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Procedural Sedation in the Pre-Hospital Setting Antoinette Eng, MD Albany Medical Center December 20, 2006 EMS Procedural Sedation: Overview Definition Indications Medications Recent Research Summary Sedation Controlled reduction of environmental awareness Sedation Dynamic A Clinical Spectrum Anxiolysis Moderate Sedation & Analgesia Deep Sedation & Analgesia Anesthesia Anxiolysis Minimal Sedation Drug-induced state Impaired cognitive function & coordination Responds to verbal commands Ventilatory and cardiovascular functions intact Anxiolysis Moderate Sedation & Analgesia Previously known as “conscious sedation” Depression of consciousness Respond purposefully to verbal commands alone or with light tactile stimulation Ventilation and cardiovascular function intact Anxiolysis Moderate Sedation & Analgesia Deep Sedation & Analgesia Depression of consciousness Not easily aroused, but responds purposefully after repeated or painful stimulation May require airway and ventilatory support Cardiovascular function maintained Anxiolysis Moderate Sedation & Analgesia Deep Sedation & Analgesia Anesthesia Loss of consciousness Patient cannot be aroused by painful stimuli Requires airway and ventilatory support Cardiovascular function may be impaired Indications Procedures Cardioversion Transcutaneous Pacing Pre/Post-Intubation Transport Extrication Patient Restraint Primary Treatment Anxiety Sympathomimetic Overdose Alcohol Withdrawal Pain Management Adjunct Trauma Acute Abdomen ACS Indications Procedures Cardioversion Transcutaneous Pacing Pre/Post-Intubation Transport Extrication Patient Restraint Primary Treatment Anxiety Sympathomimetic Overdose Alcohol Withdrawal Pain Management Adjunct Trauma Acute Abdomen ACS Procedural Sedation: Medications Benzodiazepines Etomidate Opiates Nitrous Oxide Benzodiazepines Benzodiazepines GABA is major inhibitory neurotransmitter in CNS 3 types of receptors: GABA-A, GABA-B, GABA-C GABA-A overwhelmingly numerically dominant receptor in CNS BZO bind and allosterically modify receptor Potentiate GABA response Increase hyperpolarization Increase neuronal inhibition at all levels of the neuraxis, including the spinal cord, hypothalamus, hippocampus, substantia nigra, cerebellar cortex, and cerebral cortex Sedation, amnesia, muscle relaxation, anesthesia, anti-convulsant, anxiolytic Midazolam lipid soluble in blood Rapid GI absorption, Lipid solubility = prompt passage across blood-brain barrier, rapid redistribution and short duration of action Large first-pass hepatic effect Metabolism slowed in patients on cimetidine, erythromycin, calcium channel blockers, antifungal medications, fentanyl since they also use P450 cytochrome system 1.0-2.5 mg IV Onset 30-60 seconds Time to Peak Effect 3-5 minutes Duration of Sedation 15-80 minutes Midazolam Indications: Sedation prior to cardioversion and intubation Maintenance of sedation in mechanically ventilated patients Pediatric seizure control Midazolam Adults Intubation adjunct: 0.5-5mg IV/IM may repeat every 5-10 minutes max 10 mg Status, cardioversion, pacing, inner ear problems, sedation, muscular spasms: 0.5-2.5 mg IV, 5mg IM may repeat every 5-10 mins max 5mg Midazolam Pediatric Intubation: Seizures: 0.1-0.2 mg/kg max 5 mg/dose, repeat PRN for sedation to max of 10 mg 0.2-0.4 mg/kg IN/PR IV/IM 0.05-0.2 mg/kg repeat every 5 mins PRN Sedation for painful procedures, cardioversion, pacing, muscular spasms, hyperdynamic drug ingestion/exposure: 0.05-0.1 mg/kg IV/IM/IO every 5-10 min (2-5 mins if IV) max 2.5 mg Midazolam Side Effects Ventilatory Depression caused by decrease in hypoxic drive Effects greater than for Lorazepam and Diazepam Exaggerated in presence of other opioids and CNS depressants, COPD, increasing age Diazepam Indications: Seizures/status epilepticus Sedation pre-cardioversion Acute anxiety Skeletal muscle relaxant Alcohol withdrawal Vertigo Diazepam Seizures: 2-10 mg slow IV 5-10 mg PR max 20 mg Sedation/cardioversion/pacing/muscle spasm/labyrinthitis/vertigo: 2-5 mg slow IV every 5-10 mins max 10mg Midazolam vs Diazepam More rapid onset Greater amnesia 2 to 3 times as potent Twice the affinity for benzodiazepine receptor Greater decrease in blood pressure and heart rate Systemic vascular resistance Less post-procedural sedation Same time to complete recovery Benzodiazepines Onset Diazepam Duration IV 5 min 15-60 m IM 15-30m Midazolam IV 1-3 min 15-90 m IM 5-15 min Benzodiazepines Side Effects Minor Diazepam CNS Depression Resp Depression Apnea Hypotension Cardiac Arrest “Valium rage” CNS Depression see Diazepam Cough Phlebitis @ IM site Hiccups Midazolam Major Etomidate: Properties Anesthetic Non-narcotic sedative hypnotic Increases GABA receptors, enhancing inhibitory neurotransmission Reticular activating system depression Short acting Induces sedation & amnesia No histamine release Minimal cardiac & respiratory depressive effects Etomidate: Adverse Effects ? Decreased ICP Nausea and vomiting Myoclonus Adrenocortical Suppression Etomidate Indications: Induction agent for intubation Pre-medication for cardioversion Etomidate Adults & Pediatrics Intubation: 0.3 mg/kg slow IV over 30-60 seconds, repeat as needed, maximum 0.6mg/kg Short painful procedures: 0.15 mg/kg slow IV over 30-60 seconds Etomidate vs Midazolam for Out-ofHospital Intubation: A Prospective, Randomized Trial Ann Emerg Med. 47(6):525-30, 2006 Jun Prospective, double blind, randomized 55 Versed, 55 Etomidate 75% success rate versed, 76% etomidate No difference in success rates, incidence of hypotension, number of attempts, perceived difficulty Opiates Morphine Central nervous system depressant Acts at mu receptors above and at spinal cord Decrease cardiac preload/afterload Decreases myocardial oxygen demand Releases histamine can cause hypotension Morphine Dose: Peak: Duration: 0.05-0.1 mg/kg IV 10-30 minutes 2-4 hours Morphine Adverse Reactions & Side Effects CNS: Euphoria, sedation, respiratory depression Cardiovascular: bradycardia, hypotension GI: decreased motility, nausea, vomiting GU: urinary retention Respiratory: bronchoconstriction, antitussive Fentanyl Synthetic opioid derivative 100x potency of morphine Highly lipid soluble Stored in adipose tissue to create a “reservoir” Low complication rate Doesn’t release histamine, rarely produces hypotension Fentanyl Dose: Onset: Peak: Duration: 1 mcg/kg IV Fast 2.5-10 minutes 30-90 minutes Fentanyl Respiratory depression with alcohol or versed Chest wall rigidity dose dependent not reliably antagonized by naloxone Nitrous Oxide Nitrous Oxide Colorless gas Mixed with 50% oxygen and inhaled Self-administered by patient Mild intoxicant, potent analgesic Disspiates within 2-5 minutes after stopping Nitrous Oxide Adverse Reactions Light-headed Confusion Drowsiness Nausea/vomiting Nitrous Oxide Contraindicated: Altered state of consciousness Head injury, alcohol ingestion, drug OD COPD Pneumothorax Decompression sickness Air embolus Abdominal pain with distension Pregnancy, except during delivery Unable to self-administer Nitrous Oxide Considerations Currently not on REMO protocol, but a good drug to know about Heavier than air, can accumulate at ambulance floor and affect EMS personnel Patient Restraint No standing orders Available through Medical Control: Age < 70: Haloperidol 5mg mixed with Midazolam 2mg IM Age > 70: Haloperidol 5mg IM Repeat Patient Restraint In 1998 California survey of 490 EMS providers: 61% recounted assault on the job 25% reported injury 37% of injured required medical attention 95% recounted restraining patient “Exposure of prehospital care providers to violence.” Prehospital Emergency Care. 2(2):127-31, 1998 Apr-Jun. Dangers to Patients “Positional Asphyxia During Law Enforcement Transport.” “Met Acidosis in Restraint-Associated Cardiac Arrest: A Case Series.” Am Jrnl of Forensic Med and Path. Reay DR. 13(2):90-7, 1992. Acad Emerg Med. Hick, et al. 6(3):239-44, 1999. “Sudden Death in Individuals in Hobble Restraints During Paramedic Transport.” Ann of Emerg Med. Stratton SJ, et al. 25(5):710-12, May 1995. Patient Restraint Indications: Patients at risk of causing physical harm to emergency responders, the public, and/or themselves Considerations: Cannot be transported face down If in police custody with handcuffs on, must beaccompanied by police officer in ambulance to hospital EMS may only apply “soft restraints” Haldol Dopamine blockade in mesocortex and limbic system inhibits psychoses Extrapyramidal effects (akathisia, dystonia, pseudoparkinsonism) due to dopamine blockade in niagrostriatal pathways Sedative for psychomotor agitation Minor anticholinergic and antihistaminic actions rarely cardiovascular, anticholinergic effects May cause QT prolongation, lower seizure thresholds Haldol Indications: Acute and chronic psychoses Agitation, aggression Contraindications: Parkinson’s Seizure Cocaine overdose Alcoholism Severe mental/CNS depression thyrotoxicosis Haldol Dosage 5-10mg IM Summary Sedation is a dynamic spectrum Main EMS uses: Procedures Restraint Primary Treatment Pain management adjunct Thank you for your attention!