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dhb

dhb

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  1. Attending Physician
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60 y/o M comes in with dislocated shoulder. No significant PMH, but ate a slice of bread 2h ago.
What would you do? wait vs regional vs GA?
 
How urgently does this need to get done? Are you just going to reduce it? Or, does he need surgery?

-copro
 
These hurt, real real bad and could cause neurovascular compromise. I'm not going to make the guy wait 4-6 more hours for a reduction. In the ED these get reduced with some combo of midaz/fent, etomidate or ketamine. We do see these 'failed conscious sedation' cases come to the OR from time to time. Propofol, sux, tube. Suck out the stomach. Let the surgeons work. Take it out awake. Not sure how this would fly on the oral boards though. What's the best way to handle it in that situation?
 
2ndyear said:
These hurt, real real bad and could cause neurovascular compromise. I'm not going to make the guy wait 4-6 more hours for a reduction. In the ED these get reduced with some combo of midaz/fent, etomidate or ketamine. We do see these 'failed conscious sedation' cases come to the OR from time to time. Propofol, sux, tube. Suck out the stomach. Let the surgeons work. Take it out awake. Not sure how this would fly on the oral boards though. What's the best way to handle it in that situation?
Click to expand...

We do the same thing for hips. A lot of ER docs will first try to do this as a "conscious sedation" as you describe. I don't think they have any comprehension/care about the "full stomach" thing, though. And, pulling on the quads is a bit difficult without relaxation.

If the guy isn't going to the OR (or even if he is), I'd do an RSI and just drip in some propofol while they work. Agreed about the neuro/vascular compromise, if there, in that it ups the ante.

-copro
 
P.S. No need to do an intrascalene unless you're planning on operating. Just IMHO.

-copro
 
Yes it was a reduction i guess they couldn't get it done in the ER because of the pain.
Since he wasn't NPO we went for an inter-scalene block.
I get could response in the shoulder at .4mA and inject 30cc of lidocaine 1.5% after a few minutes the guy can't move his arm but still has pain at the very top of the shoulder between the clavicule and the scapula when his arm is pulled.
Anybody knows what's up with that?
We waited a while and gave propofol/sux and just after the tube went in the shoulder was reduced.
 
this is a routine case of me....

200 mg propofol while breath 100% nrb oxygen

finger on chin pulling back..

ortho dude pops it in..

end of story..
 
On the oral boards, you would have to have a discussion with the surgeon regarding risks/benefits of waiting. They want you to function like a consultant, so these discussions are important. After that and he tells you about neurovascular compromise, you would want a protected airway, so go with GA IMHO. An ISB will fail on the boards, and with sedation the patient will go apneic and aspirate. I take these things in April, so I hope that line of thinking will fly.

In the real world, I would do what military would do. Why induce, paralyze, and intubate for a 3 minute case? A lot of times these orthopods ask for paralysis, but they don't know the difference if the patient is really paralyzed or not, they just want the patient to not move. Ketamine/propofol/fentanyl/midaz cocktail, some jaw lift, O2 mask, everyone is happy.
 
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dhb said:
Any opinions on why the IS block was insufficient?
Click to expand...


that can happen when you don't do the block high enough.......like at the brainstem level.
 
dhb said:
Any opinions on why the IS block was insufficient?
Click to expand...

May not have let it set up long enough. Maybe not. Thats the problem with nerve stim guided regional. SOmetimes you can get incomplete blocks. WIth U/S you can visualize the trunks getting bathed in the lidocaine. They always work.

So if the guy ate 2 hours ago you folks are ok with giving him deep sedation? Never had anyone aspirate with this situation? We've had folks vomit up omlets and toast n' stuff for Hip Dislocations in the PAR while giving sedation (propofol) and then aspirating.

It just doesn't seem worth it. However I am new and I wish to learn more. Teach me. Learn me.
 
VentdependenT said:
May not have let it set up long enough. Maybe not. Thats the problem with nerve stim guided regional. SOmetimes you can get incomplete blocks. WIth U/S you can visualize the trunks getting bathed in the lidocaine. They always work.

So if the guy ate 2 hours ago you folks are ok with giving him deep sedation? Never had anyone aspirate with this situation? We've had folks vomit up omlets and toast n' stuff for Hip Dislocations in the PAR while giving sedation (propofol) and then aspirating.

It just doesn't seem worth it. However I am new and I wish to learn more. Teach me. Learn me.
Click to expand...

I've been doing this since 1993....yes people do vomit...after they eat....but then I've had just as many people who vomit when they haven't eaten.

The NPO time gives people a false sense of security when all it does is tie your hands and give lawyers ammunition(if you go with clinical judgement)
 
VentdependenT said:
May not have let it set up long enough. Maybe not. Thats the problem with nerve stim guided regional. SOmetimes you can get incomplete blocks. WIth U/S you can visualize the trunks getting bathed in the lidocaine. They always work.

So if the guy ate 2 hours ago you folks are ok with giving him deep sedation? Never had anyone aspirate with this situation? We've had folks vomit up omlets and toast n' stuff for Hip Dislocations in the PAR while giving sedation (propofol) and then aspirating.
Click to expand...

Actually the attending performed a suprascapular block after the IS and it didn't solve the pb. We don't have US yet.
We didn't sedate him for the blocks, in fact we rarely use more than some midaz for surgery after regional anesthesia except maybe for shoulders.
 
dhb said:
Actually the attending performed a suprascapular block after the IS and it didn't solve the pb. We don't have US yet.
We didn't sedate him for the blocks, in fact we rarely use more than some midaz for surgery after regional anesthesia except maybe for shoulders.
Click to expand...

I frequently give tons of sedation for nerve stim blocks. Plus on board versed is a good thing for the eventual seizure which will occur from local anesthetic toxicity.

I don't know why a supra clav block would be beneficial for axillary pain. If your block doesn't set up after 20 minutes then you gotta go sedation with tube and suction around for aspiriation.
 
VentdependenT said:
I frequently give tons of sedation for nerve stim blocks. Plus on board versed is a good thing for the eventual seizure which will occur from local anesthetic toxicity.

I don't know why a supra clav block would be beneficial for axillary pain. If your block doesn't set up after 20 minutes then you gotta go sedation with tube and suction around for aspiriation.
Click to expand...
Suprascapular not supraclavicular, 2 different animals.
A suprascapular block helps anesthetize the joint capsule itself: C4 C5.
 
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