1. Hey Dr Weingart,

    Prehospital Ketamine, yea or nay? I’m a Paramedic Intern in the Boston area, and around here, we don’t even have a whiff of Ketamine. Dr Minh Le Cong of PHARM seems to love the stuff, and as far as I can tell, it seems like a great agent to use prehospitally, with it’s cardiovascular stability and multitude of uses. Thoughts on prehospital sedation and induction would be much appreciated too, if you’ve got the time.

    Sylvain Ellis
    Paramedic Intern

  2. Thanks for another great podcast Scott.
    Does this mean that you would you do electrical conversions for atrial fibrillation without symptoms of acute heart failure without a full preprocedural fasting? These patients are usually not in pain and often only mildly symptomatic. A full preprocedural fasting prior to el-con is hospital policy in most (if not all) Scandinavian hospitals.

    • if I decide to go down that road, yes, I’d have no problem ignoring last meal. If I was admitting them regardless, then it is a toss up. But like I alluded to in the cast, just choose your meds based on the situation. El-con is nice b/c they are sitting up, less chance of passive regurg.

  3. Thanks for another interesting podcast Dr. Weingart.
    Whats your take on sedating a child via the intranasal route: Intranasal midazolam vs intranasal ketamine vs intranasal dexmedetomidine? I’m an emergency medicine resident, working in the middle east.

  4. So according to the ACEP Clinical Policy:

    “Propofol can be safely administered to children and adults for procedural sedation and analgesia in the ED.”

    Propofol? An analgesic? Surely they don’t mean that.

  5. Hi Dr. Weingart,
    Since propofol is level A recommendation by acep where ketamine in adults is level c, if patients blood pressure is stable and you are doing a quick ortho procedure, should we be using propofol instead of ketamine due to the level of evidence?
    Also, how much O2 are you suggesting for pre-oxygenation and for how long before procedural sedation?
    Thanks 🙂

  6. Paul,
    Although I agree in concept with the recommendations put forward, I was a little dismayed by your apparently flip take on pre-existing fasting guidelines and the idea that you “might” have some added concern for someone who just ate six cheeseburgers before administering procedural sedation. Another point of view on what are essentially different risk tolerances: Aspiration is a low frequency, high acuity event. As Marik’s paper reports (N Engl J Med 2001; 344:665-671) aspiration can be a major cause of airway-associated morbidity and mortality. In particular, “It is also a recognized complication of general anesthesia, occurring in approximately 1 of 3000 operations in which anesthesia is administered and accounting for 10 to 30 percent of all deaths associated with anesthesia.” For the anesthesia community, if one conducts between, say 1000-3000 anesthetics/year, the statistical risk for aspiration is ~1/year, which in the course of a 40-odd year career would be a considerable number of adverse events. Consider that it takes only one of these 40-some patients to go to the ICU intubated, acquire pneumonia, sue you or die, to be a big deal to both you and the patient.
    Emergency events are different (which is why we check the ‘E’ box) and fasting guidelines should never supersede emergently needed patient care. Trauma apparently inhibits gut peristalsis and all emergent patients should be considered ‘full stomachs’. So by all means if your 6-cheeseburger patient has a knife sticking out of him then full-speed ahead. However, if your 6-cheesburger patient with hiatal hernia, obesity and severe GERD with chronic back pain comes to the ED to facilitate an MRI for which he wants to be tubed, then I’d have him wait. Patients in between these extremes should be carefully evaluated on a case by case basis.
    I do agree with you that NPO guidelines are largely arbitrary; what is really needed are hard data demonstrating patient profile at risk for aspiration (depressed LOC, GERD, DM w/ gastroparesis, hiatal hernia, obesity, pregnancy, etc.) and how these conditions quantitatively interact with fasting times. Anyway, nice blog, and thanks for taking my comments ?


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