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154 Vol 11 No 4 • Journal of Paramedic Practice
Comment
© 2019 MA Healthcare Ltd
Fascia iliaca compartment
block: a short how-to guide
The fascia iliaca compartment
block (FICB) aims to provide
anaesthesia and analgesia
to the anterior compartment of the
thigh, thereby providing analgesia for
fractures to the femur and neck of
femur, as well as potentially for soft-
tissue injures to this area.
It does this by interrupting the
conduction of nerve impulses by the
femoral nerve and lateral cutaneous
nerve of the thigh. An FICB does not
provide analgesia or anaesthesia to
the distal leg below the knee, which
is supplied by the sciatic nerve, nor to
the medial aspect of the thigh, which is
supplied by the obturator nerve.
A short guide is presented to the
landmark approach to FICB, and the
choice of local anaesthetic volume to
be given by patient’s estimated weight.
The technique
FICB is a simple technique, and allows
a high quality of analgesia to be given
without the side effects of opiate
analgesia. FICB is the current gold
standard in the management of neck of
femur fractures with pain unresponsive
to intravenous opioids and paracetamol
(National Institute for Health and Care
Excellence (NICE), 2017). It is frequently
performed in emergency departments,
but has also been used as a prehospital
intervention by nurses and paramedics,
where it has been demonstrated to be
both safe and effective (Hards et al,
2018), without reducing on-scene times
(McRae et al, 2015).
The technique is easy to learn and
can be undertaken using a landmark
technique or with ultrasound guidance
(Chesters, et al, 2009). A sample
technique monograph is included
in Table1. Although point of care
ultrasound (PoCUS) is becoming more
commonplace in prehospital care and
paramedic practice across the country, it
is unlikely that PoCUS will be available
on all frontline ambulances in the near
future. Therefore, this article will focus
on the landmark technique, which
is still widely used. Use of FICB has
been shown to be associated with a
reduced need for opiate analgesia and
is likely to lead to more effective pain
relief, with fewer side effects, than oral
or injected analgesics (Fadhlillah and
Chan, 2017; Kassam et al, 2018). FICB is
also likely to lead to improved patient
outcomes (Callear and Shah, 2016),
including increasing a person’s chances
of returning home on discharge from
hospital (Bray and Collins, 2015).
Tom Mallinson, Prehospital & Rural Medicine Doctor, Critical Care Paramedic, NHS Western Isles, Stornoway, Outer Hebrides,
Scotland. Email for correspondence: tom.mallinson@nhs.net
Table 1. Technique monograph
Fascia iliaca compartment block
Indications
lFemoral fractures including fractures to the neck of femur
lSoft-tissue injuries to the anterolateral thigh
Side effects
lHaematoma formation
lBleeding
lNerve injury
lVascular injury
lLocal anaesthetic toxicity
lFailure (inadequate analgesia)
lAllergy/anaphylaxis
lApnoea as a result of previously administered opiates
Contraindications
lOverlying infection
lAllergy to local anaesthetics
lPatient refusal
lPrevious surgery to groin
lAnticoagulated or bleeding disorder
lAge under 18 years
Administration
Levobupivicaine 0.25%
Weight
25–35kg
>40kg
Volume (of 0.25% solution)
20ml
30ml
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Journal of Paramedic Practice • Vol 11 No 4 155
Comment
© 2019 MA Healthcare Ltd
Landmark technique
The location for FICB must be
correctly identified to minimise risk of
complications. The first two important
landmarks are the anterior superior iliac
spine (ASIS) and the pubic tubercle
of the pelvis. These two points are
connected subcutaneously by the
inguinal ligament, the next important
landmark. The length of the inguinal
ligament needs to be divided into
thirds; this can be easily estimated
using the index and middle ngers of
each hand. From this point, the site
for injection is located 1–2cm distally
from the junction of the lateral and
middle third. The femoral artery can
be palpated medially to the puncture
site prior to undertaking the technique
to reassure the practitioner that their
chosen site is distant from the large
neuromuscular bundle in the thigh
(Figure1).
The point for injection can be marked
with pressure from the blunt end of
a needle or a needle cover before a
sterile area has been created. The area
surrounding the injection site is then
cleaned with 70% isopropyl alcohol
or chlorhexidine and allowed to dry
(this is especially important when
chlorhexidine is used, as it is a potent
neurotoxin). The skin can now be
anaesthetised with around 2ml of 1%
lidocaine if required.
A short bevelled or blunted needle
attached to the syringe holding the
levobupivicaine is now inserted
through the skin at a 90 angle. The
needle is advanced, producing two
palpable ‘pops’ as the needle perforates
the fascia lata and the fascia iliaca. After
advancing another 1–2mm, aspiration
is attempted to verify that the tip of
the needle is not within a blood vessel.
Once negative aspiration has been
observed, injection can begin. While
the procedure may feel uncomfortable,
there should be little resistance and
the patient should not experience pain
on injection. Once the volume desired
has been injected, remove the needle
and dispose of this safely, then apply
gentle pressure to the area for around
2minutes. Analgesia will become
apparent over the next 10–30minutes;
during this time, vital signs should be
monitored and the patient observed
for signs of local anaesthetic toxicity
(Box1).
Conclusion
FICB is a safe and effective means
of providing analgesia for injuries to
the anterolateral thigh or femur, and
although not currently a technique
widely used by paramedics within the
UK, it is certainly on the horizon for
specialist and advanced paramedics
nationwide. A short guide to the
technique has been presented here
for education and reference, although
this does not replace comprehensive
teaching and supervised practice to
achieve clinical competence. JPP
References
Bray H, Collins N. The effects of fascia iliac
compartment block for hip fractures on length
of hospital stay and discharge destination.
Emerg Med J. 2015; 32:985–986
Callear J, Shah K. Analgesia in hip fractures. Do
fascia-iliac blocks make any difference? BMJ
Qual Improv Rep. 2016; 5(1). pii: u210130.
w4147. https://doi.org/10.1136/bmjquality.
u210130.w4147
Chesters A, Elkhodair S, Mortazavi J, McAuley
D. Fascia iliaca compartment block in the
emergency department. Emerg Med J. 2009;
26(Suppl1):22. https://doi.org/10.1136/
emj.2009.082081v
Fadhlillah F, Chan D. Systematic review and meta-
analysis of analgesic effcacy and safety profile
of single injection fascia iliaca compartment
blocks in the acute pre-operative pain
management of hip fractures. Emerg Med J.
2017; 34:A891–A892
Hards M, Brewer A, Bessant G, Lahiri S. Effcacy
of prehospital analgesia with fascia iliac
compartment block for femoral bone fractures:
A systematic review. Prehosp Disaster Med.
2018; 33(3):299–307
Kassam AM, Gough AT, Davies J, Yarlagadda
R. Can we reduce morphine use in elderly,
proximal femoral fracture patients using
a fascia iliac block? Geriatric Nurs. 2018;
39(1):84–87
McRae PJ, Bendall JC, Madigan V, Middleton
PM. Paramedic-performed Fascia Iliaca
Compartment Block for femoral fractures: A
controlled trial. J Emerg Med. 2015; 48(5):
581–589
National Institute for Health and Care Excellence.
Hip fracture: management [CG 124]. https://
www.nice.org.uk/guidance/cg124 (accessed 1
April 2019)
Box 1. Signs and symptoms
of local anaesthesia toxicity
lSeizure
lPerioral tingling
lCardiac dysrhythmia
lLoss of consciousness
lCardiac arrest
The chosen site must be distant from the large neuromuscular bundle
in the thigh
©SARAH JANE PALMER FINE ART
Left middle finger
on right ASIS
Dividing distance from ASIS
to PT into thirds, using
index fingers
Right middle finger
on right PT
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