Each year in the UK, around 65 000 people experience a fractured neck of femur (NOF) (National Institute for Health and Care Excellence (NICE, 2017). While there is no literature on these patients' mode of arrival at the emergency department (ED), because of the nature of their injuries and from anecdotal evidence of the author's colleagues, their first contact is with the ambulance service.
It is estimated that 10% of patients with an NOF fracture will die within 1 month, and 33% will die within 1 year. In addition, the cost of NOF fracture, not counting substantial social care expenditure, is £1 billion per year (NICE, 2017).
The main interventions given by paramedics for NOF fractures primarily concern analgesia; there is no official protocol in place within the service for standardised treatment of any kind. The pharmacological methods carried by ambulance crews are nitrous oxide (Entonox), intravenous (IV) paracetamol and IV morphine sulphate. While analgesia is a key component of the management of any NOF fracture, paramedics may be able to influence the use of other interventions. This literature review aims to examine all forms of evidence that may apply to prehospital care, including evidence that has been produced substantially in hospital, as it may have implications for prehospital care. This review concerning NOF fracture care in the prehospital environment is timely and needed urgently, and can also help inform areas for further research.
Search strategy
The aim of the search was to identify appropriate literature and evidence which could be deemed to be useful to the prehospital management of NOF fracture.
The databases identified were NHS Evidence, PubMed, CINAHL and Medline. These databases were searched using the following Boolean search terms and operators: (Neck of Femur OR Hip OR NOF OR Femoral Neck) AND (Injury OR Fracture) AND (Treatment OR Assessment) AND (Ambulance OR Pre-hospital OR Paramedic).
Abstracts were read and, if an article was deemed eligible for inclusion, its reference list was also searched for appropriate literature. Because of the paucity of prehospital research, eligibility was not confined to literature that specifically considered the prehospital environment. Articles were deemed eligible if they considered the prehospital environment as part of their study or if the findings were appropriate to be used prehospitally.
Following this search process, 22 articles were included and comprehensively reviewed to ascertain if any themes emerged in the evidence surrounding prehospital NOF fracture care.
Discussion
Analgesia and pain appeared frequently in the literature search and were the subjects of significant amounts of research, both qualitative and quantitative. Other pertinent aspects of NOF care identified by the search included fluid resuscitation, the identification and treatment of possible complications and fast-track systems; these are aspects of care that paramedics and others in the prehospital arena can recognise and influence to improve patient care and outcomes.
Pain
Pain management with appropriate analgesia administration is widely recognised as potentially the most important intervention made when an NOF fracture is suspected by a paramedic. O'Malley et al (2011), in their synthesis of the evidence, found that the most important thing that can be done prehospitally is the provision of pain relief. Sutcliffe (2006), referring to in-hospital anaesthesia, states that pain relief is a core component of best anaesthetic practice when treating NOF fracture.
Existing pain management
Initially, pain from any fracture is usually assessed adequately but is subsequently undertreated prehospitally (Siriwardena et al, 2010). In addition, pain resulting from an NOF fracture has been shown to be poorly managed by paramedics (Perillo and Boyle, 2013).
In a case-control study of NOF pain relief for the cognitively impaired, McDermott et al (2014) felt that paramedics were generally responsible for the rapid commencement of analgesia. Wong et al (2015) state that effective pain control can reduce the incidence of postoperative delirium and improve mobility, with the consequence effect of lessening other complications. This assertion is supplemented by the finding of a systematic review by Abou-Setta et al (2011), which stated that pain that is not properly managed in geriatric patients can have deleterious effects in terms of increased risk of cardiovascular adverse effects and postoperative delirium.
Jakopovic (2015) found that ambulance crews administered different types of analgesia for an NOF fracture depending on the situation, and that pain relief is generally titrated for effect by crews. Their main finding was that ambulance crews individualise analgesia for patients depending on the circumstances, and a variety of pharmacological and non-pharmacological interventions are used for pain relief.
Aronsson et al (2014) carried out a series of interviews with patients, and made the key finding that pain relief was individualised according to the patient; patients wished to have the analgesia explained to them as well as its possible side effects.
Wong et al (2015) note that most anaesthetists favour paracetamol and morphine for the relief of pain from a fracture. These systemic analgesics are the most common ones used by UK paramedics. Although Grimson (2016) found evidence to suggest that IV paracetamol was as effective as IV morphine sulphate, Abou-Setta et al (2011) concluded that there was scant specific guidance on the selection of the systemic analgesia for NOF fracture and that further studies were required.
Ketamine
Ketamine administration has become a more accepted part of prehospital practice, with advanced and critical care paramedics in UK ambulance services using it more frequently.
Aronsson et al (2014) and Jakopovic (2015) both highlighted that ketamine is commonly used for NOF fracture analgesia in Sweden. However, many of the studies on ketamine use in NOF fracture concern its anaesthetic and perioperative use in hospital. No studies examine its use specifically for NOF fracture pain management prehospitally. In addition, Jennings et al (2011), in a systematic review, found few studies based in the prehospital environment examining the effectiveness of ketamine as an analgesic.
However, Svenson and Abernathy (2007) concluded that ketamine was ideal for prehospital use, as it is safe, effective and may be more appropriate than existing analgesics. In addition, Jennings et al (2012) found in a randomised controlled trial (RCT) that ketamine with morphine was superior to morphine alone for out-of-hospital trauma care.
This must be balanced with the finding by Aronsson et al (2014) that ketamine can have unpleasant side effects such as a reduction in respiratory effort, cardiovascular effects such as high or low pulse and blood pressure, as well as arrhythmias, nausea and vomiting, among others.
Nerve blocks
The literature review has shown that a fascia iliac block (FICB) is being used more frequently and in different settings because of poor outcomes associated with other forms of analgesia. While a wide variety of femoral nerve blocks are in use, and Wong et al (2015) state that any femoral nerve block can be used in NOF fracture, FICB appears in the evidence as the one that is most used and studied for NOF fracture because it is carried it out using a landmark technique. In his literature review of FICB in the ED, Pinson (2015) indicates that FICB is at least as effective as systemic analgesia and has fewer side effects. He concludes that it should be offered routinely to patients with NOF fracture and administered by anyone competent to do so. This study also found a benefit in the fact that FICB is a single-shot technique.
Lees et al (2016) concluded that FICB is superior to traditional analgesia for NOF fractures and should be considered as the principal means of preoperative analgesia in these patients.
When comparing the side effects of FICB with those of other types of analgesia available, Pinson (2015) found it has fewer side effects than systemic pain relief. This was corroborated by Abou-Setta et al (2011) who found that FICB reduced the need for supplemental systemic analgesia, and that this may contribute to a reduced risk of delirium.
Dochez et al (2014) carried out a feasibility study in Sweden and determined that an FICB can be performed adequately by emergency medical services staff in the acute setting without the need for ultrasound. They calculated that 96% of FICB procedures performed were successful during the feasibility study. They also found a significant reduction in the pain scores of patients who had an FICB administered. While there may be a skill difference between Sweden and the UK, this does demonstrate that it is possible to perform an FICB outside of hospital.
Pinson (2015) found evidence that staff in a wide range of grades were performing FICB in different settings with consistently high success rates and low rates of reported adverse incidents. This suggests that FICB can be carried out by a wide variety of clinical staff, including non-medical practitioners. NICE (2017), in its NOF fracture guidance, also advises that nerve blocks can be administered by non-medically qualified professionals who have been trained and following agreed protocols, in accordance with advice from the Association of Anaesthetists of Great Britain and Ireland. This advice is echoed by Dochez et al (2014), who add that it is necessary that practitioners are able to practise this skill regularly to stay competent.
White et al (2009), in their conclusions, advocate the increased use of nerve blocks to reduce the risks to renal function from systemic opioids when treating pain for NOF fractures. FICB is being investigated by Bulger et al (2017) in their RAPID trial, with a feasibility study being carried out on its appropriateness in potential NOF fractures. This UK study will help guide the evidence regarding this new potential treatment.
Cognitive impairment and pain management
Because of the demographic makeup of patients with NOF fractures, it can be expected that they will present with higher levels of cognitive impairment than the general population.
McDermott et al (2014) found that 45% of patients with cognitive impairments were given no analgesia prehospital, compared to just 8% of those who were cognitively intact. This is despite the fact that studies have shown the cognitively impaired experience pain the same as anyone else (McDermott et al, 2014). While this concerns any type of pain, it is an important consideration and learning point when considering analgesia for patients with NOF fracture. Pinson (2015) argues that FICB may be better for patients with cognitive impairment as it has fewer distressing side effects than other types of analgesia.
Splinting
Perillo and Boyle (2013) found no specific evidence that corroborates and proves the utility of splinting the injured leg to the uninjured leg, despite this being given as a possible treatment for pain in the UK Ambulance Services Clinical Practice Guidelines (Joint Royal Colleges Ambulance Liaison Committee (JRCALC), 2016). Similarly, this literature review also found no evidence to either prove or disprove this as a means of treating NOF fracture pain.
Fast-tracking
Fast tracking in hospitals exists for many specialties; patients with stroke or ST-elevation myocardial infarction (STEMI) are commonly fast-tracked. The evidence shows there has been an attempt to fast-track patients with NOF fracture to improve outcomes.
Kosy et al (2013) carried out a study of a fast-track system where paramedics alerted the emergency department (ED) when they were transporting a patient with a potential NOF fracture. There was then a further in-hospital fast-track to ensure timely treatment. The study involved 429 patients over 1 year. It found that the fast-track system decreased mean surgery time from arrival from 44.95 hours to 29.25 hours. It also reduced the mean stay in hospital from 10 to 9 days.
While this was essentially an in-hospital innovation, the role of the paramedic was key to identifying the potential NOF fracture and allowing the trauma coordinator additional time to come to the ED and prepare the hospital for the patient's arrival. Early and adequate analgesia coupled with 12-lead ECG monitoring meant that treatment could be started prehospitally. This study showed that a thorough multidisciplinary team effort, which included prehospital workers, could help improve outcomes for patients with NOF fracture.
Eriksson et al's (2012) study involved a prospective cohort whereby ambulance personnel transported patients directly to the radiology department and from there straight to the ward. They found a trend towards lower mortality and adverse incidents in the fast-track group of patients. A further benefit, not measured by the study, was humanitarian; elderly patients did not have to stay in the ED, which can be a stressful and disconcerting experience. This also meant that ED space was freed up for other patients, theoretically helping improve the hospital's performance in other areas. This was a small study, however.
In a more recent Swedish study by Larsson et al (2016), the main findings were that fast-tracking a patient straight from ambulance to radiology then onto an orthopaedic ward did not improve outcomes with regards to time to surgery, hospital stay and postoperative complications and mortality. This was the first study to be fully randomised, and has shown that, while time to x-ray was much quicker, all other measured outcomes did not see any statistical significant change. Issues such as patient satisfaction and impact on the ED were not measured by the study.
Fast-tracking for NOF fracture is a recent phenomenon that is being investigated and researched. Whether outcomes such as mortality, time to surgery and postoperative complications should be the only factors under consideration can be debated. Decreased ED pressure and improved patient satisfaction could be among the issues that may need to be investigated in future studies.
Renal complications
While there are many comorbidities and associated problems with NOF fractures, renal problems stand out in the evidence as a key issue that has not been investigated in prehospital care and can be influenced by paramedics.
Acute kidney injury and renal problems
Porter et al (2017) found that acute kidney injury (AKI) was twice as common in patients with an NOF fracture as in the general surgery population; their study found AKI present in 25% of patients with NOF fracture. In addition, mortality at 30 days and 1 year is higher in patients with NOF fracture who develop AKI and in those with pre-existing chronic kidney disease (Porter et al, 2017).
White et al (2009) found that 33% of patients who required surgical fixation of the NOF fracture had at least moderate renal failure. At the same time, 33% of patients with ‘renal dysfunction’ on admission had normal postoperative renal function. This statistic may indicate a hypothetical link between preoperative complications such as dehydration and rhabdomyolysis and AKI.
Porter et al (2017) view AKI as a potentially preventable outcome in some patients and advocate that it should be a target for intervention. White et al (2009) note that the high level of renal dysfunction found in patients with NOF fracture means risks associated with opioid analgesia are greater, given its side effect of renal dysfunction; in addition, morphine's significantly longer half-life can lead to unexpected respiratory depression through overdose.
Rhabdomyolysis is another common secondary problem in older people. Desjardins and Strange (2013) describe this as the pathological breakdown of skeletal muscle because of traumatic injury. They note it can be seen in anything from major trauma to the minor trauma that can cause an NOF fracture. Although it is not mentioned specifically by Porter et al (2017), rhabdomyolysis can cause AKI and is viewed as a risk factor for this condition in patients with NOF. An example of good practice is that, in the Northern Ireland Ambulance Service falls pathway (McKenna, 2015), anyone immobile for 4 hours or more because of a fall is deemed to be at high risk of rhabdomyolysis and therefore requires transportation to ED. This may indicate that patients with NOF may be at higher risk of rhabdomyolysis because of the circumstances surrounding their injury. As Jakopovic et al (2015) highlight, patients with a NOF fracture are found in a wide variety of circumstances and places, but the possibility of prolonged immobility is a constant factor.
Fluid therapy
Fluid therapy is closely linked with the prevention and management of AKI and renal problems. However, fluid therapy is rarely considered in the potential prehospital management of NOF fracture.
Rehydration is a key aspect of best anaesthetic care for patients with a NOF fracture, according to Sutcliffe (2006). Sutcliffe also states that, if a patient is dehydrated, their risk of mortality increases.
Porter et al (2017) found the risk of hypovolaemia was present immediately before surgery for an NOF fracture in approximately 25% of patients. This indicates a potential gap in fluid therapy. Wong et al (2015) intimated that many patients with an NOF fracture are dehydrated for various reasons and that fluid replacement is vital and should be started as soon as possible. Porter et al (2017) concluded that fluid is a potential tool in preventing AKI in patients with NOF fracture.
As well as to prevent AKI, as Desjardins and Strange (2013) note, fluid therapy is the primary treatment to be considered if a patient develops rhabdomyolysis. However, they state that, in patients with significant comorbidities, fluid therapy should be less aggressive and the possible side effects of fluid overload should be considered.
Eaton (2012) points out, as the author of the present study has also found, that the evidence supporting fluid therapy for patients with NOF fracture is gleaned entirely from in-hospital studies. There is no research specifically around the effectiveness of prehospital fluid therapy for patients with NOF fractures, on the amount that should be administered or on the type of fluid recommended.
Implications for practice
The main source of evidence and implications for prehospital practice are in the realm of pain management. The evidence has shown that, despite some instances of good management, in general, pain is undertreated in patients with a suspected NOF fracture. Each of these patients should be administered appropriate analgesia, regardless of their pain level, when their injury occurred or their cognitive functioning.
While there is significant scope to improve the use of existing interventions, there is a significant potential for new types of analgesia not currently used prehospitally (e.g. FICB or ketamine) that may improve outcomes, if studies demonstrate their efficacy in the prehospital environment. To ensure analgesia is used effectively and appropriately, there is scope for studies examining pain management in general, as well as for those focusing on the potential impact of interventions such as ketamine and FICB.
In addition, fast-track systems for NOF fractures should be further investigated. These begin with the prehospital paramedic assessment, have been shown to decrease waiting times for surgery and may have undiscovered benefits through fewer ED attendances and higher patient satisfaction. While fast-tracking is a hospital system, paramedics can play a key role by starting the pathway and ensuring vital first treatments and investigations are achieved in prehospital settings.
The presence of AKI in many patients with NOF fracture is closely connected with the potential for prehospital fluid therapy. Fluid therapy is recognised as a staple in-hospital intervention for AKI but moving this intervention to the prehospital environment could improve care. However, unfortunately, there is no evidence to support paramedics providing certain levels or types of fluid therapy.
All of the studies emphasised that NOF fractures require multidisciplinary care and each improvement usually depends on a strong emphasis on the multidisciplinary nature of teams. As care for patients develops in the prehospital arena, paramedics should start to view themselves as part of this wider multidisciplinary team and look at potential service improvements for NOF fractures, such as improved pain relief, fluid therapy and fast-track systems.