Nerve Block: Fascia Iliaca Compartment

Indication

• Femur fracture
• Hip fracture

Contraindication

• Presence of femoral vascular grafts (relative)

Medications

• Ropivacaine (Natropin) 0.5%
  • <20kg = 0.75mL/kg
  • >20kg = 0.5 ML/kg
  • ^max - 30mL

OR

• Bupivacaine 0.5%
  • studies in adults have used 25 mL of 0.5% bupivacaine or 30 mL of 0.25% bupivacaine
  • Modify based on toxic level by weight

Procedure

• Perform good neurovascular exam prior to procedure
• This block requires more volume than the standard femoral nerve block

Ultrasound guided technique

• High frequency linear probe covered with sterile tegaderm
• Sterile surgilube
• Place probe in transverse on thigh, just inferior to inguinal ligament 1/3 of way from anterior

superior iliac spine to the pubic tubercle

• Visualize fascia lata and iliaca as 2 hyperechoic lines
• Introduce 22 gauge spinal needle lateral to medial, parallel to transducer
• After puncturing through fascia iliaca, infiltrate a small volume of the anesthetic solution. Should see the fascia lift up off of the nerve. Continue to infuse anesthetic.
• Confirmation = visualizing an expanding anechoic collection just below the fascia iliaca

Landmark technique

1. Point = 2/3 laterally along line between ant/sup iliac spine and pubis
   1. i.e. sig lateral to nerve
2. 90 deg angle with 22Ga needle (spinal needle)
3. 2 "pops" through fascial planes (1 inch max)
4. Withdraw to check not in vessel
5. Apply pressure 1 inch caudally accross thigh
6. Infuse drug
7. Hold pressure on thigh for 2 minutes
   1. to encourage cephalad spread

^Should see effect in <10 min

Complications

• Intravascular injection
  • Risk of cardiac depression if injected intravascularly
  • Ultrasound guidance mitigates this risk
• Hematoma
• Use fall precautions for patient
• Case reports exist nerve blocks obscure detection of compartment syndrome. This has not held up in studies.

Source

8/07 DONALDSON (adapted from EM Annals 8/07)

Wedel DJ, Horlocker TT. Miller's Anesthesia. 7th ed. pp. 1652-1655.

Haines L, Dickman E, Ayvazyan S, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency department. J Emerg Med. 2012;43(4):692–7.

Beaudoin FL, Nagdev A, Merchant RC, Becker BM. Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures. Am J Emerg Med. 2010;28(1):76–81.

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;20(6):584–91.