77 Intra-articular Lidocaine versus Procedural Sedation for Anterior Shoulder Dislocations

Abstract

Shoulder dislocations are the most common dislocations presenting to emergency departments (EDs). Due to the large groups of muscles involved, shoulder dislocation reductions are difficult to achieve for the provider if the patient's pain is not adequately controlled. There are several ways of providing anesthesia for shoulder dislocation reductions, and two of the most common are intra-articular lidocaine (IAL) injections and procedural sedation. Prior studies have found that the use of IAL is safer and results in a shorter ED length of stay (LOS) as compared to procedural sedation, but those studies used sedative medications that have fallen out of favor. The purpose of this study was to compare IAL to procedural sedation with propofol or etomidate for closed reduction of anterior shoulder dislocations. This was a single center, open label, randomized controlled trial. ED patients from 18 to 70 years old who had an anterior shoulder dislocation without an associated fracture (other than a Hill-Sachs) were eligible for enrollment. Consenting patients were randomized to either procedural sedation (with provider’s choice of propofol or etomidate) or IAL. The dose of procedural sedation medication was per provider discretion. The initial study protocol stated that patients randomized to the IAL group would receive 20mL of 1% lidocaine into the glenohumeral joint, but due to a shortage of 1% lidocaine, injections with 10mL of 2% lidocaine were also allowed. The primary outcome measure was ED LOS. Secondarily the number of attempts required for successful reduction and patient satisfaction were compared between groups. In total, 43 patients were enrolled with 23 randomized to the IAL group and 20 to the procedural sedation group. Three patients randomized to the IAL group ended up getting procedural sedation after failed attempts at reduction. In those randomized to the IAL group, the mean ED LOS was 133 minutes as compared to 124 minutes for the procedural sedation group. The difference of 9 minutes (95% CI -22 to 41) was not statistically significant (p = 0.54). Patients in the IAL group had a higher mean number of reduction attempts at 1.9 as compared to 1.2 in the procedural sedation group (difference 0.7 [95% CI 0.2 to 1.2]). The mean patient satisfaction scores were similar at 9.7 and 9.8 for the IAL and procedural sedation groups, respectively (difference 0.1 [95% CI -0.3 to 0.4]). Although this study was underpowered to detect small differences, there was no statistically significant difference in mean ED LOS or patient satisfaction for patients who received IAL for their shoulder dislocation reduction as compared to those who received procedural sedation. Patients randomized into the procedural sedation group required less number of attempts for successful reduction compared to those randomized into the IAL group.