What is your ED policy in these circumstances

The_Squid · Jan 28, 2009

1. Why would you not want to start the vasopressors before the central line? I'm still fairly new and have only had a dozen or so situations like this but I think I would want to start the pressors asap if they're hypotensive enough to warrant them.

2. Rarely, we use nurses aides to hold unless the procedure is going to take a very long time.

3. Any time I use anything in that class, the airway could be compromised, I would want the official stamp of conscious sedation on that procedure with respiratory present.

4. Never given propofol for anything other than vented patients.

The_Squid · Jan 28, 2009

As far as actual policies, I don't think there would be a black and white one on any of these.

KyPinkRN · Jan 28, 2009

1. Why would you not want to start the vasopressors before the central line? I'm still fairly new and have only had a dozen or so situations like this but I think I would want to start the pressors asap if they're hypotensive enough to warrant them.
2. Rarely, we use nurses aides to hold unless the procedure is going to take a very long time.
3. Any time I use anything in that class, the airway could be compromised, I would want the official stamp of conscious sedation on that procedure with respiratory present.
4. Never given propofol for anything other than vented patients.

I do know from school that most vasopressors are vesicants and require a central line. Maybe that's why?

littleRNthatcould · Jan 28, 2009

1. Central lines are preferrable for pressors like Dopamine and Levophed, however it is acceptable to use a large bore cannula in a large peripheral vein to administer (18g-16g in the AC for example). Of course always watching for signs of extravasion. If the patient is unstable enough to require it, give it now and work towards the central line placement. I don't like to do it, but if it's a life and death situation, I will.

2. Never, we always go with the least invasive, least traumatic course of treatment.

3. But anytime you give medications like Versed (even in small doses) it's a sound idea to have airway management nearby and monitor, monitor, assess, assess. If that is what falls under your conscious sedation policy, then yes.

4. No propofol unless anesthesia wants to come over and do it (and monitor it themselves) Unless of course it is a continuous drip on intubated patients as previously mentioned.

Pepperlady · Jan 28, 2009

1. We start the pressors and get a central line as quickly as possible.... as already mentioned dopamine in a peripheral vein can cause problems and needs to be closely monitored for infiltration

2. Depends on the child and the procedure, a digit block can be more traumatic than an iv, we also use nasally atomized versed for kids which is really nice.

3. Giving versed always requires airway monitoring so we would cover by doing a conscious sedation protocol.

4. Yes we use propofol and the doctor is at the bedside as we give it, as the procedure is in progress sometimes the patient needs a bit more propofol and the doctor is not in the position to give it so we do.

We have pharmacy protocols for all medications ... who can give, dosing etc.

pererau · Jan 28, 2009

1. The general rule is to get a central line, but if you are weighing extravasation vs. death, you go with the pressors. I had a patient a few months ago that was getting norepinephrine in a 22g in the wrist. I paid close attention to the vein every time I did a VS/assessment. Unfortunately it was the only peripheral vein we had and there were two other even more critical patients who were eating up the doc's time.

2. If it is feasible to try another route, the docs I work with always do. We can use digital blocks, a papoose, etc. I had one the other day with a pretty bad inner-lip lac, and the only course was sedation with IM Ketamine. 2 doses, and she was still thrashing around a bit, but with four people holding, we were able to get it done. I can't imagine trying that procedure without some sedation.

3. If we only need relaxation, we use ativan. I can't imagine Versed for a CT scan - seems to dangerous for the benefit. Versed is mainly used for when we really have to get in there and do something, i.e. a shoulder dislocation or when ortho wants to set an ankle or the like. Pretty much if we are using versed, we are doing a full conscious sedation.

4. Our policy is that propofol can be pushed by an MD or PharmD. I can titrate a drip, but not push it, as a drip is considered sedating and a push is considered anesthesia. But we typically will use something with a shorter half-life than propofol for conscious sedations. Commonly we will use Versed and Fentanyl.

JD228 · Jan 29, 2009

1. we use the large bore peripheral veins until a central line can be established.

2.depends on the doctor ...we use ketamine a fair amount for lacerations.

3.versed = conscious sedation paperwork, unfortunately.

4. propofol is pushed by the mds (er) but drips are maintained by the nurses.

JessicRN · Jan 29, 2009

Thanks we have a whole slew of new attendings who are straight out of residency and they are driving us nuts. One actually let a pt who overdosed have a BP

When I try to question her she say if I have a problem with her management of patients then I should take it up with the site director. I told her I will do just that but right now I want to save what was left of the Patients lungs and kidneys. I asked to add peep since the Patient was on a respirator and again I was turned down. I informed her since his BP was so low the likely hold of ARDS is great now and PEEP could help but again she turned me down. (by the way the pt went into ARDS and died he never came off the Respirator and he had ARF anything happen to the Doctor? NOPE) This was not my patient so I did not step in sooner I wish I had. The worst part is I stepped in when they had the central line in and started the Levophed at 1mg and kept the Dopamine at 10mcg/kg/min I bumped up both and had a BP of 105/60 in 15 minutes. This doctor I hope won't question me so much I know she is humbled. Not sure if there will be a lawsuit yet, I sure there would be if someone read his chart. The nurse involved it was her first day off orientation and she never worked ED before but someone said she had ICU experience (you are kidding )

She actually tried to do it again on another patient the same day who became septic and tanked, that was my patient and I informed her I am the patients nurse and it is my goal to stabalize this pt as fast as I can so she can live not wait for a central line. I will take responsibility for my own patient I will start periperally and as soon as she gets the central line and comfirms it then and only then will I switch it out. (if took 1 hour to get a central line because she had to do the conscious sedation on the kid with the paronnychia) I informed her if she does not like this than she is welcome to take it up with my unit manager if she wished but my policy says central line preffered only and since she had no BP the RAC wins. ( she did not I think as I heard nothing).

This same Doctor ordered the conscious sedation and became upset when every nurse said it was crazy (by the way she prerformed the conscious sedation but found no infection when she I&D'd the toe it also took multiple tries to get an IV and the child screamed for 30 minutes prior to the sedation. Pediatrics you don't usually do anything for a paranychia except foot soaks and and maybe ABx

Batman24 · Jan 30, 2009

I really think you need to get her superior and yours involved immediately. She's a danger to patients.

Vito Andolini · Jan 30, 2009

Thanks we have a whole slew of new attendings who are straight out of residency and they are driving us nuts. One actually let a pt who overdosed have a BP
When I try to question her she say if I have a problem with her management of patients then I should take it up with the site director. I told her I will do just that but right now I want to save what was left of the Patients lungs and kidneys. I asked to add peep since the Patient was on a respirator and again I was turned down. I informed her since his BP was so low the likely hold of ARDS is great now and PEEP could help but again she turned me down. (by the way the pt went into ARDS and died he never came off the Respirator and he had ARF anything happen to the Doctor? NOPE) This was not my patient so I did not step in sooner I wish I had. The worst part is I stepped in when they had the central line in and started the Levophed at 1mg and kept the Dopamine at 10mcg/kg/min I bumped up both and had a BP of 105/60 in 15 minutes. This doctor I hope won't question me so much I know she is humbled. Not sure if there will be a lawsuit yet, I sure there would be if someone read his chart. The nurse involved it was her first day off orientation and she never worked ED before but someone said she had ICU experience (you are kidding )
She actually tried to do it again on another patient the same day who became septic and tanked, that was my patient and I informed her I am the patients nurse and it is my goal to stabalize this pt as fast as I can so she can live not wait for a central line. I will take responsibility for my own patient I will start periperally and as soon as she gets the central line and comfirms it then and only then will I switch it out. (if took 1 hour to get a central line because she had to do the conscious sedation on the kid with the paronnychia) I informed her if she does not like this than she is welcome to take it up with my unit manager if she wished but my policy says central line preffered only and since she had no BP the RAC wins. ( she did not I think as I heard nothing).
This same Doctor ordered the conscious sedation and became upset when every nurse said it was crazy (by the way she prerformed the conscious sedation but found no infection when she I&D'd the toe it also took multiple tries to get an IV and the child screamed for 30 minutes prior to the sedation. Pediatrics you don't usually do anything for a paranychia except foot soaks and and maybe ABx

Paronychia. Yes, soaks, local treatment, right? And since when does paronychia come before kidneys and airways??? Was this child septic or just in pain or what? How did the child get triaged to the head of the line?

Where is that doctor's supervisor? Chief of Service? Somebody who can correct her immediately, not let her kill people? The hell with her humbling, there are lives to save! Maybe a very gentle hint would be in order to the dead person's survivors that a lawyer needs to be consulted. This doctor is incompetent and needs a serious comeuppance, since she will not listen to good advice or consult her superiors. Was Resp Therapist around to advise her on PEEP?

Also, not to upset or hurt you, but if you knew that nurse was fresh out of O, you should have intervened, even if the patient was not yours, I think. There's stepping on toes and there's saving of lives. I dont know the whole story and am open to being corrected. Sorry to be critical but I am really appalled that this doc's timidity, inexperience, and arrogance, plus your not stepping in and involving your boss and the doc's boss seem to have caused an unnecessary death.

Footballnut · Jan 31, 2009

1) If you have a non trauma patient in your ED (Ie a pt who is septic or who overdosed or is in cardiogenic shock) who needs stat dopamine and levophed vasopressors and has at least one good peripheral line do you not start vasopressors peripherally but wait to start a central line (not EJ) or do you start the vasopressors first then when the patient blood pressiure is stablized place a central line.

Start fluids and then pressors while getting the central line. Since it is good practice to be sure your patient is not volume depleted before using pressors there is often a few minutes of time to get the central line anyway. Policy says central line but no one dies while we are getting a central line if we can help it.

2) How often does your doctors immediately revert to concious sedation for healthy toddlers who need minor procedures ie exploring a toe paronnychia without trying less drastic methods first ie digit block. sedation for CT does not count.

Never

3) Do you still follow conscious sedation policy when you only use a tiny amount versed (1mg for a locked jaw or CT )

Historically Versed is one of the main sedative agents that conscious sedation policies were created for. If I am attempting to sedate the patient only a little it still counts. Following the policy protects your back. I also use Versed for other reasons so I don't always use the policy. If the patient becomes sedated with any medication even if you were not intending it following the policy is a good idea.

4) Do you use propofol for conscious sedation in the ED for shoulder and hip dislocation. If so who gives it?

Love the stuff. I would call it deep sedation for these types of procedures. The patient's muscles need to relaxed enough to reduce these dislocations. 2 ED MDs must be present and one must give it, one monitor the patient. Anesthesia can also give it. We also keep RT at the patient's airway.