You are all probably aware that the service line is invested in having all of us trained and placing femoral nerve blocks for hip fractures. These blocks provide significant analgesia for 24-36 hours and minimize the complications of opioid medications that we have traditionally given. This is especially true of our elderly patients who are obviously most likely to suffer a hip fracture.
Education:
We have an educational process in place.
- You should have the opportunity to practice nerve blocks at your next Bioskills training.
- You can spend time in the PACU with our local block expert Attila Kett. Text me and I can slot you into a week. Usually we touch base with him on Mondays and the most high yield day is Thursdays when a lot of ortho cases are going. It is a nice day – meet in the PACU at 7am. I would stay until all the ortho cases were done – about 6 hours.
- Call anesthesia – they will bring their equipment down to have the block done, but are willing to walk you through a block.
- If anesthesia is unable to come to the ED for your hip fracture, call me. If I can make it, I’ll come in and do the block with you so you can teach the next person.
- There are online resources available at nwhed.org, including a review of the fascia iliaca block we will be using, the nerve block checklist which can be printed prior to the procedure, guidance on LAST treatment and the EMSL Guideline.
- For ultrasound savvy folks, 2 observed blocks are required per EMSL guidelines, and for the novice, 10 blocks are required.
Order Set
For the procedure itself, there is an order set in meditech, titled ED: Nerve Block. The orders for anesthetic are here as well as for Intralipid in the exceedingly rare case of a patient with LAST (local anesthetic systemic toxicity). You can use this order set for any other local or regional blocks you are doing should you suspect LAST.
Procedure Cart
The new procedure cart should have a Nerve Block Kit, probe sheath and block needle which you will need for the procedure.
Documentation
You can document the procedure using the .usnerveblock or .usblock dotphrases/quicktexts. This can be anywhere in your note, but would be appropriate to place in the “ultrasound” tab.
Complications
Again, complications are very rare. There is always the possibility of hematoma, or infection when you go through the skin. These patients will be on the monitor to screen for signs of LAST toxicity. LAST may begin with tinnitus, perioral numbness, and then cardiac signs – tachycardia, hypertension. These may progress to seizure > coma > death. Again this is exceedingly rare and the treatment is in the pyxis with dosing in the order set if needed. Nursing education has done a great job of bringing our nurses up to speed.
Hit me up with any questions, but especially if you want to spend time in the PACU – our new chief is going to be one of the first to spend time up there!