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

2. 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

3.  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

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

5.  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

6.  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

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

8.  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

9.  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

10.  Anesthetic agents  Propofol (diprivan)  Lipid soluble  Onset of action 6-7 min.  Resolves rapidly 5-10 min  Adult dose: 2-2.5 mg/kg  Pediatric dose: 1mg/kg

11.  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

12.  Benefits  Intractable seizure, trauma patients

13.  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 0.1-0.3 mg /kg  Peds 0.3-0.4 mg/kg

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

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

16.  Midazolam (Versed) .02-.03mg/kg  Amnesia  Inhibit GABA  Onset of action 3 minutes  Duration of action 60- 120 minutes

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

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

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

21.  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

22.  Opioids  Fentanyl (sublimaze)  80-100 times more potent than morphine  2-4 mcg/kg titrated in doses of 0.5-1.0 mcg/kg every 3-5 min  1/3 the dose is used in infants as metabolism is prolonged

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

24.  Fentanyl Lollipops  10-15 mcg/kg  Onset of action 12-30 min.  Mean time to discharge 90 min from ED  Side effects  Pruritis common  Vomiting 10% of patients

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

26.  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:  45-60 minutes  Dose 25-50 mg/kg can be given PR  Time to recovery  40 minutes

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

28.  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