Ultrasound guided interscalene block versus procedural sedation for shoulder dislocation reduction
Date First Published:
November 29, 2013
Last Updated:
March 25, 2015
Report by:
Chris Bryden, ACCS CT2 (Cheltenham General Hospital)
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.
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"
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"
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)
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):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED Blaivas M., Lyon M. May-06 United States of America | 4 adults aged 27, 32, 42 and 78. 3 male 1 female | Case series demonstrating efficacy and safety of interscalene block use - particularly in one case where preexisting comorbidities made the patient a poor candidate for elective procedural sedation. Showed patients were comfortable with sufficient muscle relaxation to perform shoulder relocation in all cases. |
small case series | ||
| A prospective comparison of procedural sedation and ultrasound-guided interscalene nerve block for shoulder reduction in the emergency department 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 | ||||
| Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED Graf 2008 United States of America | responding letter | responding letter highlights the following key points ultrasound guided interscalene blocks are probably safe and effective in skilled hands but those less skilled should beware there are significant risks associated with the procedure such as diaphragmatic paralysis and pneumothorax to name two intravenous access should be obtained as a precaution and appropriate noninvasive monitoring should be in place - including a blood pressure, pulse oximetry and electrocardiography an opinion is stated that short active lignocaine should be used as opposed to bupivacaine as the pain of the dislocation is reduced following joint reduction |
Author Commentary:
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.
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.
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:
- Blaivas M., Lyon M.. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED
- 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
- Graf. Ultrasound-guided interscalene block for shoulder dislocation reduction in the ED