Page 130 - Ultrasonography in Prehospital and Emergency Medicine - Rein Ketelaars

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Chapter 5
Discussion
We showed that, after having received appropriate training, Dutch EPs are able to safely perform UGRA in ED patients presenting with a proximal femoral fracture and severe pain. After 30 and 60 min, mean pain reduction was respectively 3.84 (50.9%) and 4.77 (64.4%). A pain score of 4 or less was reported by 69 and 83.3%, respectively, of the patients. The EPs thought the procedure was easy to perform, and they were able to obtain a good visualization of the relevant anatomy and LA spread. This means that performing a peripheral nerve block is an effective pain relief strategy provided by the very first physician they encounter upon admittance in the hospital.
To date, there are only few similar reports of EPs performing UGRA in the ED. At 30 and 60 min after the nerve block, we found a meaningful pain reduction, respectively, in 70.7 and 80.0% of the patients. We could confirm the results reported by Groot et al. who reported that on a Dutch ED, EP-performed blind FICBs were safe and effective. In 26 of 34 patients (76%), they found a clinically meaningful pain score reduction after 120 min.19 An explana- tion for the slightly better and faster pain reduction in the present study might be that we have used an ultrasound-guided technique, compared to their blind FICB. Accurate deposi- tion of the LA in relation to the fascia iliaca, or adjacent to or surrounding the femoral nerve will lead to a more effective and faster effect.
Dochez described the effect of blind FICBs performed by EMS nurses in 100 patients with suspected proximal femoral fractures. After 30 min, they reported a successful block in 96% and median pain scores were reduced from 8 to 3, and on arrival at the ED, 75% had a pain score of 4 or less.20 Median pain reduction at t = 30 and pain scores of 4 or less were compa- rable (respectively, 5 and 69.9%).
Gozlan described prehospital EP-performed blind FICBs in 52 patients with femoral frac- tures and reported a success rate of 94% and pain reduction comparable to Dochez and the present study.21 Morrison et al. compared standard analgesics with EP-performed ultra- sound-guided femoral nerve blocks and found a significant difference in favor of the latter. Baseline NRS was 6.4 in both groups and decreased to 5.3 and 3.5, respectively, after two hours. Unfortunately, they did not report within-subject pain score reduction in the nerve block group.15
A study by Beaudoin reported similar results to our study.17 Thirty-six ED patients with proximal femoral fractures were randomized between a femoral nerve block and convention- al analgesia. The median pain score in the nerve block group reduced from a mean NRS of 8