Clinical update

Pain relief for fractured neck of femur: what emergency nurses need to know

New guidance has been issued on the use of fascia iliaca block as part of pain management in emergency departments

New guidance has been issued on the use of fascia iliaca block as part of pain management in emergency departments

Coloured X-ray (front view) showing a hip fracture (at left) to the neck of the thigh bone Picture: Science Photo Library

Essential information

Every year in the UK about 65,000 people often those who are older and vulnerable sustain a common type of hip fracture called a fractured neck of femur, according to the Royal College of Emergency Medicine (RCEM) .

Of these patients, 10% will die after a month and 30% within a year.

Delivery of timely and effective analgesia

...

New guidance has been issued on the use of fascia iliaca block as part of pain management in emergency departments

Coloured X-ray (front view) showing a hip fracture (at left) to the neck of the thigh bone Picture: Science Photo Library
Coloured X-ray (front view) showing a hip fracture (at left) to the neck of the thigh bone Picture: Science Photo Library
 

Essential information

Every year in the UK about 65,000 people often those who are older and vulnerable – sustain a common type of hip fracture called a fractured neck of femur, according to the Royal College of Emergency Medicine (RCEM).

Of these patients, 10% will die after a month and 30% within a year.

Delivery of timely and effective analgesia to these patients can present major challenges for clinicians.

An RCEM audit in 2018 found almost all patients with a fractured neck of femur (93%) arrive at emergency departments (EDs) by ambulance, yet there is documented evidence of only 66% having received analgesia before arrival.

Increasingly, fascia iliaca block (FIB) is being used in EDs for pain relief in patients with fractured neck of femur.

FIB has an advantage over the use of femoral nerve block as it carries a lower risk of intraneural and intravascular injection.

What’s new?

The RCEM has published new guidance on the use of FIB in EDs.

FIB is an invasive process that involves instilling local anaesthetic into the potential space below the fascia iliaca for pain relief.

The guidance recommends that pain management for people with fractured neck of femur be instituted as soon as possible.

This suggests FIB should be available in EDs as part of the pain management strategy for patients with fractured neck of femur, although it acknowledges there are risks to consider.

The guidance includes a nurse-written competency assessment document describing a training process for nurses.

Safety considerations

Principal concerns regarding FIB are common to blocks and local anaesthetic use:

  • The possibility of trauma to closely associated structures, including femoral canal structures.
  • Local anaesthetic toxicity patients should be closely monitored during and after the procedure, and intralipid should be easily available for treatment in clinical areas.
  • Risks of infection and bleeding post-procedure.
  • Failure of technique to provide analgesia.

Other recommendations

Administration of FIB should only be undertaken by clinicians who have completed competency assessment in this skill.

An up-to-date departmental log of competent personnel should be kept.

In departments where FIB is administered, the guidance also recommends that there should be a policy available that includes details of competency assessment, monitoring of patients and treatment of complications.

The use of an invasive procedure checklist and a ‘Stop before you Block’ process is recommended.

Expert comment

Linsey SheerinLinsey Sheerin is interim service manager in the emergency department at Royal Victoria Hospital, Belfast

‘Effective and timely management of pain is a key component of the patient experience and quality of care. However, increasing demand complexity combined with crowding can often have repercussions.

'While administering opiates is often much quicker, the use of morphine is not without problems.

‘In our older population there is an increased risk of drug interactions as well as interference with chronic organ dysfunction.

‘Fascia iliaca block provides an alternative to the management of pain for these patients presenting with a hip fracture. However, only appropriately trained and competent practitioners should undertake this.

‘The Royal College of Emergency Medicine (RCEM) endorses adequately trained emergency nurses to carry out this procedure and champion excellence in this area.

RCEM best practice guidance on fascia iliaca block is an essential read for all emergency nurses.’

Find out more

Royal College of Emergency Medicine (2020) Best Practice Guideline: Fascia Iliaca Block in the Emergency Department

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