There has been much talk of fascia iliaca blocks on #FOAMed sites before, but it’s time for a St.Emlyn’s update to ensure our patients get this fantastic analgesic intervention.
Most Emergency Physicians (in the UK at least) spend a part of their training in anaesthesia. For me this was an excellent introduction to the difficult airway as a year of predominantly maternity anaesthesia, solo, in a population averse to regional anaesthesia, made it so. An aspect of anaesthesia that generally isn’t widely taught in the six month attachment – when you are gaining necessary competencies in cardiorespiratory physiology, pharmacology of anaesthetic drugs, management of the airway, CRM and dealing with surgeons – is that of regional anaesthesia. Now, many people seem to come away from their anaesthetic attachments with a view that morphine is still considered to be the “gold standard” for analgesia (although this not a view universally held by anaesthetists so it’s a bit weird where they get it from). I still use a lot of morphine, but I am increasingly using synthetic opiates such as fentanyl and non-opioid treatment such as ketamine and IV paracetamol for acute pain relief in the ED.
Whilst it may still be a gold standard by some, the use of morphine is not without it problems. In certain patient groups, notably the elderly, injudicious administration may have deleterious effects see here, here and especially here (all FOAM). Unfortunately, I suspect that in our rush to do the “sexy bits” of anaesthesia such as giving the anaesthetic and managing the airway, we EPs occasionally forget the dull, but important, bits such as the pharmacology of opiates (handy #FOAMed reminder) which are critically important in the management of elders with acute pain. The side effects of opiates are myriad and potentiated in the elderly where the risk of drug interactions and interference with chronic organ dysfunction are all too real problems. As it is inhumane and poor medicine to deny analgesia for those in pain there has to be another way.
Thankfully for patients presenting with a fractured hip there is an alternative in the form of a fascia iliaca block. I first heard of this as a registrar from a particularly bright Advanced Nurse Practitioner in training who used it as part of her course. I have from then (2008) adopted it as my standard of care and I’d like you to do the same. Here’s the pitch…
- we agree that pain relief is necessary
- we agree that opiates, whilst beneficial, have undesirable side effects
- we should search for an alternative
If you remember your anatomy (and for me it’s 2 decades ago!) you will remember that the hip is innervated by the femoral, obturator and superior gluteal nerve as well as the nerve to quadratus femoris (wonderful reminder by Teach Me Anatomy here). Also have a look at the graphics from the very useful NY School of Regional Anaesthesia should help to visualise the anatomy a little better.
Pictures are one thing, but video is bettert and this fantastic video from Andy Neill is well worth a review. Honestly, this 10 mins will revolutionise your block anatomy and thus effectiveness.
You’ll remember that the nerve is lateral (NAVY y-fronts anyone?) and has two fascial sheaths. This makes the landmark technique phenomenally easy and virtually foolproof. As the video shows, the injection site is well away from any important structures and a double pop (one for the fascia lata and another for the fascia iliaca) will get you there. If it’s unclear, it’s 2/3 of the way from pubic tubercle to ASIS and about a centimetre below).
You can see the landmarks described on a real patient on this video (sadly it won’t embed due to copyright issues).
This has been covered already by our friends at LITFL. I would have 2 caveats:
- Your dose of LA (usually lido) for the skin and your dose of LA for the block (usually bupivacaine) are additive and should be calculated with caution.
- The fascia iliaca block is a field block and depends on volume so don’t be afraid to dilute your LA for the block – it will still work and keep your patient safe
Lidocaine = 3mg/kg
Bupivicaine = 2 mg/kg
Points on dilutions
- Remember that a 1% solution contains 10mg/1ml
- 3mg/Kg in a 70 Kg man would be 210mg.
- You would have 210mg in 21mls of 1% lidocaine
So for our fascia iliaca blocks we use 0.25% Bupivicaine. This means that in our 70Kg man we can use….
- 0.25% has 2.5mg/1ml
- 2mg/Kg in a 70Kg man is 140mg
- We can use up to 56ml of 0.25% Bupivicaine.
The key thing to remember is that volume is as important as concentration so we tend to use 30ml of 0.25% in most patients. Others suggest even greater volumes.
Effects of fascia iliaca block
A rather encouraging paper was published in 2008 by Hogh et al. Albeit in an uncontrolled and rather stoic group of patients, they showed that FIB was possible, safe and effective by junior registrars (who, if we’re honest, deliver a shedload of care in our EDs) with minimal training. Candal-couto et al. showed that elders with hip fractures could be sat up better with FIB, which, given the boring nature of hospital ceilings and the incidence of respiratory complications, has to be a good thing (not FOAM). A BET that needs updating (if you fancy a publication ;-)) suggests that they are effective and opioid sparing in reviewing the evidence to 2010.
So how would I do it?
The group of patients we are discussing are generally elderly and have a significant mechanism of injury. Most of our shops also benefit from well-trained triage nurses with advanced skills. It is not unreasonable to cannulate and give IV paracetamol for those with acute pain (the cost in the BNF of IV paracetamol is less than that of suppositories). If you have a high clinical suspicion of proximal femoral fracture (Mechanism of injury, shortened, externally rotated leg, non weight bearing etc.) is an FIB not unreasonable? Even if these patients have no visible fracture, you are providing comfort and a bridge to the cross-sectional imaging you need to disprove a fracture before mobilisation. The fascia iliaca block takes as long to administer (even with assembling equipment) as it does for opiates to be signed out and given safely. If you’re not a muppet (and by reading this, I presume you’re not!) it’s safe and effective.
Personally I use the landmark and 2-pop technique which is really well described here.
@EMManchester swears by the ultrasound approach. This video from Gordon Smith in Scotland is excellent (and note credit to the patient Mr Kenneth Smith).
I believe it to be the standard of care for elders with hip fractures. Lets make 2016 better for these folk and incidentally reduce length of stay and complications within the hospital!
A handy guide with quiz from frca.co.uk is here (FOAM).
After publishing this post we have permission to share this fantastic infographic from @KirstyChallen
P.S. If the bubbly wine you drank on NYE isn’t still causing nausea, a prezi I wrote that I’m happy for you to use is here. Our audit data is much better now, you’ll be pleased to hear.
P.P.S. I’m quite happy to have the debate about landmark vs USG FIB in the comments.
- Emergency Medicine Ireland anatomy for FIB: http://emergencymedicineireland.com/2014/05/anatomy-emergency-medicine-028-fascia-iliaca-block/
- Side effects of opioids during short-term administration: Effect of age, gender, and race
- Opiates and elderly: Use and side effects
- The Role of Postoperative Analgesia in Delirium and Cognitive Decline in Elderly Patients: A Systematic Review
- The short coat: Blocked – ED Analgesia for Hip/Femur Fractures
- SGEM#138: Hip to be Blocked – Regional Nerve Blocks for Hip and Femoral Neck Fractures
- Ultrasound podcast. USS guided Fem Nerve block
- Highland Ultrasound. Fascia iliaca block
- FOAMcast: Femoral nerve blocks
- Fascia iliaca block for pain relief from proximal femoral fracture in the emergency department: a review of the literature. Adam Chesters’ paper from EMJ in 2014.