Intra-Articular Lidocaine versus Procedural Sedation for Shoulder Dislocation Reduction: A Randomized Trial.

Introduction: Two common ways of providing anesthesia for shoulder dislocation reductions in the emergency department (ED) are intra-articular lidocaine (IAL) injections and procedural sedation (PS). We sought to compare PS with propofol or etomidate to IAL for shoulder dislocation reductions in the ED. Methods: This was an open-label, randomized controlled trial of patients aged 18-70 years with anterior shoulder dislocations who presented to a single ED. We randomized patients to either PS or IAL for their shoulder dislocation reduction. The primary outcome measure was ED length of stay (LOS). Secondarily, we assessed patient satisfaction and the number of attempts required for successful reduction. Results: We identified 60 patients who met the criteria for enrollment, and were able to enroll 43. We randomized 23 patients to IAL and 20 to PS. In the IAL group, the mean ED LOS was 133 min as compared to 124 min for the PS group (difference 9 min [95% confidence interval (CI)-22-41], P = 0.54). Patients in the IAL group required an average of 1.9 reduction attempts as compared to 1.2 in the PS group (difference of 0.7 [95% CI 0.2-1.2]). The mean patient satisfaction scores were similar at 9.7 and 9.8 for the IAL and PS groups, respectively. Conclusions: This study lacked a sufficient sample size to detect small differences but found no statistically significant difference in mean ED LOS or patient satisfaction for patients who received IAL as compared to PS. Patients in the PS group required fewer attempts for successful reduction.

Point-of-Care Ultrasound Assisting in the Rapid Diagnosis of Acute Cholangitis 60 Years After Cholecystectomy.

BACKGROUND: Point-of-care ultrasound (POCUS) is used frequently to evaluate the right upper quadrant of patients with high suspicion for biliary pathology. In patients with a history of cholecystectomy, the utility of POCUS can be overlooked. CASE REPORT: We report the case of an 83-year-old female patient who was ultimately diagnosed with cholangitis more than 60 years after undergoing cholecystectomy. POCUS demonstrated a dilated common bile duct (CBD), which was confirmed by computed tomography and magnetic resonance cholangiopancreatography to be due to a large stone. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Choledocholithiasis and cholangitis can still occur in patients with a remote history of cholecystectomy. POCUS can be used to rapidly evaluate the CBD for dilatation in patients post cholecystectomy.