“Procedural Sedation and Analgesia in Children” by Eric Fleegler for OPENPediatrics
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“Procedural Sedation and Analgesia in Children” by Eric Fleegler for OPENPediatrics

September 1, 2019


Procedural Sedation and Analgesia in Children
by Eric Fleegler. Hi. My name is Eric Fleegler. I’m a pediatric emergency medicine physician
here at Boston Children’s Hospital and Co-Director of the Sedation Service. I’m going to talk about procedural sedation
and analgesia in children. I’m going to talk about the background for
pediatric sedation, indications for procedural sedation, systems for maximizing safety, and
the pharmacopeia that’s involved in pediatric sedation. Background of Pediatric Sedation. What constitutes pediatric sedation and analgesia? Well, it’s been defined as the use of sedatives,
analgesics, and/or dissociative agents that are used to relieve anxiety and pain associated
with diagnostic and therapeutic procedures. And the key thing is, this is all done while
maintaining cardiorespiratory function. The most important parts of this is to remember
that this is about relieving anxiety and pain. And so whether you’re just dealing with somebody’s
pain, with their anxiety, or needing a full pediatric procedural sedation, all of the
stuff that we’re going to be talking about is relevant. This is probably the most important picture
that I’ll show during this presentation. What you see is a young child who is getting
ready for a laceration repair. The key thing is to look at the details about
what is going on. First you’ll notice that this patient is calm
and relaxed. He’s engaged in the activities, which is here
looking at a coloring book and pointing out different objects. You’ll see that there is a doctor who is behind
him who is in the process of injecting a numbing medication. Yet, the child does not seem distressed or
anything else. What’s going on here? Well, there are a few things that I would
point out. First, the doctor has gone to lengths to make
sure that he is out of the vision of the child. It’s very easy when doing a laceration repair
be on one side of the child or the other, and they can see you directly. But if you have the opportunity to get directly
behind the child, it is very difficult for them to see you and therefore less anxiety-provoking. Furthermore, the child is looking down. He’s looking at the paper. Somebody is actively engaging the child. This can be accomplished in a number of ways,
whether you’re watching a movie, somebody is having a dialogue, reading a book, but
the goal is to have them look somewhere else. Likewise, if you have a patient who is having
a laceration repair of their chin, you can have somebody hold the book behind them so
the child is forced to look up and away from that type of procedure. Second thing, if you look at the child’s laceration,
you’ll notice that the skin surrounding it is pale. A topical analgesic has been applied that
numbs the skin. So when the doctor goes ahead and starts their
procedure, they’re already at a very comfortable place. But one of the things that I like to do is
have the parent themselves paint the medicine in. You get a really nice saturation of the medicine
into the wound itself, and you desensitize the child from being touched in that area. If their mom and dad has been touching it
for the last 20 minutes, it’s OK for the doctor to touch in that area too. The next thing you’ll notice is that the syringe
has a very small needle. There’s a 30-gauge needle, which is the smallest
that we have. The smaller the needle, the less pain associated
with it. As a matter of fact, with a 30-gauge needle,
often they won’t feel it going in at all, especially after the topical numbing medicine
has been applied. The next thing to know is that the lidocaine
has been buffered. Lidocaine, by nature, is acidic. By putting in a 1 to 10 portion of bicarb,
you can remove the acidity and decrease the burning sensation. In addition, when you’re instilling the medicine,
it’s very important to put it in very slowly. The distension of the tissue can activate
nerve fibers, and by going in slowly you’ll cause less pain as well. Another thing you can do is that you can give
medicine for anti-anxiety purposes. They don’t need to have a complete procedural
sedation with all the other requirements that we’ll discuss further to take off the anxiety
and make this a much more comfortable procedure. Thinking about pain relief, we’ve already
discussed the role of topical medicines. And there are medicines that are designed
for lacerations that are open, medicines such as LET. There are medicines that are designed for
intact skin, such as EMLA and vapocoolant, which are very good for IV placements. There are mucous membrane medications, such
as viscous lidocaine, which can numb up for lacerations that involve the lips. And, of course, there’s ophthalmic preparations
as well. Again, we talked about when you’re using an
injection, to use buffered lidocaine, to use a very small gauge needle, to go very slowly. Another alternative is to apply a block so
you can actually put the medicine away from the wound but manage all of the pain control. If they are in pain, you can use certainly
parenteral medications like ketorolac. You can use oral medications like Tylenol
and Motrin. And you can certainly, if it’s significant
pain, consider right at this point using an opioid such as morphine or fentanyl. One of the things that we’ve been using in
our emergency department with great success are intranasal medications for antianxiety
purposes. And we’ve been introducing intranasal fentanyl,
which takes two to three minutes, and does a wonderful job of controlling pain. The last thing I want to emphasize, the days
of holding patients down so we can get through our procedures should be over. You may get through the procedure during that
one ER visit, but you’re going to take a child and you’re going to make them have a great
anxiety about the medical system in the future. Indications. What are the indications for a procedural
sedation? It’s really any procedure that causes pain
or anxiety. So whether it’s incision and drainage of an
abscess, whether it’s reduction of a fracture or dislocation, whether it’s laceration repair,
lumbar punctures for patients who have great anxiety, foreign body removal can be a great
use of procedural sedation, placing things such as central lines or chest tubes are very
important to use medication to both control pain and anxiety. Some patients may need it for other things
such as PICC line placements or colonoscopies, bone marrow aspirations or thoracenteses. How did procedural sedation get started? If you go back to the 1980s and before that,
the prevailing dogma was that neonates, and even children, really didn’t experience pain
the way that adults felt pain and, therefore, would have procedures that could be quite
painful, including surgery, and were given no pain control. Fortunately, there were doctors who disagreed
with this and did research and demonstrated just that. In a landmark article that came out in 1987
in the New England Journal of Medicine entitled, “Pain and its Effects in the Human Neonate
and Fetus,” these doctors were able to definitively show that neonates do feel pain, which should
be obvious to any parent who has ever seen their newborn child feel the heel prick of
a blood draw or any other type of painful thing. Children clearly feel pain. And we have since this time demonstrated that
not only do young children feel pain, but that the memory of this pain, conscious or
unconscious, lasts with them and can affect them later on in life. Systems for Maximizing Patient Safety. We’re now going to transition and talk about
patient safety systems. We’re going to divide it into three categories. We’ll talk about the pre-sedation assessment. We’re going to talk about preparation for
the sedation, and we’re going to talk about monitoring. In the pre-sedation assessment, the first
thing to consider is the past medical history. What type of airway reactivity do they have? Do they have an active URI or a history of
asthma? Do they have a history of reflux? Are there issues related to obstructive sleep
apnea, with cardiopulmonary disease, hepatic or renal disorders which may affect the metabolism
of the medications? And consideration of allergies and adverse
reactions. All of these are going to go into considerations
about what medications are going to be appropriate, and, most importantly, is this patient a good
candidate for a procedural sedation? The common classification that is used to
decide whether a patient is a good candidate for sedation is known as the ASA physical
status classification. This divides patients into five categories. One is a normal healthy patient. Two is a patient who has a mild systemic disease. They have a systemic disease, which can include
things like diabetes or asthma, but it is well controlled. Three is a patient with severe systemic disease. They may have a disease that is like cystic
fibrosis, and they’re having difficulty controlling their respiratory function associated with
it. Four is a patient with a severe systemic disease
that is considered a constant threat to life. And five is a patient who is moribund, who
is not expected to survive without the procedure. The patients that we’re going to focus on
are in category 1 and 2. What we know is that the majority of patients
who show up in our emergency department who require a procedural sedation are going to
be either ASA 1 or ASA 2. They’re going to be patients who are appropriate
for procedural sedations. There are going to be a smaller subset of
patients who are ASA 3. They have significant systemic diseases, and
you’re going to have to make a judgment about whether they are appropriate for procedural
sedation. What we know about these ASA classes is that
as your ASA class goes up, your risk of having an adverse event increases. In one study, they were able to demonstrate
that the risk of an adverse event was about 9% for ASA 1 classifications. Patients who fit ASA 2 were around 23%. It’s important when looking at this data that
often what is considered an adverse event is hypoxia, something that can be typically
avoided with proper preoxygenation, which we’ll talk about in a little bit. Your physical exam will give you other important
key details to decide whether the patient is a good candidate and what considerations
you need to have in mind. Related to the airway, you want to look at
evidence of a short neck, macroglossia, or an enlarged tongue, micrognathia, or a small
jaw, such as a patient who has Pierre Robin, whether they have obstructive tonsillitis
or limited neck mobility. The important thing to realize is depending
on the agent that you’re using, you’re going to change the dynamics of their airway. And if they are already at a level where they
may be slightly compromised, it can certainly increase. Fasting status is another area to consider. In the world of general anesthesia, the fasting
status is very important with patients typically asked to not have any food or drink after
midnight the night before a procedure. Those are patients who are typically having
elective procedures. When a patient shows up in the emergency department,
these are not elective but are typically considered emergent or urgent procedures and so we look
at the data slightly differently. So you need to consider the degree of urgency. Is this a procedure that is considered emergent,
urgent, or just elective? And related to this, we need to think about
the medications that we’re going to use. Are we going to use a medication like ketamine,
which has minimal blunting of the airway? Or are we going to use other medications like
fentanyl and Versed or propofol, which will affect both the airway and respiratory patterns? When we look at the general anesthesia literature,
the first thing to keep in mind is that the process that the patients are going through
is very different than those who are undergoing procedural sedation. First, in the general anesthesia world, they’re
often using inhalants which are both noxious and cause emesis. The second thing is that they’re performing
laryngoscopy. They’re taking a metal blade, sticking it
in the back of the throat, and then taking a plastic tube and sticking that in their
airway. And those are all procedures that increase
the risk of a patient having emesis. Likewise, when the endotracheal tube is removed,
that is also a procedure that can cause emesis. When we look at the general anesthesia literature,
we can see that the overall risk of aspiration is about 1 in 2,500. However, when we look at the ASA 1 classification
patients, the overall risk is closer to 1 in 8,000. In the world of pediatric procedural sedation,
which does not involve laryngoscopy, we see that the numbers are actually quite different. Of the many thousands of patients that have
been studied from procedural sedation, there is actually only a history of two aspirations
that have been reported in the literature. And both of those patients had actually fasted
prior to the sedation. So after the review of thousands of patients
across multiple emergency departments in the United States, the consensus is that procedural
sedation may be safely administered to pediatric patients in the emergency department who have
had recent oral intake. Discretion, of course, is the better part
of valor. If you feel a patient has just eaten and comes
in and requires a procedural sedation, waiting some time period, whether it’s an hour or
two, may be prudent. However, there is no specific guidelines that
are given. The next thing that we’re going to talk about
is preparation for the procedural sedation. The main events that you are concerned about
is respiratory depression, apnea, whether it’s obstructive or central, and hypoxia. And we’re going to talk about how to prepare
for these events and, more importantly, how to avoid them. The other type of events that are important
to prepare for are emesis and having something available for suction, as well as hypotension,
although this is a relatively rare event in pediatric procedural sedation. Having the right equipment is very important. The type of equipment that you want to have
available and ready to use includes a bag mask ventilation system, oxygen, which can
be administered via a face mask, nasal cannula or blow-by– although I’ll argue for using
a face mask in the moment– and using that oxygen both for preoxygenation and supplemental
oxygen during the actual procedure, having end-tidal CO2 monitoring, which we’ll talk
about more in a moment, and also having suction available should the patient vomit; and also
having IV fluids available should those be necessary. There have been a number of studies that have
been done that help us understand the value of preoxygenation. One of the first studies that was done was
in 20 healthy adults who were undergoing a surgical procedure, and they were given a
dose of succinylcholine, or other paralytic agent, and they watched to see how far they
would desaturate in one minute. So, basically, taking a patient who was healthy–
these patients had a baseline saturation around 96%– and for one minute they did not breathe
at all. And what they found is that on average they
dropped their saturations to 85%. And it’s important to remember these are patients
who had been breathing room air, which is only 21% oxygen. In this study, they had some of the patients
take three maximal inhalations, breathing deeply in and out three times, they had some
of the patients wear a tight-fitting face mask with an oxygen reservoir, they had some
patients wear a loose face mask, and they had some patients who received no preoxygenation. Once anesthesia was induced, they found that
the patients who had had no preoxygenation performed, that they desaturated down to a
little bit above 90% by two minutes. However, in the patients who had either the
tight face mask or had done the three maximal inhalations, by three minutes they were still
satting 96% or higher, representing the notion that if you have preoxygenated you have a
lot longer time before somebody starts to have any significant desaturation. This is very important should a patient have
an episode of laryngospasm or apnea, that if they are preoxygenated your time as a physician
to have an intervention is much greater than those patients who are not preoxygenated. Another study, very relevant for pediatrics,
looked at different age groups of children to see how long it would take for them to
desaturate. All of these patients wore tight-fitting face
masks in advance so they’d have the nitrogen wash out and essentially had 100% oxygen available
to them. In the children who are in the youngest age
group, two days to six months, and on average it took 96 seconds for them to reach a desaturation
of 90%. The older age group, who is the 11 to 18-year-old,
the average time was 382 seconds. In other words, for adolescents, if they have
been properly preoxygenated, you may have six minutes or longer before they reach a
significant desaturation, which means should they have an event that you have a much longer
time to respond to it appropriately. In general, the time difference from a patient
who has an event who had prior to that just been breathing room air verse a patient who
has been properly preoxygenated, is a 3 to 1 time difference. So if a patient was going to desaturate from
room air in one minute, if they’ve been preoxygenated you may have up to three minutes or more. Now we’re going to take a moment and talk
about monitoring. The most important thing that you can do,
of course, is to engage with your patient and have direct monitoring them, watch how
they’re doing. The second thing is mechanical monitoring,
and this involves monitoring in three different ways. You have ventilation monitoring, which is
performed by capnography. You have oxygenation monitoring, which is
typically done by pulse oximetry. And you have hemodynamics, which is by monitoring
the heart rate and the blood pressure. I want to take a moment and look at this patient’s
monitoring record. Key things to note, if you look at the top
line, you’ll see a normal EKG rhythm. There’s no change. There’s no change in the rate. There’s no change in anything else to indicate
there’s a problem. The second middle line looks at the oxygen
saturation. It’s a normal waveform, everything looks fine. The bottom line immediately flatlines and
stays there. That’s our capnography line. What that indicates is that this patient is
having some sort of event where they are no longer having any ventilation. Why is this important? Well, we’ve just spent all this time looking
at what happens to oxygenation during an event. Whether you have a minute or three minutes
or six minutes depending on your preoxygenation status, looking at the pulse oximeter does
not tell you whether a patient is breathing. However, a capnography in one second will
immediately identify whether an event has occurred. And we’ll go through that in detail. So what does capnography tell us? Well, first you have to realize the patient
typically has a nasal cannula in place which is measuring the carbon dioxide as it is breathed
off. When a patient takes a breath in, the monitor
will say nothing is happening because no CO2 is coming out. As the patient begins to exhale, you’ll see
the monitor begins to rise and it goes into this very typical waveform where you have
a sharp slope up, a plateau phase, and then it comes off as the patient gets ready to
take in their next breath. This is very important for a number of reasons. As we’ve just shown in the previous slide,
if it flatlines we know that there is no ventilation occurring, and it’s your job to figure out
what’s going on with your patient. The second thing is for just monitoring the
level of sedation, and we’ll go through a number of those graphs to show you how this
works. The first waveform that is demonstrated is
a normal waveform that looks like the one that I’ve shown you on the previous slides. The second waveform pattern is hyperventilation. You can see that the patient is breathing
quickly and that they’re blowing out less CO2 by the height of the waveform. The next waveform represents bradypneic hypoventilation. This is what happens when you have an opioid
on board. You begin to breathe slower, your ventilation
pattern slows down, and you retain a little bit of CO2 during this process. The next one is hypopneic hypoventilation,
which typically happens with sedative hypnotics such as Versed or midazolam. Finally, we have apnea. And as you can see at this point, you cannot
distinguish apnea from obstruction from laryngospasm, but we’ll talk about that in a moment. The important take-home message is that capnography
provides early warning of potential or impending airway and respiratory adverse events that
is wholly independent of the presence, absence, or the quantity of supplemental oxygen. To put it succinctly, there was a time when
many people felt that you should not preoxygenate a patient prior to a procedural sedation,
because if they have an event you want the hypoxia to indicate that this is the time
to intervene. Our goal is to prevent that. We can preoxygenate our patients, avoid hypoxia,
and intervene well in advance of any adverse events occurring. The next thing I want to talk about is differentiating
central apnea versus obstruction. So if your capnography goes flat, the first
thing you need to decide is this patient having central apnea or is there obstruction? Well, what do you do? You look at the chest. If the chest wall is not moving, by definition
your patient has central apnea. If the chest wall is moving, indicating that
they have respiratory effort, but you have a flat capnography reading, that is an indication
that you have some sort of obstruction. The next thing you want to check is make sure
your equipment is working. Has the end-tidal CO2 monitoring equipment
come out of the nose? Are there mucus that is blocking it? Has it become disconnected from the wall? Is there some other reason why this has gone
flat? If the equipment seems to be in working order
and it is flat, the next question is, is this obstructive apnea or is this laryngospasm? And the way to differentiate that is with
your airway maneuver. So by realigning the airway, doing a little
bit of jaw thrust to help the patient along, does the patient begin to breathe? If they do begin to breathe then what you
have had is obstructive apnea, and you need to help the patient with their airway alignment. If they do not breathe with proper airway
alignment then what you have is laryngospasm. That despite the fact the patient is trying
to breathe and has an airway that is properly aligned, they’re trying to fight against closed
vocal cords. Pharmacopeia. Now we’re going to talk about the pharmacopeia
for using procedural sedation. There are five categories of medications that
we’re going to discuss. We’ll talk about sedative hypnotics. We’ll talk about analgesics. We’ll talk about dissociative medications,
inhalation medications, and, of course, reversal medications as well. Looking at the sedative hypnotics, there are
a number of medications that are available to us. Classically, chloral hydrate was available
as a medication that can be given whether PO or PR. Unfortunately, its availability is now much
more limited as the company that used to make it no longer produces it. Midazolam is a wonderful medication that’s
in the benzodiazepine family that can be given PO, intranasal, or via the IV. The PO route, which is typically given as
half to 1 milligram per kilo, we typically use 3/4 of a milligram per kilogram up to
15 milligrams, has wonderful effects on patients. It takes about 20 minutes to kick in and will
probably help 85% to 90% of patients relax. The intranasal route, where we use a half
a milligram per kilo up to 10 milligrams, takes about two to three minutes to work,
and I would say the efficacy of that is probably in the 90% to 95% range. The IV route, 0.1 milligram per kilogram up
to 2 milligrams, typically takes one to two minutes to take effect. Diazepam is certainly available as well. Pentobarbital works very well for patients
who require sedation, but are not going to have a painful procedure, such as a CT. In those cases, we’re typically giving 1 to
2 milligrams per kilo as a starting dose and then adding up to 6 milligrams per kilo to
get the patient to a nice relaxed state. Etomidate can be used for procedural sedation. It works quite effectively, 0.1 to 0.3 milligrams
per kilo. But the important thing to realize, as fast
as it comes on is as fast as it comes off. So you’ll typically only have two or three
minutes for your procedure. Propofol is a wonderful sedative, typically
given as 1 milligram per kilo for older patients, but needs to be given as 1 and 1/2 to even
2 milligrams per kilo for younger patients to achieve sedation. It’s important to remember with propofol that
there is no pain control. And if you’re going to have a painful procedure,
even though you can essentially make the patient unconscious, it’s very important to use analgesics. As far as the analgesics, the two most important
analgesics that we use in procedural sedation are fentanyl and morphine. Fentanyl is wonderful in terms of its fast
onset and its fast offset. Morphine has much longer pain control, but
also it’s important to remember it may take five to 10 minutes for the actual pain control
to kick in. So if you have a patient who’s in severe pain
right away, fentanyl is a good starting place, 1 to 2 micrograms per kilogram, to get their
pain under control. And then consider using morphine afterwards. If you’re doing a Versed-fentanyl sedation,
it’s important to remember how those two medications will affect the patient. With the Versed, what you will find is that
the patient will become unconscious before they become apneic. With fentanyl, it’s the opposite. As you give more of the opioid, they will
become apneic before they’re unconscious. What does this mean? Well, it means if you’ve given enough of the
fentanyl and they reach a point where they’re having some apnea, you can actually touch
the patient and ask them to take a deep breath and they will. However, if they become apneic in the context
of using your Versed, they’re unconscious before they’re apneic so you’re going to have
to control their airway. So as we’re doing a Versed-fentanyl sedation,
typically where I like to start is with my Versed, 2 milligrams, my fentanyl, 1 to 2
mcg per kilo, and then I’ll give another 1, 2, 3, even 4 mcg per kilo of fentanyl to try
to get good pain control. If there’s still an anxiety component, I’ll
give more Versed and then come back to fentanyl as my main drug for trying to get them under
control. The next class of medication is the dissociative
medication of ketamine. Ketamine has been one of the most wonderful
medications we’ve introduced for pediatric sedation. It’s a very well-tolerated medication. It is virtually universally effective, and
it is essentially very easy to use. A starting dose of 1 to 2 milligrams per kilo
will bring a patient into a dissociative state. It’s very important to talk with the family
in advance of the procedural sedation so they know what to expect, that the patient will
have a horizontal nystagmus and their eyes will dance back and forth, that while some
patients are quiet, some patients are not. They may verbalize by moaning. They may respond to what we do by moaning
louder. Some kids will actually talk out loud. Just let the families know in advance that
there may be some verbalization so they’re not surprised during these particular events. Ketamine is not a titratable drug. What you find is that the patient will dissociate
and need another dose of the medication, typically a half a milligram per kilo, every five to
six minutes after that. Once a patient has had two or three doses,
you may be able to go longer and just watch the patient to see when they need more medication. Ketamine also has excellent pain control. By using just a quarter milligram per kilo,
you can control pain without inducing dissociation. A couple of the concerns associated with ketamine
is the risk of laryngospasm, which is estimated to be about 1 in 2,000. A couple of the things that we believe are
associated with laryngospasm is the use of intramuscular ketamine, where you’re typically
giving 4 to 5 milligrams per kilo, which is very worthwhile for a patient who does not
have an IV. But you need to understand that there is a
risk associated with that. They’re also at an increased risk of laryngospasm
if they have active asthma, especially patients who are using rescue medications such as albuterol
on a regular basis or if they have an active URI. These are all events that you should consider
whether you want to use a different agent. The other thing to know about ketamine is
that it is a sialogogue. It will cause the patient to salivate more. It used to be that we’d use medications like
atropine to dry up their mouth. But, in general, it’s been felt not to have
any effect on the sedation, and those medications are typically no longer used. The one case where I will consider using atropine
is if I’m doing a repair inside of the mouth, such as a tongue laceration. In that event, you want to make sure to give
your atropine at least 10 to 15 minutes in advance so that you have the antisialogogue
effect. The last thing to be aware of about ketamine
is that there are some patients who can have what’s known as an emergence response. They may wake up and it looks like they’re
having a nightmare. This is typically uncommon in the pediatric
world, but is reported to be more common in the adult world. Typically giving Versed either at the time
when they’re waking up or if they have the actual response will blunt the emergence response. Nitrous oxide is a wonderful medication to
use for procedures as well. It’s easy to apply. You do not need an IV. It has antianxiety properties, it has amnestic
properties, and it does have some analgesia control as well. Typically when giving it, you want to be administering
it 50% to 70%. I have personally found that 70% is more effective,
and this is also demonstrated in the literature. This can be used for all sorts of procedures. One of the very common ones to use it for
is incision and drainage of abscesses. Even if the patient cries out a little bit
during the procedure, the amnestic effects of the nitrous typically make it so that the
procedure itself is very successful for them. It can also be used in fracture reductions
with lidocaine used as a hematoma block. Finally are the reversal drugs. It’s important to remember that two of the
medications that we’re talking about, the opioids and the benzodiazepines, can be reversed
with naloxone or flumazenil. Typically, the goal is not to do a complete
reversal of sedation, which can induce a great deal of pain, but rather just give them enough
of the medication so that they begin to breathe again. How to break a laryngospasm. Laryngospasm is one of the events that should
give you the most pause when thinking about your procedural sedation. There are six approaches that can be used
for breaking laryngospasm. The first is the simplest. You can wait. Most laryngospasm will break on its own in
30 to 60 seconds. If you have a patient who has been properly
preoxygenated, they may never drop their oxygenation below 100% during that time. The second thing to do is using positive pressure. Putting a bag mask on and giving one to two
breaths or just using CPAP, which can often break laryngospasm. The third way is using a complete dose of
succinylcholine, typically 1 milligram per kilo. This will paralyze the patient, their airway
will open, and you can now help breathe for them using the bag and mask. The fourth option is using low-dose succinylcholine. Typically, 0.1 to 0.2 milligrams per kilo,
which will help paralyze the vocal cords and cause them to open up but will not paralyze
the diaphragm. The fifth option is taking the patient deeper. By using propofol or Versed, you can actually
bring the patient to a deeper level of sedation, which will cause the vocal cords to open up. You cannot give additional ketamine to bring
a patient deeper into their sedation. The sixth option, which you should be aware
of, is known as the laryngospasm notch. This is a maneuver that anesthesiologists
use to break laryngospasm in a patient. I’m going to demonstrate that for you now. Take your thumbs and flick the bottom of your
ears. Anteriorly, you should feel the mandible. Posteriorly, you should feel the condyle of
the skull. What you want to do, using your thumbs, is
do a jaw thrust lifting the jaw forward, but at the same time press inwards towards the
brainstem. If you’re doing that with me now, you should
be feeling a little bit of pain and a little bit of nausea. That indicates that you’re in the right location. It is not entirely clear why this mechanism
works, but it is known to be very effective in the world of anesthesia. Thank you very much, and good luck with your
procedural sedations. Please help us improve the content by providing
us with some feedback.

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