Femoral nerve block for femoral shaft fractures in a paediatric Emergency Department: can it be done better?

BACKGROUND: The relatively simple technique of administering a femoral nerve block is known to be quick, safe and effective in providing prolonged analgesia to children with femoral shaft fracture. Although medical literature supports its use in the emergency setting, no studies have been conducted on how this is undertaken in practice.

OBJECTIVE: The aim of this study is to describe the practice of femoral nerve block in previously well children who present to our Emergency Department with femoral shaft fracture.

SETTING: This study was conducted at the Emergency Department of a tertiary paediatric hospital in Sydney, Australia.

METHODS: A retrospective descriptive study was conducted by gathering data on all patients presenting to the Emergency Department between 1 January 1996 and 1 July 2001 with traumatic fracture to the femoral shaft. Whether femoral nerve block had been performed in the emergency setting; the time taken for femoral nerve block to be performed; the type of local anaesthetic used; the dose of local anaesthetic administered, and the level of training and area of expertise of doctors performing the femoral nerve block were determined from the clinical records. One-way analysis of variance and Student's t-tests were conducted to compare the average dosages of local anaesthetic used by the different medical sub-specialities involved. Student's t-tests were applied to analyse the time differences for performing femoral nerve block between emergency- and non-emergency-based medical staff.

RESULTS: The majority (111) of the 117 patients who met the inclusion criteria for the study had isolated femoral shaft fractures (94.9%). Femoral nerve blocks were performed in 97 of our study patients (82.9%). No correlation was found between the age of the child and the time taken for a femoral nerve block. In 76 cases in which a femoral nerve block was given (64.9%), a member of staff external to the Emergency Department performed the procedure. The average time taken for a femoral nerve block to be performed for non-Emergency Department medical staff was significantly longer than for Emergency Department medical staff. In only 37 cases (31.9%), was a femoral nerve block administered within an hour of the time of triage. Doses used by non-anaesthetists were lower than those used by anaesthetists.

CONCLUSION: There is unnecessary delay in carrying out this procedure for children with fractures to the femoral shaft. A significant degree of reliance on staff external to the Emergency Department was reported. This paper supports increased training and supervision to promote the more widespread and prompt use of femoral nerve blocks as an important standard of care for the Emergency Department.