Regional analgesia versus systemic analgesia for femoral fractures in the ED

1. Regional analgesia versus systemic analgesia for femoral fractures in the ED Leonieke Groot, junior resident 4th Dutch North Sea Emergency Medicine Conference

2. Introduction: • Femoral fracture: high incidence 1:1000 (WFG 200/jr) • Traditional treatment: systemic opioids • Large potential for side effects: nausea, dizziness, urine retention, hypotension, respiratory depression, decreased mental state, delerium • Untreated or undertreated pain can increase delerium as well Marcantonio et al. Reducing delerium after hip fracture: a RCT. J Am Geriatr Soc 49:516-522, 2001 Morrison et al. Relationship between pain and opioid analgetics on the development of delerium following hip fracture. J Gerontol Med Sci 2003, Vol 58, No1, 76-81

3. PICO: • P = patiënts with femoral fracture in the ED • I = regional block (fascia iliaca compartment block) performed by Emergency Physicians or junior residents • C = systemic (traditional) analgesia with opioids • O = adequate analgesia and adverse effects/events

4. Fascia Iliaca Compartment Block: • Fast and consistent blockade • Simple and easy to learn and use • Distant from nerves and blood vessels • Without ultrasound guidance or nerve stimulator Capdevila et al. Comparison of the tree-in-one and fascia iliaca compartment blocks in adults: clinical and radiological analysis. Anesth Analg 1998;86:1039-44. Dalens et al. Comparison of the fascia iliaca block with the 3-in-1 block in children. Anesth Analg 1989; 69:705-13.

6. Search strategie: • PubMed search: Femoral Fractures"[Mesh] AND ("Nerve Block"[Mesh] OR "fascia iliaca compartment block"[All Fields]) AND ("Pain"[Mesh] OR "Analgesics, Opioid"[Mesh] OR "Morbidity"[Mesh] OR "complications "[Subheading] OR "adverse effects "[Subheading]) AND "humans"[MeSH Terms] AND English[lang] 52 articles; eight relevant; three best and most relevant articles. Related articles: two relevant additional articles

7. Search strategy: • Cochrane Library: one review which could not specifically answer our question • EMBASE: no additional articles found • BestBET’s: two relevant BET’s, did not specifically look at Emergency Physicians or junior residents performing this block

9. Conclusion: • For the acute management of pain in patients with femoral fractures, FICB is rapidly effective and easily learned and performed by (junior) Emergency Department staff without reported adverse effects. • FICB has the potential to reduce the reliance to opioids and their side effects, esspecially in a fragile group of patients. • Level of recommendation: B.

10. Comments: • Most of the studies were relatively small and not fully blinded

11. Clinical bottom line: • In patients with femoral fracture, FICB can be safely performed by Emergency Physicians and junior residents in the ED • FICB provides better pain relief and gives less adverse events than systemic opioids.

12. Literature: • Capdevila X, Biboulet Ph, Bouregba M, et al. Comparison of the tree-in-one and fascia iliaca compartment blocks in adults: clinical and radiological analysis. Anesth Analg 1998;86:1039-44 • Chesters A, Elkhodair S, Mortazavi, et al. Fascia iliaca compartment block in the emergency department. Emerg Med J 2009;26(Suppl I):A1-A12. • Dalens B, Vanneuville G, Tanguy A. Comparison of the fascia iliaca block with the 3-in-1 block in children. Anesth Analg 1989; 69:705-13. • Elkhodair S. Fascia iliaca compartiment block for control of hip/femur fracture pain in adult patients. BestBETs last modified 14th november 2008. • Foss NB, Kristensen BB, Bundgaard M, et al. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anaesthesiology 2007; 106:773-8. • Haddad FS, Williams RL. Femoral nerve block in extracapsular femoral neck fractures. J Bone Joint Surg Br 1995;77(6):922-3. • Hauritz RW, Gerlif C, Ronholm E. Fascia iliaca block performed by emergency department physician trainees in hip fractures. Ugeskr Laeger 2009 Feb 9;171(7):515-8.

13. Literatuur (2) • Hogh A, Dremstrup L, Skov Jensen S, Lindholt J. Fascia iliaca compartment block performed by junior registrars as a supplement for pre-operative analgesia for patients with hip fracture. Strat Traum Limb Recon (2008) 3:65-70. • Marcantonio ER, Flacker JMF, Wright RS, et al. Reducing delerium after hip fracture: a randomised clinical trial. J Am Geriatr Soc 49:516-522, 2001. • Martin B. Regional nerve block in fractured neck of femur. BestBETs. • Monzon DG, Iserson KV, Vazquez JA. Single Fascia iliaca compartment block for post-hip fracture pain relief. The J of Emergency Medicine, Vol 32, No 3, pp:257-262, 2007. • Morrison RS, Magaziner J, Gilbert M, et al. Relationship between pain and opioid analgetics on the development of delerium following hip fracture. J Gerontol Med Sci 2003, Vol 58, No1, 76-81. • Wathen JE, Gao D, Merritt G, Georgopoulos G, Battan FK. A randomized controlled trial comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department. Annals if Emergency Medicine, Volume 50, no.2:August 2007. • Yun MJ, Kim MK, Han MK. Anagesia before a spinal block for femoral neck fracture: fascia iliaca compartiment block. Acta Anaesthesiol Scand 2009; 53:1282-1287.

14. Thank you for listening Are there any questions?