Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department.
ABSTRACT Hip fracture (HFx) is a painful injury that is commonly seen in the emergency department (ED). Patients who experience pain from HFx are often treated with intravenous opiates, which may cause deleterious side effects, particularly in elderly patients. An alternative to systemic opioid analgesia involves peripheral nerve blockade. This approach may be ideally suited for the ED environment, where one injection could control pain for many hours.
We hypothesized that an ultrasound-guided fascia iliaca compartment block (UFIB) would provide analgesia for patients presenting to the ED with pain from HFx and that this procedure could be performed safely by emergency physicians (EP) after a brief training.
In this prospective, observational, feasibility study, a convenience sample of 20 cognitively intact patients with isolated HFx had a UFIB performed. Numerical pain scores, vital signs, and side effects were recorded before and after administration of the UFIB at pre-determined time points for 8h.
All patients reported decreased pain after the nerve block, with a 76% reduction in mean pain score at 120min. There were no procedural complications.
In this small group of ED patients, UFIB provided excellent analgesia without complications and may be a useful adjunct to systemic pain control for HFx.
- SourceAvailable from: PubMed Central[show abstract] [hide abstract]
ABSTRACT: The term "tactical medicine" can be defined in more than one way, but in the nonmilitary setting the term tactical emergency medical services (TEMS) is often used to denote medical support operations for law enforcement. In supporting operations involving groups such as special weapons and tactics (SWAT) teams, TEMS entail executing triage, diagnosis, stabilization, and evacuation decision-making in challenging settings. Ultrasound, now well entrenched as a part of trauma evaluation in the hospital setting, has been investigated in the prehospital arena and may have utility in TEMS. This paper addresses potential use of US in the tactical environment, with emphasis on the lessons of recent years' literature. Possible uses of US are discussed, in terms of both specific clinical applications and also with respect to informing triage and related decision making.Emergency medicine international. 01/2012; 2012:781570.
ULTRASOUND-GUIDED FASCIA ILIACA COMPARTMENT BLOCK FOR HIP
FRACTURES IN THE EMERGENCY DEPARTMENT
Lawrence Haines, MD, MPH, RDMS,* Eitan Dickman, MD, RDMS, FACEP,* Sergey Ayvazyan, MD,*
Michelle Pearl, DO, MA, RDMS,* Stanley Wu, MD, MBA, RDMS,† David Rosenblum, MD,‡
and Antonios Likourezos, MA, MPH*
*Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York, †Department of Emergency Medicine, Baylor
College of Medicine, Houston, Texas, and ‡Department of Anesthesiology, Maimonides Medical Center, Brooklyn, New York
Reprint Address: Lawrence Haines, MD, MPH, RDMS, Division of Emergency Ultrasonography, Department of Emergency Medicine, Maimonides
Medical Center, 4802 10th Ave., Brooklyn, NY 11209
, Abstract—Background: Hip fracture (HFx) is a painful
injury that is commonly seen in the emergency department
(ED). Patients who experience pain from HFx are often
side effects, particularly in elderly patients. An alternative to
This approach maybe ideally suited for the ED environment,
where one injection could control pain for many hours.
Objectives: We hypothesized that an ultrasound-guided fas-
this procedure could be performed safely by emergency phy-
sicians (EP) after a brief training. Methods: In this prospec-
tive, observational, feasibility study, a convenience sample
of 20 cognitively intact patients with isolated HFx had
a UFIB performed. Numerical pain scores, vital signs, and
side effects were recorded before and after administration
of the UFIB at pre-determined time points for 8 h. Results:
All patients reported decreased pain after the nerve block,
with a 76% reduction in mean pain score at 120 min. There
were no procedural complications. Conclusion: In this small
group of ED patients, UFIB provided excellent analgesia
without complications and may be a useful adjunct to
systemic pain control for HFx.
? 2012 Elsevier Inc.
, Keywords—hip fracture; emergency medicine; ultra-
sound; nerve block; fascia iliaca compartment block;
Hip fracture (HFx) is a painful orthopedic emergency
that commonly presents to the emergency department
(ED). In 2007, there were 281,000 hospital admissions
in the United States for hip fractures among people
age 65 and older (1). It has previously been shown that
patients with pain from HFx are under-medicated while
in the ED, particularly in overcrowded facilities (2). Cur-
rent treatment for patients in the ED who are experienc-
ing pain from acute HFx is often with intravenous
morphine sulfate (IVMS). IVMS has many undesirable
side effects, but of particular concern are delirium, hypo-
tension, and respiratory depression. These effects may be
accentuated in elderly patients and necessitate increased
patient monitoring and greater utilization of limited ED
An alternative to systemic opioid analgesia involves
peripheral nerve blockade. Anesthesiologists frequently
perform nerve blocks in the perioperative period to con-
trol pain in patients undergoing hip surgery. This ap-
proach may be ideally suited for the ED environment,
where one injection could control pain for many hours.
Evidence suggests that peripheral nerve blockade per-
formed with sonographic guidance decreases the amount
of local anesthetic needed to achieve sensory blockade
RECEIVED: 28 June 2011; FINAL SUBMISSION RECEIVED: 30 August 2011;
ACCEPTED: 22 January 2012
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–6, 2012
Copyright ? 2012 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$ - see front matter
(3,4). It also increases the success rate of the block and
decreases the time to analgesia (5,6).
There are several approaches described to block the
ED, the femoral nerve block or the 3-in-1 femoral nerve
block are utilized. Those nerve blocks attempt to place
ing the same nerves, the fascia iliaca compartment block
(FIB) attempts to place the anesthetic under the plane of
the fascia iliaca distant from the nerves of interest. This
has been previously described as an effective method for
treating pain due to HFx (7,8). The FIB has been
previously shown to provide adequate analgesia for
femur fractures in children (9,10). The studies describe
the FIB being performed using a technique based on
anatomic landmarks and a loss of resistance technique
(two tactile ‘‘pops’’ felt as the needle passes through the
fascia lata and the fascia iliaca). One recent study in the
anesthesia literature has described ultrasound guidance
of the FIB (UFIB) increasing the efficacy of the sensory
blockade when compared to the loss of resistance
technique (11). UFIB has not previously been studied in
an adult ED population for HFx.
We hypothesized that real-time UFIB could be
successfully performed in the ED and would provide an
excellent adjunct or alternative to repeat doses of IVMS
for pain control in patients with HFx.
MATERIALS AND METHODS
Data were collected prospectively from an academic ur-
ban ED with an annual census of over 110,000 patients.
This study received approval from our Institutional Re-
while being triaged. Patients then underwent an initial
evaluation by an emergency physician (EP), and if there
was clinical suspicion of HFx, one of the study investiga-
tors was contacted. A standard dose of 0.1 mg/kg of
IVMS was given to the patients while they awaited radio-
graphs. The nerve block was not performed until after the
patient received the standardized initial dose IVMS and
the radiographs were performed.
Patients were eligible for enrollment in the study if the
diagnosis of HFx was confirmed on X-ray study, if they
had a pain score of at least 5/10 at triage or upon initial
EP evaluation before the IVMS, if there was no pre-
hospital analgesia given, and if there were no concomi-
tant injuries. To be included in the study, patients were
required to be alert, oriented to person, place, and time,
and able to demonstrate understanding of the written in-
formed consent. Patients also had to be able to indicate
how much pain they were having on the visual analog
pain scale, with 0 being no pain and 10 being severe
pain, and to be able to report any side effects experienced
after administration of the nerve blockade.
The pain score assessed just before the nerve block
was consideredtime 0. Thepatients’vitalsignswere con-
tinuously monitored for a minimum of 1 h after receiving
the UFIB. The blocks were performed with dynamic so-
nographic guidance utilizing a Sonosite Micromaxx or
M-turbo (SonoSite, Inc. Bothell, WA) high-frequency
5-10 MHz linear transducer using sterile technique. One
of the study investigators (E.D.) trained the other investi-
gators in performing the UFIB, utilizing a short lecture
and assisting in their initial attempts until competency
was demonstrated. Competency was based on the ability
of the trainee to perform the procedure successfully with-
out intervention by the trainer. The number of assisted at-
tempts was not recorded.
lata and the fascia iliaca, were sonographically visualized
astwohyperechoic lines, with the probe placed inatrans-
verse orientation on the thigh just inferior to the inguinal
ligament and one-third of the distance from the anterior
superior iliac spine to the pubic tubercle (Figure 1A, B).
A 22-gauge spinal needle was introduced through the
skin in a lateral-to-medial orientation and was directed
in parallel with the transducer to allow visualization of
the full length of the needle throughout the procedure.
The needle tip was visualized penetrating the fascia lata
and then the fascia iliaca (Figure 1C). After puncturing
the fascia iliaca, 30 mL of 0.25% bupivacaine was in-
jected. An expanding anechoic collection just below the
fascia iliacawas visual confirmation of correct placement
of anesthetic (Figure 1D).
Patients were eligible to receive standardized rescue
doses of IVMS after UFIB placement if they experienced
continued pain. A 0.1-mg/kg rescue dose was given if
requested. This was followed by 0.05-mg/kg doses if
requested. Vital signs, pain scores, amount of morphine,
and side effects were monitored at predetermined time
points for 8 h.
A convenience sample of 20 patients was enrolled in this
study. Nerve blocks were placed by two emergency ultra-
sound fellowship-trained EPs, one emergency ultrasound
fellow, or three 3rd-year emergency medicine residents
(always with one of the EPs present). Eleven patients
were female. The mean age of the patients was 82 years
(SD 6 7.7 years); 55% of the HFx were intertrochan-
teric. The remaining 45% of the fractures involved the
femoral neck. Data were not obtained in 3 patients at
the 480-min time point.
The mean pain score at triagewas 7.9/10. Shortly after
triage, patients received the first dose of 0.1 mg/kg of
2 L. Haines et al.
IVMS while awaiting radiographs. Time until radio-
graphs were performed was, on average, 119 min
(SD 6 51 min). Time 0 was recorded just before the ad-
ministration of the nerve block, and the mean pain score
at time 0 was 5.5/10. Over the next 8 h, the patients re-
ported a statistically significant lower mean pain score
as compared to time 0 (Figure 2). The lowest mean pain
score of 1.3/10 was achieved at time 120 min, which rep-
resents a 76% drop in pain from just before the placement
of the block. All of the decrease in pain scores were sta-
tistically significant, with P-values for the time points 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.
After receiving the nerve block, 80% of the patients
did not request additional analgesia. Of the 4 patients
that requested the standardized doses of additional anal-
gesia,2patients receivedone doseofadditional analgesia
at 120 min, and 2 patients received one dose at 240 min.
There were no procedural complications from the
nerve block. Eighty-five percent of the patients reported
no side effects within the 8 h of data collection. Of the
3 patients that reported sided effects, one patient reported
nausea and vomiting at 30 min. The second patient re-
ported dizziness, sleepiness, nausea, and vomiting at
10 min and then only sleepiness at 20 min, with no addi-
tional reported side effects at the later time points. The
third patient reported dizziness at every time point, as
well as blurred vision at 240 min and then nausea at
480 min. Only this patient out of the 3 that reported
side effects requested an additional dose of analgesia,
which was given at 120 min.
The UFIB was chosen because it targets the femoral, ob-
turator, and lateral femoral cutaneous nerves that inner-
vate the hip joint and the area around the hip, and it has
Figure 1. (A) Placing the ultrasound-guided fascia iliaca compartment block (UFIB). ASIS =anterior superior iliac spine. (B) Ultra-
sound visualization of the fascia lata and fascia iliaca. Note the medial and lateral orientation. (C) Ultrasound image just before
local anesthetic just beneath the plane of the fascia iliaca.
Figure 2. Mean pain scores. ‘‘Triage’’ is the pain score at
triage and just before receiving intravenous morphine. Time
0 pain score is just before the nerve block, but after the mor-
phine. UFIB=ultrasound-guided fascia iliaca compartment
US-guided Fascia Iliaca Compartment Block3
been shown to provide effective analgesia for HFx. An
additional advantage of this particular nerve block is
that the needle is relatively far from the critical vascular
structures of the proximal thigh, including the femoral
vein and femoral artery. Sonographic identification of
nerves, which can be challenging in some patients, is
not necessary for this block. It has been our experience
that the traditional landmark-based technique, described
as two tactile ‘‘pops’’ felt as the needle passes through
the fascia lata and then the fascia iliaca, is often not obvi-
ous or discernable, especially in the frail, elderly patient.
Ultrasound guidance helped to ensure that we avoided
vascular structures and allowed us to visualize the correct
placement of local anesthetic.
Our medical center’s institutional review board re-
quired that HFx be confirmed radiographically before
placement of the nerve blockade. Due to the resource
constraints of the imaging department in our high-
volume, high-acuity, urban ED, it is not unusual for pa-
tientstowait2 hforradiographs.Itwasdeemed unethical
give all of our patients a weight-based dose of morphine
after initial evaluation.
The drop in pain score from triage to time 0 was likely
due to the morphine. In this case series, X-ray studies
were completed an average of 119 min (SD 6 51 min)
istration of the nerve block. Therefore, we believe that
from time 0 until the 8-h time point, the decrease in
pain was likelydueto the analgesia providedby the nerve
blockade, as this was outside the time to the maximal ef-
fect of morphine.
Anesthesiologists routinely place nerve blocks for
pain control in the operating room and postoperative pe-
riod, but have traditionally used nerve stimulators to
guide their placement. Most EPs do not routinely use
nerve stimulators. However, EPs are increasingly facile
with ultrasonography, and there is good evidence to
show that peripheral nerve blocks performed with ultra-
sound guidance can be placed with less anesthetic and
greater success. Sonographic guidance may increase the
confidence of EPs in placing these blocks and may
make placing a UFIB more routine in the ED.
We chose bupivacaine as the local anesthetic due to its
proven safety, widespread availability, and long-lasting
The major limitations of this study include its small sam-
onstrating feasibility, it seems that the UFIB can be
successfully placed by EPs after a brief training period
tive, randomized, controlled study with a larger sample
size would be needed to confirm these preliminary data.
The emergency physicians performing the UFIB were
emergency ultrasound-trained attendings, emergency ul-
trasound fellows, or 3rd-year emergency medicine resi-
dents who showed an interest in pursuing a fellowship
in emergency ultrasonography. Although this represented
a spread in the training levels of the practitioners per-
forming the block, all of the physicians involved showed
a greater-than-average level of interest and proficiency in
emergency ultrasound. Further studies are necessary to
determine whether these results can be generalized to
all EPs, including those without ultrasound training.
The patients enrolled in this study were a convenience
sample of patients that presented to the ED when the
study investigators were available to enroll the patients,
to perform the block, and to observethe patient for 8 haf-
ter the block. This may have introduced selection bias.
Also, patients that did consent to enrollment may have
been in a greater amount of pain than those that chose
not to participate.
Another limitation was giving morphine to all patients
as they waited for X-ray studies. Although the nerve
block was placed, on average, 2 h after the initial dose
of morphine, the systemic analgesia may have exagger-
ated the perceived effect of the local nerve blockade. In
addition, the 4 patients who received rescue analgesia
were included in the analysis of the pain scores. One
would expect that this would increase the perceived
efficacy of the UFIB.
pain scores, but may have caused the side effects that
were reported. Three patients reported nausea, vomiting,
dizziness, sleepiness, and blurred vision, and we did not
ask patients about side effects until after the block was
placed. We do not know if these side effects were present
before the UFIB, so we cannot say if they were caused by
the opiates or by the block itself.
Lastly, pain scores were sometimes collected by the
tial source of bias. We tried to use separate personnel as
data collectors, but due to resource limitations, it was of-
ten the person who placed the UFIB who was performing
the data collection as well. In some patients, data collec-
tion was a combined effort among several people on the
research team. We did not keep records of who was
performing the data collection.
The results of this study suggest that the ultrasound-
guided fascia iliaca compartment block can be placed
nique for pain control in patients with acute hip fracture.
4 L. Haines et al.
The nerve block provided excellent analgesic benefit for
patients and is a viable adjunct to systemic pain control.
Acknowledgment—This study received funding from the Emer-
gency Medicine Basic Research Skills grant by the Emergency
Medicine Foundation in 2009.
1. Department of Health and Human Services, the Centers for Disease
Control. National Hospital Discharge Survey (NHDS), National
2. Hwang U, Richardson LD, Sonuyi TO, Morrison RS. The effect of
emergency department crowding on the management of pain in
older adults with hip fracture. J Am Geriatr Soc 2006;54:270–5.
3. Marhofer P, Schro ¨gendorfer K, Wallner T, et al. Ultrasonographic
guidance reduces the amount of local anesthetic for 3-in-1 blocks.
Reg Anesth Pain Med 1998;23:584–8.
4. Casati A, Baciarello M, Di Cianni S, et al. Effects of ultrasound
guidance on the minimum effective anaesthetic volume required
to block the femoral nerve. Br J Anaesth 2007;98:823–7.
5. Marhofer P, Schro ¨gendorfer K, Koinig H, et al. Ultrasonographic
guidance improves sensory block and onset time of three-in-one
blocks. Anesth Analg 1997;85:854–7.
6. Reid N, Stella J, Ryan M, et al. Use of ultrasound to facilitate accu-
rate femoral nerve block in the emergency department. Emerg Med
ment blockade for acute pain control in hip fracture patients:
a randomized, placebo-controlled trial. Anesthesiology 2007;106:
8. Monzon DG, Iserson KV, Vazquez JA. Single fascia iliaca compart-
ment block for post-hip fracture pain relief. J Emerg Med 2007;32:
9. Wathen JE, Gao D, Merritt G, et al. A randomized controlled trial
comparing a fascia iliaca compartment nerve block to a traditional
systemic analgesic for femur fractures in a pediatric emergency
department. Ann Emerg Med 2007;50:162–71.
compartment block with the 3-in-1 block in children. Anesth Analg
11. Dolan J, Williams A, Murney E, et al. Ultrasound guided fascia
iliaca block: a comparison with the loss of resistance technique.
Reg Anesth Pain Med 2008;33:526–31.
US-guided Fascia Iliaca Compartment Block5