Sedation in Emergency Medicine Flashcards
(25 cards)
What are the main reasons for sedation in an ED setting?
- To facilitate medical procedures
- To relieve pain and discomfort
- Procedural sedation
- Foreign body removal
- Anxiety or agitation control
- Mechanical ventilation synchronization
- Trauma management (e.g., cervical spine injury)
- Intracranial pressure (ICP) control
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What are the four levels of sedation?
- Minimal Sedation: Responds normally to verbal commands
- Moderate Sedation: Requires light tactile stimulation
- Deep Sedation: Needs deep stimulation, may not maintain airway reflexes
- General Anesthesia: No response to pain, requires full airway management
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What are the key properties and risks of ketamine?
- Properties: Dissociative anesthetic with analgesic effects
- Uses: Procedural sedation and intubation
- Risks: Laryngospasm, emergence agitation (hallucinations upon waking)
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What is a major limitation of propofol?
- No analgesic properties (must be combined with an opioid)
- Increases cardiovascular instability → Risk of hypotension
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How does fentanyl differ from other sedative drugs?
- It is an opioid analgesic, not a sedative
- High doses can induce sedation but primarily used for pain relief
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What is ketofol, and is it more effective than using ketamine or propofol alone?
- Ketofol is a combination of ketamine and propofol
- Cochrane Review found no significant benefit over using them separately
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What are the advantages of nitrous oxide?
- Inhaled analgesic/sedative
- Short-acting, useful for minor procedures
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What are key considerations for airway management in a sedated patient?
- Proper positioning
- Jaw thrust maneuver
- Use of an oropharyngeal (Guedel) or nasopharyngeal airway
- Intubation if necessary
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What monitoring is required for sedated patients?
- Continuous visual observation
- Capnography (end-tidal CO2 monitoring)
- Vital signs (SpO2, BP, HR)
- Watch for adverse effects: Respiratory depression, hypotension, nausea, aspiration
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What are the primary reasons for intubation in the ED?
- Airway protection (GCS <8)
- Respiratory failure (fatigue, CO2 retention)
- Overdose or aspiration risk
- Severe trauma (e.g., cervical spine injury)
- Inhalation burns
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What challenges make intubation in the ED difficult?
- Full stomach (aspiration risk)
- Airway trauma or swelling
- Unstable vitals (hypotension, hypoxia)
- Limited patient cooperation
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What is the purpose of pre-oxygenation before intubation?
- Maximizes oxygen reserves → Extends safe apnea time
- Prevents rapid desaturation during intubation attempts
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What is Delayed Sequence Intubation (DSI)?
- Sedation before paralysis to allow proper pre-oxygenation
- Uses ketamine (1 mg/kg IV) for procedural sedation
- Helpful in patients who are hypoxic, confused, or uncooperative
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What are the 7 key steps in Rapid Sequence Intubation (RSI)?
- Plan & Prepare (Check airway equipment, team roles, medications)
- Protect Cervical Spine (if needed)
- Pre-Oxygenation (High-flow O2 for 3 minutes)
- Pre-Medicate (if indicated)
- Paralyze & Induce (Ketamine or Propofol + Rocuronium/Suxamethonium)
- Placement & Proof (Capnography, auscultation, chest rise, X-ray)
- Post-Intubation Management (Secure ETT, ongoing sedation, ventilation)
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Which medications are commonly used for induction in RSI?
- Ketamine
- Propofol
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Which drugs are used for paralysis in RSI?
- Depolarizing agent: Suxamethonium
- Non-depolarizing agents: Rocuronium, Vecuronium
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How is proper ETT placement confirmed?
- Capnography (ETCO2) → Gold standard
- Direct visualization of cords
- Chest auscultation (bilateral breath sounds)
- Chest X-ray confirmation
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Why is cuff pressure management important?
- Ideal pressure: 25-30 cmH2O
- Prevents air leaks while avoiding tracheal injury
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What is malignant hyperthermia and its triggers?
- A life-threatening hypermetabolic reaction to anesthetic agents
- Triggered by succinylcholine and volatile anesthetics (e.g., sevoflurane, isoflurane)
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What are early signs of malignant hyperthermia?
- Rapid increase in end-tidal CO2 (ETCO2)
- Generalized muscle rigidity
- Unexplained tachycardia and tachypnea
- Acidosis and hyperkalemia
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What are late signs of malignant hyperthermia?
- Severe hyperthermia (>1°C rise every few minutes)
- Rhabdomyolysis (elevated CK, myoglobinuria, AKI risk)
- Cardiovascular collapse
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How is malignant hyperthermia treated?
- Stop triggering agents immediately
- Administer Dantrolene (2.5 mg/kg IV) ASAP
- Aggressive cooling (ice packs, cold IV fluids, cooling blankets)
- Manage hyperkalemia (IV calcium, insulin + glucose, salbutamol)
- Correct acidosis with IV bicarbonate
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Why is pre-oxygenation the most important step in intubation?
- Extends safe apnea period up to 8 minutes
- Without pre-oxygenation, desaturation occurs within ~45 seconds
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How can ventilator-associated pneumonia (VAP) be prevented?
- Good oral hygiene (toothbrushing > chlorhexidine alone)
- Avoiding unnecessary intubation
- Closed suction systems
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