ED Awareness Study

Interventions

First, ask for post-intubation analgosedation medications when rapid sequence intubation medications are ordered. By doing so reduces your cognitive load and clarifies the plan of care. 

Second, ask for analgosedation goals. Establishing a clear, quantifiable goal among team members and allows the Bedside Warrior a target to reach for. Common goals include the Richmond Agitation Sedation Scale or Behavioural Pain Score. Recognize that if the patient is paralyzed that these analgosedation goals will not be appropriate. When using a long term paralytic, such as rocuronium, or MEGA-DOSE rocuronium, ensure deep sedation and analgesia for the duration of the paralysis.

Third, use a protocol or range of analgosedation doses to help identify what doses of analgosedation the Bedside Warrior can independently titrate. This frees up cognitive load among the prescriber and allows the Bedside Warrior to care for the patient. 

Lastly, consider what the patient needs. For the above patient who was intubated for a decreasing level of consciousness secondary to septic shock, they may benefit from pure sedation alone (though some argue treating with analgesia first). If the patient has suffered traumatic injuries, it may be beneficial to prioritize analgesia and use a sedative in the background. Furthermore, if the paralytic has worn off, the patient has been settled with necessary imaging and medical procedures, it may be reasonable to assess the appropriateness of gradually lightening sedation. Shehabi et al. (2012) found that early light sedation over heavy sedation can reduce delayed extubation and mortality. That being said, it is wise to consider what the patient needs both from a medical perspective but also from a safety perspective; emergency departments are known for being unpredictable and have a much larger ratio of nurse to patient than intensive care units and lightly sedated patients may experience accidental extubations or removal of central venous access lines.