An overview of sedation in the Emergency Department

So we're here at SMACC being treated to a fantastic conference and some superb talks. Last night (Day 1) closed with a superb panel of experts from across the globe talking on sepsis including Melvyn Singer, Paul Marik, John Myburgh, Simon Finfer, Kathryn Maitland & Flavia Machado. The panel challenged current global practice on sepsis including the use of SIRS criteria, antiobitic prescribing patterns and the utility of lactate.

Over the last few episodes we've talked about the use of vasopressors and their utility in resuscitation. It is a commonly held belief that giving vasopressors peripherally puts patients at high risk of extravasation and secondary skin necrosis. In an ideal world patients would have a central line placed and then have their vasopressors commenced, sadly life in the ED doesn't always mean that time permits this luxury......

Rapid sequence induction, or RSI, is the preferred method of emergency tracheal intubation outside the operating room because it results in a rapid state of unconsciousness (induction) and neuromuscular blockade (paralysis).

The Scottish Intensive Care Society defines RSI as follows........

We catch up with Dr David Raven, Consultant in EM at HEFT regarding his Hector project, Heartlands Elderly Care Trauma & Ongoing Recovery, with a progress report.

What does presyncope mean to you?

If you ask this question to a handful of doctors you'll get a multitude of different answers, you'll also get a huge variety of opinion as to their understanding of it's significance or associated morbidity and mortality. As with most areas of greyness in medicine this is contributed to significantly by a paucity of evidence on the topic.

In this podcast we are going­­­­­­­­­­­­­­­ to be talking about inotropes and vasopressors. And we're going to be talking about them with respect to septic shock.

In the UK we use the definition of septic shock as a patient who is hypotensive following the administration of 30 mils per kilo of IV fluids. You might wonder why we can't continue giving these patients more and more IV fluids, but as with most things in medicine there are side effects and consequences to this. This fluid (and even more so in sepsis) is going to moving from the intravascular space to other fluid compartments and can give rise to problems such as pulmonary oedema. Inotropes and vasopressors in themselves are not harmless but they do have a role in supporting the cardiovascular system in haemodynamic compromise and the surviving sepsis campaign would ask us to consider them went 30 mils per kilo has been administered to patients without the resultant rise in BP.....

Trial of Early, Goal-Directed Resuscitation for Septic Shock NEJM March 17 2015 Sepsis has been in the EM literature a lot over the past 12 months.

The phenomenal reduction in mortality that Rivers Early Goal Directed Therapy (EGDT) demonstrated in 2001 has been variably implemented.

He had demonstrated a NNT of 6 to save one life when implementing EGDT in severe sepsis or septic shock, it was however a small single center trial and many were skeptical of it's external validity.

The Surviving Sepsis Campaign has endorsed the implementation of EGDT. Despite this the implementation has not been widespread. In order to address concerns re the external validity of Rivers work the last 12 months has seen a trio of papers addressing the question;

You're in resus leading a cardiac arrest. Lying on the trolley is Dave, a 45 year old male, known hypertensive and type 2 diabetic. He collapsed whilst putting a big bet on in the bookies, having just complained of some chest pain, looked flushed and sweaty and fell to the deck. He had immediate bystander CPR, the ambulance arrived within a couple of minutes, confirmed cardiac arrest with a rhythm of VT.......

Fluid resuscitation represents the bedrock of initial treatment in the critically ill and injured patient with shock. In septic shock, fluid loading as part of early goal directed therapy was shown to confer a huge mortality benefit.

It seems intuitive that shocked patients require fluid loading however, numerous studies in critically ill patients have demonstrated that only around 50% respond to a fluid challenge. Are we over-resuscitating these patients and if so, what are the consequences? Evidence is accumulating that over-resuscitation is associated with increased morbidity and mortality.

Since clinical determination of fluid status in the haemodynamically unstable patient is unreliable, how do we assess volume status reliably to ensure those who need fluid get it?