Isolated limb injury

Any person, 4 weeks to 15 years, presenting with an isolated injury to a limb. This protocol does not apply to hip, pelvic injuries or pulled elbow.

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 work of breathing Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93%

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) Heart rate Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor 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 Consider 12 lead ECG
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, give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL

Disability

Assessment	Intervention
AVPU	If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated
Pain	Immobilise the 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
Head-to-toe inspection, including posterior surfaces	Check and document any abnormalities Hourly neurovascular observations of the affected limbs Include assessment of pain, sensation, motor function and perfusion (pulses, colour, temperature, swelling and capillary refill) Compare limbs

Fluids

Assessment	Intervention
Hydration status	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses
Nausea and/or vomiting	If present, see nausea and/or vomiting section
NBM	Consider clear fluids or NBM based on red flags and clinical severity

Glucose

Assessment

Intervention

BGL

Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria): give quick-acting carbohydrate: Up to 12 months: milk feed and/or 40% glucose gel, buccal 12 months and over: sugary soft drink or fruit juice or 40% glucose gel, buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access escalate as per local CERS protocol

Focused assessment

Complete a musculoskeletal focused assessment

Precautions and notes

• Consider the possibility of non-accidental injury, especially in infants, and non-ambulant patients.
• A ‘toddler's fracture’ is a spiral or oblique un-displaced fracture of the distal shaft of the tibia with an intact fibula. These fractures occur as a result of a twisting injury and may not be apparent on x-ray.

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 a 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.

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Analgesia

Select pain score:

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

Consider non-pharmacological pain relief (appendix).

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Nausea and/or vomiting

If nausea and/or vomiting is present and over 6 months give:

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Procedural analgesia

For pain relief required during procedures only, not used to replace appropriate analgesia.

Sucrose 24%

• 1–18 months: give 1–2 mL orally per procedure
• Maximum dose:
  • 1–3 months: up to 5 mL in 24 hours
  • 3–18 months: up to 10 mL in 24 hours.

Repeat as needed up to the maximum dose.

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Tetanus

All patients must be considered for a tetanus booster if they have a tetanus-prone wound. Refer to medical or nurse practitioner or nurse immuniser to consider tetanus immunisation requirements.

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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.
  • Ankle and/or foot x-ray: refer to Ottawa ankle appendix

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Pathology

Not usually indicated. If there is concern for urgent pathology, escalate care as per local CERS protocol.

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

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