1. Procedural Sedation - alternatives to Brutane Dr Garry Clearwater MBChB FACEM

2. Overview What is procedural sedation? Alternatives: Analgesia
Preparation
Drugs
Discharge
More alternatives…

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 medical procedure
Patient maintains their airway & breathing
- a.k.a “conscious sedation” “deep sedation”

5. 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

6. Advantages Compared to Brutane:
Less stress and anxiety… for nearly everyone
Better chance of success (relaxation, time)
Compared to GA:
PS is quicker – for the patient
PS is generally safer

7. Still some uses for Brutane…?
Simple, very quick, curative procedures:
Reduction of “pulled elbow”:
- Pronate/supinate flexed elbow
- with pressure over the radial head
Reduction of simple patella dislocation:
- Extend the knee
- with sideways pressure on the patella towards the midline.
Supplementary analgesia may be warranted before and during.

8. ANALGESIA Procedural sedation is: Pain relief + Relaxation
Pain relief by itself often reduces anxiety

9. ANALGESIA
Reassurance and explanation
Simple analgesia: paracetamol

10. ANALGESIA Reassurance and explanation Simple analgesia: paracetamol
Entonox

11. ANALGESIA Entonox: Nitrous Oxide Weak analgesic
Onset 1 min (12-15 breaths)
Peak 5 min
Need co-operative patient
Avoid in:
retained gas: SABO, pneumothorax etc
Cardiac disease, shock
Pregnancy 1st trimester
S/Es: Dysphoria, nausea

12. ANALGESIA Reassurance and explanation Simple analgesia: paracetamol
Entonox
Methoxyflurane

13. ANALGESIA Penthrox: Methoxyflurane Moderate analgesic
Fluorinated Hydrocarbon
- Metabolised to Fluoride
Onset 1-2 minutes
Peak 5 min
Avoid in:
Renal impairment, diabetes
S/Es:
- Nephrotoxic; nausea, dizziness.
- bradycardia, low BP

14. ANALGESIA Reassurance and explanation Simple analgesia: paracetamol
Entonox
Methoxyflurane
Intranasal Fentanyl

15. ANALGESIA Fentanyl Intranasal Narcotic analgesic
Children >2 yo, up to max 70 kg
Via atomiser on end of syringe
Rapid onset: 2 minutes
Duration 30 mins
Avoid in:
Nasal congestion
S/Es:
- nausea, dizziness.
- low BP

16. ANALGESIA Fentanyl Intranasal (Starship CED guideline):
100 mcg / 2 ml with 1 ml tuberculin syringe
1.5 mcg/kg (0.03 ml/kg)
Repeat if necessary:
0.5 mcg/kg
Patient sits at 45 degrees
Syringe held horizontal:
- one quick spray
Observe for 20 min after dose

17. ANALGESIA Reassurance and explanation Simple analgesia: paracetamol
Entonox
Methoxyflurane
Intranasal Fentanyl
Intravenous Morphine

18. ANALGESIA Morphine IV - Titrate Reversible 0.1 mg / kg
- 2 mg increments in adults
S/Es:
- nausea, dysphoria.
low BP
Transient anaphylactoid rash (often mislabelled as allergy)

19. ANALGESIA Morphine IV Tricks of the trade:
EMLA or Ametop skin anaesthesia for at least 30 mins
- or insulin syringe local injection
Have the morphine ready to inject as soon as IV established

20. Alternatives to Procedural Sedation…not
In general, stay away from:
SC and IM injections: variable and prolonged effects
Fallen out of favour …
Intranasal Midazolam: not an analgesic, works by ingestion
In the future …
Fentanyl lollipop?
Fentanyl nebulised?

21. ANALGESIA Horses for Courses: Renal colic: NSAIDs Biliary colic:
Antacids

22. ANALGESIA Caution…. Paradex / Capadex / Dextropropoxyphene Pethidine
(Fentanyl is an alternative to morphine)
Tramadol: Potential serotonergic interactions with…
SSRIs
Dextropropoxyphene

23. A Little Bit of Sedation…
Oral sedation: anxiolysis for children
Use the IV preparation, mix with Paracetamol or Sprite
Variable onset and effect
Low-level prolonged sedation.
Starship Hospital CED “Sedation – Paediatric” guideline:

24. ANXIOLYSIS
Midazolam PO Onset: min Duration: min Analgesia: No Dose: 0.5 mg/kg, max 15 mg Variable effect May cause Paradoxical Agitation

25. ANXIOLYSIS
Ketamine PO (3 mo – 12 yrs) Onset: min Duration: min Analgesia: Some Dose: 5-7 mg/kg mix with ml cold Sprite Maintains airway Multiple contra-indications

26. ANXIOLYSIS Ketamine PO (3 mo – 12 yrs) Contra-indications: URTI
Head injury
Psychiatric or personality disorder
Risks:
Nausea, vomiting
Transient respiratory events
Requires low-stimulation recovery

27. PREPARATION Prepare for the worst 2 clinical staff
Choose your patient carefully
Choose your poison carefully

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

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

30. 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

31. PREPARATION 2. 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.

32. PREPARATION 2. ENVIRONMENT Readily available equipment must include:
resuscitation trolley
defibrillator

33. PREPARATION 2. ENVIRONMENT Readily available equipment must include:
resuscitation trolley
Defibrillator
Bag-Valve-Mask device for ventilation

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

35. PREPARATION 1. 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.

36. PREPARATION 1. 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.

37. PREPARATION
1. 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.

38. PREPARATION 5. PATIENT PREPARATION Explanation Consent
Secure IV access is mandatory.

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

40. PATIENT SELECTION Can you hold the fort if something goes wrong?
AIRWAY:
Thyromental distance
Open mouth > 3 FB
Stable teeth
View hypopharynx
Mobile neck

41. 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)

42. PATIENT SELECTION 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

43. 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…

44. DRUGS
Choose your poison carefully… Wide variation in individual responses Clearwater’s Textbook Rule: Doctors read textbooks… but patients don’t. Titrated is best.

45. DRUGS
FENTANYL: IV adjunct Onset: 2-5 min Duration: 30 min Analgesia: Yes Advantage: Reversible (Naloxone) Alternative to Morphine But… BP drop Chest wall rigidity Nausea

46. DRUGS
MIDAZOLAM Onset: 1-2 min Duration: min Analgesia: No Advantage: Reversible But… BP drop Slower, not as deep as Propofol

47. DRUGS
ETOMIDATE Onset: <1 min Duration: 5-8 min Analgesia: No Advantage: BP maintained But… Twitching / myoclonus Nausea Not fully registered (s.29)

48. DRUGS
PROPOFOL Onset: <1 min Duration: 5-10 min Analgesia: No Advantage: Not cumulative But… BP drop Allergy soy or eggs

49. DRUGS
KETAMINE Onset: 1-3 min Duration: 5-20 min Analgesia: Yes! Advantage: Preserves ABC But… Emergence phenomena Eyes open, random movements Salivation, Laryngospasm

50. DRUGS KETAMINE Atypical reactions more common in:
older children >10 yrs
girls
agitated children
URTI / rhinitis
Need low-stimulus recovery room.
May need IV Midazolam

51. OFF WE GO…. Prepare for the worst 2 clinical staff
Choose your patient carefully
Choose your poison carefully
Keep watching the patient … during
Keep watching the patient … after
Discharge with a well-advised capable observer

52. PATIENT DISCHARGE Allow at least 1 hour after last dose given
Various criteria for discharge:
Normal vital signs
Alert / orientated / back to baseline
Able to sit / mobilise unaided
Able to drink
Sensible capable observer
Good advice

53. More alternatives to Procedural Sedation
Infant analgesia: 0 – 3 mo.
25-33% sucrose
0.25 – 2 ml PO (give with dummy)
Mild analgesia
Releases endogenous opiods:
Reversible with Naloxone
Onset mins
Duration 5-8 mins

54. More alternatives to Procedural Sedation
Wound Care: Topical anaesthesia: “Topicaine”: 0.1 ml/kg Apply to open wound on a small gauze swab; Cover with Opsite … and wait

55. More alternatives to Procedural Sedation
Wound Care: Topical anaesthesia: “Topicaine”: 0.1 ml/kg Apply to open wound on a small gauze swab; Cover with Opsite … and wait … 30 mins

56. More alternatives to Procedural Sedation
Dislocated shoulder Intra-articular anaesthesia:

57. More alternatives to Procedural Sedation
Dislocated shoulder Intra-articular anaesthesia: Lignocaine 1% 20 ml 20G 3.5 cm needle. Insert just lateral to acromion. Aim to glenoid. Aspirate sero-sanguinous fluid Inject over 30 sec. Takes min to work

58. Acknowledgements & resources
ACEM (Info Centre > Policies Guidelines):
Starship Hospital CED (Health professionals > Clinical guidelines:
Kidz First / Middlemore Hospital ED clinical guidelines
RCH Melbourne guidelines