The fascia-iliaca compartment block (FICB) was first described by Dalens and colleagues . In other studies, authors confirmed the efficacy of FICB for postoperative pain management in children , and in adults [3,4]. The advantages of this technique include the ability to perform the block without nerve stimulator, a point of puncture distant from the neurovascular structures and adequate block efficacy with a single injection [3,5]. The efficacy of FICB has been well studied in prehospital care in the French medical system (physicians are present in prehospital units in France) [6–8]. However, the use of the FICB in prehospital care in paediatrics has never been reported. We report and discuss the case of a 6-yr-old female with a femoral bone fracture due to a fall through the window, who benefited of a single injection FICB.
A 6-yr-old, 26-kg female, without past medical history, was victim of an accident having fallen through a window from the third floor. At the arrival of the medical team, the female lay supine on the floor. Standard monitoring was applied and she was haemodynamically stable (heart rate 140 min−1, arterial pressure 120/60 mmHg), oxygen saturation 98% without oxygen, she was conscious (Glasgow Coma Scale =15) and no neurological deficit was observed. The spine was not tender; abdominal palpation was unremarkable, cardiac and pulmonary auscultation was without abnormality. Femoral bone fracture was strongly suspected because of the lower limb deformation and the localization of the pain. Peripheral venous access (20-G) was established, and 450 mg of paracetamol was slowly infused. Nasal oxygen was given (5L min−1). Objective pain scale (OPS) was 7 . A FICB was performed using the technique previously described by Dalens and colleagues . A projection of the inguinal ligament was drawn on the skin and trisected. The point of puncture was marked 0.5 cm caudal to the point at which the lateral met the middle third of the inguinal ligament line. After antiseptic preparation of the area, the block needle (Plexufix® 50 mm, 24-G) was inserted at a right angle to the skin. The first loss of resistance was felt as the needle's tip crossed the fascia lata. The needle was advanced further with the same angle until the second loss of resistance was felt as the fascia iliaca was pierced. Fourteen milliliter (0.5 mL kg−1) of 1.5% lidocaine with 1/400 000 epinephrine, was slowly injected over a 2-min period. Block efficacy was assessed by testing sensory block in the medial, lateral and anterior part of the thigh using pinpick and cold (alcohol on a cotton compress). OPS was 0 after the procedure. Block was successful after 10 min. The leg was therefore immobilized without pain or grimace and the child was brought to the emergency department without pain or discomfort. Radiography of the lower limb confirmed a middle femoral bone fracture. She underwent orthopaedic surgery the day after the trauma and was discharged from the hospital few days later.
In France, physicians are present in the prehospital unit, and some of them are anaesthesiologists. Thus, they transfer their knowledge from the hospital to this particular spot, as regional anaesthesia. The aim of regional anaesthesia in prehospital medicine is to assure adequate analgesia allowing fracture reduction, leg immobilization, transport to the emergency department and radiographic diagnosis without pain. In this case report, 1.5% lidocaine with epinephrine was used in this single injection technique to avoid any interference with subsequent anaesthesia for the surgery. Moreover, the type of local anaesthetic solution and its concentration is still matter of debate in children for FICB [2,10]. Finally, fast onset and low toxicity made lidocaine a good anaesthetic solution in prehospital care especially for a single injection technique.
We and Lopez and colleagues described the feasibility of FICB for adults in prehospital setting [6,8]. Nevertheless, no conclusion can be drawn for paediatric patients. One interest of this case report is the feasibility of FICB for femoral bone fracture in children at the scene of trauma. The FICB allowed the child to be calmed down without the need for sedation (OPS = 0 after the block). FICB permitted to keep continue verbal contact allowing transporting the child in good conditions to the hospital. However, in our case it was a co-operative child, it may be more difficult with an agitated one where sedation is required.
FICB is an adequate tool in a prehospital setting because this non-stimulated technique is easy to perform, safe and inexpensive. Nevertheless, complications have been described anecdotally , and we have to keep in mind that regional anaesthesia must be performed carefully with adapted surveillance . As a nerve stimulator is not available in ambulances, this should be an effective method to obtain a lumbar plexus blockade. Moreover, some physicians in prehospital units in France are generalist physicians, so they don't have the right to use a nerve stimulator [6,13].
In summary, we report a successful FICB in a child performed by an anaesthesiologist in a prehospital unit. The block allowed transporting the child easily without any pain or discomfort.
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