procedural sedation - alternatives to brutane dr garry clearwater mbchb facem
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Procedural Sedation
- alternatives to Brutane
Dr Garry ClearwaterMBChB FACEM
Overview
What is procedural sedation? Alternatives: Analgesia Preparation Drugs Discharge More alternatives…
Overview
DISCLAIMER….
This is a very simplified overview of a complex topic.
It is not a substitute for in-depth research, background knowledge and training.
What is Procedural Sedation?
To reduce patient anxiety and awareness
To facilitate a medical procedure
Patient maintains their airway & breathing
- a.k.a “conscious sedation” “deep sedation”
Uses
Reduction of dislocations: shoulder, elbow, hip, patella, ankle
Reduction of fractures: wrist, ankle washout compound fracture
Paediatric injuries: wound inspection, closure, suturing
Abscess I&D
Advantages
Compared to Brutane: Less stress and anxiety… for nearly everyone Better chance of success (relaxation, time)
Compared to GA: PS is quicker – for the patient PS is generally safer
Still some uses for Brutane…?
Simple, very quick, curative procedures:
Reduction of “pulled elbow”:
- Pronate/supinate flexed elbow
- with pressure over the radial head
Reduction of simple patella dislocation:
- Extend the knee
- with sideways pressure on the patella towards the midline.
Supplementary analgesia may be warranted before and during.
ANALGESIA
Procedural sedation is:
Pain relief +
Relaxation
• Pain relief by itself often reduces anxiety
ANALGESIA
Reassurance and explanation Simple analgesia: paracetamol
ANALGESIA
Reassurance and explanation Simple analgesia: paracetamol Entonox
ANALGESIA
Entonox: Nitrous OxideWeak analgesic Onset 1 min (12-15 breaths) Peak 5 minNeed co-operative patient
Avoid in: retained gas: SABO, pneumothorax etc Cardiac disease, shock Pregnancy 1st trimesterS/Es: Dysphoria, nausea
ANALGESIA
Reassurance and explanation Simple analgesia: paracetamol Entonox Methoxyflurane
ANALGESIA
Penthrox: MethoxyfluraneModerate analgesicFluorinated Hydrocarbon- Metabolised to Fluoride Onset 1-2 minutes Peak 5 minAvoid in: Renal impairment, diabetesS/Es: - Nephrotoxic; nausea, dizziness.- bradycardia, low BP
ANALGESIA
Reassurance and explanation Simple analgesia: paracetamol Entonox Methoxyflurane Intranasal Fentanyl
ANALGESIA
Fentanyl IntranasalNarcotic analgesicChildren >2 yo, up to max 70 kgVia atomiser on end of syringe Rapid onset: 2 minutes Duration 30 minsAvoid in: Nasal congestionS/Es: - nausea, dizziness.- low BP
ANALGESIA
Fentanyl Intranasal (Starship CED guideline):100 mcg / 2 ml with 1 ml tuberculin syringe- 1.5 mcg/kg (0.03 ml/kg)Repeat if necessary:- 0.5 mcg/kg
Patient sits at 45 degreesSyringe held horizontal:- one quick sprayObserve for 20 min after dose
ANALGESIA
Reassurance and explanation Simple analgesia: paracetamol Entonox Methoxyflurane Intranasal Fentanyl Intravenous Morphine
ANALGESIA
Morphine IV- Titrate- Reversible
0.1 mg / kg- 2 mg increments in adults
S/Es: - nausea, dysphoria.- low BP- Transient anaphylactoid rash (often mislabelled as
allergy)
ANALGESIA
Morphine IV
Tricks of the trade: EMLA or Ametop skin anaesthesia for at least 30 mins
- or insulin syringe local injection
Have the morphine ready to inject as soon as IV established
Alternatives to Procedural Sedation…not
In general, stay away from: SC and IM injections: variable and prolonged effects
Fallen out of favour … Intranasal Midazolam: not an analgesic, works by
ingestion
In the future … Fentanyl lollipop? Fentanyl nebulised?
ANALGESIA
Horses for Courses:
Renal colic: NSAIDs
Biliary colic: NSAIDs Antacids
ANALGESIA
Caution….
Paradex / Capadex / Dextropropoxyphene
Pethidine (Fentanyl is an alternative to morphine)
Tramadol: Potential serotonergic interactions with… SSRIs Dextropropoxyphene Pethidine
A Little Bit of Sedation…
Oral sedation: anxiolysis for children
Use the IV preparation, mix with Paracetamol or Sprite
Variable onset and effect
Low-level prolonged sedation.
Starship Hospital CED “Sedation – Paediatric” guideline:
www.starship.org.nz/index.php/pi_pageid/1065.
ANXIOLYSIS
Midazolam POOnset: 10-30 min Duration: 30-90 minAnalgesia: No
Dose: 0.5 mg/kg, max 15 mg
Variable effectMay cause Paradoxical Agitation
ANXIOLYSIS
Ketamine PO (3 mo – 12 yrs)
Onset: 15-30 min
Duration: 15-60 min
Analgesia: Some
Dose: 5-7 mg/kg
mix with 15-25 ml cold Sprite
Maintains airway
Multiple contra-indications
ANXIOLYSIS
Ketamine PO (3 mo – 12 yrs)
Contra-indications: URTI Head injury Psychiatric or personality disorder
Risks: Nausea, vomiting Transient respiratory events Requires low-stimulation recovery
PREPARATION
Prepare for the worst 2 clinical staff Choose your patient carefully Choose your poison carefully
PREPARATION
Prepare for the worst …
What can go worng? Unexpected drug reaction or anaphylaxis Vomit and aspirate Obstructed airway (e.g. laryngospasm, tongue) Apnoea, respiratory arrest Profound hypotension
PREPARATION
Not quite the worst …
What can go worng? Disinhibition / agitation Terrors, nightmares Unexpected drug reactions: dystonias Inadequate sedation Unsuccessful procedure… still needs GA
PREPARATION
ACEM POLICY DOCUMENT -
USE OF INTRAVENOUS SEDATION FOR PROCEDURES IN THE EMERGENCY
DEPARTMENT
© ACEM. 5 December 2001
PREPARATION
2. ENVIRONMENT
The procedure must be performed in a suitable clinical area with facilities for:
Monitoring, Oxygen Suction immediate access to emergency
resuscitation equipment, drugs
and other skilled staff.
PREPARATION
2. ENVIRONMENT
Readily available equipment must include: resuscitation trolley defibrillator
PREPARATION
2. ENVIRONMENT
Readily available equipment must include: resuscitation trolley Defibrillator Bag-Valve-Mask device for ventilation
PREPARATION
3. MONITORING
Cardiac rhythm, non-invasive blood pressure and pulse oximetry must be monitored throughout the procedure and recovery period
PREPARATION
1. PERSONNEL
The involvement of at least two clinical staff is required:
PERSON PERFORMING PROCEDURE
must understand the procedure and its potential complications.
PERSON GIVING DRUGS AND MONITORING PATIENT - must have training and experience of resuscitation, emergency drugs and …. (details of) the drugs used.
This person is not involved in the performance of the procedure but is dedicated to care and monitoring of the patient.
PREPARATION
1. PERSONNEL
The involvement of at least two clinical staff is required:
PERSON PERFORMING PROCEDURE
must understand the procedure and its potential complications.
PERSON GIVING DRUGS AND MONITORING PATIENT - must have training and experience of resuscitation, emergency drugs and …. (details of) the drugs used.
This person is not involved in the performance of the procedure but is dedicated to care and monitoring of the patient.
PREPARATION
1. PERSONNEL
The involvement of at least two clinical staff is required:
SUPERVISING PERSON –
a specialist or advanced trainee in emergency medicine who has specific experience in airway control and resuscitation must be either directly involved in the procedure (taking one of the above roles) or must be aware of the procedure and provide overall supervision and back-up assistance.
PREPARATION
5. PATIENT PREPARATION
Explanation
Consent
Secure IV access is mandatory.
PREPARATION
Other requirements
Separate space to perform the procedure
A recovery space: ideally quiet, available for 1-2 hours, easily observed.
PATIENT SELECTION
Can you hold the fort if something goes wrong?
AIRWAY: Thyromental distance Open mouth > 3 FB Stable teeth View hypopharynx Mobile neck
PATIENT SELECTION
Can you hold the fort if something goes wrong?
BREATHING & CIRCULATION: Lung disease? Stable cardiac status? BP stable?
Medications
Allergies (e.g. watch out for soy, eggs: Propofol)
PATIENT SELECTION
Starved for how long…?
Controversial.
Probably not as rigid as anaesthetic guidelines for GA...
Depends on degree and duration of sedation
Starship CED paediatric guideline: Clear fluids: at least 2 hours Non-clear fluids and solids: at least 4 hours
READY TO GO…
Explain
Pre-oxygenate
IV Access and IV fluid running
Splints or plaster or equipment all ready to go
Hand over your phone or pager…
DRUGS
Choose your poison carefully…
Wide variation in individual responses
Clearwater’s Textbook Rule:
Doctors read textbooks…
but patients don’t.
Titrated is best.
DRUGS
FENTANYL: IV adjunct Onset: 2-5 min Duration: 30 minAnalgesia: Yes
Advantage: Reversible (Naloxone)Alternative to Morphine
But… BP dropChest wall rigidityNausea
DRUGS
MIDAZOLAMOnset: 1-2 min Duration: 10-30 minAnalgesia: No
Advantage: Reversible
But… BP dropSlower, not as deep as
Propofol
DRUGS
ETOMIDATEOnset: <1 min Duration: 5-8 minAnalgesia: No
Advantage: BP maintained
But… Twitching / myoclonusNauseaNot fully registered
(s.29)
DRUGS
PROPOFOLOnset: <1 min Duration: 5-10 minAnalgesia: No
Advantage: Not cumulative
But… BP dropAllergy soy or eggs
DRUGS
KETAMINEOnset: 1-3 min Duration: 5-20 minAnalgesia: Yes!
Advantage: Preserves ABC
But… Emergence phenomenaEyes open, random
movementsSalivation,
Laryngospasm
DRUGS
KETAMINE
Atypical reactions more common in: older children >10 yrs girls agitated children URTI / rhinitis
Need low-stimulus recovery room.
May need IV Midazolam
OFF WE GO….
Prepare for the worst 2 clinical staff Choose your patient carefully Choose your poison carefully Keep watching the patient … during Keep watching the patient … after Discharge with a well-advised capable observer
PATIENT DISCHARGE
Allow at least 1 hour after last dose given
Various criteria for discharge: Normal vital signs Alert / orientated / back to baseline Able to sit / mobilise unaided Able to drink Sensible capable observer Good advice
More alternatives to Procedural Sedation
Infant analgesia: 0 – 3 mo.
25-33% sucrose0.25 – 2 ml PO (give with dummy)
Mild analgesiaReleases endogenous opiods:- Reversible with Naloxone
Onset 2-5 minsDuration 5-8 mins
More alternatives to Procedural Sedation
Wound Care:
Topical anaesthesia:
“Topicaine”:
0.1 ml/kg
Apply to open wound
on a small gauze swab;
Cover with Opsite
… and wait
More alternatives to Procedural Sedation
Wound Care:
Topical anaesthesia:
“Topicaine”:
0.1 ml/kg
Apply to open wound
on a small gauze swab;
Cover with Opsite
… and wait
… 30 mins
More alternatives to Procedural Sedation
Dislocated shoulder
Intra-articular anaesthesia:
More alternatives to Procedural Sedation
Dislocated shoulder
Intra-articular anaesthesia:
Lignocaine 1% 20 ml
20G 3.5 cm needle.
Insert just lateral to acromion.
Aim to glenoid.
Aspirate sero-sanguinous fluid
Inject over 30 sec.
Takes 15-20 min to work
Acknowledgements & resources
ACEM (Info Centre > Policies Guidelines): www.acem.org.au
Starship Hospital CED (Health professionals > Clinical guidelines:
www.starship.org.nz
Kidz First / Middlemore Hospital ED clinical guidelines
RCH Melbourne guidelines www.rch.org.au/rchcpg
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