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How femoral nerve blocks are replacing opioids in the ER
New to emergency rooms, this safer method of pain management is improving outcomes and reducing opioid use
The pain of a hip fracture is excruciating for the approximately 300,000 Americans who suffer this injury each year. From diagnosis to treatment to recovery, opioids have been the go-to method for easing a patient's discomfort.
However, these dangerous painkillers carry many risks. Recognizing the impact they continue to have — about 130 Americans die each day from an opioid overdose — Northwell Health is pioneering the use of nerve blocks, a local anesthetic, in its emergency rooms (ER) to reduce the need for opioid medications and better manage pain throughout a patient’s hospital stay.
Systemwide, Northwell is already using nerve blocks to manage pain during and after surgery. Now, Northwell’s anesthesiologists are training emergency medicine doctors around the 21-hospital health system to use this revolutionary technique in the ER.
Led by Joseph Marino, MD, senior vice president of anesthesia for Northwell Health, this pilot program launched in May 2021 is the latest advance in the use of nerve blocks, which he says have driven a renaissance in the field of anesthesia during the last 20 years.
“The nerve block has improved how we address a patient’s pain without having to risk the potential adverse effects of opioid-based pain killers,” Dr. Marino said.
Learning the femoral nerve block
Northwell first rolled out femoral nerve block use in an ER setting at Staten Island University Hospital (SIUH).
“We have taught our emergency physician colleagues how to perform the femoral nerve block for painful conditions like hip fractures, an injury that most commonly occurs in older adults,” said Joshua Greenstein, MD, assistant medical director for the Department of Emergency Medicine at Staten Island University Hospital.
Femoral refers to the upper leg, and the femoral nerve controls sensation to the lower limbs, enabling the muscles to move the hip and straighten the leg.
Unlike an epidural or opioids, applying a nerve block injection using a local anesthetic or Novocain numbs just the area around an injury, removes any pain and facilitates a better patient experience. An ER physician will use ultrasound to visualize the tip of the needle — called in-plane technique — to ensure accurate placement during a nerve block procedure.
“Because emergency physicians already use ultrasounds in other clinical procedures— including placing an IV, central line or draining fluid from an area — the ER staff are finding it relatively easy to adopt this new approach,” Maria Tama, MD, co-director for SIUH’s division of emergency ultrasound in the hospital’s Department of Emergency Medicine, said on a recent episode of the 20-Minute Health Talk podcast.
A humane concept
After X-ray confirmation of a hip fracture, the standard of care has been to administer a few doses of an opioid. For these vulnerable patients, potent opioid pain relievers can have several side effects, including nausea, vomiting and trouble breathing. The incidence of opioid-induced delirium in the elderly population can be as high as 65% and result in admission to the ICU in severe cases.
“Witnessing first-hand the devastating effects of the opioid crisis, we know the impact extends beyond the hospital and into the home and our communities,” Dr. Marino said. “It is one of the largest causes of preventable deaths in the US. That is why we have made nerve blocks the standard of care for postoperative pain management at Northwell; and why we are committed to increasing the number of ER physicians capable of performing nerve blocks.”
The ultrasound division in SIUH’s emergency department has trained more than two-thirds of its emergency physicians in the use of the femoral nerve block. Dr. Tama, along with her co-director Simone Rudnin, DO, helps conduct these trainings to ER providers, residents and attendings as the hospital continues to expand access. Having demonstrated the safety of this approach, Northwell continues to roll it out across the health system.
When to use a nerve block in the emergency department
In addition to being extremely beneficial for patients struggling with a substance use disorder, nerve blocks are used for patients presenting with an injury that requires surgery, or admission to a different service. Those injuries include:
- Hip fracture
- Femur fracture
- Severe lacerations
- Significant burns to the thigh
In each case, a femoral nerve block not only eliminates the patient’s pain, it enables a faster hand off between departments. Getting patients to surgery early, Dr. Marino stressed, is the most important determinant for a good outcome.
“Through our system-wide geriatric orthopedic co-management (GOCO) initiative, we strive to get patients from the ER to surgery in less than 48 hours — preferably 24 hours,” he said. “The idea is to apply the block and then get them to OR before it wears off.”
That starts with ER physicians making a quick diagnosis, performing the femoral nerve block and then, in the case of a fracture, notifying the orthopedic surgeon as quickly as possible, notes Dr. Greenstein.
“Patients can navigate through their surgical journey with less pain, less opioid-related side effects and an overall enhanced patient experience,” he said. “This results in an overall shorter hospital stay — an important part of any patient’s recovery.”
Patients are also able to move without pain, a significant advantage over opioids.
"Opioid medications are minimally effective at helping pain during movement,” Dr. Marino said. “By contrast, nerve blocks can provide essentially total relief of pain while a patient is moving side to side in their bed."
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The nerve block initiative, which supports the mission of Northwell’s Opioid Management Steering Committee, is reducing the need for opioids among patients, as well as staff when it comes to deciding how to manage pain, according to Dr. Rudnin.
“Performing the nerve block procedure definitely makes you a better all-around physician,” she said. “Pain can make someone’s experience in the ER go from horrific to pleasant, and something as simple as learning these blocks has such a large impact on our patients, particularly those most vulnerable to the dangerous effects of opioids.”
With no adverse outcomes after one year of use, the SIUH team is continuing to train more staff at the SIUH Patient Safety Institute. Systemwide, Dr. Marino’s team continues to train ER staff in Northwell’s Center for Learning & Innovation which offers the Bioskills Education Center, a 6,200-square-foot, state-of-the-art education facility that brings the latest operative techniques to attending physicians, residents, medical students, nurses, surgical technologists and others in the medical field.
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