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Some of us in our ED, perform US guided 3-in-1 blocks, and there is a movement in Wales to make the landmark fasca iliaca block standard practice, to limit opiate use.
 
In some S. Wales hospitals, fascia iliaca blocks are routinely placed by orthopaedic nurse practitioners, and in the N. Wales hospitals there is a move to also make this standard practice, but the issue with that is to have an ever-present constant workforce appropriately trained (& available) to deliver the block.
 
The obvious advantage of the fascia iliaca block being that it is a much safer block landmark-wise, and therefore has an easier learning curve. Currently some of the orthopaedic medical & nursing staff are learning these, but we are still a way off having someone trained and always available & free to undertake them for every patient.
 
Also my FCEM CTR was about US guided femoral & 3-in-1 blocks, but most of the evidence is US vs. Nerve stim & always tend to be in elective pre-ops rather than traumatic injuries, so there is the issue about generalisability.
 
Ash Basu,
Consultant Emergency Physician,
Wrexham Maelor Hospital
From: [log in to unmask] href="mailto:[log in to unmask]">william niven
Sent: Wednesday, January 23, 2013 10:32 AM
To: [log in to unmask] href="mailto:[log in to unmask]">[log in to unmask]
 
Dear all
We are currently putting together a national guideline for the ED management of fractured NOF in Ireland. Not wishing to re-invent the wheel, we have been borrowing extensively from  both the NICE and SIGN guidelines. Some pain management issues nevertheless require some clarification which I would be grateful for your thoughts and reflections on!
 
1. NICE does not clarify initial dosages for the admin of opioids. Reading the following articles from anaesthesiology  had some interesting insights but was nevertheless in a post-op, PACU setting with close monitoring and small nurse to pt ratios. Unsure of its generalizability...
http://journals.lww.com/anesthesiology/Fulltext/2002/01000/Postoperative_Titration_of_Intravenous_Morphine_in.9.aspx
http://journals.lww.com/anesthesiology/Fulltext/2002/01000/Anesthesiology_and_Geriatric_Medicine__Mutual.6.aspx
Does anyone have any specific policy with respect to IV opiates in the elderly, or has there been any reliable research done on this in the ED setting?
 
2. The use of 3 in 1 / fascia iliaca blocks is gaining popularity. The evidence seems to suggest that we should be doing these under US guidance.
a) Are any departments doing these as a standard of care?
b) Is it ED or anaesthetics personnel that are doing them?
c) Have any departments been pushing this under US guidance?
A good best-bet was done on this topic http://bestbets.org/bets/bet.php?id=1024 but the real crux of the issue seems to be related to implementation and capacity building in departments with junior docs and poor staffing.

3) Does anyone do any form of initial delerium screening on their NOF patients in the ED? If not, should we, or should this be the remit of ortho-geriatrics / anaesthetics/ICU?
 
Lots of questions, looking forward to your responses!
Regards
Will Niven