Clinical Practice Guidelines

Local Anaesthetic Manipulation and Plaster LAMP

  • Doctors must discuss previous experience and training in this procedure with the Director of the Emergency Department before proceeding, and should be fully familiar with the equipment used.

    Indication

    Children over 5 yrs with forearm fractures requiring manipulation - some younger children if very cooperative. Distressed or non-compliant children may be better treated Under GA.

    Preparation

    Prior to X-Ray

    • Give adequate pain relief
      • Painstop 1.0mL/kg
      • or Pethidine 1.0-1.5mg/kg IM
      • or Morphine 0.1-0.2 mg/kg IM
    • Keep child nil orally.
    • Put EMLA/amethocaine on both hands.

    Once decision is made to proceed to LAMP

    • All LAMP procedures are to be ED admissions. A yellow form should be taken to the ward clerks to be processed. Informed consent must be obtained from parents.
    • Procedure must be performed in Proceedure Room with full resuscitation equipment. Check all Equipment.
    • Notify radiology to ensure availability of staff prior to commencing.

    Procedure

    • Two doctors must be present.
    • Apply a tourniquet to the affected arm.
    • Insert an i.v. cannula (not a butterfly) into a distal vein of both arms
    • Elevate the arm above the level of the child's heart for 1 minute with compression of the brachial artery.
    • Inflate the tourniquet cuff to 200 mmHg. This reading is maintained throughout the procedure and remains the responsibility of the second attending doctor.
    • Infuse Lignocaine 0.5% 0.6mls/kg (3 mg/kg); max dose 40ml.
    • Commence manipulation only after full anaesthesia has been obtained (usually.takes 5-10 minutes).
      Note: Nitrous oxide or intravenous opiate may be useful as an adjunct in some children.
    • Apply plaster to the forearm (below elbow).
    • Arrange portable post-reduction film in ED. If possible wait until the X-ray is available to assess the position post-manipulation before releasing the tourniquet.
    • Release the tourniquet cuff.
      Note:Not to be released before 20 minutes after lignocaine infusion. 
      Complete the plaster cast (above elbow).

    After the Procedure

    • The child may be discharged from the ED after the cuff is released.
    • Arrange plaster check LMO on the following day.
    • Organise Fracture Clinic and X-ray appointment at 5-7 days.
    • Complete yellow Discharge Summary and operative notes on Surgical Short Stay form.