Category: Basic Skills in Emergency Medicine

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Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship

Common Scenarios

• Cardioversion
• Orthopedic reductions
• Painful procedures

Three Step Approach to Procedural Sedation

• Step 1: Risk stratify the patient
  • Mallampati score (aka “How visible is the uvula?”)
    • Level 1: Can visualize THE WHOLE uvula
    • Level 2: Can visualize MOST of the uvula
    • Level 3: Can visualize SOME of the uvula
    • Level 4: Can NOT visualize the uvula
  • ASA (aka “How healthy are they?”)
    • Level 1: Healthy
    • Level 2: Mild illness
      • Hypertension
      • Hyperlipidemia
      • Anemia
    • Level 3: Major illness
      • Diabetes
      • Coronary disease
      • COPD
      • Chronic renal disease
    • Level 4: Extremely unhealthy
      • Dialysis patient
      • Severe heart failure
      • Chronically debilitated
    • Level 5: Dying
      • Patient needs operation to live
        • Intracranial hemorrhage with midline shift
        • Ruptured aortic aneurysm
        • Ruptured papillary muscle with cariogenic shock
        • Dissecting aortic aneurysm
• Step 2: Informed consent
  • Patients sign a GENERAL CONSENT to treat when registering to the department
  • Many emergency scenarios require physician to operate with IMPLIED CONSENT
  • Many patients have an ADVANCED DIRECTIVE
  • In stable patients and higher risk procedures, separate WRITTEN CONSENT is often required
    • Varies by hospital
    • Typically required for procedural sedation in stable patients
• Step 3: Gather supplies
  • Nurse and nursing supplies
    • IV
    • Cardiac monitor
  • Respiratory therapy and respiratory supplies
    • Capnography
    • Bag-valve mask
    • Airway box

Top 5 Procedural Sedation Medications

• Midazolam (“Versed”) – 0.02 mg/kg IV
  • Reduces anxiety prior to procedure
  • Provides no analgesia
• Fentanyl – 1 mcg/kg IV
  • Reduces pain
  • Useful for painful procedures
    • Incision and drainage
    • Simple reductions
• Propofol – 0.5-1mg/kg IV
  • General anesthetic
  • Best given “low and slow”
  • Short acting
  • Causes respiratory depression and hypotension
• Etomidate – 0.15 mg/kg IV
  • General anesthetic
  • Less hypotension than propofol
  • Can cause myoclonus
• Ketamine – 1-2mg/kg IV
  • “Dissociative”
  • Provides both amnesia AND analgesia
  • Can cause emergence reactions
  • Can cause laryngospasm and secretions

Additional Reading

• Mallampati Score (Wikipedia)
• ASA Physical Status Classification (Wikipedia)

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A-B-C-D-E-F-G

Two Types of X-Rays

• Anterior-Posterior (“AP”)
  • Classic “portable” xray
    • The beam shoots from in front of the patient (anterior)
    • TO
    • The plate sitting behind the patient (posterior)
• Posterior-Anterior (“PA”)
  • Requires trip to radiology
  • Results in a better picture
    • The beam shoots from behind the patient (posterior)
    • TO
    • The plate sitting in front of the patient (anterior)

Three Indicators of a High Quality Chest X-Ray

• Well inflated lungs
• Visualize spine through cardiac silhouette
• Medial aspect of both clavicles lined up
  • Evaluates for rotation

Chest X-Ray Interpretation Mnemonic

• A-B-C-D-E-F-G
• A = Airway
  • Trachea midline (rule out tension pneumothorax)
• B = Bones
  • Rib/Clavicle/Shoulder fractures
• C = Cardiac silhouette
  • Should be no bigger than 50% of distance from chest wall to chest wall
    • Larger than this may represent cardiomyopathy
• D = Diaphragm
  • Costophrenic angles should be sharp
    • Blunted in pleural effusion
• E = Equipment
  • Central lines
  • Endotracheal tubes
  • Chest tubes
• F = Lung Fields
  • The most important step
  • Look at lung markings/tissue to evaluate for…
    • Pneumothorax
    • Consolidation
    • Nodules
    • Pulmonary Edema
• G = Great vessels
  • Look for mediastinal widening (> 8cm)
    • Can be a sign of aortic injury
    • Looks falsely widened on AP/portable chest x-ray

Additional Reading

• How to Read a Chest X-Ray (Medgeeks)
• Learn to Read a Chest X-Ray in 5 Minutes (YouTube)

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Acetaminophen. Ibuprofen. Hydrocodone. Ketorolac. Morphine. Hydromorphone.

Oral Acetaminophen (Tylenol)

• Give every 4-6 hours
• Regular strength – 325mg
• Extra strength – 500mg
• Maximum Daily Dose – 3000mg

Oral Ibuprofen (Advil)

• NSAID
• Give every 4-6 hours
• Regular strength – 200mg
• Therapeutic Ceiling – 400mg

Oral Hydrocodone-Acetaminophen (Vicodin, Norco)

• Give ever 4-6 hours
• Common doses – 5-325mg, 7.5-325mg, and 10-325mg

IV/IM Ketorolac (Toradol)

• NSAID
• Common dosing – 15-30mg
• Therapeutic ceiling – 10mg

IV/IM morphine

• Classic dose (0.1mg/kg)
  • This would be 7-10mg in adults!
• More COMMON dosing is 4mg
  • Repeat as needed

IV/IM Hydromorphone (Dilaudid)

• COMMON dosing – 0.5-1mg
• This drug is notorious for bringing you to peer-review/MM conference
  • Be careful!

Contraindications to NSAIDS

• Pregnant patients
• Elderly patients
• Renal disease patients
• Cardiac patients
• GI/ulcer patients

Side Effects of Opiates

• Sedation
  • No driving
  • Do not mix with alcohol
  • Do not mix with other sedatives
• Constipation
• Opiate dependency/addiction

Additional Reading

• Pain Management In the Emergency Department: A Review (PubMed)
• Myths in EM: The Anti-Inflammatory Properties of NSAIDS (ACEP Now)

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Patient presentations are the single most important skill to develop for your Emergency Medicine rotation.

General Principles

• Stay focused, thorough, and organized
• Write out the basic 8-step presentation for reference

The 8-Step Patient Presentation

1. Summary statement
   • Demographics
   • Risk factors/Past medical history
   • Chief complaint
2. History
   • OPQRST
   • Try to give at least 4 descriptors
     • This is for billing reasons
3. Pertinent positives/negatives
   • Give approximately 5 most pertinent symptoms
4. Vitals
5. Physical exam
   • Give approximately 3 MOST pertinent findings
6. Differential diagnosis
   • Briefly argue for/against
   • Include both most likely and most dangerous
7. Testing plan
8. Treatment plan
   • This is the most commonly forgotten step of presentation

Additional Reading

• Abdominal Pain Presentation – History (EM Clerkship)
• Abdominal Pain Presentation – Exam, Plan, and Disposition (EM Clerkship)
• Patient Presentations in Emergency Medicine (EMRA)