Pain management is an integral part of providing care in the emergency setting. Lower extremity pain from hip fractures, burns, and other trauma is a common presenting complaint. Unfortunately, pain management can be difficult due to medication side effects, patient preferences, and other patient characteristics that can make intravenous analgesia less desirable. Opioid medications can be associated with respiratory depression, hypotension, mental status changes, and vomiting. NSAIDs can increase bleeding risk and exacerbate underlying gastrointestinal (GI) problems. Acetaminophen alone is often not sufficient for severe pain. Hip fractures, in particular, can cause considerable pain, and often occur in elderly adults with multiple comorbidities which make analgesia challenging.
A fascia iliaca compartment block can provide superior analgesia with minimal side effects. It can be deployed in a relatively quick fashion after a small amount of training and can be executed with high success rates under ultrasound guidance. In a study by Monzon et al., patients who received a fascia iliaca compartment block for a hip fracture had significantly reduced pain levels. The pain was initially rated at an average of 8.5 on a 10 point scale but decreased to an average of 2.3 at 2 hours post-injection. In a study by Stevens et al., in Anesthesia Intensive Care, patients who underwent a fascia iliaca compartment block used significantly less morphine over the course of 24 hours than the control group which used morphine alone. An additional advantage is the duration of effect, which has been seen for 8 to 10 hours following a single shot block. Another randomized placebo-controlled trial showed that pain relief was superior at all time points measured in the fascia iliac compartment block group as compared with a group utilizing morphine only. In fact, median total morphine consumption in the compartment block group was 0 mg due to excellent analgesia after only a compartment block. Similar results were seen in a study by Lopez et al. for femoral shaft fractures. Emergency department-specific studies using ultrasound guidance have shown 76% mean reduction of pain score in patients with hip fracture at 120 minutes.
Sensory innervation to the lower extremity is handled through the sciatic nerve, femoral nerve, obturator nerve, and lateral femoral cutaneous nerve. These originate from the lumbar plexus, except for the sciatic nerve, which receives some contribution from the sacral plexus.
The femoral nerve is the largest of the four nerves and is commonly identified on ultrasound by emergency physicians when placing central venous access into the femoral vein. It is situated just lateral to the femoral artery on top of the iliac is muscle. The fascia iliaca separates the femoral nerve from the femoral artery.
The fascia iliaca is the second fascial plane encountered when viewing the proximal lower extremity under ultrasound. It runs below the fascia lata. In blind approaches, a characteristic "2 pops" are felt which indicates entrance into the compartment. The fascia iliaca runs anterior to the iliac this muscle, psoas muscle, and pectineus muscle. The sartorius muscle, as well as the femoral vessels, is located between the fascia lata and the fascia iliac. The fascia iliac compartment block has the potential to create a sensory block of the femoral, obturator, genitofemoral, and lateral femoral cutaneous nerves.
This compartment block can be considered with any painful trauma or procedures in the lower extremity within the nervous distribution noted above. It is especially helpful in cases where opioid analgesics are not ideal or contraindicated. It can also be used in conjunction with opioids for difficult to control pain. Specific indications which have been studied include hip fractures, femoral shaft fractures, and burns.
Past literature has supported the effectiveness of regional anesthesia by both anesthesiologists as well as emergency physicians. More recent studies have shown that resident physicians can reliably perform a fascia iliaca compartment block after minimal amounts of training. A study published in the Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine has shown that prehospital EMS nurses can also demonstrate competency in a fascia iliaca compartment blocks using a blind technique.
Preparation is necessary for achieving a successful and safe compartment block. As with any other procedure, the risks and benefits of the proposed procedure should be explained to the patient in terms they can easily understand. Time should be taken to answer any questions they may have. Written consent should be obtained at that time. If deemed appropriate, a small dose of an anxiolytic may assist in relieving any pre-procedure anxiety and facilitate proper positioning and cooperation. A detailed neurovascular exam of the lower extremity should be obtained before the start of the procedure. The site of the planned compartment block should be marked with a surgical marking pen and initialed by the provider intending to complete the procedure. The equipment and supplies necessary for completing the procedure should be collected and set up in the room (see above).
The authors have utilized the following techniques and found them to be effective. The authors recognize that there are many successful strategies which have been employed to perform this block and alternative techniques may be equally appropriate.
Overall complication rates are low. In an emergency department study of 63 adult patients who underwent single fascia iliac compartment block by resident physicians after 5 minutes of instruction, there were no systemic complications found and only two local hematomas. Even when the procedure was performed blindly by EMS nurses in the prehospital setting, there were no complications noted in a study enrolling 100 patients. The distance at which the skin is punctured from the neurovascular bundle minimizes the risk of intravascular injection or nerve transection. Intravascular injection or nerve damage is exceedingly rare.
The fascia iliaca compartment block is ideally suited for the emergency department setting in that it can be utilized quickly and effectively. It has the potential to provide lasting pain relief with minimal side effects. Ultrasound guidance can improve the accuracy of anesthetic injection and increase procedural safety. The skills of ultrasound guidance for needle placement are already utilized by emergency physicians and can easily be applied to this important but often underutilized setting.
Fascia lata compartment blocks are often performed by an anesthesiologist, emergency department physicians, neurologists, orthopedic surgeons, and pain specialist. However, anyone who performs this block must have a dedicated nurse for monitoring the patient throughout the procedure. While complications are rare, resuscitative equipment must be in the room before starting the procedure. The fascia lata block is effective and produces reliable analgesia. (Level V)
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