Medication Summary
Sedation and analgesia are indicated if reduction is attempted. The componants of procedural sedation may be dictated by hospital setting. The medications traditionally used for this purpose are diazepam and morphine. Other conscious sedation protocols can be used providing the patient maintains an adequate gag reflex. Certain medications that can cause masseter spasm (eg, methohexital, chlordiazepoxide, phenothiazines) should be avoided because this complication would prevent relocation of the mandible.
Analgesics
Class Summary
Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients with injuries.
Morphine (Astramorph, Duramorph)
DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.
Fentanyl citrate (Duragesic, Sublimaze)
Potent narcotic analgesic with much shorter half-life than morphine sulfate. With short duration (30-60 min) and easy titration, an excellent choice for pain management and sedation. Easily and quickly reversed by naloxone.
Anxiolytics
Class Summary
Benzodiazepines have both anxiolytic and muscle relaxation properties. Patients with painful injuries usually experience significant anxiety. Anxiolytics allow the clinician to administer a smaller analgesic dose to achieve the same effect.
Diazepam (Valium)
Individualize dosage and increase cautiously to avoid adverse effects.
Lorazepam (Ativan)
Sedative hypnotic in benzodiazepine class that has short onset of effect and relatively long half-life. By increasing action of GABA, a major inhibitory neurotransmitter, may depress all levels of CNS, including limbic and reticular formation. Excellent medication for patients requiring sedation for >24h. Monitor BP after administering dose and adjust as necessary.
Anesthetics
Class Summary
These agents are used to reduce pain and can be used for nerve blocks in mandible reductions.
Lidocaine (Lidocaine CV, Lidopen)
Lidocaine injections can be used for nerve blocks in mandible reductions.
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The temporomandibular joint.
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Classic reduction technique. The physician places gloved thumbs on the patient's inferior molars bilaterally, as far back as possible. The fingers of the physician are curved beneath the angle and body of the mandible.
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Recumbent approach. The patient is placed recumbent, and the physician stands behind the head of the patient. The physician places his or her thumbs on the inferior molars and applies downward and backward pressure until the jaw pops back into place.
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Wrist pivot method. The patient is placed in a sitting position, and the physician stands facing the patient. The physician grasps the mandible at the apex of the mentum with both thumbs. The fingers are placed on the inferior molars.
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Ipsilateral approach - extraoral route. The patient is placed in a sitting position, and the physician stands behind the patient. The physician stabilizes the patient's head with his or her nondominant hand and uses the dominant hand to apply downward pressure on the displaced condyle that is palpated just inferior to the zygomatic arch.
