Hip fracture - patient with confirmed or clinical suspicion of hip fracture (G102)

NHS Ayrshire & Arran guidelines
NHS Ayrshire and Arran

Ensure hip imaging ASAP & "Big Six" are ALL completed

Pain scoring

 

 

Analgesia

Measure pain on movement & use scale 0-3 or Abbey pain tool for patients unable to give verbal score.


Regular paracetamol, s/c morphine/oral liquid morphine. Refer to fragility fracture analgesia bundle.

Fascia iliaca block (administered by ED Dr/ANP/Anaesthetist/deemed competent practitioner).
See Fascia iliaca block information section below.
NEWS 2 Also monitor limb for colour, sensation & movement. If patient had fascia iliaca block – monitor NEWS 2 as per guideline G074: Fascia Iliaca Block (FIB)
Delirium screening & cognitive impairment 4AT scoring & note pre-existing cognitive impairment
Ensure patient hydrated & electrolytes corrected Obtain bloods: full blood count (FBC), urea & electrolytes (U&E), liver function tests (LFTs), Coag, Group & Save x2 - may require pre-op transfusion. Bone profile.

IV fluids if poor oral intake.

Monitor fluid balance.

Hip fracture patients do not require routine urinary catheter, but may be necessary. All ortho patients can "Sip til Send". See the Sip til send guidelines.

 
Pressure area inspection Waterlow scoring & appropriate mattress.

 

ECG If any acute findings ensure medical staff informed

Patient confirmed as hip fracture:

Withhold oral anticoagulants
(warfarin, clopidogrel, non-Vitamin K antagonist oral anticoagulants (NOACS))		 Aim for INR <1.5 – see peri-op anticoagulant guidelines.

Commence DVT prophylaxis (unless contra-indicated & give no later than 1800hrs pre-op)
Ensure patient has Orthopaedic review & plan documented in medical notes Limb marked
Consent or adults with incapacity (AWI) with treatment plan completed If patient has a power of attorney (POA) – should be discussed with POA pre-op & copy of POA should accompany patient.
If patient has DNACPR: Ensure date is completed & signed by consultant/senior clinician
Ensure patient’s next of kin/POA have been informed  

If patient for theatre:

Food fasting Food until 0300 on morning of surgery (or 6 hours pre-op)
Oral fluids - Sip til Send Sip til send guidance
Repeat bloods at 6am FBC, U&E, Hb < 10 inform Ortho team*, up to date INR if usually on warfarin
Give morning medication except anti-coagulants & drugs listed on the pre-operative drugs to be omitted guideline

See the wallchart: drugs to be taken or omitted on morning of surgery.

Guideline for the management of drug therapy in the pre-operative period

*Orthopaedic team:

Crosshouse: 

Ortho on call Junior Dr: 3280

On call Registrar: 3368

Ayr:

1995 night

Fascia iliaca block summary information for nursing staff

(Adapted from NHS AAA guideline G074: Fascia Iliaca Block (FIB))

FIB provides fast, effective analgesia and significantly reduces cumulative doses of opioids in patients with neck of femur (NOF) fracture. Reduced use of opioids and NSAIDS thus reduces side effects and complications.

Inclusion criteria

Confirmed or suspected fractured neck of femur.

Contraindications

  • Patient refusal if patient lacks capacity use adults with incapacity (AWI).
  • Patients who have already had a femoral or fascia iliaca block administered within previous 6 hours.
  • Known sensitivity to local anaesthesia.
  • Infection at the site of injection.
  • Anticoagulant therapy (warfarin, clopidogrel, non-vitamin K antagonist oral anticoagulants (NOACS)) not an absolute contraindication - see guideline.
  • Clotting disorder (INR >1.5, platelet count <80)
  • Previous vascular surgery in affected limb.
  • Difficulty identifying landmarks.

Prior to procedure

  • Ensure IV access in situ and is patent.
  • Ensure patient is monitored including NIBP, ECG, SpO2.
  • Consent/AWI.

Equipment

  • Dressing pack + sterile gloves
  • Chloraprep stick 2%
  • 18ga tuohy needle
  • 1% lidocaine injection
  • 5ml syringe
  • 20ml syringe x2
  • Orange needle 25G
  • Drawing up needle (do not use to perform block)
  • 0.25% levobupivacaine injection up to 40ml - maximum dose 2mg/kg
  • Small dressing
  • FICB sticker (DRS 6168)

Observations

  • Record pain & NEWS 2 scores before the intervention.
  • Repeat NEWS & pain score 15min, 30min, 1 hour, 2 hours and 4 hours following FIB, then 4 hourly thereafter.
  • If pain scores are not improved after 30 min, ensure additional analgesia is given.
  • Monitor patients for respiratory depression - may be prone to this after FIB provides effective pain relief, especially if morphine administered within previous 2 hours.

Local anaesthetic toxicity

  • Observe patient for any signs of inadvertent intravascular injection such as circumoral tingling, light headedness, visual disturbances, seizures or arrhythmias.
  • Immediately stop injection of local anaesthetic.
  • Commence Basic Life Support if indicated.
  • Call for help - 2222 call.
  • Administer 100% oxygen + resuscitation.
  • Call anaesthetist for urgent assistance.
  • Consider lipid rescue therapy – located at bottom of Ortho cardiac arrest trolley.
  • See Guidelines for Management of Severe Local Anaesthetic Toxicity (AAGBI guidelines)

Editorial Information

Last reviewed: 19/01/2023

Next review date: 19/01/2026

Author(s): Houson R, Stewart A.

Version: 03.0

Author email(s): ruth.houson@aapct.scot.nhs.uk, angela.stewart@aapct.scot.nhs.uk.

Approved By: Orthopaedic Directorate

Reviewer name(s): aa.clinicalguidelines@aapct.scot.nhs.uk.

Document Id: NC-15-00413

Internal URL: http://athena/cgrmrd/ClinGov/Clinical%20Guidelines/G102%20Hip%20fracture%20pre%20op.pdf