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Most popular medical Questions
How is conscious sedation best managed in children?There is no single best method for the conscious sedation of pediatric patients for diagnostic, radiologic, or minor surgical procedures. Surveys indicate that a wide variety of approaches are used in emergency rooms and radiology suites, including opioids (morphine, meperidine, fentanyl, butorphanol), benzodiazepines (diazepam, midazolam), barbiturates (pentobarbital, thiopental), and nonbarbiturate anesthetic/analgesic agents (ketamine). Although conscious sedation, by definition, is a state of medically controlled depressed consciousness with a patent airway, maintained protective reflexes, and appropriate responses to stimulation on verbal command, the potential for rapidly developing problems should be anticipated. These can include hypoventilation, apnea, airway obstruction, and cardiorespiratory collapse. Consequently, pharmacologic agents used for conscious sedation should be administered under supervised conditions and in the presence of competent personnel who are capable of resuscitation, ongoing monitoring (especially pulse oximetry), and sufficient equipment for resuscitation (e.g, positive-pressure oxygen delivery system, suction apparatus). As a rule, few office settings are appropriate for conscious sedation.
Are fixed and dilated pupils a contraindication to resuscitation for a patient in cardiac arrest?
No. Pupillary dilatation begins 15 seconds after cardiac arrest and is complete after approximately 1 minute and 45 seconds. It may only be a sign of transient hypoxia. The only absolute contraindications to resuscitation are rigor mortis, corneal clouding, dependent lividity, and decapitation.
What is the Sellick maneuver?
The Sellick maneuver is the application of pressure on the cricoid ring to prevent aspiration. Cricoid pressure should be initiated during preparation for intubation from the time sedation is administered or bag-mask ventilation is initiated until the airway is demonstrated to be secured.
What is the role of high-dose epinephrine in pediatric resuscitations?
Animal studies, anecdotal reports, and small clinical trials have shown that the use of epinephrine in higher doses (100-200 times the normal dose) may facilitate the return of spontaneous circulation better than the standard lower dose. However, evidence gained from larger prospective adult studies and a recent randomized clinical trial in children have demonstrated no benefit and possible adverse effects. The American Heart Association currently recommends that, after the standard first dose of epinephrine (0.01 mg/kg of a 1:10,000 solution), subsequent higher doses (0.1-0.2 mg/kg of a 1:1,000 solution) may be considered an acceptable alternative to standard doses.
How effective is intratracheal epinephrine?
Epinephrine is poorly absorbed from the lung; if available, intraosseous or intravenous administration is preferable. If epinephrine is to be given via an endotracheal tube in an acute setting, it should be mixed with 1-3 mL of normal saline and instilled with a catheter or feeding tube beyond the end of the endotracheal tube to facilitate dispersal. The ideal endotracheal dose is unclear, but because of the poor absorption, higher initial doses (0.1-0.2 mg/kg of a 1:1,000 solution) should be used.
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