1. Sedation Complications, Urgencies and Emergencies

2. 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”

3. Golden Rule In cases of trouble
Always verify adequate respirations of your patient
Ventilate
Reverse

4. Sedation Emergencies Nausea/Vomiting Aspiration Paradoxical reactions
Oversedation
Laryngospasm

5. Nausea/Vomiting Most commonly associated with Opioids Swallowing blood
Patient movement will aggravate
Swallowing blood
Anxiety

6. Treatment of Nausea and Vomiting…
Promethazine (Phenergan)
25 mg IV, IM, oral or rectal
Additive sedative effect
Trimethylbenzamide (Tigan)
mg oral, rectal, IM
Questionable efficacy
Ondansetron (Zofran)
4 mg IV or IM

7. 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

8. 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

9. Aspiration Treatment Aggressive suctioning Head down position
Transfer to hospital quickly

10. 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?

11. Paradoxical Reactions…
Benzodiazepines primary culprit
More common in women and children
Crying
Anger
Agitation
Combativeness
Pruritis
Disorientation
Dysphoria
Tachycardia

12. Paradoxical Reactions…
Benzo’s remove inhibitions in some patients
Patients with mental disorders more likely
Treatment
Flumazenil

13. Oversedation…
Any level of sedation or anesthesia can be achieved by any route
Inhalational
Orally
Parenteral

14. Oversedation… Your patient is clearly oversedated when they do not…
Maintain their own patent airway
Breath on their own
Respond to verbal commands

15. 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

16. Oversedation… Overuse of opioids often results in…
Respiratory depression
Decreased depth, rate and drive
Decreased skeletal muscle tone

17. Respiratory Depression…
In the presence of respiratory depression patients may…
Obstruct
Muscle relaxation
Tongue position
Hypoventilation to the point of apnea

18. 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

19. Oversedation…
Oversedation will generally imply that your patient does not…
Hold his own airway
Breath spontaneously
Both

20. Oversedation… You absolutely, positively Must
be able to distinguish between the two

21. 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

22. 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: mg/kg
Naloxone
Intended use—IV
May be given—IM, SL, SC
Dose: mg
Pedi: 0.01 mg/kg

23. 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

24. 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

25. 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

26. Laryngospasm Treatment Remove any obvious foreign material
Ventilate forcefully with oxygen
Reverse the sedative agent