Conscious Sedation in the ER

We're only allowed to use propofol in a drip (after intubation), never a bolus/IVP.

It is not so much the medication as who gives it. Many board of nursing state only a physician can administer these medications and it is not within our scope of practice to give it for moderate sedation. We at first got an email by our director saying we cannot administer it but we can monitor it. Then they say we can administer it but only an emergency MD attending can do moderate sedation in our ED

For a lot of the high test sedations the nurses draw up the drugs but the docs actually push the med, taking liability off our shoulders. The one time I was asked to push propofol I declined, doc said, "just trust me and give it." "Famous last words..." I said, and there was no more coaxing, he gave the med, I wrote it down, and all remains well in the kingdom.

We used po versed and chloral hydrate on kids in a clinic setting (not at the same time). Never had a problem except for one time a kid had paradoxical reaction to the chloral hydrate and got all hyper. I dont think I really appreciated at the time how wrong things could have gone because we never had a bad problem.

we use pretty much every drug mentioned in this post - etomidate, versed/fentanyl, ketamine, and PROPOFOL (that's our main one - love using that drug!). Always have code cart nearby, usually have EtCO2 being measured, ER attending must be present while nurses give medications. We have a special chart with VS Q5min and we track heart rhythm, SpO2, level of sedation, respiratory rate, etc etc.... All of us have ACLS/PALS (duh) and in a moderately large level 1 trauma center, there are plenty of hands around if need be. Most sedations tend to be done in the trauma bay when possible so line carts, airway carts, etc are close at hand. I hate ketamine for kids though, I much prefer using propofol on them. Also, our ER is working on bringing back nitrous oxide, which is a conscious sedation per hospital protocol, but the docs want that changed. We'll see how that argument pans out.

I live and work in Nevada and under our state BON, RNs may administer medication for the purpose of induction of short-term therapeutic, diagnostic or procedural sedation. There is no limit on the type or route of the medication. There are several pages of documentation required for each procedure including q 2-5 minute VS during procedure and extensive post-procedural monitoring. RT is at the bedside, crash cart at bedside, MD at bedside, usually at least one RN at bedside. Sometimes there are 2 RNs (if you are lucky); one for documenting and the other for administering the medication and monitoring.

I would have to say propofol is the drug of choice in our department. Etomidate and Versed are also pretty common. Fentanyl is usually given as well for pain control. I do not see ketamine as often, usually only in peds cases. Ketamine is such a creepy drug to give, and I have seen pts freak out after waking up. I love propofol, especially when it seems to act as a truth serum in some patients. They say the funniest things when they are coming out of it.

iv fentanyl and versed is what i've always used. both short acting enough to get a procedure done and good recovery, in addition to reversal/metabolism on the chance there is a problem.

etomidate could only be pushed by an md or crna b/c it is an anesthetic.

I work in a very busy pediatric ER and we commonly use Ketamine and Versed for conscious sedation. Ketamine alone often has nasty side effects, using the versed helps to lesson the reactions (hallucinations, screaming, crying, etc).
We monitor VS q5min, utilize CO2 monitors, and have an attending physician present during induction. Although it's a lot of work for the nurses, it does mean less trips to the OR and an easier time for the children.

We do conscious sedation fairly often. Adults with dislocations - Etomidate and Versed, sometimes adding Morphine or Dilaudid when there is a lot of discomfort with the reduction - sometimes just Etomidate alone because it clears the system quickly and the person is back awake very shortly. This is a 1:1 procedure and RN must be in the room continuously for one hour post-drug or , if the pt is still very sedated, until they are awake and back to baseline. It CAN be a very time-consuming procedure but most of the time, one hour and you are done and can leave the room. Children - don't do many of these - have used IM Ketamine and IM atropine but each child is unpredictable in how long this drug will stay in their system and ties up a nurse with continuous monitoring until they meet discharge criteria.