#SimBlog: Preparing For The Worst
““35-year-old patient with a fracture dislocation of the ankle, with no pedal pulse. ASA 1.””
Observations
A – Clear & self maintaining
B – Rate 15, SpO2 98%
C – Pulse 96, BP 120/75
D – E4 V5 M6 pupils equal
E – Temp 35.9°C
Clinical Findings
Mallampati 1
No loose teeth, caps or crowns
Deformed ankle – pulseless/skin tenting
Why We Simulated
Procedural sedation is an important skill for those working in the Emergency Department, it enables us to perform a number of short and painful procedures that would otherwise not be tolerated. There are a number of studies showing that the use of sedation in the ED is safe (Bellolio et al 2016 and Newstead et al 2013).
However, there are complications to consider such as hypoxia, apnoea, laryngospasm, or the need for advanced airway intervention. This simulation is designed for the patient to become apnoeic and to desaturate with time.
In order to make sedation as safe as possible it is important to consider these and adequately prepare prior to the procedure. This can be helped by having a local policy or guideline to follow. It is also worth asking yourself the following:
Is the procedure appropriate for sedation? Is it a short procedure? Will it be painful?
Is there an alternative solution? e.g. local anaesthetic to reduce a dislocated shoulder?
Is the patient safe for sedation? Consider ASA grading, body habitus, intoxication or fasting status.
What is their airway like? Mallampati, neck movement, 3/3/2 assessment or Dentition.
Are the appropriate staff available? Sedationist, proceduralist, nurse or runner.
Is the correct monitoring available? ECG, waveform capnography, NIBP or pulse oximeter.
Do you have the necessary equipment? Airway equipment, tilting trolley, suction or rescue drugs.
What will you do if things go wrong? DAS algorithm, who are you going to call?
Learning Outcomes
Antidotes are available in the 1st drawer in all ER bays.
Remember to make checks before beginning.
This is a never event and will require reporting.
Positive Feedback
Use of the pro forma.
Identified that this was a critical incident.
Gained consent from the patient prior to sedation.
References:
- Bellolio, M,. Gilani, W,I. Barrionuevo,P. Hassan Murad,M. Erwin, P,J. Anderson, J,R. Miner, J,R. and Hess, E,P,. 2013 Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Br. J. Anaesth, 23(2), 119-134
- Newstead, B. Bradburn, S. Appelboam, A. Reuben, A. Harris, A. Hudson, A. Jones, L. McLauchlan, C. Riou, P. Jadav, M and Lloyd, G. 2016 Propofol for adult procedural sedation in a UK emergency department: safety profile in 1008 cases Br. J. Anaesth, 111(4), 651-655.
Further Reading:
- RCEM Learning: Sedation Modules
Banner image credit: Lemons at the Mercat Central de València, Spain. © Hans Hillewaert / CC BY-SA 4.0 (Source: Wikimedia Commons)
