Professional Documents
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COPYRIGHT 2008
BY
THE JOURNAL
OF
BONE
AND JOINT
SURGERY, INCORPORATED
DISCLOSURE: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of
their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial
entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit
organization with which the authors, or a member of their immediate families, are affiliated or associated.
J Bone Joint Surg Am. 2008;90 Suppl 2 (Part 2):218-26 doi:10.2106/JBJS.H.00314
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INTRODUCTION
In most emergency departments, the pace is fast and there
is a constant flow of personnel.
Amid all of this activity, addressing the acute pain of a femoral
fracture may not be a top priority. However, most patients use
descriptors such as excruciating or the worst pain imaginable when describing the acute
pain that they experienced in association with a femoral fracture.
A femoral nerve block can provide effective pain relief and can
be delivered safely in the emergency department with the appropriate equipment and
education of the staff.
SURGICAL TECHNIQUE
After the primary and secondary assessments have been
completed and it has been deter-
FIG. 1
Nerve stimulator and injection kit.
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FIG. 2
Contents of the nerve block kit: stimulating needle assembly, 35-mL syringe, 18-gauge needle, 25-gauge needle, prepackaged lidocaine syringe, grounding electrode (with spare), povidone-iodine swabsticks (three), sterile gloves, 30 mL of 0.5% bupivacaine.
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FIG. 3
Patient and equipment positioning.
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FIG. 4-A
Regional landmarks. A = anterior superior iliac spine, B = pubic tubercle,
and C = inguinal crease.
FIG. 4-B
Pertinent underlying anatomical structures include the femoral nerve, artery, and vein; the
inguinal ligament; and the sartorius, iliopsoas, and pectineus muscles.
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FIG. 5
Injection of 2% lidocaine at the anticipated site of stimulating needle placement.
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FIG. 6--A
Localization of the femoral nerve with the stimulating needle. The palpating hand is positioned with the fingers overlying the femoral artery
pulse. The patella (shown covered in this image) should be visible during this process so patellar twitch can be seen.
FIG. 6-B
Administration of the block.
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CRITICAL CONCEPTS
INDICATIONS:
Femoral nerve block placement in the emergency department has been shown to be effective during the treatment of diaphyseal and/or distal femoral fractures (both closed and open) in awake and alert adults who are able to respond appropriately to questions and who have a normal neurovascular examination of the injured extremity.
CONTRAINDICATIONS:
Intubated or obtunded patients or other patients who are not able to respond to questions and follow commands,
thereby precluding an adequate examination.
Patients with an injury history that is consistent with a crushing or other mechanism that places them at increased risk
for compartment syndrome.
Patients with physical examination findings that are consistent with compartment syndrome or impending compartment
syndrome.
Patients with an abnormal neurovascular examination or an unstable spine injury.
Patients with a history of a bleeding diathesis or an abnormal coagulation profile associated with a potential risk for
the development of an injection site hematoma.
PITFALLS:
Inability to access the necessary equipment in a timely fashion. This pitfall can be avoided through communication with
the emergency department staff and the trauma team before implementation of the technique and by performing a dry
run of the procedure in the trauma bay before performing it in a tense environment with an actual trauma patient.
Local anesthetic toxicity. This pitfall can complicate regional anesthetic techniques secondary to two primary mechanisms. Either the administration of an excessive amount of local anesthetic or inadvertent intravascular injection can
result in severe patient compromise. Gross overdose is readily avoided by adhering to maximum dosing guidelines; in
this case, no more than 3 mg/kg of bupivacaine is injected into the perineural space. As an example, an 80-kg patient
may safely receive 240 mg of bupivacaine (48 mL of a 0.5% bupivacaine solution). Note that this dose represents a
true minimum toxic dose yet is >50% greater than the dose that was delivered in our study population. Substantially
lower doses can produce toxic responses if injected intravascularly. Intravascular injection is avoided by frequent aspiration for blood and incremental injection with continuous monitoring for signs of toxicity such as tinnitus, circumoral
numbness, tachycardia, nystagmus, and central nervous system excitation or depression. Current approaches to
the management of local anesthetic toxicity include the selection of less toxic alternatives, such as ropivacaine or
levobupivacaine, ultrasound guidance to identify and avoid vascular structures, and the immediate availability of a lipid
emulsion such as Intralipid (Fresenius Kabi, Uppsala, Sweden). A lipid emulsion acts as a lipid sink for the fat-soluble
local anesthetics. Use of this agent has resulted in markedly improved survival after local anesthetic overdose-induced
cardiac and central nervous system dysfunction1. Unidentified intravascular injection or gross overdose are unlikely
events when this procedure is performed while carefully following the technique as described; neither has been reported in the peer-reviewed literature, to our knowledge.
Technical pitfalls, including equipment failure. A battery that lacks a full charge or improper electrical connections can
result in inadequate current delivery and failure to elicit a twitch response. The former problem can be prevented by ensuring that the stimulator is maintained with a charged battery. The latter problem can be avoided by understanding the
circuit between the patient and the stimulator required for proper stimulator function. Current delivery depends on a
closed circuit. If the light-emitting diode fails to flash, the electrocardiogram electrode and the wire connections should
be checked.
Injection of anesthetic too far distant from the femoral nerve. As mentioned above, the branch of the femoral nerve to
the sartorius muscle tends to arise anterior to the main trunk of the femoral nerve. The sartorius twitch response is
frequently encountered en route to the true quadriceps twitch of the femoral nerve itself. Premature injection on the
sartorius twitch will result in an excellent block of the sartorius but a failed femoral nerve block, which will provide inadequate anesthesia. Elicitation of a true quadriceps twitch is essential.
continued
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CRITICAL CONCEPTS
PITFALLS (CONTINUED):
Prolonged paresthesias in the femoral nerve distribution. This complication has been reported to occur very rarely, with an
incidence of 0.03%2. Brull et al. recently reported on neurological complications after regional anesthesia3. Their review of
13,378 femoral nerve blocks from four studies revealed fifty-two instances of prolonged paresthesias and one case that
had failed to resolve completely after twelve months. The cause of this complication is most likely multifactorial and may
be due to direct nerve injury, compression by hematoma, or local anesthetic toxicity. While this complication has been
shown to be rare, it should be included in the discussion of risks and benefits with the patient.
AUTHOR UPDATE:
Current data suggest that the utilization of ultrasound-guided nerve localization hastens, simplifies, and improves the accuracy of regional anesthetic/analgesic techniques4. This technique has not been reported in the emergency department
scenario and is not currently used in our facility. Our results with the simple nerve stimulator technique for nerve localization demonstrated that this method is effective. Nevertheless, ultrasound is being used for regional anesthesia needle
guidance in the elective setting and, if it can be carried out as efficiently in the emergency department setting as is the
technique of localization with the use of the nerve stimulator, a future study comparing the effectiveness of the two techniques will be undertaken.
Disposables, Hartland,
Wisconsin).
Erik J. Jensen, MD
Michael A. Manka Jr., MD
Mark J. Anders, MD
Lawrence B. Bone, MD
Departments of Anesthesiology (E.J.J.), Emergency
Medicine (M.A.M. Jr.), and Orthopaedic Surgery
(M.J.A. and L.B.B.), Erie County Medical Center,
462 Grider Street, Buffalo, NY 14215
The line drawings in this article are the work of
Jennifer Fairman (jfairman@fairmanstudios.com).
REFERENCES
1. Whiteside J. Reversal of local anaesthetic
induced CNS toxicity with lipid emulsion. Anaesthesia. 2008;63:203-4.
2. Auroy Y, Benhamou D, Bargues L, Ecoffey
C, Falissard B, Mercier FJ, Bouaziz H, Samii
K. Major complications of regional anesthesia in France: The SOS Regional Anesthesia
Hotline Service. Anesthesiology. 2002;
97:1274-80. Erratum in: Anesthesiology.
2003;98:595.
NOTE: The authors thank Mark Barnett and Van Sikes for
their assistance with the preparation of the figures for this
article.
Christopher E. Mutty, MD
Department of Orthopaedic Surgery, Wake Forest
University Health Sciences, Medical Center Boulevard, Winston-Salem, NC 27157. E-mail address:
cmutty@buffalo.edu