Sedation Complications, Urgencies and Emergencies

Medical Emergency Kit A thoughtful, calm mind is the most important part of any emergency kit What your eyes see and what your ears hear (quite doctor, the patient is telling you the diagnosis) Your ability to problem solve with your mind will largely determine the outcome of any “emergency”

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 Swallowing blood 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 Causes Inhaling of vomit into lungs Depression of protective reflexes with depressed level of consciousness Increased N/V associated with opioids Swallowing of blood

Aspiration Damage: Particles/fluids Large particles 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 NPO solids > 6 hours 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 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 Dose: 0.2 mg (2cc) Naloxone Dose: 0.1-0.4 mg 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