Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric fascia iliac block. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.
Module Goals
- List indications of performing a pediatric point-of-care ultrasound fascia iliaca nerve block (POCUS-FINB)
- List the limitations of POCUS-FINB
- Describe the technique for performing POCUS fascia iliaca nerve block
- Identify anatomical landmarks accurately on POCUS
- Calculate the maximum safe weight-based local anesthetic dose
- Recognize the signs and symptoms of local anesthetic systemic toxicity (LAST) and describe the appropriate management
Case Introduction: Child with thigh pain
Sarah is a 3-year-old girl who comes into the emergency department complaining of acute thigh pain that started 30 minutes ago. She was playing on a trampoline when she accidentally fell off. She had immediate pain to the left thigh and she’s been unable to walk since the fall. Parents carried her in to the emergency department for further evaluation.
On arrival, her vital signs are:
Vital Sign | Finding |
---|---|
Temperature | 97.5 F |
Heart Rate | 130 bpm |
Blood Pressure | 97/50 |
Respiratory Rate | 22 |
Oxygen Saturation (room air) | 100% |
- What can we do for pain control in this patient? Are there opioid-sparing options?
- Can nerve blockade be utilized in this case?
- What local anesthetic is appropriate, and what is a safe dose?
- What safety precautions need to be considered for performing a regional block?
Full Video of Fascia Iliaca Nerve Block
Video 5. POCUS clip of the complete fascia iliaca block procedure. The clip starts with an initial anatomy scan, followed by needle visualization, and lastly hydrodissection.
Case Resolution
Given that the patient remains in significant painful distress despite non-opioid analgesia, you decide to incorporate POCUS-FINB to your evaluation and treatment.
The patient is evaluated by the on-call orthopedic team member and is found to have no evidence of neurovascular compromise or signs and symptoms of compartment syndrome. You confirm the availability of lipid emulsion (intralipid) in the emergency department and calculate the maximum safe dose of your anesthetic.
- The patient weighs 20 kg.
- The MAXIMUM safe dose of 0.2% ropivacaine (3 mg/kg) equals 60 mg, or 30 mL.
- Looking at your institutional guidelines and Table 2 you decide to use 12 mL, which is well underneath this maximum dose.
- You add 3 mL of saline to increase the overall fluid volume to reach the weight-based target goal of 15 mL volume for the fascia iliaca procedure.
The patient undergoes a safe and effective fascia iliaca nerve block with her pain score improving from a 10 to a 2. The orthopedic team is able to place the patient into traction prior to transfer to the operating room.
Orthopedic Clinic Follow-Up
At her orthopedic follow-up visit 4 weeks later, she’s doing well with minimal pain. Her follow up x-ray demonstrates appropriate healing with new bone formation.
Learn More…
References
- Suresh S, Polaner DM, Coté CJ. 42 – Regional Anesthesia. In: Coté CJ, Lerman J, Anderson BJ, eds. A Practice of Anesthesia for Infants and Children (Sixth Edition). Elsevier; 2019:941-987.e9.
- Gadsen J. Local Anesthetics: Clinical Pharmacology and Rational Selection. The New York School of Regional Anesthesia website, October 2013.
- Dalens B. Lower extremity nerve blocks in pediatric patients. Techniques in Regional Anesthesia and Pain Management. January 2003 2003;7(1):32-47.
- Karmakar MK, Kwok WH. 43 – Ultrasound-Guided Regional Anesthesia. In: Coté CJ, Lerman J, Anderson BJ, eds. A Practice of Anesthesia for Infants and Children (Sixth Edition). Elsevier; 2019:988-1022.e4.
Additional Reading
- Black KJ, Bevan CA, Murphy NG, et al. Nerve blocks for initial pain management of femoral fractures in children. Cochrane Database Syst Rev. 2013(12):CD009587.
- Bretholz A, Doan Q, Cheng A, et al. A presurvey and postsurvey of a web- and simulation-based course of ultrasound-guided nerve blocks for pediatric emergency medicine. Pediatr Emerg Care. 2012;28(6):506-9. PMID 22653464
- Chenkin J, Lee S, Huynh T, et al. Procedures can be learned on the Web: a randomized study of ultrasound-guided vascular access training. Acad Emerg Med. 2008;15(10):949-954. PMID 18778380
- Coté, Charles J., et al. “Chapter 42: Regional Anesthesia.” A Practice of Anesthesia for Infants and Children, Elsevier, Philadelphia, PA, 2019.
- Frenkel O, Mansour K, Fischer JW. Ultrasound-guided femoral nerve block for pain control in an infant with a femur fracture due to nonaccidental trauma. Pediatr Emerg Care. 2012 Feb;28(2):183-4. PMID 22307191
- Heffler MA, Brant JA, Singh A, et al. Ultrasound-Guided Regional Anesthesia of the Femoral Nerve in the Pediatric Emergency Department [published online ahead of print, 2022 Jan 10]. Pediatr Emerg Care. PMID 35245015
- Lam-Antoniades M, Ratnapalan S, Tait G. Electronic continuing education in the health professions: an update on evidence from RCTs. J Contin Educ Health Prof. 2009;29(1):44-51. PMID 19288566
- Lin-Martore M, Olvera MP, Kornblith AE, et al. Evaluating a Web‐based Point‐of‐care Ultrasound Curriculum for the Diagnosis of Intussusception. Academic Education and Training. 2020 Sep 23;5(3):e10526. PMID 34041433
- Marin JR, Lewiss RE, American Academy of Pediatrics CoPEM, et al. Point-of-care ultrasonography by pediatric emergency physicians. Policy statement. Ann Emerg Med. 2015;65(4):472-478. PMID 25805037
- Neubrand TL, Roswell K, Deakyne S, Kocher K, Wathen J. Fascia iliaca compartment nerve block versus systemic pain control for acute femur fractures in the pediatric emergency department. Pediatr Emerg Care. 2014 Jul;30(7):469-73. PMID 24977991
- Thigh Arteries Schema. Wikimedia Commons, 23 July 2010. Accessed 17 Dec. 2021.
- Turner AL, Stevenson MD, Cross KP. Impact of ultrasound-guided femoral nerve blocks in the pediatric emergency department. Pediatr Emerg Care 2014 Apr;30(4):227-9. PMID 24651214
- Vieira RL, Hsu D, Nagler J, et al. Pediatric emergency medicine fellow training in ultrasound: consensus educational guidelines. Acad Emerg Med. 2013;20(3):300-6. PMID 23517263
- Wathen JE, Gao D, Merritt G, et al. A randomized controlled trial comparing a fascia iliaca compartment nerve block to a traditional systemic analgesic for femur fractures in a pediatric emergency department. Ann Emerg Med. 2007. ;50(2):162-171.e1. PMID 17210208
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