EM:RAP Emergency Medicine: Reviews and Perspectives

2012  ›  February Episode

3 Things Not To Do...

Scott has 3 items he says are not ready for prime time!. Here is his perspective..What say you?

 

Contributor

  • Scott Weingart, MD

Comments on 3 Things Not To Do...

EMCrit

<h4>Here are the promised references</h4>
For the Sedation-only intubation references, come to the EMCrit site at this link: Paralytics Debate

ETCO2 monitoring makes procedural sedation safer (Acad Emerg Med Volume 13, Number 5 500-504)

Meta-Analysis of capnography during procedural sedation (J Clin Anesth 2011;23:189) 17.6 x more likely to detect resp depression if ETCO2 is used

The Utility of High-Flow Oxygen During Emergency Department Procedural Sedation and Analgesia With Propofol: A Randomized, Controlled Trial (Ann Emerg Med. 2011 Oct;58(4):360-364)

Minh L., Dr

Hi Scott
two questions

have you found laryngospasm with the ketamine only intubation technique? Recently in my service we had one mild case with use of ketamine sedation and there is the first case report ever inthe aeromedical lit, last month of another case .

also NIPPV during proecedural sedation sounds interesting..would it not be simpler to use mask and nasal cannula oxygenation as you have suggested previously?

EMCrit

i have not seen laryngospasm in adults yet and we do a ton of adult ketamine procedural sedation. I think it is exceedingly rare, and when we take out the cases that were really upper airway obstruction, even less frequent. I'm sure now I'll have a case tomorrow.

Chris K., M.D.

Hi Scott,
I saw a really cool local anesthesia technique (used in this case for awake non intubated bronch) which was fast and furious. Trans-crico-thyroid membrane (intratracheal) injection of 4cc of 4% lidocaine. It induced the pt to cough nicely anesthetizing the chords and the posterior pharynx. It was all done in a matter of seconds...
Thoughts?

Seems like a less tedious way of anesthetizing someone for awake intubation...once the operator and the pt get past the idea of having a need thrust into their airway....

EMCrit

Chris, Check out the awake intubation talk on the essentials site or at emcrit.org.

Patrick S., M.D.

I have always thought that a benefit of paralysis was to render the patient unable to vomit, or to cough, and that a benefit of ketamine only sedation was the preservation of protective airway reflexes, which includes both coughing and gagging. I am trying to reconcile these concepts when I picture a bougie tickling the lining of a guy's trachea during sedative intubation, with incomplete success.

Johan F., M.D.

Hi Scott,
Our ED group has been reluctant to move toward capnography on our pro-sed patients. Our concern has been that this is only going to cause us to intervene unnecessarily with potential adverse procedures such as BMV with subsequent gastric distention and possible aspiration. Our patient are under for brief periods and are under direct supervision until they are awake. During these brief anesthetics surely oxygenation is more important than ventilation. I also feel that any policy needs to be driven by clinical outcomes and in our ED we have not had an adverse prosed related outcome in at least 5 years (as long as I've been here) without the use of capnography. Then again, maybe our city would have less dementia in 45 year olds if we did. Your thoughts?

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