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Date: November 29th, 2015

Guest Skeptics: Dr. Brandon Ritcey is an Emergency Medicine Resident from the University of Ottawa. Dr. Chris Bond is an Emergency Medicine physician and clinical lecturer at the University of Calgary. His interests include knowledge translation, FOAMed, and all things food and wine related. Chris has a blog called SOCMOB and is the new host of CAEP Cast.

This is another SGEM Hot Off the Press (#SGEMHOP). The goal of the #SGEMHOP is to cut the knowledge translation window down from over ten years to less than one month. This time the paper is from the Canadian Journal of Emergency Medicine (CJEM). We look forward to hearing your feedback via Twitter, Facebook and on the SGEM blog.

Case: A 75-year-old woman has a ground level fall in her apartment. She is brought to the emergency department with an isolated hip injury. She has a past medical history of high blood pressure and gastroesophageal reflex disease. Her only complaint is hip pain. On exam her vital signs are normal. The only abnormality found is a shortened and externally rotated left leg. An x-ray demonstrates a femoral neck fracture. The nurse wants to know what you want to give her for pain.

Background: Oligoanalgesia is a well-recognized problem in the emergency department (Wilson JE and Pendleton JM). It can be defined as inadequate pain control (Motov SM and Khan A). There are various groups at risk for oligoanalgesia and the elderly is one of those groups (Cavalieri TA).

Hip fractures are common in the elderly population. They are often very painful and are a significant cause of morbidity and mortality. Pain management can be challenging in these cases, particularly because of increased complications of opiate medications in this population.

Different types of regional nerve blocks have been tried to address the pain of these fractures.

Dr. Brandon Ritcey

Dr. Brandon Ritcey

  • Traditional Femoral Nerve Block (FNB) – This involves injecting local anaesthetic directly around the femoral nerve and neurovascular bundle in the groin
  • 3-in-1 Femoral Nerve Block – In this technique, you just put pressure distal to the needle while doing a traditional FNB. This allows the anaesthetic to track superiorly and also anaesthetize the obturator and lateral femoral cutaneous nerves.
  • Fascia Iliaca Compartment Block (FICB) – The fascia iliaca block indirectly anaesthetizes the same three nerves as the 3 in 1 block by injecting a large volume of dilute anaesthetic lateral to the nerve in the fascia iliaca compartment.

Clinical Question: Do regional nerve blocks effectively reduce pain, decrease opiate use and are they safe compared to standard pain management in patients with hip or femoral neck fractures?

Reference: Ritcey et al. Regional Nerve Blocks for Hip and Femoral Neck Fractures in the Emergency Department: A Systematic Review. CJEM Nov 2015

  • Population: Adults over 16 years old with femoral neck or hip fracture
  • Intervention: Femoral nerve block (FNB), 3-in-1 FNB or fascia iliaca compartment block (FICB)
  • Comparison: Standard pain management with opiates, acetaminophen or NSAIDs
  • Outcome:
    • Primary: Reduction in visual analogue scale (VAS) pain scores.
    • Secondary: Parenteral opioid use and complication rates.

Authors’ Conclusions: “Regional nerve blocks for hip and femoral neck fractures have a benefit in reducing pain and decreasing the need for IV opiates. The use of these blocks can be recommended for these patients. Further high-quality randomized controlled trials are required”.

Quality Checklist for Therapeutic Systematic Reviews:

  1. checklistThe clinical question is sensible and answerable. Yes
  2. The search for studies was detailed and exhaustive. Yes
  3. The primary studies were of high methodological quality. No
  4. The assessment of studies were reproducible. Yes
  5. The outcomes were clinically relevant. Yes
  6. There was low statistical heterogeneity for the primary outcomes. No
  7. The treatment effect was large enough and precise enough to be clinically significant. Yes

Key Results: Nine articles were included in the systematic review for a total of 547 patients. The data could not be combined into a meta-analysis.

Primary Outcome: Regional nerve blocks were equal or superior in reducing pain scores compared to standard therapy.

  • Secondary Outcomes:
    • Five out of six studies demonstrated significant reduction of parenteral opiate use
    • No life threatening complications
    • Some increase in minor complications

Screen Shot 2015-04-25 at 3.11.12 PMThis was a well-done systematic review looking at an important topic. Listen to the podcast to hear Dr. Ritcey’s respond to our questions about the strengths and weaknesses of the study.

  1. Search: It was a good search strategy of a number of databases, a hand search of references of the articles selected with no language restrictions. Awareness is one of the barriers to knowledge translation according to the Leaky Pipe Model by Pathman. We were pleased to see other languages besides English were considered. It is one of the reasons the SGEM has gone Global and being translated and podcasted in five other languages (Spanish, Portuguese, French, German and Italian).
  2. Inter Observer Reliability: There were two people independently screening the titles and abstracts for full-text review. The inter-observer reliability was assessed for the screening phase and had a kappa of 0.61 (moderate). The kappa increased to 0.79 (substantial) for the decision on what articles to include for full-text review. For more information on kappa and inter-rater reliability you can read these articles by McHugh ML , McGinn et al, and McGinn et al.
  3. Risk of Bias: The Cochrane Collaboration tool for assessing risk of bias in the randomized trials was used. Only one of the nine studies had an overall low risk of bias (Beaudoin et al). The other eight had moderate to high risk of bias. Most of the bias came from lack of double blinding in six out of the nine studies. Four studies included patients who were later unaccounted for in the final results. There was also significant variability in reporting of secondary outcomes. In particular, this included the under reporting of harms.
  4. Small Studies: These were fairly small studies with most being around 50 patients. The largest study only had 154 patients and the combined total of all nine studies was 547. We have some questions about these individual studies:
    • What was the most common form of blocks done?
    • What did they use for the anaesthetic and how much did they inject?
    • Who did the injections?
    • Were they trained to do the injections?
    • Did they use ultrasound to perform the blocks?
  5.  Meta-analysis: This was a systematic review only. A meta-analysis was not performed due to the variability and heterogeneity of the studies.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions.

SGEM Bottom Line: While the evidence comes from small studies with a moderate to high risk of bias, femoral nerve blocks appear to be an effective alternative to standard treatment of pain associated with femoral neck or hip fracture in the emergency department. More high-quality studies are needed to comment strongly about safety.

Case Resolution: You tell the nurse to start an intravenous line and you are going to talk to the patient about her pain control options. These will include intravenous opiates and/or a regional nerve block.

Clinically Application: I am going to offer regional nerve blocks to patients who present with hip or femoral neck fractures.

Dr. Chris Bond

What Do I Tell My Patient? You have broken your hip. This is a very painful injury. We can give you pain medicine like morphine. These  drugs work very well for pain but can make you sick to your stomach, hallucinate and drop your blood pressure. Another option is to inject some “freezing” in the hip that blocks the nerve. This usually works very well with few complications. It often means you do not need as much pain medication. Would you like me to do this type of nerve block?

Additional FOAMed Resource:

  • ALiEM Hip Fractures in Older Adults: An Important Source of Morbidity

Keener Kontest: Last weeks’ winner Stas Haciski from George Washington University.

Listen to the podcast for the question this week. Send your answer to TheSGEM@gmail.com and the first correct answer will receive a cool skeptical prize.

SGEM Hot Off the Press: Make sure you give us your feedback via the SGEM blog, Twitter or Facebook. We want to hear what SGEMers think about the paper. You can even ask the lead author questions for a deeper understanding of the research.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.