From the Guidelines
When assessing a 70-year-old who has fallen and possibly broken their hip, EMS providers should prioritize prompt transport to a facility with orthopedic capabilities, as early surgical intervention (within 24-48 hours) significantly improves outcomes for hip fractures in elderly patients 1.
Initial Assessment
The initial assessment should include ensuring scene safety and performing a primary assessment of airway, breathing, and circulation. Ask about the mechanism of injury, pain location and severity (using a 0-10 scale), and any inability to bear weight. Look for physical signs including shortening and external rotation of the affected leg, bruising, swelling, and deformity at the hip.
Pain Management
Pain management is essential, and consider using a multimodal pain mitigation approach, including peripheral block, as recommended by the American Academy of Orthopaedic Surgeons 1. Fentanyl 25-50 mcg IV/IN or morphine 2-5 mg IV titrated to effect can be used for pain management.
Immobilization and Transport
Immobilize the hip using a scoop stretcher or long backboard with padding and secure the legs together to prevent movement. Apply ice packs to reduce swelling. Establish IV access for fluid resuscitation if signs of shock are present. Document the time of injury, medical history, medications (especially blood thinners), allergies, and last meal.
Key Considerations
Key considerations during transport include:
- Continuously reassessing vital signs and pain levels
- Providing prompt transport to a facility with orthopedic capabilities
- Ensuring access to critical care facilities, if necessary, as recommended by the Association of Anaesthetists 1
- Developing specific discharge criteria to direct postoperative care, as suggested by the Association of Anaesthetists 1
From the Research
Initial Assessment and Treatment
- For a 70-year-old who feels they may have broken their hip, it is essential to seek immediate medical attention, as hip fractures can lead to severe complications if not treated promptly 2.
- The initial assessment should include evaluating the patient's medical history, current medications, and performing a physical examination to determine the best course of treatment.
- Preoperative care should focus on correcting any medical abnormalities and considering the appropriateness, timing, and type of surgical repair in the context of the patient's life expectancy and goals of care 2.
Pain Management
- Effective pain management is crucial for patients with hip fractures, as it can help reduce discomfort and facilitate early mobilization 3.
- Studies have shown that fascia iliaca compartment block (FICB) can be an effective method for managing postoperative pain in hip fracture patients, with lower visual analog scale (VAS) pain scores compared to intravenous acetaminophen 3.
- Intravenous acetaminophen has also been shown to improve postoperative outcomes in hip fracture patients, including reduced opioid use and shorter hospital stays 4.
Perioperative Management
- Perioperative management of patients with hip fractures should include prophylaxis with antibiotics, chemoprophylaxis for venous thromboembolism, and correction of major clinical abnormalities prior to surgery 2.
- For patients receiving anticoagulant or antiaggregant treatment, a multimodal management approach is recommended, including early surgery, peripheral nerve blocks, and optimization of haemostasis, haemoglobin, and venous thromboprophylaxis 5.
Multimodal Analgesia
- The use of multimodal non-opioid analgesia, such as combining acetaminophen with non-steroidal anti-inflammatory drugs (NSAIDs), may be beneficial in reducing in-hospital complications and improving outcomes in hip fracture patients 6.
- However, the effectiveness and safety of this approach should be carefully evaluated, and patients should be closely monitored for potential adverse effects.