Ultrasound-guidance has recently been developed for the fascia iliaca block making it likely more of a reliable "3 in 1" block ( lateral femoral cutaneous, femoral, and obturator nerves) and the best option for acute hip fracture pain management in the ED.
For a detailed review of the anatomy check out this study HERE
Indication = Hip fracture
Risks = local anesthetic toxicity, hematoma in anticoagulated patients, intrperitoneal penetration has been reported, compartment syndrome possible but unlikely, use standard precautions to avoid infection, wrong side blocks, and nerve injury.
1. Scan as you would for a femoral block and identify the femoral nerve and iliacus muscle just lateral to the femoral artery, be sure you are proximal to the bifurcation of the femoral artery.
2. Follow the contour of the iliacus muscle laterally and superiorly and rotate the probe to face the marker towards the umbilicus. To obtain the view and probe orientation seen in the figure below.
3. After placing a skin wheal with lidocaine. Use an in-plane approach aiming towards the umbilicus. If traversing the sartorius muscle, you may feel a "pop" as the needle encounters the fascia overlying the sartorius, then a second "pop" as it encounters the fascia iliaca. These pops are more likely to be felt with a blunt tip needle such as touhy.
4. The space underneath the fascia iliaca should open very readily with local anesthetic injection. As the space opens, the needle can be advanced with idea to direct the local in a proximal/cephalad direction.
5. This is a plane block; use large volume of dilute local anesthetic such as 0.25% bupivacaine or 0.5% ropivacaine. Use standard precautions to be prepared to recognize and treat LAST.
6. Mark the patient, document, and communicate with all providers participating in the patients care.
As always practice safe regional anesthesia.
Regional Block Procedural Checklist
1) Patient is identiﬁed, 2 criteria. Appropriate identifying data entered in ultrasound machine.
2) Allergies and anticoagulation status are reviewed.
3) Consent for block and any associated procedure is conﬁrmed.
4) Appropriate neurologic and vascular exam completed and documented.
5) Block plan is conﬁrmed*, site is marked.
6) Necessary equipment is present, drugs are labeled.
7) Resuscitation equipment is immediately available: airway devices, suction, vasoactive drugs, lipid emulsion.**
8) Appropriate monitors are applied; intravenous access, sedation, and supplemental oxygen are provided, if indicated.
9) Aseptic technique is used: hand cleansing is performed, and sterile gloves are used.
10) “Time out” is performed before needle insertion.
In-plane with real-time visualization of needle tip. Do not advance or inject if tip not clearly visualized.
Incremental injection after aspiration of 3-5mL at a time with confirmation of local spread on ultrasound. Total injection is 40mL 0.25% Bupivacaine.
Although the fascia iliaca block is a plane block, you should know how to monitor pressure using a compressed air technique.
This will be a long acting block, it should be well documented and communicated to all teams participating in care. The leg should be splinted and protected.
*erratum - in the training video, I mistakenly referred to 2-chloroprocaine as amide, when it is of course an ester, distinguishing itself from the more common amides--lidocaine, bupivacaine etc...
A portion of training video includes a video produced by Dr. Vlad Frenk at the Stanford school of regional anesthesia "A Ultrasound Guided Fascia Illiaca - http://www.SsraOnlineCme.com" The direct Youtube link is HERE