mmcdon78

I work at a level 1 trauma/burn ED with the luxury of an OB department on the 13th floor. If mom presents to Triage (or the ambulance ramp) crowning or hemmoraging she goes right to a Trauma bay. The NICU fellow and Labor and Delivery nurses will come to the ED to assist with birth. If they don't make it down in time, we have all of the necessary equipment to handle it until they get there. If mom is in active labor but not crowning, she is brought up to the L&D floor by the ambulance crew accompanied by an RN. We keep an equipment box at Triage with bulb suction, cord clamps, etc. to take along just in case an elevator gets stuck... It's never happened but seems to ward off "having a baby in the elevator" spirits. The equipment box also comes in handy when we proceed out to the ambulance ramp for a mom delivering in the back seat of a car.

I too work in large level one trauma and burn center. Our sedation policies are written by the Head of Anesthesiology. Any time an opiod and sedative are given together it is considered procedural sedation and a special packet of paperwork must be initiated. This packet includes initial airway assessment, consent forms, and seperate sheets to document pre, intra, and post procedural vitals and effect of meds. We most commonly use Fentanyl and Versed, but have used Morphine, Demerol, or Ativan as well, all of which can be pushed by RN's. Be aware that it usually takes 2 minutes or so after administration to reach full effect. Some residents are not aware of this, and order another dose pushed 30 seconds later when the initial dose hasn't taken effect yet. This will lead to deep sedation and/or respiratory arrest. Always make sure you have working suction and an Ambu at the bedside. Etomidate is not approved for sedation in my ED, and can only be used for RSI Propofol is only allowed to be administered to mechanically ventilated patients in our ED, however RICU can supercede this policy if they order it (such as if they are STAT paged to the ED for a difficult airway or failed intubation; doesn't happen often, have only seen it twice in my 6 years at my current facility.) Also, propofol will be given in the ED by cardiac anesthesia for TTE or cardioversion in an otherwise stable patient. Ketamine is used primarily for pedi sedation. IM is given by the RN, IV is administered by MD, usually preceeded by anticholinergic dose of Atropine. - One last note- --- Always make sure your med orders are written and signed prior to med administration if possible. You don't want someone to give verbal orders, have the patient be overmedicated and a bad outcome, and then have the ordering MD deny ordering such doses.

Usually only use Ketamine for Pedi Procedural Sedation (IM or IV), preceeded by Atropine. Ketamine is occasionally used by our MD's for RSI in asthma patients