) CPG and
                          • Multiple injuries                                                       redirect Mx to usual ED
                          • Altered conscious state including                                       care with NP
                              effects of drugs / alcohol                                            (Emergency) part of the
                          • History consistent with collapse                                        ED team.
              Initial Assessment & Interventions                                                            Outcomes
History                • Mechanisms of injuries sustained,                                          Exclusion criteria
                       • Time of injury                                                             identified → exit CPG.
                       • Treatment - given pre hospital                                             Referral to EP.
                       • Range of movement / Ability to weight
                          bear
                       • Deformity
                       • Past medical history, any previous ankle
                          injury/ medications
                       • Allergies / immunisations
                       • Last food / fluids
                       • Compensable status - MVIT / WC / DVA
                          / Private Insurance
Neurovascular          • Colour                                                                     Neurovascular
assessment             • Warmth                                                                     compromise → exit
                       • Movement                                                                   CPG. Referral to EP.
                       • Sensation
                       • Capillary refill
                       • Peripheral pulses
Focused clinical       • Ottowa Ankle/Foot Rules [1] –see                                           Determine need for
assessment                Appendices                                                                ankle x-ray
                       • Not validated for use in patients less                                     Identify patients for foot
                          than 18 years of age. Useful for                                          injury CPG
                          determining type of x-ray i.e ankle/foot,
                          to request in this age group.
                       • Patients < 18 yrs of age with tenderness
                          over growth plate require xray




Joondalup Health Campus wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of   1
the Clinical Practice Guidelines
                                     Nurse Practitioner – Emergency Services
                                       CLINICAL PRACTICE GUIDELINE
                                               INJURY - ANKLE

Pain assessment                         •   Pain scale                                              Determine need for and
                                                                                                    type of analgesia
Analgesia /                      - rest •                                                           Reduction / relief of pain
First Aid                        - ice / immobilisation                                             Minimise / prevent
                                 - compression                                                      swelling
                                 - elevation
                              • Administration of analgesia (see
                                medications)
                  Working diagnosis and Investigations                                                         Outcomes
Imaging                       • Imaging may not be required if
                                         - patient able to weight bear
                                         - no bony or focal tenderness
                                 [1]

                                 •       Ankle x-ray required                       Identify specific injury
                                            Pain in malleolar zone and              and determine patient
                                                   - +/- bony tenderness at         management
                                       posterior edge or tip of lateral malleolus
                                                   +/- bony tenderness at
                                       posterior edge or tip of medial
                                       malleolus
                                                   +/- inability to weight bear
                                       both        immediately and in the ED
                                       •
                                            Foot x-ray if pain in navicular region,
                                            base of navicular bone [1, 2] or bony
                                            tenderness at base of 5th metatarsal.
                                       •    Xray of both ankle and foot may be
                                            required if clinical signs present for
                                            both regions

Pathology                               •   Not routinely indicated but consider                    Ongoing assessment of
                                            necessity for IV access and insert                      need for intravenous
                                            cannulae if required                                    access
                                        •   Pre operative investigations may
                                            include FBP, U&E, Group and Hold
                                            and INR as discussed with admitting
                                            medical officer.




Joondalup Health Campus wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of   2
the Clinical Practice Guidelines
                                   Nurse Practitioner – Emergency Services
                                     CLINICAL PRACTICE GUIDELINE
                                             INJURY - ANKLE

Interpretation of results (diagnostic features) and management                                                 Outcomes
                             decisions
Imaging ± clinical
features

 No                                   •    NP (Emergency) review with view to Patient discharged
 fracture/dislocatio                       discharge
 n seen and weight                    •    patient education / health promotion
 bearing [2, 3]                       •    follow-up appointment with GP if
                                           required

 No                                   •    NP (Emergency) review with view to Patient discharged
 fracture/dislocatio                       discharge
 n seen and non-                      •    Tubigrip application and LMO review
 weight bearing [2,                        in 72 hours for clinical re-
 3]
                                           assessment and to check formal
                                           radiology report.
                                      •    patient education / health promotion
                                      •    crutches

No                                    •    NP (Emergency) review with view to                       Patient discharged
fracture/dislocation                       discharge
seen but open                         •    Below knee POP Backslab
growth plate on                       •    Crutches for non weight bearing
xray and                              •    Follow-up appointment with Fracture
tenderness over                            Clinic 7 days
growth plate                          •    Patient education/health promotion
  Simple,                             •    NP (Emergency) review with view to                       Patient discharged
  undisplaced                              discharge after consultation with
  Stable # with no                         senior ED doctor
  component of the                    •    Below knee POP backslab
  # at the level of                   •    Crutches for non weight bearing
  the ankle mortise
  [4]
                                      •    Follow-up appointment with Fracture
                                           Clinic 7 – 10 days
                                      •    Patient education/health promotion
                                      •    + referral to physiotherapy




Joondalup Health Campus wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of   3
the Clinical Practice Guidelines
                                   Nurse Practitioner – Emergency Services
                                     CLINICAL PRACTICE GUIDELINE
                                             INJURY - ANKLE

  Significant                       •       NP (Emergency) review with view to                      Assessment by
  ligament damage                           discharge +/- Orthopedic review                         Orthopedic Unit.
  with no #                         •       Below knee POP backslab
                                    •       Crutches for non weight bearing                         Patient discharged


  - disruption of                   •       Follow-up appointment with Fracture
  ankle     mortise                         Clinic 7-10 days
  on xray                           •       Patient education/health promotion
                                    •       + referral to physiotherapy


Displaced medial,                           •     NP (Emergency) review with view Assessment by
lateral or posterior                              to referral to Orthopaedic Unit [5] Orthopedic Unit
malleolar #                                 •     RICE
                                            •     R/V and maintain adequate
Medial Malleolar #                                analgesia
with lateral                                •     Monitor neurovascular perfusion of
ligament damage                                   foot
                                            •     Below knee POP backslab if
Lateral malleolar #                               unstable
with deltoid
ligament damage

Fibula # at or
proximal to the
tibiotalar joint line

All bi and
trimalleolar,
intraarticular, or
pilon #s [4, 5]



Associated care                         •       Consider ECG/CXR for patients
                                                who require surgical intervention
                                        •       Consider IV fluids for patients who
                                                require fasting for surgical
                                                intervention



Joondalup Health Campus wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of   4
the Clinical Practice Guidelines
                                   Nurse Practitioner – Emergency Services
                                     CLINICAL PRACTICE GUIDELINE
                                             INJURY - ANKLE

Acute                                 •    Referral to
Referral                                         +/- physiotherapy
                                                 +/- interpreter
                                                 +/- allied health etc.


                         Patient Discharge Education                                                        Outcomes
When to return                   • Verbal instructions from NP                                      Ensure patient
                                    (Emergency)                                                     understands problem,
                                 • ED written patient information                                   treatment, follow up and
                                                                                                    is safe for discharge
                                                                                                    home

Follow up                             • Verbal instructions from NP                                 Ensure patient
appointments                            (Emergency)                                                 understands problem,
                                      • Written instructions for                                    treatment, follow up and
                                        LMO/Fracture clinic (if applicable)                         is safe for discharge
                                      • OPD appointment book (if                                    home
                                        applicable)
Medication                             • Verbal instructions from NP                                Ensure patient
instructions                              (Emergency)                                               understands problem,
                                       • Contact ED Pharmacist to provide                           treatment, follow up and
                                          medication education for patient                          is safe for discharge
                                          when available. Written                                   home
                                          information as per the Hospital
                                          Pharmacy on medications
                                          dispensed.

POP care                              •    Verbal instructions from NP                              Ensure patient
                                           (Emergency)                                              understands problem,
                                      •    Plaster check 24 - 48 hrs with LMO                       treatment, follow up and
                                      •    ED written patient information                           is safe for discharge
                                                                                                    home

Safety assessment                     •    Appropriate fitting of crutches and                      Ensure patient
i.e. crutches                              ambulation instructions from NP                          understands problem,
                                           (Emergency)/ physiotherapist                             treatment, follow up and
                                      •    Patients > 60 yrs of age, consider                       is safe for discharge
                                           referrals                                                home




Joondalup Health Campus wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of   5
the Clinical Practice Guidelines
                                   Nurse Practitioner – Emergency Services
                                     CLINICAL PRACTICE GUIDELINE
                                             INJURY - ANKLE

Other                                 •    Referrals may be made for specific                       Ensure patient
Referrals                                  patient problems or as required to;                      understands problem,
                                                   - social work                                    treatment, follow up and
                                                   - physiotherapy                                  is safe for discharge
                                                   - drug and alcohol counsellor                    home
                                                   - aboriginal liaison officer

Certificates                          •    Absence from work certificates                           Appropriate
                                      •    WC certificate                                           documentation
                                      •    Certificate of attendance                                completed


Letters                               •    Local medical officer letter                             Ensures continuity of
                                                                                                    care and referral to
                                                                                                    health care team


                            Medications                                      Outcomes
All medication will be stored, labelled and dispensed in accordance with hospital policy and
relevant legislation.[6]
According to Ambulatory Pain Management Guideline.
Simple analgesia [7]                                                  Patients given analgesia
S2                       Paracetamol 500mg: 1 or 2 tablets 4-6/24, appropriate to allergies,
Mild                     not to exceed 8 tablets in 24 hrs.           current medications and
                         Children: 15 mg/kg 4 hourly up to 4 times    past medical history.
                         a day. Not to exceed 4 doses in 24 hours
                                                                      Analgesia requirements
                                                          (6)
                         Painstop Day: 0.6 - 0.8 MLS/KG               determined by ongoing
                                                                      assessment of pain and




Joondalup Health Campus wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of   6
the Clinical Practice Guidelines
                                    Nurse Practitioner – Emergency Services
                                      CLINICAL PRACTICE GUIDELINE
                                              INJURY - ANKLE

NSAIDS [7]                        ADD to paracetamol if still in pain                                adequate analgesia
S4                                Naproxen 500 mg initially then 250 mg 6 –                          Provided.
Moderate                          8 hourly
                                                                                                     Patients with excessive
                                  Children;                                                          pain or pain unrelieved
                                  Ibuprofen: 10 mg/kg 3-4 times daily to                             by analgesia need
                                  maximum of 600 mg in 24 hours (7)                                  review by EP

                                  If NSAIDS contraindicated,
                                  Tramadol
                                  Adults and Children > 12 years
                                  Contraindicated in epilepsy, SSRI use
                                  Caution in the Elderly – Maximum 300
                                  mg daily
                                  Oral: 50-100mg QID, maximum 400mg
                                  over 24 hours
                                  OR
                                  Intravenous: 50-100mg QID, maximum
                                  600mg over 24 hours

Narcotic Analgesia                ADD to paracetamol + NSAID if still in
[7]
                                  pain
S8
Severe                            Currently NPs require Medical Prescription
                                  for Schedule 8 medication

                                  Oxycodone: Adults only; Oral: 5mg every
                                  4 hours
                                  OR
                                  Morphine
                                   Adults; Intramuscular/intravenous: 2.5mg
                                  then incremental doses to a maximum total
                                  dose of 10mg (given over period of 30
                                  minutes)
                                  Children; IM – 0.2 mg/kg IV: 0.1- 0.2
                                  mg/kg/dose given in titrated doses:
                                  IF PAIN NOT CONTROLLED WITH ALL 3
                                  AGENTS, REFER TO ED CONSULTANT




 Joondalup Health Campus wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of   7
 the Clinical Practice Guidelines
                                    Nurse Practitioner – Emergency Services
                                      CLINICAL PRACTICE GUIDELINE
                                              INJURY - ANKLE

Anti-emetic           PRN         Metoclopromide hydrochloride:
[7]
                                  Oral/IM/IV:10-20mg 8/24
S4                                Prochlorperazine: Oral 5-10mg 8-12/24
                                  IM deep 12.5 mg 8/24
                                  Not in Children < 16 years of age.

Intravenous fluids                Adults: 0.9% Sodium Chloride
S4                                Intravenous fluid: 5-10ml flush of
                                  Intravenous cannula 6/24 or Infusion at 8-
                                  12hrly titrated to patients requirements.
                                  Children: Discuss with ED Consultant.

                                       Clinical audit evaluation strategies
Unexpected                        Emergency Department attendance
representation                    register and NP (Emergency) clinical log

Missed problem                    Emergency Department x-ray review

                                            References
1.       Broomhead, P. and P. Stuart, Validation of the Ottawa Ankle Rules in Australia.
         Emergency Medicine, 2003. 15(2): p. 126 - 132.
2.       McRae, R. and M. Esser, Practical Fracture Treatment. 4th Ed. 2002, Sydney: Churchill
         Livingstone.
3.       Ankle sprain. [National Guidelines Clearinghouse] c2003 2003 Jul 26 [cited 2006 Feb
         24]; Available from: http://www.guidelines.gov.
4.       Ankle and Foot. [National Guidelines Clearinghouse] c2005 [cited 2006 Feb 24];
         Available from: http://www.guidelines.gov.
5.       Naradzay, J. Fractures, Ankle. [eMedicine] c2006 2006 Jan 3 [cited 2006 Feb 15];
         Available from: http://www.emedicine.com/emerg/topic188.htm.
6.       JHC Hospital Medication Storage and Administration Policy. Available via Hospital
         Intranet
7.       eMIMS 2006 [cited 2006 Mar 16]; Available via Hospital Intranet




 Joondalup Health Campus wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of   8
 the Clinical Practice Guidelines
                                   Nurse Practitioner – Emergency Services
                                     CLINICAL PRACTICE GUIDELINE
                                             INJURY - ANKLE

                              Authorship and endorsement
     (This Guideline has been developed in collaboration with the JHC ENP CPG Review
                                       Committee)
This CPG was written by:

Bronwyn Nicholson
Nurse Practitioner – Emergency Services
Joondalup Health Campus

Terry Jongen
Emergency Nurse Practitioner Candidate
Royal Perth Hospital



Key to terms                                                          Appendices
CPG- Clinical Practice Guideline                                      Ottawa Ankle Rules
DVA- Department of Veteran Affairs
EP- Emergency Physician
PS- Pain Score
LMO- Local Medical Officer
S1-S4- Schedule of the drug administration
act
MVIT – Motor Vehicle Insurance Trust
NP (Emergency) – Nurse Practitioner –
Emergency Services
OP- Outpatients
WC- Work cover

Written: June 2006                                                      Review date: June 2008
Reviewed: N/A




Joondalup Health Campus wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of   9
the Clinical Practice Guidelines
                                   Nurse Practitioner – Emergency Services
                                     CLINICAL PRACTICE GUIDELINE
                                             INJURY - ANKLE




Joondalup Health Campus wishes to acknowledge The Alfred Hospital for their valued advice and support with regards to the creation of   10
the Clinical Practice Guidelines

				
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