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Procedural Sedation in the Pre-Hospital Setting Antoinette Eng, MD Albany Medical Center December 20, 2006.

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Presentation on theme: "Procedural Sedation in the Pre-Hospital Setting Antoinette Eng, MD Albany Medical Center December 20, 2006."— Presentation transcript:

1 Procedural Sedation in the Pre-Hospital Setting Antoinette Eng, MD Albany Medical Center December 20, 2006

2 EMS Procedural Sedation: Overview Definition Definition Indications Indications Medications Medications Recent Research Recent Research Summary Summary

3 Sedation Controlled reduction of environmental awareness

4 Sedation Dynamic

5 A Clinical Spectrum AnesthesiaAnxiolysis Moderate Sedation & Analgesia Deep Sedation & Analgesia

6 Minimal Sedation Minimal Sedation Drug-induced state Drug-induced state Impaired cognitive function & coordination Impaired cognitive function & coordination Responds to verbal commands Responds to verbal commands Ventilatory and cardiovascular functions intact Ventilatory and cardiovascular functions intact Anxiolysis

7 Previously known as “conscious sedation” Previously known as “conscious sedation” Depression of consciousness Depression of consciousness Respond purposefully to verbal commands alone or with light tactile stimulation Respond purposefully to verbal commands alone or with light tactile stimulation Ventilation and cardiovascular function intact Ventilation and cardiovascular function intact AnxiolysisModerate Sedation & Analgesia

8 Depression of consciousness Depression of consciousness Not easily aroused, but responds purposefully after repeated or painful stimulation Not easily aroused, but responds purposefully after repeated or painful stimulation May require airway and ventilatory support May require airway and ventilatory support Cardiovascular function maintained Cardiovascular function maintained AnxiolysisModerate Sedation & Analgesia Deep Sedation & Analgesia

9 Loss of consciousness Loss of consciousness Patient cannot be aroused by painful stimuli Patient cannot be aroused by painful stimuli Requires airway and ventilatory support Requires airway and ventilatory support Cardiovascular function may be impaired Cardiovascular function may be impaired Anesthesia AnxiolysisModerate Sedation & Analgesia Deep Sedation & Analgesia

10 Indications Procedures ProceduresCardioversion Transcutaneous Pacing Pre/Post-IntubationTransportExtrication Primary Treatment Primary TreatmentAnxiety Sympathomimetic Overdose Alcohol Withdrawal Pain Management Adjunct Pain Management AdjunctTrauma Acute Abdomen ACS Patient Restraint Patient Restraint

11 Indications Procedures ProceduresCardioversion Transcutaneous Pacing Pre/Post-IntubationTransportExtrication Primary Treatment Primary TreatmentAnxiety Sympathomimetic Overdose Alcohol Withdrawal Pain Management Adjunct Pain Management AdjunctTrauma Acute Abdomen ACS Patient Restraint Patient Restraint

12

13 Procedural Sedation: Medications Benzodiazepines Benzodiazepines Etomidate Etomidate Opiates Opiates Nitrous Oxide Nitrous Oxide

14 Benzodiazepines

15 Benzodiazepines GABA is major inhibitory neurotransmitter in CNS GABA is major inhibitory neurotransmitter in CNS 3 types of receptors: GABA-A, GABA-B, GABA-C 3 types of receptors: GABA-A, GABA-B, GABA-C GABA-A overwhelmingly numerically dominant receptor in CNS GABA-A overwhelmingly numerically dominant receptor in CNS BZO bind and allosterically modify receptor BZO bind and allosterically modify receptor Potentiate GABA response Potentiate GABA response Increase hyperpolarization Increase hyperpolarization Increase neuronal inhibition at all levels of the neuraxis, including the spinal cord, hypothalamus, hippocampus, substantia nigra, cerebellar cortex, and cerebral cortex Increase neuronal inhibition at all levels of the neuraxis, including the spinal cord, hypothalamus, hippocampus, substantia nigra, cerebellar cortex, and cerebral cortex Sedation, amnesia, muscle relaxation, anesthesia, anti-convulsant, anxiolytic Sedation, amnesia, muscle relaxation, anesthesia, anti-convulsant, anxiolytic

16 Midazolam lipid soluble in blood lipid soluble in blood Rapid GI absorption, Rapid GI absorption, Lipid solubility = prompt passage across blood-brain barrier, rapid redistribution and short duration of action Lipid solubility = prompt passage across blood-brain barrier, rapid redistribution and short duration of action Large first-pass hepatic effect Large first-pass hepatic effect Metabolism slowed in patients on cimetidine, erythromycin, calcium channel blockers, antifungal medications, fentanyl since they also use P450 cytochrome system Metabolism slowed in patients on cimetidine, erythromycin, calcium channel blockers, antifungal medications, fentanyl since they also use P450 cytochrome system mg IV mg IV Onset seconds Onset seconds Time to Peak Effect 3-5 minutes Time to Peak Effect 3-5 minutes Duration of Sedation minutes Duration of Sedation minutes

17 Midazolam Indications: Indications: Sedation prior to cardioversion and intubation Sedation prior to cardioversion and intubation Maintenance of sedation in mechanically ventilated patients Maintenance of sedation in mechanically ventilated patients Pediatric seizure control Pediatric seizure control

18 Midazolam Adults Intubation adjunct: Intubation adjunct: 0.5-5mg IV/IM 0.5-5mg IV/IM may repeat every 5-10 minutes may repeat every 5-10 minutes max 10 mg max 10 mg Status, cardioversion, pacing, inner ear problems, sedation, muscular spasms: Status, cardioversion, pacing, inner ear problems, sedation, muscular spasms: mg IV, 5mg IM mg IV, 5mg IM may repeat every 5-10 mins may repeat every 5-10 mins max 5mg max 5mg

19 Midazolam Pediatric Intubation: Intubation: mg/kg mg/kg max 5 mg/dose, repeat PRN for sedation to max of 10 mg max 5 mg/dose, repeat PRN for sedation to max of 10 mg Seizures: Seizures: mg/kg IN/PR mg/kg IN/PR IV/IM mg/kg IV/IM mg/kg repeat every 5 mins PRN repeat every 5 mins PRN Sedation for painful procedures, cardioversion, pacing, muscular spasms, hyperdynamic drug ingestion/exposure: Sedation for painful procedures, cardioversion, pacing, muscular spasms, hyperdynamic drug ingestion/exposure: mg/kg IV/IM/IO mg/kg IV/IM/IO every 5-10 min (2-5 mins if IV) max 2.5 mg every 5-10 min (2-5 mins if IV) max 2.5 mg

20 Midazolam Side Effects Ventilatory Depression caused by decrease in hypoxic drive Ventilatory Depression caused by decrease in hypoxic drive Effects greater than for Lorazepam and Diazepam Effects greater than for Lorazepam and Diazepam Exaggerated in presence of other opioids and CNS depressants, COPD, increasing age Exaggerated in presence of other opioids and CNS depressants, COPD, increasing age

21 Diazepam Indications: Indications: Seizures/status epilepticus Seizures/status epilepticus Sedation pre-cardioversion Sedation pre-cardioversion Acute anxiety Acute anxiety Skeletal muscle relaxant Skeletal muscle relaxant Alcohol withdrawal Alcohol withdrawal Vertigo Vertigo

22 Diazepam Seizures: Seizures: 2-10 mg slow IV 2-10 mg slow IV 5-10 mg PR 5-10 mg PR max 20 mg max 20 mg Sedation/cardioversion/pacing/muscle spasm/labyrinthitis/vertigo: Sedation/cardioversion/pacing/muscle spasm/labyrinthitis/vertigo: 2-5 mg slow IV every 5-10 mins 2-5 mg slow IV every 5-10 mins max 10mg max 10mg

23 Midazolam vs Diazepam More rapid onset More rapid onset Greater amnesia Greater amnesia 2 to 3 times as potent 2 to 3 times as potent Twice the affinity for benzodiazepine receptor Twice the affinity for benzodiazepine receptor Greater decrease in blood pressure and heart rate Greater decrease in blood pressure and heart rate Systemic vascular resistance Systemic vascular resistance Less post-procedural sedation Less post-procedural sedation Same time to complete recovery Same time to complete recovery

24 Benzodiazepines OnsetDuration Diazepam IV 5 min IM 15-30m m Midazolam IV 1-3 min IM 5-15 min m

25 Benzodiazepines Side Effects MinorMajor Diazepam CNS Depression Resp Depression ApneaHypotension Cardiac Arrest “Valium rage” Midazolam CNS Depression CoughHiccups see Diazepam IM site

26 Etomidate: Properties Anesthetic Anesthetic Non-narcotic sedative hypnotic Non-narcotic sedative hypnotic Increases GABA receptors, enhancing inhibitory neurotransmission Increases GABA receptors, enhancing inhibitory neurotransmission Reticular activating system depression Reticular activating system depression Short acting Short acting Induces sedation & amnesia Induces sedation & amnesia No histamine release No histamine release Minimal cardiac & respiratory depressive effects Minimal cardiac & respiratory depressive effects

27 Etomidate: Adverse Effects ? Decreased ICP ? Decreased ICP Nausea and vomiting Nausea and vomiting Myoclonus Myoclonus Adrenocortical Suppression Adrenocortical Suppression

28 Etomidate Indications: Induction agent for intubation Induction agent for intubation Pre-medication for cardioversion Pre-medication for cardioversion

29 Etomidate Adults & Pediatrics Adults & Pediatrics Intubation: 0.3 mg/kg slow IV over seconds, repeat as needed, maximum 0.6mg/kg Intubation: 0.3 mg/kg slow IV over seconds, repeat as needed, maximum 0.6mg/kg Short painful procedures: 0.15 mg/kg slow IV over seconds Short painful procedures: 0.15 mg/kg slow IV over seconds

30 Etomidate vs Midazolam for Out-of- Hospital Intubation: A Prospective, Randomized Trial Ann Emerg Med. 47(6):525-30, 2006 Jun Prospective, double blind, randomized Prospective, double blind, randomized 55 Versed, 55 Etomidate 55 Versed, 55 Etomidate 75% success rate versed, 76% etomidate 75% success rate versed, 76% etomidate No difference in success rates, incidence of hypotension, number of attempts, perceived difficulty No difference in success rates, incidence of hypotension, number of attempts, perceived difficulty

31 Opiates

32 Morphine Central nervous system depressant Central nervous system depressant Acts at mu receptors above and at spinal cord Acts at mu receptors above and at spinal cord Decrease cardiac preload/afterload Decrease cardiac preload/afterload Decreases myocardial oxygen demand Decreases myocardial oxygen demand Releases histamine  can cause hypotension Releases histamine  can cause hypotension

33 Morphine Dose: mg/kg IV Dose: mg/kg IV Peak:10-30 minutes Peak:10-30 minutes Duration:2-4 hours Duration:2-4 hours

34 Morphine Adverse Reactions & Side Effects Adverse Reactions & Side Effects CNS: Euphoria, sedation, respiratory depression CNS: Euphoria, sedation, respiratory depression Cardiovascular: bradycardia, hypotension Cardiovascular: bradycardia, hypotension GI: decreased motility, nausea, vomiting GI: decreased motility, nausea, vomiting GU: urinary retention GU: urinary retention Respiratory: bronchoconstriction, antitussive Respiratory: bronchoconstriction, antitussive

35 Fentanyl Synthetic opioid derivative Synthetic opioid derivative 100x potency of morphine 100x potency of morphine Highly lipid soluble Highly lipid soluble Stored in adipose tissue to create a “reservoir” Stored in adipose tissue to create a “reservoir” Low complication rate Low complication rate Doesn’t release histamine, rarely produces hypotension Doesn’t release histamine, rarely produces hypotension

36 Fentanyl Dose:1 mcg/kg IV Dose:1 mcg/kg IV Onset:Fast Onset:Fast Peak: minutes Peak: minutes Duration:30-90 minutes Duration:30-90 minutes

37 Fentanyl Respiratory depression with alcohol or versed Respiratory depression with alcohol or versed Chest wall rigidity Chest wall rigidity dose dependent dose dependent not reliably antagonized by naloxone not reliably antagonized by naloxone

38 Nitrous Oxide

39 Colorless gas Colorless gas Mixed with 50% oxygen and inhaled Mixed with 50% oxygen and inhaled Self-administered by patient Self-administered by patient Mild intoxicant, potent analgesic Mild intoxicant, potent analgesic Disspiates within 2-5 minutes after stopping Disspiates within 2-5 minutes after stopping

40 Nitrous Oxide Adverse Reactions Adverse Reactions Light-headed Light-headed Confusion Confusion Drowsiness Drowsiness Nausea/vomiting Nausea/vomiting

41 Nitrous Oxide Contraindicated: Contraindicated: Altered state of consciousness Altered state of consciousness Head injury, alcohol ingestion, drug OD Head injury, alcohol ingestion, drug OD COPD COPD Pneumothorax Pneumothorax Decompression sickness Decompression sickness Air embolus Air embolus Abdominal pain with distension Abdominal pain with distension Pregnancy, except during delivery Pregnancy, except during delivery Unable to self-administer Unable to self-administer

42 Nitrous Oxide Considerations Considerations Currently not on REMO protocol, but a good drug to know about Currently not on REMO protocol, but a good drug to know about Heavier than air, can accumulate at ambulance floor and affect EMS personnel Heavier than air, can accumulate at ambulance floor and affect EMS personnel

43 Patient Restraint No standing orders No standing orders Available through Medical Control: Available through Medical Control: Age < 70: Haloperidol 5mg mixed with Midazolam 2mg IM Age < 70: Haloperidol 5mg mixed with Midazolam 2mg IM Age > 70: Haloperidol 5mg IM Age > 70: Haloperidol 5mg IM Repeat Repeat

44 Patient Restraint In 1998 California survey of 490 EMS providers: 61% recounted assault on the job 61% recounted assault on the job 25% reported injury 25% reported injury 37% of injured required medical attention 37% of injured required medical attention 95% recounted restraining patient 95% recounted restraining patient “Exposure of prehospital care providers to violence.” Prehospital Emergency Care. 2(2):127-31, 1998 Apr-Jun.

45 Dangers to Patients “Positional Asphyxia During Law Enforcement Transport.” “Positional Asphyxia During Law Enforcement Transport.” Am Jrnl of Forensic Med and Path. Reay DR. 13(2):90-7, Am Jrnl of Forensic Med and Path. Reay DR. 13(2):90-7, “Met Acidosis in Restraint-Associated Cardiac Arrest: A Case Series.” “Met Acidosis in Restraint-Associated Cardiac Arrest: A Case Series.” Acad Emerg Med. Hick, et al. 6(3):239-44, Acad Emerg Med. Hick, et al. 6(3):239-44, “Sudden Death in Individuals in Hobble Restraints During Paramedic Transport.” “Sudden Death in Individuals in Hobble Restraints During Paramedic Transport.” Ann of Emerg Med. Stratton SJ, et al. 25(5):710-12, May Ann of Emerg Med. Stratton SJ, et al. 25(5):710-12, May 1995.

46 Patient Restraint Indications: Indications: Patients at risk of causing physical harm to emergency responders, the public, and/or themselves Patients at risk of causing physical harm to emergency responders, the public, and/or themselves Considerations: Considerations: Cannot be transported face down Cannot be transported face down If in police custody with handcuffs on, must beaccompanied by police officer in ambulance to hospital If in police custody with handcuffs on, must beaccompanied by police officer in ambulance to hospital EMS may only apply “soft restraints” EMS may only apply “soft restraints”

47 Haldol Dopamine blockade in mesocortex and limbic system inhibits psychoses Dopamine blockade in mesocortex and limbic system inhibits psychoses Extrapyramidal effects (akathisia, dystonia, pseudoparkinsonism) due to dopamine blockade in niagrostriatal pathways Extrapyramidal effects (akathisia, dystonia, pseudoparkinsonism) due to dopamine blockade in niagrostriatal pathways Sedative for psychomotor agitation Sedative for psychomotor agitation Minor anticholinergic and antihistaminic actions  rarely cardiovascular, anticholinergic effects Minor anticholinergic and antihistaminic actions  rarely cardiovascular, anticholinergic effects May cause QT prolongation, lower seizure thresholds May cause QT prolongation, lower seizure thresholds

48 Haldol Indications: Indications: Acute and chronic psychoses Acute and chronic psychoses Agitation, aggression Agitation, aggression Contraindications: Contraindications: Parkinson’s Parkinson’s Seizure Seizure Cocaine overdose Cocaine overdose Alcoholism Alcoholism Severe mental/CNS depression Severe mental/CNS depression thyrotoxicosis thyrotoxicosis

49 Haldol Dosage 5-10mg IM Dosage 5-10mg IM

50 Summary Sedation is a dynamic spectrum Sedation is a dynamic spectrum Main EMS uses: Main EMS uses: Procedures Procedures Restraint Restraint Primary Treatment Primary Treatment Pain management adjunct Pain management adjunct

51 Thank you for your attention! Thank you for your attention!


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