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Three Part Question

in [ patients needing shoulder reduction ] is [ Inter-scalene ultrasound guided nerve block done by emergency physicians in ED] offer better [ analgesia and clinical outcomes]

Clinical Scenario

a patient presenting to A&E with simple shoulder dislocation. Should they receive a USS guided interscalene block or a procedural sedation for the joint reduction

Search Strategy

Athens/Ovid search
'interscalene block' OR 'interscalene block shoulder dislocation'
and ' emergency'

Search Outcome

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. Acad. Emerg. Med. Off. J. Soc. Acad. Emerg. Med. 18, 922–927 (2011).

Blaivas, M. & Lyon, M. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. Am. J. Emerg. Med. 24, 293–296 (2006).

Bhoi, S. et al. Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians. J. Emerg. Trauma Shock 5, 28–32 (2012).

Bhoi, S., Chandra, A. & Galwankar, S. Ultrasound-guided nerve blocks in the emergency department. J. Emerg. Trauma Shock 3, 82–88 (2010).

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Blaivas, M., Adhikari, S. & Lander 2011 USA	42 ED patients presenting with shoulder dislocation Inclusion criteria: >18 yrs old Exclusion: known local anesthetic allergy, hemodynamic instability, resp distress, altered mental status 21 randomized to US, 21 to sedation.	Prospective randomized study (1+)	Length of stay (primary outcome	Sedation = 177.3 (+/-37.9), US = 100.3 (+/-28.2). P <. 0001	No blinding No measurement of other variables that might affect length of stay (e.g. time to x-ray) Convenience sample design (i.e. no all that presents) Single center study
			One-on-one health provider time (min	Sedation= 47.1 (+/-9.8), US = 5 (+/-0.7). P<.000
			Pain experiences during reduction (median)	Sedation = 0 (0-4), US= 0 (0-3). P=.9275
			Patient satisfaction	Sedation = 8.2 (+/-1.3), Us= 8.3 (+/-1). P=.7990
			Complication (hypotension, hypoxia)	No difference p=.49
Blaivas, M. & Lyon, M 2006 USA	4 patients cases needing shoulder reduction, where conscious sedation was not possible	case reports (level 3)	Complete anesthesia and muscle relaxation allow comfortable reduction	obtained in all cases,1 case of temporary recurrent laryngeal nerve palsy	V small numbers No statistical comparison Total length of stay not reported Level of expertise and training of ED physician not reported
Bhoi, Chandra & Galwankar 2010 India	8 patients over period of 3 weeks Various specialty doctors including ED residents assigned to ED	Case report (3)	If US guided upper and lower extremity peripheral nerve blockage were feasible in ED setting	Different patients with different injuries, complexities Different specialty and grade of trainee	Different patients with different injuries, complexities Different specialty and grade of trainee
Bhoi, S., Chandra, A. & Galwankar, S. 2010 India	50 patients (7-80 yrs) with limb injury needing procedural sedation Various specialty doctors including ED residents assigned to ED	Prospective observational study (2-)	% of cases completed without rescue analgesia Median reduction in pain (primary)*	None; Reduction of 7.44 (p=.00001	Observational No blinding No control
			* 2nd outcome: complication immediate or late at 3month	none. Median procedure time – 9min, median reduction of pain 5min

Comment(s)

1) US- guided interscalene nerve block for shoulder dislocation Blaivas, Adhikari & Lander (2011): Training received probably more than an average ED physician Specialized training in USS regional anesthesia - (2 hour didactic course + hands on training. All at least 2 year experience in US. Each preformed at least 10 interscalene block before) Clear inclusion and exclusion criteria. All subjects presented with simple dislocation. Might not be suitable for more complex injuries Clinical relevance: US guided interscalene nerve block appear to have similar effectiveness and safety as traditional method Cost effectiveness: US guided interscalene nerve block appear to offer speedier recovery time and require less personnel resource 2)Can emergency doctors be trained to perform this technique effectively and safely? Blaivas & Lyon, 2006 Level of expertise and training of ED physician not reported Blaivas, Adhikari & Lander, 2011 Specialized training in USS regional anesthesia (2 hour didactic course + hands on training) All at least 2 year experience in US. Each preformed at least 10 interscalene block before) Bhoi, Chandra & Galwankar (2010) Training seminar on US guided upper an lower peripheral nerve block 2/8 were anterior scalene block for shoulder dislocation. both reported complete anesthesia, dischaged after 1h observation Bhoi et al (2012) One hour diactic session and practice on live model One week practice for of nerve identification under superviion. Minimum of 5 US- guided nerve blocks on nerve model (Blue phantom 24% brachial plexus block 13 shoulder reductions

Clinical Bottom Line

US- guided interscalene nerve block can be safely and effectively performed by emergency physicians with adequate training. For simple Shoulder dislocation it had similar clinical effectiveness and safety as traditional method, with the added benefit of a speedier recovery time and less personnel resource.

References

1. Blaivas, M., Adhikari, S. & Lander A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department Academic Emergency Medicine 2011 Sep;18(9):922-7
2. Blaivas, M. & Lyon, M Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED. Am J Emerg Med 2006 May;24(3):293-6.
3. Bhoi, Chandra& Galwankar. Bhoi, S. et al. Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians . J. Emerg. Trauma Shock 5, 28–32 (2012).
4. Bhoi, S., Chandra, A. & Galwankar, S. Ultrasound-guided nerve blocks in the emergency department . J. Emerg. Trauma Shock 3, 82–88 (2010).
5. Blaivas, M., Adhikari, S. & Lander A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department Academic Emergency Medicine 2011 Sep;18(9):922-7