Pain ManagementThree-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: A randomized, controlled trial*
Introduction
Fractured neck of femur causes significant mortality and morbidity in elderly patients. Even with optimum so-called fast tracking of these patients through hospital admission, surgery, and rehabilitation, mortality rates of 18% at 90 days can be anticipated.1 Patients with fractured neck of femur are often in considerable pain, and minimizing this has important implications for patient comfort and reduction of morbidity and mortality.2 The 3-in-1 femoral nerve block is a safe and widely practiced local anesthetic technique used to supplement anesthesia and provide postoperative analgesia after hip surgery.3 Local anesthetic infiltrates the femoral nerve sheath and tracks cranially and laterally to anesthetize the femoral and obturator nerves, the lower cords of the lumbar plexus, and the lateral cutaneous nerve of the thigh (Figure 1).Two previous studies4, 5 have shown that femoral nerve block provides effective analgesia for patients with fractured neck of femur in the emergency department, but each relied on one practitioner's expertise for block administration and might consequently have been relatively selective in patients recruited. One of these studies5 did not have a control group. Another recent study6 has successfully used 3-in-1 femoral nerve block for fractures of the upper femur, but the study population was not clearly described, had no control group, and once again relied on expert block administration.
This study was conducted to assess whether 3-in-1 femoral nerve block is effective when taught to and implemented by ED medical staff. Our study was powered to detect a 40% reduction in pain scores in those given a nerve block. The applicability of the technique has been evaluated in a United Kingdom district general hospital ED setting.
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Materials and methods
The study was conducted in the ED of our medium-sized district general hospital in the United Kingdom. The ED handles 65,000 new attendances per year. Local research ethical committee approval for the study was obtained. Patients were recruited during a 6-month period, from February until August, coinciding with senior house officer (intern) posts. Two consultants, 4 middle-grade physicians, and 7 senior house officers staff our ED. An accreditation package was developed for all ED medical
Results
The characteristics of the 2 patient groups are given in Table 1.Variable Study Patients (N=24) Control Group (N=26) Mean age, y (SD) 76 (13) 80 (9) Female sex, No. (%) 17 (71) 18 (69) Intertrochanteric, No. (%) 15 (63) 15 (58) Subcapital-transcervical, No. (%) 9 (37) 11 (42) Mean time to surgery, h (SD) 29.3 (20.8) 27.4 (16.5) Mean pain score on arrival (SD) 2.8 (0.4) 2.7 (0.6)
Discussion
We show that 3-in-1 femoral nerve block is effective in producing analgesia in the ED for patients with fractured femoral neck. Analgesia is achieved substantially quicker in patients receiving the nerve blocks, and these patients require less morphine, reproducing the findings of other studies. This has many potential advantages for patient care, and above all, our data show that the 3-in-1 nerve block technique can be generally applicable. The frequency of admissions of patients with
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Address for reprints: Alan Fletcher, MRCP(UK), Department of Emergency Medicine, Northern General Hospital, Herries Road, Sheffield, United Kingdom S5 7AU; +44 0114 2714741, fax +44 0114 2560472; E-mail [email protected].