Analgesia and Procedural Sedation

Analgesia and Procedural Sedation

Dave ChoiPGY-4 ER Edmonton

Dr. A. Storck

Objectives

•Very basic pain pathophysiology

•Pain assessment

•Management of pain

•Will not cover nerve blocks, local anesthetics, or chronic pain management

QuickTime™ and aH.264 decompressor

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Pain

•Most common complaint in ED

•Essential goal of healthcare is to prevent and relieve pain

•Patients judge us by how we treat pain

•We cause pain

•Physiologic / psychologic outcomes

Case 1

•45 yo male

•Left flank pain x 8 hrs

•8/10 pain, can’t get comfortable

•PmHx: HTN, renal colic

•Please help doc!

Case 2

•70yo female

•Slipped on stairs 2 hrs ago

•Obvious deformity to left ankle

•PmHx: HTN, NIDDM, MI last year

•Grimacing in pain

Case 3

•21 yo male

•RLQ pain x 2/7

•Anorexia, mild nausea, fever

•PmHx: healthy

•Please don’t touch my stomach doc!

Pain Physiology• Nociceptor (pain receptor)

- Superficial somatic

- Deep somatic

- Visceral

• Neuropathic

- Peripheral

- Central

• Psychogenic

Pain Definition

•An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

International Association for the Study of Pain (IASP) 2007

Judging pain

•Patient complaint

•Physician impression, HR, BP, facial expression poor indicators

•Age, Sex, Race, cognitive functioning

•Numeric scale

•All very subjective

We any good?

Study

•Convenience cohort of 71 patients >18yo

•Pt rated pain with VAS and NRS

•ER docs and nurses rated patients pain

Conclusion•Docs and nurses consistently rated

pain less than the patient

•Only 30% of patients were satisfied with their pain control

•Mild/moderate pain unlikely to receive any analgesia

•2/3 of severe pain received analgesia

Pain Control

•We suck at estimating pain

•We undertreat pain

•Patients not happy

•Should give patients benefit of the doubt

Are we getting better?

•Use of analgesics increased by 18% from 1997 to 2001

McCaig. National Hospital Ambulatory Medical Care Survey: 2001 ED Summary. National Center for Health Statistics, 2003

Pain control options

•Local / Regional

•Systemic

- Anti-inflammatories

- Opioids

- Others: TCAs, anti-convulsants, relaxants, cannabis, distractions, music

Pain control•We can make pain better

•No reliable objective measures

•Avoid the “squeaky wheel gets the oil”

•Individualized pain control

•Anticipate pain and treat it

•Let patient control pain if possible

NSAIDS•Inhibit enzyme cyclooxygenase

(COX)

•Enzyme responsible for formation of prostaglandin and thromboxane

•Messenger molecules for inflammation, pain, and fever

•Also gastric lining and platelet function

Ibuprofen

•Contraindications

- GI ulcer

- Pregnancy (esp 3rd trimester)

- Acute bleeds

- Renal dysfunction

- Recent CABG

Ibuprofen

•Cautions

- ASA sensitive asthma

- ASA for cardioprotection

- ACE inhibitors / ARB

Ibuprofen

•Dosing?

•Evidence?

Ibuprofen vs Toradol

CJEM Jan 2007

Ibuprofen vs Toradol

•Numerous studies show no benefit of parenteral ketorolac over oral ibuprofen

•Belief that IM/IV medication are perceived as being stronger has been shown to be false

•Ketorolac has higher cost, risk of extravasation, risk of needle stick injuries

Other NSAIDS

•Diclofenac 50mg TID

•Naproxen 250-500mg BID

•Indomethacin 25-50mg TID

Opioids

•Opioid receptors

- Mu: analgesia, respiratory depression, euphoria

- Kappa: analgesia, sedation, respiratory depression, miosis

- Sigma: dysphoria, hallucinations, tachypnea, tachycardia

Opioids

•Metabolized by liver, excreted by kidney

•Should be given IV

•Fixed intervals with PRNs

Morphine

•Onset: 5-10min

•Peak: 15-30min

•Duration: 2-4hrs

•Routes: IV/IM/PO

•Dose: IV 0.05-0.2mg/kg, PO 0.2-0.5mg/kg

Morphine: the GOOD

•Reliable

•Lots of experience with it

•Reversal agent

Morphine: the BAD

•Histamine release

•Decreased GI motility

•Nausea

•CVS/Resp depression

Demerol

•Generic: meperidine

•Onset: 5-10min

•Peak: IV 5-15min, IM 30-60min

•Duration: 3-4hrs

•Route: PO/IV/SC/IM

•Dose: 1-2mg/kg (for all routes)

Demerol: the GOOD

•Theoretical benefit of Sphincter of Oddi relaxation

•Helps some chronic migraine patients

➡ NOT MUCH ELSE

Demerol: the BAD•Cerebral irritant (anxiety,

disorientation, tremors, seizures, hallucination, psychosis)

•Not very good analgesic compared to other opioids

•Nausea

•Dependence

•Serotonin syndrome

Demerol = Ugly

Fentanyl

•Onset: 1-2min

•Peak: 3-10min

•Duration: 30-75min

•Routes: IV/IM/TM

•Dose: IV 0.5-3ug/kg

Fentanyl: the GOOD

•Fast acting

•Potent (100x morphine)

•No histamine release

Fentanyl: the BAD

•Doesn’t last very long

•Cardiorespiratory depression

•Nausea, itchy nose

•Chest wall, glottis, diaphragm rigidity

•Potential AV prolongation and bradycardia in pediatrics with rapid dosing

Percocet•Acetaminophen 325mg, oxycodone

5mg

•Onset: 30min

•Peak: 1hr

•Duration: 2-4hrs

•Route: PO

•Dose: 1-2tabs (max 12/day)

Tylenol #3•Acetaminophen 300mg, codeine

30mg, caffeine 15mg

•Onset: 30min

•Peak: 1hr

•Duration: 2-4hrs

•Route: PO

•Dose: 1-2tabs (max 12/day)

Codeine

•Metabolized (cytochrome P450) by liver to morphine

•10% caucasians lack enzyme

•Good cough suppressant

Tylenol vs Tylenol+Codeine

•Systematic Review by Craen et al. BMJ 1996

•5% increase in analgesia with added codeine for single dose (stat significant)

•Multiple doses increased side effects

•NNT = 9 for 50% pain reduction

➡Use if patient says it works for them

Dilaudid•Generic: hydromorphone

•Onset: IV 5-10min

•Peak: IV 15-30min

•Duration: 2-4hrs

•Route: IV/SC/IM/PO

•Dose: IV 0.01-0.05mg/kg, PO x2-3 dose

Anti-emetic

•Opioid induced nausea multifactorial: histamine, direct gastroparesis, central chemoreceptor

•~20% emesis

•No need to pre-treat unless history of significant emesis/nausea previously

Competence

•Some say use of opioids affects competence and ability to give consent

•2 studies which show otherwise

•Maybe patients even pressured to sign consent if they’re in pain?

Smithline HA, Mader TJ, Crenshaw BJ. Do patients with acute medical conditions have the capacity to give informed consent for emergency medicine research? Acad Emerg Med. 1999;6:776-80 Vessey W, Siriwardena A. Informed consent in patients with acute abdominal pain. Br J Surg. 1998;85:1278-80

Masking pathology

•Lee study

•how much is too much opioids?

Pediatrics

•Yes, they feel pain too

•We are especially bad at treating kids with pain

•Choices?

•Tylenol, Ibuprofen, Opioids

•Topical / Sucrose / Sprays

•Double blind RCT

•Term newborns within 2 days

•24% sucrose PO

•Venipuncture, IM Vit K injection, heel poke for c/s

Conclusion

•Overall decrease in pain scores (Premature Infant Pain Profile)

•Reduction for venipuncture

•No reduction for IM injections

•Double blind RCT

•Children 6-12yo venipuncture

•Vapocoolant spray vs placebo

•All distracted

•Visual analogue scale

Results

•Modest reduction in pain

- 56.1 vs 36.9 (out of 100)

•Higher success rate first attemt (NNT 5)

- ?why

Case 1

•45 yo male

•Left flank pain x 8 hrs

•8/10 pain, can’t get comfortable

•PmHx: HTN, renal colic

•Please help doc!

Case 2

•70yo female

•Slipped on stairs 2 hrs ago

•Obvious deformity to left ankle

•PmHx: HTN, NIDDM, MI last year

•Grimacing in pain

Case 3

•21 yo male

•RLQ pain x 2/7

•Anorexia, mild nausea, fever

•PmHx: healthy

•Please don’t touch my stomach doc!

Procedural Sedation

Objectives

•Definitions

•Indications

•Contraindications

•Approach

•Drugs (no gases)

•Few interesting topics

Scope of Practice

•Emergency physicians are trained to:

- Monitor patients

- Recognize potential problems early

- Intervene when necessary

•American Society of Anesthesiologists “suggestion” for granting privileges to administer moderate sedation

•Suggestions on personnel, equipment, monitoring, etc

•?evidence based?

CAEP Guidelines 1999

ACEP Guidelines 2005

Case 1

•18 yo male

•Fell snowboarding and hurt right shoulder

•Obvious dislocation

•First time

Case 2

•73yo female

•FOOSH left

•Colle’s fracture

•PmHx: HTN, hypothyroid

Case 3

•3yo female

•Fell and hit forehead on coffee table

•Laceration forehead too deep/wide for glue

•No previous procedures

•++++crying, thrashing

Case 4

•61yo male

•Sudden onset palpitation during breakfast 2 hours ago

•Rapid A.fib on ECG

•PmHx: HTN, NSTEMI, ↑CHOL, smoker

Case 5

•56 yo male

•Slipped 2 steps

•Obviously deformed R ankle

•Neurovasc intact

•PmHx: morbid obesity, HTN, IDDM, MI last year, COPD, sleep apnea, smoker

Goals of PS

•Patient wellness #1

•Sedation, analgesia, anxiolysis and amnesia during painful procedure

•Minimize associated adverse psychological response

•Facilitation of procedure

•Return patient to baseline stateInnes et al. Procedural Sedation and Analgesia in the Emergency Department. Canadian Consensus Guidelines. Journal of Emergency Medicine. 1999: 17:1. 145-156

Procedural Sedation

• Reduce the patient’s anxiety and nervousness as much as possible prior to the procedure. (Anxiolysis)

• Reduce the patient’s awareness of the external environment. (Sedation)

• Reduce/eliminate any pain the patient feels during the procedure (Analgesia)

• Ensure that the patient does not remember the procedure (Amnesia)

Definition

•Technique of administering sedatives or dissociative agents and analgesia to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardio-respiratory fuction / reflexes

Terminology

• Minimal sedation (anxiolysis): a drug induced state where patients respond normally to verbal commands, cognitive function and coordination may be impared

Green et al. Procedural Sedation Terminology: Moving Beyond “Conscious Sedation” Annals of Emergency Medicine, 2002: 39:4. 433-435.

Terminology

•Moderate sedation (formerly “conscious sedation”): a drug induced depression of consciousness where patients respond purposely to verbal command, cardiorespiratory function not impared

Green et al. Procedural Sedation Terminology: Moving Beyond “Conscious Sedation” Annals of Emergency Medicine, 2002: 39:4. 433-435.

Terminology

•Dissociative sedation: trance like cataleptic state characterized by profound analgesia and amnesia with retention of cardiorespiratory function

Green et al. Procedural Sedation Terminology: Moving Beyond “Conscious Sedation” Annals of Emergency Medicine, 2002: 39:4. 433-435.

Terminology

•Deep sedation: drug induced depression of consciousness where patients cannot be easily roused, but respond purposely after repeated or painful stimulation, respiratory function may be impared

Green et al. Procedural Sedation Terminology: Moving Beyond “Conscious Sedation” Annals of Emergency Medicine, 2002: 39:4. 433-435.

Terminology

•General anesthesia: drug induced loss of consciousness where patients are not rousable, usually need help with ventilation, cardiovascular function may be impared

Green et al. Procedural Sedation Terminology: Moving Beyond “Conscious Sedation” Annals of Emergency Medicine, 2002: 39:4. 433-435.

Ideal Medication

•Anxiolytic, analgesia, amnesia

•Rapid onset, short duration

•No neurologic or cardiorespiratory depression

•Safe, effective, easy to administer, and reversible

➡DOESN’T EXIST

Indications

•Painful procedures

•Imaging

•Violent / uncooperative / anxious patient

Contraindications

•Absolute

- Inadequate experience with airway management and ALS or medications

- Inadequate monitoring or resuscitative equipment

- Allergy / sensitivity to medicationsInnes et al. Procedural Sedation and Analgesia in the Emergency Department. Canadian Consensus Guidelines. Journal of Emergency Medicine. 1999: 17:1. 145-156

Contraindications

•Relative

- Minor airway issues

- High aspiration risk

- Hemodynamically or neurologically unstable

- ASA III/IV

Innes et al. Procedural Sedation and Analgesia in the Emergency Department. Canadian Consensus Guidelines. Journal of Emergency Medicine. 1999: 17:1. 145-156

General Approach

•Pre-sedation: indication/contraindication, Hx/PE, consent, preparation

•Sedation: O2, monitoring, drugs

•Post sedation: monitor, d/c criteria / instructions

Procedural Urgency

• Emergent (eg, cardioversion for life-threatening dysrhythmia, reduction of markedly angulated fracture or dislocation with soft tissue or vascular compromise, intractable pain)

• Urgent (eg, care of dirty wounds and lacerations, animal and human bites, abscess incision and drainage, fracture reduction, hip reduction, lumbar puncture for suspected meningitis, arthrocentesis, neuroimaging for trauma)

• Semi-urgent (eg, care of clean wounds and lacerations, shoulder reduction, neuroimaging for new-onset seizure, foreign body removal, sexual assault examination)

• Non-urgent or elective (eg, non-vegetable foreign body in external auditory canal, chronic embedded soft tissue foreign body, toenail)

Green et al. Fasting and Emergency Department Procedural Sedation and Analgesia: A Consensus-Based Clinical Practice Advisory. Annals of Emergency Medicine. March 2006

ASA Class1.Healthy

2.Mild systemic disease w/o functional limitation

3.Severe systemic disease w/ functional limitation

4.Severe systemic disease w/ constant threat to life

5.Moribund patient who will die without operation

6.Probably will die during operation

Some Pearls

•Extremes of age

•TITRATE

•Minimum required medication

•Know how the procedure will be done

History

•Recent illness

•PmHx

•Medications

•Allergies

•Prior sedations / general anesthetic

•NPO?

Physical Exam

•Vitals

•LOC

•CVS/resp exam

•Airway

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Airway• Look for external characteristics known to

causes problems with BVM or intubation.

• Evaluate the 3-3-1 Rule:

- Mouth, hyoid, ant jaw subluxation

• Mallampati Score

• Obstruction – any pathology within or surrounding the upper airway

• Neck Mobility - full flexion & extension

Fasting

Green et al. Fasting and Emergency Department Procedural Sedation and Analgesia: A Consensus-Based Clinical Practice Advisory. Annals of Emergency Medicine. March 2006

Fasting Guideline

•Expert panel of emergency physicians

•MEDLINE search relevant articles

•Reviewed by emergency and non-emergency physician experts

Fasting Guideline

•Aspiration risk in procedural sedation extremely low

•Aspiration of clear liquids little risk of mobidity

• Sedation length not enough evidence

•Avoid PPV

•Rx pretreatment doesn’t help

Aspiration Risk Factors

•Airway difficulties

•Age >70

•ASA 3 or greater

•GERD predisposition: esophageal dzs, hiatus hernia, PUD, gastritis, bowel obstruction, ileus, elevated ICP

•NOT: pregnancy, DM, opioid, obesity

Fasting Guidelines

Fasting Guidelines

Consent

•Verbal / Written

•Discussion

- Objective of sedation

- Risk/benefit

- Limitations/alternatives

- Post sedation monitoring/activities

Sedation levels

Sedation Response AirwayVentilatio

nCVS

Light/Mod

PurposefulRespond to

verbalNormal Normal Normal

Deep PainPossibly interven

e

Possibly abnorma

l

Usually normal

GA NoneInterven

e

Frequently

abnormal

Maybe abnorma

l

Well...•Sedation is more of a continuum

rather than set categories

Innes et al. Procedural Sedation and Analgesia in the Emergency Department. Canadian Consensus Guidelines. Journal of Emergency Medicine. 1999: 17:1. 145-156

Smooth Sedation

•Pland ahead

•Risk assessment

•TITRATE

Oxygen Controversy

•Should pre-oxygenate?

•YES: increase reserve, lower risk desaturation

•NO: decrease detection hypoventilation

➡Probably should give some oxygen

•Nasal cannula CO2 detector for pediatric orthopedic procedures

•Prospective convenience sample observational study

Annals of Emergency Medicine, January 2007

Result•ETCO2 >50 or increase by 10

•O2 sat <90

•Apnea >30sec

•ETCO2 detected apnea before clinical exam or pulse oximetry in all cases 5/125

•ETCO2 detected airway obstruction first in 6/10 occurrences

•Prospective observatinal study

•Adults undergoing PS

•Observer ’s Assessment of Alertness/Sedation scale (OAA/S), pulse ox, nasal ETCO2

Results

•Pulse oximetry alone detected 11/33

•ETCO2 detected all episodes of respiratory depression (same cut off values)

•ETCO2 had no correlation with OAA/S

Capnography

•Clinical significance of increased ETCO2 without hypoxemia, obstruction?

•Subclinical respiratory depression important?

•ETCO2 threshold?

•ETCO2 monitoring going to decrease incidence of hypoxemia or interventions needed?

Checklist

•Who do you want?

•What do you want?

•Where do you want it?

Personnel

• 1 or 2 docs

• Nurse

• RT

• Evidence?

Equipment

•Bedside

- Drugs

- Pulse oxymeter, BP cuff, IV

- Oxygen, suction

- BVM, oral airway

Equipment

•Readily available

- Reversal agents

- Cardiac monitoring

- Intubation stuff

- Crash cart with drugs

Drugs

•Propofol

•Midazolam

•Fentanyl

•Etomidate

•Ketamine

•Ketafol

Propofol

•Alkyl phenol (non-opioid, non-barbituate)

•Sedative hypnotic

•Highly lipid soluble (BBB)

•Rapidly cleared by liver

Propofol

•Onset: 1min

•Duration: 8-10min

•IV, 10mg/ml vials

•Dosing: start low, go slow, titrate to effect

•Egg / Soy allergies

Propofol: the GOOD

•Quick on / off

•Anti-emetic

•No hangover

•Increase seizure threshold

•Amnesia

•Decreased ICP / IOP

Propofol: the BAD

•Respiratory depression

•Myocardial depressant

•No analgesia

•Pain at injection site

•Goes bad

Propofol: the Evidence

Miner and Burton. Clinical Practice Advisory: Emergency Department Procedural Sedation with Propofol. Annals of Emergency Medicine. 2007.

Propofol Highlights

•Age >55 or ASA 3 or greater have higher chance hypotension

•Should have 2 docs when available

•Give oxygen

•Monitor with pulse oxymetry +/- capnography

•Consider lidocaine 0.5mg/kg in syringe

Propofol Highlights

•Age >55 or ASA 3 or greater have higher chance hypotension

•Should have 2 docs when available

•Give oxygen

•Monitor with pulse oxymetry +/- capnography

•Consider lidocaine 0.5mg/kg in syringe

Propofol in Pediatrics

• Havel et al. A Clinical Trial of Propofol vs Midazolam for Procedural Sedation in a Pediatric Emergency Department. Acad Emerg Med. 1999;6:989-997.

• Skokan et al. Use of Propofol Sedation in a Pediatric Emergency Department: A Prospective Study. Clin Pediatr. 2001;40:663-671

Propofol in Pediatrics

•Propofol as effective as midazolam with shorter recovery time

•Complication rates for propofol and midazolam comparable

•Propofol safe and effective

Midazolam•Short acting benzodiazepine

•Anxiolysis, amnesia, sedation

•Facilitates GABA action by inhibiting glycine

•Water soluble and lipophilic so quickly crosses BBB

•Metabolized by cytochrome P450, excreted by kidneys

Midazolam

•IV/IM/PO/PR/TM

•Onset: IV 1-5min, IM 5-15min, PO>30min

•Peak: IV 1-2min, IM 15-60 min

•Duration: up to 2 hrs

•Dose: IV 0.02-0.1mg/kg, titrate to effect

Midazolam: the GOOD

•Short half life

•Good sedation, amnesia, anxiolysis

•Muscle relaxant, anticonvulsant

•Reversible

•Multiple routes

Midazolam: the BAD

•Potent respiratory depression

•Hypotension, bradycardia

•Above worse with opioid (but need it)

•Agitation, involuntary movements, nystagmus, paradoxical hyperactivity

•Class D in pregnancy

Etomidate

•Non barbituate sedative hypnotic

•GABA receptor

•Sedation

•No analgesia

Etomidate

•Dose: 0.1-0.2mg/kg

•Onset: 1min

•Duration: 10-15min

Etomidate 3Ps

•CONTRAINDICATIONS

1.Pregnant

2.Poor adrenal function

3.Prior seizures

Etomidate: the GOOD

•Cardiovascular stability

•Reduction in ICP

•Less respiratory depression

Etomidate: the BAD

•Respiratory depression

•Vomitting

•Myoclonus

•Adrenal suppression

•Propofol and Etomidate had similar efficacy and side effect profile

•Etomidate caused more myoclonus and hence slightly lower procedural success rate

Annals of Emergency Medicine, Jan 2007

Etomidate: the Evidence

Vinson DR, Bradbury DR. Etomidate for procedural sedation in emergency medicine. Ann Emerg Med 2002;39(6):592–8.

Ruth WJ, Burton JH, Bock AJ. Intravenous etomidate for procedural sedation in emergency department patients. Acad Emerg Med 2001;8(1):13–8.

Keim SM, Erstad BL, Sakles JC, et al. Etomidate for procedural sedation in the emergency department. Pharmacotherapy 2002;22(5):586–91.

Burton JH, Bock AJ, Strout TD, et al. Etomidate and midazolam for reduction of anterior shoulder dislocation: a randomized, controlled trial. Ann Emerg Med 2002;40(5):496–504.

Etomidate

•Adequate sedation

•Short duration of action

•Stable hemodynamic profile

•Few minor complications: apnea/desats, vomitting, myoclonus

Bahn and Holt. Procedural Sedation and Analgesia: A Review and New Concepts. Emerg Med Clin N Am 23 (2005) 503-517

Ketamine

•Dissociative agent

•Disconnects thalamus from limbic sysem

•Depresses cortical function while stimulating limbic system

•Trancelike state: analgesia, sedation, amnesia

Ketamine•Routes: IV/IM/PO/PR/IN

•Dose: IV 1-2mg/kg, IM 2-4mg/kg

•Onset: IV 1min, IM 5min

•Duration: IV 15min, IM 15-30min

•Highly lipid soluble

•Metabolized by liver, excreted by kidney

Ketamine

•Direct myocardial depressant

•Increased sympathetic outflow

•Tachycardia and vasoconstriction

•NOTE: profound hypovolemia or minimal sympathetic reserve may cause severe hypotension

•Ketamine Eyes

Ketamine: the GOOD

•Rapid onset / offset

•Minimal cardiovascular effects

•Minimal respiratory depression

•Analgesia

•Bronchodilation

Ketamine: the BAD

•Laryngospasm

•Increased secretions

•Muscular tone / movements

•Vomitting

•ICP? IOP

•Emergence phenomena

Emergence Reactions

•Risk Factors

- Age>15

- Women

- Large, rapid doses, after Atropine

- Already aggitated

- Personality disorder

- Excessive physical stimulation

Emergence Reactions

•Floating sensations

•Dizziness

•Blurred vision

•Out of body experiences

•Vivid dreams / nightmares

Contraindications

•Ischemic heart disease

•Prolonged stress response

•Poorly controlled hypertension

•Recent URTI

•History of psychotic illness

Ketafol: the new kid on the block

Annals of Emergency Medicine. Vol 48 No1. Jan 2007. pp 23-30.

Study•Prospective case series in community

teaching hospital July 2005 to Feb 2006

•114 procedural sedations

•Mostly orthopedic procedures

•All age groups

•Ketafol (Ketamine and Propofol at 1:1 in same syringe)

•Some pretreated with opioids

Results

•Median dose 0.75mg/kg of each

•High procedure success rate

•Low complication rate

•Hemodynamically very stable (mild tachycardia and hypertension)

•Fast recovery time (median 15min)

•High patient satisfaction

Questions

•Study under powered to do subgroup analysis for different procedures

•Optimal ratio?

•How much additional analgesia?

Pediatrics

•Higher mg/kg dosing

•Narrow safety margin

•<6mth: slower drug clearance, increased BBB permeability

Age Limit?

•Propofol >3yo

•Ketamine >3mth

•Etomidate >12yo

Reversal Agents

Narcan

•Opioid receptor antagonist

•Onset: 1-2min

•Peak: 5-10min

•Duration: 1-4hrs

•Dose: 2mg or 0.1-0.2mg (10-100mcg/kg) titrate to response up to 10mg

Narcan

•Contraindications

- Allergy

- Caution in opioid dependent patients and agitated patients

•Need to monitor for 2hrs post

Flumazenil

•Benzodiazepine receptor antagonist

•Onset: 1-2min

•Peak: 5-10min

•Duration: 45-90min

•Dose: 0.1mg (0.01mg/kg) tirate to max 2mg

Flumazenil

•Contraindications

- Allergy

- Seizure disorder

- Chronic benzo use

•Need to monitor for 2hrs post

Discharge Criteria•Baseline physical status / mental

status

•Sit, walk, and talk appropriately

•Tolerating oral fluids

•Caregiver presence

•Min 2hr observation if reversal given

•Verbal / written instructions

Discharge Instructions

•Avoid dangerous activities until 100%

•May feel dizzy, nauseated

•Avoid EtOH or other sedatives x 24h

Case 1

•18 yo male

•Fell snowboarding and hurt right shoulder

•Obvious dislocation

•First time

Case 2

•73yo female

•FOOSH left

•Colle’s fracture

•PmHx: HTN, hypothyroid

Case 3

•3yo female

•Fell and hit forehead on coffee table

•Laceration forehead too deep/wide for glue

•No previous procedures

•++++crying, thrashing

Case 4

•61yo male

•Sudden onset palpitation during breakfast 2 hours ago

•Rapid A.fib on ECG

•PmHx: HTN, NSTEMI, ↑CHOL, smoker

Case 5

•56 yo male

•Slipped 2 steps

•Obviously deformed R ankle

•Neurovasc intact

•PmHx: morbid obesity, HTN, IDDM, MI last year, COPD, sleep apnea, smoker

QUESTIONS?