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Sedation Complications, Urgencies and Emergencies Medical Emergency Kit Golden Rule In cases of trouble – Always verify adequate respirations of your patient Ventilate Reverse Sedation Emergencies Nausea/Vomiting Aspiration Paradoxical reactions Oversedation Laryngospasm Nausea/Vomiting Most commonly associated with – Opioids Patient movement will aggravate – Swallowing blood – Anxiety Treatment of Nausea and Vomiting… Promethazine (Phenergan) – 25 mg IV, IM, oral or rectal – Additive sedative effect Trimethylbenzamide (Tigan) – 200-250 mg oral, rectal, IM Questionable efficacy Ondansetron (Zofran) – 4 mg IV or IM Aspiration Defined – Inhaling of vomit into lungs Causes – Depression of protective reflexes with depressed level of consciousness – Increased N/V associated with opioids – Swallowing of blood Aspiration Damage: – Particles/fluids Cellular response to lungs (chemical burn) Respiratory lining breakdown Surfactant destroyed Alveoli collapse becoming fluid filled – Large particles Mechanical airway obstruction Atalectasis, asphyxia, death Aspiration Treatment – Aggressive suctioning – Head down position – Transfer to hospital quickly Aspiration Prevention – Identify prone patients Anxiety Problems with opioids – – – – NPO solids > 6 hours NPO clear liquids > 2 hours Vigilant suctioning of blood Prophylactics? Paradoxical Reactions… Benzodiazepines primary culprit – More common in women and children Crying Anger Agitation Combativeness Pruritis Disorientation Dysphoria Tachycardia Paradoxical Reactions… Benzo’s remove inhibitions in some patients Patients with mental disorders more likely Treatment – Flumazenil Oversedation… Any level of sedation or anesthesia can be achieved by any route – Inhalational – Orally – Parenteral Oversedation… Your patient is clearly oversedated when they do not… – Maintain their own patent airway – Breath on their own – Respond to verbal commands Oversedation… Understand dosing schedules Understand pharmacokinetics of medications used – Drug—Drug interactions – Increased concentrations of midazolam and triazolam Erythromycin Ketoconazole/iatraconazole Grapefruit juice Protease inhibitors Verapamil/diltiazem Oversedation… Overuse of opioids often results in… – Respiratory depression – Decreased depth, rate and drive – Decreased skeletal muscle tone Respiratory Depression… In the presence of respiratory depression patients may… – Obstruct Muscle relaxation Tongue position – Hypoventilation to the point of apnea Oversedation… Does not necessarily define a state of emergency, but you must be able to… – Recognize the situation – Be able to get out of it skillfully – Have the courage to ask for help Oversedation… Oversedation will generally imply that your patient does not… – Hold his own airway – Breath spontaneously – Both Oversedation… You absolutely, positively Must Must Must be able to distinguish between the two Oversedation… Of the oxygen saturation drops more than 4 points… – – – – – Gently shake or shout Open the airway (jaw thrust maneuver) Positive pressure ventilation Administer reversal agent EMS if no rapid response Our Savior Flumazenil – Approved use—IV – May be given—IM, SL, IN Dose: 0.2 mg (2cc) – Pedi: 0.01-0.02 mg/kg Naloxone – Intended use—IV – May be given—IM, SL, SC Dose: 0.1-0.4 mg – Pedi: 0.01 mg/kg Intranasal Flumazenil… Study performed on 11 kids ages 2-6 yrs. – Dose: 0.04 mg/kg via drops in nose – Adult dose 0.2 mg/70kg Both resulted in plasma concentrations 5 times that reported to reverse benzo’s Highest plasma concentrations seen with administration via both nostrils Peaked in 2 minutes Scheepers et al. Can J Anesth. 2000;47:120 Oversedation… After the administration of a reversal agent – Must continue to ventilate until spontaneous respirations return – Continue to observe patient for 2 hours to rule out resedation Laryngospasm In the event that you cannot ventilate, you must consider the presence of laryngospasm or foreign body airway obstruction Defined: – Forceful partial or complete adduction of the vocal cords Laryngospasm Treatment – Remove any obvious foreign material – Ventilate forcefully with oxygen – Reverse the sedative agent
