Episode Chapters
- Introduction – A Hot Red Arm13:31Blood Pressure Control in Acute Stroke11:10Paper Chase 1 - Pacemakers and MRI5:28Hand, Foot, and Mouth Disease8:45Difficult Conversations with Physicians11:53Wound Repair Pt 6 – Gnarly Wounds12:15Paper Chase 2 - Epi, Anaphylaxis, and the Elderly4:06Critical Care Mailbag: Vitamin C for Sepsis?6:41Pharmacology Rounds – What Works for Acute Migraine6:43Paper Chase 3 - Lysis of Intermediate Risk PE4:34Against Medical Advice26:28Annals of Emergency Medicine - Intranasal Medications8:55Strayerisms - Why Do We Intubate?Free Chapter10:21Intra-articular Lidocaine6:07Cardiology Corner - Epi In Cardiac Arrest, Again10:34Paper Chase 4 - Keeping Opioids Safe at Home3:56Down Syndrome Emergencies19:23Pharmacology Rounds – Gonorrhea Gets Some Muscle5:08EM:RAP On Location – A Case of Unusual Discharge2:40Paper Chase 5 - Do All Chest Pain Patients Need Monitoring?4:20Subarachnoid, Syncope, and Cardiac Arrest16:56The Challenging Foley24:53Mailbag and Summary20:36EM:RAP 2017 August Aussie Edition16:18EM:RAP 2017 August German Edition1h, 09mEM:RAP 2017 August French Edition41:16EM:RAP 2017 August Spanish Edition2h, 33m
Nurses Edition Commentary
Lisa Chavez, RN and Kathy Garvin, RN
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EM:RAP 2017 August Summary 718 KB - PDF
Why consider intra-articular lidocaine (over procedural sedation) in your next shoulder reduction? Fewer complications, shorter time in the department, and equal efficacy.
Challenging Foleys, Conversations, and Intubations Full episode audio for MD edition 245:15 min - 342 MB - M4AEM:RAP 2017 August Aussie Edition Australian 16:18 min - 22 MB - MP3EM:RAP 2017 August German Edition Deutsche 69:31 min - 96 MB - MP3EM:RAP 2017 August French Edition Français 41:16 min - 57 MB - MP3EM:RAP 2017 August Spanish Edition Español 153:43 min - 211 MB - MP3EM:RAP 2017 August Board Review Answers 234 KB - PDFEM:RAP 2017 August Board Review Questions 180 KB - PDFEM:RAP 2017 August MP3 315 MB - ZIPEM:RAP 2017 August Spanish Summary 1 MB - PDFEM:RAP 2017 August Summary 718 KB - PDF
Justin M., M.D. - August 4, 2017 9:15 AM
Great segment. I agree that intra-articular lidocaine is a great option. About half the time I use it, the shoulder self-reduces before I have a chance to do anything.
However, with regards to the evidence, I think there is one important point to make: we know that procedural sedation is extremely safe, with significant adverse events in the realm of 1 in 10,000. There were only 400 patients in the systematic review cited here. Although it seems like intra-articular lidocaine is a reasonable idea, if the rate of septic arthritis is 1 in 500, we wouldn't necessarily see it in the studies, but it would be high enough to to make procedural sedation the better option.
In a rheumatology clinic, the rate of post-injection infection is incredibly low (18 in 250,00 per Hollander 1953 is the best reference I can find). However, based on ultrasound and MRI studies, we know that these blind injections are rarely actually in the joint. When the shoulder is dislocated, it is very difficult to miss the joint. It is reasonable to think that the infection rate might be higher than in the rhuem literature. As far as I can tell, the evidence we have doesn't provide us with an answer.
Cheers,
Justin
Dallas Holladay, DO - August 18, 2017 2:57 PM
That's an interesting point. I wonder if this is best reserved for the patient who fails an awake procedure like the Fares or Cunningham.