ENW-Masthead2.gif (25553 bytes)

bar_green-dull.gif
SEDATED PROCEDURES
. . . Safely and Effectively . . .

An Emergency Department Outline

by Tom Trimble, RN
bar_green-dull.gif

 

DEFINITIONS, PURPOSE, & SCOPE:

DEFINITIONS:

Analgesia---Relief from pain

Anesthesia---A state with five conditions:

1. Analgesia

2. Amnesia

3. Unconsciousness

4. Muscle relaxation

5. Physiologic stability

Local anesthesia---Creating a local area of insensibility to pain by the injection of a local anesthetic

Hypnotic---An agent that promotes the onset of sleep.

Induction agent---A drug that promotes the quick short-lived onset of unconsciousness allowing endotracheal intubation to be performed; there should be unresponsiveness to command and loss of the ciliary reflex

Sedative---An agent that decreases activity, moderates excitability and calms the patient

Conscious sedation---Pharmacologically producing a state of profound sedation while maintaining all protective reflexes

Dissociative sedation---A chemically produced unique state with the following features:

1. Analgesia

2. Amnesia

3. Cooperation

4. Maintenance of all protective reflexes

Unconscious sedation---Sedation associated with loss of protective reflexes

Rapid tranquilization---Chemically sedating severely agitated or violent patient

{from "Analgesia & Sedation" by Paris, Paul M. and Stewart, Ron, in Rosen’s Emergency Medicine}

 

The purpose of conscious, dissociative, and deep sedation in the emergency department is to humanely facilitate noxious and painful procedures with minimal discomfort and minimal danger to the patient’s physiologic homeostasis.

The scope is to effectively carry out such sedation for brief procedures not requiring the extended time, monitoring, surgical relaxation, and physiologic control typical of general anesthesia in an operating room.

 

THE USE OF SEDATION IS NOT AN EMERGENCY BUT HAS THE POTENTIAL TO CAUSE EMERGENCIES!

 

CAVEATS & LEGAL CONSIDERATIONS:

1. Are YOU "prepared" by education, licensure, training, and experience to render conscious sedation? Has your competency been reviewed and approved? Are you authorized to do it? Are you fully familiar with all official Policy & Procedures, Standards or Guidelines, and customary practices effective upon that date?

2. Is the procedure indicated? Is the environment prepared, safe, and conducive to do it?

3. Does the patient meet criteria? Has valid informed consent (after explanation of risks and benefits) been obtained? If relative contraindications are present, have countermeasures been planned and provided?

4. Are you prepared and equipped to deal with any adverse event which may occur ?

5. Will your documentation comply with all applicable standards? Will any necessary additional reports such as Adverse Drug Reaction, Incident Reports, or QA-QI, be prepared also?

 

ASSESSMENT & PRE-PLANNING FOR CONSCIOUS SEDATION:

 

CONSCIOUS SEDATION "PRE-FLIGHT CHECKLIST"
{CONTROLLED ENVIRONMENT}

1. Patient pre-oxygenated with O2 4 lpm nasal prongs x 5 minutes to Sa(tc)O2 =/>95%?

2. Suction equipment set-up, function-tested, and at hand?

3. O2 BVM with correctly sized mask at hand? Anesthesia Bag may be used but self-refilling BVM must also be present.

4. Resuscitation Equipment and Airway adjuncts at hand (OPA, NPA, ETT) Laryngoscopy equipment.

5. Monitoring devices in place and functioning:

Pulse Oximetry (consider adhesive sensor, reinforce prn);

Vital Signs Monitor (DynaMap™ or Sphygmomanometer);

Cardiac Monitor (if +cardiac history, age >50 yrs., or potentially unstable)

6. Anticipated Sedatives and Analgesics, with additional doses available without leaving room. Reversal agents present in cart.

7. Patient emotionally prepared for procedure. Lights dimmed if needed (but adequate for observation).

8. Personnel present, prepared, roles agreed upon, coached as needed. Emergency Department Attending Physician or Anesthesiologist MUST be present for and throughout the procedure! [Only an individual QUALIFIED to carry-out a "worst-case" airway management scenario] Unnecessary family or personnel removed. Necessary family must be cautioned as to expectations, and to leave when signaled.

 

DURING THE PROCEDURE:

 

SIGNS OF SEDATION:

        The patient may take a few deeper breaths; the speech (e.g. counting backwards) becomes slower, softer, slurred, cognitive errors occur, and speech ceases; the face assumes a more relaxed appearance and facial tone sags, breathing becomes more shallow and slow; if airway is not supported, the lips may splutter and stertor occur with expirations; the patient no longer flutters eyelids when the lashes are gently stroked with a finger; the patient no longer responds to a noxious stimulus. The patient should still maintain his respiration and vital signs should be adequate and stable. Awakening occurs in reverse order. Amnesia is neither immediate nor invariable.

 

NON-PHARMACOLOGICAL ENHANCEMENT OF SEDATION:

        Having the patient understand, from his own point of view, what the procedure is and why it is desirable, the anticipated sequence of events, what he is likely to feel and experience during induction and wakening, to realize that any emergency is prepared for and that he will not be alone at any time.

       Talk to the patient during preparation and induction. Have others in the room remain quiet (it is easier to focus upon a single empathetic voice). The patient should never hear "OOPS!", or any gossip, clinical chatter, or joking. The patient is always listening.

        If adverse events occur, repeatedly and confidently point out to the patient his positive responses, "I see you doing so much better, your pulse is strong and firm, your breathing is easier and more relaxed, your color is so much better, you must be feeling better now than you were, keep it up! You’re doing so well!"

        If sedation lightens or the patient responds by struggling to stay awake, tell him, soothingly, "That’s right, everything is o.k., you can go back to sleep, now!

        Amnesia can be enhanced by saying "You don’t have to remember any more of this than you wish to."

        Learning can be enhanced by telling the patient "You will want to carefully remember and do all the suggestions for getting better that the doctors and nurses give you."

RECOVERY FROM SEDATION:

DISCHARGE:

POST-DISCHARGE & DOCUMENTATION:

Important Additional Readings:


"Sedated Procedures Safely and Effectively - An Emergency Department Outline"
[http://ENW.org/SedationGuidelines.htm]
is a webarticle presented by:
Emergency Nursing World ! [http://ENW.org]
Tom Trimble, RN [Tom@ENW.org]
Our DISCLAIMER completely and specifically applies to each and every part of this article.


 
 

Clinical Articles Special Articles

Links

2003 ASA
"Difficult Airway Practice Guidelines"

Airway 10 Commandments
Action Plan for Airway Hell!

Using Anesthesia Bags
Optimizing Mask Ventilation
Sedation Guidelines
Sedation Principles
Sedation Checklist

Aphorisms, Maxims, and Pearls
Discharge Instructions
I.V. Starts -Improving Your Odds!
Pediatric Hints -An ABC
Tips & Tricks -from Other Nurses
Manipulative Behaviors by Patients

Heat Emergencies
End Tidal CO2 Monitoring
in CPR: A Predictor of Outcome

Fix This Airway!
Crises in Airway Management

Bioterrorism References
Electrolytes
Headache & Stroke
Outsize Patients
--a big nursing challenge!

The Poisoned Patient
Respiratory Encounters (I Can't BREATHE! Part I)

Respiratory Encounters (I Can't BREATHE! Part II)

 

Internet Starter Set
Quick Subject Guide
Basic Desktop References
Medical Links
-  (Addiction Medicine to Gerontology)
Medical Links
- (Gov't to Medical Organizations)
Medical Links
- (Medical Records to Primary Care)
Medical Links
- [Psych. to Wilderness]
Nursing Links
[General]
Emergency Nursing Links
Pre-Hospital Links

- [Ambulance to EMS Web Pages]

Pre-Hospital Links
[Fire to Special Purpose Care Organizations]
Just for Fun Links
 
ENW !  urges help to
victims of recent disasters
American Red Cross  
donate page
 



supports and recommends

FREE EMERGENCY MEDICINE TALKS

   Emergency Medicine education for everyone.
 

MP3 files provided by: Joe Lex, MD
 


Fabulous Places!  --  Fabulous Conferences!
Check frequently for updates

   

Plan for the Year Ahead!  
Meetings & Symposia

                   Meetings of 2013

 
 
Clinical Research Behind the Scenes at ENW! The World of Emergency Nursing
Meet the Editor
Temperature Management
Gastric Decontamination

Thermometry in Acute Care
Latest Research in Resuscitation

Septic Children
ACT
INR
Carbon Monoxide
Malignant Hyperthermia
Geriatric Thermoregulation
SSRI's
"
Orthostatics"
NG Tubes
RSV
Defibrillation
Disclaimer  Applies to all portions of this site!

Policies of this Website

Information for Authors

The Emergency Nursing
& Emergency Nursing World ! FAQ


ENW is Listed@

What's This All About?

Tom Trimble's Tale
Library of Resources & Solutions
CPEN Review - Putting
 It All Together

Bedlam Among the Bedpans
Veinlite EMS
Body Piercing Removal Kit
& Training Program

Emergency Nursing 5-Tier
Triage Protocols
Emergency Newborn Care
Quick Reference to Triage
Quick-E Guides
The Emergency Nursing "Cool Web-Find!"
Honor Gallery of Previous Winners
An 1895 Look At Nursing
Beatitudes For Leaders
E-Mail Lists & Usenet Groups

Emergency Nursing WebLinks
Emergi-Lexicon
Em-Nsg-L: The Emergency Nursing List
Humor
Night-Shift Survival Tips
Old-Aid -Archaic & Obsolete
University-Level Emergency Nursing Education
Words & Thoughts
 
California ENA Website ENW! Supports ENA  

is now
http://www.CalENA.US

We Support

Use this button to
go to ENA's sit
e

Emergency
Nursing World !
is an independent entity and
NOT a component

of
ENA

 

 

 
Google


WWW ENW.org

Emergency

Nursing World !