Conscious Sedation in ED

[foragreatergood]

Is it just some good drugs to relieve pain and relax muscles? Or is it procedural sedation that requires 1:1 monitoring by a nurse? Looking for details in specific combinations of meds/timing of meds and doses for adult patients.

Ex: If you give morphine and Ativan IV at one time - does your facility classify this as sedation that requires consent, cardiac monitoring and ETCO2 monitoring?

Fentanyl/ Dilauded given with Valium?

Thanks!

[PedsED-RN]

Our Procedural Sedation policy is very specific. Defines Anxiolysis/Moderate/Deep sedation differences, including required monitoring, and gets into each drug, and the specific routes/doses that constitute each level of sedation. For example, nasal versed up to 0.2mg/kg is Anxiolysis, but any higher dose is sedation, etc. it's a pain, in that out Ad Locum docs *****, that the dose ranges are too low, but at least for my sake it's all very cut n dry, and eliminates needing to interpret gray areas. I know things are probably different for kids, but I would see how your policy lays it out, and maybe you can help spur a change if needed. =)

[EmergencyRN22]

What drugs we use is determined by the Dr doing to procedure. Ive never, in my many moons in the ER, seen Valium and dilaudid used together for conscious sedation. The drugs we normally go with is versed, fentanyl, diprivan, and etomidate. Every once in a while the Dr will throw in a dose of ativan if they deem it necessary. Our usual go to is versed and fentanyl equally, then diprivan and etomidate coming in tied at second place.

At least once a year we get a rouge Dr that likes Ketamine - just like diprivan and etomidate - I don't push ketamine either.

[Anna Flaxis, BSN, RN]

To be more specific - yesterday we had a pt come in with a shoulder dislocation. He was a big guy 30ish and obviously very uncomfortable. 1mg of IV dilauded and 5mg IV valium was ordered. The question arose that giving this combo together was actually a conscious sedation (opiod+benzo), and the policy should have been followed.

The patient was barely phased by these meds - the shoulder was reduced after xray and there were no complications. No decrease in loc, respirs, or bp. I have done conscious sedations that prop or versed is used, and obviously the policy is followed.

So my question is more this - What do you do? If you gave those 2 meds would a prudent ED RN have asked the MD to obtain consent, recorded a Mallampatti score and monitored ETCO2 etc.

As described, this was not a procedural sedation because a depressed level of consciousness was not induced.

[JenERally]

Moderate sedation is moderate sedation whenever medication is given to decrease a patient's LOC. It isn't so much the specific medication as it's more the indication for giving the medication. The I've given Benadryl as an adjunct to versed and fentanyl (a few times in place of fentanyl in Suboxone patients) in order to achieve a RASS of -2.

[applesxoranges, BSN, RN]

I always thought propofol was only if you intubated. I know the half life is short but I think our policy at my work is that it's only used for mechanical ventilation. We use etomidate,valium, versed, ketamine, diluadid, etc.

I personally never want to see ketamine done on an adult again.

[Anna Flaxis, BSN, RN]

I always thought propofol was only if you intubated. I know the half life is short but I think our policy at my work is that it's only used for mechanical ventilation. We use etomidate,valium, versed, ketamine, diluadid, etc.

We usually use Propofol for procedural sedation. Sometimes you have to do a jaw thrust or bag a little, but it does wear off quickly.

[turnforthenurse, MSN, NP]

Procedural sedation: patient needs to be in a crash cart room, IV/O2/monitor, have a consent form signed. Either 2 RNs need to be at the bedside OR 1 RN and an RT. Drugs are provider preference. The providers I work with like either etomidate or propofol with fentanyl. Ketamine for peds.