Intra-articular lidocaine versus intravenous sedation for closed reduction of acute anterior shoulder dislocation in the emergency department: a systematic review and meta-analysis

Abstract

Objective Anterior shoulder dislocations are commonly treated in the emergency department (ED). Analgesia for reduction is provided by intra-articular lidocaine (IAL) injection or intravenous sedation (IV sedation). The objective of this systematic review and meta-analysis was to compare IAL versus IV sedation for closed reduction of acute anterior shoulder dislocation in the ED. Methods Electronic searches of MEDLINE and EMBASE (1946–September 2021) were completed and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing IAL and IV sedation for reduction of acute anterior shoulder dislocations among patients ≥ 15 years old in the ED were included. Outcomes of interest included a successful reduction, adverse events, ED length of stay, pain scores, procedure time, ease of reduction, patient satisfaction, and cost. Two reviewers independently screened abstracts, assessed study quality and extracted data. Data were pooled using random-effects models and reported as mean differences and risk ratios (RR) with 95% confidence intervals (CIs). Results 12 RCTs were included with a total of 630 patients (IAL = 327; IV sedation = 303). There was no difference in reduction success between IAL and IV sedation (RR 0.93; 95% CI 0.86–1.01, I 2 = 69%), significantly lower adverse events with IAL (RR 0.16; 95% CI 0.07–0.33, I 2 = 0%), shorter ED length of stay with IAL (mean difference − 1.48; 95% CI − 2.48 to − 0.47, I 2 = 93%), no difference in pain scores post-analgesia and no difference in ease of reduction. Conclusions Intra-articular lidocaine may have similar effectiveness as IV sedation in the successful reduction of anterior shoulder dislocations in the ED with fewer adverse events, shorter ED length of stay, and no difference in pain scores or ease of reduction. Intra-articular lidocaine may be an effective alternative to IV sedation for reducing anterior shoulder dislocations, particularly when IV sedation is contraindicated or not feasible. Supplementary Information The online version contains supplementary material available at 10.1007/s43678-022-00368-z.

Intra‐articular lidocaine versus intravenous sedation for anterior shoulder dislocation reduction

“…This meta-analysis found no significant difference in reduction success rate or pain scores between either option. 8 Intra-articular lidocaine was associated with fewer adverse events, shorter ED length of stay, and reduced procedure time, while procedural sedation was associated with higher patient satisfaction.…”

“…[5][6][7] The systematic review and meta-analysis summarized here included RCTs comparing intra-articular lidocaine and IV sedation in ED patients with acute anterior shoulder dislocation. 8 Participants were ≥15 years of age undergoing closed reduction for treatment of the dislocation. Studies with pediatric populations, posterior dislocations, fracture-dislocations, and settings other than the ED were excluded.…”

“…The meta-analysis identified 12 RCTs published between 1994 to 2020 with 630 patients (327 patients receiving intra-articular lidocaine and 303 patients receiving IV sedation) conducted in the ED setting. 8 All patients in the intra-articular lidocaine group received 1% lidocaine, with 10 trials administering 20 mL of 1% lidocaine and two trials administering 4 mg/kg (maximum 200 mg). The type of IV sedation medications varied widely across all studies, with a benzodiazepine (diazepam, midazolam) in combination with an opioid (meperidine, morphine, or fentanyl) being the most common sedation regimen used.…”

“…As in the previous meta-analysis, intra-articular analgesia resulted in a shorter length of ED stay. 8,9 C AV E AT S Intra-articular lidocaine and IV sedation can be effective in facilitating the reduction of anterior shoulder dislocations, with distinct advantages and disadvantages for each. This meta-analysis found no significant difference in reduction success rate or pain scores between either option.…”

“…The systematic review and meta‐analysis summarized here included RCTs comparing intra‐articular lidocaine and IV sedation in ED patients with acute anterior shoulder dislocation 8 . Participants were ≥15 years of age undergoing closed reduction for treatment of the dislocation.…”