Shoulder reduction

[deleted875186]

There’s an interesting thread in the emergency medixine forum about shoulder reductions.

Most people do prop sedation to reduce, sounds like a few do intra articular local injection for analgesia and some benzo to reduce it.

Interestingly, there’s a few ED people that do their own interscalene block, and then reduce the shoulder awake without sedation.

If you were asked to do an interscalene for this purpose, would you do it? I think too much risk, what if there’s a nerve injury discovered later, what if there is persistent pain, how are you going to follow up for block resolution, etc. I found it interesting, wanted to hear others opinion.

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[GassYous]

I wouldn't do it for them but I don't see why they can't do it themselves

 

[caligas]

I wouldn't do it for them but I don't see why they can't do it themselves

Why not do it if credentialed and available to help?

 

[woopedazz]

Why not do it if credentialed and available to help?

I can give someone propofol and send them home shortly afterwards. I can't do that with an ISB.

 

[Twiggidy]

I can give someone propofol and send them home shortly afterwards. I can't do that with an ISB.

Exactly. Every time I've been asked for assistance with this by the ED when I give the propofol just to get the patient to sleep, all the muscles relax and the shoulder slides right in. Literally not even a minute. A ISB is overkill.

 

[Beach bum]

Exactly. Every time I've been asked for assistance with this by the ED when I give the propofol just to get the patient to sleep, all the muscles relax and the shoulder slides right in. Literally not even a minute. A ISB is overkill.

Are they npo?

 

[Simba1711]

Are they npo?

This is a good point. Most of the time Ed calls me patient isn’t npo. I wait the appropriate npo times and just do versed and propofol. I would feel comfortable doing interscalene but not sure it’s worth an invasive procedure for such a short treatment as others have mentioned.

 

[Arch Guillotti]

Exactly. Every time I've been asked for assistance with this by the ED when I give the propofol just to get the patient to sleep, all the muscles relax and the shoulder slides right in. Literally not even a minute. A ISB is overkill.

What if they are morbidly obese, severe sleep apnea and had a cheeseburger on the way in? ER calling incessantly because it is an “emergency”.

 

[deleted875186]

The NPO times are an issue. So I suppose options would be

1. Wait 6 hours, propofol sedation
2. Induce GA and put a ETT
3. Interscalene block

I geuss I have always waited forever NPO times, but the ED sedates people who are not NPO all the time.

 

[Guillemot]

Joint dislocations such as shoulder can be associated with neurological compromise … So

1. Id probably avoid nerve blocks under most circumstances.

2. Also not inclined to wait 8 hours for NPO as these cases may have some urgency to them.

So I typically RSI if they are not NPO.

If a block were indicated, what would you guys use? Chloroprocaine?

 

[GassYous]

Joint dislocations such as shoulder can be associated with neurological compromise … So

1. Id probably avoid nerve blocks under most circumstances.

2. Also not inclined to wait 8 hours for NPO as these cases may have some urgency to them.

So I typically RSI if they are not NPO.

If a block were indicated, what would you guys use? Chloroprocaine?

lido
I've never done a chloroprocaine block
No need to rsi when they are completely awake for block

 

[Urzuz]

This is a good point. Most of the time Ed calls me patient isn’t npo. I wait the appropriate npo times and just do versed and propofol. I would feel comfortable doing interscalene but not sure it’s worth an invasive procedure for such a short treatment as others have mentioned.

Off topic, but why do you give Versed right before giving another strong amnestic like propofol? Especially for a procedure that (usually) lasts on the order or seconds/minutes?

 

[GassYous]

Off topic, but why do you give Versed right before giving another strong amnestic like propofol? Especially for a procedure that (usually) lasts on the order or seconds/minutes?

Decreases the amount of propofol you need which decreases apnea time

 

[Urzuz]

Decreases the amount of propofol you need which decreases apnea time

Patients are amnestic much before the point of apnea with propofol (think about MAC cases)

 

[anbuitachi]

agree w npo. npo rules doesnt apply to ed doctors. itd be hard to help

 

[GassYous]

Patients are amnestic much before the point of apnea with propofol (think about MAC cases)

You're not giving propofol to cause amnesia

 

[Urzuz]

You're not giving propofol to cause amnesia

Right. The amnestic dose of propofol is much lower than whatever reason you’re giving it for (muscle relaxation, etc).

So why are you giving Versed again?

 

[GassYous]

Right. The amnestic dose of propofol is much lower than whatever reason you’re giving it for (muscle relaxation, etc).

So why are you giving Versed again?

I wouldn't but I can see why you would and my rationale was already posted above

 

[Twiggidy]

What if they are morbidly obese, severe sleep apnea and had a cheeseburger on the way in? ER calling incessantly because it is an “emergency”.

Yeah. It’s a tube (the book answer)

I’ll admit I’ve probably been a bit cowboy or they’ve been in the ED so long that they’re actually NPO. I don’t slug people with prop, instead 1 cc at a time until their eyes close and tell the ED or Ortho to “go”. It’s a very light sedation. I do acknowledge the situation and risk you mention

 

[Twiggidy]

Right. The amnestic dose of propofol is much lower than whatever reason you’re giving it for (muscle relaxation, etc).

So why are you giving Versed again?

I sort of support where you’re going. I don’t use versed for these or TEE exams/cardioversions and patients never remember, but they are mostly older. I don’t even thing the young reductions need the versed since they just need the “relaxation” both physical and mental to get the reduction complete. They can treat the pain after they wake up. I don’t think awareness in this situation is as big a deal vs say endoscopies, TEE, intubations, etc ….I’m young folks. Again, I’m old folks propofol does pretty good amnesia

 

[Twiggidy]

Out of wild curiosity how many on here have had to RSI/intubate a closed reduction?

 

[dabears505]

A true story about a shoulder reduction. Drunk big 300lbs guy fell down and dislocated his shoulder. ER doc gave propofol, and dude began vomiting and aspirating, and proved to be a difficult intubation for the ER person, ultimately suffered brain injury and death. So always be aware bad things can happen sedating those patients with improper NPO times.

 

[pgg]

Why not do it if credentialed and available to help?

The problem with the ER is that it's 2 floors away and the patients all eat sandwiches while checking in to triage.

I don't do PNBs in people who aren't NPO.


On the topic of sedation, I used to like propofol + alfentanil, back when we had alfentanil available. Stuns the hell out of them for a couple minutes, even for really painful procedures, then they're back.

 

[caligas]

The problem with the ER is that it's 2 floors away and the patients all eat sandwiches while checking in to triage.

I don't do PNBs in people who aren't NPO.


On the topic of sedation, I used to like propofol + alfentanil, back when we had alfentanil available. Stuns the hell out of them for a couple minutes, even for really painful procedures, then they're back.

What do you expect them to do, be in pain AND hungry? 😂

 

[GassYous]

The problem with the ER is that it's 2 floors away and the patients all eat sandwiches while checking in to triage.

I don't do PNBs in people who aren't NPO.


On the topic of sedation, I used to like propofol + alfentanil, back when we had alfentanil available. Stuns the hell out of them for a couple minutes, even for really painful procedures, then they're back.

Turkey sammichs aint gonna eat themselves

 

[coffeebythelake]

A true story about a shoulder reduction. Drunk big 300lbs guy fell down and dislocated his shoulder. ER doc gave propofol, and dude began vomiting and aspirating, and proved to be a difficult intubation for the ER person, ultimately suffered brain injury and death. So always be aware bad things can happen sedating those patients with improper NPO times.

Whoops.

 

[coffeebythelake]

The problem with the ER is that it's 2 floors away and the patients all eat sandwiches while checking in to triage.

I don't do PNBs in people who aren't NPO.


On the topic of sedation, I used to like propofol + alfentanil, back when we had alfentanil available. Stuns the hell out of them for a couple minutes, even for really painful procedures, then they're back.

We use alfentanil but only for eye cases. Honestly I could see it being used for a lot of things but that's the only use at my hospital

 

[Mman]

Out of wild curiosity how many on here have had to RSI/intubate a closed reduction?

have done it. Apparently patient was in ED all night with multiple attempts at reduction unsuccessful. Ortho consented for open reduction if needed. A little succinylcholine relaxed him enough to pop it in.

 

[nimbus]

Out of wild curiosity how many on here have had to RSI/intubate a closed reduction?

I’ve paralyzed and lma’d hip dislocations in the OR.

 

[Onefellswoop87]

Out of wild curiosity how many on here have had to RSI/intubate a closed reduction?

Done it a few times. Each time ED used what seemed like reasonable sedation/analgesia. I didn’t feel like trying sedation and then being surprised when it failed so I took ‘em to OR, respect their lack of NPO, and RSI ‘em.
One was an elbow dislocation that the patients story kept changing so it was out for anywhere for 4-24 hours. He fell sometime in the past day and then went to work for some amount of time. GETA with paralysis and the orthopod still had to yank on it to get it back in after it had been out for so long.

 

[woopedazz]

We use alfentanil but only for eye cases. Honestly I could see it being used for a lot of things but that's the only use at my hospital

I mainly use it for pilonidals/super short painful things. Especially young men. Works well. They don't spasm/bite.

 

[spike7585]

Any literature supporting the urgency of reductions? To the point that NPO status can be ignored as it's deemed an emergency? I find that difficult to believe, but would love to see anything mentioning it.

Is it time sensitive? Sure. So are hip fractures. But to the point to risk aspiration vs waiting adequate NPO for sedation (if anesthesia is involved...I get ED guys don't have those guidelines)?

 

[Twiggidy]

Any literature supporting the urgency of reductions? To the point that NPO status can be ignored as it's deemed an emergency? I find that difficult to believe, but would love to see anything mentioning it.

Is it time sensitive? Sure. So are hip fractures. But to the point to risk aspiration vs waiting adequate NPO for sedation (if anesthesia is involved...I get ED guys don't have those guidelines)?

I found this from a 2018 journal review of dislocations. Apparently they are time sensitive.

 

[turkeyjerky]

Any literature supporting the urgency of reductions? To the point that NPO status can be ignored as it's deemed an emergency? I find that difficult to believe, but would love to see anything mentioning it.

Is it time sensitive? Sure. So are hip fractures. But to the point to risk aspiration vs waiting adequate NPO for sedation (if anesthesia is involved...I get ED guys don't have those guidelines)?

Shoulders are probably the least time sensitive. Wrists typically not a big deal unless NVS compromise or severe skin tenting (rarely the case). Hips, knees and ankles are typically time sensitive and should be done asap.

 

[dhb]

10cc lido 100% of the time

 

[enpdoc]

You may want to review the ASA and ACEP guidelines on NPO status and procedural sedation in the ED.

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018 | Anesthesiology | American Society of Anesthesiologists (asahq.org)

The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) consult with a medical specialist, when appropriate, before administration of moderate procedural sedation to patients with significant underlying conditions; (2) when feasible before the procedure, inform patients or legal guardians of the benefits, risks, and limitations of moderate sedation/analgesia and possible alternatives, and elicit their preferences; (3) before the day of the procedure, inform patients or legal guardians that they should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying; and (4) on the day of the procedure, assess the time and nature of the last oral intake. All four groups of survey respondents agreed with the recommendation that in urgent or emergent situations where complete gastric emptying is not possible, do not delay moderate procedural sedation based on fasting time alone.

Procedural Sedation Delays and NPO Status for Pediatric Patients in the Emergency Department - ACEP Now
The ACEP 2013 Clinical Policy on procedural sedation and analgesia in the emergency department recommends not delaying procedural sedation in adults or pediatric emergency department patients based on fasting time (Level B).2 This is because “pre-procedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.”

 

[nimbus]

You may want to review the ASA and ACEP guidelines on NPO status and procedural sedation in the ED.

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018 | Anesthesiology | American Society of Anesthesiologists (asahq.org)

The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) consult with a medical specialist, when appropriate, before administration of moderate procedural sedation to patients with significant underlying conditions; (2) when feasible before the procedure, inform patients or legal guardians of the benefits, risks, and limitations of moderate sedation/analgesia and possible alternatives, and elicit their preferences; (3) before the day of the procedure, inform patients or legal guardians that they should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying; and (4) on the day of the procedure, assess the time and nature of the last oral intake. All four groups of survey respondents agreed with the recommendation that in urgent or emergent situations where complete gastric emptying is not possible, do not delay moderate procedural sedation based on fasting time alone.

Procedural Sedation Delays and NPO Status for Pediatric Patients in the Emergency Department - ACEP Now
The ACEP 2013 Clinical Policy on procedural sedation and analgesia in the emergency department recommends not delaying procedural sedation in adults or pediatric emergency department patients based on fasting time (Level B).2 This is because “pre-procedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.”

I kind of agree with this but I prefer ga with ETT for full stomach patients. For urgent procedures assume full stomach and proceed with RSI/ETT and extubate wide awake. One of my partners did an ankle fracture with GA/LMA who was fasted for over 24 hrs who massively aspirated and died.

 

[GassYous]

I kind of agree with this but I prefer ga with ETT for full stomach patients. For urgent procedures assume full stomach and proceed with RSI/ETT and extubate wide awake. One of my partners did an ankle fracture with GA/LMA who was fasted for over 24 hrs who massively aspirated and died.

goddamn

 

[deleted875186]

You may want to review the ASA and ACEP guidelines on NPO status and procedural sedation in the ED.

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018 | Anesthesiology | American Society of Anesthesiologists (asahq.org)

The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) consult with a medical specialist, when appropriate, before administration of moderate procedural sedation to patients with significant underlying conditions; (2) when feasible before the procedure, inform patients or legal guardians of the benefits, risks, and limitations of moderate sedation/analgesia and possible alternatives, and elicit their preferences; (3) before the day of the procedure, inform patients or legal guardians that they should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying; and (4) on the day of the procedure, assess the time and nature of the last oral intake. All four groups of survey respondents agreed with the recommendation that in urgent or emergent situations where complete gastric emptying is not possible, do not delay moderate procedural sedation based on fasting time alone.

Procedural Sedation Delays and NPO Status for Pediatric Patients in the Emergency Department - ACEP Now
The ACEP 2013 Clinical Policy on procedural sedation and analgesia in the emergency department recommends not delaying procedural sedation in adults or pediatric emergency department patients based on fasting time (Level B).2 This is because “pre-procedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.”

This is interesting, I dont think this was in the prior ASA guidelines for sedation. It is also difficult to interpret, what does urgent or emergent really mean? What does “based on fasting time alone” really mean. It is also at odds with the ASA guidelines for NPO for elective procedures.

For instance, we routinely did endovascular stroke catheter thrombectomies under sedation in residency, obviously not NPO but obviously the benefits of avoiding GA were significant. I certainly cannot say the same for a shoulder reduction however.

If you think RSI with an ETT is safest in elective procedures if there is some risk factor for aspiration, then why on earth would moderate sedation in an emergent procedure be acceptable to the ASA?

 

[enpdoc]

I kind of agree with this but I prefer ga with ETT for full stomach patients. For urgent procedures assume full stomach and proceed with RSI/ETT and extubate wide awake. One of my partners did an ankle fracture with GA/LMA who was fasted for over 24 hrs who massively aspirated and died.

The literatures disagrees with you. Huge amount of literature on the subject.

 

[enpdoc]

This is interesting, I dont think this was in the prior ASA guidelines for sedation. It is also difficult to interpret, what does urgent or emergent really mean? What does “based on fasting time alone” really mean. It is also at odds with the ASA guidelines for NPO for elective procedures.

For instance, we routinely did endovascular stroke catheter thrombectomies under sedation in residency, obviously not NPO but obviously the benefits of avoiding GA were significant. I certainly cannot say the same for a shoulder reduction however.

If you think RSI with an ETT is safest in elective procedures if there is some risk factor for aspiration, then why on earth would moderate sedation in an emergent procedure be acceptable to the ASA?

Again, there is a huge amount of literature on the subject supporting procedural sedation. It's why ER providers do it and do you ever hear of aspiration? Down many thousands of times every day in EDs across the country.

 

[spike7585]

Again, there is a huge amount of literature on the subject supporting procedural sedation. It's why ER providers do it and do you ever hear of aspiration? Down many thousands of times every day in EDs across the country.

A true story about a shoulder reduction. Drunk big 300lbs guy fell down and dislocated his shoulder. ER doc gave propofol, and dude began vomiting and aspirating, and proved to be a difficult intubation for the ER person, ultimately suffered brain injury and death. So always be aware bad things can happen sedating those patients with improper NPO times.

Ya I heard a story once about 15 posts above yours

 

[enpdoc]

This is interesting, I dont think this was in the prior ASA guidelines for sedation. It is also difficult to interpret, what does urgent or emergent really mean? What does “based on fasting time alone” really mean. It is also at odds with the ASA guidelines for NPO for elective procedures.

For instance, we routinely did endovascular stroke catheter thrombectomies under sedation in residency, obviously not NPO but obviously the benefits of avoiding GA were significant. I certainly cannot say the same for a shoulder reduction however.

If you think RSI with an ETT is safest in elective procedures if there is some risk factor for aspiration, then why on earth would moderate sedation in an emergent procedure be acceptable to the ASA?

Difficult to interpret?
Why do you have difficulty not understanding what urgent or emergent means? Same with based on fasting time. Very plain that they are saying not to base your decision to wait on fasting time alone.

 

[nimbus]

Again, there is a huge amount of literature on the subject supporting procedural sedation. It's why ER providers do it and do you ever hear of aspiration? Down many thousands of times every day in EDs across the country.

Fine. Go ahead. But that’s not the standard in anesthesia and we would be crucified if a patient had a bad outcome.

 

[Guillemot]

I havent read the literature, but if the guideline is essentially stating weigh risk/benefit... then sure that makes sense. Also if its a small propofol bolus to achieve moderate sedation followed by quick return to full consciousness then I could see the risk not being substantially different from RSI (after all RSI also has a brief period of deeper unconsciousness prior to securing airway).

When I get a chance Ill look over the guideline. Interesting to learn stuff.

 

[nimbus]

From your reference, 37% of the surveyed experts were either equivocal or disagreed with ignoring fasting guidelines. It’s still a controversial topic and not settled as you imply.

 

[deleted875186]

Difficult to interpret?
Why do you have difficulty not understanding what urgent or emergent means? Same with based on fasting time. Very plain that they are saying not to base your decision to wait on fasting time alone.

The definition of emergent is subjective.

Saying “dont base your decision solely on NPO time” could also mean, take into account risks of GA versus aspiration, in which case most anesthesiologists would still induce GA and secure an airway in a full stomach because we are obsessed about aspiration.

I will also point out that moderate sedation refers to exactly zero joint reductions, which would be classified as deep sedation, and possibly a brief period of GA for muscle relaxation. In fact, outside of perhaps a few select situations, I can’t think of a time emergent moderate sedation is needed, maybe the endovascular stroke procedure I mentioned above, maybe a cardioversion.

 

[nimbus]

I havent read the literature, but if the guideline is essentially stating weigh risk/benefit... then sure that makes sense. Also if its a small propofol bolus to achieve moderate sedation followed by quick return to full consciousness then I could see the risk not being substantially different from RSI (after all RSI also has a brief period of deeper unconsciousness prior to securing airway).

When I get a chance Ill look over the guideline. Interesting to learn stuff.

When I give a small dose of propofol for a cardioversion, I insist that the patient is fasted. If not they can come back the next day.

 

[deleted875186]

From your reference, 47% of the surveyed experts were either equivocal or disagreed with ignoring fasting guidelines. It’s still a controversial topic and not settled as you imply. View attachment 347766

It would be fascinating to see the distribution of specialists disagreeing and agreeing on this NPO point, this was apparently a multidisciplinary panel. In fact, looking through the recommendations this appears to be the most controversial statement.

 

[nimbus]

I wouldn't do it for them but I don't see why they can't do it themselves

Yep EM docs love ultrasound as much if not more than we do.