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P007: Cunningham reduction of anterior shoulder dislocation facilitated by inhaled low-dose methoxyflurane – a pilot study
- H. Wiemer, S. Campbell, R. Fitzpatrick, C. Carriere, S. Teed, P. Hico, A. Snook, J. Gallant, J. Belliveau, C. DeMone
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 22 / Issue S1 / May 2020
- Published online by Cambridge University Press:
- 13 May 2020, pp. S66-S67
- Print publication:
- May 2020
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Introduction: The Cunningham reduction method for anterior shoulder dislocation offers an atraumatic alternative to traditional reduction techniques without the inconvenience and risk of procedural sedation and analgesia (PSA). Unfortunately, success rates as low as 27% have limited widespread use of this method. Inhaled methoxyflurane (I-MEOF) offers a rapidly administered, minimally invasive option for short-term analgesia. We conducted a pilot study to evaluate the feasibility of studying whether I-MEOF increased success rates for atraumatic reduction of anterior shoulder dislocation. Methods: A convenience sample of 20 patients with uncomplicated anterior shoulder dislocations were offered the Cunningham reduction method supported by methoxyflurane analgesia under the guidance of an advanced care paramedic. Operators were instructed to limit their attempt to the Cunningham method. Outcomes included success rate without the requirement for PSA, time to discharge, and operator and patient satisfaction with the procedure. Results: 20 patients received I-MEOF and an attempt at Cunningham reduction. 80% of patients were male, median age was 38.6 (range 18-71), and 55% were first dislocations of that joint. 35% (8/20 patients) had reduction successfully achieved by the Cunningham method under I-MEOF analgesia. The remainder proceeded to closed reduction under PSA. All patients had eventual successful reduction in the ED. 60% of operators reported good to excellent satisfaction with the process, with inadequate muscle relaxation being identified as the primary cause of failed initial attempts. 80% of patients reported good to excellent satisfaction. Conclusion: Success with the Cunningham technique was marginally increased with the use of I-MEOF, although 65% of patients still required PSA to facilitate reduction. The process was generally met with satisfaction by both providers and patients, suggesting that early administration of analgesia is appreciated. Moreover, one-third of patients had reduction achieved atraumatically without need for further intervention. A larger, randomized study may identify patient characteristics which make this reduction method more likely to be successful.
P139: Procedural sedation by advanced care paramedics for emergency GI endoscopy
- H. Wiemer, M.B. Butler, P. Froese, D. Farina, A. Lapierre, C. Carriere, G. Etsell, J. Jones, J. Murray, S.G. Campbell
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- Journal:
- Canadian Journal of Emergency Medicine / Volume 18 / Issue S1 / May 2016
- Published online by Cambridge University Press:
- 02 June 2016, p. S124
- Print publication:
- May 2016
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Introduction: Acute upper gastrointestinal (UGI) bleeding is a relatively common emergency resulting in death in 6 to 8% of cases. UGI endoscopy is the intervention of choice which requires procedural sedation and analgesia (PSA). The Halifax Infirmary emergency department (ED) performs 1000 PSAs annually, performed by advanced care paramedics (ACPs). This has been shown safe for other indications for PSA, such as orthopedic procedures. Considering that UGI endoscopy involves upper airway manipulation, and patients are at an increased risk of massive bleeding, this procedure would be expected to be more complex and have an increased risk of adverse events (AEs). This study aims to compare PSA for UGI endoscopy performed by ACPs to that for orthopedic procedures for AEs, airway intervention and medication use. Methods: This study is a retrospective review of an ACP-performed ED PSA quality control database. A dataset was built matching 64 UGI endoscopy PSAs to 192 orthopedic PSAs by propensity scores calculated using age, gender and ASA classification. Outcomes assessed were hypotension (SBP < 100, or 15% decrease from baseline), hypoxia (SaO2 < 90), apnea (> 30sec), vomiting, arrhythmias and death in the ED. The need for airway intervention and medication use was assessed. Results: The UGI endoscopy group was 4.60 times more likely to suffer hypotension than the orthopedic group (OR=4.6, CI:2.2-9.6), and a fifth as likely to require airway repositioning (OR=0.2, CI:0.1-0.5). One endoscopy patient required endotracheal intubation. No patient died in either group. Compared to the orthopedic group, the UGI endoscopy group was one-third as likely to receive fentanyl (OR=0.3, CI:0.2-0.6). When fentanyl was administered, endoscopy patients received an average 26.7 mcg less than orthopedic patients. The endoscopy group was 15.4 times more likely to receive ketamine (OR=15.4, CI:4.7-66.5), and received 34.4 mg less on average. Four endoscopy patients received phenylephrine compared to none in the orthopedic group. There were no other differences. Conclusion: ED PSA for UGI endoscopy appears to differ significantly from that performed for orthopedic procedures. It was associated with more frequent hypotension and increased use of ketamine as a sedative. Patients undergoing UGI endoscopy were less likely to receive fentanyl and require airway repositioning. Only patients in the endoscopy group required intubation or a vasopressor agent.
Contributors
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- By Mohamed Aboulghar, Ahmed Abou-Setta, Mary E. Abusief, G. David Adamson, R. J. Aitken, Hesham Al-Inany, Baris Ata, Hamdy Azab, Adam Balen, David H. Barad, Pedro N. Barri, C. Blockeel, Giuseppe Botta, Mark Bowman, Chris Brewer, Dominique M. Butawan, Sandra A. Carson, Hai Ying Chen, Anne Clark, Buenaventura Coroleu, S. Das, C. Dechanet, H. Déchaud, Cora de Klerk, Sheryl de Lacey, S. Deutsch-Bringer, P. Devroey, Didier Dewailly, Hakan E. Duran, Walid El Sherbiny, Tarek El-Toukhy, Johannes L. H. Evers, Cynthia Farquhar, Rodney D. Franklin, Juan A. Garcia-Velasco, David K. Gardner, Norbert Gleicher, Gedis Grudzinskas, Roger Hart, B Hédon, Colin M. Howles, Jack Yu Jen Huang, N. P. Johnson, Hey-Joo Kang, Gab Kovacs, Ben Kroon, Anver Kuliev, William H. Kutteh, Nick Macklon, Ragaa Mansour, Lamiya Mohiyiddeen, Lisa J. Moran, David Mortimer, Sharon T. Mortimer, Luciano G. Nardo, Robert J. Norman, Willem Ombelet, Luk Rombauts, Zev Rosenwaks, Francisco J. Ruiz Flores, Anthony J. Rutherford, Gavin Sacks, Denny Sakkas, M. W. Seif, Ayse Seyhan, Caroline Smith, Kate Stern, Elizabeth A. Sullivan, Sesh Kamal Sunkara, Seang Lin Tan, Mohamed Taranissi, Kelton P. Tremellen, Wendy S. Vitek, V. Vloeberghs, Bradley J. Van Voorhis, S. F. van Voorst, Amr Wahba, Yueping A. Wang, Klaus E. Wiemer
- Edited by Gab Kovacs, Monash University, Victoria
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- Book:
- How to Improve your ART Success Rates
- Published online:
- 05 July 2011
- Print publication:
- 30 June 2011, pp viii-xii
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