Etomidate-facilitated hip reduction in the emergency department

Traumatic Native Hip Dislocations: An Audit at a Major Trauma Centre and Assessment of Clinical Practice at Centres Across the United Kingdom

INTRODUCTION

Native hip dislocations are defined as traumatic dislocations of the hip, typically high-energy and associated with polytrauma. The majority of these injuries occur following motor vehicle accidents (MVAs). Due to the inherent stability of the hip joint, a significant force is required to cause dislocation. It is critical that such injuries are managed and reduced in a timely manner. We evaluated the current practice in a major trauma centre (MTC) in Cardiff and gathered information from emergency departments (EDs) in Wales and MTCs around the United Kingdom (UK).

METHODS

We did an evaluation of the current practice with a retrospective audit of all traumatic native hip dislocations presenting to the MTC at Cardiff from August 2018 to February 2021. Data was obtained from Trauma Audit and Research Network (TARN), medical records, radiology and theatre management systems. An online survey was developed and disseminated to EDs in Wales and MTCs across the UK.

RESULTS

There were 15 traumatic hip dislocation cases over the period evaluated. Sixty percent of cases were due to MVA. Eighty-six percent of patients had an associated fracture, with one Pipkin type IV fracture dislocation. The mean time to reduction from injury was 532 minutes (240-804 minutes), with 28.6% reduced within 6 hours and 71.4% reduced within 12 hours. Two patients had reduction performed in the ED (mean time to reduction, 275 minutes). There was one occurrence of avascular necrosis (AVN) and one of chondrolysis at the follow-up. The response rate to the survey was 80% and 83% in Wales and MTCs nationally, respectively. The majority (82%) of departments did not have an established pathway in place for managing traumatic native hip dislocations with a preference for reduction in the operating theatre.

CONCLUSION

Native hip dislocations are rare, high-energy injuries associated with significant morbidity. The available evidence suggests time to reduction is imperative in reducing the risk of future complications. The establishment of a pathway to guide management and having a mechanism to perform reductions in the ED may produce significant reductions in this time, impacting outcomes.

Undersedation During Total Hip Arthroplasty Reduction Results in Worse Patient Outcomes

BACKGROUND

Total hip arthroplasty (THA) dislocation is a common reason for presentation to the emergency department (ED) postoperatively. Prior literature has shown that propofol conscious sedation provides the fewest complications and the shortest time to reduction. However, we are aware of no prior reports exploring sedative dosing regimens. We hypothesized that "undersedated" patients would have worse outcomes compared to appropriately sedated patients based on dose.

METHODS

This is a retrospective review of isolated propofol conscious sedation performed in the ED for closed reduction of THA dislocations from 2013 to 2019. Prior authors have used at least 0.5 mg/kg/dose for sedation with propofol. Therefore, to allow a 10% rounding error, a dose of less than 0.45 mg/kg/dose was considered undersedated. Demographic information was collected and outcomes including sedation time, number of doses, complications, and successful reductions were analyzed in univariable and multivariable analyses.

RESULTS

A total of 79 THAs were included for analysis with mean age 65.5 (16.2) years and weight 84.1 (21.3) kg. Thirty-seven (46.8%) patients had undergone revision surgery and 44 (55.7%) previously had a dislocation. A total of 39 patients were undersedated. There was no significant difference in demographics or arthroplasty-specific variables between undersedated and "protocol" sedation patients. In multivariable analysis, undersedated patients had significantly longer sedation time (P = .020), more re-doses (by mean 3 doses; P < .001), and greater total dose (P = .002). These patients were also more likely to have failed ED closed reduction (10.3% vs 0.0%; P = .038). One complication of a skin tear from countertraction was observed in an undersedated patient.

CONCLUSION

Historically, conscious sedation for THA dislocations has been the responsibility of the emergency room clinician. In consideration of our outcomes, we advocate for a multidisciplinary team to create a sedation protocol, emphasizing the need to maintain a dosing regimen of 0.5 mg/kg/dose to improve the care of THA patients.

Etomidate and Midazolam for Procedural Sedation in the Emergency Department of Queen Elizabeth Hospital: A Randomised Controlled Trial

Objective

The objective of the study was to compare the effectiveness and safety of intravenous etomidate against midazolam in procedures which required sedation and analgesia in our emergency department.

Methods

The study was conducted in the emergency department of Queen Elizabeth Hospital from 1st November 2005 to 30th June 2006. Adult patients who required procedural sedation and analgesia were recruited and randomised into two groups, in which either etomidate or midazolam was used as the sedative agent. Vital parameters and depth of sedation were closely monitored until they regained full consciousness.

Results

a total of 87 patients were recruited and randomised into study and control groups, of which 78 patients completed the study and were analysed – 36 patients were in the midazolam group whereas 42 patients were in the etomidate group. There was no statistical difference in mean age, mean weight and procedures between the two groups. Mean time for onset of action was 1.8 minutes for the etomidate group versus 3.4 minutes for the midazolam group (p=0.003). There were no significant differences in total procedure time, total length of stay, pain score, satisfaction score and adverse effects.

Conclusion

Etomidate achieved adequate depth of sedation for painful procedures in significantly shorter time than midazolam. There were no differences in procedure time, length of stay, pain relief and patient's satisfaction between the two drugs.

Comparison of procedural sedation for the reduction of dislocated total hip arthroplasty

Introduction: Various types of sedation can be used for the reduction of a dislocated total hip arthroplasty. Traditionally, an opiate/benzodiazepine combination has been employed. The use of other pharmacologic agents, such as etomidate and propofol, have more recently gained popularity. Currently no studies directly comparing these sedation agents have been carried out. The purpose of this study is to compare differences in reduction and sedation outcomes, including recovery times, of these 3 sedation agents.

Methods: We performed a retrospective chart review examining 198 patients who presented with dislocated total hip arthroplasty at 2 academic affiliated medical centers. The patients were grouped according to the type of sedation agent. We calculated percentages of reduction and sedation complications along with recovery times. Reduction complications included fracture, skin or neurovascular injury, and failure of reduction requiring general anesthesia. Sedation complications included use of bag-valve mask and artificial airway, intubation, prolonged recovery, use of a reversal agent, and inability to achieve sedation. We then compared the data for each sedation agent.

Results: We found reduction complications rates of 8.7% in the propofol, 24.7% in the etomidate, and 28.9% in the opiate/benzodiazepine groups. The propofol group was significantly different from the other 2agents (p ≤ 0.01). Sedation complications were found 7.3% of the time in the propofol , 11.7% in the etomidate , and 21.3% in the opiate/benzodiazepine group, (p=0.02 propofol vs. others) . Average recovery times were 25.2 minutes for propofol, 30.8 minutes for etomidate, and 44.4 minutes for opiate/benzodiazepine (p = 0.05 for propofol vs. other agents).

Conclusion: For reduction of dislocated total hip arthroplasty under procedural sedation, propofol appears to have fewer complications and a trend toward more rapid recovery than both etomidate and opiate/benzodiazepine. These data support the use of propofol as first line agent for procedural sedation of dislocated total hip arthroplasty, with fewer complications and a shorter recovery period.

Closed reduction of constrained total hip arthroplasty in the ED

A dislocated hip prosthesis is a common occurrence in the Emergency Department. To combat this problem, orthopedists use constraint devices in an attempt to reduce the incidence of dislocation. However, when these devices fail, a more complicated case arises. We discuss a case report in which a patient presented with a dislocation of his hip after implantation of a constrained total hip arthroplasty. We describe a closed reduction procedure using deep sedation, fluoroscopy, and adequate assistance.

Etomidate and midazolam for procedural sedation: prospective, randomized trial

OBJECTIVE

To evaluate whether there is a difference in the time of sedation and time to patient disposition in patients undergoing procedural sedation with etomidate and midazolam.

METHODS

Prospective, randomized, double-blind trial comparing etomidate (0.10 mg/kg) and midazolam (0.035 mg/kg) for patients requiring procedural sedation for reduction of joint dislocations or long bone fractures.

RESULTS

Forty-five patients were enrolled (24 randomized to etomidate, 21 to midazolam). Groups were similar in demographics and analgesic dosing. Mean time of sedation for etomidate was 15 minutes (SD, 10.97) and for midazolam was 32 minutes (SD, 16.13) (P<.001). Mean time to disposition for etomidate was 121 minutes (SD, 73.28) and for midazolam was 111 minutes (SD, 96.36) (P=.700). The mean quality of sedation for etomidate was 7.91 (SD, 1.53) and for midazolam was 7.48 (SD, 2.89) (P=.570).

CONCLUSIONS

The use of etomidate compared with midazolam for procedural sedation provides a significant reduction in recovery time, without a reduction in time to patient disposition, while providing equal sedation quality.

Etomidate for procedural sedation in the emergency department

OBJECTIVE

To review the current efficacy and safety evidence for the use of etomidate for procedural sedation in the emergency department (ED).

DATA SOURCES

MEDLINE (1966-December 2003), EMBASE (1980-December 2003), PubMED (1966-December 2003), and Cochrane Database of Systemic Reviews (up to December 2003) were searched for full-text reports published in English on the use of etomidate in humans. Search terms included etomidate, procedural sedation, conscious sedation, relocation, dislocation, abscess incision, abscess drainage, and cardioversion.

STUDY SELECTION AND DATA EXTRACTION

Prospective and retrospective studies evaluating efficacy or safety endpoints using etomidate for procedural sedation in the ED were included. All studies were evaluated independently by both authors. For clinical outcomes (efficacy, safety), the definitions specified by each study were used.

DATA SYNTHESIS

Three observational studies and 5 prospective, randomized controlled trials were included in this review. Onset of action and time to recovery following etomidate were rapid and found to be comparable to that of propofol and thiopental but significantly faster than that of midazolam. The dose of etomidate for procedural sedation ranged from 0.15 to 0.22 mg/kg. No significant hemodynamic effects were observed; however, respiratory depression resulting in oxygen desaturation to <90% or apnea appears to occur in approximately 10% of patients undergoing procedural sedation with etomidate with or without analgesia. The most prominent adverse effect reported with etomidate was myoclonus, occurring in 20-45% of patients.

CONCLUSIONS

Etomidate is an appropriate and valuable agent for performing procedural sedation in the ED. The rapid onset and recovery time and relative lack of significant hemodynamic and respiratory effects may facilitate optimal and safe conditions for procedural sedation in the ED.

Resuscitation of the morbidly obese patient

Obesity is a major health care problem in the United States. The body mass index (BMI) is the standard measure of obesity. A BMI >25 kg/m2 is defined as overweight and obesity as a BMI > 30 kg/m2. Recent surveys indicate that 54% of adults, or roughly 97 million people, are overweight. Given the incidence of obesity in the general population, it is likely that EM physicians will be involved in the emergency care of critically ill or injured obese patients. The objective of this article is to present the clinical problems associated with the resuscitation of the critically ill or injured obese patient and their potential solutions.

Myoclonus associated with etomidate for ED procedural sedation and analgesia

We report 3 cases of myoclonus associated with etomidate during ED procedural sedation and analgesia (PSA). EPs should be familiar with myoclonus associated with etomidate. Clinicians using this drug for PSA should be prepared to offer the brief period of support, and occasionally, respiratory assistance, required when etomidate-associated myoclonus is encountered.

Etomidate and midazolam for reduction of anterior shoulder dislocation: a randomized, controlled trial

STUDY OBJECTIVE

We determine whether patients with acute, anterior shoulder dislocation undergoing emergency department procedural sedation and analgesia (PSA) with intravenous etomidate would experience a reduced time of impaired consciousness when compared with a group of patients receiving intravenous midazolam.

METHODS

This study was a prospective, double-blinded, randomized, institutional review board-approved trial of ED patients with anterior shoulder dislocation. Patients were randomized to receive intravenous boluses of etomidate (0.1 mg/kg) or midazolam (0.033 mg/kg) during PSA. The primary outcome for comparison was PSA duration.

RESULTS

Forty-six patients with anterior shoulder dislocation were enrolled: 22 in the etomidate group and 24 in the midazolam group. Three patients sustained reduction without physician or sedative intervention. Two patients were excluded from protocol because of unavailable study drug or fracture dislocation. The median lowest modified postanesthetic recovery score observed during PSA was 5 (95% confidence interval [CI] 4 to 7) in the etomidate group and 6 (95% CI 6 to 7) in the midazolam group. The median time of PSA for patients receiving etomidate was 10 minutes (95% CI 8 to 15) compared with 23 minutes (95% CI 16 to 30) for patients receiving midazolam, with a difference between the group medians of 13 minutes (95% CI 5 to 22). Reduction success was achieved in 37 (90%) of 41 patients: 2 did not experience reduction with etomidate and 2 did not experience reduction with midazolam. There were 15 PSA complications reported.

CONCLUSION

Etomidate provides effective PSA for reduction of ED patients with anterior shoulder dislocation. When compared with midazolam, etomidate use confers a significantly shorter period of PSA.

Etomidate for procedural sedation in emergency medicine

STUDY OBJECTIVE

We describe and analyze the effectiveness and safety of etomidate for procedural sedation and evaluate the patient's perspective on effectiveness, side effects, and satisfaction.

METHODS

We conducted an observational retrospective study of all patients who received etomidate for procedural sedation over 2 years in 3 affiliated suburban emergency departments of a large group-model health maintenance organization. Data were abstracted from the ED records. Additionally, a patient questionnaire was prospectively administered by telephone.

RESULTS

Etomidate was used for sedation in 134 patients between 6 and 93 years of age during 150 procedures. The mean cumulative dose was 0.20 mg/kg. Adjunctive medication was used in 36 (23%) procedures. Moderate sedation with verbal arousability was induced in 48 (32%) patients, and deep sedation with verbal unresponsiveness was induced in 102 (68%) patients. Full recovery to the preprocedural level of alertness was achieved within 30 minutes in 142 (95%) of procedures. Mean changes in systolic blood pressure, pulse rate, and oxygen saturation were clinically insignificant. There were 7 (4.7%; 95% confidence interval [CI] 1.9% to 9.4%) adverse events, including 5 (3.3%; 95% CI 1.1% to 7.6%) cases of oxygen desaturation below 94% in older patients (>55 years of age) who received slightly higher mean doses of etomidate (0.23 mg/kg). Four of these patients received brief assisted bag-valve-mask ventilation and recovered uneventfully; none required endotracheal intubation. The questionnaire was completed by 120 (90%) of 134 patients and involved 136 procedures. During 127 (93%) of these, etomidate was believed to be extremely effective in causing sleep, and for 127 (93%) it induced complete procedural amnesia. Only 5 (4%) patients experienced nausea or vomiting. Regarding willingness to receive etomidate for their next procedure, the patients' responses were favorable: extremely, 95%; moderately, 2%; slightly, 3%; and not at all, 1%.

CONCLUSION

Etomidate is a useful agent for carefully conducted procedural sedation because it provides effective, brief, deep sedation with little hemodynamic compromise. Its safety may be jeopardized by the occurrence of respiratory depression in older patients receiving higher doses. Patients report a high degree of satisfaction with etomidate.

Etomidate for procedural sedation in the emergency department

STUDY OBJECTIVE

To review our experience with etomidate in nonintubated patients in the emergency department.

DESIGN

A 2-year retrospective chart review of consecutive patients receiving etomidate for sedation.

SETTING

Emergency department of a university-based teaching hospital.

PATIENTS

Forty-eight patients who underwent painful procedures in the emergency department.

MEASUREMENTS AND MAIN RESULTS

Demographics, dosing information, recovery times, and adverse events were abstracted using a standardized data collection form. Forty-eight nonintubated patients were sedated with etomidate. Mean age was 34 years (range 6-80 yrs); 38 were men and 10 women; two were children. The mean initial dose of etomidate was 13 mg. Adverse events occurred in 11 (21%) patients. None sustained any substantial morbidity as indicated by need for intubation, prolonged emergency department stay, or hospital admission.

CONCLUSION

Although controversial, etomidate holds promise as a potent sedative agent for patients undergoing painful procedures in the emergency department. A large prospective evaluation is needed to document the performance and complications of this agent.

Contemporary trends in pediatric sedation and analgesia

The ability to provide safe, effective procedural sedation and analgesia is a necessary skill for physicians caring for the acutely ill or injured pediatric patient. They physician should be familiar with the agent(s) chosen, including dosage, duration, adverse effects, and contraindications. The choice of agent and regimen should be individualized for the patient and situation. Successful outcomes depend on performing careful pre- and post-sedation evaluations, following appropriate monitoring and equipment guidelines, and having the knowledge and skills to manage any adverse cardiorespiratory event.

Etomidate for pediatric sedation prior to fracture reduction

OBJECTIVE

While etomidate is reported as a procedural sedative in adults, its use in children has not been extensively reported. The authors describe their experience with etomidate for procedural sedation in children with extremity fractures and major joint dislocations.

METHODS

This was a retrospective descriptive chart review. The setting was a university-based emergency department (ED) that follows national guidelines for procedural sedation. Subjects were children less than 18 years old who received etomidate prior to fracture reduction or major joint dislocations. Standardized data were abstracted from the medical records, including patient demographics, diagnosis, weight, types and doses of sedative and analgesic agents used, number of boluses of etomidate, attempts at reduction, complications encountered, vitals signs before, during, and after the reduction, disposition, and the time from procedure to discharge. Descriptive statistics calculated included means and proportions with 95% confidence intervals.

RESULTS

Fifty-three children received etomidate for fracture reduction. Their mean age was 9.7; 41.5% were females. Indications for reduction included forearm fractures (38), ankle fractures (12), upper arm fractures (2), and hip dislocations (1). In most cases (83%) reduction was successful after one attempt only. The mean initial and total doses of etomidate were 0.20 mg/kg (range, 0.1 to 0.4) and 0.24 mg/kg (range, 0.13 to 0.52), respectively. Thirteen patients required a second bolus of etomidate or midazolam. Thirty-four patients (64%) were discharged from the ED after a mean observation of 94 minutes (range, 35 to 255). There were no major adverse events (95% CI = 0% to 5.7%). One patient reported nausea and one required a fluid bolus for hypotension. One patient receiving multiple sedatives and opioid analgesics was admitted for observation due to prolonged sedation. No patient required assisted ventilation or intubation.

CONCLUSIONS

These results suggest that etomidate is a safe and effective agent for procedural sedation in children requiring fracture and major joint reductions.