Another go!

1) It doesn't matter what analgesia as long as a dose adequate to achieve
the desired effect is used. IM pethidine is fine but a normal adult warrants
150mg (not the 75 usually used), after all that is what women in labour used
to get, along with 25 phenergan! Accepted, there may be better drugs, and
there may be some problems, but the most usual one is inadequate dose! Best
is iv morphine titrated to the need. Howver, many shoulder dislocations
don't need opiates, and they shouldn't need anything extra for the
reduction.

2) My main point was that,although Kocher's is described and shown in all
text books, the vast majority have it wrong! There should be NO traction.
Traction causes pain, causes more muscle spasm, causes failed reduction and
unhappy patient. Read the original version and forget the orthopods
bastardisations over the years! Description follows:
        1 - lie patient semi recumbant on trolley
        2 - straighten them up
        3 - talk them into pulling their elbow tight against their side, ie
adducted, with elbow flexed,
        4 - talk them into allowing their arm to ext. rotate, may go to 90
deg. No force, just time and talking!
        5 - keeping arm adducted & ext rotated, gradually forward flex the
arm
        6 - when flexed to 90 deg, then int rotate it.
The whole process may take 10 mins of gentle persuasion, and Adrian's point
about this is well taken! You only have to do this once to a punter who has
terrifying tales to tell of previous episodes, to be immensely impressed by
the effusive thanks and relief as the shoulder slides effortlessly back into
place with barely a sound. They swear undying love and request to always
come back to you when they do it again!

refs:   1) "Eine neue Reductionsmethode fur Schulterverrenkung". Theodor
Kocher, Berliner Klinische Wochenschrift, 1870; 9: 101-5
        2) "Painless reduction of shoulder dislocation by Kocher's method".
Thakur & Narayan; J Bone Joint Surg [Br] 1990; 72-B: 524

> -----Original Message-----
> From: Doc Holiday [SMTP:[log in to unmask]]
> Sent: 14 December 2000 21:23
> To:   [log in to unmask]
> Subject:      Re: Sedation for shoulders
>
> >From: iain jamieson <[log in to unmask]>
>
> >I'm interested in this one.
> >1. Do people still use IM pethidine ? (I'm not saying
> >it's wrong but as an anaesthetist I've always thought
> >of it as a very unpredictable drug both for analgesia
> >and the amount of respiratory depression it produces).
> >What does interest me about pethidine as a choice of
> >drug is that pethidine is a good muscle reaxant -
> >anecdotally so perhaps this helps.? I don't know -
> >what do people think.
> >Finally, could you post up the details and drawings of
> >the technique described, because it sounds very
> >elegant - thus stopping A/E SHO's going purple in the
> >face and hanging on arms.
> >Iain
> >
>
> 1. If they're going purple, they are hanging on the wrong thing. Like many
> things, including the Kocher's method, traction looks beautiful when done
> right. The look on the face of some SHOs, when they are just slowly easing
> themselves into the traction and you tell them that they should stop and
> reassess, as the reduction has taken place ("clunk"-free), is worth
> seeing...
>
> 2. Kocher's method and all others are well described in virtually any text
> book, but I find it is better to see them done and be guided, rather than
> reading only. (I try to ensure as many SHOs see as many methods as
> possible).
>
> 3. From personal experience (as the receiver, not the giver), I can tell
> you
> that pethidine IM (100mg in my case) was about as useful as having a shiny
> Ibuprofen tablet rubbed against one's forehead. I had just as much pain,
> only I could not concentrate on telling everyone about it - that was the
> only difference. Morphine IV soon sorted the problem.
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