›Anterior dislocation reduction acceptable in ED if stable and experienced team
›Analgesia and anesthesia
›Local and regional options
›Local infiltration at SC region avoided if anatomic distortion or vascular concern
›Regional anesthesia considered per local expertise
›Procedural sedation pathway
›Airway risk assessment
›Posterior dislocation treated as potential difficult airway
›NPO status not required for emergent reduction
›Sedation medication options
›Ketamine IV
›Initial 1 mg/kg
›If inadequate, additional 0.5 mg/kg
›Propofol IV
›Initial 0.5 mg/kg
›Titrate 0.25 mg/kg every 1 to 3 minutes to effect
›Fentanyl IV for analgesia adjunct
›0.5 mcg/kg
›Repeat 0.5 mcg/kg every 5 minutes as needed
›Anterior dislocation technique principles
›Supine position with towel roll between scapulae
›Traction on abducted arm
›Direct pressure posteriorly on medial clavicle
›Posterior dislocation technique principles
›Operating room preferred
›If emergent bedside attempt, surgical team present
›Shoulder abduction and traction with extension
›Towel clip technique reserved for operative setting
›Post-reduction requirements
›Repeat neurovascular exam
›Repeat airway symptom check
›Post-reduction CT confirmation for posterior dislocation
›Immobilization plan and activity restriction
Open fracture medications and timing
›Skin breach pathway relevance
›Open injury uncommon at SC joint
›If open wound present, open fracture protocol
›Antibiotics if open injury
›Cefazolin IV 2 g
›If severe beta-lactam allergy, clindamycin IV 600 mg
›Tetanus prophylaxis
›Tdap if immunization unknown or not up to date
›Tetanus immune globulin if high-risk wound and unimmunized
DVT prophylaxis when relevant
›DVT prophylaxis considerations
›Upper extremity immobilization alone usually no pharmacologic prophylaxis
›If polytrauma admission, follow institutional VTE protocol