Otto F Sabando DO FACOEP Program Director Emergency Medicine Residency St. Joseph’s Regional Medical Center Paterson NJ

Death by over sedation! Dr Murray Using cocktail for sleep June 25 the following administered: valium 10 mg ativan 2 mg repeated doses versed 2mg repeated doses propofol 25mg

 Procedural Sedation and Analgesia (PSA)  Administer sedatives, analgesics, and/or dissociative agents to induce a state allowing the patient to tolerate an unpleasant procedure while maintaining cardiorespiratory function

 Minimal sedation (anxiolysis)  Drug induced state during which patients respond normally to verbal commands  Cognitive function and coordination may be impaired

 Moderate sedation (formerly “conscious sedation”)  Drug induced depression of consciousness during which patients respond purposefully to verbal commands either alone or accompanied by light tactile stimulation  No interventions for airway mgt. spontaneous ventilation is adequate along with cardiovascular function

 Dissociative sedation:  Trans-like cataleptic state induced by dissociative agent (ketamine) and characterized by profound analgesia and amnesia  Airway reflexes and cardiopulmonary systems are maintained by patient

 Deep sedation:  Drug-induced depression of consciousness and respond to painful stimuli  Ventilation usually needs to be assisted  Cardiovascular function is maintained

 General anesthesia  Drug-induced loss of consciousness  Not arousable by painful stimuli  Positive pressure ventilation is usually required  Cardiovascular function may be impaired Green SM, Krauss B: Procedural sedation terminology: Moving beyond “conscious sedation.” Ann Emerg Med 39:433,2002

 Ideal pharmacologic agent for sedation  Effective, rapid onset, easily titratable with predictable duration of action  Quickly eliminated or reversible  No adverse effects  Easy and painless to administer

 Anesthetic agents  Propofol (diprivan)  Lipid soluble  Onset of action 6-7 min.  Resolves rapidly 5-10 min  Adult dose: mg/kg  Pediatric dose: 1mg/kg

 Side effects:  Painful at injection site  Respiratory depression  Apnea incidence similar to thiopental, methohexital and etomidate  Cardiovascular  Hypotension (peds and elderly)  Allergies  Eggs and soy, propofol is contraindicated

 Benefits  Intractable seizure, trauma patients

 Etomidate:  Carboxylated imidazole-containing compound  Induces sedation through GABA receptors in CNS  Induction agent  Rapid onset 2 min  Lacks cardiovascular side effects  Pain on injection  Adult mg /kg  Peds mg/kg

 Side effects  Myoclonic activity  Emergence phenomenon  Adrenal suppression with prolonged use

 Anxiolytics: Benzodiazepines  Treat anxiety, unruly intoxicated patients, belligerent patients, drug induced psychosis etc.  Anticonvulsant properties  No change in intracranial pressure

 Midazolam (Versed)  mg/kg  Amnesia  Inhibit GABA  Onset of action 3 minutes  Duration of action minutes

 Side effects:  Decreased respiratory drive  Cytochrome P450 inhibitors can reduce metabolism of versed  Elderly and chronically ill patients, reduce the dose by half

 Dissociative agent  Ketamine: sedative analgesic, dissociates cortical and limbic systems  Produces sedation, analgesia and amnesia  1mg/kg

 Onset of action 1 minute  Effective in asthma/COPD  Bronchdilator effect  Emergence reaction  Tx with benzodiazepine  Multiple routes of administration

 Contraindications to ketamine use:  Age of 3 months or younger  Active pulmonary infection  Procedures resulting in large amounts or oral secretions or blood  History of tracheal stenosis  History of angina, CHF, aneurysm, uncontrolled HTN  Intracranial increase pressure, glaucoma  Psychiatric illness

 Opioids  Fentanyl (sublimaze)  times more potent than morphine  2-4 mcg/kg titrated in doses of mcg/kg every 3-5 min  1/3 the dose is used in infants as metabolism is prolonged

 Side effects  Rigid chest syndrome  Non reported in the EM literature  Respiratory depression  Less than morphine or meperidine

 Fentanyl Lollipops  mcg/kg  Onset of action min.  Mean time to discharge 90 min from ED  Side effects  Pruritis common  Vomiting 10% of patients

 Rarely indicated  Used in life-threatening cases  Should not be used for the sake of a more rapid discharge from the ED

 Chloral Hydrate: considered as a second line agent  Sedative/hypnotic, no analgesic properties  Primarily used for infants and young children for painless diagnostic procedures  Time to sedation:  minutes  Dose mg/kg can be given PR  Time to recovery  40 minutes

 Side effects:  Ectopic ventricular beats seen 10% of patients

 Always review the medical history of the patient.  Use certain medications in certain situations and watch for contraindications  Review the dosages with the nurse and make sure the weight base dose is accurate  Always monitor the patient and be prepared for unexpected complications  Make sure the patient is back to baseline prior to discharge