Adult ECAT protocol

Isolated limb injury

A9.3 Published: December 2023. Printed on 15 Jun 2024.

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

This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.

If patient meets the criteria of major trauma, switch to local trauma guidelines and major trauma protocol.

Consider compartment syndrome: disproportionate pain, pallor, pulselessness, paraesthesia, paralysis, pressure or poikilothermia (change in temperature of the affected limb).

History prompts, signs and symptoms

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

History prompts

  • Presenting complaint
  • Preceding events, e.g. syncope, chest pain or dizziness
  • Mechanism of injury
  • Time of injury
  • Ability to weight bear
  • Pain assessment – PQRST
  • Pre-hospital treatment, e.g. analgesics, splinting or wound management
  • Past admissions
  • Medical and surgical history
  • Current medications
  • Known allergies

Signs and symptoms

  • Swelling
  • Bruising
  • Point tenderness over bone
  • Pain
  • Deformity
  • Reduced range of motion

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.

Historical

Clinical

  • Compartment syndrome, symptoms include:
    • disproportionate pain
    • pallor
    • pulselessness
    • paraesthesia
    • paralysis
    • pressure
    • poikilothermia
  • Signs of haemorrhage
  • Open fracture
  • Tenting of skin
  • Gross limb deformity (including dislocation or amputation)
  • Neurovascular compromise
  • White, pale or cool limb
  • Suspected neck of femur fracture

Remember adult at risk: patient or carer concern, frailty, multiple comorbidities or unplanned return.

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

AssessmentIntervention

General appearance/first impressions

Position of comfort

Consider the position of the affected limb

Elevate in comfortable position

Airway

AssessmentIntervention

Patency of airway

Maintain airway patency

Consider airway opening manoeuvres and positioning

Breathing

AssessmentIntervention

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

AssessmentIntervention
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

AssessmentIntervention
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

AssessmentIntervention
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

AssessmentIntervention
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

AssessmentIntervention

BGL

Measure BGL, if clinically indicated

If less than 4 mmol/L, consider hypoglycaemia protocol

Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS 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


Analgesia

Select pain score:

Pain score 1–3 (mild)

Give paracetamol 1000 mg orally once only

and/or ibuprofen 400 mg orally once only

Pain score 4–6 (moderate)

Give:

oxycodone (immediate release):

  • 16–65 years: 5 mg orally and, if required, repeat once after 30 minutes, maximum dose 10 mg
  • 65 years and over: 2.5 mg orally and, if required, repeat once after 30 minutes, maximum dose 5 mg

and/or paracetamol 1000 mg orally once only

and/or ibuprofen 400 mg orally once only

Pain score 7–10 (severe)

Give one of:

Fentanyl intranasal
  • 16–65 years: 50 microg intranasally and, if required, repeat once after 5 minutes, maximum dose 100 microg. Dose to be divided between nostrils
  • 65 years and over: 25 microg intranasally and, if required, repeat once after 5 minutes, maximum dose 50 microg. Dose to be divided between nostrils

Note: ensure an extra 0.1 mL is drawn up for the first dose to account for the dead space in the mucosal atomiser device

Fentanyl IV
  • 16–65 years: 50 microg IV and, if required, repeat once after 5 minutes, maximum dose 100 microg
  • 65 years and over: 25 microg IV and, if required, repeat once after 5 minutes, maximum dose 50 microg
Morphine IV
  • 16–65 years: 5 mg IV and, if required, repeat once after 5 minutes, maximum dose 10 mg
  • 65 years and over: 2.5 mg IV and, if required, repeat once after 5 minutes, maximum dose 5 mg
Morphine IM
  • 16–65 years: 5 mg IM and, if required, repeat once after 60 minutes, maximum dose 10 mg
  • 65 years and over: 2.5 mg IM and, if required, repeat once after 60 minutes, maximum dose 5 mg
Methoxyflurane
  • Using a 3 mL self-administered device, instruct the patient to inhale through the mouthpiece and take a couple of gentle breaths to get used to the fruity smell and taste; then take 6–8 deep breaths once only

and/or paracetamol 1000 mg orally once only

and/or ibuprofen 400 mg orally once only

If pain does not improve with medication, escalate as per local CERS protocol.


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.


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.

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.

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.

Drag the table right to view more columns or turn your phone to landscape

Drug Dose Route Frequency

0.5 mL

IM

Once only

OR

0.5 mL

IM

Where ADT booster not available

Once only

16–65 years
50 microg
Maximum dose 100 microg

65 years and over:
25 microg
Maximum dose 50 microg

IV/intranasal

Pain score 7–10

Repeat once if required after 5 minutes to maximum dose

Ibuprofen H, R

400 mg

Oral

Pain score 1–10

Once only

3 mL via self–administered device

Inhalation

Pain score 7–10

Once only

Metoclopramide R

Over 20 years:
10 mg

Oral/IV/IM

Once only

16–65 years
5 mg
Maximum dose 10 mg

65 years and over:
2.5 mg
Maximum dose 5 mg

Pain score 7–10

IV Repeat once if required after 5 minutes
IM Repeat once if required after 60 minutes

Ondansetron

4 mg

Maximum dose 8 mg

Oral/IV/IM

Repeat once if required after 60 minutes

16–65 years:
5 mg
Maximum dose 10 mg

65 years and over:
2.5 mg
Maximum dose 5 mg

Oral

Pain score 4–6

Repeat once if required after 30 minutes to maximum dose

Oxygen

2–15 L/min, device dependent

Inhalation

Continuous

Paracetamol H

1000 mg

Oral

Pain score 1–10

Once only

5 mg

Oral

Once only

OR

12.5 mg

IV/IM

Once only

Sodium chloride 0.9%

250 mL

Maximum dose 1000 mL

IV/intraosseous

Bolus

Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

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.

References

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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

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/adult/isolated-limb-injury

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