NYCHHC Jacobi Medical Center

Regional Anesthesia in the Emergency Department

Purpose:
To improve pain control and standardize the treatment of trauma patients with fractures, this
protocol will place a heavy emphasis on hip fractures but can be applied to other fractures as
well.
Goals:
Primary goal is patient satisfaction, let’s make sure we provide the best care possible and ensure
these patients with fractures are not suffering in pain.
Adding regional anesthesia to traditional parenteral anesthesia in order to reduce usage of opioid
pain medications and thereby reduce delirium and hypotension, as well as other known
complications of these drugs in the elderly.
Educate providers and institute a clear protocol for regional nerve blocks performed in the
Emergency Department.
Educate providers and institute a protocol for fascia iliaca regional nerve blocks.
Background:
The American Academy of Orthopedic Surgeons gives a strong evidence-based recommendation
for usage of preoperative regional anesthesia for management of pain in hip fracture patients.
There have been multiple randomized control trials universally citing decrease in patient-rated
pain on a visual analog scale after regional nerve blocks. These blocks have also been shown to
decrease post-operative delirium in elderly patients. No significant complications were reported
in these studies, though clinical judgement should be used to identify patients at high risk for
complications. The fascia iliaca block is a commonly accepted option for pain control in hip
fractures, and is potentially safer and more effective than the femoral nerve block given distance
from vascular structures and blockage of the lateral femoral cutaneous nerve. While there hasn’t
been a lot of research with ultrasound guided blocks for hip fractures, this protocol would allow
for the opportunity to further
Literature Review:
Citation: Beaudoin FL, Nagdev A, Merchant RC, Becker BM. Ultrasound-guided femoral nerve
blocks in elderly patients with hip fractures. Am J Emerg Med. 2010 Jan;28(1):76-81.
Type of Study: Prospective observational study (n=13)
Objective: Determine the effectiveness of ultrasound guided femoral nerve block as an adjunct
for pain control in the emergency department.
Results: Decrease in pain scores of 44% and 67% at 15 minutes (p<0.002) and 30 minutes
(p<0.001) post procedure respectively.
Conclusion: Ultrasound guided femoral nerve blocks result in significant and sustained
decreases in pain scores in elderly patients with a hip fracture.

Citation: Haines L, Dickman E, Ayvazyan S, Pearl M, Wu S, Rosenblum D, Likourezos

A. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency
department. J Emerg Med. 2012 Oct;43(4):692-7.
Type of Study: Prospective observational study (n=20)
Objective: Does ultrasound-guided fascia iliaca compartment block provide an adjunct or
alterative to intravenous morphine in emergency department patients with a hip fracture.
Results: All patients reported a 76% decrease in pain score at 120 minutes as well as all other
time points (p=0.0001).
Conclusion: Ultrasound-guided fascia iliaca compartment block provided excellent
analgesia without complications.

Citation: Beaudoin FL, Haran JP, Liebmann O. A comparison of ultrasound-guided three-in-one

femoral nerve block versus parenteral opioids alone for analgesia in emergency department
patients with hip fractures: a randomized controlled trial. Acad Emerg Med. 2013 Jun;20(6):584-
91.
Type of Study: Blinded, randomized controlled clinical trial (n=18 in each group)
Objective: Superiority design looking at whether patients who receive an US-guided femoral
nerve block in addition to opioids have superior pain relief compared with patients who receive
parenteral opioids alone.
Results: Numerical rating scale of pain showed a pain-intensity difference of 36.9% in the study
group and 13.4% in the control group. (p<0.001) Additionally, the control group required
significantly more rescue morphine post procedure with an average of 5.0 mg versus 0 mg.
(p=0.028)
Conclusion: US guided femoral nerve blocks as an adjunct to morphine resulted in significantly
reduced pain over 4 hours, decreased the amount of rescue analgesia, and showed no
appreciable difference in adverse events when compared to morphine alone.

Citation: Turner AL, Stevenson MD, Cross KP. Impact of ultrasound-guided femoral nerve
blocks in the pediatric emergency department. Pediatr Emerg Care. 2014 Apr;30(4):227-9.
Type of Study: Retrospective, preimplementation and postimplementation of US guided femoral
block study (p=81)
Objective: Determine if use of US-guided femoral nerve block in the pediatric ED significantly
altered the duration of analgesia and need for pain medications in patients with a femoral
fracture.
Results: Next dose of analgesia was 2.2 hours in preimplementation and 6.1 hours in the
postimplementation patients. There was a median total dose of morphine of 14.8 mcg/kg per
hour versus 6.5 mcg/kg per hour respective.
Conclusion: Patients who underwent US-guided femoral nerve block had longer duration of
analgesia, required fewer doses of analgesic medications, and needed fewer nursing
interventions compared with those who used analgesia alone.
Citation: Oberndorfer U, Marhofer P, Bösenberg A, Willschke H, Felfernig M, Weintraud
M, Kapral S, Kettner SC. Ultrasonographic guidance for sciatic and femoral nerve blocks in
children. Br J Anaesth. 2007 Jun;98(6):797-801. Epub 2007 Apr 21
Type of Study: Randomized controlled trial (n=46)
Objective: Comparison of nerve stimulator guidance versus ultrasound guidance for lower
extremity nerve blocks in children.
Results: Two failures of therapy in nerve stimulator guided blocks, no failures in the ultrasound
guided blocks. Duration of block was longer with ultrasound guidance (508 vs 335 min). Volume
of local anesthetic was reduced when using the ultrasound compared to the nerve stimulator
(0.15 vs 0.3 ml/kg respectively)
Conclusion: Ultrasound guidance for sciatic and femoral nerve blocks resulted in increased
duration as well as decreased volume of anesthetic.

Citation: Orebaugh SL, Kentor ML, Williams BA. Adverse outcomes associated with nerve
stimulator-guided and ultrasound-guided peripheral nerve blocks by supervised trainees: update
of a single-site database. Reg Anesth Pain Med. 2012 Nov-Dec;37(6):577-82.
Type of Study: Retrospective Review (n=9301)
Objective: Evaluate safety of ultrasound versus nerve stimulator in performing a peripheral nerve
block.
Results: Four peripheral nerve injuries were documented. US guided technique was used in one
case and nerve stimulator was used in the other three. One seizure associated with local
anesthetic systemic toxicity occurred with the nerve stimulator.
Conclusion: Ultrasound is a safe method of obtaining a peripheral nerve block.

Citation: Barrington MJ, Watts SA, Gledhill SR, Thomas RD, Said SA, Snyder GL, Tay VS,
Jamrozik K. Preliminary results of the Australasian Regional Anaesthesia Collaboration: a
prospective audit of more than 7000 peripheral nerve and plexus blocks for neurologic and other
complications. Reg Anesth Pain Med. 2009 Nov-Dec;34(6):534-41.
Type of Study: Prospective (n=7156 blocks)
Objective: Determine the rate of neurologic injury following peripheral nerve block
Results: 30 (0.5%) met criteria for a neurologic assessment based on symptom complaints. Of
these 30 patients 3 of the patients were found to have an injury related to the nerve block. Eight
patients (0.1%) experienced symptoms of local anesthetic toxicity.
Conclusion: Nerve block is a safe procedure with rare complications of neurologic injury
and local anesthetic toxicity.

Overall conclusion: ultrasound is a useful tool to do nerve blocks. Nerve blocks are a safe
procedure with rare complications of a neurologic injury and local anesthetic toxicity. Femoral /
fascia iliaca blocks are beneficial to both the provider in terms of pain control and reducing the
consequences associated with opioids as well as to the patient.
Selection Criteria:

These are the guidelines for emergency regional anesthesia for

trauma orthopedic injuries. While initiating a new procedure,
we will begin with hip fractures and target the fascia iliac block
and continue to expand our practice so eventually expand to
other injuries as well with further experience and training.
These guidelines are from the Highland emergency department.

Contraindications:
Patient refusal, allergy to local anesthetic, overlying infection at
skin injection site, neurologic injury or deficit, high risk for
developing compartment syndrome.
Relative contraindications are patients who are anticoagulated,
extra care needs to be taken to avoid vascular injury.
Intoxicated patients also pose a certain challenge given the
possibility for unpredictable movements putting both
themselves as the provider as risk.

Procedural Checklist:
Please refer to procedural checklist made in separate document. These checklist will need to be
printed, filled out, signed by ED attending and sent to Dr. Sperling for collection.
Pre-filled out consent form, please view in another document, these need to be filled out and
uploaded into epic.
Fascia Iliaca Nerve Block
The fascia iliaca nerve block (FIB) is a compartment block that targets 2 nerves within the fascia
iliaca compartment, the femoral nerve and the lateral femoral cutaneous nerve. The obturator
nerve is sometimes also affected with this block, but not reliably.

Sensory Innervation Motor Innervation

Femoral n. Anterior thigh Hip flexors

Medial thigh Knee extensors
Knee
Periosteum of femur
Medial distal lower leg

Lateral Femoral Lateral thigh No motor innervation

Cutaneous n.

Obturator n. Posteromedial aspect of knee Thigh adductors

image source: https://www.bromleyemergency.com/frcem-primary-blog/core-anatomy-fascia-

iliaca-compartment/

The fascia iliaca is located anterior to the iliacus muscle (on its surface) within the pelvis. It is
bound superolaterally by the iliac crest and merges medially with the fascia overlying the psoas
muscle. Both the femoral and lateral cutaneous nerves of the thigh lie under the fascia iliaca in
their intrapelvic course. Anatomical orientation begins in the same manner as the femoral block:
identifying the femoral artery at the level of the inguinal crease. If it is not immediately visible,
sliding the transducer medially and laterally will eventually bring the vessel into view.
Immediately lateral and deep to the femoral artery and vein is a large hypoechoic structure, the
iliopsoas muscle. It is covered by a hyperechoic fascia, which can be seen separating the muscle
from the subcutaneous tissue superficial to it.

The hyperechoic femoral nerve should be seen wedged between the iliopsoas muscle and the
fascia iliaca, lateral to the femoral artery. The fascia lata (superficial in the subcutaneous layer) is
more superficial and may have more than one layer.
Moving the transducer laterally several centimeters brings into view the sartorius muscle covered
by its own fascia as well as the fascia iliaca. Additional anatomical detail can be seen in the
cross-sectional anatomy.

EQUIPMENT ANESTHETIC
- US machine with linear probe - local: lidocaine 1% for skin wheal at
- Chloraprep injection site (useful but not necessary)
- Sterile probe cover - regional: bupivacaine (0.5%), max dose
- Sterile gel 2 mg/kg diluted to 30cc with normal
- Sterile gloves saline vs. ropivacaine (0.2%)
- (2) 20mL syringes
- 5cc syringe
- 80 to 100mm 22 gauge spinal
needle (short bevel is ideal)
- Catheter extension tubing
Important tips:
- Attach catheter extension tubing to the spinal needle to make it easier to inject anesthetic
without disrupting the needle.
- Ensure to flush the spinal needle with saline and tubing so no air enter the space and
disturbs your view.

POTENTIAL COMPLICATIONS:
1. Unsuccessful nerve block
2. Hematoma formation at injection site, especially in anticoagulated patients
3. Nerve injury
4. Intravenous injection of anesthetic
5. Infection
6. Local anesthetic allergy
7. Local anesthetic systemic toxicity (see below)

Local Anesthetic Systemic Toxicity:

When performing nerve blocks with high doses of local anesthetics, providers should be well-
versed in recognition and management of local anesthetic systemic toxicity (LAST). Local
anesthetics are sodium channel blockers, thus the nervous system and heart are sensitive to
toxicity. Though rare, local anesthetic overdose can lead to seizures and cardiac arrest if not
promptly treated. Most commonly, the CNS side effects will manifest first and warrant
immediate attention. Symptoms typically appear 1-5 minutes after injection, but may be delayed
in some cases.

Clinical Manifestations:
- Nervous system: Initial CNS symptoms include tinnitus, blurry vision, dizziness, tongue
paresthesias, perioral numbness. This progresses to excitatory symptoms including
muscle twitching, restlessness, agitation, and seizures. These features progress to CNS
depression with slurred speech, lethargy, loss of consciousness, coma, and respiratory
arrest.
- Cardiovascular system: Blockage of fast sodium channels in the heart leads to a
decreased rate of depolarization. This leads to prolonged PR intervals and widened QRS
complexes, and ultimately ventricular arrhythmias/cardiac arrest. Symptoms may include
chest pain, shortness of breath, palpitations, lightheadedness, syncope.

Treatment:
- Airway/Breathing management
- 100% oxygen by non-rebreather, consider intubation
- Seizure suppression with benzodiazepines. Avoid propofol given risk of
potentiating cardiac instability
- Circulation management
- Manage hypotension with IV fluid bolus and vasopressors
- ACLS protocol for cardiac dysrhythmias or arrest.
- Favor amiodarone for arrhythmias; avoid beta blockers, calcium channel blockers,
lidocaine
- Decrease dose of epinephrine to <1mcg/kg
- Intralipid Emulsion (20%)
- Bolus 1.5mL/kg
- Continuous infusion 0.25mL/kg/min
- Repeat bolus for persistent cardiovascular collapse
- Double infusion rate to 0.5mL/kg/min if blood pressure remains low
- Continue infusion for 10 minutes after attaining circulatory stability
- Maximum dose: 10 mL/kg in first 30 minutes