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Procedural COLUMN Column Editor: Jennifer Wilbeck, DNP, RN, FNP-BC, ACNP-BC, ENP-C, FAANP

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Procedural COLUMN Column Editor: Jennifer Wilbeck, DNP, RN, FNP-BC, ACNP-BC, ENP-C, FAANP Advanced Emergency Nursing Journal Vol. 41, No. 2, pp. 135–144 Copyright C 2019 Wolters Kluwer Health, Inc. All rights reserved. Procedural COLUMN Column Editor: Jennifer Wilbeck, DNP, RN, FNP-BC, ACNP-BC, ENP-C, FAANP Utilizing Ultrasound-Guided Femoral Nerve Blocks and Fascia Iliaca Compartment Blocks for Proximal Femur Fractures in the Emergency Department Emily Marie Nagel, RN, BSN, MICN Raymund Gantioque, DNP,RNFA, ACNP-BC Taku Taira, MD, FACEP Abstract Proximal femur fractures (PFF) are one of the many common injuries that present to the emergency department (ED). The current practice for pain management utilizes systemic opioid analgesics. The use of opioids is an excellent analgesic choice, but they carry a significant burden for potential adverse effects. It is vital that providers have a variety of approaches to acute pain control. The use of femoral nerve blocks (FNBs) and fascia iliaca compartment blocks (FICB) are an alternative method of pain control in the ED. They have advantages over systemic opiates in that they do not require hemodynamic monitoring, have less adverse effects, and more importantly they in- duce rapid pain control with longer duration than systemic analgesics (Cross & Warkentine, 2016). This manuscript examines a review of literature and identifies the efficacy, patient safety, indica- tions, contraindications, patient satisfaction, and ultrasound-guided FNB and FICB techniques. Key words: emergency department, fascia iliaca compartment block, femoral nerve block, proximal femur fracture, ultrasound-guided 68-YEAR-OLD WOMAN was trans- Author Affiliations: California State University, Los ported to the emergency department + Angeles (Ms Nagel and Dr Gantioque); LAC USC Med- (ED) via ambulance after a mechani- ical Center, Los Angeles, California (Ms Nagel and A Dr Taira); Torrance Memorial Medical Center, Tor- cal ground-level fall while walking her dog. rance, California (Ms Nagel); Arcadia Methodist Hos- Upon examination, she was found to have a pital, Arcadia, California (Dr Gantioque); and San Gabriel Valley Medical Center, San Gabriel, California shortening of her right lower extremity with (Dr Gantioque). Disclosure: The authors report no conflicts of interest. sity Dr, Los Angeles, CA 90032 (emarie244@yahoo. com). Corresponding Author: Emily Marie Nagel, RN, BSN, MICN, California State University, 5151 State Univer- DOI: 10.1097/TME.0000000000000242 135 Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. 136 Advanced Emergency Nursing Journal external rotation. Circulation, motor func- morbidities, and increased sensitivity to side tion, and sensation were intact with two plus effects of systemic analgesic (Pageau, Perry, dorsalis pedis and posterior tibial pulses. She Ritcey, & Woo, 2016). A phenomenon known denied loss of consciousness, and no other as “oligoanalgesia” is the inability to pro- visible trauma was noted. vide adequate analgesia for acute pain. It is The patient was then seen by the provider, common among trauma patients in the pre- and intravenous access was obtained. The hospital and ED settings (Samet & Slade, patient weighed 80 kg (176 lb), had no major 2018). Adequate pain control is not just hu- comorbidities, and was opiate naive. Because mane but also decreases a patient’s risk of of her history of being opiate naive, mor- delirium and length of hospital stay (Faux, phine 2 mg was administered intravenously Scurrah, Shiner, & Stevens, 2018). Acquiring to address her acute pain. After the adminis- adequate pain control will allow for earlier tration of morphine, she was transported to mobilization and help assist patients back to radiology for complete hip and pelvis radiog- their normal lifestyle (Sanzone, 2016). raphy. To obtain the best optimal views, her The standard of care for managing PFF pain leg was manipulated in ways that exacerbated involves administration of oral, intramuscular, her pain. An additional 2 mg of morphine was or systemic opioids (Holroyd-Leduc, Ospina, administered intravenously without adequate & Riddell, 2015). Although opioids are excel- pain relief. Her radiographs showed an intra- lent analgesics and an acceptable choice, they trochanteric fracture of the right femur. carry an increased risk for potential adverse ef- After the two doses of morphine were ad- fects, including respiratory depression, delir- ministered, the patient was still complaining ium, and vasodilation causing hypotension, of 9/10 pain. On examination, she was alert increased staffing requirement to monitor pa- and oriented, her vital signs were stable, and tients, and increase in the patient’s length of her respiratory drive was at her baseline. stay in the ED (Gadsden & Warlick, 2015). The provider then ordered fentanyl 50 mcg One alternative to systemic opiates is the intravenously for pain control and was ad- peripheral nerve block (PNB), specifically the ministered by the nurse. During the reassess- femoral nerve block (FNB) and fascia iliaca ment 1 hr later, the nurse noticed that the pa- compartment block (FICB), which have been tient was lethargic with shallow respirations. shown to be an effective alternative approach A nonrebreather mask was quickly applied, to acute pain control in the ED. These ap- but because of the concern about her airway, proaches are proven to lower rates of com- she was emergently intubated. In the inten- plications and avoid respiratory depression sive care unit (ICU), she was ruled out for and hypotension that opioids produce, espe- other causes of respiratory failure, including cially among the elderly (Holroyd-Leduc et al., a pulmonary and fat embolus. The next day, 2015). They also provide rapid and longer last- the patient was extubated and the opioids ing pain control and can be used in conjunc- were deemed the cause for her hemodynamic tion with opioids to reduce the total dosage instability. needed (Samet & Slade, 2018). In a recent systematic review, multiple au- thors looked at the literature for the potential INTRODUCTION methods of analgesia for hip fractures. They Hip fractures occur in approximately 341,000 reviewed a total of 83 studies. These studies persons in the United States each year included multiple analgesic options for PFFs (Davenport, 2016). Proximal femur fractures that included nerve blockade, spinal anes- (PFF) are extremely painful injuries that ben- thesia, systemic analgesia, neurostimulation, efit from prompt pain control. Hip fracture traction, and alternative medicine. Within this pain is poorly managed and is often prob- review, PNBs were deemed to be the most lematic because of one’s advanced age, co- effective analgesic option for reducing acute Copyright © 2019 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. r April–June 2019 Vol. 41, No. 2 Ultrasound-Guided Femoral Nerve Blocks 137 pain without the associated problems that FICB as early as possible. These advantages opiates produce (Abou-Setta et al., 2011). include significantly lower pain scores, de- Peripheral nerve blocks can be per- creased opioid requirements, assistance in the formed by physicians and advanced practice reduction of a fracture, and facilitation in pa- providers (APPs) in the ED with the proper tient positioning (Adhikari, Amini, Kartchner, training. Their use has primarily been limited & Nagdev, 2015; Choi, Lin, & Gadsden, 2013). by practitioner comfort, concern about Peripheral nerve blocks also contribute to a technical difficulties, and lack of training. patient’s overall health by reducing pain with Providers with minimal training and expe- movement within 30 min after administra- rience with ultrasound-guided PNBs were tion, decrease the risk of pneumonia, shorten able to successfully perform this procedure theamountoftimethatisneededforfirst- to obtain adequate regional anesthesia (Bhoi, time ambulation, and reduce the cost of the Chandra, & Galwankar, 2010). It has been analgesics (Griffiths, Guay, Kopp, & Parker, demonstrated that with the appropriate train- 2018). ing, APPs without anesthetic background can A study looked at the significance of the successfully perform a PNB (Grigg, Obideyi, feasibility of ultrasound-guided FNB and its Randall, & Srikantharajah, 2008). effectiveness as an alternative for pain man- agement in the ED. Within the study, PNBs required only a single attempt, there were WHAT IS A PERIPHERAL NERVE BLOCK? no complications, and there were signifi- A PNB is a form of regional anesthesia where cant findings (44% and 67%) with a rela- an injection of anesthetic is locally deliv- tive decrease in pain scores at 15 min (p ≤ ered near specific nerves to obtain pain con- 0.002; Beaudoin, Becker, Merchant, & trol by blocking the nerve conduction. Pe- Nagdev, 2010). Providing a PNB is a safe al- ripheral nerve blocks are more commonly ternative that requires a minimal amount of used in the operating room to provide both local anesthetic or prolonged postprocedure intraoperative and postoperative pain con- observation (Bhoi et al., 2010). Patients who trol. However, PNBs are not limited to the received an FNB reported a decrease in their operating room. The ED is utilizing them pain scores when compared with traditional for rib fractures, upper and lower extrem- management with systemic opioids (Lollo, ity trauma/reductions/traction/pinnings, and Grabinsky, & Wu, 2011). evacuation of an abscess. There are many dif- In addition, the use of PNBs has been ferent types of PNBs including FNB and FICB, shown to improve analgesia
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