For some reason, I seem to be the ketamine queen in our er. The docs have started to use it on kids for extensive lacs or reductions when the kids are really (really, really) uncooperative or we are just not able to get them to be still for the tx. First time, it scared the holy *** out of me!. I looked it up before giving it, but still........... this fat little two year old went from screaming at the top of his lungs, and flailing all over the place, to this tranquil little (well, fat) kid laying limply on the stretcher with his eyes jerking back and forth. looked like he was watching tennis or something. can you say nystagmus (sp?). I got the doc because the mom was freaking out (causing me to try to look like I was NOT freaking out). He takes one look at the kid and says, "oh...he's just hallucinating" Our tech (college kid) happened to stroll by and announced to me that the kid was "in the K-Hole" (apparently the lingo when you do the drug illegaly, what do I know?:chuckle )
anyway, now I have administered it to three or four kids, and to my knowledge, none of the other nurses in the department have had this "wonderful learning opportunity" the kids come out of it fine, and I've had no problem. I have been following our iv conscious sedation protocol, but am wondering if I should be doing anything else? the protocol was written for adults, and all the little ketamine people are kids. I don't do peds! (I do that at home in my off time). anybody else have protocols specifically for ketamine or peds ivcs?
We administer mostly mild concious sedation. Our policies and such are set up and guided by the hosp Anesthesia committee. But even the Anesthesiologists I know dont even consider conscious sedation as a form of anesthesia.
Would that be like, say, RN's with no training in anesthesia who think they can safely give anesthetic drugs to patients? Just curious.
KM
Where did anyone here say "no training"?
There are cardiac gtts that are utilized by ED nurses that can have as life-threatening consequences as any of the drugs being thrown around here for conscious sedation...all are utilized safely with training and adequate resources to prepare for the possible complications.
I don't think ANYONE is advocating the free flowing use of Ketamine in the ER by any ole' person in scrubs!!
But to make a blanket statement that conscious sedation should NEVER be done in the ED setting...well, that's is simply not reality. And until all the CRNAs and anesthesiologists are ready to take call for the ED...well it will stay that way.
I'm pretty sure that you won't find an ED nurse who will fight you for the opportunity to give these drugs if you all want to step in. But the fact is...none of you has said that. So until then..
We educate (as we have with other critical drugs)
We show competency and re-validate (as we do with other critical procedures)
We take every precaution imaginable (as we do with other critical procedures)
And most important of all...
We back each other up...because Lord knows no one else is.
Quick, without looking it up, answer the following questions.
1. Name 2 genetic disorders where succinylcholine is absolutely contraindicated.
2. How are those disorders diagnosed?
3. How do you reverse succinylcholine?
4. Explain the difference between depolarizing and non-depolarizing muscle relaxants at the myoneural junction.
If you have to look up even one of those answers, you are practicing substandard nursing if you are administering succinylcholine. You should be reported to the RN Board as an unsafe practitioner.
I have driven a car for over 40 years, but wouldn't attempt to drive at NASCAR. Go to anesthesia school if you want to do anesthesia. Please for the patients sake.
Yoga CRNA
Yoga,
EMT wrote stating that they used succ in order to intubate in the field as a paramedic. If you scroll back you will see that.
Please don't tell me you don't feel that paramedics should be able to intubate in the field. They do our patients a great service and are not compensated for it. And they are highly trained and don't deserve to be called unsafe practitioners.
Perhaps you didn't realize the context of EMT's postings.
Quick, without looking it up, answer the following questions.
1. Name 2 genetic disorders where succinylcholine is absolutely contraindicated.
2. How are those disorders diagnosed?
3. How do you reverse succinylcholine?
4. Explain the difference between depolarizing and non-depolarizing muscle relaxants at the myoneural junction.
If you have to look up even one of those answers, you are practicing substandard nursing if you are administering succinylcholine. You should be reported to the RN Board as an unsafe practitioner.
I have driven a car for over 40 years, but wouldn't attempt to drive at NASCAR. Go to anesthesia school if you want to do anesthesia. Please for the patients sake.
Yoga CRNA
"Go to anesthesia school if you want to do anesthesia" GIVE ME A BREAK!!! are you proposing that we call anesthesia every time we want to give conscious sedation? HAHAHAHAHAAAAAA like that will happen. As I said before, our anesthetists wont come within 100 feet of the ED, they run like scared rabbits when we ask them to come in and do anything.
as a specialty do you really believe that you can prevent RN's from giving these meds? Please, be my guest, I have many other sick patients to take care of, I would LOVE to turf the conscious sedation to someone else more "qualified" dont forget this includes coming out at any hour of the day or NIGHT to the ER full of screaming babies, puking people, bawling drunks, stabbing and gunshot wound victims and smelly, dirty people to "do anesthesia". :rotfl: :rotfl: :rotfl:
There are cardiac gtts that are utilized by ED nurses that can have as life-threatening consequences as any of the drugs being thrown around here for conscious sedation...all are utilized safely with training and adequate resources to prepare for the possible complications.
I don't think ANYONE is advocating the free flowing use of Ketamine in the ER by any ole' person in scrubs!!
But to make a blanket statement that conscious sedation should NEVER be done in the ED setting...well, that's is simply not reality. And until all the CRNAs and anesthesiologists are ready to take call for the ED...well it will stay that way.
I'm pretty sure that you won't find an ED nurse who will fight you for the opportunity to give these drugs if you all want to step in. But the fact is...none of you has said that. So until then..
We educate (as we have with other critical drugs)
We show competency and re-validate (as we do with other critical procedures)
We take every precaution imaginable (as we do with other critical procedures)
And most important of all...
We back each other up...because Lord knows no one else is.
But to make a blanket statement that conscious sedation should NEVER be done in the ED setting...well, that's is simply not reality. And until all the CRNAs and anesthesiologists are ready to take call for the ED...well it will stay that way.
The first statement highlights exactly what I am saying. I have no problem with "conscious sedation." However, the minute you pick up the propofol or the ketamine, you have passed from conscious into unconscious sedation. The idea of conscious sedation is that the patient is calm, sedated, but conscious. They will respond to questions, rouse to voice, etc. The next time you give a patient ketamine, ask them a question once they assume the "thousand yard stare." The only response you are likely to get is a funny look from the physicians and nurses around you. I have worked in a busy ED in a Level I trauma center. I thought the same things you do. Then I started doing anesthesia, and realized just how lucky I had been.
As to taking call to the ED, I do. I currently work in a rural hospital, and anesthesia drugs are not available to the ED. If there is need of deep sedation, I (or my partner) am called in to do it. Just off the top of my head, I can recall four patients with dislocated shoulders we have been called in to sedate for reduction in the last year. And that's just the shoulder dislocations. I have no idea how many times total I've been called in to provide deep sedation in the ED. And I don't at all mind coming in to do it. If your anesthesia personnel are unwilling to do so, that is something for your ED director and hospital administration to get involved in. Were I you, I wouldn't want the potential liability of performing anesthsia.
I'm not saying that all sedating or anesthetic drugs should be taken from the ED. On the contrary, many hospitals, the one where I work included, go too far in the other direction. I don't think that sub-q administration of 0.3 cc of 2% lidocaine should be done only by qualified anesthesia providers, but my hospital does. I think Versed is a wonderful drug for use in the ER. But you really have to try to make someone apenic on Versed, and you still may not be successful. You can make someone apenic and hypoxic with propofol without even realizing it happened. That's where the education and experience in giving anesthetics becomes critical.
But to make a blanket statement that conscious sedation should NEVER be done in the ED setting...well, that's is simply not reality. And until all the CRNAs and anesthesiologists are ready to take call for the ED...well it will stay that way.
The first statement highlights exactly what I am saying. I have no problem with "conscious sedation." However, the minute you pick up the propofol or the ketamine, you have passed from conscious into unconscious sedation. The idea of conscious sedation is that the patient is calm, sedated, but conscious. They will respond to questions, rouse to voice, etc. The next time you give a patient ketamine, ask them a question once they assume the "thousand yard stare." The only response you are likely to get is a funny look from the physicians and nurses around you. I have worked in a busy ED in a Level I trauma center. I thought the same things you do. Then I started doing anesthesia, and realized just how lucky I had been.
As to taking call to the ED, I do. I currently work in a rural hospital, and anesthesia drugs are not available to the ED. If there is need of deep sedation, I (or my partner) am called in to do it. Just off the top of my head, I can recall four patients with dislocated shoulders we have been called in to sedate for reduction in the last year. And that's just the shoulder dislocations. I have no idea how many times total I've been called in to provide deep sedation in the ED. And I don't at all mind coming in to do it. If your anesthesia personnel are unwilling to do so, that is something for your ED director and hospital administration to get involved in. Were I you, I wouldn't want the potential liability of performing anesthsia.
I'm not saying that all sedating or anesthetic drugs should be taken from the ED. On the contrary, many hospitals, the one where I work included, go too far in the other direction. I don't think that sub-q administration of 0.3 cc of 2% lidocaine should be done only by qualified anesthesia providers, but my hospital does. I think Versed is a wonderful drug for use in the ER. But you really have to try to make someone apenic on Versed, and you still may not be successful. You can make someone apenic and hypoxic with propofol without even realizing it happened. That's where the education and experience in giving anesthetics becomes critical.
I am currently in Singapore and apparently they are having a big problem down here with teenagers overdosing on ketamine right now. They have huge posters all over showing kids passed out in bathrooms and on the street from it. Not sure where they are sourcing it from. Probably the kids feel it is safer because it is not a narcotic with the strict drug laws down here.
I am currently in Singapore and apparently they are having a big problem down here with teenagers overdosing on ketamine right now. They have huge posters all over showing kids passed out in bathrooms and on the street from it. Not sure where they are sourcing it from. Probably the kids feel it is safer because it is not a narcotic with the strict drug laws down here.
Our tech (college kid) happened to stroll by and announced to me that the kid was "in the K-Hole" (apparently the lingo when you do the drug illegaly, what do I know?:chuckle )
dont forget this includes coming out at any hour of the day or NIGHT to the ER full of screaming babies, puking people, bawling drunks, stabbing and gunshot wound victims and smelly, dirty people to "do anesthesia". :rotfl: :rotfl: :rotfl:
teeituptom, BSN, RN
4,283 Posts
We administer mostly mild concious sedation. Our policies and such are set up and guided by the hosp Anesthesia committee. But even the Anesthesiologists I know dont even consider conscious sedation as a form of anesthesia.