Page 121 - Ultrasonography in Prehospital and Emergency Medicine - Rein Ketelaars

Emergency physician-performed ultrasound-guided nerve blocks in proximal femoral fractures 119
Introduction
The treatment of acute pain in emergency department (ED) patients is not always optimal.1,2 Fortunately, in patients with proximal femoral fractures, peripheral nerve blocks are used increasingly to obtain adequate pain relief.3–6 In addition to providing pain relief, it may decrease the administration of systemic analgesics such as opioids and decrease their side-ef- fects.7,8 Also, undertreated pain and inadequate analgesia have the potential to cause delir- ium in patients with proximal femoral fractures.9 Fascia iliaca compartment blocks (FICB) have been performed in hip surgery patients and have shown the potential to reduce the incidence of perioperative delirium in these patients.10
Nerve blocks in femoral neck fracture patients can be achieved using different techniques. The FICB is a “blind” technique in which surface anatomy landmarks are used to determine the needle insertion point, and tactile feedback guides the correct needle position. Tech- niques based on surface landmarks have a higher incidence of paresthesia during perfor- mance of the block.11 Furthermore, they produce blocks with a slower onset, lower quality, and shorter duration compared to an ultrasound-guided technique.4,11,12 A nerve stimula- tor-guided femoral nerve block makes use of electrical nerve stimulation to locate the fem- oral nerve. If a minimal electrical current still elicits quadriceps muscle contractions, the optimal needle tip position is obtained. Especially in proximal femoral fracture patients, these contractions may be painful and are therefore undesirable.4
Ultrasound-guided nerve blocks may overcome the aforementioned drawbacks. Ultrasonog- raphy allows identification of relevant anatomical structures and continuous needle tip visu- alization, and even the spread of local anesthetic (LA) may be observed. Ultrasonography in regional anesthesia has increased the success rate and reduced the complications of periph- eral nerve blocks.13
Traditionally, only anesthesiologists performed ultrasound-guided regional anesthesia (UGRA). In recent years, though, emergency physicians (EPs) have been adopting this tech- nique.14–16 However, in the Netherlands, a lack of evidence exists on EP-performed UGRA in proximal femoral fracture patients.
An ultrasound-guided femoral nerve block and FICB appears to provide quick, safe, and effective acute pain relief and could therefore be a valuable tool adding to current pain man- agement regimes in Dutch EDs.7,17 However, EPs should gain relevant knowledge on basic ultrasonography, local anesthetics, nerve block indications, relevant anatomy, block tech- niques, and complications. Relevant skills to acquire are ultrasound scanning techniques,
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