What is your ED policy in these circumstances

[JessicRN]

I have a few questions that I am looking to see what your ED hospital policy states or what you think

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.

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.

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

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

[JessicRN]

Nope the CEO let go the director and hired a whole new group of Doctors all friends of the new director. Used to be even though we had useless Interns doing care at least we had good PA's to pick up the slack but the ED director also hired all new grad PA's There are only 3 of the old MD's left the rest are brand new. This is one of his pets. We they came in we stepped back 20 years in respect for nurses. It is really sad.

The director does not like me much because I stand my ground and when he feels the need to yell at me or someone else I stand up and say "your behavoir is totally unacceptable if you wish to talk to me talk to me with respect'. (he usually walks away and refuses to talk to me for days that included patient care he just writes the order and puts it in the rack and hopes I find it). Oh by the way the nursing chain of command has also changed all the way from the director down and none of the nursing brass ever worked in an ED before and none have degrees which was a prerequisite for the position. We had a hiring commitee who turned down all the current brass because of their lack of experience and education. They are no help because they worked with the medical ED director

Here is the new system which has changed 7 times in 1 year: We no longer have rapid assessment we have 2 RN's and one PA to assess all patients those who are 4and 5 stay in the 5 Rapid assessment rooms the pediatrics go to the pedi area no matter who sick or well and the rest go to the main. NO ONE WAITS IN THE LOBBY if there is an empty bed in the main and there is a pt with a sore throat he goes there if it is a pedi with a sore throat and there are no pedi beds then the ped goes to the main.If a patient wines really loud they get to the head of the pack. and come to the main without even being triaged.

Yes we cater to the winy and the ones who use us as a clinic. The sick ones they get short changed.

[mcvaragon]

We start the dopa/levo if patient is critical and request the central line. Chances are if you don't, you won't have a line for long and a mess on your hands.

Conscious sedation is conscious sedation..... it's the drug and not the dose. If they are calling it a "fugue state' they are just trying to get out of a consent.

Pedi sedation, depending on what is given (IM Ketamine etc...) we give it (the doc does). It's a risk/benefits issue. There is not reversal agent for Ketamine and you give supportive measures (bag 'em... etc....).

We do give propafol in the ED "procedural"... it is not deep sedation/used to induce general anesthesia. Once again, it is our docs who give it as they must give the bolus and the nurses only the drips.

Hope this Helps!

[Aneroo, LPN]

i have a few questions that i am looking to see what your ed hospital policy states or what you think

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.

the first er i worked had an unwritten rule: dopamine over 5mcgs needed a central line. 5mcg was ok in a large bore piv. realisically, if the patient is crumping and needs dopamine, we're not going to withhold pressors while we wait for a central line.

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.

i think most of ours tried to do less invasive procedures first. we were lucky at the first er b/c we had child life, and a lot of times they were able to provide enough distraction. that or else we tied them to the papoose board and did it quick!

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

if it's only versed, no. when you get two drugs together (in a close amount of time at least) we would consider is sedation.

4) do you use propofol for conscious sedation in the ed for shoulder and hip dislocation. if so who gives it?

1st er- yes. loved it, nurses gave it.

2nd er- no. crna's would come down and give it, and i think i can remember it being given once.

[fuzzy911]

Dont ever with hold a needed medication while waiting for a central line! Whats going to harm the pt first? As nurses our motto: Do no harm, would be a complet controdiction. As soon as you pop the versed and mix with narcotics its considered conciouse sedation, ive never used propofol for hips or shoulders, my facility uses versed and fentanyl (its an ortho favorite).