Sedation/paralytics

Question 1

Use of sedation for procedures in the ED

Answer 1

Reduction of joints
Fracture reduction
Suturing young children
Burn dressings

Question 2

Air way management strategies for the sedated pt

Answer 2

Chin lift/jaw thrust

BVM

Question 3

Induction Agents

Answer 3

Fentanyl (conscious sedation)
Ketamine ( GA, RSI)
Midazolam (conscious sedation) 
Propofol - induction anaesthetic/sedation, first line RSI 
Thiopental - RSI
Precedes (icu)

Question 4

Ketamine

Answer 4

Indication: induction and maintenance of anaesthesia
Accepted - procedural sedation and analgesia
Dose: 1-2mg/kg for induction in adults
Onset: 30secs
Duration: 10-20min
Side effects: increases BP and HR, hypersalivation,hallucinations, irrational behaviour. Minimise stimulation during recovery.

Question 5

Appropriate management plan for a sedated or in ED

Answer 5

Visual observation 
Continuous CM
Capnography
Ongoing assessment of level of consciousness- gcs or sedation scale
VTE prophylaxis 
Fluid status 
Pressure care
Monitor until mental status back to base line

Question 6

Fentanyl

Answer 6

Indication: opioid analgesic/ conscious sedation
Dose: adults IV 50-100mcg, maintain 25-50mg. Paeds - 5mcg/kg
Onset: <60sec
Duration: dose dependent, 30min for 1-2mcg/kg or 6hrs for 100mcg/kg
Side effects: respiratory depression, apnoea, circulation depression
Contraindications: obstructive lung disorder

Question 7

Propofol

Answer 7

Indication: short acting GA, induction of anaesthesia/sedation. *first line RSI
Dose: 2-2.5 mg/kg, sedation 3mg/kg/he
Onset: 15-45sec
Duration: 5-10 minutes
Side effects: hypotension, bradycardia
Contraindications: egg allergy; sedation in children <16yrs; haemodynaically unstable

Question 8

Rational for Pre oxygenation in tracheal intubation

Answer 8

Allows a safety buffer during periods of hypo ventilation and apnoea

Question 9

RSI

Answer 9

For pts high aspiration risk caused by critical illness. This technique is the simultaneous administration of the sedative and paralytic with no ventilation while waiting for the paralytic to take effect unless needed to prevent hypoxaemia.
Pts receive preoxygenation via a non - rebreather @15L

Question 10

RSI - desaturation

Answer 10

Will occur in 45-60 seconds between sedative and paralytic administration and airway placement.

Question 11

Pre oxygenation pre RSI

Answer 11

To bring pts Sats as close to 100%
To maximise residual capacity of the lungs (storage)
To maximumly oxygenate the blood stream
Via non rebreather 30-60L/min
Duration: 3 minutes worth of tidal-volume breathing ( ideally until end tidal oxygen level grater than 90%)

Question 12

Position of pt in pre oxygenation

Answer 12

20- degree angle where possible (increases oxygenation)

Reverse trendelenburg position can be used in spinal precautions

Question 13

Cricoid pressure

Answer 13

Firm pressure to the cricoid cartilage compresses the oesophagus while keeping the trachea open (to prevent aspiration)
* under scrutiny as causes lateral displacement of oesophagus in more than 90%

Question 14

Difference between sedation and paralysis

Answer 14

Sedation: make you sleepy and unaware of procedures
Different levels - minimal: mild anxiolysis (reduces anxiety) able to maintain airway to deep sedation requiring both airway and ventilator support
Paralytic: neuromuscular blocking agent results in blockade of skeletal function, these agents cause cessation of ventilatory function - mandating airway control and the institution of MV. They do not have analgesic or amnestic properties

Question 15

Paralytics (neuromuscular blocking agents)

Answer 15

The most common reason for NMBA administration is to facilitate MV support. Administration of NMBA eliminates the spontaneous breathing activity, thereby allowing tidal volume and the plateau pressure to be controlled with in desirable target ranges

Question 16

What is the aim of airway management

Answer 16

Opening and maintaining a patent airway. An inadequate airway requires immediate interventions
Positioning, jaw thrust, oropharyngeal, intubation

Question 17

Indication for oropharyngeal airway (Guedel’s)

Answer 17

In an unconscious to ensure airway patency, pt with loss of upper airway muscle tone - otherwise it is likely to initiate gagging and vomiting.

Question 18

Nasopharyngeal indication

Answer 18

Better tolerated than a guedels
Can use in a semi-conscious pt and less likely to induce vomiting.
Used to assist with pt oxygenation and ventilation who are difficult to oxygenate or ventilate via a BVM

Question 19

Indication for LMA - laryngeal mask airway

Answer 19

Used in unconscious pt requiring artificial ventilation.
Can be used if intubation equipment is not readily available or a trained clinician is unavailable.
Can be used as a first line airway in pts with known difficult airways

Question 20

Indication for ETT

Answer 20

Used for emergency management of the airway
Pt unable to maintain airway patency
Inability to protect own airway against aspiration
Pt failing to ventilate or oxygenate

Question 21

Complications to artificial airways

Answer 21

Guedels: can stimulate gag reflex, causing vomiting
Nasopharyngeal: can cause epistaxis and contraindicated in suspected facial trauma and Basilar skull fracture
LMA: doesn’t protect airway from aspiration of gastric juices
ETT: Laryngeal injury, excessive cuff pressure requirements, self extubating and the inability to seal the airway

Question 22

How to measure a Guedels and nasopharyngeal

Answer 22

Guedels: from pts lip to angle of jaw
Nasopharyngeal: tip of pts nose to earlobe

Question 23

Indication for ETCO2 monitoring

Answer 23

Procedural sedation - ensuring adequate ventilation
Gold standard to confirm ETT placement, dislodgement, displacement, disconnection or obstruction.
Useful in cardiac arrests in assessing effectiveness of CPR and Recognition of ROSC
Normal range: 35-45mmHg
Aim above 20mmHg in cardiac arrest

Question 24

Tidal volume

Answer 24

6-10ml/kg