Category: Basic Skills in Emergency Medicine

Procedural Sedation

Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship

Common Scenarios

  • Cardioversion
  • Orthopedic reductions
  • Painful procedures

Three Step Approach to Procedural Sedation

  • Step 1: Risk stratify the patient
    • Mallampati score (aka “How visible is the uvula?”)
      • Level 1: Can visualize THE WHOLE uvula
      • Level 2: Can visualize MOST of the uvula
      • Level 3: Can visualize SOME of the uvula
      • Level 4: Can NOT visualize the uvula
    • ASA (aka “How healthy are they?”)
      • Level 1: Healthy
      • Level 2: Mild illness
        • Hypertension
        • Hyperlipidemia
        • Anemia
      • Level 3: Major illness
        • Diabetes
        • Coronary disease
        • COPD
        • Chronic renal disease
      • Level 4: Extremely unhealthy
        • Dialysis patient
        • Severe heart failure
        • Chronically debilitated
      • Level 5: Dying
        • Patient needs operation to live
          • Intracranial hemorrhage with midline shift
          • Ruptured aortic aneurysm
          • Ruptured papillary muscle with cariogenic shock
          • Dissecting aortic aneurysm
  • Step 2: Informed consent
    • Patients sign a GENERAL CONSENT to treat when registering to the department
    • Many emergency scenarios require physician to operate with IMPLIED CONSENT
    • Many patients have an ADVANCED DIRECTIVE
    • In stable patients and higher risk procedures, separate WRITTEN CONSENT is often required
      • Varies by hospital
      • Typically required for procedural sedation in stable patients
  • Step 3: Gather supplies
    • Nurse and nursing supplies
      • IV
      • Cardiac monitor
    • Respiratory therapy and respiratory supplies
      • Capnography
      • Bag-valve mask
      • Airway box

Top 5 Procedural Sedation Medications

  • Midazolam (“Versed”) – 0.02 mg/kg IV
    • Reduces anxiety prior to procedure
    • Provides no analgesia
  • Fentanyl – 1 mcg/kg IV
    • Reduces pain
    • Useful for painful procedures
      • Incision and drainage
      • Simple reductions
  • Propofol – 0.5-1mg/kg IV
    • General anesthetic
    • Best given “low and slow”
    • Short acting
    • Causes respiratory depression and hypotension
  • Etomidate – 0.15 mg/kg IV
    • General anesthetic
    • Less hypotension than propofol
    • Can cause myoclonus
  • Ketamine – 1-2mg/kg IV
    • “Dissociative”
    • Provides both amnesia AND analgesia
    • Can cause emergence reactions
    • Can cause laryngospasm and secretions

Additional Reading

How to Interpret a Chest X-Ray

A-B-C-D-E-F-G

Two Types of X-Rays

  • Anterior-Posterior (“AP”)
    • Classic “portable” xray
      • The beam shoots from in front of the patient (anterior)
      • TO
      • The plate sitting behind the patient (posterior)
  • Posterior-Anterior (“PA”)
    • Requires trip to radiology
    • Results in a better picture
      • The beam shoots from behind the patient (posterior)
      • TO
      • The plate sitting in front of the patient (anterior)

Three Indicators of a High Quality Chest X-Ray

  • Well inflated lungs
  • Visualize spine through cardiac silhouette
  • Medial aspect of both clavicles lined up
    • Evaluates for rotation

Chest X-Ray Interpretation Mnemonic

  • A-B-C-D-E-F-G
  • A = Airway
    • Trachea midline (rule out tension pneumothorax)
  • B = Bones
    • Rib/Clavicle/Shoulder fractures
  • C = Cardiac silhouette
    • Should be no bigger than 50% of distance from chest wall to chest wall
      • Larger than this may represent cardiomyopathy
  • D = Diaphragm
    • Costophrenic angles should be sharp
      • Blunted in pleural effusion
  • E = Equipment
    • Central lines
    • Endotracheal tubes
    • Chest tubes
  • F = Lung Fields
    • The most important step
    • Look at lung markings/tissue to evaluate for…
      • Pneumothorax
      • Consolidation
      • Nodules
      • Pulmonary Edema
  • G = Great vessels
    • Look for mediastinal widening (> 8cm)
      • Can be a sign of aortic injury
      • Looks falsely widened on AP/portable chest x-ray

Additional Reading

Common Pain Medications

Acetaminophen. Ibuprofen. Hydrocodone. Ketorolac. Morphine. Hydromorphone.

Oral Acetaminophen (Tylenol)

  • Give every 4-6 hours
  • Regular strength – 325mg
  • Extra strength – 500mg
  • Maximum Daily Dose – 3000mg

Oral Ibuprofen (Advil)

  • NSAID
  • Give every 4-6 hours
  • Regular strength – 200mg
  • Therapeutic Ceiling – 400mg

Oral Hydrocodone-Acetaminophen (Vicodin, Norco)

  • Give ever 4-6 hours
  • Common doses – 5-325mg, 7.5-325mg, and 10-325mg

IV/IM Ketorolac (Toradol)

  • NSAID
  • Common dosing – 15-30mg
  • Therapeutic ceiling – 10mg

IV/IM morphine

  • Classic dose (0.1mg/kg)
    • This would be 7-10mg in adults!
  • More COMMON dosing is 4mg
    • Repeat as needed

IV/IM Hydromorphone (Dilaudid)

  • COMMON dosing – 0.5-1mg
  • This drug is notorious for bringing you to peer-review/MM conference
    • Be careful!

Contraindications to NSAIDS

  • Pregnant patients
  • Elderly patients
  • Renal disease patients
  • Cardiac patients
  • GI/ulcer patients

Side Effects of Opiates

  • Sedation
    • No driving
    • Do not mix with alcohol
    • Do not mix with other sedatives
  • Constipation
  • Opiate dependency/addiction

Additional Reading

  • Pain Management In the Emergency Department: A Review (PubMed)
  • Myths in EM: The Anti-Inflammatory Properties of NSAIDS (ACEP Now)

Patient Presentations

Patient presentations are the single most important skill to develop for your Emergency Medicine rotation.

General Principles

  • Stay focused, thorough, and organized
  • Write out the basic 8-step presentation for reference

The 8-Step Patient Presentation

  1. Summary statement
    • Demographics
    • Risk factors/Past medical history
    • Chief complaint
  2. History
    • OPQRST
    • Try to give at least 4 descriptors
      • This is for billing reasons
  3. Pertinent positives/negatives
    • Give approximately 5 most pertinent symptoms
  4. Vitals
  5. Physical exam
    • Give approximately 3 MOST pertinent findings
  6. Differential diagnosis
    • Briefly argue for/against
    • Include both most likely and most dangerous
  7. Testing plan
  8. Treatment plan
    • This is the most commonly forgotten step of presentation

Additional Reading

  • Abdominal Pain Presentation – History (EM Clerkship)
  • Abdominal Pain Presentation – Exam, Plan, and Disposition (EM Clerkship)
  • Patient Presentations in Emergency Medicine (EMRA)

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