Keep the oxygen on to give you a dead space full of oxygen in case the
patient stops breathing to buy some time before end organ damage. A wee bit
of hypercapnia never killed anyone. Don't rely on sats- when they drop, they
drop fast. Any monitoring equipment is no substitute for looking at the
patient- respiratory pattern is the most sensitive, particularly abdominal
movement. If you don't have the staff to monitor, then you don't have the
staff to do the procedure. Not so happy about flumazenil- risk of side
effects; wearing off faster than your sedation (average half lifes all very
well; but how much individual variation is there?). Fine as treatment for
established respiratory depression.
On opiates: anyone use fentanyl? Works well, wears off fast, patient feels
good after.
I agree wih Philip Belsham- reduce slowly enough that you don't get a clunk.
Holding the patient's arm with the thumb and one finger of your hand ensures
you don't push them too hard (in elderly patients you can reduce without any
sedation- they are actually more comfortable during the procedure than
before).
On the subject of post reduction care- in my experience, the type of sling
does not seem to make much difference; individual patient factors do (a lot
of young dislocators take the sling off and mobilise as soon as your back is
turned anyway). The big problem is that most of these patients will have
damaged their rotator cuffs. These don't heal spontaneously- they should at
least be considered for repair. I've now moved to passing all my dislocated
shoulders onto an upper limb surgeon.
Matt Dunn
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