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Three Part Question

In [patients with acute traumatic shoulder dislocation] is [ultrasound guided interscalene block as effective as procedural sedation] at [reducing pain, permitting joint reduction and reducing staff time demands and length of stay in the emergency department]?

Clinical Scenario

An adult, over 18 years of age, has a dislocated shoulder and you have been asked to manipulate the joint. It is a primary dislocation with no nerve damage or other associated trauma.

While assessing the patient and considering the options for relocation you recall a recent discussion from an ultrasound course regarding the use of interscalene blocks to assist the procedure.

You consider the question of "is an interscalene block better at reducing pain and facilitating joint reduction than procedural sedation" considering the time required to recover the patient from intravenous conscious sedation.

Search Strategy

Athens/Ovid search 1966-2013.
AMED, EMBASE, HMIC, MEDLINE, PsycINFO, BNI, CINAHL, HEALTH BUSINESS ELITE
"conscious sedation".ti,ab AND "interscalene block".ti,ab

also

Cochrane Central Register of Controlled Trials : Issue 11 of 12, November 2013 search
"shoulder dislocation" AND "sedation" AND "interscalene block"

Search Outcome

Athens/Ovid search 1966-2013.

3 relevant entries

Cochrane Central Register of Controlled Trials : Issue 11 of 12, November 2013 search

1 relevant entry (duplicated in Athens search)

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Blaivas M,Adhikari S,Lander L 2011 United States of America	Adults over 18 with shoulder dislocation requiring reduction.	Prospective, randomised objective study with 21 patients in each arm comparing; length of stay, one to one health care provider time, pain experienced during reduction and overall patient satisfaction. The two groups were randomised to ultrasound guided interscalene block OR procedural sedation with etomidate only. The length of stay was longer in the procedural sedation arm compared with the ultrasound guided interscalene block AND the one to one health care provider time was longer in the procedural sedation group too. There was no difference between pain experienced during reduction or patient satisfaction in either group. There was also no difference in complications such as hypoxia or hypotension between the two groups.	length of stay procedural sedation, mean (+/-SD)	177.3 +/- 37.9 min	small numbers performed in level 1 trauma centre with high level of operator sonography/regional anaesthesia skill
			length of stay ultrasound guided interscalene block, mean (+/-SD)	100.3 +/- 28.2 minutes; p < 0.0001
			one to one health care provider procedural sedation, mean (+/-SD)	47.1 (+/-9.8) minutes
			one to one health care provider interscalene block, mean (+/-SD)	5 (+/-0.7) minutes; p < 0.0001

Comment(s)

Ultrasound guided interscale block for the reduction of shoulder dislocation, in skilled hands, may be an appropriate alternative to procedural sedation - particularly if a patient is not starved or appropriate for sedation due to the prescence of comorbidities. The evidence is very limited but currently there appears to be no difference in pain experienced during reduction or patient satisfaction when comparing interscalene blocks with procedural sedation. There is weak evidence that using an interscalene block reduces the length of stay in the Emergency Department and also the amount of one to one health care provider time when compared to procedural sedation. Appropriate caution should be taken when performing ultrasound guided regional anaesthesia in accordance with national guidelines and local policy. There may be scope for the future for futher studies to demonstrate the place of ultrasound guided interscalene blocks in the management of shoulder dislocation. Complications from ultrasound guided interscalene blocks occur at a rate of 1-5%. Complications include pneumothorax, ipsilateral hemidiaphragm paresis, recurrent laryngeal nerve blockade, Horner's syndrome, peripheral neuropathy and cardiac arrhythmias should the local anaesthetic be injected directly intravenously.

Clinical Bottom Line

If you have the skill to perform ultrasound guided interscalene blocks for shoulder relocation in an appropriate patient then this is a technique that could be considered.

References

1. Blaivas M., Lyon M. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED The American Journal of Emergency Medicine (2006): 293-6
2. Blaivas M,Adhikari S,Lander L A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department Academic Emergency Medicine September 2011, vol./is. 18/9(922-927)
3. Graf Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED The American Journal of Emergency Medicine (2008): 1061