Download Procedural Sedation for EMS

Procedural Sedation in the
Pre-Hospital Setting
Antoinette Eng, MD
Albany Medical Center
December 20, 2006
EMS Procedural Sedation: Overview
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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
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Minimal Sedation
Drug-induced state
Impaired cognitive function & coordination
Responds to verbal commands
Ventilatory and cardiovascular functions intact
Anxiolysis
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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
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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
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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
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Procedures
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Cardioversion
Transcutaneous Pacing
Pre/Post-Intubation
Transport
Extrication
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Patient Restraint
Primary Treatment
Anxiety
Sympathomimetic Overdose
Alcohol Withdrawal
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Pain Management Adjunct
Trauma
Acute Abdomen
ACS
Indications
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Procedures
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Cardioversion
Transcutaneous Pacing
Pre/Post-Intubation
Transport
Extrication
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Patient Restraint
Primary Treatment
Anxiety
Sympathomimetic Overdose
Alcohol Withdrawal
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Pain Management Adjunct
Trauma
Acute Abdomen
ACS
Procedural Sedation:
Medications
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Benzodiazepines
Etomidate
Opiates
Nitrous Oxide
Benzodiazepines
Benzodiazepines
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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
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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
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Indications:
Sedation prior to cardioversion and intubation
 Maintenance of sedation in mechanically ventilated
patients
 Pediatric seizure control
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Midazolam
Adults
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Intubation adjunct:
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0.5-5mg IV/IM
may repeat every 5-10 minutes
max 10 mg
Status, cardioversion, pacing, inner ear problems,
sedation, muscular spasms:
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0.5-2.5 mg IV, 5mg IM
may repeat every 5-10 mins
max 5mg
Midazolam
Pediatric
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Intubation:
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Seizures:
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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:
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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
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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
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Indications:
Seizures/status epilepticus
 Sedation pre-cardioversion
 Acute anxiety
 Skeletal muscle relaxant
 Alcohol withdrawal
 Vertigo
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Diazepam
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Seizures:
2-10 mg slow IV
 5-10 mg PR
 max 20 mg
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Sedation/cardioversion/pacing/muscle
spasm/labyrinthitis/vertigo:
2-5 mg slow IV every 5-10 mins
 max 10mg
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Midazolam vs Diazepam
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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
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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
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? Decreased ICP
Nausea and vomiting
Myoclonus
Adrenocortical Suppression
Etomidate
Indications:
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Induction agent for intubation
Pre-medication for cardioversion
Etomidate
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Adults & Pediatrics
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Intubation: 0.3 mg/kg slow IV over 30-60 seconds,
repeat as needed, maximum 0.6mg/kg
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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
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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
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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
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Dose:
Peak:
Duration:
0.05-0.1 mg/kg IV
10-30 minutes
2-4 hours
Morphine
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Adverse Reactions & Side Effects
CNS: Euphoria, sedation, respiratory depression
 Cardiovascular: bradycardia, hypotension
 GI: decreased motility, nausea, vomiting
 GU: urinary retention
 Respiratory: bronchoconstriction, antitussive
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Fentanyl
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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
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Dose:
Onset:
Peak:
Duration:
1 mcg/kg IV
Fast
2.5-10 minutes
30-90 minutes
Fentanyl
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Respiratory depression with alcohol or versed
Chest wall rigidity
dose dependent
 not reliably antagonized by naloxone
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Nitrous Oxide
Nitrous Oxide
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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
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Adverse Reactions
Light-headed
 Confusion
 Drowsiness
 Nausea/vomiting
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Nitrous Oxide
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Contraindicated:
Altered state of consciousness
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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
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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
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Patient Restraint
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No standing orders
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Available through Medical Control:
Age < 70: Haloperidol 5mg mixed with Midazolam
2mg IM
 Age > 70: Haloperidol 5mg IM
 Repeat
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Patient Restraint
In 1998 California survey of 490 EMS providers:
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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
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“Positional Asphyxia During Law Enforcement Transport.”
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“Met Acidosis in Restraint-Associated Cardiac Arrest: A Case Series.”
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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.”
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Ann of Emerg Med. Stratton SJ, et al. 25(5):710-12, May 1995.
Patient Restraint
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Indications:
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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”
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Haldol
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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
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Indications:
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Acute and chronic psychoses
Agitation, aggression
Contraindications:
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Parkinson’s
Seizure
Cocaine overdose
Alcoholism
Severe mental/CNS depression
thyrotoxicosis
Haldol
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Dosage 5-10mg IM
Summary
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Sedation is a dynamic spectrum
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Main EMS uses:
Procedures
 Restraint
 Primary Treatment
 Pain management adjunct
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Thank you for your attention!