A Prospective Comparison of Procedural Sedation and Ultrasound‐guided Interscalene Nerve Block for Shoulder Reduction in the Emergency Department

Abstract

Objectives: Emergency physicians (EPs) are beginning to use ultrasound (US) guidance to perform regional nerve blocks. The primary objective of this study was to compare length of stay (LOS) in patients randomized to US-guided interscalene block or procedural sedation to facilitate reduction of shoulder dislocation in the emergency department (ED). The secondary objectives were to compare one-on-one health care provider time, pain experienced by the patient during reduction, and patient satisfaction between the two groups.Methods: This was a prospective, randomized study of patients presenting to the ED with shoulder dislocation. The study was conducted at an academic Level I trauma center ED with an annual census of approximately 80,000. Patients were eligible for the study if they were at least 18 years of age and required reduction of a shoulder dislocation. A convenience sample of patients was randomized to either traditional procedural sedation or US-guided interscalene nerve block. Procedural sedation was performed with etomidate as the sole agent. Interscalene blocks were performed by hospital-credentialed EPs using sterile technique and a SonoSite MicroMaxx US machine with a high-frequency linear array transducer. Categorical variables were evaluated using Fisher's exact test, and continuous variables were analyzed using the Wilcoxon rank sum test.Results: Forty-two patients were enrolled, with 21 patients randomized to each group. The groups were not significantly different with respect to sex or age. The mean (±SD) LOS in the ED was significantly higher in the procedural sedation group (177.3 ± 37.9 min) than in the US-guided interscalene block group (100.3 ± 28.2 minutes; p < 0.0001). The mean (±SD) one-on-one health care provider time was 47.1 (±9.8) minutes for the sedation group and 5 (±0.7) minutes for the US-guided interscalene block group (p < 0.0001). There was no statistically significant difference between the two groups in patient satisfaction or pain experienced during the procedure. There were no significant differences between groups with respect to complications such as hypoxia or hypotension (p = 0.49). Conclusions:In this study, patients undergoing shoulder dislocation reduction using US-guided interscalene block spent less time in the ED and required less one-on-one health care provider time compared to those receiving procedural sedation. There was no difference in pain level or satisfaction when compared to procedural sedation patients.

Acute Pain Management in the Emergency Department

“…Furthermore, length of stay in the ED was also significantly reduced when brachial plexus block was performed with length of stay being reduced almost 3 hours [90]. Similarly, patients with shoulder dislocation that underwent a brachial plexus block also showed reduction in ED length of stay, without any increased adverse events or reduction in patient satisfaction [91].…”

Comparison of ultrasound-guided interscalene block versus procedural sedation for closed shoulder reduction in a swiss university emergency department

“…If UGIB is used instead of PS, less equipment and staff are required for patient monitoring [8]. This improves resource management in the ED allowing faster patient discharge.…”

“…Compared to Blaivas et al, [8] we used the post reduction x-ray to determine the length of stay at our ED, since elderly patients with or without DF are often hospitalized for further treatment or social reasons. Furthermore, our study showed that dislocated reverse total shoulder arthroplasty may be reduced using UGIB too.…”

“…This includes the risk of a loss of airway patency or hypoventilation. More recently, it has been shown that regional anesthesia (RA) in patients with SD is a further method to reduce the joint without additional sedation [7][8][9]. There are several advantages to this procedure.…”

Identification of teaching priorities for ultrasound-guided regional anesthesia as first-line pain management in a swiss university emergency department

“…Since this time, several investigations with different blocking techniques for the shoulder and hip region have shown that the method has great benefits as first-line analgesia in the emergency setting. In 2011 Blaivas et al, showed that patients with shoulder dislocation treated with interscalene blocks had a shorter length of stay in the ED [8]. Most studies on first-line regional anesthesia in the ED have been published in the field of femoral neck fractures.…”