Pepe Joseph, Ausman Chelsea, Tafti Dawood, Madhani Neal B.
CRDAMC DEM
Brooke Army Medical Center
Pain management is an integral part of providing care in the emergency setting. Lower extremity pain from hip fractures, burns, and other trauma is a common presenting complaint. Pain management can be complex due to medication side effects, patient preferences, and other patient characteristics that can make intravenous analgesia less desirable. Opioid medications can be associated with respiratory depression, hypotension, mental status changes, and vomiting. Non-steroidal anti-inflammatory drugs (NSAIDs) can increase bleeding risk and exacerbate underlying gastrointestinal (GI) problems. Acetaminophen alone is often not sufficient for severe pain. Hip fractures, in particular, can cause considerable pain and frequently occur in elderly adults with multiple comorbidities, which makes analgesia challenging. A fascia iliaca compartment block can provide superior analgesia with minimal side effects. This block can be deployed quickly after a small amount of training and can be executed with high success rates under ultrasound guidance. In a study by Monzon et al, patients who received a fascia iliaca compartment block for a hip fracture had significantly reduced pain levels. The pain was initially rated at an average of 8.5 on a 10-point scale but decreased to an average of 2.3 at 2 hours postinjection. In a study by Stevens et al, patients who underwent a fascia iliaca compartment block used significantly less morphine over 24 hours than the control group, which used morphine alone. An additional advantage is the duration of effect, which has been seen for 8 to 10 hours following a single shot block. Another randomized placebo-controlled trial showed that pain relief was superior at all time points measured in the fascia iliac compartment block group as compared with a group utilizing morphine only. Median total morphine consumption in the compartment block group was 0 mg due to excellent analgesia after only a compartment block. Similar results were seen in a study by Lopez et al for femoral shaft fractures. Emergency department-specific studies using ultrasound guidance have shown 76% mean reduction of pain score in patients with hip fractures at 120 minutes. Notably, some physicians now prefer to use a pericapsular nerve group (PENG) block over the fascia iliaca block technique. Some studies suggest that the PENG technique provides superior pain control. Either method provides an important opiate sparing alternative for pain management in these patients.
疼痛管理是急诊护理的一个重要组成部分。髋部骨折、烧伤和其他创伤引起的下肢疼痛是常见的就诊主诉。不幸的是，由于药物副作用、患者偏好以及其他可能使静脉镇痛不太理想的患者特征，疼痛管理可能会很困难。阿片类药物可能会导致呼吸抑制、低血压、精神状态改变和呕吐。非甾体抗炎药会增加出血风险并加重潜在的胃肠道问题。单独使用对乙酰氨基酚通常不足以缓解重度疼痛。尤其是髋部骨折，会引起相当大的疼痛，并且常发生在患有多种合并症的老年人中，这使得镇痛具有挑战性。髂筋膜间隙阻滞可以提供效果优异且副作用最小的镇痛。经过少量培训后就可以以相对快速的方式进行操作，并且在超声引导下可以获得很高的成功率。在蒙松等人的一项研究中，接受髂筋膜间隙阻滞治疗髋部骨折的患者疼痛水平显著降低。疼痛最初在10分制量表上平均评分为8.5分，但在注射后2小时降至平均2.3分。在史蒂文斯等人的一项研究中，接受髂筋膜间隙阻滞的患者在24小时内使用的吗啡量明显少于仅使用吗啡的对照组。另一个优点是作用持续时间，单次注射阻滞的效果可持续8至10小时。另一项随机安慰剂对照试验表明，与仅使用吗啡的组相比，在髂筋膜间隙阻滞组测量的所有时间点疼痛缓解效果都更优。事实上，由于仅进行间隙阻滞就有出色的镇痛效果，间隙阻滞组的吗啡总消耗量中位数为0毫克。洛佩兹等人对股骨干骨折的研究也得到了类似结果。使用超声引导的急诊科专项研究表明，髋部骨折患者在120分钟时疼痛评分平均降低76%。
