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SGEM#138: Hip to be Blocked – Regional Nerve Blocks for Hip and Femoral Neck Fractures

SGEM#138: Hip to be Blocked – Regional Nerve Blocks for Hip and Femoral Neck Fractures

Podcast Link: SGEM138
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.


Dr. Chris Bond

Dr. Chris Bond

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.

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.


 

  • http://emed.wustl.edu/carpenter_christopher/Projects.aspx ACEP Geriatric Sect

    Emergency Orthogeriatrics is a fairly new concept with a rapidly expanding body of research (see http://pmid.us/20971398, which includes an illustration of the traditional femoral nerve block). Regional nerve blocks in the setting of frail elderly hip fracture patients provide one alternative to the usual opioid analgesia, which can be particularly helpful in the near-hypotensive individual following a fall while diagnostic evaluation is underway for other injuries/hemorrhage. One small study actually demonstrated feasibility in pre-hospital settings: http://pmid.us/25661312, but regional anesthesia is not commonly used in the contemporary ED (UK study http://pmid.us/23878064, Canadian survey underway http://pmid.us/23440013).

    Two questions for the authors.

    1) Ken (Dr. SGEM) Milne mentions Pathman’s Pipeline and the first barrier of “awareness”. The next 4 physician-level barriers in this pipeline are acceptance, applicability, ability to replicate, and remembering to act upon when confronted with the appropriate situation. One of the most challenging obstacles for ultrasound-guided procedures is the ability of heterogeneous physicians to replicate the technical skills necessary to master sonographic imaging & interpretation. What is the learning curve for ultrasound-guided regional nerve blocks of the hip? Is one method easier to learn than another — and can these skills be self-taught? If not, how is a physician without easy access to ultrasound mentorship supposed to learn this technique (is there a FOAMed website)?

    2) How does Jacques Lee’s multi-center RCT that is underway differ from this UK study: http://pmid.us/24885267 ?

    Thanks for this #GeriED themed first-edition of CJEM SGEM-HOP. Looking forward to much more from Ken & Chris Bond!

    Chris Carpenter

    • Matt and Mike

      Hey Chris,

      Great questions. I’ll mainly respond to the “how to learn” question. There are multiple ways to learn how to perform a femoral nerve block. There are courses, online ultrasound academies, and in person methods. I won’t mention the ones we run because of the conflict of interest, but you can simply google them and find plenty.

      You specifically ask about FOAMED sites, so I’ll point you to a few:

      1. Introduction to Bedside Ultrasound Volume 1 and Volume 2 are both free and include a chapter on this with embedded video and audio. download HERE – https://itunes.apple.com/us/book/introduction-to-bedside-ultrasound/id554196012?mt=13

      2. We did a podcast on this specifically you can find at the Ultrasound Podcast.

      • Matt and Mike

        oops. Hit “reply” too soon.

        One of my favorite sites for anything nerve block is the NYSORA site. A youtube video they made is found here:

        Their website is simply NYSORA.com.

        And the podcast I mentioned in the last post is at:

        http://www.ultrasoundpodcast.com/2012/03/episode-24-femoral-nerve/

        This is definitely a block that I’ve seen numerous physicians learn and master even if they didn’t learn it until they’re out in practice.

        Totally possible!

        Matt

    • Brandon Ritcey

      Hey Chris, great questions. Let me take a “stab” at them!

      1) I think out of the physician barriers the ability to replicate is an important issue, as people need to be properly trained to safely perform these blocks. You’re injecting a large volume of an extremely cardiotoxic medication such as bupivicaine within a few cm of the femoral artery, and that’s not to be taken lightly. I would rank the difficulty and technical skills needed to do one of these blocks is comparable to doing an ultrasound guided central line, something that more of us are familiar with. If you have a baseline comfort with ultrasound and needle guidance from central lines, this is just a small step up.

      Out of the 3-in-1 FNB and the fascia iliaca compartment block, the FICB is probably the easiest to learn because it’s purely landmark based and relies on “feel” as you pop through the fascia iliaca, and you’re not injecting close to the artery so there’s a wider margin of safety. However I argue that if you’re using ultrasound, the difference between these is really academic. If you can watch the needle pierce the fascia iliaca in real-time, why not just place that needle as close to the femoral nerve as you can get to minimize the amount of local anesthetic you need to put there?

      I think the learning curve to do these isn’t that bad, but I agree I’d be much more comfortable having someone take me through it for the first time. For example, you could wait until you have someone with a more specific indication for the block such as a patellar dislocation, a complex anterior thigh laceration, or someone who needs to be put into skeletal traction and do your first block with lidocaine, since it’s far safer than bupivicaine (but only lasts an hour or so). Also, there are many courses out there that teach this, but like Matt and Mike, I teach at one of them so I have a conflict of interest so I won’t name any.

      But really, if you have moderate ultrasound skills, you can do this. Just familiarize yourself with the anatomy beforehand and use FOAMed sources to learn how. Here’s some links:

      http://www.ultrasoundpodcast.com/2012/03/episode-24-femoral-nerve/

      2) I think the bigger issue with getting docs to perform these blocks is “acceptance,” because it’s hard to convince people that spending 20 minutes performing these blocks is worth their time. In fact, at my hospital you barely even have to see patients with hip fractures except just to do a brief neurovascular exam and call ortho, as every patient with a clinically suspected hip fracture automatically gets an x-ray and started on IV morphine before you even see them. So how do you convince docs that something that usually takes 5 minutes should take them 20 minutes instead?

      I think we care about reducing our patient’s pain, but the big-ticket to get people on board with doing these would be if there is a reduction in delirium. Unfortunately we couldn’t show this with our systematic review, but Jacques Lee’s study is specifically going to be looking at this in a large, six hospital RCT done over 4 years. The big differences with this British study you posted will be that it will be ED focused, only use single-shot nerve blocks (as opposed to continuous infusion blocks, which I don’t think any of us are going to be using), and is going to look very closely at delirium as the primary outcome.

    • http://emergdoc.com Greg Hall

      Hi Chris, Matt, Mike, Brandon, and Ken!
      Great article!

      As a completely biased enthusiast for femoral blocks I will offer some minor opinions on the topic. Yes, I too am part of a course that teaches regional blocks to ED docs in Canada and will avoid branding.

      Getting the teaching is still a problem for busy practicing physicians but not insurmountable. Lots of courses available, lots of online tutorials. Additional supervision required is going to depend on baseline POCUS skills. I bet many of us tried new blocks without any hand-holding because we were comfortable with all the component skills.

      Agree that the categorization of fem blocks is largely academic with ultrasound. Choose how close you want to get to the nerve once below the fascia iliaca and call it what you will. ( I think a moderate volume works best even if pretty close to the nerve.)
      I also agree it is not a technically challenging block to perform on the right patient. Some have difficult anatomy that might favour hydrodissection and a more lateral approach. Go low concentration and higher volume. Don’t hesitate to use some saline initially to help, etc. i.e. There are ways to mitigate the risk somewhat.

      We have moved to using ropivacaine for its lower cardiotoxicity (after realizing purchasing could get it for the same price as bupivacaine.)

      Part of uptake of these skills is stepwise and builds on other POCUS skills. The physician who is comfortable with image generation for other applications is more likely to perform this block than the complete neophyte. The physician who is comfortable with other needle guided procedures is even more likely to take on this task.

      There are enough hip fractures coming through the ED to provide ample opportunity for developing this skill once there is a critical mass of mentors.

      I believe that as the newer generation of ED practitioners graduate with core skills the barrier to adding another tool to the POCUS toolkit will be far less problematic, including blocks. Some of our most recent EM grads took to it like ducks to water as they have great probe skills already. (And probably play too many video games.)

      The other major barrier already mentioned is the time commitment. I would argue this is more a product of a system not developed to support ultrasound guided needle procedures than the application itself.

      How many lacerations would you have time to repair if the nurses were unfamiliar with the equipment required, usual positioning of patient and materials, and you had to fetch the tools from all corners of the department?

      Proper staff education on what is done and how it is done will help so they can anticipate your needs. Creating carts and trays with all requisite materials helps a lot too. (We put together a mini-tutorial on this topic on our website.) We now have PA’s trained in core POCUS skills and they are great at setting everything up so that I can come in the room and do the block in 5 minutes. One even likes to scout out the anatomy to give me a heads up on any potential challenges. Some of our nurses are now reaching a useful level of assistance.

      I think these barriers can be overcome with time and this is coming from someone who works in a very busy community hospital with single night coverage.

  • Don Melady

    Great article on an important topic — which everyone is talking about these days! I’m a co-investigator on Jacques Lee’s EDU-RAPID study — which has a number of interesting components. It looks at not only the feasibility and best methods of teaching EPs to perform the procedure; but also uses as one of its primary outcomes the incidence of in-hospital delirium and length of stay, two important patient-oriented outcome measures. As a “late adopter” of this procedure (despite knowing and agreeing with all the pro arguments) I really appreciate the plethora of resources listed in this thread.

  • Eddy Lang

    Nice discussion and great way to contextualize the review. A few thoughts come to mind. There was another review on femopral blocks by Riddell et al published in CJEM which took a bit of a different tack and reached similar but distinct conclusions. I think this would have been worth noting. I also think we need to be cautious about claims related to shortening the KT pipeline. Firstly not all K is ready for T and true KT signifies implementation and not just awareness. Kudos to Chirs and Ken overall though for bringing more attention to CJEM publications and to the SGEM HOP.

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  • TheSGem

    #SGEMHOP make the Life in the Fast Lane best of #FOAMed list! http://lifeinthefastlane.com/litfl-review-209/

  • Kirsty Challen

    Thanks for the discussion – has altered my attitude to blocks. Summarised in a pic.

    • TheSGem

      Thanks again Kirsty for summarizing another #SGEMHOP

  • Brandon Ritcey

    That’s a really interesting way to try to visually represent the results from our review! It was very difficult to create a good summary of the results of these very heterogeneous studies. The one important caveat that’s missing from this kind of diagram is a risk of bias assessment, since many of these studies were not high quality and that’s important to consider when weighing the results of these studies against each other! That’s why there’s no substitute for reading the original study.

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