Flashcards in Pharm2 9 Anesthesia & Sedation pt3 DOSES Deck (27)
Emergency Equipment to have in the room when you're doing sedation, just in case. (8)
Positive pressure ventilation
Appropriate size face mask, ambu
Laryngoscope: blades, batteries, bulb
Airways: nasal and oral
ET tubes, Cricothyrotomy set up
Defibrillator and emergency ACLS meds
Diazepam (Valium) -
Dose: 0.1 mg/kg IV, 0.5 mg/kg PR
Onset: < 1 minute
Duration: 1-2 hours
Risks: decreased respiratory drive, decreases B/P
What conclusions are made from Diazepam, based on its duration?
There aren’t too many ER surgeries that last 2 hours. So for that time that follows someone needs to be with the patient.
Or you wouldn't choose this if the surgery won't last anywhere as long as this drug.
Dose: 0.15 mg/kg IV/IM
Onset: 2 minutes IV, 10-15 minutes IM
Duration: 30 minutes IV
Risks: decreased respiratory drive, decrease B/P
With Midazolam, it stops in __ minutes, so they can...
Now this one stops in 30 minutes. Then they can sit up, take sips of liquid or ice chips. Then they don’t necessarily need to be monitored one on one (you won’t leave ‘em alone though)
Which Benzo is much more realistic in the ER?
Midazolam (30 min duration vs 2 hours with Diazepam)
*All benzo’s cause a degree of what? Which one specifically has the greatest of this effect?
*All benzo’s cause a degree of amnesia, depending on what receptors they hit, but *Midazolam has the greatest amnestic properties INCLUDING retrograde amnesia (a couple hours).
___ has the greatest amnestic properties INCLUDING retrograde amnesia (a couple hours).
Class: Opioid agonist
Dose: 1 mg/kg IV, 1-2 mg/kg IM
Onset: < 1 minute IV, 15 minutes IM
Duration: 30-60 minutes IV, 2-3 hours IM
Risks: cardiac arrhythmias,decreased respiratory drive, really bad pruritis, and vomiting
This drug is listed here b/c it’s occasionally used, but it’s so infrequent he won’t focus on this.
Class: Opioid agonist
Dose: 0.1 mg/kg IV
Onset: < 5 minutes
Duration: 3-4 hours
Risks: cardiac arrhythmias, decreased respiratory drive
What is Morphine a gold standard for?
It’s used for pain that will last a long time: Fractured femurs, MI for chest pain, burns.
Class: Opioid agonist
Dose: 2-3 µg/kg IV
Onset: 2 minutes
Duration: 30 minutes
Risks: decreased respiratory drive, decreased BP, bradycardia, rarely chest wall rigidity
This is the drug that most use for procedural sedation. “very clean” a synthetic morphine equivalent, that’s ~100x more potent.
While morphine gets a nl syringe, this is in an insulin syringe (mcg).
No nausea/vomiting “I promise you, in 99/100 patients.”
Effect of 5 mg of morphine = ___ of this other drug.
75 mcg of Fentanyl.
*the only drug that can cause rigid chest wall syndrome – the chest wall can’t expand. These pts can only breathe by moving their diaphragm.
If someone develops rigid chest wall syndrome while on ___, how do you treat it? (can’t use narcam b/c it works on diff receptors to stop the euphoria)
You need to paralyze chest muscles so they can’t contract. Rapid sequence induction – give fasiculating or nonfasiculating general anesthetic (rocuronium, vecuronium) so they are paralyzed to overcome this analgesic Fentanyl. Now this patient has lost their protective gag reflex, can’t breathe at all b/c muscles are paralyzed. Now this pt needs to be intubated and monitored overnight.
Colonoscopies, get __ then __. this is the very popular combination
midazolam, then fentanyl
Class: Dissociative agent
Dose: 1-2 mg/kg IV, 4 mg/kg IM
Onset: < 1 minute IV, ~ 5 minutes IM
Duration: 15 minutes IV, 30-60 minutes IM
Risks: increases BP/intracranial/intraoccular pressures, rare emersion reaction laryngeospasm,`
12kg little girl fell of the monkey bars, their forearm is bent at a 45º angle. They are splinted and brought in by EMS. Start IV, hook up to EKG, pulse ox, o2, first drug you give is _____. Why? What dose?
now you wanna give the kid some ______. What dose?
Stop, wait, and watch. 30 sec after this, she will develop ___ for ~10 seconds. Then that'll stop.
Next she will start gazing around (seeing Barney come out of the ceiling). Now I’ll take her both of the forearm fracture and put them back into place, the kid won’t even notice/care. Then put a splint on her, sling her, and the nurse & her will wait.
Which drug wears off first? Then what happens?
Midazolam (calm ‘em down) .15 mg/kg IV*.
ketamine 1mg/kg push (she weighs 12 kg), give her 12mg of ketamine.
Ketamine wears off first, she goes to x-ray for repeat film, and if it’s good after 30 minutes when Midazolam wears off.
Emersion reaction – very rare (he’s never seen, but heard of it happening) –
What drug is it associated with? what is it? Who does it happen to? What do you do about it?
kid wakes up seeing the delusions. They’re biting, kicking, screaming, etc until you give a Benzo (Valium) and they snooze for 4-5 hours, and they wake up & it’s gone. Rarely happens in anyone under age 10. So due to this, Ketamine is not used in anyone >10.
A child has a side effect from sedation. They look like they're trying to scream, but they can't.
What going on?
Which drug is this an adverse effect to?
How do you tx?
Laryngeal spasm, Ketamine
Take a bag valve mask that’s normally used to ventilate patient, and use this for ~10 minutes until this wears off, and it’s fine.
You can’t tx this by intubating b/c the laryngeal spasm doesn’t allow it
Milk of Amnesia's actual name is
"this is everyone's favorite"
Looks like skim milk leaking into veins
Class: Intravenous anesthetic-sedative-hypnotic
Dose: 0.5 - 1.0 mg/kg IV
Onset: 1 “arm-brain circulation”
Duration: < 5 minutes
Risks: not FDA approved for peds use, cardiac arrhythmias, decreased respiratory drive
How do you talk the patient through use of Propofol?
There’s a small burning sensation when it’s injected. “when you feel the burning in your arm count backwards from 100.” they won’t’ even make it to 99 before they’re out.
What happens to virtually everyone who is put on Propofol? What do you do about it?
Virtually everyone stops breathing when this drug is given. “but only for ~90 seconds.” So this person is ALWAYS on 100% O2 with a pulse-ox. Pre-oxygenate for 5 minutes with NRB, and it prevents this from being an issue.
When is Propofol particularly valuable?
emergency medicine. such as Putting a dislocated shoulder back in place