Shoulder Dislocation in Emergency Medicine Medication

Updated: Sep 04, 2016
  • Author: Sharon R Wilson, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Medication

Medication Summary

Opiate analgesia should be given as needed for pain in patients with shoulder dislocation. Intravenous or intramuscular medications, intra-articular injections, and regional anesthetic techniques have been reported as successful aides for reduction of shoulder dislocations.

Procedural sedation and analgesia (PSA) is commonly used to achieve adequate pain control and muscle relaxation for reduction. A randomized, controlled trial of 30 patients compared intra-articular lidocaine with PSA (morphine and midazolam). [27] All patients who received intra-articular injections obtained adequate analgesia and muscle relaxation, were free of complications, and had significantly shorter emergency department stays (78 min vs 186 min; p=0.004). [27] A Cochrane Database of Systematic Reviews study of 113 patients with acute anterior shoulder dislocation who underwent intra-articular lignocaine injection and 98 patients who underwent intravenous analgesia with sedation found that intra-articular lignocaine injection may be associated with fewer side effects and a shorter stay in the emergency department, and may be less expensive than intravenous medication. [28]

Etomidate, fentanyl/midazolam, ketamine, or propofol is commonly used for PSA. Some ED physicians prefer etomidate because of its rapid onset (< 30 sec), short duration (about 5 min), and excellent muscle relaxation. Other physicians consider propofol superior in terms of side effects and duration. Propofol's high lipid solubility results in a rapid onset (30-60 sec) and a short plasma half-life (1.3-4.1 min). The result is a rapid decline of propofol concentrations, rapid awakening, and shorter recovery times.

An ED-based study evaluated the combination of propofol and remifentanil for sedation to reduce anterior shoulder dislocations. [29] Eleven patients were given propofol 0.5 mg/kg and remifentanil 0.5 mcg/kg, intravenous (IV) over 90 seconds. Further doses of propofol 0.25 mg/kg and remifentanil 0.25 mcg/kg were administered if needed. All patients had adequate sedation and analgesia within 3 minutes. Mean time to achieve reduction after dosage was 1.6 minutes, and mean time to being clinically alert was 3 minutes. However, postreduction time in the ED ranged from 30-312 minutes. Rapid recovery was a marked feature of this study. All subjects became alert quickly and were ambulatory without assistance in less than 30 minutes.

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Analgesics

Class Summary

These agents may be used for the relief of pain and relaxation of shoulder muscles. Pain control is essential to quality patient care. It ensures patient comfort, improves likelihood of successful reduction, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients with injuries.

Fentanyl citrate (Duragesic, Sublimaze)

DOC because of its rapid, almost immediate onset and short duration of 30-60 min. Can be reversed easily by naloxone 2 mg IV as needed for respiratory depression. Often used as part of conscious sedation with midazolam (see Sedation). Useful for emergency department visits only. Not intended to be given on an outpatient basis.

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

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