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Three Part Question

Is [ultrasound guided Fascia Iliaca Block] an [effective method of pain relief] in patients with [femoral neck and shaft fratures], in the hands of ED physicians.

Clinical Scenario

A 69yrs female comes after a fall with right hip pain; x rays confirm the diagnosis of fracture neck of femur (NOF). She is very hard to cannulate and you have read an article about anaesthetists putting ultrasound guided fascia iliaca block for NOF fractures. We want to know how good it is in the hands of ED physicians.

Search Strategy

The following database/ search engines were queried:

1. MEDLINE since 1951.
2. CINAHL
3. EMBASE
4. Google Scholar.
5. Cochrane
6. Trip Data

1. MEDLINE; exp FACSIA/

2. MEDLINE; (iliaca AND block).ti,ab
3. MEDLINE; FICB.ti,ab
4. MEDLINE; (fascia AND iliaca).ti,ab
5. MEDLINE; (neural AND block).ti,ab
6. MEDLINE; exp HIP FRACTURES/

7. MEDLINE; exp FEMUR NECK/
8. MEDLINE; exp FEMORAL NECK FRACTURES/
9. MEDLINE; exp FEMORAL FRACTURES/

10. MEDLINE; 6 OR 7 OR 8 OR 9
11. MEDLINE; 1 OR 2 OR 3 OR 4 OR 5
12. MEDLINE; exp ULTRASONOGRAPHY/
13. MEDLINE; ultrasound.ti,ab
14. MEDLINE; (ultrasound ADJ guided).ti,ab

15. MEDLINE; (guided ADJ ultrasound).ti,ab

16. MEDLINE; (guided ADJ ultrasonography).ti,ab

17. MEDLINE; (ultrasonography ADJ guided).ti,ab

18. MEDLINE; 12 OR 13 OR 14 OR 15 OR 16 OR 17

19. MEDLINE; 10 AND 11 AND 13
20. MEDLINE; (ultrasonography OR ultrasound).ti,ab

21. MEDLINE; 10 AND 11 AND 20

Search Outcome

We had 136 studies, out of them 4 were done in ED.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hogh 2008 Denmark	70 patients with fractured hip in ED, 2/3 female, mean age of 80.7.	Prospective observational, Comparison of FIB efficacy performed by junior ED registrars.	Comparison of FIB efficacy performed by junior ED registrars.	The median simple verbal pain Score (0–4) pre-block was 2.2 and this improved to a median of 1.5,15 min post-block (P\0.001) and to1.3, 60 min post-block (P = 0.021). The median pain-free hip flexion pre-block was 15 degrees and this improved to a median of 28 degrees,15 min post-block (P = 0.014) and 37 degrees 60 min post-block (P = 0.030).	Small sample FIB performed on 187 patients but analysed only 70 patients due to loss of data. No blinding No set criteria for competence for junior registrars.
L Haines 2012 USA	20 patients with confirmed Hip fracture on X-ray were enrolled with the mean age of 82 years, 11M and 9F. Patient with cognitive impairment and pain score of less than 5 on VAS scale on arrival to ED were excluded	Prospective observational study.	Mean VAS score reduction with ultrasound guided FIB over 8 hrs post block.	The lowest mean pain score of 1.3/10 was achieved at 120 mins. All of the decrease in pain scores was statistically significant, with P-values of 0.029 (time 0 vs. time 10 min); 0.0001 (time 0 vs. time 20 min); 0.0001 (time 0 vs. time 30 min); 0.001 (time 0 vs. time 60 min); 0.0001 (time 0 vs. time 120 min); 0.0001 (time 0 vs. time 240 min); and 0.017 (time 0 vs. time 480 min), respectively.	Convenient sample. Small sample size. Extensive exclusion criterion. Data collected by interventionists causing Bias. Patients with FIB had morphine awaiting x-rays, introducing confounder. No comparison group
Elkhodair 2011 UK	137 patients were enrolled in our study (61 women and 76 men), with mean age: 77.2 years) which was carried out at two ED’s	Prospective cohort study.	Primary outcome was a change in the pain score; a difference of more than 3 from the patient’s baseline score was considered to be clinically significant. Secondary outcomes included adverse events, nerve Block complications.	A mean reduction of 3.29 points on the VAS from the baseline was documented at 30 min in 129 cases, P<0.0001). A further reduction of 1.94 points in the VAS was noted at 60 min in 106 cases, P<0.0001)	small sample Operator assessing the VAS scoring thus introducing bias. Post block analgesia required is not mentioned. 31 missing data at 60 minutes in 137 patients.
H Shahzad 2013 UK	19 patients were included in the study, mean age was 58.5yrs, 13 female and 6 male.	Prospective, observational study	Primary outcome was significant pain relief and patient satisfaction	Pain score improved from >7 (VAS) to 5.5, 4.5 and 3 at 15mins, 30mins and 45mins. Patient satisfaction was achieved to 4.5 on a scale of 1-5.	Single center, small sample, unclear who is doing the assessment for pain relief and satisfaction

Comment(s)

The studies have small sample sizes but have been done by the ED physicians. The results are clinically and statistically significant.

Editor Comment

BF

Clinical Bottom Line

UFIB in the hands of ED physicians is safe and effective method of giving analgesia in patients with neck and shaft of femur fractures.

References

1. Hogh FICB performed by junior registrars as supplement to pre-operative analgesia for patients wit hip fracture. Strat Trauma Limb Recon 2008; Stratigies Trauma Limb Reconstruction 2:65–70.
2. L Haines ultrasound guided fascia iliaca compartment block for hip fractures in the emergency department J Emerg Medicine
3. Elkhodair Single fascia iliaca compartment block for pain relief in patients with fractured neck of femur in the emergency department
4. H Shahzad FIB the fractured femur