Fractured neck of femur

 

LOOK UP EVIDENCE SPINAL VS GA

 

Pre-op 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? (gamechanger)

·      C-spine injury? (i.e. no spinal)

Optimisation?

·      CVS

·      Resp

·      Haem

·      Pain

Limitations to care?

·      Discuss with patient and NOK

·      Specify intra-op vs post-op

GA or spinal?

·      CVS: severe AS or MS or PHTN or RV dysfx (i.e. high risk, no spinal)

·      Resp: resp infection? (i.e. no sedation)

·      Haem: anticoagulation? (i.e. no neuraxial)

·      Lumbar spine pathology (maybe not neuraxial)

 

Approach:

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

 

Anaesthesia:

Goals

·      No cardiovascular collapse at induction

·      No cardiovascular collapse upon cementing

·      No aspiration

·      No emergence delirium

·      No excessive discomfort

Neuraxial approach

·      IVC 18g or larger

·      Arterial line

·      Fascia iliaca block: 20-40mL 0.375% ropiv

·      Ketamine 10mg-20mg stat

·      Metaraminol infusion 2.5mg/h (start when scrubbing)

·      Lateral with bad hip up

·      0.5% plain bupivacaine with fentanyl

·      Intra-op sedation only if needed

GA approach

·      IVC 18g or larger

·      Arterial line

·      Fentanyl 150mcg

·      Propofol TCI induction with Cet titrated to LOC + a bit more

·      Rocuronium 1mg/kg upon eye closure

·      Crystalloid 250mL

 

Hypotension intra-op:

Initial statement

·      Communicate

·      Temporise (fluid + pressor)

·      Simultaneously assess and treat

DDx

·      ↓SVR: anaesthetic drugs, anaphylaxis

·      ↓Preload: anaesthetic drugs, hypovolaemia, cement embolisation

·      ↓Contractility: anaes drugs or cardiac event

·      ↓↑Rate: anaes drugs

·      Arrhythmia

Assessment

·      Check A&B: look at tube, capno, sats, listen to chest

·      Check C: HR, rhythm, BP, pulse, skin colour, rash

Management

·      Fluid bolus

·      Vasopressor

·      Rest depends