1. Procedural Sedation in the Emergency Department
Deon Stoltz

2. Objectives What does it mean What needs to be considered.
What do we normally use it for.
Review commonly used agents
Briefly discuss alternatives to PSA

3. Overview
DISCLAIMER….
This is a very simplified overview of a complex topic.
It is not a substitute for in-depth research, background knowledge and training.

4. What is Procedural Sedation?
To reduce patient anxiety and awareness
To facilitate a painful medical procedure
Patient maintains their airway & breathing
- a.k.a “conscious sedation” “deep sedation”

5. Procedural Sedation Positives Negatives
Avoids the discomfort associated with local or regional anaesthetic techniques.
Doesn’t affect anatomy
Relatively simple technique
Negatives
Consumes resources
General anaesthesia in the ED
is frowned upon…

6. The goals of PS
To consider patient safety & welfare the first priority.
To provide adequate analgesia, anxiolysis, sedation and amnesia during the performance of painful diagnostic or therapeutic procedures in the ED.
To minimize the adverse psychological responses associated with painful or frightening medical interventions.
To control motor behaviour that inhibits the provision of necessary medical care.
To return the patient to a state in which safe discharge is possible.

7. How low should you go? Depth of Procedural Sedation
Minimal Sedation (Anxiolysis)
Moderate Sedation/Analgesia
Deep Sedation/Analgesia
General Anaesthesia
Normal LOC
ASA/Joint Commission of Accreditation of Healthcare Organizations – Definitions of Levels of Sedation
Minimal sedation: normal response to verbal commands. Ventillatory & CV function unaffected.
Moderate sedation: pt responds to verbal commons +/- light tactile stimulus. No interventions required to maintain airway. Spont resp. CV function maintained.
Deep sedation: pt cannot be aroused, but responds purposefully to repeated or painful stimulation. May require assistance maintaining a patent airway. Spont vent may be inadequate.
General anaesthesia: Pt is unarousable. Patient typically requires assistance maintaining an airway +/- PPV.

8. Uses Reduction of dislocations: shoulder, elbow, hip, patella, ankle
Reduction of fractures:
wrist, ankle
washout compound fracture
Paediatric injuries:
wound inspection, closure, suturing
Abscess I&D

9. Considerations for PS in the ED
Patient
Agent
Environmental

10. Case – Mr. F. B.

11. Case
A 40 yo man presents with a painful, swollen right wrist after a fall. You do an x-ray…

12. So what about our patient?
Allergies:
Eggs
Medications:
Enalapril
Salbutamol
Flovent
Past Medical History:
Asthma
Obstructive sleep apnea
Hypertension
DM II
Last Meal:
30 minutes ago
Events:
Patient came immediately to the hospital after falling.

13. To sedate or not to sedate… 86 yo female with a dislocated hip
Allergies: NKDA
Meds:
Metoprolol
Nitroglycerin patch
Enalapril
Lasix
ASA
Atrovent
Last meal:
NPO for 4 hours
PMHx:
MI x 2 (multi-vessel CAD)
Angina with minimal activity
PVD
HTN
CVA
CRF
Events:
Pt felt a pop while trying to get up from a chair.
CAD…
Limited ability to tolerate hypotension

14. To sedate or not to sedate… 22 yo intoxicated male with an ankle fracture
Allergies: NKDA
Meds: unknown
PMHx: unknown
Last meal:
Smells like EtOH
Unknown
Events:
No one really knows
Aspiration & airway reflexes:
Will he protect his airway?
No idea of NPO status
Increased risk of aspiration
Consent
Double doctor is possible
Consider timing of reduction

15. To sedate or not to sedate… 28 yo female with a fractured wrist
What risks are associated with sedation during pregnancy?
Difficult intubation
Difficult BVM
Increased risk of aspiration

16. Patient Assessment The AMPLE history Physical Exam Allergies
Medications
Past medical history
Last meal
Events before & after the incident
Physical Exam
Airway assessment
Respiratory exam
Cardiovascular exam

17. ASA Physical Status Classification
Healthy Patient
Mild systemic disease – no functional limitation
Severe systemic disease – definite functional limitation
Severe systemic disease that is a constant threat to life
Moribund patient that is not expected to survive with the operation
Low inter-observer reliability.

18. “It’s only a little chest pain” ASA Scores & PSA
The ASA classification is not validated outside of the OR.
Malviya et al showed an increased risk of adverse sedation-related events in paediatric patients with an ASA > 2.
The ASA was developed to help identify patients at risk of developing complications as a result of undergoing general anesthesia.
ASA: No formal support by emergency medicine associations; Supported by the American society of anestheologists

19. “The patient’s ASA status should be determined
“The patient’s ASA status should be determined. For non-emergent procedures, ED sedation and analgesia should be limited to ASA class 1 or 2 patients.”
Class B, Level III
Procedural sedation and analgesia in the emergency department
Canadian Consensus Guidelines
The guidelines go on to say that for ASA III-IV patients, anesthesia should be consulted and OR management should be considered.
ASA status was not addressed in the American guidelines.

20. The Last Supper Fasting & PSA
ANZCA recommendations for healthy elective GA patients:
2 h NPO for liquids
6 h NPO for solids
The risk of aspiration during PSA is extremely low.
There is no evidence that fasting improves outcome during procedural sedation and analgesia.
One large paediatric study of ED procedural sedation showed no increase in the number of adverse events in patients that were not fasting.
In addition, the ASA indicates that there is no role for the use of antacids and gastric motility agents to prevent aspiration during elective GA in healthy patients. The ACEP guidelines apply this recommendation to ED PSA patients, while the Cdn guidelines recommend their use in patients who do not meet NPO criteria.
Green proposes a number of reasons why the the ASA guidelines should not be generalized to ED PSA
Aspiration is most likely to occur during airway manipulation – this should not be happening during PSA.
PSA is typically performed in younger patients. The risk of aspiration is higher in older patients.
Most agents used during PSA are not pro-emetic, unlike the gases which are commonly used in the OR.
Ideally, PSA should be in the range of moderate sedation with intact airway reflexes
The use of dissociative amnestics (ketamine) theoretically reduces the risk of aspiration because airway reflexes are “intact”

21. Starved for how long…?
Controversial.
Probably not as rigid as anaesthetic guidelines for GA...
Depends on degree and duration of sedation
Starship CED paediatric guideline:
Clear fluids: at least 2 hours
Non-clear fluids and solids: at least 4 hours

22. PATIENT SELECTION Can you hold the fort if something goes wrong?
BREATHING & CIRCULATION:
Lung disease?
Stable cardiac status?
BP stable?
Medications
Allergies (e.g. watch out for soy, eggs: Propofol)

23. Airway Assessment
Can you bag?
Can you intubate?

24. Predictors of Difficult BVM Ventilation
Beard
Obesity
Old (age > 55 yrs)
Toothless
Snores
Langeron O, Masso E, Huraux C, et al. Prediction of difficult mask ventilation. Anesthesiology ; 92:

25. The LEMON Method of Airway Assessment
Look for external characteristics known to causes problems with BVM or intubation.
Evaluate the Rule:
Mouth opening > 3 fingers
Hyoid – chin distance > 3 fingers
Anterior low jaw subluxation > 1 finger
Mallampati Score
Obstruction – any pathology within or surrounding the upper airway
Neck Mobility - full flexion & extension

26. Considerations for PS in the ED
Patient
Agent
Environmental

27. The Perfect Drug Provides adequate sedation and analgesia for:
Patient comfort
Easy completion of the procedure
Maintains airway reflexes
Does not affect hemodynamics
Does not affect respiratory function

28. Commonly Used Agents
Propofol
Fentanyl
Ketamine
Midazolam

29. Commonly Used Agents Propofol
Category
Sedative-Hypnotic
What is it?
2,6-diisopropofol, an alkylphenol oil in an emulsion
How does it work?
Potentiates GABA activity
How much do you need?
Starting dose of mg/kg
Actual half-life of propofol is 4-7 hrs
Clearance is independent of renal or liver function and is not affected by renal or hepatic disease.
Onset is one arm-brain circulation with peak affect at s.
Anti-emetic properties

30. Commonly Used Agents Propofol
What else does it do?
CNS: Mild analgesic properties; euphoria
CVS: Myocardial depressant; vasodilation
Resp: Respiratory depressant
GI: Antiemetic
MSK: Myoclonus
What does the body do with it?
Rapid redistribution
Hepatic and extrahepatic metabolism

31. Commonly Used Agents Propofol
Pros
Shown to be safe for ED PSA use
Rapid onset and recovery
Cons
Must be combined with an analgesic agent
May cause apnea & loss of airway reflexes
Myocardial depressant and vasodilator
Symington and Thakore conducted a review of the safety of using propofol for procedural sedation in the ED and concluded that while the rate of “minor” adverse events (including transient hypoxia) was similar to other agents, the drug was overall very safe and offered advantages over other agents.

32. Commonly Used Agents Fentanyl
Category
Analgesic agent
What is it?
Synthetic opioid
How does it work?
Decreases conduction along nociceptive pathways and increases activity in pain control pathways in the brain.
How much do you need?
Starting dose of 1-2 mcg/kg
Doses > 5 mcg/kg bolused rapidly are required to cause chest wall rigidity. Rigidity is managed with paralysis or reversal agents.
May cause coughing in 50% of patients.
Peak effect in 2-3 min

33. Commonly Used Agents Fentanyl
What else does it do?
CNS: Euphoria (or dysphoria)
Resp: Respiratory depressant; chest wall rigidity
CVS: May decrease HR
GI: Decreased motility
What does the body do with it?
Hepatic metabolism (inactive metabolite)
Renal excretion

34. Commonly Used Agents Fentanyl
Pros
Good hemodynamic stability
Rapid onset and recovery
Cons
Must be combined with an amnestic agent
May cause bradycardia
May cause chest wall rigidity
May cause apnea & loss of airway reflexes
Cardiology study using high dose fentanyl for cardiac surgery – patients were hemodynamically stable and pain free.

35. Commonly Used Agents Midazolam
Category
Amnestic
What is it?
Benzodiazepine
How does it work?
Bind to benzodiazepine receptors which up- regulate GABA activity
How much do you need?
0.02 – 0.1 mg/kg IV
Use with caution in patients with renal failure b/c of potential buildup of metabolite.

36. Commonly Used Agents Midazolam
What else does it do?
CNS: Anxiolysis
CVS: Slight decrease in PVR & decreased contractility.
Resp: Respiratory depression
What does the body do with it?
Hepatic metabolism (active metabolite)
Renal excretion

37. Commonly Used Agents Ketamine
Category
Dissociative Amnestic
What is it?
Derivative of phencyclidine with some opioid properties.
How does it work?
Stimulates the limbic system while inhibiting the thalamus & cortex (dissociation)
Binds to NMDA and opioid receptors
Metabolite (norketamine) has 20-30% less activity than ketamine
Onset within 30 s of administration (IV)
Distribution half life is minutes (two compartment metabolism)

38. Commonly Used Agents Ketamine
What else does it do?
CNS: Emergence reactions
CVS: Increased contractility, HR and PVR through sympathetic stimulation. Direct myocardial depressant.
Resp: Laryngospasm, bronchodilation, increased secretions
What does the body do with it?
Hepatic metabolism
Renal excretion

39. But won’t it give him nightmares? Ketamine & Emergence Reactions
Frequency is reported to be anywhere from <1% to 50% in adults.
Treatment with benzodiazepines is the most effective way to prevent emergence reactions.
Emergence reaction: Anxiety, nightmares, hallucinations & delirium while waking up
Ketamine is extensively used in developing countries with great success.
Evidence for benzos is debateable – several peds trials show no benefit. Anecdotally, some people will wait for signs of emergence before giving midazolam while others give it with ketamine. Two trials from the 70’s show a reduction in the incidence of emergence reactions when adult patients were pretreated with midazolam

40. Commonly Used Agents Ketamine
How much do you need?
1 – 2 mg/kg IV
How much midazolam?
0.7 mg/kg given at the time of ketamine injection.
Several authors pointed out that this dose of midazolam may be higher than required to prevent emergency reactions.

41. Mix & Match Commonly used combinations: Propofol + Fentanyl
Fentanyl + Midazolam
Propofol + Midazolam + Fentanyl
Ketamine + Midazolam
Combinations of propofol + fentanyl, fentanyl + midazolam etc lead to synergistic effects on the cardiovascular system. This results in greater than expected amounts of hypotension, which is tolerated in the young health individual, but may be problematic in someone with less reserve.
Midazolam may decrease the rate of ketamine metabolism, resulting in greater duration of sedation.

42. How low should you go? Depth of Procedural Sedation
Minimal Sedation (Anxiolysis)
Moderate Sedation/Analgesia
Deep Sedation/Analgesia
General Anaesthesia
Normal LOC
ASA/Joint Commission of Accreditation of Healthcare Organizations – Definitions of Levels of Sedation
Minimal sedation: normal response to verbal commands. Ventillatory & CV function unaffected.
Moderate sedation: pt responds to verbal commons +/- light tactile stimulus. No interventions required to maintain airway. Spont resp. CV function maintained.
Deep sedation: pt cannot be aroused, but responds purposefully to repeated or painful stimulation. May require assistance maintaining a patent airway. Spont vent may be inadequate.
General anaesthesia: Pt is unarousable. Patient typically requires assistance maintaining an airway +/- PPV.

43. Considerations for PS in the ED
Patient
Agent
Environmental

44. PREPARATION Prepare for the worst…. What can go wrong?
Unexpected drug reaction or anaphylaxis
Vomit and aspirate
Obstructed airway (e.g. laryngospasm, tongue)
Apnoea, respiratory arrest
Profound hypotension

45. PREPARATION Not quite the worst … What can go wrong?
Disinhibition / agitation
Terrors, nightmares
Unexpected drug reactions: dystonias
Inadequate sedation
Unsuccessful procedure… still needs GA

46. USE OF INTRAVENOUS SEDATION FOR PROCEDURES IN THE EMERGENCY DEPARTMENT
PREPARATION
ACEM POLICY DOCUMENT -
USE OF INTRAVENOUS SEDATION FOR PROCEDURES IN THE EMERGENCY DEPARTMENT
© ACEM. 5 December 2001

47. PREPARATION ENVIRONMENT
The procedure must be performed in a suitable clinical area with facilities for:
Monitoring,
Oxygen
Suction
immediate access to emergency resuscitation equipment, drugs and other skilled staff.

48. PREPARATION ENVIRONMENT Readily available equipment must include:
resuscitation trolley
defibrillator

49. PREPARATION ENVIRONMENT Readily available equipment must include:
resuscitation trolley
Defibrillator
Bag-Valve-Mask device for ventilation

50. PREPARATION MONITORING
Cardiac rhythm, non-invasive blood pressure and pulse oximetry must be monitored throughout the procedure and recovery period

51. PREPARATION PERSONNEL
The involvement of at least two clinical staff is required:
PERSON PERFORMING PROCEDURE
must understand the procedure and its potential complications.
PERSON GIVING DRUGS AND MONITORING PATIENT - must have training and experience of resuscitation, emergency drugs and …. (details of) the drugs used.
This person is not involved in the performance of the procedure but is dedicated to care and monitoring of the patient.

52. PREPARATION PERSONNEL
The involvement of at least two clinical staff is required:
PERSON PERFORMING PROCEDURE
must understand the procedure and its potential complications.
PERSON GIVING DRUGS AND MONITORING PATIENT - must have training and experience of resuscitation, emergency drugs and …. (details of) the drugs used.
This person is not involved in the performance of the procedure but is dedicated to care and monitoring of the patient.

53. PREPARATION PERSONNEL
The involvement of at least two clinical staff is required:
SUPERVISING PERSON –
a specialist or advanced trainee in emergency medicine who has specific experience in airway control and resuscitation must be either directly involved in the procedure (taking one of the above roles) or must be aware of the procedure and provide overall supervision and back-up assistance.

54. PREPARATION PATIENT PREPARATION Explanation Consent
Secure IV access is mandatory.

55. PREPARATION Other requirements Separate space to perform the procedure
A recovery space: ideally quiet, available for 1-2 hours, easily observed.

56. READY TO GO… Explain Pre-oxygenate IV Access and IV fluid running
Splints or plaster or equipment all ready to go
Hand over your phone or pager…

57. To sedate or not to sedate…

58. Phone a friend…
Consider sending the at-risk patient to the OR.

59. So what ARE you going to do?

60. Questions?

61. Key Points Be prepared Know your drugs and your drug interactions
Consider all your options

62. Other References Guidelines
Godwin SA, Caro DA, Wolf SJ, Jagoda AS, Charles R, Marett, BE and Moore J. Clinical policy: procedural sedation and analgesia in the emergency department. Annals of Emergency Medicine. 45:2. February 2005; pp
Innes G, Murphy M, Nijessen-Jordan C, Ducharme J and Drummond A. Procedural sedation and analgesia in the emergency department. Canadian consensus guidelines. The Journal of Emergency Medicine. 17:1. January 1999; pp 145 – 156.
Textbooks
Miller RD. Miller’s Anesthesia, 6th Ed
Marx JA. Rosen’s Emergency Medicine, 5th Ed
Roberts JR. Clinical Procedures in Emergency Medicine, 4th Ed
Tintinalli JE. Emergency Medicine: A Comprehensive Study Guide, 6th Ed

63. Other References Journal Articles
Syminton L and Thakore S. A review of the use of propofol for procedural sedation in the emergency department. Emergency Medicine Journal :
Green SM and Krauss B. Propofol in emergency medicine: pushing the sedation frontier. Annals of Emergency Medicine :
Bahn EL and Holt KR. Procedural sedation and analgesia: a review and new concepts. Emergency Medicine Clinics of North America :
Green SM. Fasting is a consideration – not a necessity – for emergency department procedural sedation and analgesia. Annals of Emergency Medicine :
Green SM and Sherwin TS. Incidence and severity of recovery agitation after ketamine sedation in young adults. American Journal of Emergency Medicine :
Green SM and Li J. Ketamine in adults: what emergency physicians need to know about patient selection and emergency reactions. Academic Emergency Medicine :7(3)

64. Procedural Sedation & Analgesia in the Emergency Department