Abstract

Emergency orthopedic reductions in the emergency department (ED) require short-acting anesthesia or sedation that ensures analgesia, immobility, and rapid recovery with minimal cardiopulmonary risk. This systematic review synthesized comparative studies of ED sedation regimens (ketamine-, propofol-, etomidate-, and benzodiazepine opioid-based, with or without ketamine–propofol) for fracture and large-joint reductions and frames these findings alongside perioperative evidence relevant to neuraxial anesthesia. Seven original comparative studies met the inclusion criteria for results synthesis. Procedural success was high in regimens. Ketamine reduced hypoxia, myoclonus, and airway maneuvers compared with etomidate during large-joint reductions, while propofol shortened recovery compared with ketamine or ketamine/midazolam in several settings. Ketamine and propofol provided small gains in recovery time and less emesis versus ketamine alone in pediatrics. Although ED trials of spinal anesthesia for bedside reductions are sparse, perioperative hip-fracture data showed no superiority of spinal over general anesthesia for survival or ambulation, and dose-optimization might mitigate neuraxial hypotension in older adults. Multiple pharmacologic pathways enable safe, effective ED reductions; technique selection should be individualized to patient factors, staff expertise, and throughput goals.

Key words: Emergency department, orthopedic reduction, procedural sedation, ketamine, spinal anesthesia, systematic review