Discover Top Posts Tagged with #procedural sedation

Please don’t all board the burn train...

On one of my recent shifts we had an unfortunate string of kiddos presenting one after another with burns--the poor plastic surgery fellow had to check and re-check with us as we went room-to-room to sedate these kiddos and get their dressings changed.

The first kiddo was a 15-month-old who pulled a cup of coffee on himself and the second was an 8-month-old who spilled his grandpa’s tea onto him. The third kiddo wasn’t mine to take care of but had sustained a burn from a pan of bacon grease that fell on her leg.

My first kiddo was mad AF when we got him sedated and woke up pretty agitated; the younger bean was tranquil as you please throughout the whole procedure, despite having a much larger burn. Just goes to show how much developmental stranger danger and general temperament can affect how a procedure goes!

IMPORTANT: most burns in young children are accidental scalds from hot liquids, and many can be prevented! Please keep kettles (and their cords!) out of reach from grabby hands at the edge of your counters, and try to keep pot handles turned inward and away from the edge of your stove! It can also help to use burners that are further back to avoid contact burns from hot elements after cooking. Of course, it is impossible to keep eyes on your kiddos at all times--older infants and toddlers especially--but using travel mugs with seal-able lids, even when you’re enjoying your hot beverage at home, can help add another layer of safety even if we cannot prevent every scald injury.

#injury prevention #burn prevention #reflection #safety #pediatric emergency medicine #pem #paediatric emergency medicine #peds emerg #burn #pediatric burns #paediatric burns #fellowship #advocacy #procedural sedation #sedation #patient encounter

As part of our pre-sedation or pre-anaesthesia assessment in school-aged children, we ask them about whether they have any loose teeth; this is because a loose tooth can become a dangerous airway foreign body while you're trying to intubate. I honestly haven't had many kiddos with loose teeth thus far, but I fondly remember this 8-year-old who was extremely excited and proud of his wiggly lower incisor. It was actually just barely loose, but he already had grand plans for his Tooth Fairy reward, most of which involved sharing with his family and his friends at school.

"I'm sure all your friends must be missing you today," I said.

"Yeah," he responded, but then got even more excited. "But my teacher and my whole class sent me a message today!"

He told me about how his teacher sent his mother a video message with the whole class wishing him a speedy recovery and telling them they couldn't wait for his return to school. It was such a sweet and lovely thing for that teacher to arrange to make this little guy feel special. He was probably the happiest kiddo I've ever put to sleep!

Fellowship Pearl #6

Data suggests that most sedation-related complications in the ED are linked to pre-sedation opioids (usually within 30min of sedation).

In your pre-sedation assessment, think about when the child last received an opioid medication, and when making a plan, avoid including opioids as part of your procedural sedation. If a child requires opioid medication for pain control, consider giving a shorter-acting opioid using a non-intravenous route. Otherwise, aim to provide opioids well in advance of your sedation, then try to keep the child comfortable with non-opioid analgesics. Remember that you can always administer more opioid analgesics after your sedation, and don’t forget the efficacy of local and regional anaesthesia!

#procedural sedation #procedural analgesia #anaesthesia #anesthesia #anaesthesiology #anesthesiology #pediatric emergency medicine #paediatric emergency medicine #pem #pediatric anesthesia #paediatric anaesthesia #pediatric anesthesiology #paediatric anaesthesiology #fellowship pearls

The other day I managed the sedation for a 4yo bean to get his complex laceration repaired by plastic surgery. He was a really chill little dude that waved at me from the door every time I happened to pass by before I was able to come in to see him, then waved at me when I walked in, and waved goodbye whenever I left the room. He sat quietly and attentively as I talked to him and his mom, and was completely relaxed even as I took a look at his wound before we froze it up. (Honestly, I was super impressed because at this kiddo’s age I’m pretty sure I would’ve freaked out!)

He was very calm as we got him set up for his sedation (he was even calm and totally cooperative during his IV insertion--I was starting to get suspicious that this kid didn’t have pain receptors or something but then he definitely responded to the Plastics assessment). We got him off to sleep and he tolerated the procedure fantastically.

He was emerging from the sedation as I helped the plastics resident dress his wound, and when I stepped out of the room to do some charting I waved at him and he very loopily waved back <3

#sedation #procedural sedation #pediatric emergency medicine #pem #paediatric emergency medicine #plastic surgery #anaesthesia #pediatric anaesthesia #paediatric anaesthesia #anaesthesiology #<3 #I love the beans #all the beans #fellowship #residency #resident #patient encounter

Fellowship Pearl # 3: More Procedural Sedation Tips

Titrate, synergize, anticipate, re-evaluate!

Titrate: when inducing sedation, titrate to effect and monitor for changes in level of consciousness that are consistent with the desired depth of sedation. BE AWARE of the pharmacokinetics of your selected agents, as some will have faster or slower onsets of action, and may have delayed peak effects; higher doses up front can result in over-sedation requiring rescue.

Synergize: in the ED, many of us are used to trying to stick to one or two sedative agents at a time. This is not inherently incorrect, but if you DO start using multiple agents, their combined effect is often greater than the sum of their individual effects, therefore requiring lower doses of each agent when used together than you might have needed individually. Furthermore--the dose-dependent effects of many agents are idiosyncratic (different effects on different patients) and many are actually metabolised faster by younger patients (ex/infants can really burn through propofol!)

Anticipate: you can often avoid using large cumulative doses of sedatives if you time small boluses around big stimuli. This can also help you avoid over-sedating a patient by having a stimulus-sedative mismatch! This does, however, require that you have a good understanding of the procedure that will be done and how painful/stimulating you expect various aspects to be, and the duration of the stimulus.

Re-evaluate: did the patient cry out and withdraw when traction was applied to their fracture? Then you may need more sedation on board! What are the patient’s ABC’s doing? How is the procedure going, and is it likely going to be uncomplicated or have there already been some snags? These are all aspects of the sedation to continually re-evaluate as you monitor the patient and the procedure. Remember: in the ED, a sedation is an elective procedure, therefore it should be possible to terminate at any time for the patient’s safety or best interest. This must be something you discuss with the clinician/service that is performing the procedure, as the clinician providing the sedation needs to be able to call for the safe termination of the procedure.