States of sedation

1. Minimal - mild anxiolysis and pain control
2. Moderate - sleepy patient arousable by voice/ light touch (conscious)
3. Deep - Painful stimuli for purposeful response
4. General - no purposeful response
   

• Sedation is a dynamic process

• Politics - FDA considers etomidate, propofol, ketamine to be general anesthetics
  
• CMS says EM docs are qualified to use these medications.
  

• Pearl #1 - Match duration of action of medication with length of procedural stimulation

• Pearl #2 - Preparation is key

        -- Don't get complacement - known what you’re supposed to have and be prepared to set it up yourself
        -- Aspiration risk - sedation depth and length don’t correlate with poor outcomes;
                                   - solids vs liquids - can impact aspiration risk;
                                   - GERD & age can increase risk;
                                   - no evidence based literature that has a definite time that patient needs to be NPO for
        -- Monitoring - pulse ox, response to commands, ventilation, CO2 monitoring, continuous cardiac monitoring
                             - ETCO2 - goal 35-45 mmHg 

•   Some Specific Rxs
  

Ketamine - dissociative agent, relaxation, pain relief

• Pitfall - Emergence reaction - try to avoid this by talking about pleasant things before ketamine; occurs in 10-20% in patients; vomiting in 5-15%
• Don’t use in elderly, hypertensive, pysch patient
  

Etomidate - complications of myoclonus

Propofol - benefits - gives deep sedation, doesn’t give analgesia (need pain relief too); patients can have apnea and laryngospasm

Combining sedatives - like ketofol?  - may improve HD stability

Case - 7 month old male - hx of complex congenital heart disease

• Presented with hypoxia, unresponsiveness and cyanosis
• On arrival to OSH, patient was looking better, had CXR which showed prominent perihilar opacities, sats in high 90s on 4 L NC after one neb treatment and was DC'ed home.
  

• Note states mom was demanding and refused admission
• > 1 hr later arrived at our ED - sats have dropped to 70-80s with increased WOB;tachycardic with crackles throughout with systolic ejection murmur - per mom child missed one dose of lasix
  

• Mom is refusing IV access! 
  

           * Discussion - How do deal with difficult interactions in the pediatric ED - Dr. MacNeill:
                - Be on the same team as the parent - you both want the kid to live
                - Be aware of the limitations of the members of your team and if things aren’t going well, rearrange things
                - Be empathetic - If you can’t make it, fake it!

• Be aware of affective bias - KNOW when a patient is irritating or difficult, be aware how that is impacting your care and change your perception and management if necessary
• Often the "difficult" parents have been made difficult by the medical system and the inherent issues with having their child in the hospital for extended times with various levels of care and consistency.
  

Case 1 - Is that Tube in the Right Place?

• There are no fail-safe ways to confirm endotracheal placement of anairway, but end-tidal CO2 monitoring should be standard.
• Direct visualization with NasoPharyngeal Scope down the tube also works effective.

Case 2 - Locked-In

• Consider a basilar artery thrombosis in any patient with altered mental status or catatonic/locked-in exam.
• All patients with atrial fibrillation carry a risk of ischemic stroke.
• Basilar occlusions are hard to diagnose, frequently missed, variable in presentation and highly litigated.
• Stroke therapy is in flux, and earlier studies may need to be redone now with new data... MRI brain perfusion, newer catheters, size of clot burden vs tpa.
• In acute stroke if tPA fails, intra-arterial tPA and thrombectomy are options to discuss with consultants with little definitive evidence.

Definitions

• Disaster = "A serious disruption of the functioning of society, causing wideshpread human, material, or enviornmental losses which exceed the ability of affected society to cope using only its own resources" (UN, 1992). Emphasis is the inability of a society (community, state, nation) to respond to the event.

• Disaster cycle is composed of:
  

1. Preparation
   
2. Event Response
   
3. Recovery
   
4. Mitigation
   

• Resilience = The capacity to cope with or recover from emergencies and disasters  
  

Basics of Personal Security for Travel to Developing Countries - Macpherson

• Before you travel, do some research (can consult the following sites)
  

- http://www.travel.state.gov
- https://www.cia.gov/library/publications/the-world-factbook/
- http://www.doingbusiness.org/
- http://www.lonelyplanet.com

• The most important aspect of security when you travel is your situational awareness
  

1. Pay attention to your surroundings
   
2. Be sensitive to change
   
3. Act accordingly (trust your instincts)
   

• Travel to/from and within the country
  

1. Cell phone  - most vital piece of equipment (consider getting a local cell phone)
   
2. Don't travel with more than you are willing to lose
   
3. Don't travel with more than you can carry yourself
   
4. Have an advance plan for travel from airport to hotel
   
5. Don't travel around alone
   
6. Find out what areas to avoid
   
7. Vary your route
   

• Be careful what you post on social media  
  

Pediatric Disaster Medicine and Triage - Noste

• The pediatric population is at higher risk of injury during a MCI/disaster/CBRNE event

1. Body heat loss is increased during exposure or following decon
   
2. Vital sign screening is frequently inadequate
   
3. Internal organ damage is often overlooked
   
4. Thinner skin is more vulnerable to the effects of radiation
   
5. Typically closer to the ground and more likely to ingest heavier than air gases or contaminated particulate matter
   

•  Children <4 years old have a 4.5x rate of death from cholera  
  
• JumpSTART modifications for pediatric MCI
  

1. Why? Cap refill is unreliable and strongly influenced by the environment in the pediatric patient
2. Respirations may be normally > 30/min
3. Not all children can walk or follow commands
   
4. Biggest modifications are: Normal respiration rate 15-45 bpm, if patient is apneic after repositioning the airway give 5 rescue breaths (if no response then triage code black, if response then triage code red),
   
5. There is a high rate of "over-triage" pediatric patients in MCI (300-400%)

Gastric Perforation
13 yr old female w/ abdominal pain - recent admission for abdominal pain with EGD (with biopsies taken). Became hypotensive, tachycardic, lactate 3.5 - surgery consulted & CT showed gastric perforation.

• Plain films for identifying perforation

1. Sensitivity 70-90% - significant variability in the studies
2. Consider addition of L lateral decubitus to increase sensitivity
   

Hypotension - Beta Block Toxicity
49 y/o male from rehab - was found obtunded and hypotensive w/ BP 60/20

    > ESRD dialysis patient
    > Hypothermic w/ temp of 93, pulse 59, BP 60/18;  answering questions
    > Labs relatively unremarkable, EKG basically unchanged, CXR with pulmonary vascular congestion

    > List of meds reviewed - a LOT of antihypertensives including 1600 mg of labetolol in the past 24 hrs

• Started on high dose insulin w/ improvement in blood pressure 
• Beta blocker/CCB Toxicity Management: 
  

1. Atropine
2. Volume
3. Glucagon
4. Calcium
5. Vasopressor
6. High Dose Insulin = 1-10U/kg/hr; dextrose 0.5 gm/kg/hr
   

(D25 need CVL); POC glucose q30 min with goal BG of 200-300


Wernickes Encephalopathy
57 yr old "drunk" from medic

    > Normal vital signs, hx of COPD cirrhosis GERD and no meds
    > Wide based gait & tremulous & confused; while at rest normal neuro exam
    > Wernickes Encephalopathy - got thiamine and got better

           - Thiamine i500 mg iV over 30 minutes
           - At risk patients - anyone prone to malnutrition
           - Clinical diagnosis - consider with 2/4 nutritionally deficient, ocular findings, encephalopathy, ataxia

ACEP 2013 Guidelines

DO’s

1. Take repeat blood pressures during your patient’s stay in the ED
2. Fast track patients with severely elevated blood pressures (>180/110) to a PCP
3. Start a patient on a maintenance oral antihypertensive if BP severely elevated
    a. BUT REMEMBER!
            i. Get a BMP
            ii.Think about their comorbidities

DONT’s

1. HARMFUL! Do NOT give acute antihypertensives (i.e. clonidine, IV drugs) to asymptomatic patients.
2. Send home patient’s WITHOUT any follow up

Limitations of ACEP 2013 Guidelines: Do NOT apply these guidelines to patients who have symptoms that may be indicative of a hypertensive emergency, pregnant patients, or patients with end stage renal disease.

Pt with Syncope... what should you do?
1. Obtain 12 lead EKGs on patients of all ages with history of syncope. (Level A Evidence)
2. According to ACEP Clinical Policy on Syncope, Laboratory testing and advanced investigative testing (such as ECHO and CT Head) need NOT be routinely performed unless guided by specific findings in the history or physical exam (Level C evidence).
3. There are multiple Risk Stratification Tools for syncope, including San Francisco, Rose, OESIL, EGSYS, and Boston, which have varying levels of sensitivity and specificity.
The Boston Guidelines are the newest set of guidelines which have highest sensitivity at 100%.
4. ACEP's Clinical Policy of Syncope state the following four criteria for considering patients "high risk" following a syncopal event:
    1. Older age with associated co-mordities,
    2. Abnormal EKG,
    3. Hct < 30,
    4. History or presence of heart failure, CAD, structural heart disease