scholarly journals LO12: The utility of femoral nerve blocks in the emergency department; a national survey of practice

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S31
Author(s):  
J. Ringaert ◽  
J. Broughton ◽  
M. Pauls ◽  
I. Laxdal ◽  
N. Ashmead
Keyword(s):  
Emergency Department ◽  
Hip Fracture ◽  
Hip Fractures ◽  
Femoral Nerve ◽  
Comfort Level ◽  
Emergency Physicians ◽  
First Line ◽  
Nerve Blocks ◽  
Canadian Association ◽  
The University

Introduction: Approximately 30,000 hip fractures occur annually in Canada, and the incidence will increase with an aging population. Pain control remains a challenge with these patients, as many are elderly and prone to delirium. Regional anesthesia has shown to be very effective with minimal risks, but it is not clear how often emergency physicians are using this technique to provide analgesia for patients with proximal hip fractures. This is the first Canada-wide survey to evaluate the use of regional anaesthesia in the emergency department for hip fractures. It also evaluates physician comfort level with performing these blocks, perceived educational needs in this area, and barriers to performing nerve blocks. Methods: A 13-question survey was sent to 1041 members of the Canadian Association of Emergency Physicians via email in January and February of 2016. Data was collected and analysed using an online collection program called “Survey Monkey”. Ethics approval was obtained through the University of Manitoba Research Ethics Board. Results: 272 Emergency physicians and residents took part in the survey. The majority of respondents (75.9%) choose intravenous opioids as their first line of analgesia and only 7.6% use peripheral nerve blocks (PNB) as their first line choice for analgesia in hip fracture. In response to practitioner comfort with PNBs for hip fractures, most were not at all confident (45.0%) in their ability and many respondents have never performed a nerve block for a hip fracture (53.9%). The most commonly identified barriers to performing PNBs include lack of training, the time to perform the procedure and a lack of confidence. A larger percentage of respondents (34.2%), identified having had no training and no knowledge of how to perform PNBs for hip fractures. Conclusion: The vast majority of Canadian emergency physicians who took part in this survey do not utilize PNBs as a method of pain management for hip fractures. Over half have never performed one of these procedures and many have never received training in how to do so. Future efforts should focus on improving access to education, disseminating information regarding the effectiveness of PNB, and addressing logistical barriers in the ED.

scholarly journals MP024: Ultrasound-guided femoral nerve block versus fascia iliaca block for hip fractures in the emergency department: a randomized pilot study

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S74-S74
Author(s):  
J. Chenkin ◽  
J.S. Lee ◽  
T. Bhandari ◽  
R. Simard
Keyword(s):  
Emergency Department ◽  
Pilot Study ◽  
Nerve Block ◽  
Hip Fractures ◽  
Femoral Nerve Block ◽  
Femoral Nerve ◽  
Comfort Level ◽  
Ultrasound Guided ◽  
Nerve Blocks ◽  
Pain Scores

Introduction: Regional anesthesia has been shown to be an effective pain control strategy for patients presenting with hip fractures in the emergency department. There are two common methods for performing this block: the femoral nerve block (FNB) and the fascia iliaca compartment block (FICB). The objective of this pilot study is to determine whether one of these two ultrasound-guided block techniques provides superior analgesia to emergency department patients with hip fractures. Methods: Emergency physicians at a single institution were randomized to the FNB or FICB training groups. Participants completed a 2-hour practical workshop covering the technique, followed by a questionnaire to assess their comfort with the block. They were asked to perform their assigned nerve block on any patient in the ED presenting with a hip or femur fracture. Physician comfort level and patient pain scores using a visual analog scale (VAS) were recorded before and after the nerve block were recorded. Comparisons were performed using Student’s t-test and Fisher’s exact test. Results: A total of 20 physicians were enrolled in the study, 10 in the FNB group and 10 in the FICB group. There were no significant baseline differences between the groups with respect to ultrasound or nerve block experience. Following the training, 100% of participants in both the FNB group and FICB group felt comfortable performing the block. Nerve blocks were performed in 30/51 (58.8%) of eligible patients in the FNB group and 6/11 (54.5%) in the FICB group (p=1.0). On the 10-point VAS, pain scores decreased by a mean of 4.9 (SD 3.5) in the FNB group and 8.3 (SD 2.4) in the FICB group (p=0.056). In practice, physicians felt comfortable performing the FNB in 52.8% of cases, and the FICB in 85.7% of cases (p=0.21). Mean time to completion of the blocks was similar between the two groups (19 vs 18 mins, p=0.83). Conclusion: In this pilot study, we found a non-significant trend towards improved analgesia and higher physician comfort with the ultrasound-guided FICB compared with the FNB in patients with hip fractures. We found no differences in time to performing the blocks. These results require confirmation with a larger sample size.

scholarly journals MP033: The use of femoral nerve blocks in the emergency department for hip fracture patients

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S77-S77
Author(s):  
A. Sandre ◽  
C. Thompson ◽  
S.L. McLeod ◽  
B. Borgundvaag
Keyword(s):  
Emergency Department ◽  
Hip Fracture ◽  
Regional Anesthesia ◽  
Management Strategy ◽  
Femoral Nerve ◽  
Hospital Length ◽  
Hospital Length Of Stay ◽  
Emergency Physicians ◽  
Nerve Blocks ◽  
Pain Management Strategy

Introduction: Hip fractures affect over 30,000 Canadians each year. Delirium, or acute confusion, occurs in up to 62% of patients following a hip fracture. Delirium substantially increases hospital length of stay and doubles the risk of nursing home admissions and death. Previous studies have shown that regional anesthesia is the optimal pain management strategy for hip fracture patients and has been shown to independently reduce the rate, severity and duration of delirium. However, very few emergency physicians (EPs) have the necessary training and experience to use regional anesthesia for hip fracture in the emergency department (ED). The objective of this study was to determine the number of femoral nerve blocks performed within the ED for the management of hip fracture patients. Methods: This was a retrospective chart review of patients aged 65 years and older, presenting to an academic ED (annual census 60,000) with a discharge diagnosis of hip fracture from January 1st 2014 to July 31st 2015. Results: Of the 243 hip fractures included in this study, mean (SD) age was 82.9 (8.2) years and 187 (77.0%) were female. The majority (214, 88.1%) of patients arrived to the ED by ambulance and 182 (74.9%) were categorized as CTAS 3. The most common analgesics used in the ED were intravenous (IV) hydromorphone (51.4%), IV morphine (32.1%), or dual therapy with both IV hydromorphone and IV morphine (4.9%). Femoral nerve blocks were initiated for 13 (5.3%) patients and successfully completed in 12 (4.9%) patients in the ED. Median (IQR) ED and hospital length of stay was 5.0 (3.7, 6.6) hours and 6.0 (4.1, 10.2) days, respectively. Forty-three (17.7%) patients experienced in-hospital acute delirium. Conclusion: Despite evidence to suggest regional anesthesia may be the optimal pain management strategy for hip fracture patients, the use of femoral nerve blocks in the ED remains low. Future research should attempt to elucidate barriers to use of this procedure by emergency physicians.

scholarly journals LO58: Risk factors associated with acute in-hospital delirium for patients diagnosed with a hip fracture in the emergency department

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S47-S48
Author(s):  
V. Brienza ◽  
C. Thompson ◽  
A. Sandre ◽  
S.L. McLeod ◽  
S. Caine ◽  
...  
Keyword(s):  
Risk Factors ◽  
Emergency Department ◽  
Hip Fracture ◽  
Femoral Nerve Block ◽  
Opioid Analgesic ◽  
Femoral Nerve ◽  
Primary Objective ◽  
Hospital Length Of Stay ◽  
Multivariable Logistic Regression Analysis ◽  
Nerve Blocks

Introduction: Hip fractures affect over 35,000 Canadians each year. Delirium, or acute confusion, occurs in up to 62% of patients following a hip fracture. Delirium substantially increases hospital length of stay and doubles the risk of nursing home admissions and death. The primary objective of this study was to identify risk factors independently associated with acute in-hospital delirium within 72 hours of emergency department (ED) arrival for patients diagnosed with a hip fracture. Methods: This was a retrospective chart review of patients aged 65 years and older presenting to one of two academic EDs with a discharge diagnosis of hip fracture from January 1st 2014 to December 31st 2015. Multivariable logistic regression analysis was used to determine variables independently associated with the development of acute in-hospital delirium within 72 hours of ED arrival. Results: Of the 668 included patients, mean (SD) age was 84.1 (8.0) years and 501 (75%) were female. 521 (78.0%) patients received an opioid analgesic and/or femoral nerve block in the ED. The most common analgesics used in the ED were intravenous (IV) morphine (35.8%), IV hydromorphone (35.2%), or dual therapy with both IV hydromorphone and IV morphine (2.2%). Femoral nerve blocks were initiated for 36 (5.4%) patients and successfully completed in 35 (5.2%) patients in the ED. 181 (27.1%) patients developed delirium within 72 hours of ED arrival. History of neurodegenerative disease or dementia (OR: 5.7, 95% CI: 3.9, 8.4), age >75 (OR: 2.8, 95% CI: 1.4, 5.6) and absence of analgesia in the ED (OR: 2.1, 95% CI: 1.3, 3.2) were independently associated with acute in-hospital delirium. Conclusion: The development of in-hospital delirium is common in patients diagnosed with a hip fracture. We have identified modifiable and non-modifiable risk factors independently associated with acute in-hospital delirium, which can be identified in the ED. Clinicians should be aware of these risk factors in order to implement strategies directed at reducing the development of acute delirium. Additionally, further research is needed in order to understand the relationship between analgesia delivered in the ED and the development of delirium for patients diagnosed with a hip fracture.

scholarly journals Pericapsular nerve group block for hip fracture is safe and effective in the emergency department: a prospective observational study comparing pericapsular nerve group block to fascia iliaca compartment block and femoral nerve block

2021 ◽  
Author(s):  
Alan Fahey ◽  
Elinor Cripps ◽  
Aloysius Ng ◽  
Amy Sweeny ◽  
Peter J. Snelling
Keyword(s):  
Emergency Department ◽  
Hip Fracture ◽  
Pain Score ◽  
Regional Anaesthesia ◽  
Femoral Nerve Block ◽  
Femoral Nerve ◽  
Emergency Physicians ◽  
Opioid Use ◽  
Pain Scores ◽  
Fascia Iliaca Compartment Block

ABSTRACTBackgroundThe pericapsular nerve group (PENG) block was first described for the treatment of hip fracture, including neck of femur, in 2018. We hypothesise that the PENG block is safe and effective for patients with hip fracture when provided by emergency physicians and trainees in the emergency department (ED), for which it may be superior to fascia iliaca compartment block (FICB) and femoral nerve block (FNB).MethodsFrom October 2019 to July 2020, consecutive patients receiving regional anaesthesia for hip fracture in the ED of a single large regional hospital were prospectively enrolled. Pain scores were assessed prior to regional anaesthesia then at 15, 30 and 60 minutes after regional anaesthesia. Maximal reduction in pain scores within 60 minutes were assessed using the Visual Analogue Scale (at rest and on movement) or the Pain Assessment IN Advanced Dementia tool (at rest). Patients were followed for opioid use for 12 hours after regional anaesthesia and adverse events over the duration of their admission.ResultsThere were 67 eligible patients during the enrolment period, with 52 (78%) prospectively enrolled. Thirty-three received femoral blocks (19 FICB, 14 FNB) and 19 received a PENG block. There was no difference in maximum pain score reduction between the groups whether measured at rest or on movement. Clinicians providing the PENG block were less experienced in the technique than those providing FICB or FNB. There was no difference in adverse effects between groups. Although opioid use was similar between the groups, more patients were opioid free after a PENG block.ConclusionsAlthough there was no difference in maximal pain score reduction, this study demonstrated that the PENG block was feasible and could be provided safely and effectively to patients with hip fracture in the ED. On this basis, a larger randomised controlled study should now be designed.Key MessagesWhat is already known on this subject□There is a solid neuroanatomical rationale to suggest the PENG block may provide superior anaesthesia of hip fractures than FNB or FICB.□The technique utilises bony sonographic and tactile landmarks which make it an ideal block for emergency physicians to safely and effectively perform.□What this study adds□This is the first comparative study of the PENG block to FNB or FICB in patients with hip fracture in ED, which will provide a scaffold for future research.□This pragmatic observation of evolving practice showed that emergency physicians and trainees inexperienced in the technique could provide it safely and effectively in the ED

scholarly journals Emergency Department Femoral Nerve Blocks and 1-Year Mortality in Fragility Hip Fractures

2019 ◽  
Vol 10 ◽  
pp. 215145931989389 ◽  
Author(s):  
Michael Darren Polischuk ◽  
Nrusheel Kattar ◽  
Ashwin Rajesh ◽  
Tony Gergis ◽  
Kieran King ◽  
...  
Keyword(s):  
Emergency Department ◽  
Hip Fractures ◽  
Femoral Nerve ◽  
Early Mobilization ◽  
Opioid Use ◽  
Retrospective Case ◽  
Nerve Blocks ◽  
Significant Difference ◽  
Insight Into ◽  
Control Study

Objective: Femoral nerve blocks (FNBs) for fragility hip fractures have benefits in improving pain relief and early mobilization while decreasing opioid use and rates of pneumonia. However, no study has looked at 1-year mortality outcomes for this intervention. This study aims to provide insight into 1-year outcomes. Methods: A single-site retrospective case–control study from 2007 to 2016 in primary fragility hip fractures compared 665 patients who received an emergency department FNB to 326 patients who did not receive an FNB. The primary outcome was 1-year mortality. Secondary outcomes included mortality, mobility, and residence at discharge, 6 months, and 1-year intervals. Results: There were no significant differences in preoperative characteristics. Although there was no statistically significant difference in 1-year mortality, patients who did not receive an FNB were more likely to be nonambulant at 1 year (odds ratio 1.71, 95% confidence interval, 1.14-2.57, P = .005). There were no other significant differences in mobility, residence, or mortality. Conclusion: There was no statistically significant difference in 1-year mortality, although individuals who did not receive an FNB were more likely to be nonambulant at 1 year.

scholarly journals Use of Femoral Nerve Blocks to Manage Hip Fracture Pain among Older Adults in the Emergency Department: A Systematic Review

CJEM ◽  
2015 ◽  
Vol 18 (4) ◽  
pp. 245-252 ◽  
Author(s):  
Madison Riddell ◽  
Maria Ospina ◽  
Jayna M. Holroyd-Leduc
Keyword(s):  
Systematic Review ◽  
Older Adults ◽  
Emergency Department ◽  
Hip Fracture ◽  
Nerve Block ◽  
Femoral Nerve Block ◽  
Femoral Nerve ◽  
Cochrane Central Register ◽  
Nerve Blocks ◽  
Rescue Analgesia

AbstractObjectiveHip fractures are a common source of acute pain amongst the frail elderly. One potential technique to adequately manage pain in this population is the femoral nerve block. The objective of this systematic review was to provide updated evidence for the use of femoral nerve blocks as a pain management technique for older hip fracture patients in the emergency department (ED).Data SourcesSearches of Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were conducted between December 2010 and May 2014. The reference list of a previous systematic review was also searched.Study SelectionWe included randomized control trials examining the use of femoral nerve blocks in the ED among older adults (65 years of age or older) with acute hip fracture.Data ExtractionAmong 93 citations reviewed, seven trials were included. Four studies employed a single femoral nerve block, while three studies employed continuous (catheter-placed) femoral blocks. All but one of the studies were found to have a high risk of bias.Data SynthesisAll studies reported reductions in pain intensity with femoral nerve blocks. All but one study reported decreased rescue analgesia requirements. There were no adverse effects found to be associated with the femoral block procedure; rather, two studies found a decreased risk of adverse events such as respiratory and cardiac complications.ConclusionsFemoral nerve blocks appear to have benefits both in terms of decreasing the pain experienced by older patients, as well as limiting the amount of systemic opioids administered to this population.

BET 2: CT versus MRI for occult hip fractures

2018 ◽  
Vol 35 (10) ◽  
pp. 645-647 ◽  
Author(s):  
Bernard A Foex ◽  
Anna Russell
Keyword(s):  
Hip Fracture ◽  
Ct Scan ◽  
Hip Fractures ◽  
Clinical Suspicion ◽  
First Line ◽  
Bottom Line ◽  
X Ray ◽  
Occult Hip Fracture ◽  
Study Type ◽  
Occult Hip Fractures

A short-cut review was carried out to establish whether CT or MRI is better at detecting an occult hip fracture. Six studies were directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that CT is a valid first-line investigation for a suspected plain X-ray occult hip fracture. If clinical suspicion remains after a negative CT scan, then MRI should be used.

Analgesia and anaesthesia

2020 ◽  
pp. 281-327
Author(s):  
Jonathan P. Wyatt ◽  
Robert G. Taylor ◽  
Kerstin de Wit ◽  
Emily J. Hotton ◽  
Robin J. Illingworth ◽  
...  
Keyword(s):  
Emergency Department ◽  
Nerve Block ◽  
Local Anaesthetic ◽  
Local Anaesthesia ◽  
Femoral Nerve Block ◽  
Rapid Sequence Induction ◽  
Femoral Nerve ◽  
General Anaesthetic ◽  
Intravenous Sedation ◽  
Nerve Blocks

This chapter in the Oxford Handbook of Emergency Medicine investigates analgesia and anaesthesia in the emergency department (ED). It looks at options for relieving pain, such as the analgesics aspirin, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), morphine and other opioids, Entonox®, and ketamine, and explores analgesia for trauma and other specific situations. It discusses local anaesthesia (LA) and local anaesthetic toxicity, including use of adrenaline (epinephrine) and general principles of local anaesthesia. It explores blocks such as Bier’s block, local anaesthetic nerve blocks, intercostal nerve block, digital nerve block, median and ulnar nerve blocks, radial nerve block at the wrist, dental anaesthesia, nerve blocks of the forehead and ear, fascia iliaca compartment block, femoral nerve block, and nerve blocks at the ankle. It examines sedation, including drugs for intravenous sedation and sedation in children, and discusses general anaesthesia in the emergency department, emergency anaesthesia and rapid sequence induction, difficult intubation, and general anaesthetic drugs.

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