CHAPTER 37: Procedural Sedation

Question 1

Use of anxiolytic, sedative, hypnotic, analgesic, and/or dissociative medications(s) to attenuate anxiety, pain and/or motion

Answer 1

Procedural sedation and analgesia (PSA)

Question 2

Are defined by the patient’s level of responsiveness and cardiopulmonary function, not by the agents used

Answer 2

Levels of sedation

Question 3

Is characterized by anxiolysis but with normal or slowed responses to verbal stimuli

Answer 3

Minimal sedation

Question 4

Is characterized by a depressed level of consciousness and a slower but purposeful motor response to simple verbal or tactile stimuli

Answer 4

Moderate sedation

Question 5

Does not easily fit into the PSA continuum

Answer 5

Dissociative sedation

Question 6

Is a state of detachment from immediate surroundings, in which the cortical centers are prevented from receiving sensory stimuli

Answer 6

Dissociation

Question 7

Is a trance-like cataleptic state characterized by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations, and cardiopulmonary stability

Answer 7

Dissociation

Question 8

Are the ED PSA agents characterized by dissociative sedation

Answer 8

Ketamine & Nitrous oxide

Question 9

Is characterized by a profoundly depressed level of consciousness, with a purposeful motor response elicited only after repeated or painful stimuli

Answer 9

Deep sedation

Question 10

TRUE or FALSE?
Deep sedation generally is achieved in the ED with the same agents as moderate sedation, but with larger or more frequent doses

Answer 10

TRUE

Question 11

Is defined as a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation

Answer 11

General anesthesia

Question 12

Level of sedation and analgesia (Table 37-1 p. 249):
Normal but slowed response to verbal stimulation
A: Unaffected
B: Unaffected
C: Unaffected

Answer 12

Minimal sedation (“anxiolysis”)

Question 13

Level of sedation and analgesia (Table 37-1 p. 249):
Purposeful response to verbal or physical stimulation
A: Usually maintained
B: Usually adequate
C: Usually maintained

Answer 13

Moderate sedation

Question 14

Level of sedation and analgesia (Table 37-1 p. 249):
Trance-like state with variable responsiveness
A: Usually maintained
B: Usually adequate
C: Usually maintained

Answer 14

Dissociative sedation

Question 15

Level of sedation and analgesia (Table 37-1 p. 249):
Purposeful response after repeated or painful physical stimulation
A: May be impaired
B: May be suppressed
C: Usually maintained

Answer 15

Deep sedation

Question 16

Level of sedation and analgesia (Table 37-1 p. 249):
Not arousable, even by painful stimulation
A: Usually requires assistance
B: Often impaired
C: May be impaired

Answer 16

General anesthesia

Question 17

TRUE or FALSE?
One emergency physician is not effective as two physicians, one providing monitoring and the other performing the procedure

Answer 17

FALSE
In the emergency medicine model of PSA, clinical experience indicates that one emergency physician—providing monitoring and sedation and performing the procedure—is as effective as two physicians, one providing monitoring and the other performing the procedure.
However, the physician must be ready to resuscitate the patient immediately

Question 18

TRUE or FALSE?

Pre-procedural fasting for any duration has demonstrated a reduction in the risk of emesis or aspiration

Answer 18

FALSE
Pre-procedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration.
It is not necessary to delay ED PSA for time-sensitive procedures in adults or children based on fasting time

Question 19

PSA Monitoring:
Direct visualization of the patient’s airway (mouth, face) and chest wall motion, chest auscultation, monitoring patient responsiveness, and providing appropriate maneuvers to maintain the patient’s airway and ventilation

Answer 19

Interactive monitoring

Question 20

PSA Monitoring:

Includes continual tracking of arterial oxygenation, ventilation, blood pressure, and cardiac rate/rhythm

Answer 20

Physiologic monitoring

Question 21

TRUE or FALSE?

Pulse oximetry is a substitute for monitoring ventilation

Answer 21

FALSE
Pulse oximetry is NOT a substitute for monitoring ventilation
Because hypoventilation or apnea develops before oxygen saturation decreases, especially in patients who receive supplemental oxygen

Question 22

ETCO2 value that indicates hypoventilation

Answer 22

> 50 mm Hg or Increase of > 10 mm Hg

Question 23

Assess the severity of ventilatory abnormalities and the response to interventions and can detect changes in ventilation before clinical observation

Answer 23

Capnography

Question 24

TRUE or FALSE?

Assessing blood pressure every 5 minutes is unnecessary for ketamine dissociative sedation

Answer 24

TRUE

Question 25

A structured assessment that can be used to assess the patient’s recovery and safety for discharge

Answer 25

Aldrete Score©

Question 26

TRUE or FALSE?

Propofol has been administered safely to patients with soy, egg, and peanut allergies

Answer 26

TRUE
The American Academy of Allergy, Asthma, and Immunology supports the safety of propofol in patients with soy and egg allergies, and recent emergency medicine practice guidelines state that propofol’s only true immunologic contraindication is an allergy to the drug itself

Question 27

Suggested methods to reduce propofol infusion burning

Answer 27

Pretreating the injection-site vein with lidocaine (0.5 mg/kg) OR mixing the lidocaine with the initial propofol injection (0.5 to 1.0 mg/kg)

Question 28

Critical dosing threshold of Ketamine that when exceeded is associated with appearance of abrupt dissociative state

Answer 28

IV: 1.0 to 1.5 mg/ kg
IM: 3 to 4 mg/kg

Question 29

Medications can be given along with ketamine to minimize the development of emergence reactions

Answer 29

Midazolam OR Propofol

Question 30

Because of the possibility of emergence reactions, do not use ketamine in patients with —?—

Answer 30

Schizophrenia &Psychosis

Question 31

Some evidence that the hypersympathetic state resulting from ketamine administration may be more profound in patients with —?—

Answer 31

Porphyria & Thyroid disorders

Question 32

Medications can be given to blunt hypersalivation and bronchorrhea in patients who received Ketamine

Answer 32

Glycopyrrolate OR Atropine

Question 33

TRUE or FALSE?
There is no clear evidence that ketamine is harmful as an induction or sedation agent in patients with a potential head injury

Answer 33

TRUE
There is no clear evidence that ketamine is harmful as an induction or sedation agent in patients with a potential head injury if it is the appropriate sedative choice based on other considerations

Question 34

Its minimal hemodynamic effects, combined with a short duration of action, make an excellent agent for procedures such as cardioversion

Answer 34

Etomidate

Question 35

Etomidate is characterized by 2 issues that are not commonly seen with other PSA agents

Answer 35

Adrenocortical suppression & Myoclonus

Question 36

Medication that can reduce the incidence and severity of myoclonus induced by Etomidate

Answer 36

Midazolam (1 to 2mg IV)

Question 37

A rare side effect of synthetic opioids is skeletal muscle rigidity, which primarily affects the chest and abdominal muscles

Answer 37

Rigid chest syndrome

Question 38

High dosages of synthetic opioids that may lead to chest wall rigidity
Fentanyl: ?
Alfentanil: ?
Remifentanil: ?

Answer 38

Fentanyl: 3 to 5 mcg/kg
Alfentanil: 130 mcg/kg
Remifentanil: >1 mcg/kg

Question 39

Medications that may attenuate chest wall rigidity

Answer 39

Propofol, Thiopental OR Naloxone

Question 40

PSA in obese patients: Drugs that are based on IBW or LBW

Answer 40

Fentanyl
Ketamine
Etomidate
Propofol

Question 41

PSA in obese patients: Drugs that are based on TBW

Answer 41

Benzodiazepines

Question 42

Standardized Dosing Equations in Obesity (Table 37-5 page 256)
Measured body weight (kg)

Answer 42

Total body weight (TBW)

Question 43

Standardized Dosing Equations in Obesity (Table 37-5 page 256)
M = 50 + (2.3 [Ht. (in.) - 60])
F = 45.5 + (2.3 [Ht. (in.) - 60])

Answer 43

Ideal body weight (IBW)

Question 44

Standardized Dosing Equations in Obesity (Table 37-5 page 256)
M = (9270 × TBW)/[6680 + (216 × BMI)]
F = (9270 × TBW)/[8780 + (244 × BMI)]

Answer 44

Lean body weight (LBW)

Question 45

Standardized Dosing Equations in Obesity (Table 37-5 page 256)
Weight (kg)/height (m)2

Answer 45

Body mass index (BMI)