Fractured neck of femur

 

Assessment:

 

Questions:

 

Why fall?

·      Simple fall

·      Cardiac event

·      Neurological event

Why fracture?

·      High impact trauma (young person – what other injuries?)

·      Osteopaenia (old person – what other injuries?)

·      Pathological (where else is the cancer?)

Other injuries?

·      Head injury? (game changer)

·      C-spine injury? (i.e. difficult airway)

·      Prolonged lie? (i.e. rhabdo, renal failure)

GA or neuraxial?

·      CVS: fixed output lesion?

·      Haem: anticoagulation?

·      MSK: lumbar spine pathology?

 

Approach:

Source of info

·      Patient

·      Relatives

·      Notes

Hx

·      HOPC: the fall

·      PMHx: CVS, resp, spine

·      Meds: anticoagulants or antiplatelets, cardiovasc meds

·      Systems review: incl exercise tolerance

·      Fasting

·      Allergies

Ex

·      CVS

·      Resp

·      Airway

Ix

Blood tests:

·      FBE (?Hb ?plt)

·      UEC (?rhabdo)

·      BGHO

·      +/- Coag

Cardiac investigations:

·      ECG for all

·      TTE if suspect significant pathology and there is time

Trauma imaging:

·      TTE

·      CXR

·      Pelvic XR

·      CT brain

·      CT C-spine

 

Pre-op:

Investigations

·      Blood tests: incl FBE and coag

·      Cardiac investigations: ECG ±TTE

·      Trauma imaging: including CTB and CT C-spine

Treatment

See AAGBI: reasons for delay

·      CVS: heart failure, tachyarrhythmia

·      Resp: infection, hypoxaemia

·      Haem: coagulopathy

·      Metabolic: Na>120 and <150, K >3.5 and <6, BSL <?

·      Pain: e.g. FIB

Phone calls

Limitations of care:

·      Discuss with patient, NOK and surgeon

·      Specify intra-op vs post-op

 

 

Intra-op:

 

Neuraxial:

Anaesthetic

·      Spinal: 3mL 0.5% plain bupivacaine + 15mcg fentanyl

·      Sedation: ketamine 10-20mg pre-spinal, propofol TCI intra-op

·      Metaraminol infusion throughout

Airway

·      Native

Access

·      Large IVC

·      A-line pre-spinal

Probes

·      Standard + A-line + temp + IDC

Pain

·      Fascia iliaca block: ropivacaine 2.5mg/kg in 30mL
(beware same block in A&E)

·      Multi-modal analgesia

People

·      Standard

·      Extras for positioning pre-spinal

 

General:

Anaesthetic

·      Relaxant GA

o  Induction: prop 0.5-1mg/kg titrated, alf 5-7mcg/kg, roc 1.2mg/kg, metaraminol 0.5mg, CSL 250mL

o  Maintenance: sevo/nitrous 1MAC, metaraminol infusion

Airway

·      ETT

Access

·      Large IVC

·      A-line pre-induction

Probes

·      Standard + A-line + temp + IDC

Pain

·      Fascia iliaca block: ropivacaine 2.5mg/kg in 30mL
(beware same block in A&E)

·      Multi-modal analgesia

People

·      Standard

 

 

Cement implantation syndrome:

Risk factors

Patient

·      Older

·      ASA 3+

·      Cardiac disease (NYHA 3+)

·      Pulmonary hypertension

Fracture:

·      Intertrochanteric

·      Osteoporotic fracture

·      Pathological fracture

Surgery:

·      Virgin canal

·      Long stem prosthesis

Protective factors

Surgery:

·      Lavage

·      Venting

·      Short prosthesis

·      Non-cemented prosthesis!

Presentation

·      Hypoxaemia

·      Cardiovascular collapse
? RV failure

Anticipation

·      Arterial line

·      ±CVC, PAC

Treatment

·      Supportive

·      Pressor

·      Volume

 

Approach to sudden intra-op hypotension:

Immediate

·      Communicate

·      Fluid

·      Pressor

DDx

·      Most likely = BCIS

·      ↓SVR: anaesthetic drugs, anaphylaxis

·      ↓Preload: hypovolaemia

·      ↓Contractility: AMI

·      Arrhythmia

Assessment

·      Scan monitors: HR, ABP, SpO2

·      Scan ventilator: capno, flow, pressure

·      Check patient: pulse, rash

 

 

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