April 17, 2018 by jtreb
Procedural sedation is not an uncommon procedure in the emergency department. It can go smoothly without difficulty, or can require emergency intubation/resuscitation. Ideally, you want to put the patient to sleep, have the procedure (shoulder reduction, etc) be performed, and then have the patient wake up. However, unexpected complications can occur. A way to ameliorate the effects of these complications is to be prepared for all possible outcomes in addition to taking a good history and physical.
WHAT: Procedural sedation: a technique of administering sedatives or dissociative agents to induce a state that allows a patient to tolerate procedures while maintaining cardiorespiratory function
TYPES OF SEDATION: Minimal –> Airway, ventilations, and cardiovascular function unaffected; good for anxiolysis, pain relief, before an LP
Moderate –> Purposeful responses to verbal/tactile stimulation. Airway, ventilations, and cardiovascular function unaffected.
Deep –> Patient can respond to repeated/painful stimulation; airway/ventilations may need to be assisted depending on amount of deep sedation given; good for reductions, burn wound debridement
WHAT TO ASK YOUR PATIENT: Last meal
History of allergic reactions/reactions to anesthetic agents
History of intubations and difficult airways
History of OSA
THE CHECKLIST: Consent
Two Peripheral IVs (or two points of IV access)
ETCO2 monitoring and SpO2 monitoring
Two suction devices
Backup blade (glidescope, mac/miller)
Backup backup (bougie, LMA)
ETT with stylet
IV saline bag
Medications (three most commonly used are below)
-Propofol = 1mg/kg IV
-Etomidate = 0.15mg/kg IV
-Ketamine = 1mg/kg IV
COMPLICATIONS: Patient not adequately sedation (may require more agent)
Patient too sedated
Allergic reactions (treated similarly to any other allergic reaction with consideration of dantrolene for malignant hyperthermia)
Interventions can include stimulating patient, jaw thrust, increasing oxygen delivery, assisting respirations with BVM, and ultimately, intubation
Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med. 2010 Mar;55(3):258-64.
Tintinalli JE, Stapczynski JS, Ma JO, Cline DM, Cydulka RK, and Meckler GD. 2011. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th edition. The McGraw-Hill Companies, Inc. Chapter 41 pp283-91.