A little over half a million individuals visit the emergency department (ED) each year for a joint dislocation. Putting the dislocation back into place (reduction) is painful, requiring proper sedation and pain relief. EDs are doing an excellent job of caring for these patients, concludes a new study. It found that emergency physicians are able to perform procedural sedation safely without involvement of an anesthesiologist in the vast majority of cases.
The researchers reviewed the medical charts of 1,980 patients with various dislocations treated at 47 EDs across 19 States between 2003 and 2005. All of the EDs had high patient volumes and 83 percent had an emergency medicine residency program.Using pain management standards and recognized sedation procedures, the researchers developed five quality measures for dislocation care in the ED. These measures covered pain assessment and medication, vital sign monitoring, assessment of the limb’s neurologic and vascular status, and successful reduction of the dislocation.
Nearly half of all patients (46 percent) received midazolam, fentanyl, or both as sedation, while 21 percent received propofol. Most had shoulder dislocations and stayed in the ED around 4 hours before going home. Overall, dislocation care was excellent. Higher concordance with quality measures was positively associated with better outcomes, including successful reduction. Only 6.3 percent of patients experienced an adverse event.
The most common was the administration of a reversal agent (2.3 percent), followed by bag-mask ventilation (2.0 percent), and vomiting (1.3 percent). Being female and having chronic obstructive pulmonary disease predicted a higher frequency of adverse events. Shoulder dislocations were most likely to be reduced successfully compared to hip, knee, and ankle dislocations.
The study was supported by AHRQ (HS13099). See "Quality of care for joint dislocation in 47 US EDs," by Chu-Lin Tsai, M.D., Sc.D., Ashley F. Sullivan, M.S., M.P.H., James A. Gordon, M.D., M.P.A., and others in the American Journal of Emergency Medicine 30, pp. 1105-1113, 2012.