© 2008 lww chapter 5. immediate care of acute orthopedic injuries

© 2008 LWW

Chapter 5. Immediate Care of Acute

Orthopedic Injuries

© 2008 LWW

RICESRICES• The prescription for immediate care• RICES

– Rest– Ice– Compression– Elevation– Stabilization

© 2008 LWW

Immediate Care MythsImmediate Care Myths• Acute care and immediate care are the same.• Ice decreases swelling.• The goal of immediate care is to decrease

inflammation.• The purpose of ice is to decrease hemorrhaging.• Inflammation and swelling are the same.• Ice should be applied for 20 min during

immediate care. • All injuries should be treated for the same

amount of time.

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What Is Immediate Care?What Is Immediate Care?

• Care given immediately after an acute orthopedic injury

• Subset of acute orthopedic injury care

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Acute Orthopedic Injury CareAcute Orthopedic Injury Care

Typically three stages• Acute (0–4 days) • Subacute (5–14 days) • Postacute (>14 days)

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Acute Orthopedic Injury Care (cont.)Acute Orthopedic Injury Care (cont.)

Problems with the typical three stages• Range of acute care too wide

– Treatment 10 min after injury is not the same as that needed 3 days after the injury.

– Acute care, therefore, must be subdivided. • Injuries heal at different rates

– Type and severity of injury– Individual patient differences

• Care dictated by patient progress, not by specific time frames

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Acute Orthopedic Injury Care (cont.)Acute Orthopedic Injury Care (cont.)

New three stages• Acute (0–4 days)

– Emergency care (e.g., CPR, if needed)– Immediate care (0–12 hr)– Transition care (12 hr to 4 days)

• Subacute (5–14 days), • Postacute (>14 days)

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Why RICES?Why RICES?

• To limit (decrease):– Total injury– Swelling– Pain– Further injury– Muscle spasm– Inflammation? NONO

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RICES TheoryRICES Theory

• Rest• Ice• Compression• Elevation• Stabilization

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Rest: Why?Rest: Why?

Limits injury aggravation• Should be total during

immediate care• Transition to “relative” rest• Different from, but related

to, stabilization

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Ice/Cold: Why?Ice/Cold: Why?

• Most think it’s to control swelling.– Important but only part of immediate care

• Limiting secondary injury and neural inhibition are more important than controlling swelling.

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Ice/Cold: Why? (cont.)Ice/Cold: Why? (cont.)Ice/Cold: Why? (cont.)Ice/Cold: Why? (cont.)

• Two theories– Circulatory or decreased blood flow

theory– Decreased secondary injury theory

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Decreased Blood Flow TheoryDecreased Blood Flow Theory• Older, traditional theory• Cold decreases blood flow.• Logic of theory

– Cold causes vasoconstriction– Which decreases blood flow and therefore– Decreases hemorrhaging and therefore– Swelling is reduced

• Flaw: Clotting occurs before tissue is cooled enough to substantially decrease blood flow.

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Decreased Secondary Injury TheoryDecreased Secondary Injury Theory• History

– First proposed in 1976

– Refined in 1985– Tweaked in

2002

• Flaw:– Cold application

has little effect on hemorrhaging.

• Limits amount of secondary injury and, therefore, edema.

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Decreased Secondary Injury Theory (cont.)Decreased Secondary Injury Theory (cont.)

• Cold decreases cellular metabolism in viable cells, thus– Reduces oxygen demand

(consumption)– Less secondary hypoxic injury– Less total injury– Less free protein generated by

phagocytosis– Less edema

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Decreased Secondary Injury Theory (cont.)Decreased Secondary Injury Theory (cont.)

© 2008 LWW

Metabolism and CoolingMetabolism and Cooling• Direct relationship

– More cooling means greater decrease in metabolism

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Metabolism and Cooling (cont.)Metabolism and Cooling (cont.)

• Heat increases metabolism.– Causes more secondary injury

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Cryotherapy and SwellingCryotherapy and Swelling

• Decreased edema, not hemorrhage– Most occurs hours after injury, as free

protein accumulates from phagocytosis

• Cold reduces edema formation– By preventing secondary injury and thus

less free protein accumulation

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Compression: Why?Compression: Why?• Controls edema beyond normal volume

(i.e., after tissue spaces are filled)• Apply constantly until swelling is over.

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Compression: Why? (cont.)Compression: Why? (cont.)• Compression enhances cooling.

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Elevation: Why?Elevation: Why?

• Decreases capillary hydrostatic pressure

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Stabilization: Why?Stabilization: Why?

Controls neural inhibition• Process in which neural pathway is

blocked so impulses cannot pass– Intended function does not occur.

• Can be partial so function is diminished or total so function is abolished temporarily

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Stabilization: Why? (cont.)Stabilization: Why? (cont.)Allows muscles to relax, thus• Decreases pain–spasm–pain cycle • Numerous braces and splints for

stabilization

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RICES Theory: RevisitedRICES Theory: Revisited

• Rest

• Ice• Compression• Elevation• Stabilization

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What Is the Goal of Cold?What Is the Goal of Cold?• Decrease tissue metabolism!• More cooling means greater decrease

in metabolism.

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Does It Matter How You Apply Does It Matter How You Apply Cold?Cold?Does It Matter How You Apply Does It Matter How You Apply Cold?Cold?• Yes

– Great differences in tissue cooling

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Cryotherapy Physics and Physiology Cryotherapy Physics and Physiology

• Cold does not exist; it is not a physical substance.

• Cold is absence of heat.

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Physiology of Heat TransferPhysiology of Heat Transfer

Conduction• Exchange of energy (heat) between two

substances in contact with each other • Heat moves from body of higher energy to

body of lower energy.• Causes warmer body to cool and cooler body

to warm, until they reach equilibrium

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Rate of ConductionRate of Conduction• Temperature differential between body and

modality• Regeneration of body heat and modality

cooling• Heat storage capacity of cold modality• Size of the cold modality• Amount of tissue in contact with pack• Length of application• Individual variability

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Heat Storage CapacityHeat Storage Capacity

• Specific heat • Latent heat of fusion

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Heat Storage Capacity (cont.)Heat Storage Capacity (cont.)Specific heat• Amount of heat energy required to raise 1

kg of a substance 1°C– Ice = 0.5 cal/g– Water = 1 cal/g

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Heat Storage Capacity (cont.)Heat Storage Capacity (cont.)

• Latent heat of fusion– Amount of heat energy needed to

convert a substance from a solid state to a liquid state without changing its temperature

– Phase change– Ice to water = 80 cal/kg

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Crushed ice pack better than gel pack• Gel pack ~22 kcal

– Water from −17°C to 5°C

• Crushed ice pack ~ 86 kcal– Ice from −1°C to 0°C, – Heat of fusion – Water from 0°C to 5°C

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Crushed ice pack better than gel pack

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Temperature Changes Resulting from Cold Pack ApplicationTemperature Changes Resulting from Cold Pack Application

• Surface temperature– Repeated applications

• Time ratio• Activity between applications

(shower)– Compression wrap over cold pack

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Temperature Changes Resulting from Cold Pack Application, (cont.)Temperature Changes Resulting from Cold Pack Application, (cont.)

© 2008 LWW

Temperature Changes Resulting from Cold Pack Application (cont.)


• Tissue temperature– Depends on depth and type of

tissue– Delayed response– Continues to decrease after

application

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Temperature Changes Resulting from Cold Pack Application (cont.)Temperature Changes Resulting from Cold Pack Application (cont.)

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• Tissue temperature– Amount of adipose tissue– Rewarming takes hours

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Temperature Changes Resulting from Cold Pack Application (cont.)Temperature Changes Resulting from Cold Pack Application (cont.)

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• Articular temperature– Similar to tissue temperature– Delayed response– Continues to decrease after application– Amount of adipose tissue

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Rewarming after application• Depth of tissue• Amount of heat available to rewarm area:

function of circulation and environmental temperature.

• Activity level before cryotherapy and palmer• Amount of heat removed from body during

application (i.e., magnitude and duration of cold exposure)

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Cryotherapy: Application Principles Cryotherapy: Application Principles

• Tissue cooling depends on – Cold modality used– How modality is applied

• Many protocols suggest– Length – Frequency – Duration

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Factors That Effect Tissue CoolingFactors That Effect Tissue Cooling• Type of cold pack

– Heat of fusion

• Duration of application– Longer the

application• More cooling• Slower rewarming

• Size of cold pack– Larger cold pack,

more cooling

• Amount of tissue in contact with pack– More tissue

contact, more cooling

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Factors That Effect Tissue Cooling (cont.)Factors That Effect Tissue Cooling (cont.)

• Depth of target tissue– Deeper target,

less cooling

• Type of cold pack

• Method of application – On skin or over a

towel or wrap– Compression over

pack (per Merrick)

© 2008 LWW

Types of Cold PacksTypes of Cold Packs

Four general types:• Crushed ice• Gel (Chattanooga,

Cramer)• Artificial ice

– Water in vinyl (Dura*Kold)

• Chemical– Double bags,

crushable – Powder types

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Types of Cold Packs (cont.)Types of Cold Packs (cont.)

Crushed ice• Most effective because of heat of fusion• Excellent for on-the-field use because

they don’t melt for hours stored if in insulated cooler

• Should not be used if kept in a freezer (too cold)

© 2008 LWW


Gel pack• Water, alcohol, and gel substance• Cooled to ~1°F (−17°C), so dangerous• Not as effective as crushed ice packs

(no heat of fusion)• Even less effective if wrapped in towel

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Types of Cold Packs (cont.)Types of Cold Packs (cont.)Gel pack• Dangerous if applied directly on skin

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Artificial ice • Water in vinyl pouches, surrounded by

nylon cover (Dura*Kold)• Better than gel because of heat of

fusion• Not as good crushed ice because of

insulation from nylon cover• Good for home use

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Chemical: double bags, crushable• Chemical reaction when inner bag is

crushed and contents react with outer chemicals

• Least cooling• Not recommended

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Cold: Application ProtocolCold: Application Protocol• Apply directly to skin, not over a towel

or elastic wrap – Except for gel packs– Except for crushed ice from freezer

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Cold: Application Protocol (cont.)Cold: Application Protocol (cont.)

– Insulation decreases effectiveness

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Cold: Cold: Length of ApplicationCold: Cold: Length of Application• Intermittent,

30–60 min every 2 hr

• Depth of target tissue

• Adipose tissue

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Cold: Cold: Duration of TherapyCold: Cold: Duration of Therapy

• Severity of injury• Transition from RICES to cryotherapy

techniques involving exercise

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Preventing vs. Removing SwellingPreventing vs. Removing Swelling

• Preventing secondary injury vs. removing free protein from extracellular spaces

• Prevent: decrease metabolism– Cold effective

• Remove: stimulate lymph flow– Cold is a waste of time

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Preventing vs. Removing Swelling (cont.)Preventing vs. Removing Swelling (cont.)• Removing free protein

from extracellular spaces

– Must stimulate lymph flow

– Requires intermittent compression• Massage• Lymphedema pump• Active exercise (muscle

pump)

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Compression: Application PrinciplesCompression: Application Principles

• Elastic wraps preferred– Plastic wraps not as effective

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Compression: Application Principles (cont.)Compression: Application Principles (cont.)• Apply elastic

wraps over ice pack

– Compression same as if wrap applied first

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Compression: Application Principles (cont.)Compression: Application Principles (cont.)

• Stretch elastic wraps ~75% as they are applied.

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Cryotherapy: Contraindications and Precautions

Cryotherapy: Contraindications and Precautions

Cold is dangerous if • Too cold or too long• Under excessive compression• Patient suffers from some specific diseases,

such as – Raynaud– Cold hypersensitivity– Cold urticaria

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Five-Step Application for Immediate CareFive-Step Application for Immediate Care

• Foundation• Preapplication tasks• Application parameters• Postapplication tasks• Maintenance

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Step 1. FoundationStep 1. Foundation

• Definition• Effects• Advantages• Disadvantages• Indications• Contraindications• Precautions

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EffectsEffects Ice decreases metabolism in the injured

tissue. Decreases the need for oxygen Decreases secondary hypoxic injury

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Effects (cont.)Effects (cont.)

Compression and elevation Counteract edema and result in a decrease in

swelling

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Effects (cont.)Effects (cont.)

StabilizationStabilization Allows musculature around the injury to

relax Along with ice, limits pain–spasm–pain

cycle

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AdvantagesAdvantages

Less total tissue damage means less healing needed.

Decreased swelling means less pain. Decreased pain means less neural

inhibition. Ice is relatively inexpensive.

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DisadvantagesDisadvantages

Effectiveness diminishes with time. Full effects only if applied within 5–10

min after injury

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ContraindicationsContraindications

Do not use with a person who is

Hypersensitive to cold Allergic to cold Has circulatory abnormalities

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PrecautionsPrecautions

Ice packs not directly on skin continuously >60 min

Cold packs cooled to or less than −17°C(0°F) should not be applied directly to the skin.

© 2008 LWW

Step 2. Preapplication TasksStep 2. Preapplication Tasks

Selecting the proper modality Preparing the patient physically Preparing the patient physically Preparing the equipment

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Selecting the Proper ModalitySelecting the Proper Modality

Evaluate the injury or problemDetermine the treatment goalsCheck for contraindicationsHypersensitive to cold?

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Preparing the Patient PhysicallyPreparing the Patient Physically

Remove overlying clothing. Remove braces and bandages, as

necessary. Place patient in a comfortable position

and so that the injured area is elevated.

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Preparing the Patient PsychologicallyPreparing the Patient Psychologically

Pain and frustration from the injury are usually the biggest problems.

Reassure the athlete. Warn about precautions.

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Preparing the EquipmentPreparing the Equipment Prepare the ice

pack Crushed ice in a

plastic bag Big enough to

extend 2–3 in. beyond injury

Evacuate as much air as possible from the bag.

Tie a knot in bag.

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Preparing the Equipment (cont.)Preparing the Equipment (cont.)

Elastic wraps Prefer 6 in., never <4 in. Double length or multiple

for large areas Splint or sling,

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Step 3. Application ParametersStep 3. Application Parameters

• Procedures– Ice bag– Elastic wrap– Stabilize– Elevate– Dosage– Duration– Frequency of application

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Ice BagIce Bag

Place directly on skin Center over middle of injury Shape to general contour

of body part

,

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Elastic WrapElastic Wrap

,

Apply snugly, but not too tightly (stretch to ~75% of length).

Cover the entire area. Secure with clips, tape, or tuck. Wear constantly for 20–24 hr, except

when changing ice bag No Flexi-Wrap, no compression

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StabilizeStabilize

Splint, sling, or brace Goal is total muscle relaxation. Sling for upper extremity

injuries, if muscle guarding occurs

Crutches for lower extremity injuries, if walking causes pain and/or limping

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Length of ApplicationLength of Application

Ice bag, intermittently 20–60 min depends on injury and skinfold

20 min, finger 30 min ankle, arm 45 min, thigh +1 min per millimeter of skinfold

Compression and elevation constantly Rest and stabilization until pain free

,

© 2008 LWW

Frequency of ApplicationFrequency of Application

Ice 5–10 min after injury Second application 30–60 min later, after

shower and go home Every 2 hr thereafter (don’t stay up into

night) Rest, compression, elevation, and

stabilization constantly,

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Step 4. Postapplication TasksStep 4. Postapplication Tasks Replace equipment/clean up area

Drain water and ice from ice pack (save the plastic bag for another use).

Return cold pack to refrigeration unit. Give patient written instructions

Time of next appointment Rest injury Time for reapplication of ice Phone number for emergency

Record treatment and unique patient response to treatment

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Step 5. MaintenanceStep 5. Maintenance

Keep ice machine in good repair. Replace elastic wraps as they

deteriorate.

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Crutch UseCrutch Use

Who? Any patient unable to walk without a limp

Why? Crutches facilitate proper gait by using arms

to substitute for, or supplement, leg power Failure to use crutches may result in:

Delayed healing Permanent abnormal gait

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Crutch Use (cont.)Crutch Use (cont.)

Proper use requires• Proper fitting of crutches• Selecting the appropriate gait• Instructing patient to walk properly• Observing the patient practice the gait• Periodic reevaluating to make sure patient is

using crutches properly

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Crutch fitting• Adjust length so 2–3 inches between

top and axilla.• Adjust hand piece

so elbow is flexed 30°.

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Select gait• Swing, if all weight off• 3-point for partial weight bearing

– Use this as much as possible– Gradually increase weight on foot

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Walking instructions• Proper gait• Amount of weight on foot• Up and down stairs

– The phrase “the good go up to heaven, the bad down to hell” may help you remember which foot or leg goes first when walking up and down stairs.

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Medicated Ice Cups (cont.)Medicated Ice Cups (cont.)Materials • 4 2-oz. disposable cups• 1 oz. of 2% lidocaine• 3 oz. of 10% povidine-iodine• 3 oz. of distilled or boiled water• Plastic stir sticks (handle)• Adhesive tape (to secure stir sticks in center

of cup

Mix together and pour into cups. Secure sticks in center of each cup with tape. Label and freeze overnight.

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Medicated Ice Cups (cont.)Medicated Ice Cups (cont.)

Medicated ice massage • Seek physician advice and approval before

using. • Hold by stir stick and roll the ice back and

forth along lacerated skin ~10 min. • As ice melts, medicines flow into wound. • Débride the area (remove foreign materials). • Treat and protect the area as any open

wound, emphasizing sterility. • Apply an ice pack for 20–30 min each hour

and compression constantly

© 2008 lww chapter 5. immediate care of acute orthopedic injuries

Documents

secondary injury theory

days slide

total injury

lww rest

lww metabolism

metabolism slide

immediate care transition

goal of immediate care