Background <p>Hip fractures (HFs) managed in the emergency department (ED) are associated with severe pain. Locoregional anaesthesia (LRA) using the pericapsular nerve group (PENG) block may be an effective option for pain management in the ED, helping to reduce morphine use and improve postoperative rehabilitation.</p> Methods <p>Patients admitted to the ED of a French tertiary hospital with suspected HF were enrolled and randomised into two groups: a standard of care (SOC) group receiving systemic analgesia in line with current recommendations, and an experimental group receiving systemic analgesia plus a PENG block. The primary outcome was morphine consumption per hour from randomisation until 24 hours post-randomisation or until surgery, if performed earlier.</p> Results <p>Among the 35 randomised patients, 32 were included in the final analysis (11 men and 21 women; median age of 81 [74–91] years). Median morphine consumption per hour was significantly lower in the PENG group compared to the SOC group (0.2 [0.0–0.5] mg vs 0.4 [0.3–0.8] mg, respectively; <i>p</i> = 0.03). No significant differences were observed between groups in terms of total morphine use, pain scores (numeric rating scale), adverse events, or ED length of stay.</p> Conclusion <p>Early PENG block appears to be a feasible and safe LRA technique when performed by trained emergency physicians and may reduce opioids requirements in patients with HF in the ED. Larger, adequately powered studies are warranted to confirm these findings.</p> Trial registration <p>The study was registered prospectively at <a href="https://www.clinicaltrials.gov/">https://www.clinicaltrials.gov/</a> on 5 January 2023 (NCT05673486).</p>