Feb 12, 2014- CKulstad subbing for Dr. Girazadas who is attending AAEM

8-9 Procedural sedation Study guide-  Lovell

Minimal sedation = anxiolysis. Spontaneous breathing, airway unaffected.

Moderate sedation- purposeful response to verbal or light tactile stimuli. Standard examples- midazolam/fentanyl

Deep sedation- what actually happens during procedural sedation most of the time. Responds only to painful or repeated verbal stimuli. Airway reflexes may be lost, respiratory effort may be inadequate.

General anesthesia- all reflexes lost. Must support airway and possibly CV system

Dissociate sedation- trancelike, cataleptic state. Airway reflexes maintained

Sedation is a continuum- be prepared to treat someone on a stage deeper than you intend.

NPO-ACMC: No solids 8 hrs prior, no clear liquids 2 hrs before. Anesthesia national guidelines say 2 hrs npo for clear liquids, 4 hrs for breast milk, 6 hrs for solids. Harwood adds these guidelines originally derived from c-section data on term pregnant women who have very high vomiting risks

This is out-dated. ACEP guidelines say fasting rules not supported by evidence.

ASA classifications- procedural sedation generally only for patients in category 1-3. Add “E” to the category for “emergency” and you’re saying you have to do procedure (pulseless limb s/p dislocation)

1-      Healthy

2-      Mild systemic disease that is well controlled

3-      Severe systemic disease- eg symptomatic wheezing in COPD

4-      Life-threatening illness

5-      Dying patient

6-      Brain death

Tips for safe sedation- use monitoring (ECG for hx of cardiac patients). You’re in charge of everything. If you use Demerol, it can cause CNS excitation (seizures). Fentanyl can cause respiratory depression, esp in elderly. Generally better to give meds slowly and titrate doses.


Midazolam (Versed) 1mg (0.025 mg/kg)

Fentanyl (Sublimaze) 25-50 mcg (0.5-1 mcg/kg)

Flumazenil for benzodiazepines only 0.1-0.2 mg

Narcan for opioids only- suggested dosing- dilute 0.4 mg in 10 ml normal saline, then 1 ml/dose

-5 ways to decrease pain of local anesthesia- add bicarb, warm it, inject slowly, use small needle, distract patient, inject through wound margins

-Eutectic mixture of local anesthetic is what EMLA stands for. Other fast acting topicals- LET (lidocaine- epinephrine-tetracaine) for not-intact skin, ELA-Max-liposomal lidocaine for intact skin

-Side effects of ketamine- rare laryngospasm. More likely with suctioning or with lots of secretions. Usually able to bag someone through it. Can use in kids 3 months or older. OK to use in head injury but not in hydrocephalus or known increased ICP. Additional benzos not recommended for kids, is for adults.

-Treatment with opioids in ED is not the same for all racial/ethnic groups (JAMA 2008). Be aware of your biases.

-Can treat benign headache with injection of local anesthetic (bupivacaine) in paraspinous muscles in lower cervical spine. See EMRAP or Youtube for more details (Dr. Mellick).

-Local anesthetic allergy: 2 classes amides (lidocaine, bupivacaine, prilocaine- all have ”i” before “caine”) esters (procaine, benzocaine, tetracaine). If allergic to both, can inject diphenhydramine as local

-Toxicity of lidocaine- CNS (seizure, coma) then CV (dysrhythmias, myocardial depression). Before that get symptoms that sound like anxiety (perioral numbness, not feeling right). Treat with benzos then amiodarone. Short lived toxicity which Andrea has never seen. Intralipid for bupivacaine overdose.

-Nitrous oxide needs to have a well-ventilated room, can go into gas filled cavities so avoid in ptx, sbo, balloon-tipped catheter. Altered patients should not get NO as patients control their dose.

-Discharge requirements- ambulate, responsible person to watch (no driving for 24 hours), normal vital signs. See modified Aldrete score for more details

-Max dose local anesthetics: lidocaine 4 mg/kg plain 7 mg/kg with epi. Bupivacine 3 mg/kg plain, 5 mg/kg with epi


9-930: Geriatrics in ED – Beckemeyer

Geriatric population is increasing- 20% by 2039, and 25% in 2050. And >65 fill out surveys.

Every ED visit  at age >65 is a sentinel event for further decline so transitions in care critical. Social work, home visits, prompt PMD visit, action plan for decompensation.

4/2014 roll out date for new geriatric ED experience. Goal- age >65 is no wait for all complaints. Go to “senior care area” in former GC front area. Have specific assessment protocols (ADL/med questions, fall risk, social support), and specially trained techs.

Will also have specific protocols so care can be started prior to MD eval for common geriatric problems.

Discharge packet will include senior specific support info (eg meals on wheels).

Will use grants for inexpensive changes- eg clocks with large numbers, magnifying glasses, bedside commodes, more comfortable carts, more pillows and blankets available, possible carry Ensure in ED.

Try to speak more slowly and loudly- face patient at eye level. Elderly patients often overwhelmed/scared in ED.

930-10: Safety lecture- Cash

Had unscheduled downtime early Jan- Firstnet, allegra, pacs, phones all down. Code triage called, went on bypass. Concern for safety issues.

Issues- unclear if orders when through prior to downtime. Delay in identifying which patients needed to be seen. Hard to track workup for find results. Hard to identify acuity, when patient for which team. Patient lost to system. No one familiar with paper system.

Scheduled downtime for computer maintenance- extra staff and materials ready. There are few downtime computers throughout ED- very basic list of patients. One for main room adults, one for fasttrack and peds.

Use whiteboards and paper packets. Whiteboards will list patient by color (red, blue, and black for gold team). Make sure papers have patient stickers. Lab results are faxed to ED and placed in physical chart- you have to keep checking.

To discharge patients find a downtime computer and hit depart. Discharge instructions under “patient ed” which pulls up your usual discharge instructions. Can also use uptodate patient instructions.

10-1030: Advanced DKA

Brian Febbo is a second year resident.

DKA defined by serum or urine ketones, glc usually >250, anion gap acidosis

Euglycemic DKA (below 250) exists. It is not equivalent to mild DKA.  Associated with continued insulin use as DKA develops, pregnancy, and starvation.

If a patient has low albumin, the anion gap may be falsely low. Correct by adding 2.4(4.4 – [albumin]).

Mixed acid-base disorders are common- vomiting can falsely normalized pH.

Serum ketones would be very helpful but are not available in ED at ACMC. Urine ketones have other causes, so less specific.

HHS- older, sicker, more dehydrated. Will need much more fluids. Give IVF alone for first couple of hours as they will significantly drop glucose and potassium. These patients need extensive workup.

Look for precipitating factors. Usually infection, lack of insulin, or other critical illness (medications, pancreatitis, MI, PE, other endocrine abnormality).

But non-specific lab abnormalities are very common- especially leukocytosis and lactate- so difficult to diagnosis.

Management- Fluids early and aggressively. Use isotonic fluids, will need to change additives throughout.

Insulin- 0.1 U/kg/hr or 0.14 U/kg/hr gtt. If you want to give a bolus, it is also 0.1 U/kg but utility is questionable.

SubQ  insulin used to good effect in mild or moderate, stable DKA patients. They need an IV or IM bolus dose.

Remember about pseudo hyponatemia- use corrected to calculate AG

Hyperchoremic acidosis common with large volume IVF resuscitation so consider using LR

Must check potassium before starting insulin- can trigger malignant arrhythmia if it was low and you give insulin.

DKA in ESRD- total body water is near normal, most in extracellular space. Treat with insulin gtt alone.

Pediatric DKA- no evidence that aggressive IVF repletion causes cerebral edema but standard practice in US is to replete fluids over 48 hours.

1030-1230 Sedation small groups