Pain therapy in patients with trauma is a relevant element of medical management and a challenge for the personnel of Hospital Emergency Departments (HEDs). Satisfactory, effective and safe methods of analgesia have been continuously searched for.  Nerve and nerve plexus blocks exhibit numerous features indicating their potential usefulness in medical emergencies.

The aim of the study was to assess the clinical usefulness of two techniques of regional analgesia, i.e. fascia iliaca compartment block and sciatic nerve block, for lower limb trauma used in the emergency department setting.

METHODS

The medical records of patients with lower limb trauma were retrospectively analysed. In patients with thigh injuries, a fascia iliaca compartment block, described by Dalens, was performed [1] (group 1). Patients with injuries of the distal shin and ankle underwent a sciatic nerve block from the popliteal approach according to Zetlaoui [2] and Vloka [3] (group 2).

In each case, idications for blocks were determined individually based on the severity of pain, type of trauma and surgical procedures to be carried out. Various doses and combinations of drugs were used depending on indications and patients’ conditions. In all cases, popliteal block was supplemented with subcutaneous circular injection of a local anaesthetic at the level of tibial tuberosity to anaesthetize the distal sciatic nerve branches.

The devices and drugs available in the HED were used, no stimulators of peripheral nerves were applied.

The effectiveness of blocks was assessed according to the local anaesthesia protocol used in the hospital. Patients evaluated their pain sensations according to the Numerical Rating Scale (NRS) from 0 – no pain to 10 maximum, imaginable pain, on admission and at min 10, 20 and 30 since the block. Additionally, the sensation of skin temperature in the anaesthetized area was assessed about 20 min after anaesthesia.

RESULTS

Medical records of 25 patients were analysed. Group 1 consisted of 6 female and 6 male patients aged 42 years whereas group 2 of 5 female and 8 male patients aged 40 years.

All patients arriving at HED were earlier provided with assistance by emergency teams or the Tatra Mountain Rescue Service. In total, 7 patients received analgesics before anaesthesia.

All fascia iliaca compartment blocks were conducted using the standard injection needle, 18 G and 3.8 cm long. The popliteal blocks were carried out with subarachnoid needles, 27 G in one, 25 G in 2 and 22 G in 11 patients.

Complete analgesia was achieved in 7 out of 12 patients in group 1, partial anaesthesia in 4. In two cases, blocks failed. One female patient with unsatisfactory block complained of moderate pain (NRS 4) despite the lack of skin sensations in the anaesthetized area.  In 10 patients with femur fractures, a direct traction was applied: in 2 cases, additional infiltration anaesthesia of the thigh skin was required, in another 2 – intravenous opioid analgesia; in the remaining patients, the anaesthesia was satisfactory. In 1 patient, bilateral sciatic nerve block was performed, one of which failed. In all cases, anaesthesia of the femoral innervation was provided. Three patients had skin sensations preserved in the region supplying the cutaneous lateral femoral nerve; in another 3 patients – skin sensations were present within the area supplied by the obturator nerve (Table 1).

In group 2, complete anaesthesia within the region of the tibial and common peroneal nerves was achieved in 6/13 patients whereas partial anaesthesia in 4 (in 1 patient – anaesthesia of the common peroneal nerve failed; in 2 – of the tibial nerve and in one of the femoral nerve branches). In 3 patients the anaesthesia was unsuccessful (Table 2). Manual reposition without additional analgesia was applied in 5 cases; in 2 other patients, general anaesthesia was needed and in 1 – supplementary opioid analgesia. One patient required sedation.

In total, complete anaesthesia was achieved in 13 out of 26 blocks performed in 25 (50%) patients. Two blocks in group 1 and 3 (19%) in group 2 failed; in the remaining 8 cases (31%), partial anaesthesia was provided.

Effective analgesia with fascia iliaca compartment block was provided in 10 cases (77%); in 11 – with supplementary methods applied (84.5%). Likewise, popliteal blocks were effective in 9 (69%) cases; in 11 (84.5%) – once other methods were additionally used. No anaesthesia-related side effects or complications were observed.

Twenty-one patients were admitted for treatment to the trauma surgery department; one patient was transported to another specialist centre while three were discharged home.  

DISCUSSION

In the 90-ties of the XX century, the term of „oligoanalgesia” was introduced to define ineffectiveness of pain management in patients with trauma admitted to HEDs [4]. It is estimated that abandonment of analgesia or ineffective analgesia involved even 40-70% of patients [5, 6, 7]. In most cases, the reasons leading to abandonment of analgesia include ungrounded fears concerning diagnostic difficulties or side effects of drugs administered [8]. Regional analgesia is rarely used, as it requires qualifications and special skills. Under some circumstances, however, this analgesia may be a valuable alternative for pharmacological methods, particularly in limb trauma cases [9, 10, 11, 12, 13, 14]. Nerve blocks do not impair the consciousness, do not depress the circulatory or respiratory system or modify pain sensations of other body regions. Depending on the drugs used, such blocks may even provide the several-hour analgesia.

A fascia iliaca compartment block and a sciatic nerve block in the popliteal region were chosen for our analysis due to their usefulness in the HED setting. No special devices are needed to perform them. Both blocks have already been successfully used even in the pre-hospital period [9, 11]. The set of necessary agents and instruments may be easily prepared in HEDs; in general, the time needed to administer them is several minutes [2]. Pharmacological pain management may be safely used as a supplement or if the block has failed. The time to provide analgesia is comparable to that of intravenous morphine [15].

The fascia iliaca compartment block is an element of the “three in one” block of the lumbar plexus. Since the needle is inserted at a safe distance from nerves and blood vessels,  the risk of complications is minimized. Moreover, the block is useful in femur fractures and knee injuries – both in adults and children [1, 10, 11, 13]. The technique does not require paraesthesia or a nerve stimulator, a single injection of local anaesthetic under the iliac fascia provides anaesthesia of the anterior, medial and lateral surfaces of the thigh. Even several minutes of training of the HED staff are enough to administer it properly [15].

The sciatic nerve block in the popliteal region is more difficult and less predictable due to anatomical conditions [2, 3, 14, 16]. Although the block may be provided with a single  local anaesthetic injection, with or without induction of paraesthesias, better results are observed when a nerve stimulator is used and both branches of the sciatic nerve are identified (which may be functionally independent even in their common part). The block enables to anaesthetize the foot as well as lateral and posterior surfaces of the shin. In order to anaesthetize the medial surface, it is necessary to block nerves circularly in the subcutaneous tissue at the level of tibial tuberosity. Successful popliteal blocks without stimulators require anaesthetic qualifications and experience in regional anaesthesia, which unfortunately limits its usefulness in HEDs.

CONCLUSIONS

1.A fascia iliaca compartment block is a useful management method in HEDs and worth recommending for medical emergencies due to its easy provision.

2. A sciatic nerve block in the popliteal region may be considered an alternative method of analgesia in lower limb trauma due to its higher equipment demands and lesser efficacy.

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REFERENCES

1.    Dalens B, Vanneuville G, Tanguy A: Comparison of the fascia iliaca compartment block with the 3-in-1 block in children. Anesth Analg 1989; 69: 705-713.

2.    Zetlaoui PJ, Bouaziz H: Lateral approach to the sciatic nerve in the popliteal fossa. Anesth Analg 1998; 87: 79-82.

3.    Vloka JD, Hadzić A, April E, Thys DM: The division of the sciatic nerve in the popliteal fossa: anatomical implications for popliteal nerve blockade. Anesth Analg 2001; 92: 215-217.

4.    Wilson JE, Pendleton JM: Oligoanalgesia in the emergency department. Am J Emerg Med 1989; 7: 620-623.

5.    Fosnocht DE, Swanson ER, Barton ED: Changing attitudes about pain and pain control in emergency medicine. Emerg Med Clin N Am 20052; 3: 297-306

6.    Petrack EM, Christopher NC, Kriwinsky J: Pain management in the emergency department: patterns of analgesic utilization. Pediatrics 1997; 99: 711-714.

7.    Selbst SM, Clark M: Analgesic use in the emergency department. Ann Emerg Med 1990; 19: 1010–1013.

8.    Gallagher EJ, Esses D, Lee C, Lahn M: Randomized clinical trial of morphine in acute abdominal pain. Ann Emerg Med 2006; 48: 150-60.

9.    Kosiński S: Analgezja z wykorzystaniem technik znieczulenia regionalnego w ratownictwie górskim. Anest  Inten Terap  2006; 38: 94-96.

10.    Wathen JE, Gao D, Merritt G, Georgopoulos G, Battan FK: A ranomized controlled trial comparing fascia illiaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department. Ann Emerg Med 2007; 50: 162-171.

11.    Lopez S, Gros T, Bernard N, Plasse C, Capdevila X: Fascia iliaca compartment block for femoral bone fractures in prehospital care. Reg Anesth Pain Med 2003; 28: 203-207.

12.    Steward B, Smith C, Teebay L, Cunliffe M: Emergency department use of a continuous femoral nerve block for pain relief for fractured femur in children. Emerg Med  J 2007; 24: 113-114.

13.    Foss NB, Kristensen BB, Bundgaard M: Fascia iliaca compartment blockade for acute pain control in hip fracture patients. A randomized, placebo-controlled trial. Anesthesiology 2007; 106: 773–778.

14.    Ledoux X: Regional anesthesia in mountain medicine. Congress of International Comission of Alpine Rescue, Zakopane 2005.

15.    Paqueron X, Bouaziz H, Macalou D, Labaille T: The lateral approach to the sciatic nerve at the popliteal fossa: one or two injections? Anesth Analg 1999; 89: 1221-1225.

16.    Fletcher AK, Rigby AS, Heyes FL: Three-in-one femoral nerve block as analgesia for fractured neck of femur in the emergency department: a randomized, controlled trial. Ann Emerg Med 2003; 41: 227-233.

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Address:

*Sylweriusz Kosiński
Tatrzańskie Ochotnicze Pogotowie Ratunkowe
ul. Piłsudskiego 63a, 34-500 Zakopane
e-mail:kosa@mp.pl

Received: 05.06.2009
Accepted: 22.07.2009