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This PowerPoint file is a supplement to the video presentation. Some of the educational content of this program is not available solely through the PowerPoint file. Participants should use all materials to enhance the value of this continuing education program. Taylor Ratcliff, MD, FF, EMT-LP Terminology Anxiolysis, Sedation, Anesthesia Anxiolysis Process of decreasing anxiety or stress related to a situation Anxiolysis Talk therapy Distraction/ redirection Medications Sedation Multiple different levels recognized by the American Society of Anesthesiologists (ASA) Sedation Light, moderate, deep Anesthesia Various stages based on stimuli required to obtain a response and central nervous system effects Anesthesia Emergency medical services (EMS) usually wants patients deeply anesthetized, quickly Risk/Benefit Analysis Risk/Benefit Analysis Pain ›for some patients, analgesia can be provided to reduce pain Risk/Benefit Analysis Pain ›is temporary. but death is permanent Risk/Benefit Analysis What is the absolute benefit of your procedure... Risk/Benefit Analysis ...versus the perceived negative consequences without it, and the possible complications? Procedural Sedation: Applications For EMS Induction: Anesthesia (Intubation) Pharmaceutically- assisted intubation Perhaps the most debated Anxiolysis/Light Sedation Cardiac pacing, cardioversion Pleural decompression, intraosseous (IO)? Applications for EMS Premedication for painful lifting, moving, and extrication Applications for EMS Psychotic patients Excited delirium Following Taylor Ratcliff there will be a presentation by Darrin M. Batty touching on excited delirium and in-custody situations Applications for EMS Others ›radiological procedures Risks/Complications Threat of death from your medical director Risks/Complications Medication intolerances/side effects: Risks/Complications ›each agent has its own set of problems and specific side effects Risks/Complications ›idiosyncratic/allergic reactions Risks/Complications Oversedation/ respiratory insufficiency: Risks/Complications ›fast vs. long-acting agents, reversibility ›ability to monitor and ventilate your patient Risks/Complications Loss of protective airway reflexes (aspiration) Side Effect Matchup Ketamine Propofol Etomidate Benzodiazepines Opiates Ketamine Tachycardia Hypertension (HTN) Emergence reaction Propofol Respiratory depression Hypotension Egg/soy allergy Etomidate Vomiting Fasciculations Benzodiazepine Somnolence Decreased respiratory drive Opiates Histamine release Hypotension Respiratory depression I Want a New Drug Does the perfect agent for sedation exist? I Want a New Drug If so, what qualities would it have? I Want a New Drug My perfect list: Does it exist? My Perfect List Results reliable and reproducible in children and adults My Perfect List Able to give intravenous (IV), IO, intermuscular (IM) My Perfect List Quick onset and rapid duration of action My Perfect List Minimal effects on hemodynamic parameters My Perfect List Applicable to wide variety of situations Does it exist? Minimal side effect profile ›vomiting ›myoclonus Does it exist? Reversible in emergency Does it exist? Provides ›sedation ›anxiolysis Does it exist? Provides ›analgesia ›amnesia Does it exist? Use permitted by all levels of responders Does it exist? Nonaddictive Drug Election Five Major Drug Classes and Application The Lineup Drug class and examples Primary indications, routes The Lineup Pharmacokinetics and mechanism of action Most common side effects Reversibility agents Opiates (and Opioids) Organic Semisynthetic Synthetic analgesic Opiates (and Opioids) Fentanyl Methadone Morphine Tramadol Dilaudid Heroin Oxycodone Opiates (and Opioids) Variety of routes Opiates (and Opioids) Binds opioid receptors in central nervous system: Opiates (and Opioids) ›Mu (38%) ›Delta (16%) ›Kappa 3 (43%) Opiates (and Opioids) Onset of action - variable Opiates (and Opioids) Side effects ›sedation ›respiratory depression Opiates (and Opioids) Side effects ›hypotension ›nausea ›allergic reactions Opiates (and Opioids) Side effects ›allergic symptoms common (histamine), itching, hives, etc. Opiates (and Opioids) Reversibility agents - naloxone (can be dose dependent) Benzodiazepines Drug class and examples ›sedative hypnotic Benzodiazepines Drug class and examples ›Valium® ›Versed® Benzodiazepines Drug class and examples ›Ativan® ›Xanax® Benzodiazepines Primary indications ›anxiolysis ›sedation ›seizure control Benzodiazepines Primary indications ›muscle spasm mitigation ›vertigo Benzodiazepines Routes › by mouth (PO) ›IM ›IV Benzodiazepines Routes ›subcutaneous (SC) ›IO Benzodiazepines Most common side effects ›sedation ›somnolence Benzodiazepines Most common side effects ›hypoventilation ›hypotension ›coma Benzodiazepines Most common side effects ›some patients are sensitive to them (idiosyncratic effect) Benzodiazepines Reversibility agents - Flumazenil ® (Romazicon ) Ketamine Drug class ›dissociative anesthetic ›hypnotic Ketamine Drug examples ›commonly used illicitly Ketamine Drug examples ›street/slang names = special K, K-hole, etc. Ketamine Most common side effects ›tachycardia ›hypertension Ketamine ›“emergence phenomenon” secretions increased Ketamine patients maintain respiratory drive Ketamine Pharmacokinetics - works on central nervous system... Ketamine Pharmacokinetics ...N-Methyl-Daspartate (NMDA) receptors Ketamine Research ›using for patients with excited delirium Ketamine Research ›use in patients that are acutely combative and violent Ketamine Reversibility agents - none Ketamine Emergence phenomenon patients dissociated when it starts to wear off Propofol Propofol Drug class and example ›sedative hypnotic ›anesthetic ® (Diprivan ) Propofol Most common side effects ›has antiemetic properties Propofol ›causes significant hypotension ›respiratory depression Propofol ›cross-allergy to eggs and soy problematic Nitrous Oxide Drug class and examples ›inhalational anesthetic ›anxiolytic Nitrous Oxide Drug class and examples ›laughing gas Nitrous Oxide Most common side effects ›nausea ›dysphoria Nitrous Oxide ›hypoxia ›hypotension ›respiratory depression Nitrous Oxide Must be mixed with oxygen to avoid making patient hypoxic Situational Choices Ideal medication may not exist, but the situation may be helpful Situational Choices Can be based on: ›patient condition and vital signs ›needed duration of action Situational Choices Can be based on: ›desired effect, analgesia vs. amnesia vs. sedation Situational Choices Local protocols and accessibility Scenarios Pediatric Entrapment Pediatric Entrapment You are called to scene where a 10-year-old male with his arm stuck in a coke machine slot: Pediatric Entrapment ›no medical history ›normal anatomy/exam Pediatric Entrapment ›cannot access the arm Pediatric Entrapment Extrication: fire department advises they will have to “pull” on the arm Child with Entrapped Arm Desired effect: analgesia, axolysis Child with Entrapped Arm Duration: short term (<10 minutes) Child with Entrapped Arm Delivery route/available: all available Child with Entrapped Arm Anticipated complications/side effects ›difficulty in controlling airway Child with Entrapped Arm Anticipated complications/side effects ›vomiting problematic Child with Entrapped Arm Contraindications: patient has an egg allergy Child with Entrapped Arm Justified ›risk of severe pain in a child ›visible disfigurement Best drug choices for entrapped child? Ketamine would have been an excellent choice Elderly Person with Fractured Hip Elderly with Fractured Hip 85-year-old female; fall and hip injury: Elderly with Fractured Hip ›severe pain with any movement ›begs you not to “move her” and screams Elderly with Fractured Hip ›history of hypertension,... Elderly with Fractured Hip ...coronary artery bypass graft (CABG), diabetes mellitus (DM) Elderly with Fractured Hip ›vital signs (V/S) blood pressure (BP) 106/70 heart rate (HR) 110 Elderly with Fractured Hip ›vital signs (V/S) respiratory rate (RR) 24 Elderly with Fractured Hip Desired effect: analgesia Duration: long term Elderly with Fractured Hip Delivery route/available: IV/IO/IM Elderly with Fractured Hip Anticipated complications/side effects: ›airway modifications Elderly with Fractured Hip Anticipated complications/side effects: ›respiratory depression Elderly with Fractured Hip Contraindications: hypotension (relative) Elderly with Fractured Hip Audience electronic response ›opiates ›demerol Elderly with Fractured Hip Audience electronic response ›etomidate Elderly with Fractured Hip Audience electronic response ›propofol ›benzodiazepine Elderly with Fractured Hip Audience electronic response ›nitrous oxide ›succinylcholine Patient Needing Cardioversion Cardioversion 35-year-old male with chest pain ›supraventricular tachycardia (SVT), hypotensive Cardioversion 35-year-old male with chest pain ›long history, knows when he “goes into it”, 30 minutes ago Cardioversion 35-year-old male with chest pain ›says, “don’t you shock me while I’m awake again” Cardioversion ›history of WolffParkinson-White (WPW) syndrome, SVT,... Cardioversion ...hypertrophic cardiomyopathy (HCM), ablation 1 year ago Cardioversion ›exam reveals anxious patient, poor pulses BP 86/48 HR 176 RR 30 Cardioversion Desired effect ›analgesia and amnesia ›axiolysis Cardioversion Duration; very short term Delivery route/available; IV/IO/IM Cardioversion Contraindications; hypotension Cardioversion Justified; cases of documented post-traumatic stress disorder Cardioversion Audience electronic response ›Versed® ›Ativan® ›Valium® Cardioversion How about Etomidate? Cardioversion Ketamine Pediatric Asthma: Intubated Pediatric Asthma: Intubated You arrive to transfer a 6-year-old male with asthma: Pediatric Asthma: Intubated ›patient already intubated Pediatric Asthma: Intubated ›not well sedated, difficult to bag (very “tight”, fighting the vent) Pediatric Asthma: Intubated ›no other medical history Pediatric Asthma: Intubated ›V/S BP 132/90 HR 100 Pediatric Asthma: Intubated ›V/S RR 32 spontaneous oxygen saturation (hemoglobin) or SaO2 90% Pediatric Asthma: Intubated Desired effect? ›analgesia ›amnesia ›decreased respiratory drive Pediatric Asthma: Intubated Desired effect? ›increased pulmonary compliance (ease of ventilation) Pediatric Asthma: Intubated Audience electronic response ›opiates ›ketamine Pediatric Asthma: Intubated Audience electronic response ›propofol ® ›Versed Pediatric Asthma: Intubated Caregiver precautions ›approved use ›appropriate age ›authorization to use General Summary Thoughts General Summary Thoughts Use pain medication for most pain General Summary Thoughts Quick procedures should merit a quick-acting agent General Summary Thoughts Take advantage of the known side effects of different medications General Summary Thoughts Know the specific contraindications to specific agents Extenuating Circumstances Extenuating Circumstances Should we ever intubate patients for severe pain? Extenuating Circumstances ›going to the operating room anyway ›risks/complications Extenuating Circumstances What about sedation for violent or combative patients? Extenuating Circumstances Following this part of the program, Darrin M. Batty presents Positional Asphyxia: An In-Custody Phenomenon Partner with Law Enforcement Some noncompliant citizens may actually be people in the throws of a medical emergency Partner with Law Enforcement EMS can help mitigate the issue Sudden In-Custody Death Positional/postural asphyxia - is a form of asphyxia which occurs when someone's... Sudden In-Custody Death ...position prevents them from breathing adequately Sudden In-Custody Death Excited delirium or "acute exhaustive mania,” is a state of extreme... Sudden In-Custody Death ...mental and physiological excitement Sudden In-Custody Death A misunderstood phenomenon Sudden In-Custody Death Police procedures, techniques, and tools have been blamed: Sudden In-Custody Death ›1980 - "choke holds“ Sudden In-Custody Death ›“Hogtie" hobble device Sudden In-Custody Death ›intermediate tools chemical agents and electronic weapons, ® such as Tasers Sudden In-Custody Death None of these tools or techniques are the causes in and of themselves Excited Delirium 50 to 105 in-custody deaths every year: Excited Delirium ›police department (PD) sees as detain and arrest scenarios, not serious medical issues Excited Delirium ›similar deaths also occur in psychiatric and geriatric care facilities Excited Delirium People with a mental illness, (bipolar disorder or schizophrenia) Excited Delirium Chronic, illicit stimulant (cocaine, methamphetamine, phencyclidine [PCP]) abusers... Excited Delirium ...and ecstasy, marijuana, or alcohol abusers Excited Delirium Combination of mental illness and substance abuse Excited Delirium Most subjects police encounter with excited delirium are males... Excited Delirium ...between the ages of 30 and 40 (rarely seen in females) The Perfect Storm Pathology/physiology Illicit substances Law enforcement Pathology/Physiology Predisposed to sudden death Pathology/Physiology Organic disease: Pathology/Physiology ›preexisting cardiac abnormality (cardiomyopathy) ›obesity Pathology/Physiology ›chronic alcohol abuse Pathology/Physiology Mental illness ›bizarre behavior ›anxious Pathology/Physiology Mental illness ›irrational ›violent Pathology/Physiology ›not communicating or communication is incomprehensible or repetitive Pathology/Physiology ›exhibit extreme paranoia ›screaming for no reason or at no one Pathology/Physiology ›may shed clothing or be naked ›hallucinating Pathology/Physiology Metabolic acidosis Hyperthermia Dehydration Illicit Substances Under the influence of something (with alcohol) Illicit Substances Also under the influence of illicit drugs such as: Illicit Substances ›cocaine ›methamphetamine ›PCP Illicit Substances May be sweating profusely Illicit Substances No apparent sensitivity to pain stimuli Illicit Substances Display superhuman endurance and strength Illicit Substances Body temperature is elevated (face, head, and neck appear reddened or flushed) Law Enforcement Able to violently resist several officers and application of restraints Law Enforcement After control is achieved, the person continues to struggle Law Enforcement May exhibit muscle rigidity Law Enforcement Breathing may become impaired or restricted by control and restraint techniques... Law Enforcement ...or due to overexertion or exhaustion Law Enforcement After sustained and extreme exertion, the person suddenly becomes still and quiet Law Enforcement Death may occur What do police do to gain compliance? Chemical Agents Chemical Agents Deployment of chemical agents ›direct application ›space deprivation Chemical Agents Decontamination ›tincture of time and fresh air › cool water Chemical Agents Decontamination ›folk remedies (baby shampoo, milk) Chemical Agents (Medical Concerns) Respiratory irritation (worsen preexisting conditions such as asthma) Chemical Agents (Medical Concerns) Anxiety High blood pressure Chemical Agents (Medical Concerns) Lasts longer time than expected Medical conditions Oleoresin Capsicum Oleoresin capsicum ® (OC), Cap-Stun , or pepper spray - causes swelling of eyes and respiratory distress Oleoresin Capsicum Inflicts pain on skin that can outlast other symptoms Oleoresin Capsicum Symptoms can reoccur hours later OC - Pepper Spray Chemical Agents Orthochlorbenzalmalononitrile (CS) “Tear Gas” Tear Gas Causes uncontrolled blinking and excessive discharge from the nose Tear Gas Heavy coughing and sneezing is a common result Syncope is rare CS - Tear Gas Conducted Energy Weapons Taser® Electro-muscular Disruption Weapon Taser® Range of up to 21 feet; 24 feet for tactical operations Taser® 50,000 volts, 26 watts, and 3.5 milliamps; 60 muscular contractions per second Taser® Probes penetrate less than quarter inch One of the most researched, less lethal weapons (LLW) Taser® Injuries Small metal probes: ›enter skin only 5-7 mm Taser® Injuries Small metal probes ›standard operating procedure: leave in place, cut the wires Taser® Injuries Small metal probes ›tasered subjects go to emergency department Taser® Injuries Falls ›standing height - not much risk ›What might they hit? Taser® Injuries Falls ›treat injuries ® (remove Taser hooks) Taser® Positional Asphyxia Three-point Landing Three-point Landing Struggle/resistance OC ® or Taser used create window of opportunity to Three-point Landing Restraint technique Restriction of chest wall may prevent full breaths Positional Asphyxia Three-point Landing Three-point Landing Officer’s weight Obesity Three-point Landing Hand Cuffs Arms restrict chest movement Three-point Landing Hobbled Legs Pull arms; restricting the chest Three-point Landing Do NOT leave restrained prone Three-point Landing Do NOT leave restrained prone Do NOT leave alone Three-point Landing Continued struggle = excited delirium Three-point Landing EMS called for assessment and evaluation, if in doubt Management of Excited Delirium Management Tranquilizer/sedative ® ›Haldol ›Valium® ›Versed® Management Reduce temperature Manage acidosis and dehydration Management Ventilation Management Sedation decreases exertion/agitation Management Re-restraint allows caregiver to reassess the patient In-Custody Death Factors Death Factors Struggle prior to arrest Prone restraint Stimulant or hallucinogenic usage Death Factors Drug or alcohol intoxication Obesity Other medical issues Death Factors Excited delirium Summary Not without risk (but less risk for officers and for public) Summary Be hypervigilant in recognizing symptoms Summary Educate law enforcement if not already Thank You EMS 80411 Prehospital Setting: Sedation/Positional Asphyxia If you have any questions about the program you have just watched, you may call us at: (800) 424-4888 or fax (806) 743-2233. Direct your inquiries to Customer Service. Be sure to include the program number, title and speaker. EMS 80411 Release Date: 12/01/2011 The accreditation for this program can be found by signing in to www.ttuhsc.edu/health.edu EMS 80411 This continuing education activity is approved by the Continuing Education Coordinating Board for Emergency Medical Services for 1.5 basic CEH. You have participated in a continuing education program that has received CECBEMS approval for continuing education credit. If you have any comments regarding the quality of this program and/or your satisfaction with it, please contact CECBEMS at: CECBEMS -12200 Ford Road, Suite 478 Dallas, TX 75234 Phone: 972-247-4442 [email protected]