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sedate or not to sedate, that is the prehospital question

Sedate or not to sedate, that is the prehospital question

You are attending to an elderly man who has dementia.  He is in an aged care residence and, looking at him, doesn’t have much of the muscle strength he may have had when he was a few decades younger.  As you try to assess him, you appreciate just what the nurses were talking about as he grabs your arm and tries to pull you toward him.  His other arm claws at your face making anything nearer than the foot of the bed a place of hazard.

You back away toward the lounge-room door as the young man turns toward you snarling.  He is angry at the world and threatens to smash the wall of the house.  Little of what he says makes sense, unsurprisingly since it is clear he has indulged in a range of illicit stimulant drugs.  Your brief attempt at de-escalation has fallen well short of placating the man and now he is giving every appearance of violently sharing his psychosis with all nearby.

The brief moment of joy has passed as the pragmatic realisation that the return of the patient’s pulse has also brought a return of more pressing visible signs of life.  The patient is gagging on the supraglottic airway and has managed to localise to the uncomfortable device with one arm.

Each of these patients have at least one problem in common.  They all are difficult to manage because of their physical behaviour.  To varying degrees they are agitated, irritated or restless making them difficult, if not impossible, to effectively manage.  Their own behaviour is forcing inferior and inadequate care to be afforded to them.

What to do?

Sedation comes to mind.  Sedation is the administration of a drug to induce a calmer or more compliant state to help overcome these or other similar problems.  But it has a down side.  Depending on the drug chosen, each has side effects and unwanted actions.  You get the calming as long as you accept possible loss of airway reflexes, hypotension or respiratory depression to name a few.

This means you should consider sedation when that is the only way to proceed with managing the patient.  You should be ready for the unwanted actions and able to either accept them for the time being or able to take corrective action if they happen.  To take advantage of the upside of sedation, you have to be ready with the answer to the next question.

So what happens after you give them?

Sedation may be the temporary end point in prehospital patient care.  Or it might be just a step to allow another endpoint to be reached.  Which is it in the case presenting to you?

Consider first where sedation is the prehospital end point.  This might be the psychotically disturbed patient from any cause including illicit drugs or mental health problems.  The end point is to keep them safe and protected until the behaviour resolves.  It may or may not involve further medical interventions once the patient is contained.  For the prehospital responder, the end point is to render the patient manageable.  This will take firstly exploring de-escalation strategies before accepting that sedation is the only option.  Sedation should not be the first or an easily accepted option.  Once it is accepted that sedation is required, what and how?  Midazolam is always good as it is quick acting and relatively short acting if it causes problems.  For many patients including the elderly or medically unwell, small amounts of this drug will typically be enough.  If the patient is extremely agitated, something more heavy duty may be needed such as ketamine.  Both options can be given via IM injection.  If ketamine has to be resorted to, subsequent IV midazolam can be used to help keep the patient subdued.  Remember, the end point here is safe patient compliance.  Administer the minimal amount of drug necessary to successfully achieve the task.  The patient will likely be in a state where they can be roused with light stimulation rather than deeply unconscious.  They will also stop demonstrating the behaviours that were causing the problems.  For mental health patients, haloperidol options are also acceptable though these are typically slower in onset and have a broader side effect profile including QT prolongation and extrapyramdical disorders.  The other critical consideration is to ensure paramedic safety during and after the process.  This may include using restraint devices and ensuring sufficient people to assist with patient restraint during drug administration.

For many patients though sedation will not be the end point.  Instead, sedation will be used to allow some other form of therapy to be provided.  This is a critical difference.  Firstly, the interference of the sedation will likely not help the other underlying problem.  Rather, the deterioration in consciousness, airway reflexes and perfusion might all become seriously problematic.  As such, just enough sedation should be used, only when necessary and always with the mindset that the real therapy option will be introduced as quickly as possible.  These therapies vary considerably but include to allow procedures such as musculoskeletal injury management, pre-oxgenation prior to intubation or even to allow a hypoxic/hypercapneic respiratory failure patient to receive oxygen/nebulised drug therapy or even CPAP.  In the case of pre-oxygenation, the intubation should be attempted as soon as the patient is sufficiently ready and the amount of sedation included in any further addition.  In the case of respiratory failure, everything about sedation takes the patient in the wrong direction.  Patients fighting to breathe are using accessory muscles of respiration.  Sedation reduces this.  If sedation is used in such cases, it should be minimal and with the appreciation that a patient may become in need of respiratory support afterward.  In such cases, small doses of midazolam might be suitable.  In many cases though small doses of an opioid such as fentanyl or morphine might be better where the safer side effect profile can offset the reduced sedative ability.  Opioids or even small dose ketamine might also be the best choice for musculoskeletal injury management.

Jeff Kenneally www.prehemt.com

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