EDAITUTOR
ED Procedures · 03 v0.1 · illustrated Educational use only

Fascia Iliaca
Block

Opioid-sparing analgesia for the hip / neck-of-femur fracture — an ultrasound-guided femoral & lateral-femoral-cutaneous nerve block, with LAST always front of mind.

🔴 Local anaesthetic safety — before you inject

Calculate the maximum safe LA dose by weight, aspirate before & during, and inject incrementally. Insert the needle lateral to the femoral artery. Have IV access, full monitoring and 20% lipid emulsion immediately available — LAST can present late and can be fatal. Document any pre-existing neurological deficit first.

When to use
  • Neck-of-femur (hip) fracture analgesia
  • Femoral shaft fracture
  • Analgesia to position for spinal
  • Opioid-sparing in the frail elderly
  • Anterior thigh wounds / burns
  • Paediatric femoral fracture (cast / traction)
⚪ noteBlocks the femoral (100%) & lateral femoral cutaneous (~80–100%) nerves; obturator cover is variable.
🟢 LITFL · RCEM · BJA Education
Avoid / Caution
  • Patient refusal · inability to consent
  • Allergy to local anaesthetic
  • Infection at the block site
  • Previous femoral bypass / vascular graft
  • Anticoagulation / coagulopathy (relative)
  • Pre-existing femoral neuropathy (document first)
⚪ noteCounsel re: quadriceps weakness & falls risk after the block — institute falls precautions.
🟡 BJA Education · RCEM
Anatomy
Lateral → medial · NAVEL
fascia lata fascia iliaca iliopsoas A V N LA — deep to fascia iliaca
  • Nerve (lateral) · Artery · Vein · Empty · Lymphatics
  • Two fascial layers: fascia lata then fascia iliaca
  • Inject lateral to the artery, under fascia iliaca
🟢 LITFL · NYSORA · BJA Education
Equipment
  • US machine + linear probe + sterile sheath & gel
  • Block needle (50–100 mm, short-bevel / echogenic)
  • Long-acting LA — ropivacaine / bupivacaine / levobupivacaine, dose by weight
  • Saline for hydrodissection
  • Chlorhexidine, drape, sterile gloves, 1% lignocaine for skin
  • Full monitoring (ECG, SpO₂, BP) + IV access
  • 20% lipid emulsion + LAST kit immediately available
🔴 mandatoryNever block without monitoring, IV access & lipid emulsion to hand.
🟢 LITFL · AAGBI / ANZCA
Best practice — effective & safe

Ultrasound-guided

The supra-inguinal approach gives reliable cephalad spread & LFCN cover. See the needle & LA spread under fascia iliaca.

🟢 LITFL · NYSORA · BJA Ed

mg/kg

Calculate the max dose

Work out the maximum safe LA dose by weight (lean body) before drawing up — and don't exceed it.

🟢 AAGBI / ANZCA

Aspirate & titrate

Aspirate before & during; inject in small aliquots with intermittent aspiration. Talk to the patient throughout.

🟢 LAST prevention (AAGBI)

Monitor + lipid ready

Full monitoring, IV access & 20% lipid emulsion immediately available — every block, every time.

🟢 AAGBI / ANZCA · ASRA

Ultrasound anatomy — inguinal crease, short axis
Short axis (SAX) · inguinal crease
LINEAR · INGUINAL CREASE Femoral nerve — lateral, deep to fascia iliaca
Matched cross-section · NAVEL
fascia lata fascia iliaca iliopsoas Femoral nerve Artery Vein
⚠ orient yourselfAt the crease, lateral→medial is N·A·V·E·L — the femoral nerve sits lateral to the artery, deep to fascia iliaca and lying on iliopsoas. Insert the needle lateral to the artery, pierce fascia iliaca, and watch the LA lift the fascia off the muscle — a smooth spread, not a muscle bulge or vascular blush.
Step-by-step — ultrasound-guided fascia iliaca block
1

Prepare

  • Consent; document neuro deficit
  • IV access, monitoring, lipid ready
lipid emulsion to hand
2

Position & scan

  • Supine, expose groin
  • Identify artery, nerve, fascia iliaca
3

Calculate & draw up

max mg/kg
  • Max safe LA by weight
  • Dilute volume (e.g. 30–40 mL)
4

Sterile prep

  • Chlorhexidine, drape
  • Sterile probe sheath; skin wheal
5

Needle in-plane

  • Lateral → medial, away from artery
  • Pierce fascia iliaca (feel the "pops")
6

Aspirate & test

  • Aspirate — negative for blood
  • 1–2 mL → see fascia lift off muscle
no muscle bulge / no blush
7

Inject incrementally

  • Small aliquots, intermittent aspiration
  • Watch spread medial & lateral
talk to the patient
8

Assess block

onset ~15–30 min
  • Assess onset & sensory block
  • Document; counsel falls precautions
9

Observe

  • Keep on monitoring post-block
  • Watch for LAST — can be delayed
LAST may present late
10

Document

  • LA drug, dose, volume, time
  • Block effect & any complications
Watch — supra-inguinal fascia iliaca block, demonstrated
Video preview
Fascia Iliaca Block — a Definitive "How-To" Guide
▶ YouTubeDr Ki-Jinn ChinSupra-inguinal

External educational video — tap to play an embedded YouTube clip by Dr Ki-Jinn Chin (not produced by ED AI Tutor). Watch on YouTube ↗ · always confirm technique & LA doses against your local protocols.

Local anaesthetic systemic toxicity — LASTEmergency

1Recognise

CNS first, then cardiovascular
  • Early CNS: perioral / tongue numbness, metallic taste, tinnitus, visual change, agitation, confusion, drowsiness
  • Then: seizures → loss of consciousness
  • Cardiovascular: hypo/hypertension, brady- or tachy-arrhythmia, conduction block, VT/VF, asystole
  • May be atypical or delayed (up to ~30–60 min) — CVS-only presentations occur

2Treat

Stop · support · resuscitate
  • STOP injecting LA; call for help & the LAST kit
  • Airway: 100% O₂, secure if needed
  • Seizures: small-dose benzodiazepine
  • Arrest → CPR / ALS; expect prolonged resuscitation (>1 hr)
Avoid: lidocaine & other anti-arrhythmics, vasopressin, Ca-channel & β-blockers. Use small adrenaline boluses (≤ 1 µg/kg).

3Lipid rescue

20% lipid emulsion (Intralipid)
20% lipid emulsion
Bolus over 1 min1.5 mL/kg
Then infusion15 mL/kg/hr
Repeat bolus ×2 (5 min apart) if unstable1.5 mL/kg
Double infusion if needed30 mL/kg/hr
Max cumulative12 mL/kg
≈ 70 kg: 100 mL bolus → 1000 mL/hr → max ≈ 840 mL. Continue CPR throughout.
Local anaestheticApprox. max dose
Lignocaine (plain)3 mg/kg
Lignocaine + adrenaline7 mg/kg
Bupivacaine / levobupivacaine2 mg/kg
Ropivacaine3 mg/kg

⚠ verify Use lean / ideal body weight in the frail elderly, and confirm maxima against your local formulary. These are guides, not absolutes — toxicity depends on site, rate, vascularity and patient factors.

Regimen per Association of Anaesthetists (AAGBI) 2010, endorsed by ANZCA. Report cases to your local registry.

Complications
  • LAST see above
  • Vascular puncture / haematoma
  • Nerve injury / neuropraxia
  • Infection
  • Quadriceps weakness → falls
  • Block failure
⚪ supra-inguinalRarely — peritoneal or bladder puncture if too cephalad / deep.
🟢 BJA Education · LITFL
Key tips
  • Calculate the max LA dose before drawing up
  • Insert lateral to the femoral artery
  • Watch the fascia lift off the muscle — not a bulge or blush
  • Aspirate before & during; inject in aliquots
  • Keep talking to the patient
  • Full monitoring + lipid emulsion ready
  • Counsel quadriceps weakness & falls
  • Document drug, dose, volume, time & effect
🟢 LITFL · NYSORA · AAGBI
Paediatric notes
  • Useful for femoral shaft fracture analgesia & cast application
  • Weight-based LA dosing is critical — small margins for error
  • Ultrasound-guided; smaller volumes & needle
  • Lipid emulsion dosing is also weight-based (same regimen)
Max LA dose (paeds)
AgentMax
Lignocaine (plain)3 mg/kg
Bupivacaine / levo-2 mg/kg
Ropivacaine3 mg/kg

Guide only — confirm with RCH / Starship & local formulary; use actual weight, watch totals.

🟢 RCH · Starship · APA

ED AI Tutor — ED Procedures Series · v0.1 · For clinician education only. Not a substitute for clinical judgment, local guidelines or senior oversight. Always verify local anaesthetic doses, lipid emulsion regimens and contraindications against current institutional protocols.