Nerve Block vs. Sedation for Reduction of Anterior Shoulder Dislocation

Authors: Raeyat Doost E et al., Am J Emerg Med 2017 Apr 14;

Nerve block was faster but sedation was somewhat more effective in this small randomized trial.

For reduction of anterior shoulder dislocations, options include procedural sedation, intraarticular lidocaine injection, nerve block, and manipulation without sedation. Investigators in Iran randomized 60 adults undergoing anterior shoulder dislocation to ultrasound-guided interscalene brachial plexus block or sedation with fentanyl (2 µg/kg) plus propofol (1 mg/kg). Primary outcomes were patient-reported pain and emergency department (ED) length of stay (time from commencement of the nerve block or sedation procedure to discharge); secondary outcomes included patient satisfaction.

The nerve block group had a significantly shorter ED stay than the sedation group (mean, 80 vs. 109 minutes) but more pain during the procedure (mean score, 3.4 vs. 0.4 points on a 5-point numeric rating scale) and lower satisfaction (mean score, 3.0 vs. 3.6 on a 4-point scale). No significant adverse events were recorded.

Comment

Procedural sedation is the most common and accepted method for control of symptoms during reduction of anterior shoulder dislocations. In this study, the use of fentanyl at a dose of 2 µg/kg might have deepened the sedation and prolonged the length of stay. With propofol, lower analgesic doses or no analgesic at all might be faster. Nerve block is a great option for patients facing high risk from procedural sedation, such as the very elderly and those with relevant comorbidities, and if it can be performed soon after injury, scapular manipulation without any sedation may be possible as well.