sinaiem.org

Dr. Lewis Goldfrank’s lecture on alcohol withdrawal is now up on the Conference page.  Give it another listen, as Dr. Goldfrank is a very engaging and provocative speaker. And be sure to review our own Dr. Olmedo’s chapter on withdrawal syndromes, which includes a great section on alcohol.

As for my senior lecture, there were many topics I didn’t get to include — so let me just point you to a few excellent articles and some practical tips:

Miner JR, Krauss B. Procedural sedation and analgesia research: state of the art.
Acad Emerg Med. 2007 Feb;14(2):170-8. PMID: 17267532

Green SM, Krauss B. Barriers to Propofol Use in Emergency Medicine.Ann Emerg Med. 2008 Feb 21. [Epub ahead of print] PMID: 18295374

That new prospective ketamine study in adult EM PSA I was touting: Newton A, Fitton L. Emerg Med J. 2008 Aug;25(8):498-501. PMID: 18660398

ACEP’s two recent clinical policies (2005 and 2008’s peds edition).

EMCrit has lots of collected wisdom, as usual.

Miner wrote some wise words in his Propofol vs. Etomidate RCT in Annals of EM, Jan 2007:

A wide range of outcome measures has been suggested for sedation research, and all measures have significant limitations…. Decreases in the ETCO2 are associated with airway obstruction, and increases are representative of hypercarbia. It is possible for a patient with hypoventilation and increasing airway obstruction to maintain a stable ETCO2 value; we therefore continue to use pulse oximetry and the absence of the ETCO2 waveform as additional criteria for the detection of subclinical respiratory depression. Because we are assuming unmeasured combinations of airway obstruction and hypoventilation, we have used the presence or absence of ETCO2 changes rather than comparing the values or the direction of changes. A decreased oxygen saturation or an absent ETCO2 waveform is likely a more ominous sign of impending respiratory depression than an isolated change from baseline ETCO2.

This came after literally years of debate as to what combination is best to monitor patients: pulse ox, capnometry, with or without supplemental O2. If you’re ever trying to convince someone of the importance of NOT giving a patient supplemental O2 here’s some concise evidence-based wisdom from Deitch and Chudnofsky in 2008:

The goal of supplemental oxygen is to increase oxygen reserves, thereby delaying or preventing the onset of hypoxia. However, increasing oxygen reserves is not without risk. It has been shown that superoxygenated patients desaturate only after prolonged apnea. This negates the use of pulse oximetry as an early warning device for respiratory depression, which is concerning in light of the fact that emergency physicians rarely recognize respiratory depression in sedated patients who do not become hypoxic.

Posted on Saturday, September 13th, 2008 at 6:29 pm by Nick. Filed under Monitoring, Post-Conference Letter, Pain Management, Procedures, Toxicology, Blog.
You may post a comment.