EM Ottawa

DECEMBER 14, 2023

In part 1 of this series, we focused on the physiologic and hemodynamic consequences of aortic stenosis, as well as management in atrial fibrillation and procedural sedation. In this part, we will focus on the management of decompensated aortic stenosis with heart failure, and the approach to PoCUS.

Wellness 83

Wellness Shock 83

Don't Forget the Bubbles

NOVEMBER 22, 2023

Commonly referred to as “the milk of amnesia”, propofol is a drug used for induction and maintenance of general anaesthesia and for procedural sedation. Unfortunately, the procedure was prolonged and complicated, and she required subsequent admission to PICU. What is Propofol?

Pediatrics 126

Pediatrics Research EKG/ECG Operations 126

The Trauma Pro

DECEMBER 12, 2023

They may choose to use sedation, which may not be as readily available on a surgery ward. Will they need any procedures after arrival that are more easily done in your ED? Will they require conscious sedation for a procedure? Here’s an example. Are you unsure of the most appropriate admitting service?

Emergency Department 162

Emergency Department Operations Hospitals Radiology 162

EMergucate

FEBRUARY 10, 2014

HOT OFF THE PRESS: ACEP has just published a new Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department, in … Continue reading →

Emergency Department 40

Emergency Department 40

Ultrasound Gel

JANUARY 30, 2023

Is it a helpful way to assess the effect of fasting prior to procedural sedation? Is it a helpful way to assess the effect of fasting prior to procedural sedation? Is fasting itself a helpful way to empty the stomach?? link] [link] Delia and Lianne take on the topic of pediatric gastric POCUS.

Pediatrics 52

Pediatrics 52

The Trauma Pro

JULY 25, 2023

Procedural sedation is required for all reductions, since it makes the patient much more comfortable and reduces muscle tone. An AP pelvic X-ray will show the femoral head out of the socket, but it may take a lateral or Judet view to tell if it is posterior vs anterior.

Dislocations 130

Dislocations Wellness 130

ALiEM

APRIL 14, 2023

Welcome to the AIR Procedures Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to related to procedures in the Emergency Department. Please go to the above link.

EMS 98

EMS Ultrasounds Academics Fractures 98

Don't Forget the Bubbles

JUNE 26, 2023

The underlying heart defect determines the precise operation performed – you might have heard of the Norwood procedure , an example used for HLHS specifically. Regardless of the precise operation, there are THREE key characteristics that any circulation must have upon completion of the Stage 1 procedure: 1.

Operations 128

Operations Research Hyperthermia / Hypothermia Hospitals 128

Taming the SRU

JULY 2, 2023

Procedural Sedation There are a number of studies that prove that capnography during sedation detects apnea earlier, leads to earlier intervention, and decreases morbidity and mortality when compared to pulse oximetry monitoring. Capnography enhances surveillance of respiratory events during procedural sedation: a meta-analysis."

Emergency Department 77

Emergency Department Pediatrics CPR Administration 77

The Skeptics' Guide to EM

NOVEMBER 1, 2022

Comparative efficacy of sedation or analgesia methods for reduction of anterior shoulder dislocation: A systematic review and network meta-analysis. Comparative efficacy of sedation or analgesia methods for reduction of anterior shoulder dislocation: A systematic review and network meta-analysis.

Dislocations 59

Dislocations Ultrasounds Emergency Department 59

Pediatric EM Morsels

JULY 7, 2023

Procedural sedation may also be needed. With appropriate pain control/sedation, you may be able to manually reduce the tibiofibular joint dislocation and heal with your bare hands! Some cases do require CT or MRI to confirm. MANAGE PAIN! Local anesthetic may be used. Hold knee in flexed position at 90 degrees.

Dislocations 141

Dislocations Fractures Pediatrics EMS 141

PHARM

MAY 15, 2023

This retrospective observational study evaluated the safety and efficacy of the ketamine and dexmedetomidine combination (keta-dex) compared to ketamine or dexmedetomidine alone for sedation of patients with acute respiratory distress due to COVID-19 pneumonia who require non-invasive ventilation. The mean duration of sedation was 28.12

40

40

RebelEM

JULY 24, 2023

Background: Rapid Sequence Intubation (RSI) is a procedure fraught with potential complications including hypotension which, in turn, can result in cardiovascular collapse. While there are numerous potential causes of hypotension peri-RSI, induction medications represent an important, modifiable variable. Paper: Driver BE et al.

Resuscitation 97

Resuscitation Outcomes Emergency Department EMS 97

RCEM Learning

APRIL 9, 2024

Curriculum Category Syllabus Questions SLO1 Complex stable patient Allergy Cardiology Dermatology Ear, nose and throat Elderly care / frailty Endocrinology Environmental emergencies Gastroenterology and hepatology Haematology Infectious diseases Maxillofacial / dental Mental Health Musculoskeletal (non-traumatic) Nephrology Neurology Obstetrics & (..)

Infectious Diseases 52

Infectious Diseases Airway Management Dislocations Resuscitation 52

PHEM Cast

MARCH 3, 2019

For analgesia (IV/IO): 0.1 – 0.5mg/kg For analgesia (IN): 3mg/kg For sedation (IV/IO): 1mg/kg For sedation (IM): 4-5mg/kg For anaesthesia (IV): 1-2mg/kg Click here for an example of how ketamine can affect patients. Pre-hospital use of ketamine for analgesia and procedural sedation. Know the concentration you carry!

Emergency Department 52

Emergency Department Head Injuries Hospitals Pediatrics 52

Taming the SRU

NOVEMBER 21, 2023

Prevention of hypoxia Use adequate preoxygenation and procedural oxygenation. Physiologic optimization Mitigate adverse effects of underlying illness and sedatives Consider fluid boluses and pressors. If refractory hypotension, will need to consider awake look intubation. Consider using HFNC during an endoscopic awake look.

Pediatrics 80

Pediatrics EKG/ECG Resuscitation Dehydration 80

ACEP Now

JANUARY 14, 2024

15 We should be aware that fentanyl administration during procedural sedation in patients taking serotonin reuptake inhibitors may result in serotonin syndrome, which therefore should be on our differential diagnosis in patients who emerge from sedation with agitation. Ann Palliat Med. 2020;9(2):542-557. 2020;37(10):452-459.

Psychiatric 52

Psychiatric Emergency Department Hospitals EMS 52

Mount Sinai EM

OCTOBER 5, 2023

There are several different techniques we can use: Mandible reduction techniques For closed anterior dislocation without fracture: reduce in ED ourselves Superior or open dislocations or associated fracture: do not reduce it. consult ENT (or max-face surgeon depending on who is covering).

Dislocations 130

Dislocations Fractures Seizures Operations 130

ALiEM

MAY 24, 2023

On a busy shift, you want a simple way to handle zipper injuries that minimizes pain, doesn’t require resource-intensive procedural sedation, and is quick. His penile skin is trapped in the zipper of his jeans. Background The 4 most common types of zippers are nylon coil zip, plastic mold zip, metal zip, and invisible zip.

Pediatrics 93

Pediatrics 93

Taming the SRU

JUNE 26, 2023

morbidity and mortality - wellness: behind the curtain Morbidity and mortality WITH dr. zalesky Meningitis Meningitis is an extremely difficult diagnosis with almost no clinical findings that can aid in the diagnosis outside of suspicion and a LP Seizures can be a presenting sign of infections, often without fevers or leukocytosis Of patients with (..)

Seizures 52

Seizures Best Practices Wellness Outcomes 52

Taming the SRU

MAY 10, 2024

Factors associated with worse outcomes in the setting of a TCA: Firearm involvement Self-inflicted injury PEA with a rate <40bpm Wide-complex rhythm (excluding VT) Number of pre-hospital procedures Role of chest compressions in TCA: Chest compressions are unlikely to be helpful in the setting of a traumatic cardiac arrest.

Leadership 73

Leadership CPR Head Injuries Outcomes 73

EMDocs

AUGUST 22, 2023

Correction: Correction to ‘Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department’ [Annals of Emergency Medicine 63 (2014) 247-258.e18]. 2016;149(2):576-585. PMID: 26447854 Godwin SA, Burton JH, Gerardo CJ, et al. Ann Emerg Med. 2017;70(5):758. PMID: 28395927 Panchal AR, Berg KM, Hirsch KG, et al.

Emergency Department 66

Emergency Department Blood Transfusions Resuscitation Sepsis 66

EMergucate

MAY 30, 2016

Drugs for conscious sedation Conscious sedation, part of what is now expanded into procedural sedation, is now a routine part … Continue reading →

EMS 40

EMS 40

Mind The Bleep

FEBRUARY 29, 2024

Some reasons for an increased FiO2 include;-increased secretion burden / respiratory infection-hypoventilation because of pain, sedation or analgesia Ventilator settings One of the forms of organ support which can seem most complex to new starts is ventilation. These are both important to include in a daily review if it is happening!

Documentation/Coding 52

Documentation/Coding Hospitals Wellness Best Practices 52

Resus Review

FEBRUARY 12, 2015

Part of performing a bedside percutaneous tracheostomy is the procedural documentation. Given that this is a surgical procedure, the documentation should be more thorough than you may be accustomed to doing for an arterial line or central line. I have included a sample procedure note below. Bronchoscopy Assistant: Doctor 2, MD.

Documentation/Coding 40

Documentation/Coding 40

Don't Forget the Bubbles

AUGUST 28, 2023

This is often not feasible in kids who would not tolerate the procedure without significant sedation (have you seen the size of those lines!). – Anaesthesia/sedation may reduce airway tone and worsen compression! Use lower limbs veins for cannulas. Some have suggested pre-emptive ECMO for high-risk patients.

Pediatrics 97

Pediatrics Research Emergency Department Wellness 97

Taming the SRU

AUGUST 25, 2023

to 1 mcg/kg/hour procedural sedation loading dose: 0.5-1 to 1 mcg/kg/hour procedural sedation loading dose: 0.5-1 1 mcg/kg over 10 minutes followed by continuous infusion: 0.2 1 mcg/kg over 10 minutes followed by continuous infusion: 0.2

Seizures 66

Seizures Fractures EKG/ECG Resuscitation 66

The Skeptics' Guide to EM

MAY 24, 2019

His research interests include diabetic emergencies, procedural sedation, and cardiac care. Premedication With Midazolam or Haloperidol to Prevent Recovery Agitation in Adults Undergoing Procedural Sedation With Ketamine: A Randomized Double-Blind Clinical Trial.

Domestic Violence 40

Domestic Violence Sexual Assault Research Diabetic Emergencies 40

Taming the SRU

JULY 26, 2023

vancomycin + piperacillin-tazobactam) Not all aspiration needs antibiotic coverage- especially patients suspected to have aspiration pneumonitis

EMS 68

EMS Wellness Research Hospitals 68

Resus Review

APRIL 1, 2015

It is important post-procedure to monitor for overt bleeding, hemodynamic changes, symptomatic anemia, and hemoglobin drops. A hemoglobin drop without evidence of hemorrhage may reflect the preprocedural preparations or procedural techniques. Definite fatal bleeding Minimizing the procedural blood losses should be priority.

Research 52

Research Academics Hospitals Wellness 52

Resus Review

FEBRUARY 13, 2015

Sedation with medications that allow spontaneous breathing and allow the patient to protected the airway are useful, avoiding deep sedation and paralytics as used in RSI. Procedure Steps Remove 15mm adaptor form endotracheal tube and on fiberoptic scope. Provide patient extra sedation if required. Well lubricated, a 6.5

Wellness 52

Wellness 52

EM Curious

JULY 29, 2015

More FOAMed THE AORTA WILL F*&% YOU UP AORTIC DISSECTION [SCREENCAST]: EM Basic brings us a high yield review of aortic dissection, including both common and uncommon presentation, imaging, treatment and more.

Sepsis 52

Sepsis EMS Emergency Department Ultrasounds 52

Resus Review

APRIL 15, 2015

The Rise of Prone Positioning Prone positioning has transitioned from a salvage procedure for ARDS, to a more routine part of the armamentarium (including , neuromuscular blockade, inhaled prostacyclin, APRV ) based on the dramatic success seen in the study by Claude Guérin published in the New England Journal of medicine in 2013.

EKG/ECG 52

EKG/ECG Wellness 52

The Skeptics' Guide to EM

JANUARY 25, 2020

However, there are aspects of the procedure that have been debated, one of which is how best to oxygenate the patient during the apneic period while not increasing rates of aspiration. Outcome: * Primary Outcome: The lowest oxygen saturation observed during the interval between induction and two minutes after tracheal intubation.

Airway Management 40

Airway Management EMS Administration Resuscitation 40

PHEM Cast

FEBRUARY 2, 2016

Israeli combat bandage) Preparation: Sedation or anaesthesia Brief team Plan next phase Stages of amputation process: Apply an effective proximal tourniquet. Life, limb and sight-saving procedures–the challenge of competence in the face of rarity. Amputate as distally as possible. Perform a guillotine amputation. Emerg Med J.

Military 52

Military 52

Resus Review

SEPTEMBER 9, 2015

size) Lubricant Phenylephrine or oxymetazoline Cetacaine spray (optional) Sedation medications (see below) Patient Preparation and Anesthesia for Nasotracheal Intubation The key to performing awake nasotracheal intubations is patient preparation and achieving adequate anesthesia of the intubation path. Provide sedation as needed (see above).

Burns 52

Burns Wellness Emergency Department Hospitals 52

Mind The Bleep

FEBRUARY 9, 2024

Patient baseline An intensive care stay puts a huge amount of physiological stress on patients; intensivists demand a lot of patients, whether the physical rigor of interventions or procedures, intensive physiotherapy regimes, plus the metabolic stress of the condition that indicated for intensive care in the first place.

Hospitals 52

Hospitals Resuscitation Fluid Resuscitation Shock 52