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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

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. 


Contraindication
  • 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)
  • Obtain Verbal Consent
  • Do a neuromuscular 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 1cm inferior to this line at the junction of lateral and middle 1/3  (i.e a1cm inferior to the junction of medial 2/3 and lateral 1/3)
  • Feel for femoral artery and ensure that you are at least 3 cm lateral to it. 
  • Anesthetise skin with 2-3 ml 1% Lidocaine 
  • Injection 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 5mls. 
  • 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




Monday, July 10, 2017

Trauma Calls and Pan CT - Are we doing it the right way?

Pan CT is almost becoming a norm for trauma, regardless of examination findings. Major Trauma Centers love it. Often patients fit into the "trauma activation" criteria but are stable enough to walk into the ED, look very well and have a completely unremarkable exam. 

Do we really need to activate "trauma call" and involve an anaesthetist, orthopod and surgeon for a patient who walked into the Emergency Department or should we just observe them for a few hours? 

Is it mandatory to scan them if they alert and oriented, look well, are hemodynamically stable but meet a significant injury criteria?






Well, every scenario is different and "pan scanning" and "trauma activation" depends entirely on your gestalt in addition to vital signs and exam findings. A 90 yo on NOACs can develop a Subdural and massive hemothorax due to fall from 3 feet height whereas a 30 year old may not sustain any injuries on falling from a height of 10 feet. My threshold to activate trauma for elderly is much low as minor falls can lead to significant injuries in older adults. But I always get perturbed when I see a patient being discharged (especially young patients) from resuscitation room after a pan-scan! 

There are plenty of other issues with pan scanning:


1. Clinically Insignificant Injuries
We might end up picking clinically insignificant injuries and then ponder what to do with them? Do they just need admission or follow up or a delayed intervention? More importantly, this adds to patient anxiety, additional use of resources. Arguments offered by the proponents of Pan CT are "we never know" and "what if we miss something" etc. Unfortunately, we live in a "no miss" culture and it can be a task to explain this to a distressed patient especially in case of a mishap. But very frequently, patients do understand the pros and cons of radiation and happy to accept minimal risk instead of radiation. Shared decision making (in low risk cases) and safety netting is the way to go rather than pan-scanning. And also remember, clinical examination still remains superior to pan-scans. With all this said, hard findings on exam should certainly mandate a relevant imaging. 




2. Radiation 
More scanning leads to more radiation exposure and higher chances of developing a malignancy in future. Click here to calculate risk of malignancy with various imaging studies. 





3. Skipping examination because we are doing a  CT
Sadly, CT Scanning is now become an excuse for not performing clinical examination. Working under immense pressures of timelines, scans are now being ordered without even evaluating a patient. More than often, physicians are correct in making these decisions but medicine is being practice the other way round where we see the blood results/imaging first and then greet the patient. 

As soon as you enter the room, the patient asks - Is my scan normal? A positive nod cuts the interview very short and saves our time but at the cost of irradiation. Clinical exam is then performed only as a formality. 

Scanning reassures the patients psychologically as well as the treating physician from a medico-legal standpoint. If we are likely to get sued for missing clinically insignificant injuries, then aren't we equally liable to land up in trouble for ordering an unwarranted pan-Scan. 



4. Holding life-saving treatment 
It is unacceptable to hold life saving intervention awaiting CT scan. For instance, decision to insert a chest drain is based on clinical exam and CXR/USG. Subcutaneous emphysema is enough to justify a chest tube insertion even if CXR does not show a clear Pneumothorax. Never withhold a life saving treatment awaiting a CT scan. CT scanning rarely changes the management of blunt chest trauma. In an ideal world, any unstable (hypotensive) trauma should go to OR based on the presumed site of blood loss. Outcomes can be dramatically improved if the Surgeons/Orthopods liaise well with each other. 






CT scans are not a part of primary survey in trauma. As a clinician, you must assess ABCDE at bedside and ensure hemodynamic stability prior to scanning. 


5. Cost and Utilisation of Resources
Pan-Scanning can cost anywhere between 20,000-30,000 INR at a private hospital in India. In government run healthcare systems, the issue is wastage of time and resources. 

The difference between physicians and other healthcare providers is that physicians use clinical judgement, weigh the pros and cons before taking a decision unlike most other allied healthcare workers who are trained to follow the protocols. We all know that everyone brought in with a "high risk" mechanism of injury may not need triple immobilisation, 2 wide bore IVs and Rectal Exams. Protocols are always made with a valid rationale behind them and should always have some degree of flexibility based on the clinical acumen of treating physician. 



Guidelines are made to guide us, not to be followed as hard and fast rules. 


Summary:
Patients who require pan-CT should be carefully selected based on gestalt, mechanism, vital signs and exam findings and not just based on the mechanism. Also, consider pan-scanning for those with difficult body habitus and altered mental status (of course with some clinical judgement). We need to be more responsible when we use the power of technology and make sure everything is done keeping in mind the best interests of our patients. There is something grossly wrong if we are frequently discharging patients from ED after pan scanning (This means we suspected multiple external or internal injuries on examination, but found none on Scanning). Consider observation and good safety netting in patients with low likelihood of injuries. Likewise, Trauma Call Activation needs to be individualised and we should not be blinded by the "high risk mechanism". 


Further Reading:


  1. Surendran A, et al. Systematic review of the benefits and harms of whole-body computed tomography in the early management of multitrauma patients: are we getting the whole picture? J Trauma Acute Care Surg. 2014 Apr; 76(4):1122-30.
  2. Holmes JF, Wisner DH, McGahan JP, et al. Clinical prediction rules for identifying adults at very low risk for intra-abdominal injuries after blunt trauma. Ann Emerg Med. 2009; 54:575-584. 
  3. http://stemlynsblog.org/jc-always-need-whole-body-ct-trauma-st-emlyns/
  4. http://thesgem.com/2017/06/sgem181-did-you-ever-have-to-make-up-your-mind-pan-scan-or-leave-other-scans-behind/
  5. http://www.thebottomline.org.uk/summaries/em/react-2/
  6. Kroczek EKWieners GSteffen I, et al
    Non-traumatic incidental findings in patients undergoing whole-body computed tomography at initial emergency admission
  7. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial Sierink, Joanne C et al. The Lancet , Volume 388 , Issue 10045 , 673 - 683




    Posted by:

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

     @EMDidactic