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Presenting complaint:

History of presenting complaint:

Incident details:

Orthopaedic Trauma Clerking Sheet

Name:

Date of Birth:

Hospital No:

NHS No:

Consultant:

Patient detailsor sticker

Date: ____ / ____ / ________ Time:

PD4975 v4 PRC PILOT

Issue date: November 2010Review date: November 2012

Events leading to any fall: Clear story of trip, slip or accident Palpitations, chest pain or SOB

Aura, fit, tongue biting, incontinence Dizzy, light headed, pale, sweaty

Other associated medical symptoms Unexplained loss of consciousness

Details: Other

Mechanism of injury: RTA / fall > 2 meters / fall < 2 meters / sport / stabbing / other assaultDetails:

RTA: Driver / FSP / RSP / cyclist / motorcyclist / pedestrian / intrusion / ejection / entrapment / other death

Protective devices: none / seatbelt / airbag / helmet / other

PILOT

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Patient name: .............................................................................

Hospital number: ....................................................................

Past medical history:

MI/angina Heart failure Pacemaker Hypertension Diabetes

Asthma/COPD DVT/PE Anticoagulated Jaundice Stroke/TIA

Epilepsy Dementia Smoking Alcohol

Psychiatric illness Previous surgery Other

Details:

Drug history: Allergies:

Occupation:

System enquiry:

Social history:

Admitted from: Own home/sheltered housing

Resisdential care/Nursing home/ long term care hospital

Rehabilitation unit

Acute hospital

Already in hospital

Other

Unknown

Walking ability indoors pre-admission:

Regularly walked without aids

Regularly walked with one aid

Regularly walked with two aids or frame

Unknown

Walking ability outdoors pre-admission:

Regularly walked without aids

Regularly walked with one aid

Regularly walked with two aids or frame

Wheelchair or bedbound

Unknown

Accompanied to walk indoors pre-admission: Yes No

Accompanied to walk outdoors pre-admission: Yes No

NB: Holiday residence/respite care is classifiedas admitted from ownhome

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Patient name: .............................................................................

Hospital number: ....................................................................

Airway:

Airway and cervical spine: clear / blood / vomit / stridor

Breathing:

Respiratory rate:________/min

O2Sats (% O2/air)

Circulation: Abdomen:

Peripheral pulses:

BP: ........................

cap. refil ............................. seconds

Temperature:

Peripheral oedema:

Neurological:Glasgow Coma Scale

Eye Opening Spontaneous = 4To command = 3To pain = 2None = 1

Verbal Response Oriented = 5Confused = 4Random = 3Grunts = 2None = 1

Motor Response Obeys = 6Localises pain = 5Withdraws = 4Flexes to pain = 3Extends to pain = 2None = 1

Total /15

Pupils:

Right size

reaction

Left size

reaction

Cranial nerves:

AMT

Age ...............

D.O.B. ...............

Year ...............

Place ...............

Time (to hour) ...............

Monarch ...............

WW1 ...............

Recognise 2 people ...............

Count 20-1 backwards ...............

Recall address ...............

Total / 10

Hand dominances (circle): R L

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Patient name: .............................................................................

Hospital number: ....................................................................

Power: (use MRC grading; x / 5)

right left right leftShoulder C5 Hip flexion L2/L3abductionElbow C5/C6 Knee extension L3/L4flexionWrist C6/C7 Foot dorsiflexion L4/L5extensionElbow C7/C8 EHL L5extension

Grip C7/C8 Knee flexion L5/S1

Finger T1 Foot plantarflexion S1/S2abduction

Reflexes: (mark: - - = absent; - = reduced;+ = normal; ++ = brisk)

right left

Biceps C6

Triceps C7

Knee L3/4

Ankle S1/S2

Plantar response right left

PR examination: (describe)

Perianal sensation:

Anal tone:

Anal squeeze:

Summary of neurological assessment:(include level and grade in spinal cord injuries and any suspected peripheral nerve injuries)

Spinal neurological assessment

Tone: (circle as appropriate) R L

Upper limbs normal flaccid spasticity clonus normal flaccid spasticity clonus

Lower limbs normal flaccid spasticity clonus normal flaccid spasticity clonus

Sensation: (mark and label areas of reduced or absent sensation)

Patient name: .............................................................................

Hospital number: ....................................................................

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Date: ____ / ____ / ________ Time:

VARIABLE VALUE POINTSAge 66-85 years 11

≥ 86 years 14Sex Male 4

Female 0Admission Hb ≤ 10 3

> 10 0Admission AMT ≤ 6 out of 10 4

> 6 out of 10 0Living in a Yes 4institution No 0Number of 0 0comorbidities 1 2

2 53 84 115 20

Total points:

NHFS Mortality NHFS Mortality NHFS Mortality11 3% 24 17% 37 57%12 4% 25 19% 38 60%13 4% 26 22% 39 64%14 5% 27 24% 40 67%15 5% 28 27% 41 70%16 6% 29 30% 42 73%17 7% 30 33% 43 76%18 8% 31 36% 44 78%19 9% 32 39% 45 81%20 10% 33 43% 46 83%21 12% 34 46% 47 85%22 13% 35 50% 48 86%23 15% 36 53%

Predicted 30 day mortality =

Musculoskeletal/pressure areas/bruises/wounds:

ECG: Musculoskeletal x-rays:

CXR:

Nottingham Hip Fracture Score (NHFS)

Comorbidities: CV disease, Malignancy, Stroke, Paget’s, Respiratory disease,Smoking, Renal disease, Steroids, Diabetes, Warfarin, Rheumatoid disease,Clopidogrel, Parkinson’s disease, 4 or more medications.

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Patient name: .............................................................................

Hospital number: ....................................................................

Main injuries / problems and action plan:

Initial treatment regime prompt:

Analgesia, antiemetics and aperients

Thromboprophylaxis prescribed Yes No

2o fracture prevention IV fluids Skin marking

Antibiotic cover Consent Trauma conference

Inform relatives if indicated

Has the patient ever been informed that they are at risk of CJD for public health purposes? Yes No

Has the patient ever been informed that they are at risk of vCJD for public health purposes? Yes No

Date: ____ / ____ / ________ Time:

Signature: Print:

Grade: Bleep: Date: ____ / ____ / ________ Time:

Routine pre-op. investigations Additional tests- in ALL patients - to be performed if indicated

Hb

WCC

Platelets

INR (if warfarin)

Na+

K+

Urea

Creatinine

Ca2+/albumin

Group and save

Blood glucose

LFT

Clotting screen

Arterial blood gases

pH

pO2

pCO2

BE

MRSA screen

Blood cultures

Sputum cultures

MSU

Result Sent Results

Authors: S Madan, C TimmJointly agreed by orthopaedic surgeons, anaesthetists and orthogeriatricians

PD5714 Issue date: April 2010. Revised September 2010. Review date: April 2011 PRC021/10_Rev1 Authors: Rhona Maclean & Becs Walsh, based on Department of Health National Tool

RISK ASSESSMENT FOR VENOUS THROMBOEMBOLISM (VTE) FOR ORTHOPAEDIC PATIENTS Date of admission: …………………………………………..

Risk assessment by: …………………………………………

Signature: ………………………………………………………

Designation: ……………………………………………………

Date of assessment: .…………………………………………

All patients should be risk assessed on admission to hospital. Patients should be reassessed

within 24 hours of admission and whenever the clinical situation changes Thrombosis (VTE) Risk Patient related Tick Admission related Tick Active cancer or cancer treatment Significantly reduced mobility for 3 days or more Age greater than 60 Hip or knee replacement Dehydration Hip fracture Use of oestrogen-containing contraceptive therapy

Total anaesthetic plus surgical time greater than 90 minutes

One or more significant medical comorbidities (e.g. heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions)

Surgery involving pelvis or lower limb with a total anaesthetic plus surgical time greater than 60 minutes

Personal history or first-degree relative with a history of VTE

Acute surgical admission with inflammatory or intra-abdominal condition

Obesity (BMI greater than 30kg/m2) Critical care admission Use of hormone replacement therapy Surgery with significant reduction in mobility Known thrombophilias Varicose veins with phlebitis Pregnancy or less than 6 weeks post partum – complete “Risk assessment for VTE in pregnancy & up to 6 weeks postpartum”

Bleeding Risk Patient related Tick Admission related Tick Active bleeding Neurosurgery, spinal surgery or eye surgery Acquired bleeding Other procedure with high bleeding risk Concurrent use of anticoagulants known to increase the risk of bleeding (see guideline “Peri-Operative Management of Patients on Oral Anticoagulant Therapy” via Intranet)

Lumbar puncture/ epidural/ spinal anaesthesia expected within the next 12 hours

Uncontrolled systolic hypertension (230/120 mmHg or higher)

Lumbar puncture/ epidural/ spinal anaesthesia within the previous 4 hours

Acute stroke Thrombocytopaenia (platelets below 75 x109/L) Untreated inherited bleeding disorders (such as haemophilia and von Willebrand’s disease)

Action taken (see overleaf for advice) by prescriber: ……………….……….(sign)………………………..…(print) Tick No thrombosis risk factors present so no prophylaxis needed Thrombosis risk factors present but no prophylaxis prescribed: state reason why (e.g. already on anticoagulation therapy, bleeding risk outweighs thrombosis risk)……………………………………………….

mechanical prophylaxis prescribed and/or enoxaparin prescribed whilst inpatient

Thrombosis risk factors present:

and patient to be considered for extended thromboprophylaxis

Name: Date of birth: Hospital No: NHS No: Consultant:

PD5714 Issue date: April 2010. Revised September 2010. Review date: April 2011 PRC021/10_Rev1 Authors: Rhona Maclean & Becs Walsh, based on Department of Health National Tool

RISK ASSESSMENT FOR VENOUS THROMBOEMBOLISM (VTE) FOR ORTHOPAEDIC PATIENTS

Assessment Assess all patients for VTE and bleeding risk factors using the tick-box table overleaf

Mechanical Prophylaxis

Prescribe anti-embolism stockings (unless contraindicated*) Anti-embolism stockings should be prescribed on the drug prescription and administration record and continued until mobility no longer significantly reduced. Use Flowtron® boots *** intraoperatively for all patients with VTE risk factors having a general anaesthetic whose surgical procedure is over 30 minutes.

Enoxaparin If thrombosis risk factors are present prescribe enoxaparin UNLESS bleeding risk outweighs VTE risk, or enoxaparin is contraindicated** Prescribe enoxaparin 40mg once daily, at 18:00 or 6-8 hours post-operatively unless contraindicated**, (use 20mg once daily if patient weighs less than 50kg or Cr greater than 200µmol/L in males or 150µmol/L in females). Continue until patient is no longer at increased risk of VTE. Pre-operative doses are not normally recommended.

Mobilisation Encourage ALL patients to mobilise as soon as possible and avoid dehydration Information Ensure patient is given booklet “Preventing Blood Clots while you are in Hospital” Monitoring for Heparin-Induced Thrombocytopaenia

• Inpatients: check FBC every two to three days between days 4 and 14 of enoxaparin administration. • Outpatients receiving enoxaparin: check FBC after 5-7 days and 10-14 days of starting enoxaparin.

If platelet count falls by more than 50% or symptoms of thrombosis develop, call Haematology for advice. Elective Hip replacement

Prescribe enoxaparin & mechanical prophylaxis as above; switch to oral rivaroxaban**** 10mg OD for 30 days on discharge

Elective Knee replacement

Prescribe enoxaparin & mechanical prophylaxis as above; switch to oral rivaroxaban 10mg OD for 10 days on discharge

Hip fracture Prescribe enoxaparin & mechanical prophylaxis as above; continue for 35 days post-operatively

Spinal surgery Omit enoxaparin before and for 24-48 hours post-op (use mechanical prophylaxis only) until risk of VTE outweighs risk of bleeding

Pelvic Surgery Prescribe enoxaparin & mechanical prophylaxis as above. Consider warfarin for 3 months at Consultant’s discretion

Upper limb surgery do not routinely offer VTE prophylaxis of any kind unless considered at high risk for VTE Circular fixators/ closed corticotomy

Prescribe mechanical prophylaxis with Flowtron® boots. If patient is at increased risk of VTE prescribe enoxaparin at discharge at Consultant’s discretion

Other orthopaedic surgery

Use mechanical prophylaxis as above. If patient has additional risk factors for VTE prescribe enoxaparin as above. Continue until mobility no longer significantly reduced

Lower limb casts Patients with additional risk factors for VTE (incl. cancer, previous VTE, family history VTE in first degree relative, known thrombophilia, pregnancy) or other high-risk patients may be prescribed oral rivaroxaban 10mg OD at discharge at the Consultant’s discretion until the cast is removed or normal mobility is regained. Pregnant patients and those in whom rivaroxaban is contra-indicated **** should continue on enoxaparin.

For further guidance on thromboprophylaxis see “STH Guidelines for the prevention of Venous Thromboembolic Disease” or NICE Clinical Guideline 92 “Venous Thromboembolism: Reducing the risk” via www.nice.org.uk/guidance/CG92 * Contraindications to anti-embolism stockings: peripheral arterial disease (suspected or proven); peripheral artery bypass grafting; peripheral neuropathy or other sensory impairment; fragile skin, gangrene, dermatitis or recent skin graft; known allergy to material; cardiac failure, severe leg oedema or pulmonary oedema from congestive heart failure, unusual leg size or shape, major limb deformity preventing correct fit. risk or creatinine clearance 15-29mls/min, or 30-49 mls/min and/ or taking interacting drugs. See BNF or product literature for more information. ** Contraindications to enoxaparin: patients with acute bacterial endocarditis, active major bleeding and conditions with a high risk of uncontrolled haemorrhage, including recent haemorrhagic stroke; thrombocytopenia in patients with a positive in-vitro aggregation test in the presence of enoxaparin (Heparin Induced Thrombocytopaenia); active gastric or duodenal ulceration; hypersensitivity to either enoxaparin sodium, heparin or its derivatives including other Low Molecular Weight Heparins. Use with caution in patients with hyperkalaemia. *** Contraindications to Flowtron® boots: known allergy to material of manufacture. ****Contraindications to Rivaroxaban: clinically significant active bleeding, pregnancy or breastfeeding, hepatic disease associated with coagulopathy and clinically relevant bleeding risk, hypersensitivity to the active substance or to any of the excipients, creatinine clearance less than 15mls/min. Use with caution in patients with moderate hepatic impairment, increased bleeding risk, creatinine clearance 15-29mls/min or 30-49 mls/min and/ or taking interacting drugs. See BNF or product literature for more information.