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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.
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CASE PRESENTATION: A 53-year-old male presented to the emergency department with acute onset of bilateral hearing loss as well as vertigo and severe vomiting. The Head Impulse- Nystagmus-Test of Skew exam was indicative of a central neurologic process. Computed tomography angiogram of the head and neck revealed near-total bilateral vertebral artery occlusions in the second and third segments. The patient was admitted for further evaluation; subsequent magnetic resonance imaging revealed multiple areas of infarction in the cerebellar hemispheres, medulla, and occipital lobes. DISCUSSION: This case describes a unique presentation of a posterior stroke. Common symptoms include vertigo, loss of balance, and vomiting. However, bilateral hearing loss as a prominent symptom is uncommon. Imaging revealed a rare finding of bilateral vertebral artery occlusion.
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Acute adrenocortical insufficiency is a critical care emergency characterized by hemodynamic instability, lethargy, and cardiovascular collapse. Acute adrenal insufficiency has many etiologies, from rapid withdrawal of exogenous glucocorticoids to adrenocortical destruction to poor adrenal reserve after administration of steroid synthesis inhibitors. Etomidate, a parenteral hypnotic agent, is a steroid synthesis inhibitor. Although the use of continuous etomidate infusion in the intensive care unit fell from favor secondary to reports of adrenal crisis, single-dose etomidate for induction of anesthesia is common for the hemodynamically unstable patient or in patients who may not tolerate wide variance in heart rate or blood pressure. A case is presented of acute adrenocortical insufficiency and crisis after a standard induction dose of etomidate. Acute adrenal insufficiency should be suspected in intensive care unit patients who have undergone general anesthesia with etomidate induction and present with hypotension refractory to standard vasopressor administration.