P007: Cunningham reduction of anterior shoulder dislocation facilitated by inhaled low-dose methoxyflurane – a pilot study

Abstract

Introduction: The Cunningham reduction method for anterior shoulder dislocation offers an atraumatic alternative to traditional reduction techniques without the inconvenience and risk of procedural sedation and analgesia (PSA). Unfortunately, success rates as low as 27% have limited widespread use of this method. Inhaled methoxyflurane (I-MEOF) offers a rapidly administered, minimally invasive option for short-term analgesia. We conducted a pilot study to evaluate the feasibility of studying whether I-MEOF increased success rates for atraumatic reduction of anterior shoulder dislocation. Methods: A convenience sample of 20 patients with uncomplicated anterior shoulder dislocations were offered the Cunningham reduction method supported by methoxyflurane analgesia under the guidance of an advanced care paramedic. Operators were instructed to limit their attempt to the Cunningham method. Outcomes included success rate without the requirement for PSA, time to discharge, and operator and patient satisfaction with the procedure. Results: 20 patients received I-MEOF and an attempt at Cunningham reduction. 80% of patients were male, median age was 38.6 (range 18-71), and 55% were first dislocations of that joint. 35% (8/20 patients) had reduction successfully achieved by the Cunningham method under I-MEOF analgesia. The remainder proceeded to closed reduction under PSA. All patients had eventual successful reduction in the ED. 60% of operators reported good to excellent satisfaction with the process, with inadequate muscle relaxation being identified as the primary cause of failed initial attempts. 80% of patients reported good to excellent satisfaction. Conclusion: Success with the Cunningham technique was marginally increased with the use of I-MEOF, although 65% of patients still required PSA to facilitate reduction. The process was generally met with satisfaction by both providers and patients, suggesting that early administration of analgesia is appreciated. Moreover, one-third of patients had reduction achieved atraumatically without need for further intervention. A larger, randomized study may identify patient characteristics which make this reduction method more likely to be successful.

Closed Reduction of Anterior Shoulder Dislocations Performed by Ski Patrollers in the Alpine Prehospital Environment: A Retrospective Review Demonstrating Efficacy in a Canadian Ski Resort

“…33 A comparison of the success rate of our ski patrol to the ASD reduction success rates in the literature suggests that ski patrollers can reduce ASD consistently. 16,29,30,32 –35…”

“…33 A comparison of the success rate of our ski patrol to the ASD reduction success rates in the literature suggests that ski patrollers can reduce ASD consistently. 16,29,30,[32][33][34][35] Although biomechanical techniques may be more tolerable without analgesia, pain management was available for use in this protocol. Administration of over-thecounter ibuprofen and acetaminophen to all patients was encouraged, and nitrous oxide and methoxyflurane were available for patrollers to administer if required.…”

“…Success rates of 35 to 100% exist in the literature. 34,35 The FARES has less published data on its success rate, but 1 randomized control trial found a success rate of 89%. 33 A comparison of the success rate of our ski patrol to the ASD reduction success rates in the literature suggests that ski patrollers can reduce ASD consistently.…”