Morning Report

Morning Report: Conscious Sedation – Propofol, Etomidate, or Ketamine?

Presented by Dr. F. Johnston

Summary:
13 y.o. male presented with an injury to his left elbow that occurred while wrestling. He complained of severe pain to his elbow and exam appeared to show a deformity. On xray he was found to have a posterior dislocation and impaction fracture on the inner aspect of the trochlear epiphysis. A reduction was performed with a ketamine bolus.

Learning Points:
Reduction Technique. Sedation Choices.

13 y.o. male.

CC: elbow injury

DDX: fx, dislocation, sprain/strain, muscle tear

Diagnosis: posterior dislocation

Unreduced posterior dislocations of the elbow should be immobilized and reduced. The common components include:

  1. Supination of the forearm
  2. Elbow flexed to 90 degrees
  3. Counter for status stabilizes the humerus
  4. Gentle axial traction on the forearm

If not successful, adding more elbow flexion, volar directed pressure on the olecranon process as well as gentle pressure on the proximal forearm in a volar direction may be helpful. Splint immobilization may be needed for 7 to 10 days, sling 2-3weeks.

Evidence Review:

Randomized clinical trial of etomidate versus propofol for procedural sedation in the emergency department. Ann Emerg Med. 2007;49(1):15.

  1. propofol has highest success rate,
  2. ketamine 28% agitation,
  3. edtomidate myoclonus in 20%
  4. Propofol averaged 7.9% SBP decrease
  5. Respiratory depression over various measures similar in all groups.

References: 

  • Miner JR, Danahy M, Moch A, Biros M. Randomized clinical trial of etomidate versus propofol for procedural sedation in the emergency department. Ann Emerg Med. 2007;49(1):15.
  • Jones DR1, Salgo P, Meltzer J. Conscious sedation for minor procedures in adults. N Engl J Med. 2011 Jun 23;364(25):e54. doi: 10.1056/NEJMvcm0800732.
  • Miner JR1, Gray RO, Bahr J, Patel R, McGill JW. Randomized clinical trial of propofol versus ketamine for procedural sedation in the emergency department. Acad Emerg Med. 2010 Jun;17(6):604-11. doi: 10.1111/j.1553-2712.2010.00776.x.com
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