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Increased frequency of manipulation of paediatric forearm fractures with morphine/Nitrous oxide in the emergency department.
This approach, whilst part of standard practice, has been an enormous asset during the Covid-19 crisis and the collaborative approach that has been adopted during this period, should be retained and encouraged when “new normal” practice resumes.
Kurian et al demonstrated the safety and potential cost saving associated with this approach and the purpose of posting this idea is to encourage widespread application in the post-Covid period
Manipulation and reduction of paediatric fractures of the distal radius and forearm using intranasal diamorphine and 50% oxygen and nitrous oxide in the emergency department
Bone Joint J 2016;97-B:131–6 A retrospective study was performed in 100 children aged between two and 16 years, with a dorsally angulated stable fracture of the distal radius or forearm, who were treated with manipulation in the emergency department (ED) using intranasal diamorphine and 50% oxygen and nitrous oxide. Pre- and post-manipulation radiographs, the final radiographs and the clinical notes were reviewed. A successful reduction was achieved in 90 fractures (90%) and only three children (3%) required remanipulation and Kirschner wire fixation or internal fixation.
The use of Entonox and intranasal diamorphine is safe and effective for the closed reduction of a stable paediatric fracture of the distal radius and forearm in the ED. By facilitating discharge on the same day, there is a substantial cost benefit to families and the NHS and we recommend this method.
What is needed to sustain the change?
There are frequent publications demonstrating that paediatric fractures requiring manipulation can safely be managed in the emergency department with low risks to the child, high levels of patient and parental satisfaction, and clinical outcomes comparable to management using general anaesthesia.
Despite this, a recent nationwide audit demonstrated that manipulation of forearm fractures was permitted in only 35% of Emergency Departments.
The variation in practice which exists both within and between units is irrational and underscores the need for evidenced practice guidelines.
Guidelines have been produced by individual departments but there is a clear need for a nationally coordinated approach.
The British Orthopaedic Association have produced a series of guidelines (https://www.boa.ac.uk/standards-guidance/boasts.html) and there is a clear need for specific BOAST guidance for manipulation of paediatric fractures in the ED.
What is your region?
South West
Is this done by the on call T+O team or by the clinical staff in ED?
I am guessing T+O - If so what grade of staff performs this? FY2/JCF/ST? or senior staff.
Thanks for the info.
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Status labels added: Collaboration, Collaboration Of T&O and MIU, Consent, Education, Effective Team Working, Equipment, Guidance, Implementation, Integration Of Resources, Medication, Pathway Redesign, Patient Activation, Patient Selection, Referral Pathway Redesign, Shared Decision Making, Staff & Patient Collaboration, Upskilling Of Staff, Horizon 1
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Status labels removed: Collaboration, Collaboration Of T&O and MIU, Consent, Education, Effective Team Working, Equipment, Guidance, Implementation, Integration Of Resources, Medication, Pathway Redesign, Patient Activation, Patient Selection, Referral Pathway Redesign, Shared Decision Making, Staff & Patient Collaboration, Upskilling Of Staff
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