Midazolam or propofol added to ketamine: Which combination is better for the reduction of shoulder dislocation in the emergency department?

For anterior shoulder dislocations treated in the emergency department, the combination of ketamine and propofol (KP) provided deeper sedation, shorter procedure and recovery times, and fewer adverse events than the combination of ketamine and midazolam (KM). The average Ramsay sedation score was higher with KP, and procedure time averaged 5.7 minutes and recovery time 36.3 minutes, both significantly shorter in the KP group. Adverse events such as respiratory depression and tachycardia were more common in the KM group. The ketamine-propofol combination appears to be a safe and effective option for procedural sedation during shoulder reduction.

Study at a glance

Abstract

Glenohumeral dislocation is the most common type of shoulder dislocation and a leading cause of shoulder instability. Adequate muscle relaxation and pain control are essential for successful reduction. This study compared the effectiveness and safety of ketamine-midazolam (KM) versus ketamine-propofol (KP) for procedural sedation in anterior shoulder dislocations in the emergency department (ED). Effectiveness was evaluated using Ramsay sedation scale (RSS) scores, sedation onset, total procedure and recovery times, and reduction success. Safety was assessed by recording adverse events. This prospective, single-blind, randomized trial included patients ≥18 years presenting to a tertiary ED with anterior shoulder dislocation. Patients were randomized into two groups: KM (ketamine plus midazolam) and KP (ketamine plus propofol). Demographic and clinical characteristics, RSS scores, procedure and recovery times, adverse events, and additional sedation requirements were recorded. Sixty-four patients were analyzed, 32 in each group. The overall mean RSS score was 4.5 ± 1.0, significantly higher in the KP group (P < 0.001). Adverse events were more common in the KM group, including higher rates of respiratory depression (P = 0.023) and tachycardia (P < 0.001). The mean procedure time was 5.7 ± 4.7 min, and recovery time was 36.3 ± 14.4 min, both significantly shorter in the KP group (P = 0.025 and P < 0.001, respectively). In the ED, the ketamine-propofol combination appears to be a safe and effective option for procedural sedation and analgesia, particularly in interventions such as shoulder reduction.