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Procedural Sedation and Analgesia in the Emergency Department

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Key concepts of PSA - Procedural Anesthesia and Sedation in the Emergency Department. Presented for Emergency Medicine resident conference. Assumes pre-existing knowledge. Not medical advice. Always work within your scope of practice and consult a standard reference.

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Procedural Sedation and Analgesia in the Emergency Department

  1. 1. Putting the Pro Back in Procedural Sedation David Marcus, MD @EMIMDoc / EMIMDoc.org Residency Director, Combined Program in EM/IM/CCM Northwell Health, New Hyde Park, NY #EMconf - 11/8/2017 – Northwell PJI
  2. 2. How Bout Now? 45 yr old F pending DC cardioversion 58 yr old F with mental retardation pending pelvic exam 75 yr old M, COPD, pending tube thoracostomy 33 yr old M with autism, minor laceration repair 53 yr old F, asthma with hypoxic respiratory distress 21 yr old M pending shoulder reduction
  3. 3. The Playlist • How deep is your love? (The Bee Gees) • He Ain’t Heavy He’s My Brother (Bill Medley) • Check Yourself Before You Wreck Yourself (Ice Cube) • Hit Me Baby One More Time (Brittany Spears) • Love Kills (The Ramones) • Know Your Enemy (Rage Against the Machine) • One Step at a Time (Jordin Sparks)
  4. 4. Minimal Sedation (Anxiolysis) Deep Sedation General Anesthesia/Sedation Moderate (Conscious) Sedation
  5. 5. Responsiveness Ventilation Airway Hemodynamics
  6. 6. Responsiveness 1. Normal response, may be “sleepy” 2. Purposeful response to verbal/tactile stim 3. Purposeful response only with repeated or aggressive stim 4. No response
  7. 7. Airway1. Unaffected 2. No intervention needed 3. May require intervention 4. Intervention often needed
  8. 8. Ventilation Hemodynamics 1. Unaffected 2. Usually Maintained 3. Usually Maintained 4. May be compromised 1. Unaffected 2. Adequate 3. May be inadequate 4. Generally inadequate
  9. 9. Moderate/Conscious Sedation • Purposeful response to verbal/tactile stim • No AW intervention needed • No resp support needed • No hemodynamic support
  10. 10. Conscious Sedation (Easily arouseable, Ill suited for painful procedures) vs. Procedural Sedation and Anesthesia (PSA) Variable depth, on the entire continuum, procedure dependant
  11. 11. Is this an appropriate patient? Risky Patients: • OSA • Obesity • Dentures • Anesthesia problems • Cardioresp Reserve? • Recent meal?
  12. 12. Ice Cube implores us to:
  13. 13. “No I'm not a sucker, sittin’ in a House of Pain”
  14. 14. Check your: • Airway (LEMON) AW risk assessment tools are generally unreliable, but it’s important to consider complications. Always prepare for the worst.
  15. 15. Check your: • Patient • IV x 2 • ETCO2 ON • Nasal O2+NRB ON • Fluids running • Monitor, Sat, Auto BP
  16. 16. Check your: • Equipment • AW Box Open • Difficult AW supplies • AMBU on O2 • Working Suction • Glidescope?
  17. 17. Check your: • Paperwork • Informed Consent • Sedation Packet
  18. 18. Check your: • Staff • Resident • RN • EDT • Attending
  19. 19. The Meds: Etomidate Pro Con AW/Resp Reversal Onset Duration Dosing Ultra fast on/Fast off; Benign hemodynamic profile No analgesia; Vomiting; Adrenal Suppression Minimal effect None < 1 minute Around 5 minutes 0.2 mg/kg slow push
  20. 20. The Meds: Ketamine Pro Con AW/Resp Reversal Onset Duration Dosing Analgesic; Benign hemodynamic profile; Dissociative; Reflexes; Titratable; Redosable Laryngospasm; Central Apnea; Vomiting; Secretions; Emergence; Enhanced muscle tone? Laryngospam 0.4% None 1 minute 10-20 minutes 1.5 mg/kg slow push or piggyback – THRESHOLD MED, NOT ON THE CONTINUUM
  21. 21. The Meds: Propofol Pro Con AW/Resp Reversal Onset Duration Dosing Fast on/Fast off; Titratable; Patient experience; Muscle relaxation No analgesia; Narrow window; Hemodynamic effects; Burning sensation; Loss of AW Easily compromised None 1.5 minutes 10 minutes 1 mg/kg slow push; Prepare aliquots
  22. 22. The Meds: Versed/Fentanyl Pro Con AW/Resp Reversal Onset Duration Dosing Fast on; Titratable; Reversible; Amnestic Prolonged duration; CV/AW/Resp Risks Potentially significant Flumazenil/Naloxone 2-3 minutes 30-60 minutes Fentanyl: 1 mcg/kg slow push q5min until effect Midazolam 0.02 mg/kg push q5min until effect
  23. 23. Etomidate Ketamine Propofol Mid/Fent Primary AE Emergence AW/CV AW/CV Analgesia - ++ - ++ AW/Resp +/- ++ --- --- CV +/- +/- --- -- Reversal 0 0 0 +/+ Onset +++ ++ ++ ++ Duration + +++ ++ ++++ Dosing 0.2 mg/kg 1.5 mg/kg 1mcg/kg 0.02mg/kg 1 mcg/kg
  24. 24. Love Kills Sid never meant any harm He shot some dope into his arm All he wanted was some fun Now she's lying in a pool of blood Always loaded, always high Why did you have to die?
  25. 25. Love Kills Hypercapnia or Hypoxia Reposition, Check FiO2, NPA if snoring; Jaw Thrust +/- Rescue Breaths LMA? ETI? Laryngospasm Laryngeal Notch Maneuver Agitation Re-Dose if appropriate, Benzo Pain Re-Dose if appropriate Vomiting Suction Hypotension IV Bolus, Hold Meds Consider pressor
  26. 26. KETOFOL? NPO? RASS SCORE?
  27. 27. KETOFOL? NPO? RASS SCORE?
  28. 28. 1. Consent 2. Premedicate 3. Prepare 4. Preoxygenate 5. Meds + Reversal 6. Sedate 7. Procedure 8. Monitor 9. Discharge
  29. 29. Summary • Procedural Sedation and Analgesia • Before – Select the right patient, the right agent, the right time – Reversals and backups at bedside – If < 6 hours NPO, may proceed if benefits outweigh risk (and document!) • During – Hypercapnia predicts hypoxia – Continuous monitoring • After – Stay in room until patient awake – Keep monitor connected until patient “normal” • As learners, try different regimens • Review the ACEP PSA in ED Clinical Policy
  30. 30. Additional Reading ACEP PSA Policy: https://www.acep.org/Physician-Resources/Clinical/Procedures-and-Skills/Procedural- Sedation/Clinical-Policy--Procedural-Sedation-and-Analgesia-in-the-Emergency-Department/ Green et al. Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory. Ann Emerg Med. 2007 Apr;49(4):454-61. Epub 2006 Nov 1. https://www.ncbi.nlm.nih.gov/pubmed/17083995 ACEP Procedural Sedation Resources and References: https://www.acep.org/Physician- Resources/Procedural-Sedation/#sm.00000v44pyaqwhdksz5e382dybgna Ketofol (follow the citations): http://stemlynsblog.org/jc-is-ketofol-worth-the-hassle-st-emlyns/ Procedural Sedation and Analgesia: • http://www.asahq.org/~/media/Sites/ASAHQ/Files/Public/Resources/standards- guidelines/continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of- sedation-analgesia.pdf • https://www.rcemlearning.co.uk/foamed/a-primer-on-procedural-sedation/ • http://emupdates.com/2013/11/28/the-procedural-sedation-screencast-trilogy/ Laryngospasm Notch: https://www.aliem.com/2010/12/trick-of-trade-laryngospasm-notch/

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