Key concepts of PSA - Procedural Anesthesia and Sedation in the Emergency Department. Presented for Emergency Medicine resident conference. Assumes pre-existing knowledge. Not medical advice. Always work within your scope of practice and consult a standard reference.

1. Putting the Pro Back in
Procedural Sedation
David Marcus, MD
@EMIMDoc / EMIMDoc.org
Residency Director, Combined Program in EM/IM/CCM
Northwell Health, New Hyde Park, NY
#EMconf - 11/8/2017 – Northwell PJI

2. How Bout Now?
45 yr old F pending DC cardioversion
58 yr old F with mental retardation pending pelvic exam
75 yr old M, COPD, pending tube thoracostomy
33 yr old M with autism, minor laceration repair
53 yr old F, asthma with hypoxic respiratory distress
21 yr old M pending shoulder reduction

3. The Playlist
• How deep is your love? (The Bee Gees)
• He Ain’t Heavy He’s My Brother (Bill Medley)
• Check Yourself Before You Wreck Yourself (Ice Cube)
• Hit Me Baby One More Time (Brittany Spears)
• Love Kills (The Ramones)
• Know Your Enemy (Rage Against the Machine)
• One Step at a Time (Jordin Sparks)

5. Minimal Sedation (Anxiolysis)
Deep Sedation
General Anesthesia/Sedation
Moderate (Conscious) Sedation

6. Responsiveness
Ventilation
Airway
Hemodynamics

7. Responsiveness
1. Normal response, may be “sleepy”
2. Purposeful response to
verbal/tactile stim
3. Purposeful response only with
repeated or aggressive stim
4. No response

8. Airway1. Unaffected
2. No intervention needed
3. May require intervention
4. Intervention often needed

9. Ventilation Hemodynamics
1. Unaffected
2. Usually Maintained
3. Usually Maintained
4. May be compromised
1. Unaffected
2. Adequate
3. May be inadequate
4. Generally inadequate

10. Moderate/Conscious Sedation
• Purposeful response to
verbal/tactile stim
• No AW intervention needed
• No resp support needed
• No hemodynamic support

11. Conscious Sedation
(Easily arouseable, Ill suited for painful procedures)
vs.
Procedural Sedation and Anesthesia (PSA)
Variable depth, on the entire continuum, procedure dependant

12. Is this an appropriate
patient?
Risky Patients:
• OSA
• Obesity
• Dentures
• Anesthesia problems
• Cardioresp Reserve?
• Recent meal?

13. Ice Cube implores us to:

14. “No I'm not a sucker, sittin’ in a House of Pain”

15. Check your:
• Airway (LEMON)
AW risk assessment tools are
generally unreliable, but it’s
important to consider
complications. Always prepare
for the worst.

16. Check your:
• Patient
• IV x 2
• ETCO2 ON
• Nasal O2+NRB ON
• Fluids running
• Monitor, Sat, Auto BP

17. Check your:
• Equipment
• AW Box Open
• Difficult AW supplies
• AMBU on O2
• Working Suction
• Glidescope?

18. Check your:
• Paperwork
• Informed Consent
• Sedation Packet

19. Check your:
• Staff
• Resident
• RN
• EDT
• Attending

21. The Meds: Etomidate
Pro
Con
AW/Resp
Reversal
Onset
Duration
Dosing
Ultra fast on/Fast off; Benign hemodynamic profile
No analgesia; Vomiting; Adrenal Suppression
Minimal effect
None
< 1 minute
Around 5 minutes
0.2 mg/kg slow push

22. The Meds: Ketamine
Pro
Con
AW/Resp
Reversal
Onset
Duration
Dosing
Analgesic; Benign hemodynamic profile; Dissociative; Reflexes;
Titratable; Redosable
Laryngospasm; Central Apnea; Vomiting; Secretions; Emergence;
Enhanced muscle tone?
Laryngospam 0.4%
None
1 minute
10-20 minutes
1.5 mg/kg slow push or piggyback – THRESHOLD MED, NOT ON
THE CONTINUUM

23. The Meds: Propofol
Pro
Con
AW/Resp
Reversal
Onset
Duration
Dosing
Fast on/Fast off; Titratable; Patient experience; Muscle relaxation
No analgesia; Narrow window; Hemodynamic effects; Burning
sensation; Loss of AW
Easily compromised
None
1.5 minutes
10 minutes
1 mg/kg slow push; Prepare aliquots

24. The Meds: Versed/Fentanyl
Pro
Con
AW/Resp
Reversal
Onset
Duration
Dosing
Fast on; Titratable; Reversible; Amnestic
Prolonged duration; CV/AW/Resp Risks
Potentially significant
Flumazenil/Naloxone
2-3 minutes
30-60 minutes
Fentanyl: 1 mcg/kg slow push q5min until effect
Midazolam 0.02 mg/kg push q5min until effect

25. Etomidate Ketamine Propofol Mid/Fent
Primary AE Emergence AW/CV AW/CV
Analgesia - ++ - ++
AW/Resp +/- ++ --- ---
CV +/- +/- --- --
Reversal 0 0 0 +/+
Onset +++ ++ ++ ++
Duration + +++ ++ ++++
Dosing 0.2 mg/kg 1.5 mg/kg 1mcg/kg
0.02mg/kg
1 mcg/kg

26. Love Kills
Sid never meant any harm
He shot some dope into his arm
All he wanted was some fun
Now she's lying in a pool of blood
Always loaded, always high
Why did you have to die?

27. Love Kills
Hypercapnia
or
Hypoxia
Reposition, Check FiO2, NPA if
snoring; Jaw Thrust
+/- Rescue Breaths
LMA? ETI?
Laryngospasm Laryngeal Notch Maneuver
Agitation Re-Dose if appropriate, Benzo
Pain Re-Dose if appropriate
Vomiting Suction
Hypotension IV Bolus, Hold Meds
Consider pressor

29. KETOFOL?
NPO?
RASS SCORE?

30. KETOFOL?
NPO?
RASS SCORE?

31. 1. Consent
2. Premedicate
3. Prepare
4. Preoxygenate
5. Meds + Reversal
6. Sedate
7. Procedure
8. Monitor
9. Discharge

32. Summary
• Procedural Sedation and Analgesia
• Before
– Select the right patient, the right agent, the right time
– Reversals and backups at bedside
– If < 6 hours NPO, may proceed if benefits outweigh risk (and
document!)
• During
– Hypercapnia predicts hypoxia
– Continuous monitoring
• After
– Stay in room until patient awake
– Keep monitor connected until patient “normal”
• As learners, try different regimens
• Review the ACEP PSA in ED Clinical Policy

33. Additional Reading
ACEP PSA Policy: https://www.acep.org/Physician-Resources/Clinical/Procedures-and-Skills/Procedural-
Sedation/Clinical-Policy--Procedural-Sedation-and-Analgesia-in-the-Emergency-Department/
Green et al. Fasting and emergency department procedural sedation and analgesia: a consensus-based
clinical practice advisory. Ann Emerg Med. 2007 Apr;49(4):454-61. Epub 2006 Nov 1.
https://www.ncbi.nlm.nih.gov/pubmed/17083995
ACEP Procedural Sedation Resources and References: https://www.acep.org/Physician-
Resources/Procedural-Sedation/#sm.00000v44pyaqwhdksz5e382dybgna
Ketofol (follow the citations): http://stemlynsblog.org/jc-is-ketofol-worth-the-hassle-st-emlyns/
Procedural Sedation and Analgesia:
• http://www.asahq.org/~/media/Sites/ASAHQ/Files/Public/Resources/standards-
guidelines/continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-
sedation-analgesia.pdf
• https://www.rcemlearning.co.uk/foamed/a-primer-on-procedural-sedation/
• http://emupdates.com/2013/11/28/the-procedural-sedation-screencast-trilogy/
Laryngospasm Notch: https://www.aliem.com/2010/12/trick-of-trade-laryngospasm-notch/