Another month, another practice changer. Another needle, another spot.
This is a case you see frequently in your emergency department. She's in room 5A, or in room 19, or room 3. She's the little old lady with a broken hip. She's adorably sweet, dressed in her nightgown; her foot is shortened and externally rotated as EMS brings her in, and you sigh with relief as you realize how easy the workup will be. Nothing better than “x-ray, pain meds, page ortho,” right?
So you do all that, occasionally passing by the room while you're seeing other patients, and she just looks miserable. Incredibly uncomfortable, she really seems to be in pretty severe pain from her hip. EMS has already given her a hefty dose of narcotics, and you've already given her morphine, but you write for another dose. Fifteen minutes later, she's still in pain. “More morphine, I guess,” you think to yourself. Finally — finally! — she's calm.
Another half-hour passes, and you see the nurse has put her on some supplemental oxygen. She desaturated a bit from a little central hypoventilation. Forty-five minutes later, she's awake yet again and in incredible discomfort. You give her more morphine, and she desats. You try lower doses of narcotics more frequently. You try different narcotics. She has had only two states for the length of your entire shift (there are no beds upstairs, of course): severe pain or obtundation. Her family is there, and you tell them narcotics are really hard to titrate in the elderly.
I used to have this case all of the time, and it really bugged me. I hated that a patient under my care was in excruciating pain or knocked out, and I knew that the rest of her stay was going to be just as miserable — transferring from gurney to hospital bed, Foley placement and stooling, sitting up to get spinal anesthesia prior to surgery. My hospitalist colleagues would be playing the same game with her the entire stay. Throw in some delirium from the narcotics, a little aspiration from the obtundation, and some constipation in an already frail patient, and I worried about how my patient would do recovering.
But luckily, this is no sob story. This is no fatalistic, Kafkaesque, Dante's Inferno tale. Allow me to introduce the hip block.
The hip block, as I'm calling it, is a femoral nerve block from one of a few different routes. I'll be telling you about the fascia iliaca block (because that's the one with which I've become very familiar over the past few months), but the direct approach (the femoral block) works just as well. And practice-changers they are. I'll bullet-point the basics to keep you awake:
- Blocking the femoral nerve blocks, the anterior and medial thigh, and lower extremity.
- You use a long-acting local anesthetic. Ropivacaine is our preference.
- You inject 10-30ml next to the femoral nerve under constant ultrasound guidance.
- You're injecting into the fascia iliaca, a fascia that houses the nerve itself, so the anesthetic will creep over to the femoral nerve and turn it off.
- The block starts working in about 15 minutes and lasts 12 to 24 hours.
- The block usually takes less than10 minutes start to finish, including setup.
- It's incredibly easy with some basic familiarity with ultrasound. You can do this block if you have done an ultrasound-guided central line with a little instruction and practice.
- Safety first: You probably shouldn't do high-volume blocks like this without some basic protocol and knowledge of local anesthetic toxicity.
A huge number of online resources can help you learn more about hip blocks, some from the anesthesia literature, some from emergency medicine as well. Highland Ultrasound is my go-to source (http://highlandultrasound.com/), and YouTube has more than 50 videos, but I'd definitely recommend some formal training to set yourself up for success first. It took me about two hours of regional block workshops until I really felt comfortable with what I was seeing on the screen. I am not ultrasound fellowship trained, but I consider myself an ultrasound enthusiast.
That's my personal experience, but plenty of literature is out there if you're interested. I typically ask my patients with hip fractures how much pain they are having before and after my blocks, and I'd say most people report a 5-7/10 pain at rest and 10/10 with any movement of the hip initially. After the block, they have 0-1/10 pain at rest and 3-5/10 with movement. I consider this a major win compared with the patient with whom I struggled before. I am often giving these patients no narcotics throughout their entire ED stay (just some IV Tylenol).
A few final thoughts for skeptics, naysayers, and safety experts alike: First, I wouldn't start this without talking to ortho and anesthesia first. They'll probably love you, but this is also a motor block, so you obviously need a protocol for patients and a clearly documented neurologic exam first. Second, the risk of local anesthetic toxicity is rare but real. By doing this under ultrasound, you can see your needle tip and where you're injecting the entire time to prevent injection into a vessel. Third, there are lots of regional anesthesia courses you can take if you don't have a local ultrasound guru. Finally, this is not a pre-operative block. This is to reduce pain, not eliminate it, but it makes the process of doing a pre-operative spinal block much easier for the anesthesiologist. Patients have to sit up to have a spinal done, which is tough to do with a broken hip.
Are you doing this already? Am I late to the party? I'd love to know your thoughts.
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