A St.Emlyn’s fascia iliaca block update.

Fascia Iliaca Blocks

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…

  1. we agree that pain relief is necessary
  2. we agree that opiates, whilst beneficial, have undesirable side effects
  3. 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).

 

LA dose

This has been covered already by our friends at LITFL. I would have 2 caveats:

  1. 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.
  2. 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

  1. Remember that a 1% solution contains 10mg/1ml
  2. 3mg/Kg in a 70 Kg man would be 210mg.
  3. 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….

  1. 0.25% has 2.5mg/1ml
  2. 2mg/Kg in a 70Kg man is 140mg
  3. 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

From Kirsty Challen based on the SGEM podcast from Ken Milne.

From Kirsty Challen based on the SGEM podcast from Ken Milne.

vb

Alan

@dralangrayson

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.

 

Further reading.

17 Comments

  1. Pete

    Great article Alan, thanks. In a previous hospital our anaesthetic colleagues tried to introduce this but insisted it should be done with US and ECG monitoring. The result was that no one actually got the block. We introduced the landmark technique and 84% of #NoFs got a FICB in the ED with no complications over the last four years. Now changed departments and starting all over again but will use this article to help pursuade the nay-sayers. All the best. Pete

    Reply
    1. Simon Carley

      Interesting. Always a tricky one when being dictated to by external forces. Sounds as though you overcame the politics to the benefit of your patients.
      We do use ECG/SaO2 monitoring as it’s easy and quick, does not delay and is widely recommended. I presume you still do monitoring (was it just the USS as the barrier to delivery?).

      S

      Reply
  2. Mike Blackburn

    I have found that one can spend an inordinate amount of time with the ultrasound trying to locate a nerve in what is essentially a field block. So I don’t use it. My £0.02

    Reply
    1. Simon Carley

      I like the USS and if it’s available it’s my technique of choice. However, if there were barriers to using USS (availability/competence/time) then I’d be happy with the 2-pop technique. It does seem to still work so perhaps it’s an unnecessary complication.

      With USS I’m pretty confident that I’m doing a fascia iliaca block rather than just a fem nerve block….., but as the paper by Chester’s et al suggest – maybe that really doesn’t make that much of a difference.

      Bottom line – JFDE*

      S

      * Just Do Either

      Reply
  3. Jo

    Who is trained to do the blocks at your place? Just doctors? ANP’s/ENP’s? Other nurses? Think they are a great idea. One barrier we’ve had is not having the specialised nerve block needles, so liked the fact that on the video link he used a red fill needle, we got loads of those!
    Jo

    Reply
    1. Simon Carley

      Just the doctors at the moment. I can’t see any reason why the ANPs could not be trained up to do it though.

      S

      Reply
      1. Gareth Roberts

        actually talking to nursing staff re possibility of training them up currently.

  4. Aasir Abuelnaga

    Thanks Alan
    Great article as usual.

    Reply
  5. Dino

    I agree that FIB is the way to go in managing pain from #NOF and I’ve been using the anatomical landmark 2-pop technique for years.
    One question that I’ve always had though… Are there any caveats if suspected pathological fracture due to possible bony metastasis? Had worked in one institution where the orthopaedic department didn’t want us to do them if we suspected this was a possibility.

    Reply
    1. Simon Carley

      Hmm, I can’t think of a good reason why not. Did they give you an explanation or reason why?

      S

      Reply
      1. Dino

        It was concerns re potential of seeding malignant cells along the needle track. I would imagine that this is unlikely to happen though as the needle should be nowhere near the pathological fracture site itself.

  6. Casey

    Hi chaps
    Great review Alan. Here’s my anecdotal practice.

    Why wait until after the XRay to do a FICB? In most EDs that means 2 or 3 painful transfers from bed to bed…..
    I like to use the US to look at the femoral neck at triage, NOFs are barn-door obvious in most cases.
    See the fracture in an old lady with a good story, shortened leg – no XRay – no problem.
    Carry on and do an US guided block before you move them at all. Wait, move them once comfortable
    Why not?
    Maybe the ambos can do this in the home where they fell and save a few more transfers / pain in the future
    Last point – placing an epidural catheter into the FI Compartment can allow a repeat bolus or infusion technique for long time lags ( all of our NOFs go 2000km south, often 12 – 36 hours later.

    Casey

    Reply
    1. Gareth Roberts

      I’d be interested to hear what training you needed to diagnosed NOF on ultrasound and whether it helps you diagnosed patients you didn’t already think had one given a presentation of a shorted externally rotated leg?

      Reply
    2. Rachel Rowlands

      We recently had a teen with a fairly innocent fall- ambulance crew thought dislocated hip. Intranasal diamorphine on arrival. He was in a really tricky position on the trolley so we USS his hip- saw in joint (thought it was unlikely to be out!)
      Then scanned femur and spotted fracture, block using USS as unable to position to check landmarks.
      Taken for X-ray to confirm diagnosis once comfortable post block. Thomas splint applied in department and admitted to ward.
      Satisfied patient and doctors.

      Reply
    3. alig (Post author)

      I agree with everything you say Casey. I tend to put in a block in all in whom I have a better than 50% clinical suspicion (>60, fall onto hip, shortened/externally rotated and NWB) before Xray. I’m assured by the radiographers that they get better pictures that way too. I have no experience in hip US but I don’t reckon it an be that difficult and I’m game to give it a try.

      On the point of monitoring, the anaesthetic association of GB and Ireland are very clear on their standards – you do it!. ECG/SpO2/NIBP and observation are all part of good care and whilst the incidence of complication is low, significant local anaesthetic toxicity with cardiac or cerebral adverse events should be treated as a SUI.
      Guidance is here if you want to read – it’s a well written little booklet and one that we probably all should remind ourselves of from time to time – https://www.aagbi.org/sites/default/files/standardsofmonitoring07.pdf

      VB

      Al

      Reply
    4. Sam Wak

      Good suggestion there Casey. Am particularly interested in the practice of placing the epidural catheter in the FI compartment. Seen it done for post op patients and never occurred to use these in ED. Some of our ED patients with #NOF are on trolleys for 12 hours or more at a time.

      BR

      Sam

      Reply
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