Winter arrives in Minnesota with a snowy vengeance as an ice-storm hits Rochester on December 1.  An unfortunate 96-year-old female arrives to the emergency department (ED) from a rural county hospital with left hip pain after a slip on her driveway while trying to retrieve the mail. She has osteoporosis and a handful of prior falls over the last 5-years.  X-ray demonstrates an intertrochateric fracture.  As you evaluate her future fall risk (https://gearnetwork.org/2021/07/05/gear-1-falls/ and http://pmid.us/33977589 and http://pmid.us/25293956) and contemplate her immediate pain management strategies while awaiting Ortho-Trauma recommendations, you note that her blood pressure is 90/40 after 25 mcg of fentanyl and she is still very uncomfortable.  You wonder whether a (fascia illiaca, pericapsular nerve group [PENG] hip block, or femoral) nerve block would be a safe alternative analgesic strategy that would be acceptable to the Ortho-Trauma service. Remembering a prior Journal Club on this topic at Washington University (https://emergencymedicine.wustl.edu/items/6389/) as well as prior episodes of both Skeptics Guide to Emergency Medicine (https://thesgem.com/2015/11/sgem138-hip-to-be-blocked-regional-nerve-blocks-for-hip-and-femoral-neck-fractures/) and EM Cases (https://emergencymedicinecases.com/regional-nerve-blocks-hip-fractures/) you are also cognizant of the potential harms of these nerve blocks associated with anesthetic toxicity. You also note that the American Academy of Orthopaedic Surgeons provide a strong recommendation favoring multimodal analgesia pre-operatively including nerve blocks (see page 41 of https://www.aaos.org/globalassets/quality-and-practice-resources/hip-fractures-in-the-elderly/hipfxcpg.pdf).

Patient – older adults in the ED with a hip fracture

Intervention – ultrasound guided single injection regional nerve block with any local anesthetic for analgesia (femoral nerve block, 3-in-1 nerve block, fascia iliaca block, PENG hip block)

Control – standard pain management strategy without regional nerve block

Outcomes – pain scores during ED period of care, time to effective analgesia, delirium, opioid side effects (hypotension, vomiting), anesthetic toxicity, recovery & hospital length of stay.

You use PubMed Clinical Queries for “therapy” and “hip fracture anesthesia” and then combine that Clinical Queries search with “emergency*” to narrow the search to 131 documents (https://tinyurl.com/MayoEMJCSearchDec24). The PubMed Clinical Queries search yields multiple systematic reviews over the last 5 years. You also find multiple published study protocols that are apparently not yet completed, so you make a note to check back on this topic in a few years.

PGY-1’s:  The Effect of Fascia Iliaca Compartment Blockade on Mortality in Patients with Hip Fractures:  Systematic Review and Meta-Analysis of Randomized Controlled Trials

PGY-2’s:  Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture:  A Randomized Controlled Trial PGY-3’s:  Point-of-Care Ultrasound-Guided Regional Anaesthesia in Older ED Patients with Hip Fractures:  A Study to Test the Feasibility of a Training Programme and Time Needed to Complete Nerve Blocks by ED Physicians after Training [Answer Key]