Presentation to the Emergency Room

1. Assessment by the ED
2. Radiographs

i.Low AP pelvis, AP of affected hip, AP and lateral of affected femur

ii.MRI indicated if high suspicion but no clear fracture on x-ray, CT scan if MRI not available

3. Preoperative labs drawn

i.CBC, Chem 10, Coags, Vitamin D

ii.Type and Cross for 2 units pRBCs

iii.Type and cross for 2 units FFP if patient on Warfarin

4. Chest radiograph if clinically indicated (hx of heart or lung problems or sx)
5. ECG if clinically indicated (hx of heart problems or new sxs)
6. Pain Control

i. Pre-operative Fascia Iliaca block (ED provider to page the Anesthesia Acute Pain Service 24/7 @ 443-6889 to notify them of the patient if block not already placed).  (see Regional Anesthesia and Pain Control for Acute Hip Fractures in the ED)

ii.Tylenol 1000mg TID ATC (IV ok if pt unable to take po); 650mg po TID if liver problems

iii.If age>70, start Oxycodone 2.5mg po Q 3 hours prn, Dilaudid 0.4mg Q2 hour prn severe pain

iv.If age<70, start Oxycodone 5mg po Q 3 hours prn, Dilaudid 0.6 mg Q2 hours prn severe pain

v.Avoid Fentanyl (short-acting)

7. If patient on Warfarin and adherent to dosing schedule give Vitamin K 5mg PO x 1 ASAP (Do not wait for labs)
8. Orthopedics/geriatrics or medicine consulted as soon as hip fracture known
9. Geriatric service called if 8AM – 5PM (443-2690) for pts 65+, Medicine called if <65 5PM – 8AM (443-8691) for preoperative optimization if needed.
10. Admit patient to Orthopedics or Medicine and request 7L bed if available
11. Delirium or "Agitation"

i.Avoid benzodiazepines (or Benadryl/anticholinergics)!

ii.Prefer consult Geriatrics or Medicine to manage in ED but if patient is at risk of harm to self or others follow UCSF Delirium Harm Avoidance Protocol:

1. Age >70
   1. PO Seroquel 12.5mg po x 1 (can repeat x1 in 2 hrs)
   2. If need IM or IV:  Haldol 0.5mg IV/IM x 1 (can repeat x 1 in 1hr)
2. Age <70
   1. Per Seroquel 25mg po x 1 (can repeat x 1 in 2 hrs)
   2. If need IM or IV: Haldol 1mg IV/IM x 1 (can repeat x1 in 1 hr)
3. Other consults as warranted

Anticoagulation

1. Continue Aspirin at all doses
2. Warfarin

i.Hold Warfarin, give Vitamin K 5mg PO x 1 ASAP

ii.Type and cross for 2 units FFP

iii.Goal INR for OR is 1.5 or less for surgery, Goal INR for neuraxial anesthesia is 1.3 or less

iv.Re-check INR 12 hours after vitamin K dose

v.Can proceed with surgery if INR 1.8 or less and patient can get FFP on the way to the OR (patient will receive GETA)

3. Clopidogrel, prasugrel, ticagrelor, cilostazol

i.Continue any Acute Coronary Syndrome (treated medically or with stent) within last 12 months

ii.Continue if drug-eluding stent in last 6 months (in non-ACS)

iii.Continue if bare metal stent within last 1 month (in non-ACS)

iv.No need to delay surgery (patient will receive GETA)

4. NOACs (dibigatran, rivaroxaban, apixiban, edoxaban)

i.Hold, record time of last dose taken clearly. Clearance dependent on renal function.

ii.Generally hip fracture surgery with general anesthesia only can be undertaken 24 hours after last dose for all medications and normal renal function (48 hours for Dabigatran and Apixiban and high risk of bleeding). Risks and benefits should be weighed by teams (ortho, medicine, geriatrics, and anesthesia) for delaying surgery more than 24 hours.

5. Bridging

i.Bridging therapy with heparin indicated if any of the very high risk conditions below:

ii.Very high risk conditions

1. Mechanical heart valve
   1. Mitral prosthesis
   2. Caged ball/tilting aortic prosthesis
   3. Stroke/TIA within 6 months
2. Atrial Fibrillation
   1. CHADS-VASC score 7-9  + absence of additional bleeding risk
   2. Stroke/TIA or systolic embolism within 3 months
3. VTE
   1. VTE within 3 months
   2. Severe thrombophilia
   3. History of VTE during discontinuation of anticoagulation