Emergency Sedation Research Articles

Use of Intraosseous Vascular Access During Neonatal Resuscitation at a Tertiary Center.

Introduction: Emergency vascular access is rarely required during neonatal resuscitation. We aimed to analyze frequency of use, success, and complication rates of intraosseous (IO) vascular access in neonates at a single tertiary neonatal intensive care unit.Method: We performed a questionnaire-based survey among pediatric residents, pediatricians, and neonatologists, asking for the use of IO access in neonates between April 1st, 2015, and April 30th, 2020. We then reviewed electronic patient charts of all identified neonates for demographic data as well as indications and complications of IO puncture.Results: All 41 questionnaires were answered. Nine physicians had attempted IO access 15 times in a total of 12 neonates. Among them were eight term neonates, three preterm neonates, and one former extreme preterm neonate at a post-menstrual age of 42 weeks (m:f = 6:6). The overall success rate was 75%. IO access was attempted primarily during post-natal resuscitation (11/12 neonates, 91.7%) and after unsuccessful peripheral venous puncture (8/12 neonates, 66.7%). It was used to administer adrenaline, fluid and/or blood, and emergency sedation after intubation. Minor short-term complications were reported in three of nine successful IO punctures (33.3%).Discussion: Over the study period of 61 months, IO access was rarely attempted during neonatal resuscitation. Our success rate was lower than reported elsewhere, suggesting that IO puncture may be more challenging in neonates than in older infants and children. No severe short-term complications occurred.

Clinical profile of older adults presenting to psychiatric emergency services: A retrospective study from South India

Background: Older adults constitute an important subgroup among those presenting to psychiatric emergency services. Psychiatric emergencies in older adults are particularly understudied in India. Objective: The objective was to study the clinical profile of older adults presenting to psychiatric emergency services. Method: All case records of older adults (60 years and above) presenting to Emergency psychiatry and Acute care (EPAC) in a tertiary care Neuropsychiatric institute from July 2018 to December 2018 were reviewed. The details pertaining to sociodemography, clinical profile, medical comorbidity and clinical management were reviewed and analyzed. Results: 230 older adults were seen in EPAC during the study period. This constituted 6.7% of the 4200 patients of all age groups seen in EPAC during this period. The mean age of the study group was 68.77 years (standard deviation-7.23) with 61.30% males and 38.69% females. The frequency of individuals with at least one co-morbid medical illness was 62.6%. The common diagnosis was mood disorders (30.87%), followed by dementia (16.52%) and delirium (10.43%. Agitation/aggression (46.52%), confusion (31.74%), and risk of self-harm (13.47%) were the most frequent reasons for presentation to EPAC. Neuropsychiatric disorders (31.30%) and mood disorders (30.87%) constituted the most common diagnosis in the group. Among those who required parenteral sedation, lorazepam (18.7%) was the most preferred agent followed by haloperidol (16.1%). Discussion and Conclusion: Older adults in our study predominantly had depression, behavioral and psychological symptoms of dementia and delirium although the proportion of delirium is smaller when compared to western studies. The most common reason for older adults' visit to emergency was agitation/aggression which is in agreement to other similar studies. Nearly half were managed without emergency sedation. However, smaller proportion of patients received sedation with haloperidol and lorazepam. The study was done in a primary psychiatry setup where general medical emergency is not available. This could be the probable reason for lower prevalence of delirium in our study compared to previous studies which is a limitation.

Pre-hospital use of capnography during emergency sedation analgesia

Background: Providing optimal patient care in the challenging, uncontrolled, and sometimes hostile pre-hospital environment may require the use of potent analgesics and sedatives. During pre-hospital emergencies, narcotics or sedatives administered for sedation, anxiolysis, or analgesia to allow the patient to tolerate unpleasant procedures, such as traction splint application, can result in cardiovascular and respiratory adverse events.1 Early recognition of poor oxygenation may prevent unnecessary patient hypoxia. The European Society of Anaesthesiology and the American Society of Anaesthesiologist mandate continuous capnography, in addition to standard monitoring which include pulse oximetry, 4-lead ECG, blood pressure, and heart rate measurements.1,2 Capnography refers to the non-invasive measurement of the partial pressure of carbon dioxide (CO2) in exhaled breath. Monitoring respiratory status provides early warning, thereby allowing clinicians to intervene before the onset of respiratory depression, potentially leading to bradypnoea, apnoea, hypoxia, and death.3 In addition, late identification of respiratory failure may lead to unnecessary endotracheal intubation and mechanical ventilation, increasing risk of protracted hospital stay and associated hospital-acquired infections.Oxygenation and ventilation must be measured in both intubated and spontaneously breathing patients. While clinical indicators like chest rise or the plethysmography-derived respiratory rate can be used, monitoring the capnographic waveform for hypopnoeic and bradypnoeic patterns provides the clinician with a quick, accurate indication of acute adverse respiratory events.4 In two randomized trials, patients monitored with capnography in addition to standard of care, experienced significantly fewer episodes of hypoxia than those monitored without capnography.3,5 Hamad Medical Corporation Ambulance Service (HMCAS) in Qatar introduced a new clinical practice guideline (CPG) for safe sedation and monitoring in August 2017, mandating the routine use of capnography for all sedated patients. Safe sedation is achieved when the patient's oxygenation, ventilation, or haemodynamic status is not negatively impacted by the sedation procedure. Methods: The study aimed to describe trends in the use of capnography and other monitoring modalities for patients receiving Ketamine, Fentanyl, or Midazolam. Retrospective quantitative analysis of an existing HMCAS medical records database linked to a Business Intelligence (BI) tool enabled direct analysis on the tool and via a linked Microsoft Excel® spreadsheet, reviewing all emergency cases from 1st January 2017 to 31st December 2018. Frequency analysis and measures of central tendency was applied to the relevant clinical variables. All patient and practitioner identifiable data fields were redacted and not reported on. Results: Oxygen saturation (SpO2) and blood pressure monitoring was used on all patients (n = 5157, 100%), 4-lead ECG was placed on 3710 (72%) patients, while capnography was used on 4096 patients (79%, range = 39% to 99%). Capnography usage steadily improved over the 24-month period, especially for patients receiving Fentanyl (Figure 1). Conclusion: There was a significant improvement in the use of capnography during monitoring of patients that received Fentanyl, Ketamine, or Midazolam, with the most significant improvement for patients receiving Fentanyl alone. Further studies are required to determine the impact of this improvement on actual adverse event frequency.

‘Rapid tranquillisation’: an historical perspective on its emergence in the context of the development of antipsychotic medications

This paper examines factors involved in the theory and practice of emergency sedation for behavioural disturbance in psychiatry in the mid-twentieth century, and the emergence of the concept of 'rapid tranquillisation'. The practice received little attention until the arrival of antipsychotic drugs, which replaced older sedatives and became the agents most strongly associated with the treatment of aggression and challenging behaviour. Emergency sedation was subsequently portrayed in psychiatric literature and advertising as a therapeutic and diagnosis-driven endeavour, and the concept of rapid tranquillisation emerged in this context in the 1970s. Use of non-antipsychotic sedatives, like the benzodiazepines, is barely visible in contemporary sources, and the research suggests that antipsychotics became the mainstay of rapid tranquillisation strategies because of beliefs about their specific therapeutic properties in psychosis and schizophrenia, and not because of demonstrated superiority over other agents.

세보플루란 깊은 진정의 응급과 비응급적 사용에 관한 실태조사

심한 불안이나 불수의적인 움직임으로 행동조절이 어려운 소아와 장애인의 치과치료를 위해 깊은 진정법이 고려된다. 응급 치과진료에 있어 세보플루란 흡입을 이용한 깊은 진정이 빠른 유도와 회복으로 인해 선호된다. 2013년 1월부터 2013년 10월까지 세보플루란을 이용한 깊은 진정을 받은 소아와 장애인 121명을 대상으로 조사분석하였다. 깊은 진정법을 사전 계획한 환자군과 소아외상이나 장애인의 특성 등으로 응급으로 시행한 환자군을 비응급 세보플루란진정군과 응급 세보플루란진정군으로 나누었다. 비응급 세보플루란진정을 받은 환자는 95명이었고 응급 세보플루란진정을 받은 환자는 26명이다. 두 군간에 성별, 나이, 진정법을 시행한 이유, 유도방법, 진정시간 및 치료시간, 치료내용, 진료과를 비교분석하였다. 비응급 세보플루란진정은 소아와 장애인의 행동조절에 안전하고 효과적으로 사용되었고 응급 세보플루란진정은 외상을 입은 어린 소아환자의 짧고 간단한 치료에 유용하게 사용되었다. 세보플루란을 이용한 깊은 진정은 점차적으로 전신마취의 사용을 줄이고 소아와 장애인 환자의 응급 치과진료에 유용한 방법이었다. Deep sedation is considered for the dental treatment of pediatric or disabled patients who have severe anxiety or involuntary movement. Deep sedation using sevoflurane inhalation in emergency dental practice, therefore, is also preferred for fast induction and recovery. This survey consists of 121 people with pediatric or disabled patients who underwent dental treatment under deep sedation using sevoflurane inhalation from January 2013 to October 2013. Patients who were scheduled for deep sedation were classified into a non-emergency sevoflurane sedation group, whereas patients who underwent emergency sedation due to trauma and patients with disabled characteristics itself were classified into an emergency sevoflurane sedation group. Of 121 patients studied, 95 patients received dental care under non-emergency sedation, 26 patients received dental care under emergency sevoflurane sedation. The two groups were analyzed according to: gender; age; primary reason for sedation; duration of sedation; treatment time; induction methods; treatment information; and departments. Non-emergency sevoflurane sedation in pediatric or disabled patients was safe and effective for controlling the behavior. Emergency sevoflurane sedation was a useful method for younger pediatric patients with traumatic injury who need simple, short time emergency treatment. Deep sedation using sevoflurane inhalation not only will reduce the use of general anesthesia gradually but also will be a useful method to emergency treatment for pediatric or disabled patients.

120 Procedural Sedation and Analgesia in the Paediatric Emergency Department

Pain is one of the most common reasons for which children visit the emergency department (ED). Nevertheless, pain is frequently under-recognized and under-treated in this setting. Ongoing evidence continues to...

OC-013 Hospital attendances after outpatient colonoscopy: the hidden healthcare burden?

IntroductionWith the introduction of national bowel cancer screening and increased surveillance, colonoscopy is being increasingly used as both a diagnostic and therapeutic tool. It is deemed a relatively safe procedure...

Risks of being an anaesthesiologist

Risks of being an anaesthesiologist

Practical guidelines for the acute emergency sedation of the severely agitated older patient

The vulnerability of older people to serious underlying medical illness and adverse effects of psychotropics means that the safe and effective treatment of severe agitation can be lifesaving, the primary management goals being to create a safe environment for the patient and others, and to facilitate assessment and treatment. We review the literature on acute sedation and provide practical guidelines for the management of this problem addressing a range of issues, including aetiology, assessment, pharmacological and non-pharmacological strategies, restraint and consent. The assessment of the agitated older patient must include concurrent assessment of the likely aetiology of, the risks posed by, and the risks/benefits of management options for, the agitation. A range of environmental modifications and non-pharmacological strategies might be implemented to maximize the safety of the patient and others. Physical restraints should only be considered after appropriate assessment and trial of alternative management and if the risk of restraint is less than the risk of the behaviour. Limited evidence supports a range of pharmacological options from traditional antipsychotics to atypical antipsychotics and benzodiazepines. It is advised to start low and go slow, using small increments of dose increase. Medical staff are frequently called to sedate agitated older patients in hospital settings, often after hours, with limited access to relevant medical information and history. Safe and effective management necessitates adequate assessment of the aetiology of the agitation, exhausting all non-pharmacological strategies, and resorting to pharmacological and/or physical restraint only when necessary, judiciously and for a short-term period, with frequent review and the obtaining of consent as soon as possible.

Emergency Sedation and Pain Management

Emergency Sedation and Pain Management

Emergency Sedation and Pain Management

Emergency Sedation and Pain Management

The practice of pediatric procedural sedation and analgesia in the emergency department

The treatment of acute pain and anxiety in children undergoing therapeutic and diagnostic procedures in the emergency department has improved dramatically over the last few years. The availability of noninvasive monitoring devices and the use of short-acting sedative and analgesic medications enable physicians to conduct safe and effective sedation and analgesia treatment. In today's practice of pediatric emergency medicine, sedation and analgesia has been considered as the standard of care for procedural pain. The following article describes the basic principles of pediatric procedural sedation and analgesia in the emergency department.

Sedation for the care of patients with advanced cancer

Sedation in the context of palliative medicine is the monitored use of medications to induce varying degrees of unconsciousness to bring about a state of decreased or absent awareness (i.e. unconsciousness) in order to relieve the burden of otherwise intractable suffering. Sedation is used in palliative care in several settings: transient controlled sedation, sedation in the management of refractory symptoms at the end of life, emergency sedation, respite sedation, and sedation for refractory psychological or existential suffering. Sedation is controversial in that it diminishes the capacity of the patient to interact, function, and, in some cases, live. There is no distinct ethical problem in the use of sedation to relieve otherwise intolerable suffering in patients who are dying. Since all medical treatments involve risks and benefits, each potential option must be evaluated for its promise with regards to achieving the goals of care. When risks of treatment are involved, to be justified these risks must be proportionate to the gravity of the clinical indication. Some aspects of management, such as the need for hydration in patients undergoing sedation and the use of sedation in the management of psychological and spiritual suffering, remain controversial.

Emergency Sedation of Agitated Patients: What Works Best?

Agitated emergency department patients commonly require chemical restraint, but what is the ideal agent? Researchers compared intramuscular midazolam

Prehospital and emergency room pain management for the adult trauma patient

Emergency pain control, analgesia, and sedation are very challenging areas for physicians. Life-threatening injuries must be diagnosed and controlled before giving analgesic drugs. The choice of analgesia procedure depends on the general status of the patient and the location, type, and number of lesions. Copyright © 2002 by W.B. Saunders Company

Paediatric special interest group in medicine Haematometra and haematocolpus in a teenage girl Lies, damned lies and EDIS data: Statistics built on sand Lies, damned lies and EDIS data: Statistics built on sand: Reply Emergency sedation intubation Emergency sedation intubation: Reply Emergency physicians roles in managing HIV seroconversion illness: Take stock or take HAART? Emergency physicians roles in managing HIV

Emergency MedicineVolume 11, Issue 3 p. 196-204 Paediatric special interest group in medicineHaematometra and haematocolpus in a teenage girlLies, damned lies and EDIS data: Statistics built on sandLies, damned lies and EDIS data: Statistics built on sand: ReplyEmergency sedation intubationEmergency sedation intubation: ReplyEmergency physicians roles in managing HIV seroconversion illness: Take stock or take HAART?Emergency physicians roles in managing HIV seroconversion illness: Take stock or take HAART? Reply First published: 27 February 2002 https://doi.org/10.1046/j.1442-2026.1999.00046.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume11, Issue3September 1999Pages 196-204 RelatedInformation

Use of an emergency sedation protocol to assist intubation in helicopter patient retrieval in Victoria

Abstract Objectives: To review emergency sedation intubation as practised in the Melbourne-based ambulance helicopter. Specifically, to describe patient profiles, drug dosage, difficulties encountered, success rate and patient outcomes. Methods: Retrospective review of all helicopter primary and secondary retrieval patients, who received application of the emergency sedation intubation protocol using morphine and diazepam during a 3 year period (January 1995 to December 1997). Data were collected from an audit of patient care records completed by flight paramedics and from hospital records. Results: Emergency sedation intubation was performed on 128 patients: 103 adults and 25 children. The median dose of drugs required for emergency sedation intubation by adult patients was 20 mg morphine and 20 mg diazepam. The overall success rate for emergency sedation intubation was 94.5%, with 73.6% of these being successful intubations at the first attempt. On intubation, 54.1% of patients were fully relaxed, while a gag reflex was still present in 45.9% of patients during or just after emergency sedation intubation. Twenty-two per cent of patients had a change in blood pressure of more than 20 mmHg. The maximum rise in blood pressure was 60 mmHg and the maximum fall was 80 mmHg. Conclusions: Flight paramedics achieved a high success rate for intubation with the morphine/ diazepam emergency sedation intubation protocol. However, there was still a significant percentage of patients for whom more than one attempt was required to achieve emergency sedation intubation and, in almost half the patients, gag reflexes remained present either during or immediately after intubation. Additionally, some patients experienced blood pressure changes following intubation that may have potential adverse consequences in terms of compromised cerebral perfusion or rises in intracranial pressure. Consideration should be given to revision of the protocol to allow the use of neuromuscular blocking agents and alternative airway management techniques, such as cricothyroidotomy, for specified circumstances in the aeromedical environment.

Utilisation du Diprivan ® pour les urgences préhospitalières

The use of propofol at the scene of an accident or during transport to the hospital: 1. Should be restricted to fully qualified anaesthetists of an Emergency Mobile Hospital Unit. 2. Is probably rather limited, as: the indications for anaesthesia in this context are relatively rare; they are dominated by trauma cases (which represent 20 to 30 per cent of the activity of an Emergency Mobile Hospital Unit) and other accident-related conditions; furthermore, in most emergency situations, sedation and/or analgesia of varying depth are more often required; the indications for propofol would be rare because of: its haemodynamic effects, especially as hypovolaemia is extremely frequent, as neurological damage is often existing, and the medical history of the patient is frequently unknown; the possible choice of other agents, such as midazolam, which is widely used as well as etomidate or ketamine; 3. Should follow the same guidelines as those in use for its intra-hospital administration: propofol is undoubtedly a valuable agent as it allows a rapid induction, depresses the pharyngo-laryngeal reflexes, and has the advantage of producing a rapid, good quality recovery which provides an important element of safety; however, for as long as prospective comparative studies have not specifically been carried out in the area of pre-hospital anaesthesia, the greatest circumspection is required. Any contraindication and precaution recommended from hospital use should be strictly adhered to and amplified because of the difficult circumstances and the other available alternatives kept in mind.

Enhancing the hospital treatment of dissociative disorder patients by developing nursing expertise in the application of hypnotic techniques without formal trance induction.

Many symptoms suffered by dissociative disorder patients are unresponsive or incompletely responsive to medications. This poses a unique challenge to the staff of specialized dissociative disorder units, in which many such patients who require hospital care suffer serious distress that may not respond predictably to the pharmacological interventions that are available. However, the majority of their symptoms are dissociative in nature, and dissociative disorder patients generally are quite hypnotizable. Anticipating the need for nonpsychopharmacological interventions that we could use in the absence of the treating psychiatrist, we taught the unit's nursing and social work staff to rely on the inherent trance-proneness of these patients to utilize hypnotic techniques without the formal induction of hypnosis. Their implementation facilitated crisis resolution, led to a greater sense of safety on the part of the patients, enhanced the staff's sense of mastery, and minimized the need for emergency sedation and restraints.