Medications for Closed Reduction of Shoulder Dislocation
Etomidate and propofol are the most effective sedative agents for closed shoulder reduction, with etomidate providing shorter procedural sedation time (10 minutes vs 23 minutes for midazolam) and excellent success rates. 1
First-Line Medication Options
Etomidate: Provides effective sedation for shoulder dislocation reduction with shorter procedural time (median 10 minutes) compared to midazolam. Initial dosing should be titrated based on patient response. 1
Propofol: Safe and effective alternative with quick recovery time (approximately 15 minutes compared to 76 minutes for midazolam). Initial dosing of 1 mg/kg followed by 0.5 mg/kg supplements as needed. Often combined with fentanyl for analgesia. 1, 2
Fentanyl + Propofol combination: Effective for procedural sedation, with fentanyl providing analgesia while propofol provides sedation. Typical dosing is 2 mg/kg of fentanyl with propofol at 0.21 mg/kg/min. 1, 3
Alternative Options
Midazolam: Effective but has longer recovery time (median 23 minutes). For adults, initial dose of 0.02-0.03 mg/kg IV over at least 2 minutes, waiting 2+ minutes to evaluate effect before additional dosing. 1, 4
Intra-articular lidocaine (IAL): Associated with fewer complications and shorter hospital stays compared to IV sedation. Takes longer from injection to reduction but has similar success rates and patient satisfaction. 5
Reduction Techniques and Medication Considerations
External Rotation Method (ERM): Can be performed without sedation or analgesia in some patients (78.7% success rate without medications), particularly in males. This approach significantly reduces emergency department length of stay (55 vs 118 minutes). 6
Scapular manipulation: Reported as the least painful reduction technique (VAS 1.47) with highest success rate (97%) and fastest reduction time (1.75 minutes), potentially requiring less medication. 7
FARES method: High success rate (92%), quick reduction time (2.24 minutes), and low pain scores (VAS 1.59), making it a good alternative that may require less medication. 7
Medication Administration Considerations
When using both a benzodiazepine and an opioid, administer the opioid first (which poses greater risk of respiratory depression) and then titrate the benzodiazepine dose. 1
Respiratory depression risk increases with combined use of benzodiazepines and opioids, requiring careful monitoring. 1
Propofol may cause transient decreases in blood pressure and oxygen saturation in some patients, requiring appropriate monitoring. 1
Pitfalls and Caveats
Etomidate may cause myoclonus in approximately 21% of patients. 1
Propofol can cause pain on injection (reported in 3 of 20 patients in one study). 1
Respiratory depression requiring brief bag-mask ventilation has been reported with both etomidate and propofol, though serious complications are rare when properly monitored. 1
Older patients and those with severe systemic disease typically require lower doses of sedative medications. 4, 2