Ultrasound guided fascia iliac block in the hands of ED physicians.

Date First Published:

February 11, 2014

Last Updated:

February 27, 2014

Report by:

M Azam Majeed, Consultant EM (University Hospitals Birmingham)

Three-Part Question:

Is [ultrasound guided Fascia Iliaca Block] an [effective method of pain relief] in patients with [femoral neck and shaft fratures], in the hands of ED physicians.

Clinical Scenario:

A 69yrs female comes after a fall with right hip pain; x rays confirm the diagnosis of fracture neck of femur (NOF). She is very hard to cannulate and you have read an article about anaesthetists putting ultrasound guided fascia iliaca block for NOF fractures. We want to know how good it is in the hands of ED physicians.

Search Strategy:

The following database/ search engines were queried:

1.tMEDLINE since 1951.
2.tCINAHL
3.tEMBASE
4.tGoogle Scholar.
5.tCochrane
6.tTrip Data

Search Details:

1. MEDLINE; exp FACSIA/
t
2.tMEDLINE; (iliaca AND block).ti,abtttt
3.tMEDLINE; FICB.ti,abtttttt
4.tMEDLINE; (fascia AND iliaca).ti,abtttt
5.tMEDLINE; (neural AND block).ti,abtttt
6.tMEDLINE; exp HIP FRACTURES/
tttt
7.tMEDLINE; exp FEMUR NECK/ttttt
8.tMEDLINE; exp FEMORAL NECK FRACTURES/ttt
9.tMEDLINE; exp FEMORAL FRACTURES/t
tt
10.tMEDLINE; 6 OR 7 OR 8 OR 9ttttt
11.tMEDLINE; 1 OR 2 OR 3 OR 4 OR 5tttt
12.tMEDLINE; exp ULTRASONOGRAPHY/tttt
13.tMEDLINE; ultrasound.ti,abttttt
14.tMEDLINE; (ultrasound ADJ guided).ti,abt
tt
15.tMEDLINE; (guided ADJ ultrasound).ti,abt
tt
16.tMEDLINE; (guided ADJ ultrasonography).ti,abt
t
17.tMEDLINE; (ultrasonography ADJ guided).ti,ab
tt
18.tMEDLINE; 12 OR 13 OR 14 OR 15 OR 16 OR 17t
t
19. MEDLINE; 10 AND 11 AND 13ttttt
20. MEDLINE; (ultrasonography OR ultrasound).ti,abt
t
21.tMEDLINE; 10 AND 11 AND 20t

Outcome:

We had 136 studies, out of them 4 were done in ED.

Relevant Paper(s):

Study Title	Patient Group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
FICB performed by junior registrars as supplement to pre-operative analgesia for patients wit hip fracture. Strat Trauma Limb Recon 2008; Hogh 2008 Denmark	70 patients with fractured hip in ED, 2/3 female, mean age of 80.7.	Prospective observational, Comparison of FIB efficacy performed by junior ED registrars.	Comparison of FIB efficacy performed by junior ED registrars.	The median simple verbal pain Score (0–4) pre-block was 2.2 and this improved to a median of 1.5,15 min post-block (P\0.001) and to1.3, 60 min post-block (P = 0.021). The median pain-free hip flexion pre-block was 15 degrees and this improved to a median of 28 degrees,15 min post-block (P = 0.014) and 37 degrees 60 min post-block (P = 0.030).	Small sample FIB performed on 187 patients but analysed only 70 patients due to loss of data. No blinding No set criteria for competence for junior registrars.
ultrasound guided fascia iliaca compartment block for hip fractures in the emergency department L Haines 2012 USA	20 patients with confirmed Hip fracture on X-ray were enrolled with the mean age of 82 years, 11M and 9F. Patient with cognitive impairment and pain score of less than 5 on VAS scale on arrival to ED were excluded	Prospective observational study.	Mean VAS score reduction with ultrasound guided FIB over 8 hrs post block.	The lowest mean pain score of 1.3/10 was achieved at 120 mins. All of the decrease in pain scores was statistically significant, with P-values of 0.029 (time 0 vs. time 10 min); 0.0001 (time 0 vs. time 20 min); 0.0001 (time 0 vs. time 30 min); 0.001 (time 0 vs. time 60 min); 0.0001 (time 0 vs. time 120 min); 0.0001 (time 0 vs. time 240 min); and 0.017 (time 0 vs. time 480 min), respectively.	Convenient sample. Small sample size. Extensive exclusion criterion. Data collected by interventionists causing Bias. Patients with FIB had morphine awaiting x-rays, introducing confounder. No comparison group
Single fascia iliaca compartment block for pain relief in patients with fractured neck of femur in the emergency department Elkhodair 2011 UK	137 patients were enrolled in our study (61 women and 76 men), with mean age: 77.2 years) which was carried out at two ED’s	Prospective cohort study.	Primary outcome was a change in the pain score; a difference of more than 3 from the patient’s baseline score was considered to be clinically significant. Secondary outcomes included adverse events, nerve Block complications.	A mean reduction of 3.29 points on the VAS from the baseline was documented at 30 min in 129 cases, P<0.0001). A further reduction of 1.94 points in the VAS was noted at 60 min in 106 cases, P<0.0001)	small sample Operator assessing the VAS scoring thus introducing bias. Post block analgesia required is not mentioned. 31 missing data at 60 minutes in 137 patients.
FIB the fractured femur H Shahzad 2013 UK	19 patients were included in the study, mean age was 58.5yrs, 13 female and 6 male.	Prospective, observational study	Primary outcome was significant pain relief and patient satisfaction	Pain score improved from >7 (VAS) to 5.5, 4.5 and 3 at 15mins, 30mins and 45mins. Patient satisfaction was achieved to 4.5 on a scale of 1-5.	Single center, small sample, unclear who is doing the assessment for pain relief and satisfaction

Author Commentary:

The studies have small sample sizes but have been done by the ED physicians. The results are clinically and statistically significant.

Bottom Line:

UFIB in the hands of ED physicians is safe and effective method of giving analgesia in patients with neck and shaft of femur fractures.

References:

Hogh. FICB performed by junior registrars as supplement to pre-operative analgesia for patients wit hip fracture. Strat Trauma Limb Recon 2008;
L Haines. ultrasound guided fascia iliaca compartment block for hip fractures in the emergency department
Elkhodair. Single fascia iliaca compartment block for pain relief in patients with fractured neck of femur in the emergency department
H Shahzad. FIB the fractured femur