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Sedation Complications, Urgencies and Emergencies

Sedation Complications, Urgencies and Emergencies. Medical Emergency Kit. Golden Rule. In cases of trouble Always verify adequate respirations of your patient Ventilate Reverse. Sedation Emergencies. Nausea/Vomiting Aspiration Paradoxical reactions Oversedation Laryngospasm.

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Sedation Complications, Urgencies and Emergencies

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  1. Sedation Complications, Urgencies and Emergencies

  2. Medical Emergency Kit

  3. Golden Rule • In cases of trouble • Always verify adequate respirations of your patient • Ventilate • Reverse

  4. Sedation Emergencies • Nausea/Vomiting • Aspiration • Paradoxical reactions • Oversedation • Laryngospasm

  5. Nausea/Vomiting • Most commonly associated with • Opioids • Patient movement will aggravate • Swallowing blood • Anxiety

  6. Treatment of Nausea and Vomiting… • Promethazine (Phenergan) • 25 mg IV, IM, oral or rectal • Additive sedative effect • Trimethylbenzamide (Tigan) • 200-250 mg oral, rectal, IM • Questionable efficacy • Ondansetron (Zofran) • 4 mg IV or IM

  7. Aspiration • Defined • Inhaling of vomit into lungs • Causes • Depression of protective reflexes with depressed level of consciousness • Increased N/V associated with opioids • Swallowing of blood

  8. Aspiration • Damage: • Particles/fluids • Cellular response to lungs (chemical burn) • Respiratory lining breakdown • Surfactant destroyed • Alveoli collapse becoming fluid filled • Large particles • Mechanical airway obstruction • Atalectasis, asphyxia, death

  9. Aspiration • Treatment • Aggressive suctioning • Head down position • Transfer to hospital quickly

  10. Aspiration • Prevention • Identify prone patients • Anxiety • Problems with opioids • NPO solids > 6 hours • NPO clear liquids > 2 hours • Vigilant suctioning of blood • Prophylactics?

  11. Paradoxical Reactions… • Benzodiazepines primary culprit • More common in women and children • Crying • Anger • Agitation • Combativeness • Pruritis • Disorientation • Dysphoria • Tachycardia

  12. Paradoxical Reactions… • Benzo’s remove inhibitions in some patients • Patients with mental disorders more likely • Treatment • Flumazenil

  13. Oversedation… • Any level of sedation or anesthesia can be achieved by any route • Inhalational • Orally • Parenteral

  14. Oversedation… • Your patient is clearly oversedated when they do not… • Maintain their own patent airway • Breath on their own • Respond to verbal commands

  15. Oversedation… • Understand dosing schedules • Understand pharmacokinetics of medications used • Drug—Drug interactions • Increased concentrations of midazolam and triazolam • Erythromycin • Ketoconazole/iatraconazole • Grapefruit juice • Protease inhibitors • Verapamil/diltiazem

  16. Oversedation… • Overuse of opioids often results in… • Respiratory depression • Decreased depth, rate and drive • Decreased skeletal muscle tone

  17. Respiratory Depression… • In the presence of respiratory depression patients may… • Obstruct • Muscle relaxation • Tongue position • Hypoventilation to the point of apnea

  18. Oversedation… • Does not necessarily define a state of emergency, but you must be able to… • Recognize the situation • Be able to get out of it skillfully • Have the courage to ask for help

  19. Oversedation… • Oversedation will generally imply that your patient does not… • Hold his own airway • Breath spontaneously • Both

  20. Oversedation… You absolutely, positively Must Must Must be able to distinguish between the two

  21. Oversedation… • Of the oxygen saturation drops more than 4 points… • Gently shake or shout • Open the airway (jaw thrust maneuver) • Positive pressure ventilation • Administer reversal agent • EMS if no rapid response

  22. Flumazenil Approved use—IV May be given—IM, SL, IN Dose: 0.2 mg (2cc) Pedi: 0.01-0.02 mg/kg Naloxone Intended use—IV May be given—IM, SL, SC Dose: 0.1-0.4 mg Pedi: 0.01 mg/kg Our Savior

  23. Intranasal Flumazenil… • Study performed on 11 kids ages 2-6 yrs. • Dose: 0.04 mg/kg via drops in nose • Adult dose 0.2 mg/70kg • Both resulted in plasma concentrations 5 times that reported to reverse benzo’s • Highest plasma concentrations seen with administration via both nostrils • Peaked in 2 minutes Scheepers et al. Can J Anesth. 2000;47:120

  24. Oversedation… • After the administration of a reversal agent • Must continue to ventilate until spontaneous respirations return • Continue to observe patient for 2 hours to rule out resedation

  25. Laryngospasm • In the event that you cannot ventilate, you must consider the presence of laryngospasm or foreign body airway obstruction • Defined: • Forceful partial or complete adduction of the vocal cords

  26. Laryngospasm • Treatment • Remove any obvious foreign material • Ventilate forcefully with oxygen • Reverse the sedative agent

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