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.
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