Anyone use Ntrous Oxide in their ED?

N20RN · Apr 3, 2009

For a majority of the population your statement is correct, but nitrous oxide oxygen sedation is titrated to the desired effect. Some patients may do well with 30% and others require 50% or up to 70%. The traditional Entonox demand valve is also rather difficult for pediatrics to trigger the valve release which is one reason we prefer continuous flow deliver devices. (Lastly, Entonox or "pre-packaged" 50/50 nitrous/oxygen is not currently FDA approved in the United States unfortunately... but I am sure it is effective for a large portion of the patient population).

ZippyGBR, BSN, RN · Apr 3, 2009

the current generation of demand valves are very easy to trigger , if you were speaking of the old ohmeda sets i've agree with you about demand valve triggering but the current kit takes a fraction of the inspiratory effort.

RedCell · Apr 6, 2009

For a majority of the population your statement is correct, but nitrous oxide oxygen sedation is titrated to the desired effect. Some patients may do well with 30% and others require 50% or up to 70%. The traditional Entonox demand valve is also rather difficult for pediatrics to trigger the valve release which is one reason we prefer continuous flow deliver devices. (Lastly, Entonox or "pre-packaged" 50/50 nitrous/oxygen is not currently FDA approved in the United States unfortunately... but I am sure it is effective for a large portion of the patient population).

There is also a website out there that claims to teach registered nurses and GI physicians how to safely administer propofol in 2 days time. That to me does not make it right as these dudes are clueless when it comes to advanced airway management. Apparently, the manufacturer of propofol agrees as evidenced by their package insert. Still however, the website is there for the taking to anyone who wants to pay some money. Similar to your website.

Running an end tidal of 70% nitrous is close to a MAC of gas. That is not what I would consider “sedation”. That is basically a room air general anesthetic. Sure N2O is safe most of the time. Sometimes though, things can happen requiring rapid intervention that are well beyond the knowledge base and training of a registered nurse. For a website run by a Dr Dentist and an RN, two individuals with probably under 100 intubations between them, I think this is a bad idea to be peddling off on other practitioners with even less airway experience.

There are many contraindications to the administration of nitrous. In an ER patient, whose history is sometimes difficult to obtain, some of these contraindications may be overlooked. Due precisely to the pharmacokinetics, this is not the first drug that would come to mind when choosing how to provide analgesia in this population. Again, maybe it is a good idea to leave the administration of inhaled anesthetics to those with a little more experience in airway management.

Then again, maybe I could start a website showing ER staff how to administer isoflurane or desflurane to patients in pain. These inhaled volatile anesthetics can be administered through a similar setup, work just as well and come with less than half of the problems nitrous can potentially create!:chuckle

Seriously though, congratulations on your poster presentation.

ThrowEdNurse, BSN, RN · Apr 7, 2009

What do registered nurses know about diffusion hypoxia or any other various complication that relates to N2O? If you have a situation where you need an inhalational anesthetic gas, call anesthesia.

Yeah, that's kind of what makes us ED RNs. It's this ability to like learn things and junk and apply it safely. By your standards RNs should never use new meds, new equipment, new procedures, etc because we may not know anything about it. If I can administer a paralytic, I can administer inhaled analgesia. Get over yourself.

ZippyGBR, BSN, RN · Apr 7, 2009

entonox (50/ 50 nitrous /oxygen pre mixed) has been used successfully for many years in the UK with few if any adverse events. It is successfully used by first aiders with limited extra training ( although their list of contra indications is some what larger than the scanty list in JRCALC).

JRCALC has 3 contra indications for Entonox

- serious head injuries

- risk of decompression sickness

- violently disturbed patients

it gives one caution

-undrained Pneumothorax

historically possible intestinal obstruction was given as caution for the same reasons as undrained pneumothorax.

some organisations restrict the use of entonox in the first trimester becasue of the concerns over thepossible tetrogenic effect of Nitrous.

some organisations restrict or caution the use of entonox in those who have consumed alcohol becasue of the potential for potentiating the depressant effects ( and potentiating the emetic effects ! )

in terms of redcell's comment aobut the use of volatiles - in Australia volatiles are used as inhalational analgesia - methoxyflurane , wider use is limited becasue ofthe issues with it as an anaesthesia agent meaning Marketing authority in other countries has been withhdrawn.