Medication Summary
The goals of pharmacotherapy are to reduce morbidity and prevent complications.
Anxiolytics, Benzodiazepines
Class Summary
Administration of temazepam immediately before a procedure can decrease the risk of tachycardia and hypertension resulting from anxiety regarding the operation. In the operating room, intravenous (IV) administration of a small dose of midazolam before arterial line insertion can also reduce anxiety, tachycardia, and hypertension.
Midazolam
Midazolam is a short-acting benzodiazepine with a rapid onset of action.
Local Anesthetics, Amides
Class Summary
Local anesthetics block the initiation and conduction of nerve impulses. Anesthetics used for the procedure include lidocaine.
Lidocaine and epinephrine (Xylocaine MPF with Epinephrine)
Lidocaine is an amide local anesthetic used in 1% concentration. It inhibits depolarization of type C sensory neurons by blocking sodium channels.
Epinephrine prolongs its effect and enhances hemostasis (maximum epinephrine dose, 4.5-7 mg/kg).
Lidocaine anesthetic (Xylocaine, Zingo)
Anesthetic Agents
Class Summary
After standard monitoring equipment is attached and peripheral venous access achieved but before the arterial line is inserted, the midazolam dose is administered. Before placement of the arterial line, it should be ensured that a radial artery graft will not be used for coronary artery bypass grafting.
Propofol (Diprivan)
Propofol is a phenolic compound unrelated to other types of anticonvulsants. It has general anesthetic properties when administered intravenously. Intravenous propofol produces rapid hypnosis, usually within 40 seconds. The effects are reversed within 30 minutes following the discontinuation of infusion. Propofol has also been shown to have anticonvulsant properties.
Etomidate (Amidate)
Amidate is a nonbarbiturate imidazole compound with sedative properties. It is short acting and has a rapid onset of action; the duration of action is dose dependent (15-30 min). Its most useful feature as an induction agent is that it produces deep sedation while causing minimal cardiovascular effects.
The major application of etomidate is induction for endotracheal intubation, particularly in patients with, or at risk for, hemodynamic compromise. Etomidate has been shown to depress adrenal cortical function; however, this effect is not significant clinically during short-term administration. Since the drug is mixed in propylene glycol, continuous infusion is not recommended.
Opioid Analgesics
Class Summary
Analgesics ensure patient comfort, promote pulmonary toilet, and have sedating properties that are beneficial for patients who experience pain.
Fentanyl citrate (Duragesic, Abstral, Actiq, Fentora, Onsolis)
Fentanyl citrate is a synthetic opioid that has 75-200 times more potency and a much shorter half-life than morphine sulfate. It has fewer hypotensive effects than morphine and is safer in patients with hyperactive airway disease because of minimal or no associated histamine release. By itself, fentanyl citrate causes little cardiovascular compromise, although the addition of benzodiazepines or other sedatives may result in decreased cardiac output and blood pressure.
Fentanyl citrate is highly lipophilic and protein-bound. Prolonged exposure to it leads to accumulation of the drug in fat and delays the weaning process.
Morphine sulfate (Duramorph, Astramorph, MS Contin, Avinza, Kadian)
Morphine sulfate has reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various intravenous doses are used; it is commonly titrated until the desired effect is obtained.
Hydromorphone (Dilaudid, Dilaudid-HP, Exalgo)
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Ultrasound probe placement for viewing glenohumeral joint via posterior approach.
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Ultrasound image of normal (right) and anteriorly dislocated shoulder (left). Arrow points to humeral head. Image courtesy of Michael A Secko, MD, RDMS.
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Reduction of shoulder dislocation: Stimson maneuver.
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Reduction of shoulder dislocation: Stimson maneuver.
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Reduction of shoulder dislocation: scapular manipulation. Hand placement.
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Reduction of shoulder dislocation: scapular manipulation. Sitting position.
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Reduction of shoulder dislocation: external rotation.
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Reduction of shoulder dislocation: Milch technique.
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Reduction of shoulder dislocation: Spaso technique.
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Reduction of shoulder dislocation: traction and countertraction.
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Reduction of shoulder dislocation: traction and countertraction.
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Classic presentation of inferior shoulder dislocation. Affected arm is hyperabducted, with elbow flexed and forearm resting on top of head.
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"Regimental badge" area. Examine pinprick sensation to this area to assess axillary nerve sensory function.
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Reduction of shoulder dislocation: axial traction and countertraction. Axial traction is applied to arm, and parallel countertraction is applied with sheet wrapped over shoulder. Increasing degree of abduction (if possible) and applying cephalad pressure to displaced humeral head (star) can aid in reduction.
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Reduction of shoulder dislocation: axial traction and countertraction. After inferior dislocation is reduced, arm is adducted, supinated, and immobilized for postreduction radiography.
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Reduction of shoulder dislocation: two-step reduction. Step 1, part 1. Push anteroinferiorly on midhumerus with hand A while pulling posteriorly on medial condyle with hand B.
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Reduction of shoulder dislocation: two-step reduction. Step 1, part 2. After conversion of inferior dislocation to anterior dislocation, adduct arm and grasp patient's wrist.
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Reduction of shoulder dislocation: two-step reduction. Step 2. Hand A holds patient's arm in adduction while hand B externally rotates arm to reduce now anteriorly dislocated humeral head.
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Anteroposterior radiograph of left shoulder shows posterior glenohumeral dislocation. Impaction of humeral head on posterior glenoid results in reverse Hill-Sachs defect (trough sign) on anterior aspect of humeral head. Image courtesy of Dr M A Png, Singapore General Hospital.
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Axial spin-echo T1-weighted magnetic resonance arthrogram of right shoulder shows tear of posterior glenoid labrum (arrow) and reverse Hill-Sachs defect (arrowhead). Patient had previous posterior dislocation.
