The present paper aims at discussing the case of Dierdre, an 80-year-old female. The patient fell in the car park after a morning swims in a heated swimming pool. Dierdre had obviously damaged her collarbone, as she experienced 4/10 pain in the area at rest and 10/10 at movement or palpation. Her right collarbone was deformed with redness and swelling. Her arm had limited movement, and the sensation in her fingers was reduced. Among other abnormalities, the patient seemed to experience hypothermia (body temperature 35°C). The patient was given a blanket to increase body temperature. No other traumas or abnormalities were found during the assessment.
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Clinical Approach to Assessment
The purpose of the assessment is to confirm or reject the diagnosis and identify possible comorbidities and associated traumas. The clinical assessment also helps to identify the most appropriate treatment strategy and referrals. In the present case, collarbone fracture is to be suspected due to the obvious history of trauma, pain, and swelling in the area of the right collarbone, and limited movement of the right arm. When assessing patients with clavicle fractures, it is crucial to conduct both physical examination and radiographic assessment. Physical examination should include pain, deformity, vascular, neurologic, respiratory, and mediastinal contents assessments (1). First, patients with collarbone fractures experience focal pain (1). Second, deformity needs to be assessed for obvious displacement, motion, or crepitus (1). Third, the arm needs to be compared to the healthy one in terms of vascular status, and any sign of arterial injury should be investigated (1). Fourth, the neurological assessment of the brachial plexus should also be assessed by comparing it to the contralateral side (1). Finally, respiratory function and injury to the esophagus, trachea, or great vessels should also be assessed (1).
Radiographic assessment is also crucial for acquiring a detailed view of the damaged area. The appropriate X-ray views include upright anteroposterior (AP) clavicle view, Zanca view, serendipity view, and AP chest views if concerns about pneumothorax arise (1). CT scans may also be needed for medial clavicle fractures or if there is concern about arterial injuries (1). In rare cases, EMG may be required with brachial plexus injuries (1). However, the majority of cases are diagnosed with X-rays only.
Pain Management Options
Pre-hospital pain management is crucial for improving patient outcomes. Pain management for paramedics, however, is not merely providing pharmacological treatment. Paris and Phrampus (2) claim that pain management is to be based on SPLINT principles. The mnemonic stands for splint (immobilize), pharmacology, lift (elevate), ice, neurovascular check, and talk (communicate) (2). Thus, pain management should always start with immobilization, and only then, pain medications are to be provided. Common medicines include nitroglycerin, morphine, fentanyl, Dilaudid, Toradol, Nitronox, and Ketalar (2). Paramedics need to ensure that appropriate medication is provided to reduce the possibility of side effects. After drugs are provided, paramedics should apply ice to the fractured bone and continue communication to break the pain-anxiety cycle (2). In summary, even though pain management options for paramedics are limited, careful assessment is still crucial to utilize the best available treatment.
Description of Procedures
All the procedures concerning the case are to be divided into two parts. Pain assessment is to be conducted based on OPQRST mnemonic, which stands for onset, provoking factors, quality, radiation, severity, and time sequence (2). The details of the case demonstrate that pain assessment had been conducted earlier, which implies that it may be no longer needed. After the assessment, SPLINT is to be applied to Dierdre. First, the fractured collarbone needs to be immobilized using a sling or a special bandage called a figure-of-eight splint (3). Second, the patient needs to provide appropriate pain medications, considering the age-related changes in pharmacokinetics and pharmacodynamics (4). After immobilization, pain is moderate (4/10), which implies that there is no need to administer opioids. Mild-to-moderate pain is usually treated with acetaminophen and nonsteroidal anti-inflammatory drugs; however, opioids may still be needed due to reduced response to drugs among older adults (4). Third, the treatment should be enhanced by the application of ice to reduce local sensation (2,4). Ice will also help with redness and swelling of the extremity.
Special attention will need to be given to patient communication. According to Paris and Phrampus (2), the way patients perceive the people caring for them has a tremendous impact on the level of suffering. The paramedic needs to develop trusting relationships with the patient by demonstrating professionalism and explaining all the steps of the procedures. Special attention should be paid to alerting the patient about possible onsets of pain before the final immobilization of her right arm.
Consideration of Ongoing Assessments
Clavicle fractures are expected to heal within five weeks after final immobilization. It may take longer in older adults due to age-related changes (3). However, ongoing assessments are required to ensure that the selected treatment plan is both safe and effective. First, it must be considered is pain management, as it is a very challenging process when speaking about older adults. The central problem is that pain is often underreported and undertreated among older adults (4). This implies that the patient may continue to take acetaminophen and nonsteroidal anti-inflammatory drugs even if they are ineffective. Thus, care providers need to conduct repeated pain assessments to adjust the treatment plan. However, care providers should also be cautious when prescribing opioids for pain treatment to avoid addiction.
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Second, continuous assessment is required to understand if surgical fixation is needed. Care providers need to check for indications for operative treatment to ensure the best outcome. Third, care providers should look for possible complications and address them timely to decrease morbidity. Common complications of non-surgical treatment include non-union (up to 20%), symptomatic mal-union (15%), shoulder asymmetry, scapular winging, and thoracic outlet syndrome (1). In summary, ongoing assessment is crucial to avoid complications and improve the quality of life.
Discussion of Anomalies
There were two abnormalities present in the patient that should alert care providers. First, the pulse in the fractured arm was weak, which is a sign of concern. A weak pulse may be a sign of arterial injury, which implies that the patient needs urgent care (1). Fractures often put pressure or damage arteries, which blocks the ability to transfer blood to the arm. Thus, it is recommended that a CT angiogram is performed to delineate the injury to the vascular structures (1). Additionally, a vascular surgery consultation may be required to avoid associated adverse events (1). Paramedics need to remember that weak or no pulse below the fractured bone can be an indication for immediate hospitalization.
Second, the body temperature of the patient was low (35°C), which is a sign of hypothermia. The condition is prevalent among older adults and may lead to severe complications. Body temperature below 36°C is a sign that the thermal regulation function of the body is failing (7). The condition has a significant negative effect on cardiovascular, neurologic, hematologic, and respiratory systems (7). Hypothermia also depresses metabolic functions of the body (7). Hypothermia often leads to increased blood pressure due to increased secretion of norepinephrine. Considering that the fact that Dierdre has hypertension, further increase in blood pressure may lead to cardiac arrest or other cardiovascular conditions. Thus, addressing the problem in the patient is crucial for the patient.
Justification of Management Plan
Pain treatment in older adults is a complicated task, as it requires an understanding of age-related changes. Geriatric patients often experience changes in absorption, distribution, metabolism, and excretion of drugs. Thus, it is usually recommended that high-extraction drugs are prescribed with caution due to decreased first-pass metabolism (5). Additionally, care providers need to be cautious when prescribing renally excreted drugs due to decreased kidney excretion in older adults (5). Additionally, it is recommended that the prescription of opioids to older patients is avoided due to a high possibility of respiratory depression (6). All these recommendations are considered in the management plan. Both acetaminophen and nonsteroidal anti-inflammatory drugs are less harmful to older adults than opioids for pain treatment. At the same time, the treatment plan provisions the use of opioids in case of insufficient response to treatment, which is central to person-centered care. Finally, the treatment plan adheres to the guidelines, and best practices described by Vries, Gravel, Horn McLeod, and Varner (4) in their systematic review. Thus, the proposed treatment plan is optimal, considering the symptoms and assessment results described in the case study.
Dehghan N, Mckee, MD. Evaluation and management of clavicle fractures: Midshaft, lateral and medial [Internet]. London (UK): Haymarket Media, Inc. 2020. Web.
Paris P, Phrampus PE. A guide to pre-hospital pain management. JEMS. 2016; 41(11). Web.
John Hopkins Medicine. Clavicle Fractures [Internet]. Hopkins Medicine. 2020. Web.
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