LOADING AWESOME
'EMERGENCY'
FASCIA ILIACA BLOCK
www.propofology.com
Dr. David Lyness
@Gas_Craic
The fascia iliaca covers three of the four main nerves of the lower extremity.
Pre-op and post-op
hip fracture patients.
FAST, EASY, SAFE
Pain is not good for the cohort most likely to have broken their hips (elderly), rapid access to this analgesic block should be a standard of care.
The idea being that you place a high volume of local anaesthetic in the fascia iliaca compartment to bathe the femoral nerve and provide rapid and long lasting analgesia.
The block itself is usually not dense enough as a solo agent for surgery, but it is definitely enough for pre and post-op analgesia in a lot of cases.
It is likely that using ultrasound provides safer, denser blocks with a higher success rate, but if landmark, this is a low-skill, inexpensive analgesic method.
Posterior aspect of the thigh is not blocked.
Pain affecting the thigh, the hip joint and/or the femur
Prepare:
2x Syringe with 20ml of diluted LASkin marker (if needed)
5ml of1% Lidocaine
Blue Needle (or similar),
Blunted/Short-Bevel Needle,
Dressing Pack, Sterile Gloves,
Chlorhexidine Wash
Wash hands.
1. LANDMARKS - feel for the femoral pulse, find the anterior superior iliac spine and the pubic tubercle. - Divide the line between ASIS and PT into three.
- 1cm inferior to the lateral and medial third junction = injection point
- The femoral PULSE should be 1.5-2cm away from this point = safety
2. Clean skin and infiltrate 1% lidocaine into local tissues at the point.
- Leave for a few minutes so the LA can act.
3. - Insert blunted/bevel needle at a right angle to the skin.
- Once in, adjust needle to slightly toward the head (60 degrees)
- Keep this needle in the sagittal plane to avoid vessels/peritoneum.
- Advance the needle slowly.
- Fascia Lata then Fascia Iliaca Penetration will let you feel two 'POPS'
- After 2nd POP, reduce the angle to 30 degree and advance 1-2mm
4. ASPIRATE - should be negative. Then aspirate every 5ml of LA injected - should also be negative and resistance free. If there is resistance - you are likely in the iliacus muscle, so withdraw slightly.
NO PAIN OR PARAESTHESIA SHOULD BE FELT ON INJECTION - STOP IF THIS OCCURS.
LA shouldn't return too much on aspiration, but it is common to see on syringe changes.
30-40ml of long-acting local anaesthetic should be used for the VOLUME,
The actual dose (mg) of LA is dependent on patient's weight and can be diluted
into the required higher volume. Always calculate your mg/kg dose.
Common agents include BUPIVACAINE, LEVOBUPIVACAINE and ROPIVACAINE.
MAX DOSES
Bupivacaine = 2mg/kg
Levobupivacaine = 2.5mg/kgRopivacaine = 3mg/kg
(all without adrenaline)
Femoral nerve, LFCN
Obturator nerve.
