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Widmer LW, Lerch TD, Genthner A, Pozzi L, Geiger J, Frei HC. Fast treatment of anterior shoulder dislocations with two sedation-free methods: The Davos self-reduction method and Arlt method. Shoulder Elbow 2024; 16:38-45. [PMID: 38435044 PMCID: PMC10902407 DOI: 10.1177/17585732221145608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/21/2022] [Accepted: 11/28/2022] [Indexed: 03/05/2024]
Abstract
Background Various reduction techniques exist to treat traumatic shoulder dislocation, but best management remains unclear. Aims To investigate the reduction rate of traumatic anteroinferior shoulder dislocations using two sedation-free techniques and success rates of subgroups. Methods A single-center study was performed analysing shoulder dislocations in a two-year period. Adult patients with anteroinferior shoulder dislocation were included. Two sedation-free reduction techniques were used: the Davos self-reduction technique and the Arlt-chair technique. Two attempts were performed before sedation. All patients gave informed consent to study participation. Results The investigated 106 patients (106 shoulder dislocations) had a mean age of 48 ± 18 years (74% male patients). The majority occurred during winter sports (76%). The overall success rate for both sedation-free reduction techniques was 82% (87 reduced shoulders, two attempts). A significantly increased success rate was found in patients without greater tuberosity fracture (86% without vs. 68% with fracture, p = 0.002) and for patients with repeated dislocation (93% vs. 80% for primary dislocation, p = 0.004). Time for reduction was 5 minutes (Davos technique) and 1 minute (Arlt-chair-technique). Associated injuries were mostly Hill Sachs lesions (78%). There was no major complication and no new-onset sensory deficit. Conclusion Davos and Arlt reduction techniques allowed sedation-free and fast treatment for anteroinferior shoulder dislocation during winter sports.
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Affiliation(s)
- Lukas Werner Widmer
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Till Dominic Lerch
- Department of Radiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anna Genthner
- Department of Surgery, Hospital Davos, Davos Platz, Switzerland
| | - Lara Pozzi
- Department of Surgery, Hospital Davos, Davos Platz, Switzerland
| | - James Geiger
- Department of Surgery, Hospital Davos, Davos Platz, Switzerland
| | - Hans-Curd Frei
- Department of Surgery, Hospital Davos, Davos Platz, Switzerland
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2
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Gawel RJ, Grill R, Bradley N, Luong J, Au AK. Ultrasound-Guided Peripheral Nerve Blocks for Shoulder Dislocation in the Emergency Department: A Systemic Review. J Emerg Med 2023; 65:e403-e413. [PMID: 37741738 DOI: 10.1016/j.jemermed.2023.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/26/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Shoulder dislocations are among the most common orthopedic emergencies encountered in the emergency department (ED). Ultrasound-guided peripheral nerve blocks (USG-PNBs) are increasingly being used for acute pain management in the ED, but clinical evidence supporting their utility for shoulder dislocation is limited and often conflicting. OBJECTIVE The aim of this review was to summarize and evaluate the utility of USG-PNB for analgesia during closed reduction of dislocated shoulders in the ED. METHODS Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic literature search of the PubMed, Scopus, and Cochrane databases was performed from database inception to September 2022. We included clinical studies examining USG-PNB for pain management of dislocated shoulders in the ED. Information collected from eligible studies included patient demographic characteristics, USG-PNB approach, alternate analgesia techniques, anesthetic regimens, clinical outcomes, and adverse events. RESULTS Five studies met inclusion criteria, all of which were randomized controlled trials comparing USG-PNB with procedural sedation and analgesia. Pooled patient satisfaction scores were similar for both analgesia methods (3.5 ± 0.6 vs. 3.9 ± 0.6 out of 5; p = 0.76). Patients managed with procedural sedation and analgesia achieved higher rates of overall shoulder reduction (100% vs. 67%; p < 0.001) and successful reduction on the first attempt (86% vs. 48%; p < 0.001). The USG-PNB groups in all but one study had shorter lengths of ED stay. Overall, USG-PNB was associated with a lower risk of adverse events and complications (3.9% vs. 24.9%; p < 0.001), especially adverse respiratory events (0% vs. 14.7%; p < 0.001). CONCLUSIONS USG-PNBs performed by adequately trained emergency physicians should be considered a safe and effective alternative for analgesia during closed reduction of dislocated shoulders in the ED, particularly in patients with cardiorespiratory comorbidities.
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Affiliation(s)
- Richard J Gawel
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania.
| | - Renee Grill
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Nathaniel Bradley
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jennifer Luong
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Arthur K Au
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
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3
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Jo S, Chan Kye Y, Lee J, Jung E, Kang M, Kim B, Kim D, Park B. The effect of shoulder muscle succinylcholine injection on the foreleg raising power: Sion's local paralysis. Heliyon 2023; 9:e14468. [PMID: 37035370 PMCID: PMC10073639 DOI: 10.1016/j.heliyon.2023.e14468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 02/28/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023] Open
Abstract
Objective We examined the change in foreleg raising power after Sion's local paralysis (SLP) with succinylcholine in the shoulder muscle. Methods A randomized, double blind, placebo-controlled, porcine study was designed and performed at a research institution. Ten male Korean native pigs were randomized into an intervention group (n = 5) and a control group (n = 5). The injection points were in the middle of the left trapezius muscle and the middle of the left deltoid muscle. The control group received 2 ml normal saline (NS), 1 ml injected in each point. The intervention group received 0.4 mg/kg succinylcholine diluted to 2 ml in NS, and 1 ml was injected in each point. To represent the foreleg raising power, the height of the left forelegs from baseline (experiment table) was measured. We measured the foreleg height and oxygen saturation at -4, -2, 0, +2, +4, +6, +8, +10, +20, +30, and +60 min. Results After SLP, foreleg height immediately declined in the intervention group. It recovered slightly for a few minutes and declined from 4 to 8 min. In the control group, foreleg height was relatively similar throughout the study period. A repeated-measure analysis of variance revealed a significant group × time interaction (F10,80 = 2.37, P = 0.017), a significant main effect for group (F1,8 = 6.25, P = 0.037), and a significant main effect for time (F10,80 = 4.41, P < 0.001). Post hoc analysis demonstrated that the intervention group showed significantly less foreleg raising power than the control group at 0, 4, 6, 8, 20, and 30 min (P < 0.05). Conclusions Compared with the control group, the foreleg raising power in the intervention group immediately decreased significantly and persisted for a period after SLP, without hypoxia, in a pig model.
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Hayashi M, Kano K, Kuroda N, Yamamoto N, Shiroshita A, Kataoka Y. Comparative efficacy of sedation or analgesia methods for reduction of anterior shoulder dislocation: A systematic review and network meta-analysis. Acad Emerg Med 2022; 29:1160-1171. [PMID: 35872652 DOI: 10.1111/acem.14568] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 07/13/2022] [Accepted: 07/20/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND We performed a network meta-analysis (NMA) to compare the efficacy and safety of intravenous sedation (IVS), intraarticular anesthetic injection (IAA), and peripheral nerve block (PNB) as sedation or analgesia methods for the reduction of anterior shoulder dislocation. METHODS We included randomized controlled trials (RCTs) comparing different sedation or analgesia methods for anterior shoulder dislocation reduction. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, ICTRP, ClinicalTrials.gov, and Google Scholar databases were searched in October 2021. We conducted a random-effects NMA within a frequentist framework. We evaluated the confidence in each outcome using the CINeMA tool. RESULTS Sixteen RCTs (957 patients) were included. Regarding the primary outcomes, the three methods might result in little to no difference in the immediate success rate of reduction and patient satisfaction. The IAA method had a shorter emergency department length of stay than that of the IVS method (mean difference [MD] -107.88 min, 95% confidence interval [CI] -202.58 to -13.18). In the secondary outcomes, the IAA method had a lower pain score than that of the PNB method (standardized MD -1.83, 95% CI -3.64 to -0.02). The IAA and PNB methods might require a longer time for reduction than that of the IVS method (MD 5.3 min, 95% CI 2.4 to 10.36; MD 15.25, 95% CI 5.49 to 25.01). The three methods might result in little to no difference in the number of reduction attempts and total success rate of reduction. However, the confidence ratings for all treatment comparisons were very low. IAA and PNB had no adverse respiratory events. CONCLUSIONS The results of our NMA indicated that three sedation or analgesia methods (IVS, IAA, and PNB) might result in little to no difference in the success rate of reduction and patient satisfaction. IAA and PNB had no adverse respiratory events.
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Affiliation(s)
- Minoru Hayashi
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui City, Fukui, Japan
| | - Kenichi Kano
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui City, Fukui, Japan
| | - Naoto Kuroda
- Department of Pediatrics, Wayne State University, Detroit, Michigan, USA.,Department of Epileptology, Tohoku University Graduate School of Medicine, Sendai, Japan.,Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan
| | - Norio Yamamoto
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan.,Department of Orthopedic Surgery, Miyamoto Orthopedic Hospital, Okayama, Okayama, Japan.,Department of Epidemiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan
| | - Akihiro Shiroshita
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan.,Department of Respiratory Medicine, Ichinomiyanishi Hospital, Ichinomiya, Aichi, Japan
| | - Yuki Kataoka
- Scientific Research Works Peer Support Group (SRWS-PSG), Osaka, Japan.,Department of Internal Medicine, Kyoto Min-Iren Asukai Hospital, Kyoto, Japan.,Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan.,Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/Public Health, Kyoto, Japan
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Stitt R, Jull A. Review article: Ankle intra-articular haematoma block for reduction of unstable ankle fractures in the emergency department: An integrative review. Emerg Med Australas 2022; 34:854-861. [PMID: 36055674 DOI: 10.1111/1742-6723.14060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/12/2022] [Accepted: 08/01/2022] [Indexed: 11/28/2022]
Abstract
A review was conducted to assess the efficacy and safety of the intra-articular haematoma block (IAHB) for manipulation of ankle fractures in ED. Any study investigating the success of IAHB for ankle fracture reduction published in English was sought. Seven databases were searched. The Cochrane Risk of Bias tool was used to quality assess the included studies. Three studies met the inclusion criteria (n = 436 patients). Just one study was a randomised controlled trial (n = 42). The two non-randomised studies that included the majority of patients were assessed as at high overall risk of bias. The studies reported no significant difference in the overall rate of successful reduction or patient-reported pain scores between IAHB and procedural sedation groups. A subgroup analysis in one study suggested timelier reduction by 51.4 min (P = 0.01) for fractures involving subluxation when using IAHB, but that more patients with dislocation were reduced on first attempt when using procedural sedation compared to IAHB (74.0% vs 54.8%, P < 0.01). No adverse events were reported from using IAHB, although no study measured events such as joint sepsis or chondrolysis. Findings suggest that IAHB might be safe and effective but the evidence is very limited. High-quality research is required before IAHB can be considered a routine alternative. However, IAHB could be considered in situations where the risk of procedural sedation outweighs the likely very low risk of chondrolysis.
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Affiliation(s)
- Rebecca Stitt
- Adult Emergency Department, Auckland City Hospital, Auckland, New Zealand
| | - Andrew Jull
- School of Nursing, The University of Auckland, Auckland, New Zealand
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6
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Hassen GW, Bergmann-Dumont D, Duvvi A, Sudol S, Choy D, Yeo T, Viswanath A, Roffe E, Kim CL, Elnatour A, Arias MG, Kalantari H. The Use of a Suprascapular Nerve Block to Facilitate the Reduction of an Anterior Shoulder Dislocation: An Alternative for Elderly and Patients With Cardiopulmonary Comorbidities? J Emerg Med 2022; 63:265-271. [PMID: 36045024 DOI: 10.1016/j.jemermed.2022.04.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 04/04/2022] [Accepted: 04/23/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Anterior shoulder dislocation is a common presentation to the emergency department (ED). Dislocations are spontaneous or traumatic. Generally, a reduction is performed under procedural sedation and analgesia (PSA). Other approaches include the use of intra-articular lidocaine or, in rare instances, nerve blocks. Here we discuss the case of a 66-year-old female patient who presented with left shoulder pain and limited range of motion after a fall. After discussing potential treatment options to reduce the dislocation, the patient agreed to a nerve block. DISCUSSION The dislocation was reduced successfully with a suprascapular nerve block (SSNB) without complications. The duration of the patient's ED stay was shorter than those who had received PSA. CONCLUSIONS SSNB could be an alternative method for shoulder dislocation reduction, particularly for patients who are obese, older, or have cardiopulmonary comorbidities.
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Affiliation(s)
- Getaw Worku Hassen
- Department of Emergency Medicine, New York Medical College (NYMC), Metropolitan Hospital Center, New York, New York
| | - Dahlia Bergmann-Dumont
- Department of Emergency Medicine, New York Medical College (NYMC), Metropolitan Hospital Center, New York, New York
| | - Anisha Duvvi
- Department of Emergency Medicine, New York Medical College (NYMC), Metropolitan Hospital Center, New York, New York
| | - Samantha Sudol
- Department of Emergency Medicine, New York Medical College (NYMC), Metropolitan Hospital Center, New York, New York
| | - Danny Choy
- Department of Emergency Medicine, New York Medical College (NYMC), Metropolitan Hospital Center, New York, New York
| | - Theresa Yeo
- Department of Emergency Medicine, New York Medical College (NYMC), Metropolitan Hospital Center, New York, New York
| | - Avinash Viswanath
- Department of Emergency Medicine, Harlem Hospital Center, New York, New York
| | - Estrella Roffe
- Department of Emergency Medicine, New York Medical College (NYMC), Metropolitan Hospital Center, New York, New York
| | - Cei Lim Kim
- Department of Emergency Medicine, New York Medical College (NYMC), Metropolitan Hospital Center, New York, New York
| | - Ali Elnatour
- Department of Emergency Medicine, New York Medical College (NYMC), Metropolitan Hospital Center, New York, New York
| | - Mauricio Gonzalez Arias
- Department of Emergency Medicine, New York Medical College (NYMC), Metropolitan Hospital Center, New York, New York
| | - Hossein Kalantari
- Department of Emergency Medicine, New York Medical College (NYMC), Metropolitan Hospital Center, New York, New York
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Yu M, Shalaby M, Luftig J, Cooper M, Farrow R. Ultrasound-Guided Retroclavicular Approach to the Infraclavicular Region (RAPTIR) Brachial Plexus Block for Anterior Shoulder Reduction. J Emerg Med 2022; 63:83-87. [PMID: 35934656 DOI: 10.1016/j.jemermed.2022.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 02/17/2022] [Accepted: 04/23/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Shoulder dislocations are a common presenting injury to the emergency department (ED), with anterior dislocations comprising the majority of these cases. Some patients may tolerate gentle manipulation and reduction, but many require analgesia of some type. Oral or parenteral pain medication is often used alone or in combination with procedural sedation if gentle manipulation fails to achieve reduction. Recently, this treatment algorithm has grown to include regional anesthesia as a mode of analgesia for reduction of shoulder dislocations in the form of brachial plexus blocks. It has been well described that the interscalene and supraclavicular approach to the brachial plexus can be used to assist in reduction of anterior shoulder dislocations; however, there has yet to be any published literature regarding the use of ultrasound-guided retroclavicular approach to the infraclavicular region (RAPTIR) brachial plexus blocks for shoulder reduction. CASE REPORT We describe three patients who presented to the ED with anterior shoulder dislocations. The RAPTIR block was performed, provided effective analgesia, and facilitated successful shoulder reduction in all three patients.Why Should an Emergency Physician Be Aware of This? The RAPTIR nerve block is a safe and effective option for analgesia in the patient with an anterior shoulder dislocation. It may have advantages over other brachial nerve blocks and avoids the risks and disadvantages of procedural sedation and opioids.
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Affiliation(s)
- Melissa Yu
- Department of Emergency Medicine, Crozer-Chester Medical Center, Upland, Pennsylvania
| | - Michael Shalaby
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, Florida
| | - Josh Luftig
- Department of Emergency Medicine, Highland Hospital, Alameda Health System, Oakland, California
| | - Maxwell Cooper
- Department of Emergency Medicine, Crozer-Chester Medical Center, Upland, Pennsylvania
| | - Robert Farrow
- Department of Emergency Medicine, Mount Sinai Medical Center, Miami Beach, Florida
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Isobe F, Nakamura K, Yamazaki H, Hayashi M, Itsubo T, Komatsu M, Uchiyama S, Takahashi J. Difficult closed reduction of elbow dislocations: two case reports from a multicenter retrospective chart review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:113-116. [PMID: 37588293 PMCID: PMC10426589 DOI: 10.1016/j.xrrt.2021.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Fumihiro Isobe
- Department of Orthopaedic Surgery, North Alps Medical Center Azumi Hospital, Ikeda, Nagano, Japan
| | - Koichi Nakamura
- Department of Orthopaedic Surgery, North Alps Medical Center Azumi Hospital, Ikeda, Nagano, Japan
| | - Hiroshi Yamazaki
- Department of Orthopaedic Surgery, Aizawa Hospital, Matsumoto, Nagano, Japan
| | - Masanori Hayashi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Toshiro Itsubo
- Department of Orthopaedic Surgery, Iida Municipal Hospital, Iida, Nagano, Japan
| | - Masatoshi Komatsu
- Department of Orthopaedic Surgery, Red Cross Society Suwa Hospital, Suwa, Nagano, Japan
| | - Shigeharu Uchiyama
- Department of Orthopaedic Surgery, Okaya City Hospital, Okaya, Nagano, Japan
| | - Jun Takahashi
- Department of Orthopaedic Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
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Sithamparapillai A, Grewal K, Thompson C, Walsh C, McLeod S. Intra-articular lidocaine versus intravenous sedation for closed reduction of acute anterior shoulder dislocation in the emergency department: a systematic review and meta-analysis. CAN J EMERG MED 2022; 24:809-819. [PMID: 36181665 PMCID: PMC9525937 DOI: 10.1007/s43678-022-00368-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/28/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Anterior shoulder dislocations are commonly treated in the emergency department (ED). Analgesia for reduction is provided by intra-articular lidocaine (IAL) injection or intravenous sedation (IV sedation). The objective of this systematic review and meta-analysis was to compare IAL versus IV sedation for closed reduction of acute anterior shoulder dislocation in the ED. METHODS Electronic searches of MEDLINE and EMBASE (1946-September 2021) were completed and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing IAL and IV sedation for reduction of acute anterior shoulder dislocations among patients ≥ 15 years old in the ED were included. Outcomes of interest included a successful reduction, adverse events, ED length of stay, pain scores, procedure time, ease of reduction, patient satisfaction, and cost. Two reviewers independently screened abstracts, assessed study quality and extracted data. Data were pooled using random-effects models and reported as mean differences and risk ratios (RR) with 95% confidence intervals (CIs). RESULTS 12 RCTs were included with a total of 630 patients (IAL = 327; IV sedation = 303). There was no difference in reduction success between IAL and IV sedation (RR 0.93; 95% CI 0.86-1.01, I2 = 69%), significantly lower adverse events with IAL (RR 0.16; 95% CI 0.07-0.33, I2 = 0%), shorter ED length of stay with IAL (mean difference - 1.48; 95% CI - 2.48 to - 0.47, I2 = 93%), no difference in pain scores post-analgesia and no difference in ease of reduction. CONCLUSIONS Intra-articular lidocaine may have similar effectiveness as IV sedation in the successful reduction of anterior shoulder dislocations in the ED with fewer adverse events, shorter ED length of stay, and no difference in pain scores or ease of reduction. Intra-articular lidocaine may be an effective alternative to IV sedation for reducing anterior shoulder dislocations, particularly when IV sedation is contraindicated or not feasible.
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Affiliation(s)
- Arjun Sithamparapillai
- grid.17063.330000 0001 2157 2938Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON Canada
| | - Keerat Grewal
- grid.17063.330000 0001 2157 2938Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, ON Canada ,grid.512298.5Schwartz/Reisman Emergency Medicine Institute, Toronto, ON Canada ,grid.492573.e0000 0004 6477 6457Sinai Health, Toronto, ON Canada
| | - Cameron Thompson
- grid.512298.5Schwartz/Reisman Emergency Medicine Institute, Toronto, ON Canada ,grid.492573.e0000 0004 6477 6457Sinai Health, Toronto, ON Canada
| | - Chris Walsh
- grid.17063.330000 0001 2157 2938Department of Family and Community Medicine, University of Toronto, Toronto, ON Canada
| | - Shelley McLeod
- grid.512298.5Schwartz/Reisman Emergency Medicine Institute, Toronto, ON Canada ,grid.492573.e0000 0004 6477 6457Sinai Health, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Department of Family and Community Medicine, University of Toronto, Toronto, ON Canada
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Omer T, Perez M, Berona K, Lam CN, Sajed D, Brandon C, Falkenstein J, Kang T, Mailhot T. Accuracy of Landmark-guided Glenohumeral Joint Injections as Assessed by Ultrasound in Anterior Shoulder Dislocations. West J Emerg Med 2021; 22:1335-1340. [PMID: 34787559 PMCID: PMC8597695 DOI: 10.5811/westjem.2021.3.50266] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/08/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction To determine the accuracy of landmark-guided shoulder joint injections (LGI) with point-of-care ultrasound for patients with anterior shoulder dislocations. Methods Patients with anterior shoulder dislocations who underwent LGI were enrolled at our tertiary-care and trauma center. LGI attempts were recorded by an ultrasound fellowship-trained ED physician who determined if they were placed successfully. Pain and satisfaction scores were recorded. Results A total of 34 patients with anterior shoulder dislocation and their treating ED physicians were enrolled. 41.1% of all LGI were determined to be misplaced (n=14). Patients with successful LGI had a greater decrease in mean pain scores post-LGI. Conclusions LGI had a substantial failure rate in our study. Using ultrasound-guidance to assist intra-articular injections may increase its accuracy and thus reduce pain and the need for subsequent procedural sedation.
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Affiliation(s)
- Talib Omer
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Michael Perez
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Kristen Berona
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Chun Nok Lam
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Dana Sajed
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Caroline Brandon
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Jeffrey Falkenstein
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Tarina Kang
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Thomas Mailhot
- Keck School of Medicine of the University of Southern California, Department of Emergency Medicine, Los Angeles, California
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11
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Furuhata R, Kamata Y, Matsumura N, Kono A, Morioka H. Risk factors for failure of reduction of anterior glenohumeral dislocation without sedation. J Shoulder Elbow Surg 2021; 30:306-311. [PMID: 32599286 DOI: 10.1016/j.jse.2020.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 06/04/2020] [Accepted: 06/08/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although anterior glenohumeral dislocations are common, the reduction procedure is often difficult, requiring sedation or anesthesia. To date, the risk factors for reduction failure without sedation have not been fully investigated. This study aimed to clarify the predictive factors that render the reduction of anterior glenohumeral dislocation without sedation difficult by use of multivariate analyses. METHODS We retrospectively reviewed 156 patients who underwent attempted reduction of anterior glenohumeral dislocation between 2006 and 2019. Patients were included based on the following criteria: traumatic dislocation, undergoing attempted reduction using the traction-countertraction method, and acute dislocation in which reduction was attempted within 2 days of the injury. The dependent variable was set as an irreducible glenohumeral dislocation without sedation, which was defined as a reduction failure in this study. Explanatory variables included age, sex, side of injury, recurrent dislocation, axillary nerve injury, time from dislocation to attempted reduction, greater tuberosity fracture, humeral neck fracture, glenoid rim fracture, and glenohumeral osteoarthritis. We evaluated these outcomes from radiographs and clinical notes. Univariate and multivariate analyses were performed. Baseline variables, which were observed to be significant in the univariate analysis, were included in multivariate models, which used logistic regression to identify independent predictors of reduction failure. RESULTS Of the 156 patients, 25 (16.0%) experienced reduction failure. Multivariate analyses showed that older age (≥55 years) (odds ratio [OR], 3.4; 95% confidence interval [CI], 1.1-10.4; P = .036), greater tuberosity fractures (OR, 3.6; 95% CI, 1.1-12.2; P = .033), and glenoid rim fractures (OR, 11.5; 95% CI, 1.5-87.7; P = .018) were risk factors for reduction failure. CONCLUSIONS Our results demonstrated that multiple factors were associated with unsuccessful reduction of anterior glenohumeral dislocation without sedation. In elderly patients or patients with concurrent greater tuberosity fractures and glenoid rim fractures, reduction failure could occur in the absence of sedation; thus, the administration of sedatives or anesthesia should be considered.
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Affiliation(s)
- Ryogo Furuhata
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Tokyo, Japan.
| | - Yusaku Kamata
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Noboru Matsumura
- Department of Orthopaedic Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Aki Kono
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Hideo Morioka
- Department of Orthopaedic Surgery, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
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Penn DM, Williams O. BET 1: Can acute shoulder dislocations be reduced using intra-articular local anaesthetic infiltration as an alternative to intravenous analgesia with or without sedation? Emerg Med J 2020; 37:725-728. [PMID: 33097554 DOI: 10.1136/emermed-2020-210736.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
A short cut review was carried out to establish whether intra-articular injection of local anaesthetic is an effective alternative to intravenous analgesia with or without sedation to facilitate reduction of acute shoulder dislocations. Eleven studies were considered relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these studies are tabulated. The clinical bottom line is that intra-articular injection of local anaesthetic is a safe and effective method of providing procedural analgesia for the reduction of acute shoulder dislocations.
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Affiliation(s)
- Dr Michael Penn
- Northumbria Specialist Emergency Care Hospital, Cramlington, UK
| | - Owen Williams
- Northumbria Specialist Emergency Care Hospital, Cramlington, UK
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13
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Afzalimoghaddam M, Khademi MF, Mirfazaelian H, Payandemehr P, Karimialavijeh E, Jalali A. Comparing Diazepam Plus Fentanyl With Midazolam Plus Fentanyl in the Moderate Procedural Sedation of Anterior Shoulder Dislocations: A Randomized Clinical Trial. J Emerg Med 2020; 60:1-7. [PMID: 33097351 DOI: 10.1016/j.jemermed.2020.09.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 08/09/2020] [Accepted: 09/12/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The reduction of shoulder dislocation requires adequate procedural sedation and analgesia. The mixture of midazolam and fentanyl is reported in the literature, but long-acting benzodiazepines in conjunction with fentanyl are lacking. STUDY OBJECTIVE Our aim was to compar e IV diazepam with IV midazolam in moderate procedural sedation (based on the classification of the American Society of Anesthesiologists) for the reduction of shoulder dislocation. METHODS This was a randomized controlled clinical trial conducted from April 2019 to December 2019 in the emergency department of a university-affiliated hospital in Tehran, Iran. Participants were adult patients (aged 18-65 years) with anterior shoulder dislocation. Group A (n = 42) received diazepam 0.1 mg/kg plus fentanyl 1 μg/kg IV and group B received midazolam 0.1 mg/kg plus fentanyl 1 μg g/kg IV. Main outcomes measured were onset of muscle relaxation, time taken to reduction, total procedure time, number of the reduction attempts, patient recovery time, the occurrence of the adverse effects, amount of the pain reported by the patients using visual analog scale, and patients and physicians overall satisfaction with the procedure using a Likert scale question. RESULTS Eighty-one patients were included. The mean ± standard deviation time of the onset of the muscle relaxation and time taken to reduction was shorter in the diazepam plus fentanyl group (p = 0.016 and p = 0.001, respectively). Adverse effects and pain relief were not statistically different between the two groups. Patient recovery time and total procedure time was shorter in the midazolam plus fentanyl group (p = 0.008 and p = 0.02, respectively). The overall satisfaction of patients and physicians was higher in the diazepam plus fentanyl group. CONCLUSIONS As compared with midazolam plus fentanyl, diazepam plus fentanyl was superior in terms of the onset of the muscle relaxation, patient and physician satisfaction, and time taken to reduction.
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Affiliation(s)
- Mohammad Afzalimoghaddam
- Department of Emergency Medicine, Prehospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Feyiz Khademi
- Department of Emergency Medicine, Prehospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Hadi Mirfazaelian
- Department of Emergency Medicine, Prehospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Pooya Payandemehr
- Department of Emergency Medicine, Prehospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ehsan Karimialavijeh
- Department of Emergency Medicine, Prehospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Jalali
- Department of Emergency Medicine, Prehospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Baden DN, Roetman MH, Boeije T, Mullaart-Jansen N, Burg MD. A Survey of Emergency Providers Regarding the Current Management of Anterior Shoulder Dislocations. J Emerg Trauma Shock 2020; 13:68-72. [PMID: 32395054 PMCID: PMC7204951 DOI: 10.4103/jets.jets_87_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/25/2019] [Indexed: 11/17/2022] Open
Abstract
Background: Anterior shoulder dislocations (ASDs) are frequent painful injuries commonly treated in the emergency department. The last decade new potentially less traumatic and painful reduction techniques for ASDs have been introduced. Recent literature comparing best reduction techniques, medication use, and approaches is limited. To better guide future research including the use of these newer techniques, information about the current use of different reduction techniques and medication is needed. Methods: Our primary aim was to survey the techniques used by emergency practitioners to reduce ASDs. Our secondary objective was to gather data on medication usage during reduction. To these ends, we surveyed members of the Netherlands Society of Emergency Physicians. Results: Forty-four percent of respondents reported using a traction-based technique (Hippocrates or Stimson). Biomechanical techniques were used by 40% of respondents. Twelve percent reported using the Kocher leverage-based technique. Five percent of the techniques used could not be classified. A wide variety of procedural sedation and pain management interventions were reported, with an opioid and propofol being used most commonly. Approximately 9% of the reductions were attempted without any medications. Conclusions: To our knowledge, this is the first study of its kind on ASD management by emergency practitioners. Our results indicate that Dutch emergency practitioners employ all three classes of reduction techniques: traction-countertraction most commonly, closely followed by biomechanical techniques. Medication use during repositioning varied widely. Per our survey, emergency practitioners are desirous of an evidence-based guideline for ASD management.
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Affiliation(s)
- D N Baden
- Department of Emergency Medicine, Dijklander Ziekenhuis, Hoorn, Netherlands
| | - M H Roetman
- Department of Emergency Medicine, Flevoziekenhuis, Almere, Netherlands
| | - T Boeije
- Department of Emergency Medicine, Dijklander Ziekenhuis, Hoorn, Netherlands
| | - N Mullaart-Jansen
- Department of Emergency Medicine, Dijklander Ziekenhuis, Hoorn, Netherlands
| | - M D Burg
- Department of Emergency Medicine, UCSF/Fresno, Fresno, CA, USA
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Stelter J, Malik S, Chiampas G. The Emergent Evaluation and Treatment of Shoulder, Clavicle, and Humerus Injuries. Emerg Med Clin North Am 2020; 38:103-124. [DOI: 10.1016/j.emc.2019.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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16
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Magidson PD, Thoburn AK, Hogan TM. Emergency Orthogeriatrics: Concepts and Therapeutic Considerations for the Geriatric Patient. Emerg Med Clin North Am 2019; 38:15-29. [PMID: 31757248 DOI: 10.1016/j.emc.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Appropriate recognition of the physiologic, psychological, and clinical differences among geriatric patients, with respect to orthopedic injury and disease, is paramount for all emergency medicine providers to ensure they are providing high-value care for this vulnerable population.
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Affiliation(s)
- Phillip D Magidson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, 4940 Eastern Avenue, A1 East Suite 150, Baltimore, MD 21224, USA.
| | - Allison K Thoburn
- Department of Medicine, Section of Geriatrics and Palliative Medicine, University of Chicago Medicine, 5841 South Maryland Avenue, MC 6098, Chicago, IL 60637, USA
| | - Teresita M Hogan
- Department of Medicine, Division of Emergency Medicine, University of Chicago School of Medicine, 5841 South Maryland Avenue, MC 6098, Chicago, IL 60637, USA
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17
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Busse P, Vater C, Stiehler M, Nowotny J, Kasten P, Bretschneider H, Goodman SB, Gelinsky M, Zwingenberger S. Cytotoxicity of drugs injected into joints in orthopaedics. Bone Joint Res 2019; 8:41-48. [PMID: 30915209 PMCID: PMC6397327 DOI: 10.1302/2046-3758.82.bjr-2018-0099.r1] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objectives Intra-articular injections of local anaesthetics (LA), glucocorticoids (GC), or hyaluronic acid (HA) are used to treat osteoarthritis (OA). Contrast agents (CA) are needed to prove successful intra-articular injection or aspiration, or to visualize articular structures dynamically during fluoroscopy. Tranexamic acid (TA) is used to control haemostasis and prevent excessive intra-articular bleeding. Despite their common usage, little is known about the cytotoxicity of common drugs injected into joints. Thus, the aim of our study was to investigate the effects of LA, GC, HA, CA, and TA on the viability of primary human chondrocytes and tenocytes in vitro. Methods Human chondrocytes and tenocytes were cultured in a medium with three different drug dilutions (1:2; 1:10; 1:100). The following drugs were used to investigate cytotoxicity: lidocaine hydrochloride 1%; bupivacaine 0.5%; triamcinolone acetonide; dexamethasone 21-palmitate; TA; iodine contrast media; HA; and distilled water. Normal saline served as a control. After an incubation period of 24 hours, cell numbers and morphology were assessed. Results Using LA or GC, especially triamcinolone acetonide, a dilution of 1:100 resulted in only a moderate reduction of viability, while a dilution of 1:10 showed significantly fewer cell counts. TA and CA reduced viability significantly at a dilution of 1:2. Higher dilutions did not affect viability. Notably, HA showed no effects of cytotoxicity in all drug dilutions. Conclusion The toxicity of common intra-articular injectable drugs, assessed by cell viability, is mainly dependent on the dilution of the drug being tested. LA are particularly toxic, whereas HA did not affect cell viability. Cite this article: P. Busse, C. Vater, M. Stiehler, J. Nowotny, P. Kasten, H. Bretschneider, S. B. Goodman, M. Gelinsky, S. Zwingenberger. Cytotoxicity of drugs injected into joints in orthopaedics. Bone Joint Res 2019;8:41–48. DOI: 10.1302/2046-3758.82.BJR-2018-0099.R1.
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Affiliation(s)
- P Busse
- University Center for Orthopaedics and Traumatology, and Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - C Vater
- University Center for Orthopaedics and Traumatology, and Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - M Stiehler
- University Center for Orthopaedics and Traumatology, and Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - J Nowotny
- University Center for Orthopaedics and Traumatology, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - P Kasten
- Orthopädisch-Chirurgisches Centrum Tübingen, Tübingen, Germany
| | - H Bretschneider
- University Center for Orthopaedics and Traumatology, and Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - S B Goodman
- Departments of Orthopaedic Surgery and Bioengineering, Stanford University, Stanford, California, USA
| | - M Gelinsky
- Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - S Zwingenberger
- University Center for Orthopaedics and Traumatology, and Center for Translational Bone, Joint and Soft Tissue Research, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
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Risler Z, Magee MA, Mazza JM, Goodsell K, Au AK, Lewiss RE, Pugliese RS, Ku B. A Three-dimensional Printed Low-cost Anterior Shoulder Dislocation Model for Ultrasound-guided Injection Training. Cureus 2018; 10:e3536. [PMID: 30648069 PMCID: PMC6318112 DOI: 10.7759/cureus.3536] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Anterior shoulder dislocations are the most common, large joint dislocations that present to the emergency department (ED). Numerous studies support the use of intraarticular local anesthetic injections for the safe, effective, and time-saving reduction of these dislocations. Simulation training is an alternative and effective method for training compared to bedside learning. There are no commercially available ultrasound-compatible shoulder dislocation models. We utilized a three-dimensional (3D) printer to print a model that allows the visualization of the ultrasound anatomy (sonoanatomy) of an anterior shoulder dislocation. We utilized an open-source file of a shoulder, available from embodi3D® (Bellevue, WA, US). After approximating the relative orientation of the humerus to the glenoid fossa in an anterior dislocation, the humerus and scapula model was printed with an Ultimaker-2 Extended+ 3D® (Ultimaker, Cambridge, MA, US) printer using polylactic acid filaments. A 3D model of the external shoulder anatomy of a live human model was then created using Structure Sensor®(Occipital, San Francisco, CA, US), a 3D scanner. We aligned the printed dislocation model of the humerus and scapula within the resultant external shoulder mold. A pourable ballistics gel solution was used to create the final shoulder phantom. The use of simulation in medicine is widespread and growing, given the restrictions on work hours and a renewed focus on patient safety. The adage of "see one, do one, teach one" is being replaced by deliberate practice. Simulation allows such training to occur in a safe teaching environment. The ballistic gel and polylactic acid structure effectively reproduced the sonoanatomy of an anterior shoulder dislocation. The 3D printed model was effective for practicing an in-plane ultrasound-guided intraarticular joint injection. 3D printing is effective in producing a low-cost, ultrasound-capable model simulating an anterior shoulder dislocation. Future research will determine whether provider confidence and the use of intraarticular anesthesia for the management of shoulder dislocations will improve after utilizing this model.
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Affiliation(s)
- Zachary Risler
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Mark A Magee
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Jacob M Mazza
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Kelly Goodsell
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Arthur K Au
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
| | - Resa E Lewiss
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
| | | | - Bon Ku
- Emergency Medicine, Thomas Jefferson University, Philadelphia, USA
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Kranc DA, Jones AW, Nackenson J, Davis CA, Abo BN, Hawkins SC. Use of Ultrasound for Joint Dislocation Reduction in an Austere Wilderness Setting: A Case Report. PREHOSP EMERG CARE 2018; 23:584-589. [PMID: 30303761 DOI: 10.1080/10903127.2018.1532474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Point-of-care ultrasound has been shown to have a demonstrable impact in the austere/out-of-hospital environment. As ultrasounds become more affordable and portable, a myriad of uses in austere environments are becoming recognized. We present a case of a stranded hiker with an ultrasound-confirmed glenohumeral joint dislocation who underwent ultrasound-guided intra-articular lidocaine injection and ultrasound-confirmed reduction. This procedure allowed the patient to hike out under his own power, avoiding the potential dangers of extrication to both patient and rescuers. We believe this case demonstrates the feasibility and utility of ultrasound in the out-of-hospital environment both procedurally and diagnostically.
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20
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Gould FJ. An Effective Treatment in the Austere Environment? A Critical Appraisal into the Use of Intra-Articular Local Anesthetic to Facilitate Reduction in Acute Shoulder Dislocation. Wilderness Environ Med 2018; 29:102-110. [PMID: 29373217 DOI: 10.1016/j.wem.2017.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 09/11/2017] [Accepted: 09/27/2017] [Indexed: 10/18/2022]
Abstract
Acute shoulder dislocation is a common injury in the outdoor environment. The objective of this systematic review of the literature was to determine if intra-articular local anesthetic (IAL) is an effective treatment that could have prehospital application. A methodical search of MEDLINE, PubMed, and EMBASE databases targeted publications from January 1, 1990 until January 1, 2017. Eligible articles compared IAL with other analgesic techniques in patients 16 years or older experiencing acute glenohumeral dislocation. Reduction success, complications, and patient-reported outcome measures underwent comparison. All identified publications originated from the hospital setting. Procedural success rates ranged widely among randomized control trials comparing IAL with intravenous analgesia and sedation (IAL 48-100%, intravenous analgesia and sedation 44-100%). A pooled risk ratio [RR] favored intravenous analgesia and sedation (RR 0.91, 95% confidence interval [CI] 0.84-0.98), but there was significant inconsistency within the analysis (I2 = 75%). IAL provided lower complication rates (4/170, 2%) than intravenous analgesia and sedation (20/150, 13%) (RR 1.11, 95% CI 1.04-1.19, I2 = 63%). One trial found a clinically relevant reduction in visual analogue pain scores when comparing IAL against no additional analgesia in the first minute (IAL 21±13 mm; control 49±15 mm; P<0.001) and fifth minute (IAL 10±10 mm; control 40±14 mm, P<0.001) after reduction. The results suggest that IAL is an effective intervention for acute anterior shoulder dislocation that would have a place in the repertoire of the remote physician. Further research might be beneficial in determining the outcomes of performing IAL in the prehospital setting.
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Affiliation(s)
- Fraser John Gould
- British Antarctic Survey Medical Unit, South Georgia & the South Sandwich Islands.
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Bambaren IA, Dominguez F, Elias Martin ME, Domínguez S. Anesthesia and Analgesia in the Patient with an Unstable Shoulder. Open Orthop J 2017; 11:848-860. [PMID: 29114334 PMCID: PMC5646176 DOI: 10.2174/1874325001711010848] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 10/21/2016] [Accepted: 10/28/2016] [Indexed: 12/01/2022] Open
Abstract
Introduction: The patient with an unstable shoulder represents a challenge for the anesthesiologist. Most patients will be young individuals in good health but both shoulder dislocation reduction, a procedure that is usually performed under specific analgesia in an urgent setting, and instability surgery anesthesia and postoperative management present certain peculiarities. Material and Methods: For the purpose of the article, 78 references including clinical trials and reviews were included. The review was organized considering the patient that presents an acute shoulder dislocation and the patient with chronic shoulder instability that requires surgery. In both cases the aspects like general or regional anesthesia, surgical positions and postoperative pain management were analyzed. Conclusion: The patient with an acutely dislocated shoulder is usually managed in the emergency room. Although reduction without analgesia is often performed in non-medical settings, an appropriate level of analgesia will ease the reduction procedure avoiding further complications. Intravenous analgesia and sedation is considered the gold standard but requires appropriate monitorization and airway control. Intraarticular local analgesic injection is considered also a safe and effective procedure. General anesthesia or nerve blocks can also be considered. The surgical management of the patient with shoulder instability requires a proper anesthetic management. This should start with an exhaustive preoperative evaluation that should be focused in identifying potential respiratory problems that might be complicated by local nerve blocks. Intraoperative management can be challenging, especially for patients operated in beach chair position, for the relationship with problems related to cerebral hypoperfusion, a situation related to hypotension events directly linked to patient positioning. Different nerve blocks will help attaining excellent analgesia both during and after the surgical procedure. An interescalene nerve block should be considered the best technique, but in certain cases, other blocks can be considered.
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Affiliation(s)
| | - Fernando Dominguez
- Ramón y Cajal Hospital. Anesthesia and Intensive Care Department. Madrid. Spain
| | | | - Silvia Domínguez
- Ramón y Cajal Hospital. Anesthesia and Intensive Care Department. Madrid. Spain
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Baden DN, Roetman MH, Boeije T, Roodheuvel F, Mullaart-Jansen N, Peeters S, Burg MD. Biomechanical reposition techniques in anterior shoulder dislocation: a randomised multicentre clinical trial- the BRASD-trial protocol. BMJ Open 2017; 7:e013676. [PMID: 28729305 PMCID: PMC5577902 DOI: 10.1136/bmjopen-2016-013676] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Glenohumeral (shoulder) dislocations are the most common large joint dislocations seen in the emergency department (ED). They cause pain, often severe, and require timely interventions to minimise discomfort and tissue damage. Commonly used reposition or relocation techniques often involve traction and/or leverage. These techniques have high success rates but may be painful and time consuming. They may also cause complications. Recently, other techniques-the biomechanical reposition techniques (BRTs)-have become more popular since they may cause less pain, require less time and cause fewer complications. To our knowledge, no research exists comparing the various BRTs. Our objective is to establish which BRT or BRT combination is fastest, least painful and associated with the lowest complication rate for adult ED patients with anterior glenohumeral dislocations (AGDs). METHODS AND ANALYSIS Adults presenting to the participating EDs with isolated AGDs, as determined by radiographs, will be randomised to one of three BRTs: Cunningham, modified Milch or scapular manipulation. Main study parameters/endpoints are ED length of stay and patients' self-report of pain. Secondary study parameters/endpoints are procedure times, need for analgesic and/or sedative medications, iatrogenic complications and rates of successful reduction. ETHICS AND DISSEMINATION Non-biomechanical AGD repositioning techniques based on traction and/or leverage are inherently painful and potentially harmful. We believe that the three BRTs used in this study are more physiological, more patient friendly, less likely to cause pain, more time efficient and less likely to produce complications. By comparing these three techniques, we hope to improve the care provided to adults with acute AGDs by reducing their ED length of stay and minimising pain and procedure-related complications. We also hope to define which of the three BRTs is quickest, most likely to be successful and least likely to require sedative or analgesic medications to achieve reduction. TRIAL REGISTRATION NUMBER NTR5839.
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Affiliation(s)
- David N Baden
- Emergency department, Westfriesgasthuis Hoorn, Hoorn, The Netherlands
| | - Martijn H Roetman
- Emergency department, Flevoziekenhuis Almere, Almere, The Netherlands
| | - Tom Boeije
- Emergency department, Westfriesgasthuis Hoorn, Hoorn, The Netherlands
| | - Floris Roodheuvel
- Emergency department, Flevoziekenhuis Almere, Almere, The Netherlands
| | | | - Suzanne Peeters
- Emergency department, Flevoziekenhuis Almere, Almere, The Netherlands
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Abstract
PURPOSE To identify the optimal technique for closed reduction for shoulder instability, based on success rates, reduction time, complication risks, and pain level. METHODS A PubMed and EMBASE query was performed, screening all relevant literature of closed reduction techniques mentioning the success rate written in English, Dutch, German, and Arabic. Studies with a fracture dislocation or lacking information on success rates for closed reduction techniques were excluded. We used the modified Coleman Methodology Score (CMS) to assess the quality of included studies and excluded studies with a poor methodological quality (CMS < 50). Finally, a meta-analysis was performed on the data from all studies combined. RESULTS 2099 studies were screened for their title and abstract, of which 217 studies were screened full-text and finally 13 studies were included. These studies included 9 randomized controlled trials, 2 retrospective comparative studies, and 2 prospective non-randomized comparative studies. A combined analysis revealed that the scapular manipulation is the most successful (97%), fastest (1.75 min), and least painful reduction technique (VAS 1,47); the "Fast, Reliable, and Safe" (FARES) method also scores high in terms of successful reduction (92%), reduction time (2.24 min), and intra-reduction pain (VAS 1.59); the traction-countertraction technique is highly successful (95%), but slower (6.05 min) and more painful (VAS 4.75). CONCLUSION For closed reduction of anterior shoulder dislocations, the combined data from the selected studies indicate that scapular manipulation is the most successful and fastest technique, with the shortest mean hospital stay and least pain during reduction. The FARES method seems the best alternative.
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Flinders A, Seif D. Point-of-Care Ultrasound in Diagnosis and Treatment of Luxatio Erecta (Inferior Shoulder Dislocation). J Med Ultrasound 2016. [DOI: 10.1016/j.jmu.2016.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Abstract
Pain is the most common complaint for which patients come to the emergency department (ED). Emergency physicians are responsible for pain relief in a timely, efficient, and safe manner in the ED. The improvement in our understanding of the neurobiology of pain has balanced the utilization of nonopioid and opioid analgesia, and simultaneously has led to more rational and safer opioid prescribing practices. This article reviews advances in pain management in the ED for patients with acute and chronic pain as well as describes several newer strategies and controversies.
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Affiliation(s)
- Sergey M Motov
- Department of Emergency Medicine, Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, USA.
| | - Lewis S Nelson
- New York University School of Medicine, 455 First Avenue, New York, NY, USA
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Kashani P, Asayesh Zarchi F, Hatamabadi HR, Afshar A, Amiri M. Intra-articular lidocaine versus intravenous sedative and analgesic for reduction of anterior shoulder dislocation. Turk J Emerg Med 2016; 16:60-64. [PMID: 27896323 PMCID: PMC5121259 DOI: 10.1016/j.tjem.2016.04.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 02/03/2016] [Accepted: 04/10/2016] [Indexed: 11/29/2022] Open
Abstract
Objective This prospective clinical trial was performed to compare the safety and efficiency of intra-articular lidocaine (IAL) versus intravenous sedative and analgesic (IVSA) in reduction of anterior shoulder dislocation. Materials and methods Patients with anterior shoulder dislocation were randomly divided into 2 groups to receive IAL and IVSA. One group patients received an intravenous dose of 0.05 mg/kg midazolam and 1 μg/kg fentanyl, while the other group received 20 mL intra-articular lidocaine (1%). Patient satisfaction (via a standard 5-choice questionnaire), pain score (based on visual analog scale ranging from 0 to 10 points), comfort reduction, recovery time, and side effects were recorded and compared between the two groups before, during and after the reduction procedure. Results Totally 104 patients with acute anterior shoulder dislocation and the mean age of 28.75 ± 7.24 years were included (86.5% male). There was no statistically significant difference between IAL and IVSA groups regarding age (p = 0.45) and gender (p = 0.25). A total of forty-seven (45.2%) patients, distributed in both groups, had a history of anterior shoulder dislocation. A significant difference was seen with regard to diminished pain intensity during reduction in IAL group (p < 0.001); Complications including nausea, apnea, hypoxia and headache were only observed in IVSA group, and there was no adverse effect in IAL group; increased patient satisfaction in IVSA group (p = 0.007); similar success rate at first attempt of reduction in both groups, and a shorter time to discharge in IAL group (p < 0.001). Conclusion It seems that the use of intra-articular lidocaine for reduction of anterior shoulder dislocation is effective, safe, and time saving in the emergency department and has few complications. It can be considered as the first line analgesia in managing anterior shoulder dislocation.
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Affiliation(s)
- Parvin Kashani
- Department of Emergency Medicine, Loghmane Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fatemeh Asayesh Zarchi
- Department of Emergency Medicine, Loghmane Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Hatamabadi
- Safety Promotion & Injury Prevention Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abbas Afshar
- Department of Management, Mofateh Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Marzieh Amiri
- Department of Emergency Medicine, Shahid Beheshti Hospital, Guilan University of Medical Sciences, Anzali, Iran
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Desai N, Caperell KS. Joint Dislocations in the Pediatric Emergency Department. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2016. [DOI: 10.1016/j.cpem.2016.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Hames H, McLeod S, Millard W. Intra-articular lidocaine versus intravenous sedation for the reduction of anterior shoulder dislocations in the emergency department. CAN J EMERG MED 2015; 13:378-83. [DOI: 10.2310/8000.2011.110495] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACTObjective:The objective was to compare intra-articular lidocaine (IAL) versus intravenous sedation (IVS) for the reduction of acute, anterior shoulder dislocations in the emergency department (ED) in terms of ED length of stay, rate of successful reductions, patient satisfaction, and complications.Methods:This was a prospective, randomized trial. Patients in the IAL group received 4 mg/kg (up to 200 mg) of 1% lidocaine injected into the glenohumeral joint using a lateral approach. Patients in the IVS group received medications for sedation as per the discretion of the treating physician. Follow-up was arranged within 2 weeks of the ED visit to assess for complications.Results:Forty-four patients (25 IAL, 19 IVS) were included. This trial was stopped early owing to a combination of unexpected findings in success, resource limitations, and difficulty in patient enrolment. Median time from first physician assessment to patient discharge was not different between the IAL (170 minutes) group and the IVS (145 minutes) group (Δ –25 minutes; 95% CI –32, 70;p= 0.46). There was a significantly lower rate (p< 0.001) of successful closed reduction in the IAL group (48%) compared to the IVS group (100%). Patient satisfaction and physician ease of reduction were higher in the IVS group compared to the IAL group (p< 0.05). There were no reported complications in either group at time of reduction or follow-up.Conclusions:There was no difference in ED length of stay between groups. There was a lower rate of successful reductions and lower satisfaction scores in the IAL group.
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Abstract
The shoulder joint has the greatest range of motion of any joint in the body. However, it relies on soft-tissue restraints, including the capsule, ligaments, and musculature, for stability. Therefore, this joint is at the highest risk for dislocation. Thorough knowledge of the shoulder's anatomy as well as classification of dislocations, anesthetic techniques, and reduction maneuvers is crucial for early management of acute shoulder dislocation. Given the lack of comparative studies on various reduction techniques, the choice of technique is based on physician preference. The orthopaedic surgeon must be well versed in several reduction methods and ascertain the best technique for each patient.
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Intra-articular lidocaine versus intravenous analgesia and sedation for manual closed reduction of acute anterior shoulder dislocation: an updated meta-analysis. J Clin Anesth 2014; 26:350-9. [PMID: 25066879 DOI: 10.1016/j.jclinane.2013.12.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 12/17/2013] [Accepted: 12/19/2013] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE To compare intra-articular lidocaine (IAL) with intravenous analgesia and sedation (IVAS) for manual closed reduction of acute anterior shoulder dislocation. DESIGN Meta-analysis. SETTING Metropolitan medical university. MEASUREMENTS A literature search was conducted of PubMed, Ovid and Cochrane Library, to identify randomized controlled trials (RCTs) published from January 1, 1990 to September 1, 2012, that compared IAL with IVAS for manual closed reduction of acute anterior shoulder dislocation. Effective data were pooled using fixed-effects or random-effects models with mean differences (MDs) and risk ratios (RRs) for continuous and dichotomous variables, respectively. MAIN RESULTS Nine RCTs comprising 438 patients were analyzed. Statistical analyses showed that IAL was superior to IVAS with respect to lower complication risk (P < 0.00001) and shorter mean hospital length of stay (P = 0.03). No significant differences were noted in success of joint reduction (P = 0.16), patient satisfaction (P = 0.12), or postreduction pain relief (P = 0.76). However, IAL required more time than IVAS from injection to reduction (P < 0.00001). Subgroup analyses showed that IVAS was associated with higher risks of respiratory depression (P < 0.0001), vomiting (P = 0.04), and thrombophlebitis (P = 0.008), but no statistical differences were identified in nausea (P = 0.06), hypotension (P = 0.10), drowsiness (P = 0.45), or headache (P = 0.29). CONCLUSIONS Intra-articular lidocaine injection may be safer than IVAS because there are fewer risks of postoperative complications with IAL. Both techniques are similarly effective for manual closed reduction of acute anterior shoulder dislocation.
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Abstract
Anterior shoulder dislocation is the most common joint dislocation seen in the emergency department. Although emergency medicine providers use several techniques for reduction, each method is associated with potential discomfort for the patient. In addition, pain from the dislocated shoulder causes muscle spasm that impedes reduction. Therefore, both analgesia and procedural sedation are often used to reduce pain and enable reduction. Intra-articular injection of lidocaine has demonstrated efficacy in reduction of pain and facilitation of shoulder reduction compared with analgesia and sedation. Intra-articular lidocaine may also reduce time to successful reduction of shoulder dislocations.
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Ultrasound-guided intra-articular lidocaine block for reduction of anterior shoulder dislocation in the pediatric emergency department. Pediatr Emerg Care 2014; 30:217-20. [PMID: 24589815 DOI: 10.1097/pec.0000000000000095] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report a case of successful reduction of an anterior shoulder dislocation after ultrasound-guided intra-articular lidocaine (IAL) block with subsequent sonographic confirmation of reduction. Current literature suggests that IAL can provide similar levels of analgesia as intravenous sedation, and IAL block is associated with lower complication rates and shorter emergency department stays. However, these studies may be limited by uncertainty about the accuracy of landmark-based glenohumeral injections. The use of beside ultrasound may improve the effectiveness of IAL block for reduction of anterior shoulder dislocation and provide a mechanism for immediate postreduction evaluation of the placement of the humeral head.
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Vinson DR, Hoehn CL. Sedation-assisted Orthopedic Reduction in Emergency Medicine: The Safety and Success of a One Physician/One Nurse Model. West J Emerg Med 2013; 14:47-54. [PMID: 23447756 PMCID: PMC3582522 DOI: 10.5811/westjem.2012.4.12455] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 04/09/2012] [Accepted: 04/30/2012] [Indexed: 02/01/2023] Open
Abstract
Introduction Much of the emergency medical research on sedation-assisted orthopedic reductions has been undertaken with two physicians––one dedicated to the sedation and one to the procedure. Clinical practice in community emergency departments (EDs), however, often involves only one physician, who both performs the procedure and simultaneously oversees the crendentialed registered nurse who administers the sedation medication and monitors the patient. Although the dual-physician model is advocated by some, evidence in support of its superiority is lacking. Methods: In this electronic health records review we describe sedation-assisted closed reductions of major joints and forearm fractures in three suburban community EDs. The type of procedure and sedation medication, need for specialty assistance, success rates, and intervention-requiring adverse events are reported. Results: During the 18-month study period, procedural sedation was performed 457 times on 442 patients undergoing closed reduction for shoulder dislocations (n = 111), elbow dislocations (n = 29), hip dislocations (n = 101), and forearm fractures (n = 201). In the vast majority of this cohort (98.4% [435/442]), a single emergency physician simultaneously managed both the procedural sedation and the initial orthopedic reduction without the assistance of a second physician. The reduction was successful or satisfactory in 96.6% (425/435; 95% confidence interval [CI], 95.8–98.8%) of these cases, with a low incidence of intervention-requiring adverse events (2.8% [12/435]; 95% CI, 1.5–4.8%). Conclusion: Sedation-assisted closed reduction of major joint dislocations and forearm fractures can be performed effectively and safely in the ED using a one physician/one nurse model. A policy that requires a separate physician (or nurse anesthetist) to administer medications for all sedation-assisted ED procedures appears unwarranted. Further research is needed to determine which specific clinical scenarios might benefit from a dual-physician approach.
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Affiliation(s)
- David R Vinson
- Kaiser Permanente Roseville Medical Center, Department of Emergency Medicine, Roseville, California ; The Permanente Medical Group, Oakland, California
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Abstract
Musculoskeletal injury and diseases are common presentations in the Emergency Department. Emergency physicians must be versed in the critical procedural skills necessary to diagnose joint infection, manage fractures and dislocations, and assess for compartment syndrome. Arthrocentesis, splinting, dislocation reduction, and the evaluation of limb compartment syndrome are reviewed.
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Affiliation(s)
- Stuart E Boss
- Department of Emergency Medicine, The University of Texas Medical School at Houston, 6431 Fannin, JJL 431, Houston, TX 77030, USA.
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Abstract
Context: The shoulder is the most commonly dislocated joint, and shoulder dislocations are very common in sports. Many of these dislocations present to the office or training room for evaluation. Usual practice is an attempt at manual reduction without analgesia and then transfer to the emergency department if unsuccessful. The clinical efficacy of intra-articular lidocaine for reduction of anterior shoulder dislocations in the outpatient setting was examined. Evidence Acquisition: An OVID MEDLINE search (1966-present) was performed using the keywords shoulder, reduction, and analgesia as well as shoulder, intra-articular, and lidocaine. Search limits included articles in the English language. Bibliographic references from these articles were also examined to identify pertinent literature. Results: Six randomized controlled clinical trials were identified that directly addressed this clinical technique. Although the reduction techniques used in these studies were not controlled, there was no statistically significant difference in success rates between groups. The complication rate, length of stay, and costs were significantly less in the intra-articular lidocaine group when compared with the intravenous sedation group. Conclusions: According to current evidence, the use of intra-articular lidocaine injection for reduction of anterior shoulder dislocations is not harmful and is likely advantageous in the outpatient clinical setting.
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Affiliation(s)
- Anna L Waterbrook
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona
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Holdgate A, Taylor DM, Bell A, MacBean C, Huynh T, Thom O, Augello M, Millar R, Day R, Williams A, Ritchie P, Pasco J. Factors associated with failure to successfully complete a procedure during emergency department sedation. Emerg Med Australas 2011; 23:474-8. [PMID: 21824315 DOI: 10.1111/j.1742-6723.2011.01420.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine factors associated with failure to successfully complete a procedure during sedation in the ED. METHODS Eleven Australian EDs enrolled consecutive adult and paediatric patients between January 2006 and December 2008. Patients were included if a sedative drug was administered for an ED procedure and the success or failure of the procedure was recorded. RESULTS Data were available for 2567 patients. Of these, 1548 (60.3%, 95% CI 58.4-62.2) were male and 456 (17.8%, 95% CI 16.3-19.3) were age <16 years. The most common procedures performed were reduction of major joints and laceration repair. A total of 149 procedures (5.8%, 95% CI 5.0-6.8) failed. There were significant differences in failure rates between the types of procedure undertaken, with reduction of hips, digits and mandibles associated with the highest failure rates (P < 0.001). In adults, body weight >100 kg was also associated with increased risk of procedural failure (odds ratio 2.3, 95% CI 1.3-4.1). Ketamine used as a single agent had the lowest procedural failure rate (2.5%, 95% CI 1.1-5.4) whereas propofol had the highest (5.9%, 95% CI 4.6-7.6). However, these two drugs were generally used in different age groups and for different procedures. CONCLUSIONS Procedures performed under sedation in the ED have a low failure rate. However, increased body weight and specific procedures, such as hip reduction, are associated with significantly higher failure rates. Special consideration should be given to these patient groups before undertaking sedation in the ED.
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Affiliation(s)
- Anna Holdgate
- Liverpool Hospital, Sydney, New South Wales, Australia
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Malik S, Chiampas G, Leonard H. Emergent evaluation of injuries to the shoulder, clavicle, and humerus. Emerg Med Clin North Am 2010; 28:739-63. [PMID: 20971390 DOI: 10.1016/j.emc.2010.06.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This article provides a review of the evaluation and treatment of common injuries to the shoulder, humerus, and clavicle in the emergency department (ED) setting. In addition to a focused review of the shoulder's physical examination, topics include common emergent injuries such as glenohumeral dislocations, proximal humerus fractures, and acromioclavicular separations as well as less common, but important injuries including pectoralis and biceps tendon injuries and sternoclavicular dislocations. Accurate recognition and management of these injuries is essential in the optimal care of patients in the ED.
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Affiliation(s)
- Sanjeev Malik
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, 259 East Erie Street, Suite 100, Chicago, IL 60610, USA.
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Current World Literature. Curr Opin Anaesthesiol 2009; 22:539-43. [DOI: 10.1097/aco.0b013e32832fa02c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Perron A, Gibbs M. It is nice to have options. Acad Emerg Med 2008; 15:757-8. [PMID: 18627582 DOI: 10.1111/j.1553-2712.2008.00172.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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