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Podcast 876: Sedation Pearls

Emergency Medical Minute

Release Date: 11/06/2023

Episode 902: Liver Failure and Cirrhosis show art Episode 902: Liver Failure and Cirrhosis

Emergency Medical Minute

Contributor: Travis Barlock MD Educational Pearls: How do you differentiate between compensated and decompensated cirrhosis? Use the acronym VIBE to look for signs of being decompensated. V-Volume Cirrhosis can cause volume overload through a variety of mechanisms such as by increasing pressure in the portal vein system and the decreased production of albumin. Look for pulmonary edema (dyspnea, orthopnea, wheezing/crackles, coughing up frothy pink sputum, etc.) or a tense abdomen. I-Infection The ascitic fluid can become infected with bacteria, a complication called Spontaneous...

info_outline Episode 901: Underdosing in Status Epilepticus show art Episode 901: Underdosing in Status Epilepticus

Emergency Medical Minute

Contributor: Aaron Lessen MD Educational Pearls: Lorazepam (Ativan) is dosed at 0.1 mg/kg up to a maximum of 4 mg in status epilepticus Some ED protocols only give 2 mg initially The maximum recommended dose of levetiracetam (Keppra) is 60 mg/kg or 4.5 g In one retrospective study, only 50% of patients received the correct dose of lorazepam For levetiracetam, it was only 35% of patients Underdosing leads to complications Higher rates of intubations More likely to progress to refractory status epilepticus References 1. Cetnarowski A, Cunningham B, Mullen C, Fowler M....

info_outline Episode 900: Ketamine Dosing show art Episode 900: Ketamine Dosing

Emergency Medical Minute

Contributor: Travis Barlock MD Educational Pearls: Ketamine is an NMDA receptor antagonist with a wide variety of uses in the emergency department. To dose ketamine remember the numbers 0.3, 1, and 3. Pain dose For acute pain relief administer 0.3 mg/kg of ketamine IV over 10-20 minutes (max of 30 mg). Note: There is evidence that a lower dose of 0.1-0.15 mg/kg can be just as effective. Dissociative dose To use ketamine as an induction agent for intubation or for procedural sedation administer 1 mg/kg IV over 1-2 minutes. IM for acute agitation If a patient is out of control and a...

info_outline Episode 899: Thrombolytic Contraindications show art Episode 899: Thrombolytic Contraindications

Emergency Medical Minute

Contributor: Travis Barlock MD Educational Pearls: Thrombolytic therapy (tPA or TNK) is often used in the ED for strokes Use of anticoagulants with INR > 1.7 or  PT >15 Warfarin will reliably increase the INR Current use of Direct thrombin inhibitor or Factor Xa inhibitor  aPTT/PT/INR are insufficient to assess the degree of anticoagulant effect of Factor Xa inhibitors like apixaban (Eliquis) and rivaroxaban (Xarelto)  Intracranial or intraspinal surgery in the last 3 months Intracranial neoplasms or arteriovenous malformations also increase the risk of...

info_outline Episode 898: Takotsubo Cardiomyopathy show art Episode 898: Takotsubo Cardiomyopathy

Emergency Medical Minute

Contributor: Ricky Dhaliwal, MD Educational Pearls: Takotsubo cardiomyopathy, also known as "broken heart syndrome,” is a temporary heart condition that can mimic the symptoms of a heart attack, including troponin elevations and mimic STEMI on ECG. The exact cause is not fully understood, but it is often triggered by severe emotional or physical stress. The stress can lead to a surge of catecholamines which affects the heart (multivessel spasm/paralysed myocardium). The name "Takotsubo" comes from the Japanese term for a type of octopus trap, as the left ventricle takes on a...

info_outline Episode 897: Adrenal Crisis show art Episode 897: Adrenal Crisis

Emergency Medical Minute

Contributor: Ricky Dhaliwal MD Educational Pearls: Primary adrenal insufficiency (most common risk factor for adrenal crises) An autoimmune condition commonly known as Addison's Disease Defects in the cells of the adrenal glomerulosa and fasciculata result in deficient glucocorticoids and mineralocorticoids Mineralocorticoid deficiency leads to hyponatremia and hypovolemia Lack of aldosterone downregulates Endothelial Sodium Channels (ENaCs) at the renal tubules Water follows sodium and generates a hypovolemic state Glucocorticoid deficiency contributes further to hypotension...

info_outline Podcast 896: Cancer-Related Emergencies show art Podcast 896: Cancer-Related Emergencies

Emergency Medical Minute

Contributor: Travis Barlock, MD Educational Pearls: Cancer-related emergencies can be sorted into a few buckets: Infection Cancer itself and the treatments (chemotherapy/radiation) can be immunosuppressive. Look out for conditions such as sepsis and neutropenic fever. Obstruction Cancer causes a hypercoagulable state. Look out for blood clots which can cause emergencies such as a pulmonary embolism, stroke, superior vena cava (SVC) syndrome, and cardiac tamponade. Metabolic Cancer can affect the metabolic system in a variety of ways. For example, certain cancers like bone...

info_outline Episode 895: Indications for Exogenous Albumin show art Episode 895: Indications for Exogenous Albumin

Emergency Medical Minute

Contributor: Travis Barlock MD Educational Pearls: There are three indications for IV albumin in the ED Spontaneous bacterial peritonitis (SBP) Patients with SBP develop renal failure from volume depletion Albumin repletes volume stores and reduces renal impairment Albumin binds inflammatory cytokines and expands plasma volume Reduced all-cause mortality if IV albumin is given with antibiotics Hepatorenal syndrome Cirrhosis of the liver causes the release of endogenous vasodilators The renin-angiotensin-aldosterone system (RAAS) fails systemically but maintains...

info_outline Episode 894: DKA and HHS show art Episode 894: DKA and HHS

Emergency Medical Minute

Contributor: Ricky Dhaliwal, MD Educational Pearls: What are DKA and HHS? DKA (Diabetic Ketoacidosis) and HHS (Hyperosmolar Hyperglycemic State) are both acute hyperglycemic states. DKA More common in type 1 diabetes. Triggered by decreased circulating insulin. The body needs energy but cannot use glucose because it can’t get it into the cells. This leads to increased metabolism of free fatty acids and the increased production of ketones. The buildup of ketones causes acidosis. The kidneys attempt to compensate for the acidosis by increasing diuresis. These patients...

info_outline Episode 893: Home Treatments for Button Battery Ingestion show art Episode 893: Home Treatments for Button Battery Ingestion

Emergency Medical Minute

Contributor: Aaron Lessen MD Educational Pearls: Button batteries cause alkaline corrosion and erosion of the esophagus when swallowed Children swallow button batteries, which create a medical emergency as they can perforate the esophagus A recent study compared various home remedies as first-aid therapy for button battery ingestion Honey, jam, normal saline, Coca-Cola, orange juice, milk, and yogurt The study used a porcine esophageal model to assess resistance to alkalinization with the different home remedies Honey and jam demonstrated a significantly lower esophageal tissue...

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Contributor: Travis Barlock MD

Educational Pearls:

Common sedatives used in the Emergency Department and a few pearls for each.

  • Propofol

    • Type: Non-barbiturate sedative hypnotic agonizing GABA receptors.

    • Benefit: Quick on and quick off (duration of action is approximately 2-7 minutes), helpful for suspected neurologic injury so the patient can wake up and be re-evaluated. Also has the benefit of reducing intracranial pressure (ICP).

    • Downsides: Hypotension, bradycardia, respiratory depression.

    • What should you do if a patient is getting hypotensive on propofol?

      • Do not stop the propofol. Start pressors. May have to reduce the propofol dose if delay in pressors.

  • Dexmedetomidine (Precedex)

    • Type: Alpha 2 agonist - causes central sedation

    • Uses: Patients are more alert and responsive and therefore can be on BiPAP instead of being intubated. Does not cause respiratory depression.

    • Downsides: Hypotension and Bradycardia.

    • Caution in using this for head injuries, its side effects can mask the Cushing reflex and make it more difficult to spot acute elevations in ICP and uncal herniation.

  • Ketamine

    • Type: NMDA antagonist and dissociative anesthetic, among other mechanisms.

    • Benefits: Quick Onset (but slower than propofol). Does not cause hypotension, but can even increase HR and BP (Thought to potentially cause hypotension if patient is catecholamine-depleted (ie. sepsis, delayed trauma)).

    • Dosing ketamine can be challenging. Typically low doses (0.1-0.3mg/kg (max ~30mg)) can give good pain relief. Higher doses (for intubation/procedural sedation) are generally thought to have a higher risk of dissociation.

    • Downsides: Emergence reactions which include hallucinations, vivid dreams, and agitation. Increased secretions.

  • Benzos

    • Type: GABA agonists.

    • Benefits: Seizure, alcohol withdrawal, agitation due to toxic overdoses. 

    • Push doses are useful because doses can stack. Longer half-life than propofol.  

    • Downsides: Respiratory depression. Longer half-life can make neuro assessments difficult to complete.

  • Etomidate

    • MOA: Displaces endogenous GABA inhibitors.

    • Useful as a one-time dose for quick procedures (cardioversion, intubation). Often drug of choice for intubation since it is thought to have no hemodynamic effects. 

    • Downsides; If used without paralytic - myoclonus. Though to have some adrenal suppression.

  • Fentanyl

    • Type: Opioid analgesic. Not traditional sedative.

    • Benefits: There are many instances in emergency medicine in which sedation can be avoided by prioritizing proper analgesia. Fentanyl can even be used to maintain intubated patients without needing to keep them constantly sedated.

    • Downsides: Respiratory depression. Patients may have tolerance.

References

  1. Chawla N, Boateng A, Deshpande R. Procedural sedation in the ICU and emergency department. Curr Opin Anaesthesiol. 2017 Aug;30(4):507-512. doi: 10.1097/ACO.0000000000000487. PMID: 28562388.

  2. Keating GM. Dexmedetomidine: A Review of Its Use for Sedation in the Intensive Care Setting. Drugs. 2015 Jul;75(10):1119-30. doi: 10.1007/s40265-015-0419-5. PMID: 26063213.

  3. Lundström S, Twycross R, Mihalyo M, Wilcock A. Propofol. J Pain Symptom Manage. 2010 Sep;40(3):466-70. doi: 10.1016/j.jpainsymman.2010.07.001. PMID: 20816571.

  4. Matchett G, Gasanova I, Riccio CA, Nasir D, Sunna MC, Bravenec BJ, Azizad O, Farrell B, Minhajuddin A, Stewart JW, Liang LW, Moon TS, Fox PE, Ebeling CG, Smith MN, Trousdale D, Ogunnaike BO; EvK Clinical Trial Collaborators. Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med. 2022 Jan;48(1):78-91. doi: 10.1007/s00134-021-06577-x. Epub 2021 Dec 14. PMID: 34904190.

  5. Mihaljević S, Pavlović M, Reiner K, Ćaćić M. Therapeutic Mechanisms of Ketamine. Psychiatr Danub. 2020 Autumn-Winter;32(3-4):325-333. doi: 10.24869/psyd.2020.325. PMID: 33370729.

  6. Nakauchi C, Miyata M, Kamino S, Funato Y, Manabe M, Kojima A, Kawai Y, Uchida H, Fujino M, Boda H. Dexmedetomidine versus fentanyl for sedation in extremely preterm infants. Pediatr Int. 2023 Jan-Dec;65(1):e15581. doi: 10.1111/ped.15581. PMID: 37428855.

Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII