Shoulder Reduction Advice

[TheComebacKid]

So I'm on a real dry spell here. The last three shoulders I've had had significant issues and I haven't been able to get them in, had to ask for help from a colleague, and today had to call ortho. I'm not sure what I'm doing wrong here...

I've had some decent success with ultrasound guided intra-articular lidocaine injection and a touch of versed in the past. Butoday I literally could not get this shoulder to budge. Today the patient refused a joint injection, so I sedated them with almost 150 of ketamine still couldn't get it.

Everyone has "a go to technique" that they swear works, and it never works for me. I did Fares, Kocher (Even though I know it's not really recommended), scapular manipulation, traction/counter traction. I'm not sure what I'm doing wrong.

I really hate using propofol but of course ortho swears this is where I'm messing up and need more muscle relaxation, but many of my colleagues successful reduce shoulders without any sedation whatsoever.

Someone tell me what the hell I'm doing wrong. I did pretty good with reducing these in residency but now as a new attending I'm starting to really second guess myself.

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[pollyspockets]

So I'm on a real dry spell here. The last three shoulders I've had had significant issues and I haven't been able to get them in, had to ask for help from a colleague, and today had to call ortho. I'm not sure what I'm doing wrong here...

I've had some decent success with ultrasound guided intra-articular lidocaine injection and a touch of versed in the past. Butoday I literally could not get this shoulder to budge. Today the patient refused a joint injection, so I sedated them with almost 150 of ketamine still couldn't get it.

Everyone has "a go to technique" that they swear works, and it never works for me. I did Fares, Kocher (Even though I know it's not really recommended), scapular manipulation, traction/counter traction. I'm not sure what I'm doing wrong.

I really hate using propofol but of course ortho swears this is where I'm messing up and need more muscle relaxation, but many of my colleagues successful reduce shoulders without any sedation whatsoever.

Someone tell me what the hell I'm doing wrong. I did pretty good with reducing these in residency but now as a new attending I'm starting to really second guess myself.

Why do you hate using propofol? This is my preferred orthopedic sedation agent.

 

[TheComebacKid]

With the exception of hips, I've never felt like I needed propofol for shoulders. Also the last few shoulders were in much older patients, multiple comorbidities and were just higher risk in general and I've just seen so much hypotension with propofol. I suppose I could do ketofol which I've had decent success with.

I'm just more comfortable with straight ketamine for whatever reason. Maybe that's the issue and I should use more propofol.

Regardless it seems like so many people don't require any sedation whatsoever but I always end up with these shoulders that are just really stubborn.

 

[Jabbed]

I do intra-articular lido as well + IV valium. This technique is not 100% for me if patient is not cooperative or has a lot of muscle mass (fasciculation). I'll still try it the majority of the time because it is full ninja to reduce a shoulder awake. I typically do light traction with external rotation and abduction while putting pressure on the humeral head. I've had patients tolerate a full traction/counter-traction reduction while awake though.

I don't like using ketamine as a sole sedative. They tense up. Why force the square peg into the round hole?

The main drawback to me for propofol (aside from hemodynamics) is that there are plenty of times that you end up using sky-high doses of 3-5 mg/kg due to people being on chronic benzos or EtOH. Also consider that propofol isn't an analgesic and a lot of the time we end up sedating people more deeply than we need to because they are in pain.

My go-to now is 0.5 mg/kg ketamine and PRN propofol typically starting at 0.5 mg/kg. I like it because 99% of the population is sensitive enough to ketamine that I seldom have to re-dose.

If you're really paranoid about the effects of transient hypotension in old people and don't want to use phenylephrine pushes, consider using etomidate. I use 0.1 mg/kg (mainly for cardioversion) and am always amazed at how potent a sedative it is. People are knocked the **** out at 1/3rd the dose of what we use for RSI. Occasional side effect is myoclonus, but it's never interfered with a procedure for me.

 

[RustedFox]

1. Get a heavy, strong person on the other side.
2. Wrap a bedsheet around patient's torso and have Fatboy give countertraction.
3. Sedate.
4. Put your forearm in his armpit, under the arm. This is your fulcrum.
5. Reach with your other arm, OVER the patients humerus. This is your leverarm.
6. Clasp your hands together.
7. Move the leverarm, rotating as necessary.
8. ???
9. Profit.

 

[betamale]

Try Stimson and FARES. Stimson is my favorite, last 3 reductions have been 100% after trials of FARES, Davos, Kocher. Have to use like 10 lbs. Wait 10-15 min, pt capn be unsupervised while you go deal with other pts. Very little discomfort and disruption to you and pt. I'm planning to use Stimson at the get go from now on, just seem less barbaric and iatrogenic injury inducing...and no moderate sedation charting!!!

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[Angry Birds]

So I'm on a real dry spell here. The last three shoulders I've had had significant issues and I haven't been able to get them in, had to ask for help from a colleague, and today had to call ortho. I'm not sure what I'm doing wrong here...

I've had some decent success with ultrasound guided intra-articular lidocaine injection and a touch of versed in the past. Butoday I literally could not get this shoulder to budge. Today the patient refused a joint injection, so I sedated them with almost 150 of ketamine still couldn't get it.

Everyone has "a go to technique" that they swear works, and it never works for me. I did Fares, Kocher (Even though I know it's not really recommended), scapular manipulation, traction/counter traction. I'm not sure what I'm doing wrong.

I really hate using propofol but of course ortho swears this is where I'm messing up and need more muscle relaxation, but many of my colleagues successful reduce shoulders without any sedation whatsoever.

Someone tell me what the hell I'm doing wrong. I did pretty good with reducing these in residency but now as a new attending I'm starting to really second guess myself.

I really don't understand this at all. So, you try a non-sedation and fail. That's normal. Happens all the time. But, what I can't wrap my head around is that you get help from a colleague or ortho instead of just giving the patient a blast of propofol and reducing it. Once the sedation is in, I'm not even sure if medical training is really necessary to get that back in. All you do is tug. It goes back in. If it doesn't you move it this way, then that way, and then eventually it goes in. At least 98% of the time. If it really doesn't wanna go back even with all that, it's a sheepish call to Ortho.

I'd feel so embarrassed to ask a colleague to do it.

 

[Groove]

1. Get a heavy, strong person on the other side.
2. Wrap a bedsheet around patient's torso and have Fatboy give countertraction.
3. Sedate.
4. Put your forearm in his armpit, under the arm. This is your fulcrum.
5. Reach with your other arm, OVER the patients humerus. This is your leverarm.
6. Clasp your hands together.
7. Move the leverarm, rotating as necessary.
8. ???
9. Profit.

Are your hands pointed towards the patient's back or chest? I'm trying to figure out which arm you are using for your fulcrum, left? I've never even heard or seen this technique, very cool. I'll have to try it. Sounds like the "Park technique" except you use your forearm.

 

[Groove]

The only shoulders I've ever had a colleague ask me to help reduce were 100% ketamine. As you yourself said and plenty of others have said, propofol provides superior muscle relaxation. Don't be afraid of the respiratory depression. If they stop breathing or sats start dropping, you simply bag them for 1-2 minutes until they start breathing again. I've had this happen maybe 4 times in my entire career. I typically give 50mg bolus, followed by 20-25mg aliquots until they are adequately sedated.

I typically do a modified external rotation technique with traction/adduction of the humerus. It's really rare for me not to be able to get it in on the first try. I'll occasionally do a cunningham method for the stoic types that can tolerate but it seems like I always get the melodramatic shoulders.

All that being said, since I started doing more interscalene blocks...paralysis of the shoulder provides superior reduction conditions. After most interscalene blocks, I don't even have to do a technique...more like wiggle the wrist and the shoulder pops back into place all by itself. It's an amazing block. I realize that many are not comfortable with it though.

All my reductions, regardless of joint are with propofol. The majority of my shoulders these days are with interscalene block unless it's a pulmonary patient or some other contraindication. I've found discharge times are much faster and the reductions go much easier. Most of my expertise with the block was picked up AFTER residency, so it's def a skill that can be self taught though I'm sure anesthesia would frown on that approach. I do feel like most blocks, and procedures for that matter can be done after watching enough YouTube videos these days.

 

[TheComebacKid]

I really don't understand this at all. So, you try a non-sedation and fail. That's normal. Happens all the time. But, what I can't wrap my head around is that you get help from a colleague or ortho instead of just giving the patient a blast of propofol and reducing it. Once the sedation is in, I'm not even sure if medical training is really necessary to get that back in. All you do is tug. It goes back in. If it doesn't you move it this way, then that way, and then eventually it goes in. At least 98% of the time. If it really doesn't wanna go back even with all that, it's a sheepish call to Ortho.

I'd feel so embarrassed to ask a colleague to do it.

I feel embarrassed too, not particularly proud of it. It's part of the reason why I made this thread because I was curious to hear people's suggestions But when I can't get it in, sometimes I think its best for the patient to give someone else a try. Maybe I need to hit the weights more.

I'll probably have to change my practice. I've had good success with ketamine only sedation and sometimes pain dose ketamine, but the last few shoulders I had with straight ketamine just would not budge.

I've definitely had to bag people through propofol, or watch their pressures plummet, but I was trying to avoid it. Again, ketamine only has worked in the past. Maybe it was luck.

 

[RustedFox]

Are your hands pointed towards the patient's back or chest? I'm trying to figure out which arm you are using for your fulcrum, left? I've never even heard or seen this technique, very cool. I'll have to try it. Sounds like the "Park technique" except you use your forearm.

Towards the chest; like you're praying over the patient's chest. Do this with the bed at about a 30 degree angle.

Edit: if it's the right shoulder that is out, it's your left forearm that is the fulcrum in your armpit and your right arm is pushing down on the leverarm. The real key is getting a proper heavyman on the other side to hold the bedsheet.

 

[Groove]

I feel embarrassed too, not particularly proud of it. It's part of the reason why I made this thread because I was curious to hear people's suggestions But when I can't get it in, sometimes I think its best for the patient to give someone else a try. Maybe I need to hit the weights more.

I'll probably have to change my practice. I've had good success with ketamine only sedation and sometimes pain dose ketamine, but the last few shoulders I had with straight ketamine just would not budge.

I've definitely had to bag people through propofol, or watch their pressures plummet, but I was trying to avoid it. Again, ketamine only has worked in the past. Maybe it was luck.

I feel like the propofol induced hypotension and respiratory depression are almost always either from too much initial bolus or going too fast. Although my initial 50mg bolus is fast, I go slower with the 20mg aliquots titrating for sedation. I recently had a post surgical hip that ortho attending and his chief resident wanted to come in and reduce and I gave the propofol too fast feeling the pressure of them standing there wanting to get the procedure done and low and behold had to bag the patient for a minute or two. I knew I was going too fast and had been there thinking "damn, I pushed that a little too quick, I hope they don't stop breathing.....and.....great....they stopped breathing". Luckily, no complications otherwise. I really can't remember anyone ever having a bad outcome from prop sedation. If I anticipate sedating them, I almost never give morphine or dilaudid prior to the propofol since that obviously increases your risk. You know all that though.

If you want a happy medium between the two agents and would prefer to minimize the resp depression and hemodynamics, how about starting to use ketofol? Just make it easy and mix up the ketamine/propofol at 1:1. You'd probably get better muscle relaxation.

 

[BoardingDoc]

Do an interscalene nerve block. Paralyzes the arm, muscle spasm becomes irrelevant. Shoulder frequently relocates spontaneously then, or goes in with minimal effort.

 

[Angry Birds]

I feel embarrassed too, not particularly proud of it. It's part of the reason why I made this thread because I was curious to hear people's suggestions But when I can't get it in, sometimes I think its best for the patient to give someone else a try. Maybe I need to hit the weights more.

I'll probably have to change my practice. I've had good success with ketamine only sedation and sometimes pain dose ketamine, but the last few shoulders I had with straight ketamine just would not budge.

I've definitely had to bag people through propofol, or watch their pressures plummet, but I was trying to avoid it. Again, ketamine only has worked in the past. Maybe it was luck.

Prop wears off super fast. Just do the right dose, give half off the bat, then 25% when pulling, and sometimes you don't even need the other 25%.
Have a bag of IV fluids ready. Easy.

 

[Zebra Hunter]

The last 3 times my non-sedation shoulder reduction techniques failed, I used propofol and the shoulder immediately reduced spontaneously after administration. Love me some prop for ortho sedations. I haven't had to actually tug on a sedated shoulder in years.

 

[Jabbed]

The only shoulders I've ever had a colleague ask me to help reduce were 100% ketamine. As you yourself said and plenty of others have said, propofol provides superior muscle relaxation. Don't be afraid of the respiratory depression. If they stop breathing or sats start dropping, you simply bag them for 1-2 minutes until they start breathing again. I've had this happen maybe 4 times in my entire career. I typically give 50mg bolus, followed by 20-25mg aliquots until they are adequately sedated.

I typically do a modified external rotation technique with traction/adduction of the humerus. It's really rare for me not to be able to get it in on the first try. I'll occasionally do a cunningham method for the stoic types that can tolerate but it seems like I always get the melodramatic shoulders.

All that being said, since I started doing more interscalene blocks...paralysis of the shoulder provides superior reduction conditions. After most interscalene blocks, I don't even have to do a technique...more like wiggle the wrist and the shoulder pops back into place all by itself. It's an amazing block. I realize that many are not comfortable with it though.

All my reductions, regardless of joint are with propofol. The majority of my shoulders these days are with interscalene block unless it's a pulmonary patient or some other contraindication. I've found discharge times are much faster and the reductions go much easier. Most of my expertise with the block was picked up AFTER residency, so it's def a skill that can be self taught though I'm sure anesthesia would frown on that approach. I do feel like most blocks, and procedures for that matter can be done after watching enough YouTube videos these days.

What needles are you using? Are you bringing the needle right to the plexus or just beneath the fascial layer?

 

[DrDrummer]

As soon as you think you might need to give Propofol (assuming not some trainwreck of a HFrEF patient in which case deep sedation with Propofol has other reasons you might want to avoid it), just have the RN hang a liter of fluids. This will help mitigate a lot of the hypotension in your drunk-in-the-sun-all-day population.

I tend to give Fentanyl + intra-articular lidocaine under US and use FARES and it works 80% of the time. If they're tough, try Cunningham (watch his video on https://dislocation.com.au/ -- there is so much wisdom here and he covers more than just his technique). After that it's Propofol 100% of the time. Just give less than you think you need to and give it time to work once you've gotten towards 1-1.5 mg/kg, have a phenyl stick at the bedside if you're concerned you'll precipitate an MI from hypotension -- but really, if they're that poor of protoplasm, you should be pretty thoughtful about your sedation approach and at many hospitals it would be reasonable to involve anesthesia if you're that nervous about it and they're available. (I realize this is controversial to say, and do not often do this myself, but I have been involved with sedation reviews at multiple hospitals and if you actually read most of the agreements you sign when becoming credentialed for deep sedation often you'll find policies that recommend anesthesia consults in ASA Class x for non-life threatening indications e.g. dislocations).

 

[GassYous]

The only shoulders I've ever had a colleague ask me to help reduce were 100% ketamine. As you yourself said and plenty of others have said, propofol provides superior muscle relaxation. Don't be afraid of the respiratory depression. If they stop breathing or sats start dropping, you simply bag them for 1-2 minutes until they start breathing again. I've had this happen maybe 4 times in my entire career. I typically give 50mg bolus, followed by 20-25mg aliquots until they are adequately sedated.

I typically do a modified external rotation technique with traction/adduction of the humerus. It's really rare for me not to be able to get it in on the first try. I'll occasionally do a cunningham method for the stoic types that can tolerate but it seems like I always get the melodramatic shoulders.

All that being said, since I started doing more interscalene blocks...paralysis of the shoulder provides superior reduction conditions. After most interscalene blocks, I don't even have to do a technique...more like wiggle the wrist and the shoulder pops back into place all by itself. It's an amazing block. I realize that many are not comfortable with it though.

All my reductions, regardless of joint are with propofol. The majority of my shoulders these days are with interscalene block unless it's a pulmonary patient or some other contraindication. I've found discharge times are much faster and the reductions go much easier. Most of my expertise with the block was picked up AFTER residency, so it's def a skill that can be self taught though I'm sure anesthesia would frown on that approach. I do feel like most blocks, and procedures for that matter can be done after watching enough YouTube videos these days.

I think interscalene blocks are great with high levels of success and ease of performance due to its very superficial nature. The problem is that it has a high chance of something going wrong. Lots of blood vessels and nerves in the area. It also has the highest possibility of nerve damage in our closed claims system. Just don't bag the phrenic (basically 100% chance) or cause a pneumothorax on a terrible copder. But as long as your patient is giving you reasonable feedback and you can see the entire needle on the ultrasound you should be able to avoid most major issues.

I think the nerve block alone would be better than messing around with anesthetics or opiates. Just read up on nysora and watch the videos on youtube. I like using a 2 inch 22 gauge stimuplex but if you don't have it, you can use any regular 22-25 gauge needle although you will have trouble seeing it on ultrasound. Pop into the sheath but stop and reposition the needle if the patient reports too much pressure in the neck or pain going down the arm.

Ultrasound-Guided Interscalene Brachial Plexus Nerve Block - NYSORA

Describes the anatomy and practical approaches to the block of the brachial plexus at the interscalene space (above the clavicle).

www.nysora.com

 

[Groove]

What needles are you using? Are you bringing the needle right to the plexus or just beneath the fascial layer?

I did a thread on the technique awhile back, lemme find it. I use whatever is available. 1.5 inch needle preferred. I've done it with everything from a 27g, 25g, 23g, 21g, 18g, tuohy, Quincke, etc.. (The 18g was an accident, I thought the nurse had set me up with a 23g and was teaching a resident and didn't notice until afterwards.) An atraumatic tip is probably the safest thing to use but the reality is that most ERs have a limited selection of needles. I ordered some AccuTarg 25g 1.5" needles that show up a little better under ultrasound but I have zero problems doing it with say...your typical 27g in a lac repair cart. Even when you can't see the needle great, if you use hydrodissection techniques and take it slow, it's pretty easy. Obviously, the more parallel you have the needle to your probe, the better you can see it unless you have needle acquisition software on your US which is super nice. It's a pretty superficial injection. I typically will place no more than 10ccs total local anesthetic when I have good view. I tend to go over if I am in suboptimal location. I've only been doing them regularly the past few years. 10ccs I have found to be adequate and after scanning my pt's diaphragm, seems to be a volume that lessens ipsilateral diaphragmatic paralysis though over time I've found this to be more unreliable than I initially thought. The reality is that if you use lidocaine, the diaphragmatic paralysis wears off before you discharge them. I haven't had a pt yet who can actually detect that their hemidiaphgragm is out. I've had zero complications so far (knock on wood). Appropriate patient selection is key.

Here's that thread. I think we've had a few others since then if you're interested. They should show up in search.

Interscalene Blocks for Shoulder Reductions

Anybody else doing these? I had a ridiculous delay from nursing setting up for procedural sedation for a young, healthy, male shoulder dislocation and the guy was having a lot of pain so I threw in a quick US guided inter scalene block and was amazed at how well it worked. I'm savvy with most...

forums.studentdoctor.net

 

[Groove]

I take that back. I had one lady in her early 30s that I put about 15ccs in, had a great reduction and about 15 mins later she started having cramps in her side that was probably contralateral diaphragmatic spasm after ipsilateral transient paralysis. She had no respiratory issues and was a little melodramatic from the side cramp but after about 30-40 mins she was asymptomatic. That's the only real "complication" that I can think of so far. I'm sure @GassYous or some of the other anesthesia guys who have more under their belt could report other complications that they've seen. I really do feel that if you focus on technique and choose optimal location, the risk of PTX and intravascular injection is small. You're just so far away from lung or carotid, etc.. You'd have to be wildly stabbing with the needle unless you are too distal on the neck and/or too medial on needle entry.

This is the original study that got me interested in doing more of these in the ED.

 

[GassYous]

There have been reports of people using as little as 5 ccs and getting a great block. But even low volumes can get the phrenic. More volume leads to a longer duration but not necessarily a better block. I've never used under 10 but usually use 20 cc. People have described doing a suprascapular block instead of an interscalene for shoulder surgeries in patients with poor respiratory status but I haven't done it myself.

The most common thing to happen in my experience is that the patient gets a little hypoxic but that improves with a little nasal cannula + time. Another thing that can happen (<1% of the time for me) is hitting the stellate ganglion and getting horners. It goes away when the local wears off but people can freak out if they see an eyelid start to droop (important for us because a lot of shoulder surgeries are done in sitting position with sick patients and concerned about perioperative stroke).

It's not the carotid that's the worry but the vertebral. Less of a worry with ultrasound but sometimes it's hard to tell what's what.

 

[RustedFox]

Do an interscalene nerve block. Paralyzes the arm, muscle spasm becomes irrelevant. Shoulder frequently relocates spontaneously then, or goes in with minimal effort.

Love the idea, but I wonder which is more time consuming and tedious... Conscious sedation paperwork and set up, or scalene block paperwork and set up.

Genuinely asking. Not being a smartass for once.

 

[Groove]

Love the idea, but I wonder which is more time consuming and tedious... Conscious sedation paperwork and set up, or scalene block paperwork and set up.

Genuinely asking. Not being a smartass for once.

Check out that link to the 2011 study above. Discharge times were definitely shorter with interscalene. Anecdotally, it seems to be 50% shorter LOS IMO. You can set up and perform the block in no time. No minimal observation time by nursing for procedural sedation. None of the paperwork. You can do it as fast as you can set up the ultrasound with lidocaine and materials. It's truly an easy block. All you need to do is watch a few NYSORA and YouTube videos. I personally think more regional anesthesia should be incorporated into our core didactic curriculum within EM.

 

[TheComebacKid]

I see you guys feel way more comfortable with propofol than I am. Outside of using ketofol, I bolus propofol as a single agent pretty much never unless they are already intubated. That's probably overly cautious on my end.

But I think outside of intubation, procedural sedation is literally one of the highest risk things we do that's fraught with the most complications. The established dosing ranges for these meds in my experience have vastly unpredictable effects in patients. I understand the principle of dose titration and starting small, but even then, I find it contributes to prolonged stays and delayed disposition.

The inter scalene block seems pretty cool, but I feel like I'd have to go through some sort of regional anesthesia workshop before I felt comfortable with it.

Also, as great as regional nerve blocks are, and given how good their patient outcomes are, convincing patients to participate in it is such a long drawn out process because they have huge issues with needles. Their answer is always "NO, just knock me out". Even getting them to do intraarticular lidocaine is like 10 minute conversation and trying to convince them.

 

[RustedFox]

Everyone post their "propofol for sedation" recipe so that comeback kid can see that it's not that esoteric.

Again; not being a smartass - I see this as being a helpful exercise and there's a good concept to be learned/reviewed here, which is what SDN is good for.

 

[RustedFox]

I see you guys feel way more comfortable with propofol than I am. Outside of using ketofol, I bolus propofol as a single agent pretty much never unless they are already intubated. That's probably overly cautious on my end.

But I think outside of intubation, procedural sedation is literally one of the highest risk things we do that's fraught with the most complications. The established dosing ranges for these meds in my experience have vastly unpredictable effects in patients. I understand the principle of dose titration and starting small, but even then, I find it contributes to prolonged stays and delayed disposition.

The inter scalene block seems pretty cool, but I feel like I'd have to go through some sort of regional anesthesia workshop before I felt comfortable with it.

Also, as great as regional nerve blocks are, and given how good their patient outcomes are, convincing patients to participate in it is such a long drawn out process because they have huge issues with needles. Their answer is always "NO, just knock me out". Even getting them to do intraarticular lidocaine is like 10 minute conversation and trying to convince them.

Yep.
The less a patient says, the better. Trying to explain the process to them, even though it is elementary and logical to us, gives them nothing but nightmare fuel.

 

[BoardingDoc]

Everyone post their "propofol for sedation" recipe so that comeback kid can see that it's not that esoteric.

Again; not being a smartass - I see this as being a helpful exercise and there's a good concept to be learned/reviewed here, which is what SDN is good for.

I still do prop for patients who really hate needles, and I used to use prop all the time for my shoulders before doing blocks. It's still my go to for things like hip reductions, cardioversions, etc....

Patient weight in kg = x.
If x > 100, preload pt with 100mcg fent. If x<100, give 50mcg of fent. Do this while you're setting up the monitor, end tidal, etc etc.
Once pt is setup, keep them on a NC blowing 6+LPM up their nose to keep them oxygenated. I usually use 10L for more passive flow.
Prop initial push = (0.5*x)

You can get by using MUCH lower doses of prop if you preload the patient with fent.

E.g. a 70kg guy with a dislocated shoulder usually goes, 50mcg fent preload --> 5-10min later push 40 of prop. Add on 20-30 at a time as needed every minute or two --> put shoulder back in --> patient wakes up.

If you overmedicate them and they start to get apenic, just jaw thrust them for a minute. Or pull on their arm really hard to get their sympathetic drive going harder.

I am a huge fan of prop and do it routinely as my sedation med of choice. Have probably done over 100 prop sedations at this point.

 

[southerndoc]

With the exception of hips, I've never felt like I needed propofol for shoulders. Also the last few shoulders were in much older patients, multiple comorbidities and were just higher risk in general and I've just seen so much hypotension with propofol. I suppose I could do ketofol which I've had decent success with.

I'm just more comfortable with straight ketamine for whatever reason. Maybe that's the issue and I should use more propofol.

Regardless it seems like so many people don't require any sedation whatsoever but I always end up with these shoulders that are just really stubborn.

You should change that philosophy. I've literally only had 1 shoulder in 17 years that I couldn't put in with propofol. It was the brother of a very prominent politician who was outside the room, so Murphy's law would be that I couldn't get it in. Of course it had been out for almost a week before the patient went to the urgent care and was subsequently referred to us. He was a tough guy who thought he had just "pulled it."

I propofol all reductions. I don't fool around with hematoma blocks, intrarticular injections, etc. All it does is make the patient antsy where they won't relax enough to reduce it. Patients feel much better not knowing what you're doing.

 

[TheComebacKid]

Just out of curiosity, why fentanyl + propofol as opposed to ketamine + propofol? Not to say I'm not comfortable with fentanyl, but I feel like I would be happy with the theoretical sympathetic boost you get with ketamine. And I guess a lot of it is just training and comfort, I've used so much ketamine over the course of residency.

Ketamine does give you analgesic effects too...

Aren't we all ER docs here? Why am I getting a lot of anti-ketamine sentiment here... am I in the wrong forum? 🤣

 

[TheComebacKid]

I still do prop for patients who really hate needles, and I used to use prop all the time for my shoulders before doing blocks. It's still my go to for things like hip reductions, cardioversions, etc....

Can you clarify the rationale for using propofol for a cardioversion? I'm assuming you mean for a patient who is hemodynamically stable, right?
I go with 0.15/kg of etomidate and that's worked pretty well for me for pretty much all cardioversions.

 

[RustedFox]

Just out of curiosity, why fentanyl + propofol as opposed to ketamine + propofol? Not to say I'm not comfortable with fentanyl, but I feel like I would be happy with the theoretical sympathetic boost you get with ketamine. And I guess a lot of it is just training and comfort, I've used so much ketamine over the course of residency.

Ketamine does give you analgesic effects too...

Aren't we all ER docs here? Why am I getting a lot of anti-ketamine sentiment here... am I in the wrong forum? 🤣

I don't think there's a "wrong" answer between those two options, amigo.

 

[thegenius]

With the exception of hips, I've never felt like I needed propofol for shoulders. Also the last few shoulders were in much older patients, multiple comorbidities and were just higher risk in general and I've just seen so much hypotension with propofol. I suppose I could do ketofol which I've had decent success with.

I see that a lot. Although one could argue that 10 minutes of hypotension (e.g. 80/40) is ultimately not that pernicious

 

[thegenius]

If you're really paranoid about the effects of transient hypotension in old people and don't want to use phenylephrine pushes, consider using etomidate. I use 0.1 mg/kg (mainly for cardioversion) and am always amazed at how potent a sedative it is. People are knocked the **** out at 1/3rd the dose of what we use for RSI. Occasional side effect is myoclonus, but it's never interfered with a procedure for me.

Second using etomidate.
Get some health, beefy, 36 yo guy who has more muscle in his left upper extremity than you have on your entire body.
Etomidate 0.15 mg / kg.

He's out

Breathing.

Just out.

Literally.

Like he's in a coma.
COMA I SAY!!

You've got 10-15 minutes to get a shoulder back in on a patient who is BREATHING and in a COMA.

 

[thegenius]

I really don't understand this at all. So, you try a non-sedation and fail. That's normal. Happens all the time. But, what I can't wrap my head around is that you get help from a colleague or ortho instead of just giving the patient a blast of propofol and reducing it. Once the sedation is in, I'm not even sure if medical training is really necessary to get that back in. All you do is tug. It goes back in. If it doesn't you move it this way, then that way, and then eventually it goes in. At least 98% of the time. If it really doesn't wanna go back even with all that, it's a sheepish call to Ortho.

I'd feel so embarrassed to ask a colleague to do it.

I hear ya

We have all pulled here....
Pulled to the left
Pulled to the right

Twisted
Pulled
Turned

Pulled some more
Laid down
Pulled sideways

We have tried to put that shoulder in and the fuuuucker just won't go in.

I call my colleagues because my colleagues are understanding that sometimes procedures just don't go your way and they are willing to help.
I don't like calling Orthopedics because they generally are not helpful. Almost never.

 

[thegenius]

All that being said, since I started doing more interscalene blocks...paralysis of the shoulder provides superior reduction conditions. After most interscalene blocks, I don't even have to do a technique...more like wiggle the wrist and the shoulder pops back into place all by itself. It's an amazing block. I realize that many are not comfortable with it though.

I watched a video on it (as I've done in the past). Are you all gowned up like you are doing a central line? Are you watching for fasciculations? or inducing them?

It seemed awfully time consuming

 

[Apollyon]

Just remember what the anesthesiologists call it - "vomidate".

Just sayin'.

 

[thegenius]

If you want a happy medium between the two agents and would prefer to minimize the resp depression and hemodynamics, how about starting to use ketofol? Just make it easy and mix up the ketamine/propofol at 1:1. You'd probably get better muscle relaxation.

Used it the other day for a Colle's. It was wonderful.
You get the best of both worlds (ketamine + propofol) without the side effects of both.

I put 50 mg propofol (6 ml) + 50 mg ketamine into a syringe. They are different volumes. Then I added NS to the syringe to have an even 20 ml of 50 propofol + 50 mg ketamine and it went well.

 

[thegenius]

Love the idea, but I wonder which is more time consuming and tedious... Conscious sedation paperwork and set up, or scalene block paperwork and set up.

Genuinely asking. Not being a smartass for once.

Yea it seems that 50 propofol + 25 PRN is just easier. And quicker. For an ER where there are two docs and 42 patients.

One of the vast problems with the ER, probably number 32 on your list of all the bad things about being an ER doc....is that we are just not incentivized to do cool things like interscalene blocks that appear to take much more time than just giving propofol. I could be wrong on this...but if I want to give propofol:
- RN has pt sign paperwork
- RN calls RT
- RN places IV and runs heplock IVF
- RT places pt on NC and gets pt ready to go
- RN calls you

and you come in and give propofol and you're done 5 minutes later.
AND
you've seen a young non-sense abdominal pain and 54 yo woman with a fibromyalgia flare in the meantime.

 

[Jabbed]

I did a thread on the technique awhile back, lemme find it. I use whatever is available. 1.5 inch needle preferred. I've done it with everything from a 27g, 25g, 23g, 21g, 18g, tuohy, Quincke, etc.. (The 18g was an accident, I thought the nurse had set me up with a 23g and was teaching a resident and didn't notice until afterwards.) An atraumatic tip is probably the safest thing to use but the reality is that most ERs have a limited selection of needles. I ordered some AccuTarg 25g 1.5" needles that show up a little better under ultrasound but I have zero problems doing it with say...your typical 27g in a lac repair cart. Even when you can't see the needle great, if you use hydrodissection techniques and take it slow, it's pretty easy. Obviously, the more parallel you have the needle to your probe, the better you can see it unless you have needle acquisition software on your US which is super nice. It's a pretty superficial injection. I typically will place no more than 10ccs total local anesthetic when I have good view. I tend to go over if I am in suboptimal location. I've only been doing them regularly the past few years. 10ccs I have found to be adequate and after scanning my pt's diaphragm, seems to be a volume that lessens ipsilateral diaphragmatic paralysis though over time I've found this to be more unreliable than I initially thought. The reality is that if you use lidocaine, the diaphragmatic paralysis wears off before you discharge them. I haven't had a pt yet who can actually detect that their hemidiaphgragm is out. I've had zero complications so far (knock on wood). Appropriate patient selection is key.

Here's that thread. I think we've had a few others since then if you're interested. They should show up in search.

Interscalene Blocks for Shoulder Reductions

Anybody else doing these? I had a ridiculous delay from nursing setting up for procedural sedation for a young, healthy, male shoulder dislocation and the guy was having a lot of pain so I threw in a quick US guided inter scalene block and was amazed at how well it worked. I'm savvy with most...

forums.studentdoctor.net

My general hesitation has always been that I don't have access to atraumatic needles or anything fancy like a nerve stimulator or manometer. I'm all about peripheral nerve blocks, fascia iliacus blocks, superficial cervical plexus blocks, and even infraclavicular brachial plexus nerve blocks (abscess I&Ds). I do wish that we had more formal training in this and wider availability of supplies. At the end of the day I feel that we're sub-optimally equipped though and if I had a bad outcome I could not honestly say that I did everything to prevent it.

There was a post in some ACEP blog about only placing the needle deep to the prevertebral fascia and letting the lido dissect down to the plexus. Seemed safer given that you're keeping the needle away from the nerve plexus entirely.

I'll start survey scanning necks again at least..

 

[BoardingDoc]

Can you clarify the rationale for using propofol for a cardioversion? I'm assuming you mean for a patient who is hemodynamically stable, right?
I go with 0.15/kg of etomidate and that's worked pretty well for me for pretty much all cardioversions.

I used to do etomidate too. Now I've gotten the knack of prop down so it's easier. No vomiting afterwards. They wake up much quicker. Faster dc.

And yeah, if they're unstable, they are either getting ketamine, or more likely, nothing.

 

[Jabbed]

Yea it seems that 50 propofol + 25 PRN is just easier. And quicker. For an ER where there are two docs and 42 patients.

One of the vast problems with the ER, probably number 32 on your list of all the bad things about being an ER doc....is that we are just not incentivized to do cool things like interscalene blocks that appear to take much more time than just giving propofol. I could be wrong on this...but if I want to give propofol:
- RN has pt sign paperwork
- RN calls RT
- RN places IV and runs heplock IVF
- RT places pt on NC and gets pt ready to go
- RN calls you

and you come in and give propofol and you're done 5 minutes later.
AND
you've seen a young non-sense abdominal pain and 54 yo woman with a fibromyalgia flare in the meantime.

You'll still tie up the bed for a longer period of time than if you had been able to do it awake. Yes your actual workflow is easier, but you're seeing fewer patients and making less money. You also get minimal RVUs for a sedation in which you are also performing the procedure.

 

[Groove]

My general hesitation has always been that I don't have access to atraumatic needles or anything fancy like a nerve stimulator or manometer. I'm all about peripheral nerve blocks, fascia iliacus blocks, superficial cervical plexus blocks, and even infraclavicular brachial plexus nerve blocks (abscess I&Ds). I do wish that we had more formal training in this and wider availability of supplies. At the end of the day I feel that we're sub-optimally equipped though and if I had a bad outcome I could not honestly say that I did everything to prevent it.

There was a post in some ACEP blog about only placing the needle deep to the prevertebral fascia and letting the lido dissect down to the plexus. Seemed safer given that you're keeping the needle away from the nerve plexus entirely.

I'll start survey scanning necks again at least..

Most of the time I don't have an atraumatic needle, just a small gauge needle that's long enough that I can find in the lac repair cart. Usually 27g or 23g. It's kind of difficult to inject into the nerve. It takes more pressure than you realize and most of the time the nerve root will just blow off the tip of the needle. An old school anesthesia technique is to fill the syringe with a column of air and if you have to depress the column of air 50% or more then the pressure is too high and you may be intraneural. Honestly, the pt will usually let you know if you are starting to inject into the nerve. I tell them to let me know if they feel any lancinating pain down the arm. Sometimes I stab the nerve while optimizing my position for deposition of the anesthetic and they tell me they feel something but that's not going to cause any permanent damage with a small needle. You'd have to be sawing back and forth with an 18g. It's an easy block. Watch some videos and try it out sometime. It's really gratifying for the pt's in a great deal of pain when I've got a good block. I can be halfway through the block and they take a big breath and start thanking me for the pain relief.

 

[Groove]

I watched a video on it (as I've done in the past). Are you all gowned up like you are doing a central line? Are you watching for fasciculations? or inducing them?

It seemed awfully time consuming

I do not gown up for this one. Typically, I will use a big tegaderm over the probe, thoroughly clean the neck with betadine or chlorhexidine, sterile gloves and that's it. You are basically injecting away from the probe site so it's kind of like doing a trigger point injection or peripheral nerve block as far as sterile conditions are concerned. When I'm done, I go see a pt and come back after the encounter and the arm is usually dead. The paralysis is incredible and many times the shoulder will auto reduce by the time I get back. If not, I just have to jiggle the arm and it pops right in.

 

[Fox800]

I'm spoiled. The nurses handle the sedation consent, get all the supplies (ETCO2, meds), round up RT, and have everything ready for me when I walk in the room. We time out, push the medications (propofol), and go. I usually go for the Hennepin method first (adducted arm, elbow at 90...externally rotate the shoulder then abduct). Traction-countertraction if that doesn't work.

It's actually faster for me to do the sedation than going to retrieve the ultrasound machine, asking the RNs/techs to get a sterile probe cover, long needle...waiting for them to find all that stuff then realizing we are still missing something, getting interrupted by a "trauma alert" (71 year old person slipped and fell on their butt), injecting the anesthetic, re-evaluating the patient and they still need additional pain medications, etc.

 

[Rendar5]

my safe propofol protocol for when I actually was in a facility that allowed use for sedation:

1. Calculate my expected total dose:
Peds - 2mg/kg
Adults - 1.5 mg/kg
Elderly - 1mg/kg


2. Give 50% expected total dose as initial bolus
3. Give q1min boluses of 10-20% expected total dose until adequate sedation achieved.

Sometimes I would end up giving double my expected total dose by the end of the sedation sometimes the initia bolus would be sufficient.

 

[BoardingDoc]

my safe propofol protocol for when I actually was in a facility that allowed use for sedation:

1. Calculate my expected total dose:
Peds - 2mg/kg
Adults - 1.5 mg/kg
Elderly - 1mg/kg


2. Give 50% expected total dose as initial bolus
3. Give q1min boluses of 10-20% expected total dose until adequate sedation achieved.

Sometimes I would end up giving double my expected total dose by the end of the sedation sometimes the initia bolus would be sufficient.

Are you working somewhere which doesn't allow the ed to use prop? Are you writing this post from 2004?

 

[Fox800]

Are you working somewhere which doesn't allow the ed to use prop? Are you writing this post from 2004?

Welcome to North Dakota. We were not allowed to perform procedural sedation for "routine" procedures because the ED nurses were not capable/whatever of "monitoring patients under sedation" as determined by the ND Board of Nursing. So yes, physicians could order and give the medications but the RNs can't "monitor" the patient, enter CRNA job protection.

Although we were allowed to give the same medications for RSI...and we were allowed to for an "emergent" procedure like surgical chest tube placement, emergent fracture/dislocation reduction (pulseless limb or tenting), lateral canthotomy, etc.

Cue wonderful times like CRNAs refusing to sedate a child with an angulated forearm fracture because they ate one piece of candy 2.5 hours ago, so we had to transfer then 2 hours away to for sedation and reduction. Or giving IV ketamine then walking away to go get a coffee after the procedure was done (so the patient was unattended), causing my ED charge to tell them to get their #$$ back in the room to monitor the patient (that's what they're getting paid to do) who was still dissociated.

 

[Groove]

Welcome to North Dakota. We were not allowed to perform procedural sedation for "routine" procedures because the ED nurses were not capable/whatever of "monitoring patients under sedation" as determined by the ND Board of Nursing. So yes, physicians could order and give the medications but the RNs can't "monitor" the patient, enter CRNA job protection.

Although we were allowed to give the same medications for RSI...and we were allowed to for an "emergent" procedure like surgical chest tube placement, emergent fracture/dislocation reduction (pulseless limb or tenting), lateral canthotomy, etc.

Cue wonderful times like CRNAs refusing to sedate a child with an angulated forearm fracture because they ate one piece of candy 2.5 hours ago, so we had to transfer then 2 hours away to for sedation and reduction. Or giving IV ketamine then walking away to go get a coffee after the procedure was done (so the patient was unattended), causing my ED charge to tell them to get their #$$ back in the room to monitor the patient (that's what they're getting paid to do) who was still dissociated.

That sounds miserable. Mental note never to look for jobs in ND.

 

[GassYous]

I do not gown up for this one. Typically, I will use a big tegaderm over the probe, thoroughly clean the neck with betadine or chlorhexidine, sterile gloves and that's it. You are basically injecting away from the probe site so it's kind of like doing a trigger point injection or peripheral nerve block as far as sterile conditions are concerned. When I'm done, I go see a pt and come back after the encounter and the arm is usually dead. The paralysis is incredible and many times the shoulder will auto reduce by the time I get back. If not, I just have to jiggle the arm and it pops right in.

You don't even need the sterile gloves or probe cover. You can use chloroprep at the site you are going to inject and also use it as your us medium. No need to drape the probe or get out sterile gel. Start to finish it can be done in under 5 minutes.

 

[CoolDoc1729]

The only shoulders I've ever had a colleague ask me to help reduce were 100% ketamine. As you yourself said and plenty of others have said, propofol provides superior muscle relaxation. Don't be afraid of the respiratory depression. If they stop breathing or sats start dropping, you simply bag them for 1-2 minutes until they start breathing again. I've had this happen maybe 4 times in my entire career. I typically give 50mg bolus, followed by 20-25mg aliquots until they are adequately sedated.

I typically do a modified external rotation technique with traction/adduction of the humerus. It's really rare for me not to be able to get it in on the first try. I'll occasionally do a cunningham method for the stoic types that can tolerate but it seems like I always get the melodramatic shoulders.

All that being said, since I started doing more interscalene blocks...paralysis of the shoulder provides superior reduction conditions. After most interscalene blocks, I don't even have to do a technique...more like wiggle the wrist and the shoulder pops back into place all by itself. It's an amazing block. I realize that many are not comfortable with it though.

All my reductions, regardless of joint are with propofol. The majority of my shoulders these days are with interscalene block unless it's a pulmonary patient or some other contraindication. I've found discharge times are much faster and the reductions go much easier. Most of my expertise with the block was picked up AFTER residency, so it's def a skill that can be self taught though I'm sure anesthesia would frown on that approach. I do feel like most blocks, and procedures for that matter can be done after watching enough YouTube videos these days.

Thanks for the tip about the block .. the typical practice in my dept is to sedate but we never have any nurses sooooo… YouTube it is !