A few points:
As often happens, there are more than one ways of getting a compliant
patient for a reduction, Midazolam among them. I have no objection to anyone
using Flumazenil in principle, so long as they are aware of the many good
points mentioned by others on the list, especially the lower seizure
threshold in susceptible patients.

Only a few days back here had a colleague dealing with a male patient,
around 20 years old, off his motorbike, with a deformed femur fracture and
slight agitation. A few days later, we now know that there were no other
lesions found other than the femur shaft #. At the time, not confident with
a femoral block aand with a haemodynamically stable patient, my colleague
went for a bit of morphine and midazolam before reduction.

Bronchospasm followed and sats began to drop rapidly so, after a quick tweek
and fix of the femoral deformity, he tried to reverse the midazolam with
flumazenil in addition to using the usual anti-anaphylaxis measures. (Again,
in retrospect and with another similar reaction at a later stage, we now
know this patient has a strong histamine reaction to morphine).

At the time, when Flumazenil was given, the patient became more agitated and
then went on to have two short seizures. It was later discovered that the
patient had had febrile seizures nearly to age 10 and one further possible
seizure as a teenager. CT on the day was NAD. He later admitted to Marijuana
& alcohol use, but denied any Cocaine use, which was suspected.

He will spend a few months on anti-convulsants at least and then be
reviewed. There would normally also be many implications as to driving
ability etc... (well, lucky/unlucky for him, he's in a country where even a
blind-alcoholic-epileptic-drug-dependent-psycopath can hold a driver's
lisence without difficulty, so long as he "takes it easy", so he's not
worried...)

Anyway, back to shoulder dislocations and the like: I try to premedicate
well with opiates (usually morphine before patient goes to X-ray, if they
are getting an X-ray). Then, with everything set up and Oxygen on and
monitors, I give Midazolam very slowly, usually 2mg to start and then 1mg at
a time with 2-3 minute bolus gaps and good flush through. I educate the
patient well before and during the procedure as to what's expected, and I
may top up the OPIATES if I think I'm not heading towards a relaxed patient
quickly enough. It is a rare day when I don't succeed with 3-4mg of
midazolam total. On those handful of occasions, I simply give another 1mg
bolus here and there - have never needed more than 7mg total ONCE. But even
then, the patient is talking with eyes open and merely looking sleepy.

Flumazenil never used, although I have always made sure that there is an
ampule of it available and not expired within easy reach... Just a bit
further from where my airway equipment is!

As soon as the procedure is done, I retest axillary nerve sensation strap
the limb down as usual. One favorite, especially when I have students or
junior colleagues to impress, is to then encourage the patient to fall
asleep, stay with them for 1 minute or so and gently wake them up right
there. Then we demonstrate how well the amnesic effect of midazolam works
(we usually place a bet on how far back they will forget - the patients
usually love this). I have done a few without midazolam and have noted no
amnesia. I THINK I might have had perhaps one patient EVER who could
remember the procedure, but not sure. It just seems to work, without evident
risk nor Flumazenil.

But I'm sure Propofol, "talk-down" sedation and other methods, especially
with adequate analgesia, do also safely work. Then, of course, there is the
"Lethal Weapon" method, but having seen one presentation of a #clavicle
after someone tried that (and still had the dislocation afterwards) I do not
often recommend it...

Now... Has anyone had any success with educating recurrent anterior shoulder
dislocators on self-reduction???

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