- SEDATED AND PARALYSED PATIENT - Flashcards
Discuss the use of sedation for procedures in the emergency department (ED)
. - procedural sedation
- analgesia
- anxiety/aggitation control
- facilitation of care
- adaptation to ventilatory support
Discuss airway management strategies for the sedated patient in the ED
- positioning
- jaw thrust, head tilt, chin lift
- oro/nasopharangeal airway
- intubation
Explain the difference between sedation and paralysis
Sedation - act of calming by administering a sedative; inducing the nervous system to calm
Paralysis - blocking communication between nerves and muscles by administering neuromuscular blocking agents
Describe an appropriate management plan for a sedated patient in the ED
Airway (patency and efficiacy)
Breathing (monitor SpO2. humidification, monitor assist WOB)
Circulation (haemodynamic monitoring, IV fluid, maintain normovolaemia, warm blankets, ?IDC
Disability (adequate sedation and pain relief, PAC, mouth and eye care, positioning
State the aim of airway management
To secure an airway of any sort that will allow for adequate ventilation
Discuss the indications and nursing / medical considerations for an oropharyngeal airway
Indications:
- unconsciousness
- general anaesthesia
- when manual methods fail to maintain a patent airway
Considerations:
- gagging, vomiting, aspiration
- soft tissue trauma to the tongue, palate and pharynx
- biting down on hard surface can injure teeth
Discuss the indications and nursing / medical considerations for an nasopharyngeal airway
Indications:
- to provide an airway for pts with intact gag reflex
- facilitate suctioning in patients unable to clear upper airway secretions
Considerations:
- epistaxis and aspiration
- ulceration
- insertion through cibriform plate into brain
- sinusitis
- may still stimulate gag reflex
- PAC
Discuss the indications and nursing / medical considerations for an laryngeal mask airway
Indications:
- rescue a failed intubation
- facilitate the blind insertion of boogie or ETT
- improve oxygenation as part of RSI
- ventilation in elective procedures in fasted pts
- difficult BVM fit
Considerations:
- inability to achieve seal and ventilate
- regurgitation and aspiration
- gas insufflation
- partial airway obstruction
- shaft kinking
- dislodgement
- laryngospasm
- trauma to upper airway
Discuss the indications and nursing / medical considerations for an endotracheal tube
Indications:
- support ventilation
- protect the airway
- ensure airway patency
- anaesthesia and surgery
- suctioning
Considerations:
- oxygenation
- 2nd and 3rd options
- BP
- cuff inflation
Identify the correct measurements for each of the artificial airways
OPA - teeth to angle of mandible
NPA - tip of nose to ear lobe
LMA - size 4&5 for adults, 1-3 for paeds
ETT - adult female approx 7.5, adult male approx 8.5
Discuss the application of cricoid pressure
Technique used to assist in intubation and reduce the risk of regurgitation through applying backward, upward rightward pressure over cricoid cartilage to compress/occlude oesophagus
List the indications for use of ETCO2 monitoring in the clinical setting
- anaesthesia
- procedural sedation
- intubation
- cardiac arrest
- ventilation
Identify the range considered normal when monitoring ETCO2
35-45mmHg
Interpret the components of a capnography waveform
Phase I - inspiration
Phase 2 - Beginning of expiration (expiratory upstroke)
Phase 3 - Expiration continues, represents alveolar CO2
Phase 0 - beginning of inspiration (inspiratory down stroke)
Discuss the specific nursing / medical considerations related to paediatric intubation
- type and size of ETT (3 - up to 6 months, 4 >6 months, age/4 + 4 for >12 months)
- securing the ETT (with tape or securing device)
- suctioning (vital in paeds as their secretions increase, only suctioning when indicated)
Sedation is used for a variety of purposes in the ED. Identify appropriate sedation that could be used for relocation of a dislocated shoulder
. - morphine
- midazolam
- propafol
Sedation is used for a variety of purposes in the ED. Identify appropriate sedation that could be used for the insertion of IV in paediatric patient
Nitrous oxide
Sedation is used for a variety of purposes in the ED. Identify appropriate sedation that could be used for
the chemical restraint of aggressive and threatening patient
.Benzodiazepines (midazolam, diazepam, lorazepam)
Antispychotics (halloperidol, risperidone, olazapine)
State the action of ketamine
Non-competitive NMDA-R antagonist –> inhibits glutemate binding and subsequent depolarization of afferent neurons –> Prevents transmission of pain impulses and generates dissociative state
List the indications for ketamine
- Induction agent for RSI
- Post-Intubation Sedation
- Excited Delirium
- Pain Management
State the action of nitrous oxide
- interacts with opioid receptors
- stimulates mid-brain
- activation of inhibitory pathways
- alters the processing of pain in the spinal cord
List the indications of nitrous oxide
- distressed pt
- painful procedure
- paediatrics
State the action of midazolam
Inhances the affinity of gamma-aminobutyric acid (GABA) to the receptors the principal inhibitory neurotransmitter in the CNS. This leaves neaurons more resistant to excitation
List the indications for midazolam
- status epilepticus
- sedation
- aggitation/aggretion
State the action of diazepam
Inhances the affinity of gamma-aminobutyric acid (GABA) to the receptors the principal inhibitory neurotransmitter in the CNS. This leaves neaurons more resistant to excitation
List the indications for diazepam
- status epilepticus
- acute anxiety
- muscle spasms
- alcohol withdrawal psychosis
- pre-med for cardioversion
State the action of haloperidol
Anti-psychotic.
Exact MOA unclear: appears to block dopamine receptors in the brain associated with mood and behavior. Exerts strong antiemetic effects and impairs central thermoregulation. Also produces weak central anti-cholinergic effects
List the indications for haloperidol
- schizophrenia
- manic states
- drug induced psychosis
State the action of fentanyl
- binds with stereospecific receptors at many sites within the CNS
- inhibits ascending pain pathways
- It decreases the feeling of pain and a person’s response to pain
List the indications of fentanyl
- pain relief
- sedation
- chronic pain management
State the action of propofol
- sedative-hypnotic effects through a GABAA receptor interaction
- GABA is the principal inhibitory neurotransmitter in the CNS
List the indications for propofol
- sedation (procedural and induction)
- general anaesthesia
Outline the nursing management of a patient sedated for a procedure
- ensure procedure is appropriate (indicated, enrionment, staffing)
- educate patient
- airway equipment
- administration of agents
- frequent obs
- monitoring airway and level of sedation
Outline the purpose of sedation in the intubated patient
- Adaptation to ventilatory support
- Prevent / minimise thoracic barotrauma
- ICP control
- Cervical spine immobilisation
List the signs of inadequate sedation in the muscle relaxed / paralysed patient
Rise in Richmond Agitation-Sedation Score (RASS) any movement or response to stimuli
Discuss the difference between depolarising and non-depolarising muscle relaxants
Non-depolarising:
- blocks the binding of ACh to its receptors
- inhibiting the stimulation of muscle contraction and PNS
- muscle weakness and paralysis
Depolarising
- Acts similar to ACh
- Binds to ACh receptors
- causing PNS stimulation and muscle contration
- muscle fasciculations and paralysis
Differentiate between in-line and normal suctioning processes
In line suction involves a multi-use catheter enclosed in a plastic sheath
- closed system means you do not have to disconnect the ventilator or oxygen source
- reduces risk of infection and desaturation
A 26 year old man is admitted to your unit following a polypharmacy overdose. On arrival to your unit, he is lying in the left lateral position, his primary survey reveals his GCS is 3. He has no respiratory effort & is being manually ventilated with an air viva. His observations are as follows: HR 110, BP 105/55, manual RR 12, GCS 3, SpO2 94% 15L O2 insitu. His weight is estimated as 80kg.
Describe how will you prepare for the intubation of this patient?
State the drugs you will prepare for the intubation of this patient? (include the appropriate dosage)
- Airway Equipment + plans B and C
- Monitoring (incl. ETCO2)
- Pharmaceuticals
- Patient positioning (sniffing)
- Team
- PPE
- Pre-oxygenation
- Paralysis with induction
Induction agents: Ketamine 1.5-2 mg/kg Etomidate 0.3-0.4 mg/kg Fentanyl 2-10 mcg/kg Midazolam 0.1-0.3 mg/kg Propofol 1-2.5 mg/kg Thiopental 3-5 mg/kg
Neumuscular blockers:
Suxamethonium 1-2 mg/kg
Rocuronium 0.6-1.2 mg/kg
Vecuronium 0.15-0.25 mg/kg
What are the 9 Ps of RSI?
- Plan
- Preparation (drugs, equipment, people, place)
- Protect the cervical spine
- Positioning (some do this after paralysis and induction)
- Preoxygenation
- Pretreatment (optional; e.g. atropine, fentanyl and lignocaine)
- Paralysis and Induction
- Placement with proof
- Postintubation management
