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Three part screencast covering the essentials of procedural sedation and analgesia for emergency clinicians.

Part one covers how to think about and prepare for PSA, including a discussion of fasting guidelines. 13 minutes.

Part two describes how patients are harmed during PSA and how to prevent patients from being harmed during PSA. 29 minutes.

Part three discusses contemporary PSA pharmacology. 16 minutes.

 

References

Slideset

Emergency Department PSA Checklist

 

airway-breathing-aes-during-psa

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Designed to be used as a single, double-sided page. 

pdf for printing

pdf vector image for screen viewing

for PSA mastery, see the PSA screencast trilogy

If you’d like to modify the checklist for your institution, I can send you the original layout (omnigraffle format) and tables (excel format).

Update: Egg and soy allergy is NOT a contraindication to propofol.

Update: ACEP’s procedural sedation clinical policy stipulates “Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.” See the harms of fasting.

Newborn: Kyan James

Guest post by Greg Press

 

The second perimortem C-section of my career happened last week. The first was almost ten years ago. While I’m hardly an expert (takes three to be an expert), I have some pointers worth sharing.

The first case happened on the first day of my first job, in Houston, having just completed my ultrasound fellowship in New York. The night started with a guy shot in the right chest: intubation and chest tube. His girlfriend was brought in next, pregnant, shot in the head: perimortem c-section and neonatal intubation.

The second was just the other day. It was my first code at my new job at a small hospital in Wellington, New Zealand. A young girl hanged herself, was found by family who called EMS. They found in her VFib, defibrillated, started CPR, intubated and called to warn us of her arrival. They reported she was in asystole, a bad sign for mom. They reported she was 22 weeks pregnant, a bad sign for baby.

There have been a few PMCS reviews circulating recently in the EM world and I agree with most of their recommendations. But I have differing thoughts on a few points.

Do not memorize the number 24. Or 23. Or 25, or whatever the gestational age your neonatologists say they can currently save premies. You are unlikely to know the precise age–the mother is generally the most reliable source for this information, but generally not in this circumstance. We understood the hanged woman to be 22-weeks pregnant; post-mortem estimates placed the baby at 26 weeks. More importantly, you are not doing this procedure for the baby: PMCS is a resuscitative intervention for the mother. You’re trying to save mom, first and foremost, and then baby, maybe. So, whether the gestational age is 22, 24, or 26 weeks is irrelevant.

But you don’t want to do this procedure for a first-trimester pregnancy, so when do you do it?

  1. When you have a reported gestational estimate anywhere near viability. Or…

  2. When the tummy is big. If the fundal height is above the umbilicus, great. If this assessment escapes your mind in the chaos of the moment, just recognize that the tummy is big. Or…

  3. When the baby looks big on ultrasound. Ultrasound does not need to be performed routinely, particularly if the mother is bursting with baby. But if you’re not certain, put the probe on the belly, not to measure biparietal diameter, just to see is this a big baby? You will probably not be able to resist the urge to look for a fetal heartbeat, but do not delay the intervention of interest.

Do not memorize the number 4. This is the supposed number of minutes after maternal arrest when we see a precipitous decline in fetal neurologic outcome and survival. The number 4 is even more irrelevant than the number 24, because, again, the procedure is done primarily for the mother. And the procedure is done as soon as possible. As soon as possible is the only time consideration.

So what is most important to know? There are two things you must do and a few nuances to keep in mind.

Assuming you have some forewarning, the two things you must do are GET HELP and GET STUFF.

Call the obstetrician.  Call the NICU, or PICU, or whomever can help you take care of the baby.

Get stuff for mom. Get a kit. You may only have a thoracotomy kit or some other all purpose ED kit – get it. If you don’t have a kit, get a scalpel, real surgical scissors, towels, and clamps for the cord.

Get stuff for baby. Get a baby warmer. Get a neonatal BVM. Get a neonatal intubation kit, and an IO, and the dose of epinephrine.

Assign someone to manually displace the uterus to the left. Tell this person she must do this nonstop until the scalpel hits the skin. And then she must immediately shift focus to assure CPR continues until all efforts cease. There will be others responsible for CPR, ideally a line of people performing CPR, but it’s easy to neglect once scalpel hits skin, and so it is important to have someone assigned as insurance just at the moment when this oversight is most likely to occur.

Forget the mommy-tilting ramp. It will be hard to find the ramp, harder to jerry-rig one, and harder still to perform CPR and the procedure on a tilt. Assign a tummy-pusher.

The patient will arrive, and if she’s arrested you will have to secure the airway, perform CPR, obtain IO or IV access, give drugs, possibly defibrillate. This will seem simple because you do it all the time.

And then you will have to perform the perimortem C-section. Perhaps an obstetrician has by now arrived. If not, two thoughts might cross your mind: there’s very little to gain and I’m not going to be a hero. Erase both of those thoughts; there’s even less to lose and it’s time to be a hero.

Cut a vertical incision from the top of the belly’s curve to the pubis. With an earlier pregnancy and heftier mother, there may be fat to get through to the peritoneal wall – you can use your fingers as claws to bluntly dissect a parting to the peritoneum. Then cut through the peritoneum vertically, ideally with scissors (you can use the scalpel to initiate an opening inferiorly). Pull out the big uterus and cut it open vertically in the same manner until you get the baby out. Be careful not to cut the baby.

When the baby comes out it will be very alarming. If it is very premature, it will look like a purple alien. The first time I saw this it was disturbing. The second time I was quite aware how disturbing it was for everyone else in the room. The cord will have to be clamped twice and cut in between. Grab the baby, wrap it in a warm towel, bring it to the warmer you have prepared. Most likely you will immediately start bagging the neonate, unless it is near-term and crying. Look for signs of life such as attempts to breathe, cry or move. Both times for me there have been none. If there is no heartbeat or signs of life, start CPR. To determine if there is a heartbeat, listen with your stethoscope over the chest or feel for umbilical pulsations. If there is a heartbeat and it is slow (<60 bpm) just bag the baby, if it doesn’t improve quickly (30 seconds) start CPR. If the eyelids are fused it is probably too premature to be viable. If the baby is an early premie and bagging and CPR do not resuscitate the child I would stop efforts. If it is a full or near-term baby that cannot be resuscitated by bagging and compressions, intubate, obtain IO/UV access and start in with epinephrine and advanced neonatal life support.

Once more: the delivery is a resuscitative intervention for the mother first and foremost. Make sure maternal CPR and resuscitation continue throughout and after delivery. Don’t let the splayed open belly and uterus concern you, just pack them with towels, it will bleed less than you anticipate. Mom is likely young and healthy. After a few minutes our mother had a strong pulse and a good blood pressure. She is alive in the ICU as of this writing.

Despite having read this and feeling prepared, expect a shit storm. The unique scenario of your case will bring unanticipated events. Get help and get stuff (mommy and baby stuff) early. Assign the tummy-pusher-turned-CPR-advocate. Cut the tummy, cut the uterus, cut the cord. Expect to bag the baby and perform compressions unless near term and breathing. Continue efforts with mom until after the procedure.

Finally, I would like to comment on a dramatic difference between the Houston and New Zealand experiences. Following the case in New Zealand, there have so far been two debriefing sessions. Both have been held to address the clinical and emotional aspects of such a difficult case. In Houston, ten minutes after PMCS we moved on to the next case, another critically injured patient, and that was that. Everybody involved in the New Zealand case was invited to the second debriefing session, from the ambulance crew to the students to the doctors and nurses from the ED, obstetrics and the ICU. A psychologist ran the session, and though I was skeptical, she was quite good. Was very interesting to hear how students, pregnant nurses, old cranky doctors and everyone in between felt about the experience. It was just as important to air out clinical concerns and perspectives unique to each specialty, to avoid frustrations and move closer to optimal care for next time. I suggest you try to make this happen for the next once-in-a-lifetime case you experience.

Greg Press

A correspondence from New Zealand

From Rose 2015 summarized by Cabrera

RH

Awake Intubation: A Very Brief Guide

July 7th, 2013
by reuben in airway

 

 

Awake intubation is placing an endotracheal tube in the trachea while the patient continues to breathe. The principle advantage over RSI is that you do not take away the patient’s respirations or airway reflexes, which makes the process safer in many circumstances. The disadvantages are that the patient’s personality and movements, as well as the patient’s airway reflexes, must be managed, which takes time, and even when done well, the view you get won’t be as good as in a paralyzed patient.  Instrumenting the back of the throat may cause gagging and possibly vomiting, though this is quite unlikely to lead to clinically significant aspiration (because the patient is awake).  The more difficult airway features, and the less urgent the intubation, the more likely you should intubate awake. Patients who are at high risk to vomit are not good candidates for an awake technique.

The two arms of awake intubation are local anesthesia and systemic sedation. The more cooperative your patient, the more you can rely on local; perfectly cooperative patients can be intubated awake without any sedation at all. More commonly in the ED, patients will require sedation. Ketamine is the agent of choice in most circumstances, as it sedates without depressing respiration or airway reflexes. In somewhat cooperative patients, 20 mg boluses, titrated to effect, work very well. In very uncooperative/agitated patients, a full dissociative dose (1.5 mg/kg) is an effective strategy though a brief period of apnea is usual if dissociative doses are delivered as a bolus, and laryngospasm is a possible complication. For those patients where raising heart rate or blood pressure is undesirable, benzodiazepine sedation will have a less effective but still salutary effect. Dexmedetomidine is probably a better agent in these scenarios, but is a little tricky to use and not available in most EDs.

Even if using full dissociative dose ketamine, do your best to anesthetize the airway, using the steps listed in the box above, excerpted from the ED intubation checklist. Local is much facilitated by a dry mucosa, so the first step, if possible, is to dry the mucosa with glycopyrolate or atropine, followed by suction and dabbing with gauze. Once this is done, anesthesia is delivered by nebulization, atomization (ideally using a purpose-built atomizer like a MAD device), and drip techniques.

Once the patient is adequately anesthetized/sedated, you gently proceed with your intubation method of choice. When you see the cords, you can pass the tube without paralysis, place the bougie and then paralyze, or paralyze before placing the bougie/tube. I recommend the second option, and I also recommend that you prepare to do a full RSI, with whatever equipment and drugs you would use in an RSI case.

When done well, awake intubation is quite anticlimactic, as the patient simply continues to breathe, and saturation is maintained, for as long as needed. While RSI is terrific and will work very well in most cases, if you perform RSI on a patient who was a good candidate for an awake technique, and it doesn’t go well, you have made a consequential mistake. Awake technique requires little additional skill; it is under-utilized in emergency medicine because it requires what emergency providers often lack: patience. In this case, however, patience is well rewarded.

Hypotension: Differential Diagnosis

June 22nd, 2013
by reuben in .shock

hypotensionDdx.001

 

It’s an important differential. For emphasis, and in case you need to paste it somewhere, here it is again, in text form.

vasodilatory
sepsis
anaphylaxis
neurogenic

obstructive
tension pneumothorax
cardiac tamponade
pulmonary embolism
abdominal compartment syndrome (thanks GW)

cardiogenic
arrhythmia
ischemia
valvulopathy
myopathy

 

hypovolemic (hemorrhage)
chest
abdomen
retroperitoneum
GI tract
thigh
street

hypovolemic (not hemorrhage)
vomiting, diarrhea
inadequate fluid intake
diuresis, hyperglycemia
diaphoresis, hyperthermia
cirrhosis, pancreatitis, burn

 

toxicologic
calcium channel blocker
beta blocker
clonidine
digoxin
opiates
sedatives
valproic acid
TCA
phenothiazine
CO, CN-

metabolic
hypoadrenalism
hypo/hyperthyroidism

spurious
(equipment or technique failure)

A few other considerations:

auto-PEEP if intubated

hypocalcemia