ED hip reduction

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ethilo

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Hey all,
This evening I had a request from an orthopedist to help with sedation for hip dislocation reduction of a patient with a previous THR in ED. ED MD attempted the sedation previously with 40 mg prop and 40 mg ketamine but couldn't get her deep enough safely without desaturation so they asked if I could pop down for the sedation. I went ahead used 170 mg prop and 20 mg ketamine, they attempted and thought they felt it reduce but on Xray it wasn't. So now they are admitting her and adding her onto the OR schedule for tomorrow morning for intraop reduction.

I was wondering if it would have been reasonable to give prop/ket/sux and mask the patient until the paralysis wears off to give a better shot at reducing it. I basically just did MORE of prop/ket than the ED doc but I feel a little unsatisfied with having just did the same thing and not offering something different. I kind of think if they are calling for ME they want something more, so maybe that could have been something useful to offer.

Patient was ASA2, NPO>8h, BMI 35 in her mid-60s female, normal airway, s/p THR.
 
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paralysis will give them the best shot. prop/sux or prop/roc/sugg. LMA if you don't feel like holding a mask while they wrench on her leg for longer than you think it's gonna take.
 
If they want my help they are booking a closed reduction in the OR.

Insanity is trying the same thing twice and expecting different results. They had already tried once with ketamine and propofol and they couldn't do it, i.e.: you know it isn't going to be straightforward. They can come up with whatever excuses they want, but the bottom line is that it is silly to try the exact same thing again with just different doses. Sure it might work, but for the best chance of success, bring the patient up to the OR and the surgeon can eff around with their hip all they want after you slip an LMA in, give paralytic, or whatever. Most importantly, they are asking for YOUR help, so don't do things out of your comfort zone. Have them bring the patient upstairs where you have everything you need and let the surgeon play all he wants while you browse SDN on your phone.
 
We do these in the OR all the time with prop sux and mask ventilation. No reason that the same thing can’t be done in the ED (so long as patient is NPO, appropriate airway and monitoring equipment is available, and there are staff available to recover the patient.
 
dannyboy1 said:
We do these in the OR all the time with prop sux and mask ventilation. No reason that the same thing can’t be done in the ED (so long as patient is NPO, appropriate airway and monitoring equipment is available, and there are staff available to recover the patient.
Click to expand...

I mean you could do a trach or a thoracotomy in the ED as well but that doesn't make it a good idea
 
Depends on your incentives- what else is going on in the OR, impending C-sec, send someone home as soon as this case is done? Just push a few sticks of drugs in the ER for 10 minutes or book a case, wait for transport, an OR to be turned over, Nursing to do their thing, etc.,etc.,


Sent from my iPhone using SDN mobile
 
Psai said:
I mean you could do a trach or a thoracotomy in the ED as well but that doesn't make it a good idea
Click to expand...
Giving sedation/short acting paralytic does not need an OR. Again, will depend on the scenario. 350 lb guy you want to bring to the OR so you have the ability to hook him up to the vent and this guy should really be watched in a formal PACU for a while. Little old lady with an easy airway, maybe not. At my shop it is a huge PITA to bring in nursing, wait for transport, security for valubles, ect.
Plenty of anesthesia is provided in non OR settings and can be done safely.
 
dr doze said:
Depends on your incentives- what else is going on in the OR, impending C-sec, send someone home as soon as this case is done? Just push a few sticks of drugs in the ER for 10 minutes or book a case, wait for transport, an OR to be turned over, Nursing to do their thing, etc.,etc.,


Sent from my iPhone using SDN mobile
Click to expand...

Yeah, that's exactly it - it's after-hours with just 2 of us anesthesiologists in-house and we're doing cases upstairs in the ORs. I came down to the ED to eval another patient in the ED for the next case in the add-on list and the ortho doc asked me to help him out in between the flow. He was in his street clothes, no one wants to make this thing bigger than it has to be. NO ONE wants to bring this up into the OR - way too resource intensive for this time of day.

I was just reflecting on what I provided or did differently that the ED doc didn't do. I basically got the patient much deeper than when he attempted. I think with his sedation attempt they may not have even got a good try at reduction since she was moving too much. So at least they got a good attempt at reduction. In terms of improving their chances of success, sux administration is probably literally the only thing that is going to be bought by booking the OR for the next day. I think next time in a similar situation I might just do the sux. It'd avoid the hospital admission and OR utilization.
 
Just looked at the chart following up - pt finally got it reduced in the OR. She essentially got the same anesthetic without paralytic given. The only difference between what we did in the ED was it was done in the OR with a different orthopedist. I guess 3rd time's a charm!
 
ethilo said:
Just looked at the chart following up - pt finally got it reduced in the OR. She essentially got the same anesthetic without paralytic given. The only difference between what we did in the ED was it was done in the OR with a different orthopedist. I guess 3rd time's a charm!
Click to expand...
Next time he asks for your help call his partner 😀
 
Did one of these in the OR the other night after failure to reduce in the ED. Put in an LMA, paralyzed, and despite some serious exertions by surgeon, it just wasn't working. And this is an experienced and good orthopedic surgeon. He eventually gave up. Turned out that once he got a hold of the surgeon who did the original THR (called him in the morning), he was told that this set of hardware was impossible to re-align without opening up the joint again and that no one could have been able to get the hip back in without an open incision. The patient went back to the OR that next day and after opening, all was made right.

At first, I took his word for it. But while I was reading this thread I was wondering if he was making that part up to save face. Has anyone else run into issues like that? A total hip design that doesn't allow reduction seems sillier and sillier the more I think about it. Might be worth noting that this was a hip replacement due to a bone tumor, not wear and tear. Just curious if anyone else has run into this.
 
rakotomazoto said:
Did one of these in the OR the other night after failure to reduce in the ED. Put in an LMA, paralyzed, and despite some serious exertions by surgeon, it just wasn't working. And this is an experienced and good orthopedic surgeon. He eventually gave up. Turned out that once he got a hold of the surgeon who did the original THR (called him in the morning), he was told that this set of hardware was impossible to re-align without opening up the joint again and that no one could have been able to get the hip back in without an open incision. The patient went back to the OR that next day and after opening, all was made right.

At first, I took his word for it. But while I was reading this thread I was wondering if he was making that part up to save face. Has anyone else run into issues like that? A total hip design that doesn't allow reduction seems sillier and sillier the more I think about it. Might be worth noting that this was a hip replacement due to a bone tumor, not wear and tear. Just curious if anyone else has run into this.
Click to expand...

I did one recently in the ED. Ortho PA was on the phone the whole time with his attending. Apparently it was one of those joints you’re talking about, notoriously difficult to realign. The PA was going to give one try and if didn’t work, would have to book for OR for the next day. He was so surprised that he popped it back in without much problems.
 
IMGASMD said:
I did one recently in the ED. Ortho PA was on the phone the whole time with his attending. Apparently it was one of those joints you’re talking about, notoriously difficult to realign. The PA was going to give one try and if didn’t work, would have to book for OR for the next day. He was so surprised that he popped it back in without much problems.
Click to expand...

You didn't take them to the OR for awake fiberoptic intubation, central line and ECMO???
 
Arch Guillotti said:
You didn't take them to the OR for awake fiberoptic intubation, central line and ECMO???
Click to expand...

I must have missed the memo.... please put me in the anesthesia jail, for not following the gold standard of anesthesia. While I am there, probably need to serve some time for not intubating for food impaction while not NPO.....
 
ethilo said:
Hey all,
This evening I had a request from an orthopedist to help with sedation for hip dislocation reduction of a patient with a previous THR in ED. ED MD attempted the sedation previously with 40 mg prop and 40 mg ketamine but couldn't get her deep enough safely without desaturation so they asked if I could pop down for the sedation. I went ahead used 170 mg prop and 20 mg ketamine, they attempted and thought they felt it reduce but on Xray it wasn't. So now they are admitting her and adding her onto the OR schedule for tomorrow morning for intraop reduction.

I was wondering if it would have been reasonable to give prop/ket/sux and mask the patient until the paralysis wears off to give a better shot at reducing it. I basically just did MORE of prop/ket than the ED doc but I feel a little unsatisfied with having just did the same thing and not offering something different. I kind of think if they are calling for ME they want something more, so maybe that could have been something useful to offer.

Patient was ASA2, NPO>8h, BMI 35 in her mid-60s female, normal airway, s/p THR.
Click to expand...

I don’t know what others think, but that much prop probably would give pretty good muscle relaxation even without sux.
 
ethilo said:
Hey all,
This evening I had a request from an orthopedist to help with sedation for hip dislocation reduction of a patient with a previous THR in ED. ED MD attempted the sedation previously with 40 mg prop and 40 mg ketamine but couldn't get her deep enough safely without desaturation so they asked if I could pop down for the sedation. I went ahead used 170 mg prop and 20 mg ketamine, they attempted and thought they felt it reduce but on Xray it wasn't. So now they are admitting her and adding her onto the OR schedule for tomorrow morning for intraop reduction.

I was wondering if it would have been reasonable to give prop/ket/sux and mask the patient until the paralysis wears off to give a better shot at reducing it. I basically just did MORE of prop/ket than the ED doc but I feel a little unsatisfied with having just did the same thing and not offering something different. I kind of think if they are calling for ME they want something more, so maybe that could have been something useful to offer.

Patient was ASA2, NPO>8h, BMI 35 in her mid-60s female, normal airway, s/p THR.
Click to expand...
I commend you for posting this and acknowledging that you feel like yo7 could have done better.
You basically answered your own question and I’m sure the next time you are called to assist with something like this you will adjust your anesthetic accordingly. And save the pt an OR visit.
Cudos to you.
 
ethilo said:
Hey all,
This evening I had a request from an orthopedist to help with sedation for hip dislocation reduction of a patient with a previous THR in ED. ED MD attempted the sedation previously with 40 mg prop and 40 mg ketamine but couldn't get her deep enough safely without desaturation so they asked if I could pop down for the sedation. I went ahead used 170 mg prop and 20 mg ketamine, they attempted and thought they felt it reduce but on Xray it wasn't. So now they are admitting her and adding her onto the OR schedule for tomorrow morning for intraop reduction.

I was wondering if it would have been reasonable to give prop/ket/sux and mask the patient until the paralysis wears off to give a better shot at reducing it. I basically just did MORE of prop/ket than the ED doc but I feel a little unsatisfied with having just did the same thing and not offering something different. I kind of think if they are calling for ME they want something more, so maybe that could have been something useful to offer.

Patient was ASA2, NPO>8h, BMI 35 in her mid-60s female, normal airway, s/p THR.
Click to expand...
ive not only giving sux ive intubated and bagged for 15 mins then extubated. All in the ED. The ED nurses yelling at me, "we cant recover this patient", Im like Junior is sitting up asking for milk toast, Talk to the hand!!!
 
dipriMAN said:
I don’t know what others think, but that much prop probably would give pretty good muscle relaxation even without sux.
Click to expand...
That depends on how long it’s out of socket. The muscles tend to spasm and can make things very difficult. Best chance it the first chance and therefore we should optimize all conditions. Sux is the answer.
 
IMGASMD said:
I did one recently in the ED. Ortho PA was on the phone the whole time with his attending. Apparently it was one of those joints you’re talking about, notoriously difficult to realign. The PA was going to give one try and if didn’t work, would have to book for OR for the next day. He was so surprised that he popped it back in without much problems.
Click to expand...

Typically, primary total hips are easily reduced in the ER with some sedation. The hip you are talking about is a constrained liner. This is used in revision hips to lock the head into the poly which is in the socket. It has a locking mechanism and usually takes the mechanism to break to dislocate or an incredible force (400+lbs of pressure) .

Once the constrained liner is dislocated, the poly part has to be lined up perfectly with the head to reduce. If the poly rotated, then you won't reduce it. I don't attempt to reduce them in the ER if they have a constrained liner, but will take it to the OR with paralysis If I can't get it closed then open revision of the locking mechanism.
 
SaltyDog said:
Have fun positioning for that.
Click to expand...
Actually, having had a hip dislocation personally I can tell you that there is a position that makes this doable. But it is awfully painful gettting to that position. So I agree with Salty that this isn’t the best ideal but it is an option.
 
Noyac said:
Actually, having had a hip dislocation personally I can tell you that there is a position that makes this doable. But it is awfully painful gettting to that position. So I agree with Salty that this isn’t the best ideal but it is an option.
Click to expand...
Thanks! I was wondering about options for the patients for whom I'd rather not do a GA - cardiac, lung, pulm HTN, etc.
 
Not that this is a poll but....

A vote for prop sux tube in the ED. As long as the airway looks ok and the patient is otherwise reasonably healthy (the debate about healthy is a separate topic entirely)

I’ve had a few instances of the ED asking for help because ortho couldn’t reduce it. I’ve been surprised by how quickly it’ll pop back in with sux. Even the orthopods say “yeah it’s just so much easier when you guys come down and give paralytic.”

As for tube vs mask or whatever, the tube is less work and it’s more secure. Plus I can’t remember saying “damn I wish I didn’t tube them” but I sure have said “damn I wish I tubed them.”

Anyway, that’s my 0.005 cents
 
TimesNewRoman said:
You have 50 kg patients???
Click to expand...

Yes the completely emaciated ones. I made the mistake of giving 50mg propofol to a bed bound guy for egd to see why he was so emaciated who was barely with it and the cuff wouldn't get a reading until I chased it down with way too much neo and ephedrine
 
Wolverines83 said:
As for tube vs mask or whatever, the tube is less work and it’s more secure. Plus I can’t remember saying “damn I wish I didn’t tube them” but I sure have said “damn I wish I tubed them.”

Anyway, that’s my 0.005 cents
Click to expand...

For the few times I ever gave sux, the patient just had to be masked for a couple of minutes. Seems much easier than putting a tube in.
 
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Off topic.. does anyone else get an uptick in old people and broken hips on Friday night? We had 6 last Friday and already 5 tonight. They go on Saturday however.
 
dhb said:
I like myself a 20mg sux with a little masking.
Click to expand...

Why such a low dose if you want muscle relaxation. It will take longer to work. Is the offset time that much faster? I would imagine it takes at least 5 min to do the reduction, why not just give a full dose?
 
dipriMAN said:
Why such a low dose if you want muscle relaxation. It will take longer to work. Is the offset time that much faster? I would imagine it takes at least 5 min to do the reduction, why not just give a full dose?
Click to expand...

More like 5 seconds if they know what they are doing.
 
2Fast2Des said:
Yes the completely emaciated ones. I made the mistake of giving 50mg propofol to a bed bound guy for egd to see why he was so emaciated who was barely with it and the cuff wouldn't get a reading until I chased it down with way too much neo and ephedrine
Click to expand...

Arent these egd ?

How about the ones like this AND on ACE-I but denied taking their ACE-I, but after 2 sticks of neo from only 100-150mg of propofol you're like yeah they definitely took their ACE-I.
 
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