Page 123 - Ultrasonography in Prehospital and Emergency Medicine - Rein Ketelaars
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                 Emergency physician-performed ultrasound-guided nerve blocks in proximal femoral fractures 121
A prospective observational study in ED patients with proximal femoral fractures was con- ducted from June 2014 until June 2017. The aim of the study was to evaluate the effectiveness, safety, and satisfaction of EP-performed ultrasound-guided nerve blocks in the emergency department. The study was deemed exempt from formal review by the regional ethics review board of Arnhem and Nijmegen, and approval was obtained from the institutional review board of the Radboud university medical center. Before the nerve blocks was performed, oral informed consent was asked and obtained as part of the standard operating procedure.
Recruitment and setting
Adult patients admitted to the Radboud university medical center ED with a proximal femo- ral fracture, including trochanteric and femoral neck fractures, in whom an ultrasound-guid- ed femoral nerve block or FICB was planned in the ED were included. Exclusion criteria were any sign of infection at the injection site, hemorrhagic diathesis (e.g., hemophilia and use of anticoagulant drugs with international normalized ratio (INR) > 2.0), an allergy to ropiva- caine, and multiple traumata.
A 1-day course and an e-learning module were developed by a collaboration of anesthesi- ologists with extensive experience in UGRA and EPs experienced in general ultrasound. Every EP and EP in training participated in this hands-on course focusing on UGRA of the femoral nerve and FICB. The online pre-course e-learning module and course lectures dealt with basic theory of ultrasound, pharmacology of local anesthetics, indications, rel- evant anatomy, block techniques, complications and their treatment, and follow-up. Live anatomy and practical block techniques were taught on human cadavers at the Radboud Anatomy Department. Scanning techniques and sonoanatomy were taught and practiced on the participants themselves. Ultrasound-guided needle handling was practiced on blocks of tofu with tiny artifacts inserted.
The UGRA-trained EPs were supervised by skilled (resident) anesthesiologists for five, or more if desired, ultrasound-guided femoral nerve blocks or FICBs until the EPs had gained the knowledge, expertise (as judged by the anesthesiologist), and confidence to perform the procedure independently. A dedicated pool of anesthesiologists and residents with exten- sive experience in UGRA provided immediate and direct supervision on weekdays during regular business hours. Outside of these hours, supervision was provided depending on the

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