this pathway is intended as a guide only and does not
TRANSCRIPT
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Facility: Liverpool Hospital
CLINICAL PATHWAY -
FRACTURED RIBS COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
NO WRITING Page 1 of 10
FAMILY NAME MRN
GIVEN NAMES MALE FEMALE
D.O.B. ______/_______/_________ M.O.
ADDRESS
LOCATION / WARD
Hole
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2828.1
: 2012
THIS PATHWAY IS INTENDED AS A GUIDE ONLY AND DOES NOT REPLACE CLINICAL JUDGEMENT
STAFF MEMBERS DIRECTLY INVOLVED IN THE PATIENT’S CARE ARE RESPONSIBLE FOR COMPLETING THIS FORM
Instructions for use:
Patients recognised as fitting the criteria should start the clinical
pathway immediately
Start a new page for each day
A patient taken off a clinical pathway must have reasons clearly
documented
On completion, this form should remain with the clinical record
All staff involved with patient care or management are encouraged to
complete the pathway
PATIENTS MUST MEET ALL BELOW CRITERIA FOR USE
1. Age > 14 years
2. Patients with fractured ribs or a fractured sternum diagnosed
radiologically or clinically should be commenced on this path-
way
BLUNT CHEST TRAUMA FRACTURED RIBS
FRACTURED STERNUM
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Facility: Liverpool Hospital
CLINICAL PATHWAY -
FRACTURED RIBS COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
FAMILY NAME MRN
GIVEN NAMES MALE FEMALE
D.O.B. ______/_______/_________ M.O.
ADDRESS
LOCATION / WARD
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Blunt Chest Injury / Fractured Ribs (Clinically or Radiologically)
All Patients
Regular paracetamol charted
PCA commenced with IV Fluids
If NO PCA then must have regular analgesia charted - first dose must be given prior to leaving Emergency Department (+/- breakthrough doses charted)
NO
Request admission to Trauma Ward
YES
Requires ICU admission, must have ICU review prior to leaving ED
Pain team consideration for regional block techniques
Consider early Geriatrician
involvement for 65
High risk of delirium/previous delirium in hospital
Frailty score 5 - 8 (page 8)
ON CALL PAGE # 50323
Is Any of the Following Present? Flail segment
4 Ribs
2 significantly displaced fractured ribs
Chest wall deformity or defect
Significantly displaced fractured sternum
Hypoxia (supplemental oxygen required to maintain SpO2 >94%)
Lung contusions (on CXR or CT)
Chronic respiratory failure or cardiac failure
Age 65
Consider Early Rib fixation
(Refer to Potential Criteria on page 7 in document)
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Facility: Liverpool Hospital
CLINICAL PATHWAY -
FRACTURED RIBS COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
FAMILY NAME MRN
GIVEN NAMES MALE FEMALE
D.O.B. ______/_______/_________ M.O.
ADDRESS
LOCATION / WARD
Hole
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EMERGENCY DEPARTMENT CHECKLIST
Must be completed prior to ED discharge
ICU Review as per diagram
INVESTIGATIONS / PLAN
Documented plan by admitting team
CXR / Bloods / ECG
VTE prophylaxis (if appropriate)
Stool softeners charted
Regular medications charted
If NSAIDS commenced also chart PPI / regular paracetamol
ANALGESIA
PCA charted and commenced (ideally fentanyl), IV Fluids charted commenced
APS registrar contacted for all patients starting PCA for consideration of regional
block
If not appropriate for PCA must have regular analgesia charted (+/- breakthrough
doses)
OTHER
Powerchart physiotherapy referral
Page ED Physiotherapist (#50816) for review
If unable to complete any of the above, please document why: _______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
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Facility: Liverpool Hospital
CLINICAL PATHWAY -
FRACTURED RIBS COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
FAMILY NAME MRN
GIVEN NAMES MALE FEMALE
D.O.B. ______/_______/_________ M.O.
ADDRESS
LOCATION / WARD
Hole
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Date Day of Admission
Surgical team assessment and definitive plan documented in notes
Surgical team to consider early rib fixation - see criteria
Fractured sternum patients to have ECG, troponin and Echo
Tertiary Survey completed
Careful consideration of geriatric patients on multimodal analgesia
Regular medications charted (stool softeners / chemical VTE / NSAIDS / PPI)
Tests / Investigations ordered reviewed (CXR / Pathology / CT)
Patients meeting frailty score 5 - 8 (page 8) should be referred to geriatrics
Medical Assessment: To be completed daily by admitting medical team
Nursing Assessment: completed daily
Ask patient to take a deep breath and cough, ask patient to rate pain 0 = no pain to 10 = worst pain, document score. Aim for pain score < 3
Check pain score 2/24. If pain score 5 contact admitting team
Regular medications administered (stool softeners / chemical VTE / NSAIDS / PPI)
Ensure prn medication charted, patient may need additional dose if pain 5 and unable to cough effectively
Patient sitting up in chair unless contraindicated. (If unable elevated head of bed as tolerated)
Encourage hourly breathing exercises
Mobilise at least three times a day unless contraindicated (don’t wait for physiotherapy)
Physiotherapy referral via powerchart as well as page physiotherapy
Consider other allied health interventions
Acute Pain Service (APS): completed daily
Review both IV and oral medication
Review patient and consider if suitable for regional block and discuss with admitting team. If not suitable for block please document why not
Physiotherapy: completed daily
Physiotherapy assessment completed and plan documented
Patient is provided with a copy of the Active Breathing Technique (ACBT) located at back of pathway
Mobilise patient if appropriate
Additional Comments: if unable to complete
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Facility: Liverpool Hospital
CLINICAL PATHWAY -
FRACTURED RIBS COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Date Day One
Surgical team assessment and definitive plan documented in notes
Surgical team to consider early rib fixation - see criteria
Fractured sternum patients to have ECG, troponin and Echo
Tertiary Survey completed
Regular medications charted (stool softeners / chemical VTE / NSAIDS / PPI)
Tests / Investigations ordered reviewed (CXR / Pathology / CT)
Patients meeting frailty score 5 - 8 (page 8) should be referred to geriatrics
Medical Assessment: To be completed daily by admitting medical team
Nursing Assessment: completed daily
Ask patient to take a deep breath and cough, ask patient to rate pain 0 = no pain to 10 = worst pain, document score. Aim for pain score < 3
Check pain score 2/24. If pain score 5 contact admitting team
Regular medications administered (stool softeners / chemical VTE / NSAIDS / PPI)
Ensure prn medication charted, patient may need additional dose if pain 5 and unable to cough effectively
Patient sitting up in chair unless contraindicated. (If unable elevated head of bed as tolerated)
Encourage hourly breathing exercises
Mobilise at least three times a day unless contraindicated (don’t wait for physiotherapy)
Physiotherapy referral via powerchart, page physio (also consider other allied health interventions)
Acute Pain Service (APS): completed daily
Review both IV and oral medication
Consider regional block (based on individual patient assessment). If not suitable for block please document why not
Physiotherapy: completed daily
Physiotherapy assessment completed and plan documented
Patient is provided with a copy of the Active Breathing Technique (ACBT) located at back of pathway
Mobilise patient in ward / chair as appropriate
Additional Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
FAMILY NAME MRN
GIVEN NAMES MALE FEMALE
D.O.B. ______/_______/_________ M.O.
ADDRESS
LOCATION / WARD
BIN
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Facility: Liverpool Hospital
CLINICAL PATHWAY -
FRACTURED RIBS COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
FAMILY NAME MRN
GIVEN NAMES MALE FEMALE
D.O.B. ______/_______/_________ M.O.
ADDRESS
LOCATION / WARD
Hole
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Date Day Two
Surgical team assessment and definitive plan documented in notes
Tertiary Survey completed (if appropriate)
Regular medications charted (stool softeners / chemical VTE / NSAIDS / PPI)
Tests / Investigations ordered reviewed (CXR / Pathology / CT)
Patients meeting frailty score 5 - 8 (page 8) should be referred to geriatrics
Medical Assessment: To be completed daily by admitting medical team
Nursing Assessment: completed daily
Ask patient to take a deep breath and cough, ask patient to rate pain 0 = no pain to 10 = worst pain, document score. Aim for pain score < 3
Check pain score 2/24. If pain score 5 contact admitting team
Regular medications administered (stool softeners / chemical VTE / NSAIDS / PPI)
Ensure prn medication charted, patient may need additional dose if pain 5 and unable to cough effectively
Patient sitting up in chair unless contraindicated. (If unable elevated head of bed as tolerated)
Encourage hourly breathing exercises
Mobilise at least three times a day unless contraindicated (don’t wait for physiotherapy)
Physiotherapy referral via powerchart (also consider other allied health interventions)
Acute Pain Service (APS): completed daily
Review both IV and oral medication
Consider regional block (based on individual patient assessment.). If not suitable for block please document why not
Physiotherapy: completed daily
Physiotherapy assessment completed and plan documented
Patient is provided with a copy of the Active Breathing Technique (ACBT) located at back of pathway
Mobilise patient in ward / chair as appropriate
Additional Comments: if unable to complete
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Facility: Liverpool Hospital
CLINICAL PATHWAY -
FRACTURED RIBS COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
Flail Chest
Non-intubated patients with flail chest and worsening respiratory function
Intubated patients with flail chest
Patients with extensive and/or bilateral flail chest without respiratory failure
Flail sternum
Chest Wall Deformity/ Defect
Loss of thoracic volume or significant deformity that may limit chest wall function
Open chest defect
Rib perforation of vital structures and/or pulmonary herniation
Fractured Ribs - non-flail
Patients with multiple displaced fractured ribs
Painful non-union
Pain Control
Uncontrolled pain despite multimodal analgesia including regional blocks and IV narcotics
Indications
Contra-indications
Patient unlikely to survive due to other injuries or age or multiple co-morbidities
Other injuries that will likely prolong tracheal intubation and mechanical ventilation e.g. significant head injury, spinal cord injury resulting in paralysis of some or all of the respiratory muscles etc.
Any contra-indication to surgery including severe immunosuppression or severe chronic disease
Pregnant women
How to refer patients
The Trauma Department is the point of contact for referrals for possible rib fixation - trauma will review and involve Cardiothoracic as appropriate
3D reconstructions of the chest wall need to be organised (request from CT Radiographer)
Referrals and consults should be made within 24-48 hours of admission - Contact the Trauma Fellow or Trauma Consultant directly
FAMILY NAME MRN
GIVEN NAMES MALE FEMALE
D.O.B. ______/_______/_________ M.O.
ADDRESS
LOCATION / WARD
CRITERIA FOR RIB FRACTURE FIXATION
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Facility: Liverpool Hospital
CLINICAL PATHWAY -
FRACTURED RIBS COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
FAMILY NAME MRN
GIVEN NAMES MALE FEMALE
D.O.B. ______/_______/_________ M.O.
ADDRESS
LOCATION / WARD
Hole
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S2828.1
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BIN
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Facility: Liverpool Hospital
CLINICAL PATHWAY -
FRACTURED RIBS COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
FAMILY NAME MRN
GIVEN NAMES MALE FEMALE
D.O.B. ______/_______/_________ M.O.
ADDRESS
LOCATION / WARD
Hole
s P
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ACBT - Active Cycle of Breathing Technique
Repeat _____ cycles
Every 1 - 2 hours
Left side lying Right side lying Sitting upright
Start Here!
____ Deep Breaths
3 Seconds Hold
____ Relaxed Breaths ____ Relaxed Breaths
____ Coughs
____ Relaxed Breaths
Created by Physiotherapy Department, Liverpool Hospital Updated November 2017
____ Coughs
____ Deep Breath 3 Seconds Hold
____ Huffs
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Facility: Liverpool Hospital
CLINICAL PATHWAY -
FRACTURED RIBS COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE
FAMILY NAME MRN
GIVEN NAMES MALE FEMALE
D.O.B. ______/_______/_________ M.O.
ADDRESS
LOCATION / WARD
Hole
s P
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S2828.1
: 2012
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