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Sections Hip Dislocation Management in the ED
Overview
Presentation
DDx
Workup
Treatment
Guidelines
Medication
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References

Medication

Medication Summary

Administer adequate parenteral analgesia. The emergency physician, the consultant, and the patient must decide on the most appropriate type and place for reduction: open versus closed and emergency department versus operating room.

If closed reduction is attempted in the ED, procedural sedation is required. Procedural sedation policies should be established to define who can administer medication, who must monitor the patient, which classes and doses of procedural sedation medications should be used, and what resources should be kept on hand for resuscitation.

In addition to airway protection and rescue, procedural sedation goals must include pain relief, muscle relaxation, and procedure amnesia.

General anesthesia in the operating room may be required for patients with dislocations that are irreducible by closed means and for those with significant associated fractures, central dislocation, or associated neurovascular injury.

Class Summary

Pain control is essential for good-quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. The analgesic must have rapid onset and predictable action and must be easily titratable.

Morphine sulfate (Duramorph, MS Contin, MSIR)

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Drug of choice (DOC) for analgesia because of reliable and predictable effects, good safety profile, and ease of reversibility with naloxone.

Various IV doses are used; commonly titrated until desired effect is obtained.

Fentanyl citrate (Duragesic, Sublimaze)

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More potent narcotic analgesic with shorter half-life than morphine sulfate. Suitable for procedural sedation analgesia. Excellent choice for pain management and sedation; short duration (30-60 min) and easy to titrate. Easily and quickly reversed by naloxone.

Meperidine (Demerol)

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Narcotic analgesic with multiple actions similar to those of morphine. May produce less constipation, smooth muscle spasm, and depression of cough reflex than similar analgesic doses of morphine.

Class Summary

These agents should be used for procedural sedation with rapid onset and short duration.

Propofol (Diprivan)

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Phenolic compound; sedative-hypnotic agent used for induction and maintenance of anesthesia or sedation; anticonvulsant properties.

Class Summary

Patients with painful injuries usually experience significant anxiety. Anxiolytics allow the clinician to administer a decreased dose of an analgesic while achieving the same effect.

Diazepam (Valium)

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Increasing the activity of GABA, a major inhibitory neurotransmitter, depresses all levels of CNS, including limbic and reticular formation. Dose should be individualized and increased cautiously to avoid adverse effects.

Lorazepam (Ativan)

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Sedative-hypnotic in benzodiazepine class that has a short onset of effect and a relatively long half-life. Increasing the activity of GABA, a major inhibitory neurotransmitter, may depress all levels of CNS, including limbic and reticular formation. Excellent medication when patient needs to be sedated longer than 24 hours.

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Media Gallery

A normal anteroposterior (AP) pelvis radiograph.
Right posterior hip dislocation in a young woman following a high-speed motor vehicle collision (MVC).
Fracture-dislocation of the right hip. The bony fragments are likely part of the acetabulum.
Posterior dislocation of right hip with acetabular fracture.
Portable AP pelvis with subtle presentation of right posterior hip dislocation. Abnormal rotation is present, and the right femoral head appears smaller, indicating that it is further away.

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Author

Stephen R McMillan, MD Resident Physician, Clinical Assistant Instructor, Department of Emergency Medicine, Kings County Hospital Center, State University of New York Downstate Medical Center

Stephen R McMillan, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Christopher I Doty, MD, MAAEM, FAAEM, FACEP Tenured Professor of Emergency Medicine, University of Kentucky College of Medicine; Vice Chair of Education, Department of Emergency Medicine, University of Kentucky Chandler Medical Center

Christopher I Doty, MD, MAAEM, FAAEM, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Residency Directors in Emergency Medicine

Disclosure: Nothing to disclose.

Edward T Tham, MD Fellow in Emergency Ultrasound, Clinical Instructor, Department of Surgery, Section of Emergency Medicine, Yale University School of Medicine

Edward T Tham, MD is a member of the following medical societies: Alpha Omega Alpha

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Legome, MD Professor and Chair, Department of Emergency Medicine, Mount Sinai St Lukes and Mount Sinai West; Vice Chair of Academic Affairs, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai

Eric L Legome, MD is a member of the following medical societies: American College of Emergency Physicians, Eastern Association for the Surgery of Trauma, New York American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Barry E Brenner, MD, PhD, FACEP Program Director, Emergency Medicine, Einstein Medical Center Montgomery

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, New York Academy of Medicine, New York Academy of Sciences, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

James E Keany, MD, FACEP Associate Medical Director, Emergency Services, Mission Hospital Regional Medical Center, Children's Hospital of Orange County at Mission

James E Keany, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Sports Medicine, California Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors, Jerome FX Naradzay, MD, Paul Carter, MD, and Edward Newton, MD, to the development and writing of this article.

Sections Hip Dislocation Management in the ED
Overview
Presentation
DDx
Workup
Treatment
Guidelines
Medication
Media Gallery
References

Hip Dislocation Management in the ED Medication

Medication Summary

Analgesics

Class Summary

Morphine sulfate (Duramorph, MS Contin, MSIR)