Background Information
A 76 year old lady who lives alone had a mechanical fall at home and fell onto her left side and injured her left hip. She managed to alert her neighbour who contacted her GP, who requested an ambulance to manage and transport her to the Emergency Department UCHG for assessment and treatment of a probable left hip fracture.
Reason for reviewing this case
“Hip fractures are one of the most serious injuries due to a fall (approximately 2,800 admissions each year)”(1). Irelands population is ageing and the risk of falls increases with age. “11% of population aged 65 and over. This will increase to 18% in next 25 years to over one million people.”(1). “Mortality rates in the year following a hip fracture are about 25 percent” (2).
In the ambulance service we get called regularly for elderly people who have fallen, and with this there is a high incidence of them suffering a hip fracture. I wanted to research the causes and complications of hip fractures in the elderly and to see how our management compares to other services.
Incident
A 76 year old lady who lives alone suffered a mechanical fall in her kitchen when she tripped over a small bin and landed on her left side onto a tiled floor. She experienced pain to her left hip and was unable to get up. She managed to drag herself across the floor and into the sitting room where she could reach the telephone and alert her neighbour to what had happened. Her neighbour was unable to help her up and he rang her GP to come and assess her. In the meantime another neighbour had turned up and between them they managed to help her up off the floor and into an arm chair.
GP Attended
The GP arrived and assessed this lady after taking a history of the event. He was satisfied that the injury was due to a mechanical fall and he rang ambulance control to request an ambulance to transfer her to the Emergency Department UCHG for assessment and management. His impression was that of a possible left hip fracture due to mechanical fall. As the two neighbours were remaining at the scene the GP left and advised them to inform ambulance crew that he would fax on referral letter to the ED UCHG.
Ambulance crew arrival
The crew carried out an assessment and gained a brief history of event. The patient stated she had minor pain at rest but had severe pain in her left hip on movement. Her pain was evaluated to be 7 out of 10 on movement. An Advanced Paramedic was not available and so the crew took an AMPLE history and decided to offer Entonox for pain relief for the transfer from chair to stretcher. The crew decided to use a vacuum mattress on the stretcher to limit movement of the patient during transport and so help with pain management. The patient self administered the Entonox with good effect for this movement. A more thorough assessment was carried out when patient was transferred to the ambulance. Vital signs recorded were HR = 68 regular, RR = 16 normal, BP = 130/76, GCS = 15, Spo2 = 99% on room air, cap refill < 2 seconds, Temperature = 36.9 degrees Celsius, ECG showed NSR, Blood glucose level = 5.7 mmol/L and Pain scale was now 5 out of 10. The patient was then administered Paracetemol 1 gram PO and Ibuprofen 400 mg PO as they were not contraindicated. Circulation, sensory and motor function distal to injury was intact. The patient was transported to ED UCHG and observations remained stable with her pain scale dropping to 3 out of 10 by the time they arrived 20 minutes later.
Emergency Department
The patient was triaged on arrival and handover given by crew.
AMPLE
A= No known allergies
M = Ursofalk 250mg and Vitamin D
P= Osteopenia, Primary billary cirrhosis and compound fracture left wrist 2014.
L= breakfast 08.30 am.
E= mechanical fall causing left hip pain and unable to weight bare.
No syncope,no head injury,no loss of consciousness, no chest pain, no weakness.
No anticoagulants.
Social history = lives alone. Non drinker. Non smoker. Independent of activities of daily living. Husband passed away recently. Son and daughter living in England.
Vitals normal. Pain to left hip.No other complaints. Tenderness and pain mostly at left greater trochanter. No deformity or bruising noted. No shortening or external rotation of left leg noted. Circulation, sensory and motor function to distal foot intact.No knee or ankle pain. Increasing pain to hip on movement. Pain evaluated to be 5 out of 10 now.
Socrates
Site of pain-Patient states pain is at left greater trochanter.
Onset- Pain started after she fell on tiled floor at home.
Character- Patient describes pain as dull but becoming sharp on movement.
Radiating- Patient states pain dosent appear to be radiating anywhere.
Associated symptoms- Pain is associated with movement of left leg.
Timing- Pain has no time pattern only that of movement and sudden jerking movements.
Exacerbating factors- Patient states the only exacerbating factors are movement.
Severity- Pain is now evaluated by the patient to be 5 out of 10 on pain scale.
Cardiovascular, respiratory and abdominal assessment are normal. Impression is Fracture left neck of femur.
Plan/Investigations
IV access
Bloods (FBC, U+E, CRP, Smack 20, Group and Hold and Coagulation and ABGs)
Pain relief (morphine 2 mg IV) with good effect.
Fluids (NaCl 0.9% 1 L IV)
Left hip x-ray, and Chest x-ray
12 lead ecg
Results
Left hip x-ray = Intertrochanteric fracture
Chest x-ray = No abnormalities detected
ECG = normal sinus rhythem
Blood results = white cell count = 12
Haemoglobin = 12
Platelet count = 306
Urea and electrolytes, Liver function tests, C reactive protein all normal.
Diagnosis/ follow on care
Left intertrochanteric fracture.
Nil by mouth.
Femoral nerve block. (Lidocaine2% 5ml + Marcaine 0.25% 5ml)
Refer to orthopaedics.
Transfer to orthopaedic ward for management on pressure relieving mattress.
Surgery morning. (Patient had general anaesthetic and a Dynamic Hip Screw procedure carried out in theatre).
“Early surgical fixation, the role of anti-thromboembolic and anti-infective prophylaxis , good pain control at the perioperative, detection and management of delirum, correct urinary tract management, avoidance of malnutrition, vitamin D supplementation, osteoporosis treatment and promotion of early mobilization to improve functional recovery and falls prevention are basic recommendations for an optimal maintenance of hip fractured patients”.(3)
Rehabilitation post surgery will involve a multidisciplinary team approach with collaboration between orthopaedic surgeon, geriatric physican, nurses, physiotherapists, occupational therapists and dietican. Rehabilitation should commence early to promote independent mobility and function.
Advanced pre hospital interventions that would have been of value on this call
Pain management options – Morphine IV acts on central nervous system to reduce pain and anxiety. “Morphine remains the most valuable opoid analgesic for severe pain “ (4). It could have been administered with caution for pain relief in this case at 2 mg increments .
IN Fentanyl 0.1 mg the narcotic analgesic would also have been an option for pain relief. It has a rapid onset of action and a short half life. It could have been repeated once if required after 10 minutes.
Sodium Chloride 0.9 % (NaCl) 250 ml IV the isotonic crystalloid solution could have been considered in this case as the patient was approximately 20 minutes transport time to the ED.
Queensland Ambulance Service Pain Management Options
Managment of hip fractures is generally the same, analgesia positioning and immobilisation and consider IV fluids. However they do have the option of Ketamine and methoxyflurane for pain relief.
Methoxyflurane (belongs to the fluorinated hydrocarbon group).” It is a volatile liquid intended for vapourisation and administration by inhalation using the penthrox inhaler”.(5)“Methoxyflurane vapour provides analgesia when inhaled at low concentrations. It is indicated for emergency relief of pain by self administration in conscious haemodynamically stable patients with trauma and associated pain, under supervision of personnel trained in its use.”(5) It has a quick onset of action and a short duration of effect.
Contraindications are Renal Failure, Respiratory Depression and Cardiovascular compromise.
Ketamine is an anaesthetic agent. It works in the brain to inhibit painful sensations. At lower doses the drug produces significant analgesia, whilst the airway reflexes and respiratory drive are preserved. There is minimal haemodynamic compromise as ketamine acts as a sympathmemetic agent. It is indicated for severe traumatic pain, and maximum dose is 1 mg/ kg.(6)
Risk factors for hip fractures in elderly
Age – Rate of hip fractures increases with age due to decreased bone density, declining vision and sence of balance, and weakened muscles if inactivity is a factor.
Gender – Approximatley 80% of hip fractures occur in women as they loose bone density at a faster rate than men. The menopause speeds up bone loss due to the drop in oestrogen levels.
Certain Drugs – taken for chronic conditions like asthma and high blood pressure can have a weakening effect on bone health. (steroids, diuretics)
Chronic medical conditions – Osteoporosis, overactive thyroid and Gastro intestinal disorders which may reduce absorption of calcium and Vitamin D.
Nutritional – Reduced or inadequate intake of vitamin D and Calcium when you are young can increase the risk of fractures when your older due to lower peak bone mass.
Tobacco and Alcohol use – Excessive alcohol consumption and smoking can interfere with the normal processes of bone building and remodelling, resulting in bone loss.
Inactivity – Physical inactivity and prolonged bed rest weaken bones and muscles and can lead to bone loss.
Information available at reference (3)
Medical complications of fractured hip in elderly people and incidence
Neuroligical – “Postoperative delirum in patients with hip fracture appears normally after surgery, and affects 13.5 % to 33 % of these patients”(3).
Cardiac and Vascular – Arrythmia, Heart Failure and Myocardial Ischemia (35% to 42%)
DVT/PE (27%)
Pulmonary – Exacerbations of chronic lung disease, atelectasis, respiratory failure, PE and ARDS . (4%) Hospital acquired pneumonia (7%)
Urinary Tract – Urinary retention/ Urinary tract infections (12% to 61%)
Acute Kidney Injury (11%)
Hematologic – Anemia (24% to 44%)
Endocrino-Metabolic – Malnutrition (20% to 70%). “ Diabetes decompensation is a quite common preoperative complication of patients that undergo hip fracture surgery, and is associated with both increased risk of asymptomatic coronary heart disease and perioperative infection”(3)
Pressure sores – (7% to 9%)
Anesthetic Complications – “The incidence of anaesthetic complications during hip fracture surgery is influenced not only by the anesthetic technique used, but also by patient comorbidities, the delay between admission and operation, and the surgical technique employed”(3).
Information available at reference (3)
Conclusion
Primary Billary Cirrhosis
Is a chronic and progressive cholestatic disease of the liver.The cause is unknown but presumed to be auto immune in nature. It causes a destruction of the small to medium bile ducts which lead to progressive cholestasis, and often end stage liver disease. Most frequently a disease of women that occurs between the fourth and sixth decades of life. Symptoms include Fatigue(65%), Pruritus (55%), and right upper quadrant discomfort (8% – 17%). No cure. Liver transplantation is the only treatment option for the terminal stages of the disease. Pharmalogical management is Ursodeoxycholic acid which is used to slow the progression of the disease.(7)
Bile produced by the liver plays an important role in digestion of fats. As flow is obstructed in people with Primary Billary Cirrhosis the condition can cause problems absorbing fat soluble vitamins A,D,E and K.
Osteopenia
A medical condition in which the protein and mineral content of bone tissue is reduced, but less severly than in osteoporosis. It is the early stage of osteoporosis.
References
(1) www.hse.ie/eng/services/publications/olderpeople/executive-summary-strategy-to-prevent-falls-and-fractures-in-irelands-ageing population.pdf
(2) www.aplaceformom.com/senior-care-resources/articles/hip-fractures-in the-elderly
(3) Complications of hip fracture :A review , by Pedro Carpenteiro, Jose Ramon Caeiro. The world journal of orthopaedics. Available at www.ncbi.nlm.gov/pmc/articles/pmc4133447/
(4) BNF Edition 64, page 269.
(5) http;//ambulance.gld.gov.au/docs/clinical/dtprotocols/DTP-Methoxyflurane.pdf
(6) http://ambulance.gld.gov.au/docs/clinical/dtprotocols/DTP-Ketamine.pdf
(7) www.emedicine.medscape.com/article/17117-overview#a6