Isolated limb injury

Any person, 16 years and over, presenting with isolated injury to lower or upper limb, excluding fractured neck of femur.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions	Position of comfort Consider the position of the affected limb Elevate in comfortable position

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation, as clinically indicated Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92%

Circulation

Assessment	Intervention
External signs of bleeding	Control external bleeding by using direct pressure, elevation, pressure dressing or haemostatic dressing
Perfusion (capillary refill, skin warmth and colour) Pulse rate Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern
IVC and/or pathology	Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Disability

Assessment	Intervention
ACVPU	If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment, as clinically indicated
Pain	Immobilise limb with splinting or sling Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment Consider compartment syndrome

Exposure

Assessment	Intervention
Temperature	Measure temperature
Skin inspection, including posterior surfaces	Check and document any abnormalities Hourly neurovascular observations of the affected limbs Include assessment of sensation, motor function and perfusion, i.e. pulses, colour, temperature, swelling and capillary refill Compare limbs

Fluids

Assessment	Intervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited	Commence fluid balance chart, as required
NBM	Consider clear fluids or NBM based on red flags and clinical severity
Nausea and/or vomiting	If present, see nausea and/or vomiting section

Glucose

Assessment	Intervention
BGL	Measure BGL, if clinically indicated If less than 4 mmol/L, consider hypoglycaemia protocol

Focused assessment

Complete a musculoskeletal focused assessment.

Precautions and notes

• Potential life-threatening complications include compartment syndrome, embolisms and uncontrolled haemorrhage.
• Elevation and splinting of fractures reduce movement and pain, as well as minimising the likelihood of exacerbating existing neurovascular damage.

Interventions and diagnostics

Specific treatment

Closed injury

• Provide analgesia
• Remove all jewellery or constricting clothing from affected limb
• Provide any wound treatment as per minor wounds protocol
• Apply splint and/or sling to immobilise the joint above and below the suspected fracture or injury
• Splint should be firm and supportive
• Ice can be applied where appropriate
• Regular neurovascular observations of the affected limbs
• Include assessment of pain, sensation, motor function and perfusion, i.e. pulses, colour, temperature, swelling and capillary refill

Open fractures

• Irrigate with sodium chloride 0.9% and apply a compress soaked in sodium chloride 0.9%.
• Do not reposition protruding bone ends.
• Stabilise limb.
• Escalate care urgently as per local CERS protocol.

Amputation or partial amputation

• If the digit or limb has been completely amputated:
  • Wrap the amputation in gauze soaked with sodium chloride 0.9%.
  • Place in a clean bag, and then in another bag with ice slurry.
  • Do not sit the amputation directly in the ice slurry.
• If partial amputation:
  • Perform neurovascular exam.
  • Irrigate with sodium chloride 0.9% and apply dressing soaked in sodium chloride 0.9%.
• If an x-ray is ordered, ask the radiographer to include the amputated tissue within the parameters of the x-ray. This will help determine the degree of bone or tissue loss, if any.
• Escalate care urgently as per local CERS protocol.

Suspected mid-shaft femur fracture

• Stabilise with traction splint. Perform neurovascular observations pre and post splinting.
• Consider hip fracture (suspected) protocol.

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Analgesia

Select pain score:

• 1–3 (mild)
• 4–6 (moderate)
• 7–10 (severe)

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Nausea and/or vomiting

If nausea and/or vomiting is present, give:

• metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
• or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
• or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.

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Tetanus

If patient has a ‘tetanus-prone’ wound, consider giving a tetanus booster vaccine.

• Diphtheria and tetanus (ADT booster) vaccine should be given as per the Australian Immunisation Handbook Guide for tetanus prophylaxis in wound management.
• If ADT booster is not available then diphtheria/tetanus/pertussis (Boostrix) vaccine can be used.
• If no documented history of a primary vaccination course (3 doses) with a tetanus toxoid-containing vaccine: refer to medical or nurse practitioner or nurse immuniser.
• If pregnant or breastfeeding: dTpa vaccine (diphtheria-tetanus-acellular pertussis) is recommended. Refer to medical or nurse practitioner or nurse immuniser.

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Radiology

• Consider history of injury and clinical signs, including point tenderness, deformity, limited range of movement and swelling, when ordering imaging. If concerned, discuss optimal imaging with radiographer.
• Upper limb x-ray: may include clavicle, shoulder, humerus, elbow, forearm, wrist, hand, finger and scaphoid (snuff box tenderness or pain on axial loading of thumb).
• Lower limb x-ray: may include mid-shaft femur, knee, tibia, fibula, ankle and foot.
  • Use decision-making tools as required:
    • Ankle and/or foot x-ray: refer to Ottawa ankle appendix
    • Knee x-ray: refer to Ottawa knee appendix

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Pathology

Not usually required unless surgery indicated.

• Preceding event such as syncope and/or special populations such as the elderly or those with multiple comorbidities: FBC, UEC
• Significant bleeding: group and hold
• Warfarinised: INR

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Medications with contraindications or requiring dose adjustment are marked:

• ^H for patients with known hepatic impairment
• ^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au