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

Mert Pehlivan; Selen Acehan; Salim Satar; Muge Gulen; Sarper Sevdimbas; Ihsan Dengiz; Melike Kucukceylan; Mehmet Gorur

doi:10.4103/tjem.tjem_211_25

Mert Pehlivan¹, Selen Acehan², Salim Satar², Muge Gulen², Sarper Sevdimbas², Ihsan Dengiz³, Melike Kucukceylan⁴, Mehmet Gorur⁵

¹Emergency Medicine Clinic, Van Özalp State Hospital, Van, Türkiye
²Emergency Medicine Clinic, Adana City Training and Research Hospital, Health Sciences University, Adana, Türkiye
³Emergency Medicine Clinic, Basaksehir Cam Sakura City Hospital, Istanbul, Türkiye
⁴Emergency Medicine Clinic, Sanliurfa Birecik State Hospital, Sanliurfa, Türkiye
⁵Emergency Medicine Clinic, Kadirli State Hospital, Osmaniye, Türkiye

Keywords: Emergency department, ketamine, midazolam, propofol, sedation, shoulder reduction

Abstract

OBJECTIVE: 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.

METHODS: 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.

RESULTS: 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).

CONCLUSION: 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.

How to cite this article: Pehlivan M, Acehan S, Satar S, Gulen M, Sevdimbas S, Dengiz I, et al. Midazolam or propofol added to ketamine: Which combination is better for the reduction of shoulder dislocation in the emergency department? Turk J Emerg Med 2026;26:62-70.