Authors: Becky Maxwell, Craig Davidson, Andy Neill, Chris Connolly / Code: CAP37, CAP4, CC21 / Published: 07/09/2017
Clinical Question to be answered
- For reduction of anterior shoulder dislocation is an injection of intra-articular lidocaine comparable in terms of safety and efficacy to intraveous procedural sedation?
Title of paper
- Intra-articular lidocaine versus intravenous sedative and analgesic forreduction of anterior shoulder dislocation
Journal and year
- 2016 Turkish Journal of Emergency Medicine
Name of contributor
- Becky Maxwell
- Adults (18-40 yo) who had an anterior shoulder dislocation who attended one of two EDs
- Intra-articular injection Lidocaine 20mls 1%using landmark technique – reduction was attempted 15 minutes after this intervention
- Procedural sedation using midazolam (0.05mg/kg) and fentanyl (1mcg/kg) as their sedation agents
- Multiple outcomes – we have discussed issues with not have one outcome before in this podcasts.
- Patient satisfaction (using a 5-choice ques-tionnaire),
- pain measurement (using a visual analog scale rangingfrom 0 to 10 points),
- recovery time, and
- side effects during and after reduction were assessed and compared between the two groups.
Summary of results
- 104 patients with acute anterior shoulder dislocation
- mean age of 28.75 ( all relatively young!)
- No significant difference was seen in average pain intensity before and after the reduction in the 2 groups.
- Mean pain intensity during reduction in sedation group was significantly higher than intra-articular group
- Patient satisfaction in sedation group was significantly higher than intra-articular group (odd considering the above result about pain!). Look at table 3 – 9 patients were completely dissatisfied with the intra-articular injection!
- Success rate at reduction was similar in both groups
- Unsuprisingly time to discharge was significantly shorter in the Intra-articular group!
- Adverse events were higher in the sedation group: there were 0 adverse events with the injections, versus 11% apnea and 10% hypoxia with the sedation. .
- Prospective randomised study that attempts to answer a question that important to us clinically in the ED. Groups were matched.
- Choice of sedative midazolam and fentanyl – most people use something else these days.
- Certainly i reach for the propofol and fentanyl in this group. Midazolam ‘dirty drug’ I tend to try and avoid using these days.
- Choice of rigid dosing for sedation rather than use a sedation scale to achieve the level of sedation they want – could this account for the pain scores in the sedation group – perhaps some people weren’t as well sedated as they should have been. Midazolam should have an amnesic effect therefore why ask the pain score at all during procedure?? Is this reliable???
- Adverse reactions really high – 11% people with hypoxia and 10% with apnoea in sedation group – is this due to choice of sedative??
Clinical Bottom Line
- Going to take the clinical bottom line from two viewpoints:
1. as a clinician – I don’t sedate too many shoulders anyway so perhaps the introduction of an intra- articular injection in my weaponry for those patients I’m not sedating would be worth a go…..
2. as the patient – I choose this paper as alongside some of my colleagues we decided to do a gentle jog around a muddy obstacle course this weekend. Simon was consultant on call for our ED and I said to him if I disclosed my shoulder and came in that I wanted the “good drugs”. Simon suggested an IA injection. As it stands as a patient I still want the good drugs!
Any other FOAM sites where you found it or who have discussed it already so that we can be sure to give kudos
- Cochrane review of IA lignicaine
Ultrasound diagnosis of dislocation and injection
Landmark guided injection