Dear Editor,
We read with some dismay the results of the survey of current
practice of the administration of femoral nerve blocks in the emergency
department (ED), reported by Mittal and Vermani.[1] The survey response
rate of 230 EDs out of a possible 252, is to be commended. We are
concerned though that of the EDs that responded, only 55% regularly gave
femoral nerve blocks to patients with fractured femurs. This falls short
of the standards of care we should expect for patients with acute pain
following a femoral fracture.
It is also surprising that of the respondents who give femoral nerve
blocks, 32% preferred to use a blind technique, despite having ultrasound
in their department. This is despite the growing amount of evidence that
ultrasound provides a more superior nerve blockade than blind or even
neurostimulation.[2] More specifically, the evidence suggests reduced
block failure, faster performance of the block, a more rapid onset and
longer duration with the use of ultrasound. Safe and effective performance
of ultrasound guided femoral nerve blocks has been demonstrated in both
the elderly with proximal femoral fractures and children with femoral
fractures.[3,4]
The authors state that the reasons given for not using ultrasound
included lack of training, greater confidence in the administration of
blocks using a blind technique, and time constraints. We are surprised
that 24% replied that they did not use ultrasound because of insufficient
training. Ultrasound has become one of the major diagnostic tools of the
emergency physician and trainees are expected to be competent in its use.
Competency in the administration of the femoral nerve block is also a
component of the Acute Care Common Stem training.[5] The marriage of these
skills should equate to confidence in performing these blocks in the ED.
Time constraints should not be an excuse for substandard care, given that
the block may be performed in 8 minutes.[3]
The benefits of the use of femoral nerve blocks as part of a
multimodal analgesic approach should not be underestimated. Furthermore
the ultrasound technique will maximize the success and effectiveness of
this block. An effective nerve block in the ED may make the patient's
journey a much more tolerable experience and so should be the accepted
standard of care in this ever increasing patient population.
References
1. Mittal R, Vermani E. Femoral nerve blocks in fractures of femur:
variation in the current UK practice and a review of the literature.
Emergency Medicine Journal Feb 2013 online first (accessed 01/03/2013)
2. Abrahams MS, Aziz MF, Fu RF, Horn JL. Ultrasound guidance compared
with electrical neurostimulation for peripheral nerve block: a systematic
review and meta-analysis of randomized controlled trials. British Journal
of Anaesthesia 2009;102: 408-17.
3. Beaudoin FL, Nagdev A, Merchant RC, Becker BM. Ultrasound-guided
femoral nerve blocks in elderly patients with hip fractures. American
Journal of Emergency Medicine 2010;28: 76-81.
4. Oberndorfer U, Marhofer P, Bosenberg A et al. Ultrasonographic
guidance for sciatic and femoral nerve blocks in children. British Journal
of Anaesthesia 2007;98: 797-801.
5. Acute Care Common Stem Core Training Programme. The College of
Emergency Medicine, 2010.
Conflict of Interest:
None declared
Dear Editor,
We read with some dismay the results of the survey of current practice of the administration of femoral nerve blocks in the emergency department (ED), reported by Mittal and Vermani.[1] The survey response rate of 230 EDs out of a possible 252, is to be commended. We are concerned though that of the EDs that responded, only 55% regularly gave femoral nerve blocks to patients with fractured femurs. This falls short of the standards of care we should expect for patients with acute pain following a femoral fracture.
It is also surprising that of the respondents who give femoral nerve blocks, 32% preferred to use a blind technique, despite having ultrasound in their department. This is despite the growing amount of evidence that ultrasound provides a more superior nerve blockade than blind or even neurostimulation.[2] More specifically, the evidence suggests reduced block failure, faster performance of the block, a more rapid onset and longer duration with the use of ultrasound. Safe and effective performance of ultrasound guided femoral nerve blocks has been demonstrated in both the elderly with proximal femoral fractures and children with femoral fractures.[3,4]
The authors state that the reasons given for not using ultrasound included lack of training, greater confidence in the administration of blocks using a blind technique, and time constraints. We are surprised that 24% replied that they did not use ultrasound because of insufficient training. Ultrasound has become one of the major diagnostic tools of the emergency physician and trainees are expected to be competent in its use. Competency in the administration of the femoral nerve block is also a component of the Acute Care Common Stem training.[5] The marriage of these skills should equate to confidence in performing these blocks in the ED. Time constraints should not be an excuse for substandard care, given that the block may be performed in 8 minutes.[3]
The benefits of the use of femoral nerve blocks as part of a multimodal analgesic approach should not be underestimated. Furthermore the ultrasound technique will maximize the success and effectiveness of this block. An effective nerve block in the ED may make the patient's journey a much more tolerable experience and so should be the accepted standard of care in this ever increasing patient population.
References
1. Mittal R, Vermani E. Femoral nerve blocks in fractures of femur: variation in the current UK practice and a review of the literature. Emergency Medicine Journal Feb 2013 online first (accessed 01/03/2013)
2. Abrahams MS, Aziz MF, Fu RF, Horn JL. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a systematic review and meta-analysis of randomized controlled trials. British Journal of Anaesthesia 2009;102: 408-17.
3. Beaudoin FL, Nagdev A, Merchant RC, Becker BM. Ultrasound-guided femoral nerve blocks in elderly patients with hip fractures. American Journal of Emergency Medicine 2010;28: 76-81.
4. Oberndorfer U, Marhofer P, Bosenberg A et al. Ultrasonographic guidance for sciatic and femoral nerve blocks in children. British Journal of Anaesthesia 2007;98: 797-801.
5. Acute Care Common Stem Core Training Programme. The College of Emergency Medicine, 2010.
Conflict of Interest:
None declared