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I am at last compelled to write to the list, as this subject is one that is often discussed and appears seldom understood! Any acute injury, including shoulder dislocation, requires analgesia - in an ideal world, this would be titrated intravenously, but this is often not very practical in our time-pressured world. Simple im pethidine in adequate dosage (our SHOs usually use homeopathic doses!) suffice. The point I want to make is that the reduction should cause no additional pain if you use the correct technique. Kocher described his technique in a classic anatomically based paper in 1870 (I have the reference somewhere, with a translation from the classical German). He stressed then that there must be no traction. It is sad that subsequent descriptions of his technique have misquoted him (as with GCS, Duke's classification, and many others) and most orthopaedic texts have inserted traction! The real technique was rediscovered by two orthopaedic surgeons writing in Bone and Joint in about 1989. I have used the technique with great success since. The essence is that it takes 10 mins or so to very slowly move the limb through the range described by Kocher. The reduction is often so smooth that you doubt it is reduced until you re-examine! Many recurrent dislocators are terrified of what you will do to them (based on their past experience) and you have to be very patient. It is very rare to require any sedation or additional analgesia. Use the proper technique (not applicable to anterior dislocations with # of labrum or greater tuberosity)! With regard to sedation, if you read the product insert with midazolam, it states you should use small doses incrementally (0.75-1.5mg) and wait for an effect for at least 2 mins before giving more. This way you will avoid the oversedated patient and any requiremtent for flumazenil. I have personally performed about 2000 procedures under sedation with midazolam and have never needed to use an antidote. I once saw an orthopaedic surgeon inject a bolus of 20mg midazolam into an old man - the subsequent anaesthesia, with apnoea, did allow easy reduction! He then reversed the effect with flumazenil and left! Not a technique to be recommended! Sorry for the lengthy first offering! Philip Belsham A&E consultant Royal Free Hospital.