2024; 7(3): 35-47

DOI: 10.32114/CCI.2024.7.3.35.47
Published online: 2024-09-30 (first online 2024-08-15)

Fascia iliaca compartment blocks by paramedics for suspected proximal femoral fracture in the prehospital setting: a rapid scoping review.

Jaike Bray [1,2] , Chris Pritchard [1,2] , Kacper Sumera [1,3] , Carl A. Webster [2,3] .

[1] East Midlands Ambulance Service NHS Trust, Nottingham, United Kingdom
[2] Institute of Health and Allied Professions, Nottingham Trent University, Institute of Health and Allied Professions, Nottingham, United Kingdom
[3] European Pre-hospital Research Network, United Kingdom

    Abstract:

Abstract [EN]   - INTRODUCTION: Over 70,000 cases of Proximal Femoral Fracture (PFF) occur annually in the United Kingdom (UK), primarily affecting the elderly. These injuries are associated with high morbidity and mortality, and often see inadequate pain management in the prehospital setting. The Fascia Iliaca Compartment Block (FICB), a regional anaesthesia technique, is the gold standard of care in Emergency Departments (ED). This review aims to assess the literature on paramedic-performed FICB for suspected PFF in the prehospital setting, highlighting benefits and challenges to guide future practice and policy in the ambulance sector. MATERIALS AND METHODS: A rapid scoping review was conducted following the Joanna Briggs Institute (JBI) methodology, with modifications for this project’s limitations. A systematic search of the databases CINHAL, PubMed, EMBASE, and Medline was performed. A synthesis matrix was created to extrapolate data from the included studies and allow for a coherent interpretation of results. Each included study was subject to a critical appraisal conducted using the Mixed Methods Appraisal Tool (MMAT). RESULTS: Data was extracted from three studies and two reports which identified four key themes emerged: paramedic competency in performing FICB, patient perspectives, adverse events, and training and governance. Studies showed paramedics can competently perform FICBs in prehospital settings. Verbal pain scores were lower following an FICB compared to standard care with IV morphine, which required more supplementary morphine for break-out pain. Concern for causing harm was a consistent theme among the paramedics performing FICB, particularly in precipitating an adverse event sequela. Adverse events were more common in non-FICB groups, with only one case of local anaesthetic toxicity in the FICB group, which was correctly managed by the paramedic. CONCLUSIONS: Paramedics can competently perform FICB in the prehospital setting, showing promising results in pain relief compared to intravenous morphine. However, higher-level research is needed for confirmation. Patients generally tolerated paramedic-led FICB well, with minimal concerns. Training and governance remain significant barriers to implementing FICB in local ambulance services.

Streszczenie [PL]   - WSTĘP: Ponad 70 000 przypadków złamania bliższego kości udowej (PFF) występuje corocznie w Wielkiej Brytanii (UK), dotykając głównie osoby starsze. Urazy te wiążą się z wysoką zachorowalnością i śmiertelnością, a często wymagają nieodpowiedniego leczenia bólu w warunkach przedszpitalnych. Blokada przedziału powięzi biodrowej (FICB), technika znieczulenia regionalnego, jest złotym standardem opieki w oddziałach ratunkowych (ED). Niniejszy przegląd ma na celu ocenę literatury na temat FICB wykonywanego przez ratowników medycznych w przypadku podejrzenia PFF w warunkach przedszpitalnych, podkreślając korzyści i wyzwania, aby ukierunkować przyszłą praktykę i politykę w sektorze pogotowia ratunkowego. MATERIAŁY I METODY: Przeprowadzono szybki przegląd zakresu zgodnie z metodologią Instytutu Joanny Briggs (JBI), ze zmianami dotyczącymi ograniczeń tego projektu. Przeprowadzono systematyczne przeszukanie baz danych CINHAL, PubMed, EMBASE i Medline. Stworzono macierz syntezy, aby ekstrapolować dane z uwzględnionych badań i umożliwić spójną interpretację wyników. Każde uwzględnione badanie zostało poddane krytycznej ocenie przeprowadzonej przy użyciu narzędzia Mixed Methods Appraisal Tool (MMAT). WYNIKI: Dane zostały wyodrębnione z trzech badań i wyłoniły się dwa raporty, które zidentyfikowały cztery kluczowe tematy: kompetencje ratowników medycznych w zakresie wykonywania FICB, perspektywy pacjentów, zdarzenia niepożądane oraz szkolenie i zarządzanie. Badania wykazały, że ratownicy medyczni mogą kompetentnie wykonywać FICB w warunkach przedszpitalnych. Wyniki werbalnego bólu były niższe po FICB w porównaniu ze standardową opieką z morfiną dożylną, która wymagała większej ilości dodatkowej morfiny w przypadku bólu wybuchowego. Obawa przed spowodowaniem szkody była stałym tematem wśród ratowników medycznych wykonujących FICB, szczególnie w przypadku wywoływania następstw zdarzeń niepożądanych. Zdarzenia niepożądane były częstsze w grupach bez FICB, z tylko jednym przypadkiem toksyczności znieczulenia miejscowego w grupie FICB, który został prawidłowo opanowany przez ratownika medycznego. WNIOSKI: Ratownicy medyczni mogą kompetentnie wykonywać FICB w warunkach przedszpitalnych, wykazując obiecujące wyniki w łagodzeniu bólu w porównaniu z dożylną morfiną. Jednak w celu potwierdzenia potrzebne są badania wyższego szczebla. Pacjenci ogólnie dobrze tolerowali FICB prowadzone przez ratowników medycznych, z minimalnymi obawami. Szkolenie i zarządzanie pozostają istotnymi barierami wdrażania FICB w lokalnych usługach pogotowia ratunkowego.

    Citation:

VANCOUVER FORMAT

Bray J, Pritchard Ch, Sumera K, Webster CA. Fascia iliaca compartment blocks by paramedics for suspected proximal femoral fracture in the prehospital setting: a rapid scoping review. Crit. Care Innov. 2024; 7(3): 35-47.
DOI: 10.32114/CCI.2024.7.3.35.47

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    References:

[1]	National Institute for Health and Care Institute (NICE), 2023. The management of hip fracture in adults. | (WWW) |
[2]	Royal College of Physicians (RCOP), 2023. 15 years of quality improvement: the 2023 National Hip Fracture Database report on 2022. | (WWW) |
[3]	Pourabbas B, Emami MJ, Vosoughi AR, Mahdaviazad H, Kargarshouroki Z. Mortality and Function After Surgically-Treated Hip Fracture in Adults Younger than Age 60. Acta Ortop Bras. 2017; 25(4): 129-131. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[4]	Emmerson BR, Varacallo M, Inman D. Hip Fracture Overview. StatPearls Publishing: Treasure Island; 2024. | PubMed (NCBI) | Scholar Google |
[5]	JRCALC Clinical Guidelines 2022. Association of Ambulance Chief Executives (AACE) and Joint Royal Colleges Ambulance Liaison Committee (JRCALC). | (WWW) |
[6]	Davis S, Olaussen A, Bowles KA, Shannon B. Review article: Paramedic pain management of femur fractures in the prehospital setting: A systematic review. Emerg Med Australas. 2021; 33(4): 601-609. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[7]	Herrick C, Steger-May K, Sinacore DR, Brown M, Schechtman KB, Binder EF. Persistent pain in frail older adults after hip fracture repair. J Am Geriatr Soc. 2004; 52(12): 2062-2068. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[8]	Balen RV, Essink-Bot ML, Steyerberg E, Cools H, Habbema DF. Quality of life after hip fracture: a comparison of four health status measures in 208 patients. Disabil Rehabil. 2003; 25(10): 507-519. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[9]	Morrison RS, Magaziner J, Gilbert M, Koval KJ, McLaughlin MA, Orosz G, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. 2003; 58(1): 76-81. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[10]	RCEM Clinical Guidance The Royal College of Emergency Medicine (RCEM) has clinical guidelines available for professionals working in emergency medicine. | (WWW) |
[11]	Quality Improvement Information about delivering quality care and quality improvement, alongside the Royal College of Emergency Medicine's Clinical Audit resources and reports. | (WWW) |
[12]	Wan HY, Li SY, Ji W, Yu B, Jiang N. Fascia Iliaca Compartment Block for Perioperative Pain Management of Geriatric Patients with Hip Fractures: A Systematic Review of Randomized Controlled Trials. Pain Res Manag. 2020; 2020: 8503963. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[13]	Obideyi A, Srikantharajahb I, Grigg L, Randall A. Nurse administered fascia iliaca compartment block for pre-operative pain relief in adult fractured neck of femur. Acute Pain 2008; 10(3): 145-149. | Digital Object Identifier (DOI) | Scholar Google |
[14]	Randall A, Grigg L, Obideyi A, Srikantharajah I. Fascia Iliaca compartment block: A nurse-led initiative for preoperative pain management in patients with a fractured neck of femur. J Orthop Nurs. 2008; 12(2): 69-74. | Digital Object Identifier (DOI) | Scholar Google |
[15]	Peters MDJ, Godfrey C, McInerney P, Munn Z, Tricco AC, Khalil H. Scoping Reviews (2020). Aromataris E, Lockwood C, Porritt K, Pilla B, Jordan Z, editors. JBI Manual for Evidence Synthesis. JBI; 2024. | Digital Object Identifier (DOI) | Scholar Google |
[16]	Arksey H, O’Malley L Scoping studies: towards a methodological framework. Internat J Soc Res Method. 2002; 8(1): 19-32. | Digital Object Identifier (DOI) | Scholar Google |
[17]	Pollock D, Peters MDJ, Khalil H, McInerney P, Alexander L, Tricco AC, et al. Recommendations for the extraction, analysis, and presentation of results in scoping reviews. JBI Evid Synth. 2023; 21(3): 520-532. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[18]	Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Systematic Reviews 2016; 5: 210. | Digital Object Identifier (DOI) | Scholar Google |
[19]	Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71. | Digital Object Identifier (DOI) | Scholar Google |
[20]	Haddaway NR, Page MJ, Pritchard CC, McGuinness LA. PRISMA2020: An R package and Shiny app for producing PRISMA 2020-compliant flow diagrams, with interactivity for optimised digital transparency and Open Synthesis. Campbell Syst Rev. 2022; 18(2): e1230. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[21]	McGuinness LA, Higgins JPT. Risk-of-bias VISualization (robvis): An R package and Shiny web app for visualizing risk-of-bias assessments. Res Synth Methods. 2021; 12(1): 55-61. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[22]	McRae PJ, Bendall JC, Madigan V, Middleton PM. Paramedic-performed Fascia Iliaca Compartment Block for Femoral Fractures: A Controlled Trial. J Emerg Med. 2015; 48(5): 581-589. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[23]	Jones JK, Evans BA, Fegan G, Ford S, Guy K, Jones S, et al. Rapid Analgesia for Prehospital hip Disruption (RAPID): findings from a randomised feasibility study. Pilot Feasibility Stud. 2019; 5: 77. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[24]	Vetrano DL, Calderón-Larrañaga A, Marengoni A, Onder G, Bauer JM, Cesari M, et al. An International Perspective on Chronic Multimorbidity: Approaching the Elephant in the Room. J Gerontol A Biol Sci Med Sci. 2018; 73(10): 1350-1356. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[25]	Evans BA, Brown A, Bulger J, Fegan G, Ford S, Guy K, et al. Paramedics' experiences of administering fascia iliaca compartment block to patients in South Wales with suspected hip fracture at the scene of injury: results of focus groups. BMJ Open 2019; 9(2): e026073. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[26]	Fordyce E. Allied health professional confidence in giving prehospital fascia iliaca blocks. J Paramedic Practice. 2023; 15(1): 16-26. | Digital Object Identifier (DOI) | Scholar Google |
[27]	Evans BA, Brown A, Fegan G, Ford S, Guy K, Jones J, et al. Is fascia iliaca compartment block administered by paramedics for suspected hip fracture acceptable to patients? A qualitative study. BMJ Open 2019; 9(12): e033398. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[28]	The standards of proficiency for paramedics. | (WWW) |
[29]	Williams B, Beovich B, Olaussen A. The Definition of Paramedicine: An International Delphi Study. J Multidiscip Healthc. 2021; 14: 3561-3570. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[30]	Murdoch S. Clinical decision-making and its place in paramedic practice. J Paramedic Practice. 2021; 11(5): 1–5. | Digital Object Identifier (DOI) | Scholar Google |
[31]	Murphy PB, Bechmann S, Barrett MJ. Morphine. StatPearls Publishing: Treasure Island; 2024. | PubMed (NCBI) | Scholar Google |
[32]	Electronic Medicines Compendium (EMC), 2023. Morphine sulfate 10mg/ml solution for injection: Healthcare Summary of Product Characteristic. | (WWW) |
[33]	Kassam AAM, Gough AT, Davies J, Yarlagadda R. Can we reduce morphine use in elderly, proximal femoral fracture patients using a fascia iliac block? Geriatr Nurs. 2018; 39(1): 84-87. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[34]	Hirst JA, Hill N, O'Callaghan CA, Lasserson D, McManus RJ, Ogburn E, et al. Prevalence of chronic kidney disease in the community using data from OxRen: a UK population-based cohort study. Br J Gen Pract. 2020; 70(693): e285-e293. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[35]	Merchant AA, Ling,E. An approach to treating older adults with chronic kidney disease. CMAJ 2023; 195(17): E612-E618. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[36]	Basu NN, Kald B, Heath D. Morphine delays discharge following ambulatory surgery: a prospective institutional study. J Perioper Pract. 2009; 19(8): 254-256. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[37]	Walker J, Webster CA. Pharmacological considerations for fracture management.Pharmac J. 2023; 311(7980). | Digital Object Identifier (DOI) |
[38]	Ambulance Quality Indicators Data 2024-25. | (WWW) |
[39]	Henderson T, Endacott R, Marsden J, Black S. Competence of UK paramedics in performing standard paramedic skills. J Paramedic Practice. 2023; 15(10): 410-417. | Digital Object Identifier (DOI) | Scholar Google |
[40]	Deakin CD, King P, Thompson F. Prehospital advanced airway management by ambulance technicians and paramedics: is clinical practice sufficient to maintain skills? Emerg Med J. 2009; 26(12): 888-891. | Digital Object Identifier (DOI) | PubMed (NCBI) | Scholar Google |
[41]	College of Paramedics (COP), 2018. Intubation Consensus Statement. | (WWW) |
[42]	Culture review of ambulance trusts | (WWW) |
[43]	NHS Long Term Workforce Plan. | (WWW) |
[44]	Kingston M, Jones J, Black S, Evans B, Ford S, Foster T, et al. Clinical and cost-effectiveness of paramedic administered fascia iliaca compartment block for emergency hip fracture (RAPID 2)—protocol for an individually randomised parallel-group trial. Trials 2022; 23: 677. | Digital Object Identifier (DOI) | Scholar Google |