Is Indiana RN allowed to give Ketamine for procedural sedation ??

RNCENCCRNNREMTP · Sep 19, 2005

100% wrong. If you are administering conscious sedation to a patient and using propofol and NOT using O2, it is negligent, and you will find a long line of expert witnesses that will be more than happy to testify against you.
And in the case of propofol - reverse what? It can't be reversed.
This is absolutely the heart of the debate about non-anesthesia providers using propofol for conscious sedation. It is not about a turf war. It is about doing what is best for the patient. Is it best for the patient for an RN to be administering propofol for conscious sedation to a patient in the ER or endoscopy suite? Absolutely not.

If you had read my post carefully I did state use reversal "IF POSSIBLE" understanding that not all agents we use can be reversed Propofol, ketamine just to name a couple but as you and I know there are many more.).

Never said anything about a turf war either, just that I am every night called upon to administer conscious sedation in the ER for a variety of procedures on adults and children.

I am certified by my hospital in their conscious sedation protocol which was established by the anesthesia department and it is by an anesthesiologist that I was trained.

maturner · Sep 20, 2005

As an SRNA and former ER nurse that frequently administered conscious sedation, I believe there is a place for nurses adequately trained and directly supervised to administer medications such as ketamine, midazolam, and fentanyl for conscious sedation. However there is a limit to conscious sedation and that limit has to be respected or it will bite you.

The poster to whom I am responding is certainly a highly skilled professional whose prior posts I have greatly respected and found to be very good. However, after reading the last two posts on this thread I have to respond. The tone comes across a cavalier and frankly does not sit well.

"What I find most frightening is the assumption that:

#1 Conscious sedation and general anesthesia are the same thing (they are NOT)"

You are correct; however, GA is what you get when CS goes too far and becomes a CF.

"#2 That nurses cannot recognize a failing airway"

Recognize, YES without a doubt. Truly Effectively manage, very very few. Many RTs, and MDs don't manage Airways well either, this is not a ding on nurses.

"#3 That nurses, since they cannot intubate, cannot fix a failing airway."

If intubation is required, failure to fix the airway has already occurred, please refer to point #2.

"Laryngospasm you say from ketamine?"

YOU BET, check the literature! Ineffective management of those secretions and vocal cords in an overly sedated or "partially anesthetized state" and one can indeed buy a patient a laryngospasm.

"Well then a little positive pressure ventilation until it passes or then yes, the doctor paralyzes and intubates (or I do depending upon the situation)."

Before jumping right to intubating the patient, one might want to consider 0.15-0.3 mg/kg of succinylcholine to break the spasm as this is the next line of treatment following a failure of PPV to break the spasm. After the laryngospasm, a provider better be prepared to deal with the possibility that the patient may have caused themselves (or rather the provider caused the patient) to have negative pressure pulmonary edema.

Larygospasm, NPPE are rare but definitely possible complications that nurses had better be aware of and prepared to treat. These are Nothing to be cavalier about.

"Drops in the SpO2? My first (and your first) action better not be to put on O2, open the airay and do a little positioning or stimulating or maybe even some reversing agent (when possible). Falling SpO2 is the early sign of increased CO2 and adding more O2 is not going to help that at all, need to ventilate better. If you add more O2 sure their SpO2 may come up but you still have that problem you completely ignored, increased CO2."

A falling SpO2 is NEVER an EARLY sign of ANYTHING except that may you have the BP cuff on the same arm as the pulse ox probe. You have already missed the boat when the pulse ox starts to drop. You should have intervened well before that point! And, the O2 had better been on the patient from the get go.

A Drop in SpO2 is a LATE sign of poor ventilation!!!!!!!!!!! Not an increase in pCO2. The increased pCO2 is initially a result of the sedation medications you have been giving and their effect on the brain. These drugs shift the CO2 response curve to the right, which simply means that a higher pCO2 is required to stimulate the respiratory center in the brain to get the body to breathe on its own. In these cases an elevated pCO2 is actually good thing as it will stimulate the body to breathe on its own.

The next reason for this increased pCO2 is a result of poor ventilation and airway management. Refer to #2

You are correct in stating that a hypercarbia can be bad. If the pCO2 during

C O N S C I O U S S E D A T I O N is allowed to raise to the point where excessive CO2 truly becomes an issue.... A multitude of errors have already occurred and the CS is a CF.

"Simple procedures are far and away what are required when the sedation gets a little deep; open the airway, position the head, stimulate, reverse, then add some O2 and then consider, if still having issues, to start bagging them and then finally consider an ETT. But far more often than not, those simple procedures that every conscientious nurse knows will be more than enough."

This sounds great except for the O2. There had better be some oxygen already on the patient or this is gross negligience.

One note about reversals, these are not like get out of jail free cards. They have there own side effects and complications such a seizures.

"It is not anesthesia we are talking about here, where the patient will have a period of apnea after induction with GENERAL anesthetics and PARALYTICS and needs an O2 reserve."

"This thread started about CONSCIOUS SEDATION and unless there is a prior physiologic need, you do not start them on O2 beforehand."

One creates a physiologic need when they start pushing sedative medications. A nurse who performs CONSCIOUS SEDATION without oxygen on the patient prior to pushing sedation drugs is being NEGLIGENT.

Editorial Team / Admin · Sep 20, 2005

As an SRNA and former ER nurse that frequently administered conscious sedation, I believe there is a place for nurses adequately trained and directly supervised to administer medications such as ketamine, midazolam, and fentanyl for conscious sedation. However there is a limit to conscious sedation and that limit has to be respected or it will bite you.
The poster to whom I am responding is certainly a highly skilled professional whose prior posts I have greatly respected and found to be very good. However, after reading the last two posts on this thread I have to respond. The tone comes across a cavalier and frankly does not sit well.
"What I find most frightening is the assumption that:
#1 Conscious sedation and general anesthesia are the same thing (they are NOT)"
You are correct; however, GA is what you get when CS goes too far and becomes a CF.
"#2 That nurses cannot recognize a failing airway"
Recognize, YES without a doubt. Truly Effectively manage, very very few. Many RTs, and MDs don't manage Airways well either, this is not a ding on nurses.
"#3 That nurses, since they cannot intubate, cannot fix a failing airway."
If intubation is required, failure to fix the airway has already occurred, please refer to point #2.
"Laryngospasm you say from ketamine?"
YOU BET, check the literature! Ineffective management of those secretions and vocal cords in an overly sedated or "partially anesthetized state" and one can indeed buy a patient a laryngospasm.
"Well then a little positive pressure ventilation until it passes or then yes, the doctor paralyzes and intubates (or I do depending upon the situation)."
Before jumping right to intubating the patient, one might want to consider 0.15-0.3 mg/kg of succinylcholine to break the spasm as this is the next line of treatment following a failure of PPV to break the spasm. After the laryngospasm, a provider better be prepared to deal with the possibility that the patient may have caused themselves (or rather the provider caused the patient) to have negative pressure pulmonary edema.
Larygospasm, NPPE are rare but definitely possible complications that nurses had better be aware of and prepared to treat. These are Nothing to be cavalier about.
"Drops in the SpO2? My first (and your first) action better not be to put on O2, open the airay and do a little positioning or stimulating or maybe even some reversing agent (when possible). Falling SpO2 is the early sign of increased CO2 and adding more O2 is not going to help that at all, need to ventilate better. If you add more O2 sure their SpO2 may come up but you still have that problem you completely ignored, increased CO2."
A falling SpO2 is NEVER an EARLY sign of ANYTHING except that may you have the BP cuff on the same arm as the pulse ox probe. You have already missed the boat when the pulse ox starts to drop. You should have intervened well before that point! And, the O2 had better been on the patient from the get go.
A Drop in SpO2 is a LATE sign of poor ventilation!!!!!!!!!!! Not an increase in pCO2. The increased pCO2 is initially a result of the sedation medications you have been giving and their effect on the brain. These drugs shift the CO2 response curve to the right, which simply means that a higher pCO2 is required to stimulate the respiratory center in the brain to get the body to breathe on its own. In these cases an elevated pCO2 is actually good thing as it will stimulate the body to breathe on its own.
The next reason for this increased pCO2 is a result of poor ventilation and airway management. Refer to #2
You are correct in stating that a hypercarbia can be bad. If the pCO2 during
C O N S C I O U S S E D A T I O N is allowed to raise to the point where excessive CO2 truly becomes an issue.... A multitude of errors have already occurred and the CS is a CF.
"Simple procedures are far and away what are required when the sedation gets a little deep; open the airway, position the head, stimulate, reverse, then add some O2 and then consider, if still having issues, to start bagging them and then finally consider an ETT. But far more often than not, those simple procedures that every conscientious nurse knows will be more than enough."
This sounds great except for the O2. There had better be some oxygen already on the patient or this is gross negligience.
One note about reversals, these are not like get out of jail free cards. They have there own side effects and complications such a seizures.
"It is not anesthesia we are talking about here, where the patient will have a period of apnea after induction with GENERAL anesthetics and PARALYTICS and needs an O2 reserve."
"This thread started about CONSCIOUS SEDATION and unless there is a prior physiologic need, you do not start them on O2 beforehand."
One creates a physiologic need when they start pushing sedative medications. A nurse who performs CONSCIOUS SEDATION without oxygen on the patient prior to pushing sedation drugs is being NEGLIGENT.

Truly excellent post!!:balloons:

RNCENCCRNNREMTP · Sep 20, 2005

As an SRNA and former ER nurse that frequently administered conscious sedation, I believe there is a place for nurses adequately trained and directly supervised to administer medications such as ketamine, midazolam, and fentanyl for conscious sedation. However there is a limit to conscious sedation and that limit has to be respected or it will bite you.
The poster to whom I am responding is certainly a highly skilled professional whose prior posts I have greatly respected and found to be very good. However, after reading the last two posts on this thread I have to respond. The tone comes across a cavalier and frankly does not sit well.
"What I find most frightening is the assumption that:
#1 Conscious sedation and general anesthesia are the same thing (they are NOT)"
You are correct; however, GA is what you get when CS goes too far and becomes a CF.
"#2 That nurses cannot recognize a failing airway"
Recognize, YES without a doubt. Truly Effectively manage, very very few. Many RTs, and MDs don't manage Airways well either, this is not a ding on nurses.
"#3 That nurses, since they cannot intubate, cannot fix a failing airway."
If intubation is required, failure to fix the airway has already occurred, please refer to point #2.
"Laryngospasm you say from ketamine?"
YOU BET, check the literature! Ineffective management of those secretions and vocal cords in an overly sedated or "partially anesthetized state" and one can indeed buy a patient a laryngospasm.
"Well then a little positive pressure ventilation until it passes or then yes, the doctor paralyzes and intubates (or I do depending upon the situation)."
Before jumping right to intubating the patient, one might want to consider 0.15-0.3 mg/kg of succinylcholine to break the spasm as this is the next line of treatment following a failure of PPV to break the spasm. After the laryngospasm, a provider better be prepared to deal with the possibility that the patient may have caused themselves (or rather the provider caused the patient) to have negative pressure pulmonary edema.
Larygospasm, NPPE are rare but definitely possible complications that nurses had better be aware of and prepared to treat. These are Nothing to be cavalier about.
"Drops in the SpO2? My first (and your first) action better not be to put on O2, open the airay and do a little positioning or stimulating or maybe even some reversing agent (when possible). Falling SpO2 is the early sign of increased CO2 and adding more O2 is not going to help that at all, need to ventilate better. If you add more O2 sure their SpO2 may come up but you still have that problem you completely ignored, increased CO2."
A falling SpO2 is NEVER an EARLY sign of ANYTHING except that may you have the BP cuff on the same arm as the pulse ox probe. You have already missed the boat when the pulse ox starts to drop. You should have intervened well before that point! And, the O2 had better been on the patient from the get go.
A Drop in SpO2 is a LATE sign of poor ventilation!!!!!!!!!!! Not an increase in pCO2. The increased pCO2 is initially a result of the sedation medications you have been giving and their effect on the brain. These drugs shift the CO2 response curve to the right, which simply means that a higher pCO2 is required to stimulate the respiratory center in the brain to get the body to breathe on its own. In these cases an elevated pCO2 is actually good thing as it will stimulate the body to breathe on its own.
The next reason for this increased pCO2 is a result of poor ventilation and airway management. Refer to #2
You are correct in stating that a hypercarbia can be bad. If the pCO2 during
C O N S C I O U S S E D A T I O N is allowed to raise to the point where excessive CO2 truly becomes an issue.... A multitude of errors have already occurred and the CS is a CF.
"Simple procedures are far and away what are required when the sedation gets a little deep; open the airway, position the head, stimulate, reverse, then add some O2 and then consider, if still having issues, to start bagging them and then finally consider an ETT. But far more often than not, those simple procedures that every conscientious nurse knows will be more than enough."
This sounds great except for the O2. There had better be some oxygen already on the patient or this is gross negligience.
One note about reversals, these are not like get out of jail free cards. They have there own side effects and complications such a seizures.
"It is not anesthesia we are talking about here, where the patient will have a period of apnea after induction with GENERAL anesthetics and PARALYTICS and needs an O2 reserve."
"This thread started about CONSCIOUS SEDATION and unless there is a prior physiologic need, you do not start them on O2 beforehand."
One creates a physiologic need when they start pushing sedative medications. A nurse who performs CONSCIOUS SEDATION without oxygen on the patient prior to pushing sedation drugs is being NEGLIGENT.

Okay let us regroup.

I appreciate the compliment this poster has given me for my previous posts. I try to practice good nursing and paramedical care and try to share what I have learned from books and experience with others. Unfortunately, since the internet is poor at expressing tone some of my previous comments, meant in a joking manner or sarcastic tone, have been interpreted as lack of knowledge on my part.

Let us regroup.

This post originally started about the idea of Indiana nurses administering ketamine for sedation and has exploded into comments about turf wars and unsafe practices.

I believe that any nurse who is involved with the practice with conscious sedation needs to be certified by his/her institution to perform that practice. However, the education and learning does not stop there and each encounter the nurse must take that experience and add it to their knowledge base.

When I made the comment about laryngospasm after ketamine it was not as a disbelieving novice, it was written as a scenario question. As in "You are having laryngospasm from ketamine?" I have experienced a case of this and it was managed very well with positive pressure ventilation until the spasm abated and never had a problem with SpO2 throughout. NOt being cavalier about it at all, sorry if it seemed that way.

Let me clarify my comments about drops in SpO2, which I should have done at the onset. I am referring to the patient with the slight drops in SpO2. The patient who had been satting around 98-100 and now has settled into a steady 90-95%. That is the patient who needs to have airway maneuvers, stimulation and possible administration of reversal agents (IF you gave an agent that can indeed be reversed) first. No need to go right to bag mask ventilation or non-rebreather masks. I apologize for this enormous error on my part for not clarifying this subtle point.

And yes reversal agents are a potential problem as well, narcan can cause seizures and pulmonary edema, especially in the chronic narcotic user (but not always the chronic user) and the same can be said for romazicon, again especially in the chronic benzo user. I have rarely used reversals just because we do so well with basic maneuvers and assisting when needed until the sedation starts to wean off on its own.

I must also confess that I have never seen a sedation protocol that required pre-sedation O2 to the patient who is otherwise healthy and without heart or lung problems and may be more sensitive to the sedation and result in a more depressed respiratory drive. Certainly we put O2 on these patients but the healthy teenager or young adult, no we do not apply pre-sedation O2.

I also just read an article, posted on a critical care site that discusses SpO2 and sedation and it talks about the error of going right to O2 when the SpO2 starts to trend down a little and not recognizing that this is a natural event during hypoventilation due to CO2 retention. I will find the article and post it here, or at least the high points and source.

Thanks to all who have commented. Give me a day to find the article in my home computer.

Medic173 · Sep 20, 2005

And to answer your question once again, YES Medics and RNs can give Ketamine for CS in the State of Indiana.

Jeez!

jwk · Sep 20, 2005

And to answer your question once again, YES Medics and RNs can give Ketamine for CS in the State of Indiana.
Jeez!

Medics giving conscious sedation? For what?!!?

rgroyer1RNBSN, BSN, RN · Sep 20, 2005

This question is directed to all Indiana RN's.
Does anyone know if RN's in IN are allowed to administer Ketamine IV/IM for procedural sedation?
What is your hospital policy?

I dont know about Indiana but I live in MO St.Louis, And we are allowed to.

and genrally are RSI Protocol usually is the following:

Vancuronium(Pavillion) or sucs

Morphine or Meperidine

Etomidate

Versed or Diazepam

Atropine or Robinul

Benadryl or hydroxine

Promethazine(phenergan)

Then we keep them sedated with propofol

rn29306 · Sep 20, 2005

Medics giving conscious sedation? For what?!!?

Hey JWK, clean out your mailbox. Can't send you a PM because you sequester all the old ones.

RNCENCCRNNREMTP · Sep 20, 2005

American Journal of Emergency Medicine (2005) 23, 497-500

The sensitivity of room-air pulse oximetry in the

detection of hypercapnia

Many reports, including one from the American Society

of Anesthesiologists, have indicated that pulse oximetry

cannot be used to assess ventilation, these claims being based

entirely on failure to detect hypoventilation in patients

receiving supplemental oxygen. However, in patients

breathing room air, the alveolar gas equation imposes an upper limit on the pulse oximetry value for any given Paco2

value. In fact, a room-air pulse oximetry cutpoint of 96%

detected 12 of 12 cases of hypercapnia in a small validation

set. In this study, we estimate the sensitivity of room-air

pulse oximetry V96% to detect moderate hypercapnia

(Paco2 N50 mm Hg) in a larger number of patients.

In addition to limiting the use of ABG sampling, room-air

pulse oximetry hypercapnia screening has a potential use in

conscious sedation. The goal of conscious sedation is

achieving a depth of anesthesia at which patients can still

respond to stimulation while maintaining airway protection

and ventilatory reflexes. In an emergency setting,

where patients frequently have full stomachs, conscious

sedation is the preferred depth of anesthesia. In these patients,

failure to detect hypoventilation may cause excessive

sedation and undue risk. If an end-tidal CO2 monitor is not

available, a room-air pulse oximetry drop to 95% or below

can alert the treating physician to the onset of hypoventilation,

cautioning against inducing deeper sedation.

In ED practice, clinicians tend to respond to low oximetry values

by giving supplemental oxygen and implementing measures

to improve ventilation, not by obtaining a room-air ABG

measurement.

jwk · Sep 20, 2005

American Journal of Emergency Medicine (2005) 23, 497-500
The sensitivity of room-air pulse oximetry in the
detection of hypercapnia
Many reports, including one from the American Society
of Anesthesiologists, have indicated that pulse oximetry
cannot be used to assess ventilation, these claims being based
entirely on failure to detect hypoventilation in patients
receiving supplemental oxygen. However, in patients
breathing room air, the alveolar gas equation imposes an upper limit on the pulse oximetry value for any given Paco2
value. In fact, a room-air pulse oximetry cutpoint of 96%
detected 12 of 12 cases of hypercapnia in a small validation
set. In this study, we estimate the sensitivity of room-air
pulse oximetry V96% to detect moderate hypercapnia
(Paco2 N50 mm Hg) in a larger number of patients.
In addition to limiting the use of ABG sampling, room-air
pulse oximetry hypercapnia screening has a potential use in
conscious sedation. The goal of conscious sedation is
achieving a depth of anesthesia at which patients can still
respond to stimulation while maintaining airway protection
and ventilatory reflexes. In an emergency setting,
where patients frequently have full stomachs, conscious
sedation is the preferred depth of anesthesia. In these patients,
failure to detect hypoventilation may cause excessive
sedation and undue risk. If an end-tidal CO2 monitor is not
available, a room-air pulse oximetry drop to 95% or below
can alert the treating physician to the onset of hypoventilation,
cautioning against inducing deeper sedation.
In ED practice, clinicians tend to respond to low oximetry values
by giving supplemental oxygen and implementing measures
to improve ventilation, not by obtaining a room-air ABG
measurement.

Most of us wouldn't bat an eye at a 96% SaO2 on room air with a non-sedated patient, so I'm not really sure this study is worth much. 96 to 95 doesn't show much either - it's within the tolerance range of most devices.

I'll repeat - if you're giving conscious sedation, especially with propofol, and not giving supplemental O2, you're negligent. Period. You will find an infinite number of expert witnesses that would testify against any nurse or physician who did not use supplemental O2 for cases with sedation. Why would you not want to use O2 and get that extra margin of safety? You have yet to address this issue.

Hypoxia comes on quickly. Hypercarbia does not. If I had to pick between a pulse ox and an ETCO2 monitor in the OR, the pulse ox wins every time. Why? Because although I'm concerned about both problems, I'm MUCH more concerned about hypoxia than hypercarbia.

RNCENCCRNNREMTP · Sep 20, 2005

Most of us wouldn't bat an eye at a 96% SaO2 on room air with a non-sedated patient, so I'm not really sure this study is worth much. 96 to 95 doesn't show much either - it's within the tolerance range of most devices.
I'll repeat - if you're giving conscious sedation, especially with propofol, and not giving supplemental O2, you're negligent. Period. You will find an infinite number of expert witnesses that would testify against any nurse or physician who did not use supplemental O2 for cases with sedation. Why would you not want to use O2 and get that extra margin of safety? You have yet to address this issue.
Hypoxia comes on quickly. Hypercarbia does not. If I had to pick between a pulse ox and an ETCO2 monitor in the OR, the pulse ox wins every time. Why? Because although I'm concerned about both problems, I'm MUCH more concerned about hypoxia than hypercarbia.

Freeman, ML, et. al: Carbon dioxide retention and oxygen desaturation during gastrointestinal endoscopy.

Gastroenterology 1993;105:331-9.

Study: pCO2 was measured in 101 patients breathing room air while undergoing sedation for endoscopy. Oxygen was

applied if SpO2 declined below 90%.

Conclusions of the study:

"Although oxygen supplementation readily corrects hypoxemia, it does not correct underlying hypoventilation; once

oxygen is applied, severe hypoventilation may occur without reliable detection by either pulse oximetry or clinical

observation. Severe hypoventilation is generally well tolerated... but it can progress to respiratory arrest."

The two independent predictors of hypercapnia (in addition to fentanyl and midazolam doses) were use of oxygen to maintain SpO2, and dementia.

Even transient further desaturation in patients already given oxygen indicated worsening CO2 retention (i.e.

hypoventilation) -- which preceded respiratory arrest in one patient (the only notable adverse event in the study).

This occurred at a peak pCO2 > 84, in the absence of hypoxemia because the patient was wearing oxygen! (Note that these

are practitioners with significant expertise in IV procedural sedation.)

From J.S. Gravenstein's book " Gas Monitoring and Pulse Oximetry" circa

1990: " Thus, when giving oxygen to the patient, do not assume that all is

well just because the patient's blood is well oxygenated. Some clinicians do

not enrich the air with oxygen in a conscious patient ( under regional or

local anesthesia) whose hemoglobin is well saturated so that the first

decrease in SpO2 can reveal a respiratory depression, which calls into

action whatever measures are needed to diagnose the problem and correct it."

berry · Sep 21, 2005

Talk about beating a dead horse this has gone from a mildly educating thread into a pissing contest.

Can conscious sedation be performed safely in ER settings? yes

Is it always safe? NO allot of times not

Are there nurses pushing drugs even with mds involved which the have no understanding of how they work and have no business pushing? A resounding yes

I have worked with nurses whose logic was "I got a doc so they can intubate if something goes wrong." (Yeah this is a recipe for disaster)

Any conscious sedation that ends in a vented pt and icu admit, I would bet dollars to doughnuts fails to meet standard of care for both the physician and nurse and I hope your charting is bullet proof when the lawyers come calling.

All things even I have been involved with conscious sedation numerous time without event the goal of conscious sedation is to provide MILD sedation were a pt maintains spontaneous respirations and an intact airway. In both ERs I worked, it required additional training and education on monitoring, and drugs used. Both facilities required a rn acls cert (pals if needed) at bedside for administering of drugs and monitoring of pt. Separate from staff helping with procedure usually reduction of fx, or dislocation occasionally i/d of abscess. Prior to procedure pt on cm/nipb/pusle ox, 2lnc, iv with crystalloids at kvo suction on, ambu at bedside, reversal agents and airway equipment at bedside not across the er. As of yet never needed reversals or ambu. At both facilities, we have primarily premeditated with morphine or demerol and phenergan on arrival. To help with pain control and help pt position better during x-ray. We usually dose again with narcotics and give a small dose valium, ativan or versed depending on md then repeat 1mg doses as needed. Let me restate again one rn with sole purpose of monitoring pt pre/during/post procedure. The goal of conscious sedation is not to gork the pt so they don't flinch. I have never heard of diprivan for conscious sedation here only pts RNs use it on in my hospital is vented pts in the icu.

In a court of law, a rn pushing rsi drugs or paralytics and sedatives such as diprivan can be made to look like a fool on the stand. When they hold up the vial and ask you to read the warning on it, which states something to the effect of only for use by persons skilled in airway management or for intubated pts only. I as a rule of thumb I try to think about the ability to defend my actions. The only time I could defend pushing these are a vented pt or for rsi with a md who I feel confident can obtain an airway standing at the head of the bed. Nurses in hospital are not allowed to intubate 99.9% of the time in hospital. ACLS does not qualify you intubate most nurses who are allowed to intubate are allowed prehospital and for rn/paramedics when you cross that line into a hospital most states do not allow you to intubate while working in hospital. If your are the "only one around" my question and the plaintiffs attorney is does the hospital have a code blue/1 whatever policy? Where are the ER attendings? Where is RT (most hospitals I have worked for several RT who are legal covered to intubate in hospital but only in arrest situations cannot give paralytics...as are most paramedics prehospital only flight teams around here are set up with rsi drugs)?

Again I believe conscious sedation can be handled safely in the ER but from reading allot of the post on here people are placing their pts well-being, and their license on the line needlessly.