Ultrasound-Guided Fascia Iliaca Compartment Block (FICB)

Hip Fracture

Any of the following present? 1) Neurologic deficit 2) Multisystem Trauma 3) Allergy to local anesthetic Yes *Anticoagulated patients – physician No discretion

Standard Care Procedure Details 1) PO acetaminophen 1) Document distal neurovascular exam in EPIC 2) Consult ortho (do not need to await callback) (1,000mg) 3) Obtain verbal consent from patient 2) Consider 0.1 mg/kg 4) Position Patient and U/S Machine morphine or opioid 5) Order Bupivacaine (dose dependent) equivalent a. Max 2 mg/kg b. i.e. 100 mg safe for 50 kg patient 3) Screening labs, CXR, 6) Standard ASA monitoring (telemetry during procedure with ECG, type and screen continuous pulse oximetry, BP measurement, and IV access) 4) Consult orthopedics 7) Perform FICB and medicine as 8) Inform patients on block characteristics: a. Onset ~ 20 minutes necessary b. Duration ~ 8-12 hours

Equipment Required Counseling Ultrasound Machine 1) Linear/Vascular Probe set to “Nerve” Benefits setting for best results Decreases: Anesthetic: 1) Pain 1) 0.5% Bupivacaine (20-30 cc) 2) 1% Lidocaine (3-5 cc) 2) Delirium 3) Opioids Saline (10 cc) 4) Hypoxia Syringes: 1) 30 cc Risks 2) 3-5 cc Needles: 1) Pain at injection site 1) Blunt fill 2) Temporary nerve palsy 2) 25G 3) 18G LP needle 3) Intravascular injection Chloroprep or Alcohol swab(s) 4) Local Anesthetic Systemic Toxicity * (LAST)

* LAST (local anesthetic systemic toxicity) 1) Rare and only with intravascular injection which an ultrasound guided approach prevents. 2) Signs include arrhythmias, seizures, convulsions 3) Treatment a. Supportive and standard care b. Consider Lipid Emulsion therapy in cardiovascular collapse (found in Pyxis MedStation) (1.5 ml/kg bolus then infusion)

This guideline was ratified by the Emergency Department faculty at Maine Medical Center in December 2014. It reflects our expert opinion and is not necessarily applicable to all institutions. It is intended to be a reference for clinicians caring for patients and is not intended to replace providers’ clinical judgment.

Produced by: Peter Croft, M.D.

Ultrasound-Guided Fascia Iliaca Compartment Block (FICB)

A Quick FICB Video Refresher

References 1) Mouzopoulos, G., Vasiliadis, G., et al. Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study. Journal of Orthopaedics and Traumatology. June 2009 2) Foss, N., Kristensen, B., et al. Fascia Iliaca Compartment Blockade for Acute Pain Control in Hip Fracture Patients. A Randomized, Placebo-Controlled Trial. Anesthesiology 2007 3) Monzon, D., Vazquez, J., et al. Pain treatment in post-traumatic hip fracture in the elderly: regional block vs. systemic non-steroidal analgesics. International Journal of Emergency Medicine. Sept 2010 4) Capdevila, X., Biboulet, P., et al. Comparison of the Three-in-One and Fascia Iliaca Compartment Blocks in Adults: Clinical and Radiographic Analysis. Anesthesia and Analgesia 1998.

Produced by: Peter Croft, M.D.