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Intra-articular Lidocaine

Patrick Bafuma, PA
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06:07
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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00:40

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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.

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Justin M., M.D. -

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 -

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.

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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

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