What are the recommended techniques and medications for shoulder reduction in the emergency room (ER)?

Shoulder Reduction Techniques in the Emergency Department

Recommended Reduction Techniques

The Milch technique should be your first-line reduction method for anterior shoulder dislocations, achieving 82.8% success rate on first attempt without sedation, significantly superior to other techniques like Stimson (28% success rate). 1

Primary Technique Selection

• Milch technique is the preferred initial approach, with mean reduction time of only 4.68 minutes compared to 8.84 minutes for Stimson technique 1
• The Davos technique (Boss-Holzach-Matter technique) represents an excellent alternative, achieving 86% success rate with superior patient tolerance and no neurological complications in 100 consecutive cases 2
• Multiple techniques should be in your repertoire, as individual success rates range from 60-100% across 26 documented reduction methods 3

Factors Affecting Reduction Success

Critical predictors of successful reduction include:

• Time to reduction: Earlier attempts have significantly higher success rates; delays from presentation to first reduction attempt lower overall success 3, 1
• Pain level on admission: Lower pain scores at presentation favor successful reduction 1
• Reduction technique selected: Choice of method is the most important modifiable factor 1

Procedural Sedation Medications

First-Line Sedation Options

Etomidate (0.1-0.2 mg/kg IV) is recommended by the American College of Emergency Physicians as the preferred agent, providing effective sedation with median procedural time of 10 minutes. 4

Propofol (1 mg/kg initial dose, then 0.5 mg/kg supplements) offers the fastest recovery time at approximately 15 minutes, compared to 76 minutes for midazolam-based regimens. 4

Combination Regimens

• Diazepam 0.1 mg/kg plus fentanyl 1 μg/kg IV demonstrates superior onset of muscle relaxation and time to reduction compared to midazolam/fentanyl, with higher patient and physician satisfaction 5
• Ketamine/midazolam combination (0.5 mg/kg ketamine up to 2 mg/kg, plus 0.1 mg/kg midazolam) shows greater efficacy than fentanyl/midazolam for orthopedic procedures with fewer respiratory complications 4
• When using benzodiazepine/opioid combinations, administer the opioid first, then titrate the benzodiazepine dose 4

Medication Administration Sequence

1. Administer opioid analgesic first (if using combination therapy) 4
2. Titrate benzodiazepine or sedative agent based on patient response 4
3. Have reversal agents immediately available (naloxone for opioids, flumazenil for benzodiazepines) 4

Critical Safety Considerations

Respiratory Monitoring

• Respiratory depression risk increases dramatically with combined benzodiazepine/opioid use: hypoxemia occurs in 25% of patients receiving fentanyl/midazolam, and apnea in 50% receiving both medications 4
• Careful preparation and continuous monitoring are essential to prevent harmful sequelae 4
• Brief bag-mask ventilation may be required with etomidate or propofol, though serious complications are rare with proper monitoring 4

Common Adverse Effects

• Etomidate causes myoclonus in approximately 21% of patients, which is generally benign 4
• Propofol may cause pain on injection and transient decreases in blood pressure and oxygen saturation, requiring appropriate monitoring 4
• Ketamine/midazolam can cause vomiting in 4% of patients in weeks following the procedure 4

Practical Algorithm for ED Shoulder Reduction

Step 1: Initial Assessment and Timing

• Attempt reduction as early as possible after presentation to maximize success 3, 1
• Assess pain level on admission (lower pain predicts higher success) 1

Step 2: Consider Reduction Without Sedation First

• In compliant patients with early presentation and lower pain scores, attempt Milch technique with oral analgesics only 1
• 18 of 100 patients in one series required no analgesia using the Davos technique 2

Step 3: Sedation Selection When Needed

• For fastest procedure: Use etomidate 0.1-0.2 mg/kg IV 4
• For fastest recovery: Use propofol 1 mg/kg IV with 0.5 mg/kg supplements 4
• For best muscle relaxation: Use diazepam 0.1 mg/kg plus fentanyl 1 μg/kg IV 5

Step 4: Reduction Technique

• First attempt: Milch technique (82.8% success rate) 1
• If unsuccessful: Davos technique (86% success rate, extremely well-tolerated) 2
• Avoid: Entonox inhalation (only 10% success rate) 6

Step 5: Post-Reduction Care

• Discharge approximately 30 minutes after final medication administration in patients without serious adverse effects 4
• Recovery time varies: propofol 14.9±11.1 minutes, midazolam-based regimens significantly longer 4

Common Pitfalls to Avoid

• Do not delay reduction attempts: Success rates decline with time from injury to reduction 3, 1
• Do not use Entonox as primary sedation: Only 10% success rate compared to 80% with IV midazolam/fentanyl 6
• Do not combine benzodiazepines and opioids without careful respiratory monitoring: 50% apnea rate with combined use 4
• Do not rely on a single reduction technique: Failed initial attempts require alternative methods, and familiarity with multiple techniques is essential 3