Bedside ultrasound in the emergency department for reduction and radial manipulation of distal radial fractures.

OBJECTIVE: Distal radial fracture reduction is a common procedure in the ED. Previous studies have suggested that ultrasound (US)-guided reduction improves outcomes for patients who undergo manipulation and reduction of distal radial fractures in the ED. We aimed to investigate this with the first randomised controlled trial looking at US-guided distal radial fracture reduction. Our primary objective was to compare rates of operative intervention between the study groups. Rate of re-manipulation was compared as a secondary outcome. METHODS: ED patients were prospectively randomised to either standard landmark guided or US-guided closed reduction of distal radial fractures. The closed reductions were performed by senior emergency clinicians and the USs were performed by emergency physicians experienced in point-of-care US. Following reduction patients were managed equally and referred to the local orthopaedic service who were blinded to whether US was used to assist manipulation or not. This service decided on the need for re-manipulation or operative intervention. RESULTS: One hundred patients were enrolled and randomised equally into each cohort. We found no statistically significant difference between the control and intervention groups of our study. In the control group, 46% of patients underwent operative fixation, compared to 48% in the US-guided group (P = 0.36). Our secondary intervention of re-manipulation in the ED or theatre following the initial reduction showed no statistically significant difference between the groups (P = 1.0). CONCLUSION: US-guided reduction of dorsally displaced, distal radius fractures in the ED setting, did not improve measured clinical outcomes.

Predrawn prehospital medications are microbiologically safe for up to 48 hours.

BACKGROUND: Prehospital medical teams are commonly required to administer a range of medications for urgent stabilisation and treatment. The safe preparation of medications during resuscitation requires attention, time and resources, and can be a source of medication error. In our two road and HEMS (Helicopter Emergency Medical Service) prehospital services, medication errors are mitigated by predrawing commonly used medications to set concentrations daily (Hunter Retrieval Service, HRS) or second-daily (CareFlight Sydney, CFS). However, there are no published data confirming that such practice is microbiologically safe. METHODS: A convenience sample of 299 predrawn medication syringes with syringe dwell times up to 48 hours were collected at the end of their operational deployment. Predrawn medication syringes collected for culture were ketamine, midazolam, fentanyl, thiopentone, rocuronium, suxamethonium, metaraminol and normal saline. The samples were incubated and cultured at a tertiary hospital pathology laboratory using best-practice methodology for non-tissue samples. The samples were collected from June 2017 to February 2018. RESULTS: The mean dwell times ranged from 30.7 hours (fentanyl at HRS) to 48.5 hours (rocuronium at CFS). None of the 299 cultured samples yielded significant micro-organisms. One sample of suxamethonium with a syringe dwell time of 34 hours grew Bacillus cereus but was likely a contaminant introduced during sample collection. CONCLUSION: Predrawing of the eight studied medications for urgent prehospital procedures appears to be a microbiologically safe practice with syringe dwell times up to 48 hours.