Intra-articular lidocaine versus intravenous sedation for the reduction of anterior shoulder dislocations in the emergency department.

OBJECTIVE: The objective was to compare intra-articular lidocaine (IAL) versus intravenous sedation (IVS) for the reduction of acute, anterior shoulder dislocations in the emergency department (ED) in terms of ED length of stay, rate of successful reductions, patient satisfaction, and complications. METHODS: This was a prospective, randomized trial. Patients in the IAL group received 4 mg/kg (up to 200 mg) of 1% lidocaine injected into the glenohumeral joint using a lateral approach. Patients in the IVS group received medications for sedation as per the discretion of the treating physician. Follow-up was arranged within 2 weeks of the ED visit to assess for complications. RESULTS: Forty-four patients (25 IAL, 19 IVS) were included. This trial was stopped early owing to a combination of unexpected findings in success, resource limitations, and difficulty in patient enrolment. Median time from first physician assessment to patient discharge was not different between the IAL (170 minutes) group and the IVS (145 minutes) group (Δ -25 minutes; 95% CI -32, 70; p  =  0.46). There was a significantly lower rate (p < 0.001) of successful closed reduction in the IAL group (48%) compared to the IVS group (100%). Patient satisfaction and physician ease of reduction were higher in the IVS group compared to the IAL group (p < 0.05). There were no reported complications in either group at time of reduction or follow-up. CONCLUSIONS: There was no difference in ED length of stay between groups. There was a lower rate of successful reductions and lower satisfaction scores in the IAL group.

Use of intra-articular lidocaine as analgesia in anterior shoulder dislocation: a review and meta-analysis of the literature.

INTRODUCTION: The shoulder joint is the most commonly injured major joint in patients who present to the hospital emergency department today. In the community the incidence of shoulder joint injuries is 11.2 cases per 100,000 person-years. Traditionally, procedural sedation and analgesia (PSA) has been used to facilitate the reduction of anterior shoulder dislocations. However, there are risks of complication, such as respiratory depression, particularly in certain populations. As such, the use of intra-articular lidocaine (IAL) has been suggested as an alternative method of analgesia. METHODS: We searched EMBASE (Ovid) and MEDLINE (PubMed) databases using the keywords "shoulder, dislocation, and/or reduction" from the respective start dates of the databases until October 2008. RESULTS: Based on the current literature, it appears that the IAL method provides, at a minimum, the same level of pain control and reduction success as the procedural sedation method, while markedly reducing the time spent by the patient in the emergency department and the cost of treatment. The likelihood of complications is arguably less with the use of IAL. CONCLUSION: Although more research is this area is merited, physicians may consider IAL as an alternative to PSA in the management of anterior shoulder dislocations.

A palatability study of a flavored dexamethasone preparation versus prednisolone liquid in children.

BACKGROUND: Palatability is an important factor in medication compliance for children where the acceptability of a liquid medication and its ease of administration will be greatly affected by its taste. OBJECTIVES: The objective of this study was to determine which, if any of two steroid preparations, oral dexamethasone or oral prednisolone, was more palatable to children requiring steroid treatment for asthma. METHODS: A single-blind taste test of 2 different steroid suspensions, liquid prednisolone (1mg/ml) versus liquid dexamethasone (1mg/ml), was conducted in children aged 5-12 years, presenting to the pediatric emergency department with an exacerbation of asthma requiring steroid treatment. Children received 2.5mls of either prednisolone or dexamethasone and were asked to score their impression of taste on a 10 cm visual analog scale. After cleansing of the palate they were given the other steroid and scored its taste. RESULTS: Thirty-nine children (54% male) were enrolled in the study. The mean age was 7.1 years (SD=2.0). The median visual analog scale measurement for dexamethasone was 8.2 cm (IQR= 5.2) whilst the median measurement for prednisolone was 5.0 cm (IQR= 7.3), p=0.03. Male children were more likely to prefer dexamethasone than females with a median score of 9.9 cm (IQR=3.8) for males vs. 5.9 cm (IQR=9.3) for females, p=0.005. There was no gender preference for prednisolone. CONCLUSIONS: There was a statistically significant difference between the taste of dexamethasone and prednisolone, with dexamethasone being the preferred steroid among pediatric patients with asthma. Males were much more likely to prefer dexamethasone than females.

The effect of patient transfer on outcomes after rupture of an abdominal aortic aneurysm.

OBJECTIVE: Centralization of vascular surgery services has resulted in patients being transferred longer distances for treatment of life-threatening conditions. The purpose of this study was to determine whether patient transfer adversely affects the survival of people with a ruptured abdominal aortic aneurysm (RAAA). METHODS: We performed a retrospective review of all patients undergoing attempted repair of an RAAA at our centre, over a recent 3.5-year period (August 2000-December 2003). Patients were divided into those presenting directly to our centre and those transferred from another hospital. The main outcome variable was in-hospital or 30-day mortality, with secondary variables including time to surgical treatment, mortality in the first 24 hours and length of hospitalization. RESULTS: Eighty-one patients (73% men) underwent attempted open repair of an RAAA at our centre during this period. Twenty-four patients (29.6%) presented directly to our hospital, while 57 (70.4%) were transferred from another institution. The overall mortality rate was 53%. Although transferred patients took twice as long as direct patients to get to the operating room (6.3 v. 3.2 h, p=0.03), there was no difference in mortality between the 2 groups (50% v. 54%, p=ns). However, deaths of transferred patients were more likely to occur in the first 24 postoperative hours, compared with direct patients (40% v. 33%, p<0.05). Neither mean intensive care unit stay (5.8 and 8.1 d) nor total hospitalization (20.9 and 18.8 d) differed between the 2 groups. CONCLUSIONS: Although the transfer of patients with RAAA results in a treatment delay, it does not adversely affect the already high mortality rates associated with this condition. These results may be attributed to a preselection of patients who are able to tolerate such a delay.