Anatomy for Emergency Medicine 028: Fascia Iliaca Block

Hi Guys, sorry for the big gap in posting.

Life has a way of taking over as you all know.

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I’m currently trying to introduce fascia iliaca blocks as part of routine care for patients in our department so i thought a podcast on some of the anatomy wouldn’t go a miss. If you want some light reading on the literature, then I’ve included a big list below.

If you’re more practically orientated then I’d strongly recommend the following:

Ultrasound Podcast: Fem Nv Block

NYSORA: Fascia Iliaca Block.

 

References:

Gray’s Anatomy 41st Edition

1.Godoy Monzón D, Vazquez J, Jauregui JR, Iserson KV. Pain treatment in post-traumatic hip fracture in the elderly: regional block vs. systemic non-steroidal analgesics. Int J Emerg Med. 2010;3(4):321–5.

2.Mouzopoulos G, Vasiliadis G, Lasanianos N, Nikolaras G, Morakis E, Kaminaris M. Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study. J Orthopaed Traumatol. 2009 Aug 19;10(3):127–33.

3.Høgh A, Dremstrup L, Jensen SS, Lindholt J. Fascia iliaca compartment block performed by junior registrars as a supplement to pre-operative analgesia for patients with hip fracture. Strat Traum Limb Recon. 2008 Sep 2;3(2):65–70.

4.Godoy Monzón D, Iserson KV, Vazquez JA. Single fascia iliaca compartment block for post-hip fracture pain relief. JEM. 2007 Apr;32(3):257–62.

5.NZ Guidelines Group. Acute Management and Immediate Rehabilitation After Hip Fracture Amongst People Aged 65 Years and Over. 2003;:1–40.

6.National Clinical Guideline Centre. The management of hip fracture in adults. 2011;:1–664.

7.SIGN SIGN. Management of hip fracture in older people. 2009 Jun;:1–56.

8.(null) INHFDSG. Irish Hip Fracture Database Preliminary Report 2013. 2014 Mar 4;:1–50.

9.(null) TCOEM. Clinical Standards for Emergency Departments. 2013;:1–16.

10.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. Academic Emergency Medicine. 2013 Jun 12;20(6):584–91.

11.Elkhodair S, Mortazavi J, Chester A, Pereira M. Single fascia iliaca compartment block for pain relief in patients with fractured neck of femur in the emergency department: a pilot study. Eur J Emerg Med. 2011 Dec;18(6):340–3.

12.Williams R, Saha B. Best evidence topic report. Ultrasound placement of needle in three-in-one nerve block. Emergency Medicine Journal. 2006 May;23(5):401–3.

13.Christos SC, Chiampas G, Offman R, Rifenburg R. Ultrasound-guided three-in-one nerve block for femur fractures. West J Emerg Med. 2010 Sep;11(4):310–3.

14.Fletcher AK, Rigby AS, Heyes FLP. Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: a randomized, controlled trial. Ann Emerg Med. 2003 Feb 1;41(2):227–33.

15.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.

16.Haines L, Dickman E, Ayvazyan S, Pearl M, Wu S, Rosenblum D, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. JEM. 2012 Oct;43(4):692–7.

17.Rashid A, Beswick E, Galitzine S, Fitton L. Regional analgesia in the emergency department for hip fractures: survey of current UK practice and its impact on services in a teaching hospital. Emergency Medicine Journal. 2013 Jul 22.

18.Abou-Setta AM, Beaupre LA, Rashiq S, Dryden DM, Hamm MP, Sadowski CA, et al. Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Ann Intern Med. 2011 Aug 16;155(4):234–45.

19.Parker MJ, Griffiths R, Appadu BN. Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures. Cochrane Database Syst Rev. Wiley Online Library; 2002;1.

20.Foss NB, Kristensen BB, Bundgaard M, Bak M, Heiring C, Virkelyst C, et al. Fascia iliaca compartment blockade for acute pain control in hip fracture patients: a randomized, placebo-controlled trial. Anesthesiology. 2007 Apr;106(4):773–8.

What lies beneath

One of the key things in looking at x-rays is being able to visualise the anatomy – what does each shadow and each area of whiteness represent anatomically. The x-ray is a rough representation of the anatomy lying under the skin.

The image below is a great example of what you’re really looking at when you look at the CXR. The mediastinum on the CXR looks like a fairly boring blob of white, but what secrets it contains!

Thoracic Angio CXR

Click for larger image

Thoracic angio from farm6.staticflickr.com via medical school

And annotated

Normal CXR AP

via Mike Cadogan on GMEP

Anatomy for Emergency Medicine 027: Basic Anatomy of Abdomen and Pelvic Trauma

This is the second part of a recent lecture I gave to some first year med students to get across how important their anatomy is to understanding trauma.

First part lives here

You may have to click through to the GMEP site to see the full HD version

PDF of slides

Cranial Nerve Palsies -III, IV and VI

This isn’t so much an AFEM post but more of a brief review of a paper and a video.

Everyone finds neuroanatomy tough, you’re not alone. Most of it doesn’t really concern us in the ED that much. However we will have people attend or be referred with isolated III, IV and VI palsies.

If you understand the basics you can  know when to get worried and scan and admit and to relax and explain to the patient that this will likely improve with time.

First I suggest watching this video from the single best eye teaching source I’ve found [Chris Nickson found it for me of course :-)]

I also found this paper [via the only neuro blog I read] which covers the anatomy but also some advice on when to image and when not to. This is my basic summary.

In general

  • a lot of isolated palsies can be observed as most are vasculopathic and will resolve
  • isolated palsies in young people should cause consideration for mass. Non-vasculopathic sixth palsies are relatively high risk here
  • the key point is identifying isolated. If they have headache or other signs then it’s not isolated
  • temporal arteritis can be involved in all of them, as can myasthenia but there should be other signs/symptoms

III

  • if motor only can usually be observed as most will be vasculopathic if the risk factors exist
  • if mixed motor and pupil should be imaged
  • if pupil only then think about compression

IV

  • even traumatic IVs don’t need imaging for ICH (though maybe for fracture)
  • head tilt is common along with pupils not at the same level
  • some are congenital that have decompensated
  • again the vasculopathic ones do quite well
  • sub-arach space rarely involved
  • isolated non-vasculopathic ones may (with caveats) be observed (unlike VI and III)

VI

  • traumatic VI needs a scan
  • vasculopathic can be observed
  • non-vasculopathic should get scanned (they quote a 25% malignancy rate which seems awful high)
  • they oddly don’t mention benign raised ICP as a cause

In the ED it’s not always as straightforward as this as the key is follow up. Depending on your access to neurology/ophthalmology will dictate how you manage them.

Anatomy for Emergency Medicine 026: Basic Anatomy of Chest Trauma

This is a screencast of a recent lecture I gave to some first year med students. It’s mainly to give the students some clinical info to keep their regular anatomy teaching relevant. It’s not designed to be a comprehensive intro to trauma in any way.

It’s longer than the usual podcasts so I’ve split into two parts.

Feedback, is as always, welcome.

You may have to click through to the GMEP site to see the full HD version

PDF of slides.