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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 


Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland
drlakshayem@gmail.com

Monday, July 17, 2017

Fascia Iliaca Compartment Block (FICB)

Nerve blocks are used in Emergency Departments to decrease the need for systemic analgesia and avoid opioid/NSAID side effects especially in elderly population. One of the commonly performed block is Fascia Iliaca Block for fractured femurs. The major advantage of a FICB is that the nerve and artery can be avoided as the site of injection is much lateral to Femoral artery in contrast to Femoral Block. It is important to note that FICB is a compartment block and thus needs at least 30ml of Local Anesthetic

Let's review the anatomy of femoral nerve and then go through through the landmark technique to perform FICB.


Anatomy 

Femoral Nerve
The femoral nerve is formed from the lumbar plexus ( L2 to L4). It supplies periosteum of the femur, motor innervation to the extensors of the knee, sensory innervation to the anterior thigh, anteromedial aspect of the knee, medial lower leg and the medial aspect of the ankle and foot. 


FN emerges below the inguinal ligament lateral the femoral vein and artery. It is covered by, and separated from the vascular bundle by the fascia iliaca. Overlying fascia iliaca, there is fascia lata which runs together with the fascia iliaca laterally. The fascia iliaca compartment within the pelvic brim also contains the lateral cutaneous nerve of the thigh laterally. This nerve supplies sensory supply to the lateral thigh.

Red dot on the image above represents the site of injection. Note, it is at least 2-3cm lateral from femoral artery unlike femoral block.  


FICB

This compartment allows deposition of local anaesthetic of sufficient volumes (at least 30mls) spread to at least two of the three major nerves that supply the medial, anterior and lateral thigh with one simple injection, namely the femoral and lateral femoral cutaneous nervesObturator nerve is often not blocked despite good technique. 

Indication: Peri-operative analgesia for patients with neck of femur or femoral shaft fractures. 


Contraindications
  • Patient not co-operative or refusing
  • Allergic reaction to Local 
  • Infection over the site
  • Previous femoral-bypass surgery
  • Anticoagulation – INR >1.5 (Relative)

Equipment
1 One Compartment Tray 
1 FIB Needle
1 Injection needle 25G
1 Drawing Up needle 18G 

1 Syringe 5 ml
2 Syringes 20 ml
5 Gauze swabs 

Intralipid


Technique (Landmark)
  • Place the patient supine and obtain Verbal/Written consent
  • Do a neurovascular exam prior to the block
  • Follow Aseptic precautions
  • Draw a line between ASIS and Pubic Tubercle and divide it into 3 parts (see image below)
  • Point of injection is 1-2cms inferior to this line at the junction of lateral and middle 1/3  (i.e 1cm inferior to the junction of medial 2/3 and lateral 1/3)
  • Feel for femoral artery and ensure that you are at least 3-4 cm lateral to it. 
  • Anesthetise skin with 2-3 ml 1% Lidocaine 
  • Inject Bupivacaine - Advance the needle and feel for two distinct “pops” (fascia lata and then fascia iliaca). Advance the needle a further 1-2mm.
  • Aspirate, and if negative inject slowly. There should be no resistance to injection. If there is, it means you are too deep. Withdraw the needle until injection is easy. There should be no pain or paraesthesia on injection. Inject slowly, aspirating with every 2-3 mls. 
  • Withdraw the needle at the end of the procedure and apply a little pressure to the area for up to two minutes. The idea to to ensure maximum drug is delivered proximal to the site of injection and thus reaching all the three nerves. 



Draw a line between ASIS and Pubic tubercle and inject local 1cm inferior to the junction of medial 2/3 and lateral 1/3. Inject liberally at least 30mls of 0.25% Bupivacaine.



Take Home
  • FICB is an effective way to provide pain relief and avoid side effects of systemic pain killers.
  • It is a compartment and thus adequate amount of local needs to be injected. 
  • It aims to block three nerves (Femoral, Obturator and Laternal Cutaneous). Despite a good technique, obturator is often not blocked. 


Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic




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