Regional analgesia versus systemic analgesia for femoral fractures in the ED

Leonieke Groot, junior resident

4th Dutch North Sea Emergency Medicine Conference

Introduction:

Femoral fracture: high incidence 1:1000 (WFG 200/jr)

Traditional treatment: systemic opioids

Large potential for side effects: nausea, dizziness, urine retention, hypotension, respiratory depression, decreased mental state, delerium

Untreated or undertreated pain can increase delerium as well

Marcantonio et al. Reducing delerium after hip fracture: a RCT. J Am Geriatr Soc 49:516-522, 2001

Morrison et al. Relationship between pain and opioid analgetics on the development of delerium following hip fracture. J Gerontol Med Sci 2003, Vol 58, No1, 76-81

PICO:

• P = patiënts with femoral fracture in the ED

I = regional block (fascia iliaca compartment block)

performed by Emergency Physicians or junior residents

C = systemic (traditional) analgesia with opioids

O = adequate analgesia and adverse effects/events

Fascia Iliaca Compartment Block:

• Fast and consistent blockade

• Simple and easy to learn and use

• Distant from nerves and blood vessels

• Without ultrasound guidance or nerve stimulator

Capdevila et al. Comparison of the tree-in-one and fascia iliaca compartment blocks in adults: clinical and radiological analysis. Anesth Analg 1998;86:1039-44.

Dalens et al. Comparison of the fascia iliaca block with the 3-in-1 block in children. Anesth Analg 1989; 69:705-13.

Search strategie:

• PubMed search:

Femoral Fractures"[Mesh] AND ("Nerve Block"[Mesh] OR "fascia iliaca compartment block"[All Fields]) AND ("Pain"[Mesh] OR "Analgesics, Opioid"[Mesh] OR "Morbidity"[Mesh] OR "complications "[Subheading] OR "adverse effects "[Subheading]) AND "humans"[MeSH Terms] AND English[lang]

52 articles; eight relevant; three best and most relevant articles.

Related articles: two relevant additional articles

Search strategy:

• Cochrane Library: one review which could not specifically answer our question

• EMBASE: no additional articles found

• BestBET’s: two relevant BET’s, did not specifically look at Emergency Physicians or junior residents performing this block

Conclusion:

• For the acute management of pain in patients with femoral fractures, FICB is rapidly effective and easily learned and performed by (junior) Emergency Department staff without reported adverse effects.

• FICB has the potential to reduce the reliance to opioids and their side effects, esspecially in a fragile group of patients.

• Level of recommendation: B.

Comments:

• Most of the studies were relatively small and not fully blinded

Clinical bottom line:

• In patients with femoral fracture, FICB can be safely performed by Emergency Physicians and junior residents in the ED

• FICB provides better pain relief and gives less adverse events than systemic opioids.

Literature:

• Capdevila X, Biboulet Ph, Bouregba M, et al. Comparison of the tree-in-one and fascia iliaca compartment blocks in adults: clinical and radiological analysis. Anesth Analg 1998;86:1039-44

• Chesters A, Elkhodair S, Mortazavi, et al. Fascia iliaca compartment block in the emergency department. Emerg Med J 2009;26(Suppl I):A1-A12.

• Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca block with the 3-in-1 block in children. Anesth Analg 1989; 69:705-13.

• Elkhodair S. Fascia iliaca compartiment block for control of hip/femur fracture pain in adult patients. BestBETs last modified 14th november 2008.

• Foss NB, Kristensen BB, Bundgaard M, et al. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anaesthesiology 2007; 106:773-8.

• Haddad FS, Williams RL. Femoral nerve block in extracapsular femoral neck fractures. J Bone Joint Surg Br 1995;77(6):922-3.

• Hauritz RW, Gerlif C, Ronholm E. Fascia iliaca block performed by emergency department physician trainees in hip fractures. Ugeskr Laeger 2009 Feb 9;171(7):515-8.

Literatuur (2)

• Hogh A, Dremstrup L, Skov Jensen S, Lindholt J. Fascia iliaca compartment block performed by junior registrars as a supplement for pre-operative analgesia for patients with hip fracture. Strat Traum Limb Recon (2008) 3:65-70.

• Marcantonio ER, Flacker JMF, Wright RS, et al. Reducing delerium after hip fracture: a randomised clinical trial. J Am Geriatr Soc 49:516-522, 2001.

• Martin B. Regional nerve block in fractured neck of femur. BestBETs.

• Monzon DG, Iserson KV, Vazquez JA. Single Fascia iliaca compartment block for post-hip fracture pain relief. The J of Emergency Medicine, Vol 32, No 3, pp:257-262, 2007.

• Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgetics on the development of delerium following hip fracture. J Gerontol Med Sci 2003, Vol 58, No1, 76-81.

• Wathen JE, Gao D, Merritt G, Georgopoulos G, Battan FK. A randomized controlled trial comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department. Annals if Emergency Medicine, Volume 50, no.2:August 2007.

• Yun MJ, Kim MK, Han MK. Anagesia before a spinal block for femoral neck fracture: fascia iliaca compartiment block. Acta Anaesthesiol Scand 2009; 53:1282-1287.

Thank you for listening

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