295:. It takes 40 seconds for the effects of propofol to kick in, and effects last six minutes. Propofol has both sedative and amnestic effects, but provides no analgesia. Adverse effects to look out for include hypotension (low blood pressure) and respiratory depression, manifested as mild drops in oxygen saturation levels. Propofol is also painful when administered intravenously, therefore, lidocaine is commonly used as a pretreatment to help decrease the pain associated with administering propofol. Additionally, it has antiemetic properties that are also useful in these types of procedures.
168:
patient will not respond appropriately to medications, as is the case with older patients or those with medical comorbidities, but that if there is a complication, it will be more difficult for the physician to protect the patient's airway and save them from complications. It is generally advised to consider alternatives to PSA if the patient is assessed to have a difficult airway. Measures such as reducing starting dose, giving drugs slowly, and redosing less frequently will not change risk of PSA complications in a patient with a difficult airway.
335:
is that it does not compromise the patient's airway protective reflexes, keeps the upper airway muscle tone, and allows for spontaneous breathing. A common side effect of ketamine is emergence reactions. The patient may become disoriented, entranced, or experience hallucinations. Although usually benign, these reactions may also be frightening for the patient. Other reported complications include fast heart rate, elevated blood pressure, nausea, vomiting, and laryngospasm, but usually in the context of oropharyngeal manipulation.
469:
2178:
1732:
456:
there is evidence to suggest that fasting is not required to prevent aspiration in most cases. However, when possible, fasting is still preferred. For most agents, the patient should have had nothing to eat for at least six hours. Clear fluids can be allowed up to two hours before the procedure. One can consider using ketamine if there is a high risk of aspiration, given ketamine does not compromise protective airway reflexes. However, in the
2190:
1742:
405:. This system starts at ASA 1 which is a healthy individual and escalates to ASA 6 which is a brain dead individual. It is safe to perform sedation in the emergency room on patients who are ASA 1 or 2. If the patient is ASA 3 or 4 additional resources might be needed, such as a person with more training in procedural sedation, an anesthesiologist. Furthermore, before a qualified anesthesia professional performs PSA, an
323:
so it was commonly used with fentanyl for effective PSA prior to propofol and etomidate. Midazolam collects in the body's fatty tissues, so a possible complication includes prolonged sedation. As a result, the elderly, the obese, and those with kidney or liver disease are more vulnerable to prolonged sedation with midazolam. Respiratory depression is also associated with midazolam when given in high doses.
74:) is a technique in which a sedating/dissociative medication is given, usually along with an analgesic medication, in order to perform non-surgical procedures on a patient. The overall goal is to induce a decreased level of consciousness while maintaining the patient's ability to breathe on their own. Airway protective reflexes are not compromised by this process and therefore
159:
respiratory depression. Generally, patients with ASA Class III or greater are more likely to develop such complications. Similar to previously described, consider starting with a smaller dose, giving the medication slowly, and giving repeat doses of the medications less often to decrease risk of complications associated with comorbidities.
438:
cuff, and an end tidal carbon dioxide monitor. Deep sedation resulting in respiratory depression can cause some quantitative changes to these monitors, hence why it is important to monitor them. One of the first things that can be seen is a rise in end tidal carbon dioxide. This happens well before a drop in
437:
It is important to keep track of the patient's vital signs, especially oxygen saturation and blood pressure when giving PSA to ensure adequate cardiopulmonary function. Monitors are also useful for PSA safety. These include cardiac monitoring such as electrocardiogram, pulse oximetry, blood pressure
412:
Airway assessment is one of the most important parts of the physical exam when done as part of the pre-procedure work-up. There is always a risk that a patient is sedated more heavily than intended and consequently require some sort of airway intervention. Therefore, the anesthetist should perform an
158:
Patients with serious medical conditions are at greater chance for negative side effects after receiving PSA. Examples of comorbidities include heart failure, COPD, neuromuscular disease. Use the ASA Classification to predict a patient's risk for serious complications from PSA, such as hypotension or
322:
that acts by stimulating inhibitory GABA receptors. Effects are seen within 2–5 minutes, and last 30–60 minutes. Its main effect is anxiolysis, helping to reduce feelings of anxiety, and amnestic effects, helping the patient to forget memories associated with the procedure. It provides no analgesia,
306:
is an imidazole derivative, commonly used for the induction of general anesthesia. Effects kick in almost immediately, within 5–15 seconds, and last 5–15 minutes. Etomidate carries sedative effects only; it does not provide pain relief. Side effects of etomidate include myoclonus (involuntary muscle
381:
is a synthetic opioid, 75-125 times stronger than morphine, that acts by activating opioid receptors in the nervous system. Its effects begin in 2–3 minutes, and last 30–60 minutes. Fentanyl provides analgesia and sedative properties; it does not have any amnestic effects. It was commonly used with
334:
is a dissociative sedative, meaning it takes the patient into a dream-like level of consciousness. Effects occur within 30 seconds, and last 5–20 minutes. Ketamine has sedative, analgesic, and amnestic properties, but most of its uses today are focused on analgesia. Some of the benefits of ketamine
149:
Although there is no age limit for PSA, the elderly have a greater chance of complications such as longer than intended sedation time, increased sensitivity to medications, adverse effects of medications, and higher than expected drug levels due to difficulty clearing the drugs. To help reduce risk
176:
While procedural sedation is often used to avoid airway intervention, sedation is a continuum and a patient can easily slip into a deeper state. For this reason, a physician who is performing PSA should be prepared to care for a patient at least one level of sedation greater than that intended. In
455:
There is a theoretical concern that performing PSA on a patient with food in their stomach can increase the risk of aspiration. Currently, there is no evidence to suggest clinically significant risk of aspiration of stomach contents if performing PSA on a patient with recent food intake. In fact,
506:
agent used. Some agents are more likely to cause complications than others, but all sedative agents can cause complications if not used properly. Titration is a common technique used to reduce these complications. Additionally, some agents have antagonists, reversal agents, that can be used to
167:
An airway is assessed by the patient's ability or the physician's ability to oxygenate (provide oxygen) or ventilate (exhale carbon dioxide). Examples of a difficult airway include a thick neck/obese patient, head and neck structural abnormalities, and lung disease. The problem is not that the
507:
reverse the effects or reduce the amount of sedation. Additionally, a person is assigned to monitor the status of the patient and should be able to recognize the complications of PSA. Their ability to alert others and respond accordingly reduces complications.
346:
is a more recent agent used in this process. It is an alpha-2 adrenergic agonist that causes sedation and does have some analgesic properties. It has minimal effect on respiratory function. It will affect cardiac function as the dose increases.
307:
jerking) and respiratory depression. One of the major benefits of etomidate is that it does not cause cardiovascular or respiratory instability. This makes it a potentially more preferable choice for those with already lower blood pressure.
446:
or other airway interventions to stabilize the patient. Visual assessment is also an important part of PSA. To quantify the level of consciousness, the physician uses different levels of stimulation and observes the patient's response.
1636:
668:
Hohl, Corinne Michèle; Sadatsafavi, Mohsen; Nosyk, Bohdan; Anis, Aslam Hayat (16 January 2008). "Safety and
Clinical Effectiveness of Midazolam versus Propofol for Procedural Sedation in the Emergency Department: A Systematic Review".
640:
388:, as stated above, has both analgesic and sedative properties and can be useful as an alternative analgesic agent; small doses of ketamine have been found to be safer than fentanyl when used in combination with propofol.
150:
of complications, consider a less aggressive approach to PSA, including starting with a smaller dose than given for non-elderly patients, giving the medication slowly, giving repeat doses of the medications less often.
476:
There are a few criteria for discharging a patient who has undergone procedural sedation. The recovery time for a patient to be ready for discharge varies but is typically 60–120 minutes. The criteria are as follows:
396:
Any patient undergoing anaesthesia must be pre-assessed for risk using a classification system, such as the one devised by the
American Society of Anesthesiologists (ASA). In addition to pre-assessment, the patients
644:
141:
There are no absolute reasons that immediately disqualify a patient from receiving PSA. However, a patient's age, medical comorbidities, or evidence of a difficult airway are important considerations.
271:
There is another type of sedation known as dissociative sedation. It causes profound amnesia but allows spontaneous respiration, cardiopulmonary stability, and airway reflexes are still intact.
1682:
382:
midazolam for effective PSA prior to propofol and etomidate. The major complication of fentanyl is respiratory depression, which can be made worse when given with other sedative agents.
460:
setting, PSA is usually administered without waiting the full six hours, unless there is clear evidence that the patient may not be able to maintain his/her airway on their own.
1672:
177:
order to do this, a practitioner must be able to recognize the level of sedation and understand the increasing cardiopulmonary risk that is associated with deeper sedation.
1483:
1687:
502:
PSA can cause several complications. These include allergic reactions, over-sedation, respiratory depression, and hemodynamic effects. These typically depend on the
1717:
421:. If the patient is deemed to have a difficult airway, there should be adequate resources in case airway intervention is required. These include things like a
1702:
622:
2014:
493:
In a special population patient, such as a very young or mentally disabled patient, they should be about as responsive as they were pre-sedation.
2018:
86:
This technique is often used in the emergency department for the performance of painful or uncomfortable procedures. Common purposes include:
2034:
1778:
1364:
2140:
2029:
1667:
789:
Miner, James R.; Burton, John H. (August 2007). "Clinical
Practice Advisory: Emergency Department Procedural Sedation With Propofol".
2006:
1712:
1319:
1235:
402:
2024:
1064:
2044:
1697:
2054:
1894:
1615:
742:"Subdissociative-dose Ketamine versus Fentanyl for Analgesia during Propofol Procedural Sedation: A Randomized Clinical Trial"
715:
Miller, Ronald D.; Eriksson, Lars I.; Fleisher, Lee A.; Wiener-Kronish, Jeanine P.; Cohen, Neal H.; Young, William L. (2014).
1677:
724:
590:
2049:
1866:
991:
2134:
2064:
2039:
1707:
1518:
1283:
1101:
291:
is a non-barbiturate derivative that is thought to act by stimulating inhibitory GABA receptors and blocking excitatory
1595:
1394:
371:. They will cause some dose dependent cardiopulmonary suppression. They have addictive properties and have led to the
1605:
1513:
132:
and certain imaging or minor procedures where the patient is unable (or unwilling) to keep still—especially children
1889:
1831:
1771:
1468:
1146:
740:
Messenger, David W.; Murray, Heather E.; Dungey, Paul E.; van Vlymen, Janet; Sivilotti, Marco L.A. (October 2008).
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2068:
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2110:
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1651:
1298:
127:
2193:
2098:
2081:
1641:
1534:
1153:
1047:
375:. When used for procedural sedation these are started at low dose then titrated to reach the desired effect.
515:
Some resistance to sedation techniques used outside the operating room by non-anesthetists has been voiced.
2122:
2104:
2087:
1836:
1189:
2220:
2181:
1764:
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1204:
1806:
1585:
1447:
1359:
78:
is not required. PSA is commonly used in the emergency department, in addition to the operating room.
1493:
1199:
544:
Walls, Ron M., MD; Hockberger, Robert S., MD; Gausche-Hill, Marianne, MD, FACEP, FAAP, FAEMS (2018).
1554:
1508:
1374:
1265:
1245:
984:
641:"Continuum of Depth of Sedation; Definition of General Anesthesia and Levels of Sedation/Analgesia"
27:
1735:
1559:
1549:
1503:
1194:
1184:
1106:
1069:
401:
should be taken with special attention to history of anaesthesia. These things contribute to the
1821:
1610:
1498:
898:
Krauss, Baruch; Green, Steven M (March 2006). "Procedural sedation and analgesia in children".
368:
2162:
1933:
1906:
1745:
1432:
1121:
1086:
484:
The patient should be easy to arouse and have intact reflexes such as a gag and cough reflex.
426:
364:
1939:
1816:
1801:
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1407:
1384:
1288:
457:
418:
8:
2215:
1918:
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1402:
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1250:
1141:
1131:
1096:
1091:
1035:
1018:
977:
443:
75:
180:
The
American Society of Anesthesiologists defines the continuum of sedation as follows:
2092:
1996:
1787:
1488:
1344:
1214:
1126:
1111:
1074:
1059:
1052:
923:
866:"BestBets: Does the time of fasting affect complication rates during ketamine sedation"
771:
911:
802:
1991:
1826:
1811:
1590:
1417:
1412:
1303:
1230:
1136:
958:
915:
847:
806:
763:
758:
741:
720:
686:
682:
442:. Depending on the how substantial the respiratory depression, the physician can use
439:
106:
927:
826:"Pulmonary aspiration during procedural sedation: a comprehensive systematic review"
1580:
1369:
1329:
1042:
907:
837:
798:
775:
753:
678:
414:
406:
47:
1334:
1209:
1169:
398:
372:
343:
33:
969:
481:
Patient must be stable from a cardiovascular standpoint and have an open airway.
1923:
1885:
1874:
1442:
1437:
1349:
1004:
468:
319:
292:
2209:
1851:
1564:
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1354:
1179:
487:
They should be approaching their baseline in terms of talking and sitting up.
118:
1846:
1427:
1255:
1240:
962:
946:
919:
865:
851:
810:
767:
690:
558:
1981:
1945:
1631:
1339:
1293:
1081:
842:
825:
546:
Rosen's
Emergency Medicine: Concepts and Clinical Practice. Ninth Edition
41:
57:
2157:
1966:
1880:
1379:
1174:
1000:
422:
367:(MOR) in addition to various other opioid receptors located within the
2076:
1961:
1928:
1756:
315:
303:
112:
100:
94:
714:
1986:
1976:
1971:
1324:
1023:
643:. American Society of Anesthesiologists (ASA). 2009. Archived from
503:
385:
378:
331:
288:
272:
360:
1856:
739:
1673:
American
Society of Anesthesia Technologists & Technicians
275:
is a commonly used drug that can cause this type of sedation.
1637:
Helsinki
Declaration for Patient Safety in Anaesthesiology
1484:
Effects of early-life exposures to anesthesia on the brain
591:"Procedural sedation in adults outside the operating room"
1688:
710:
708:
706:
704:
702:
700:
667:
1718:
European
Society of Anaesthesiology and Intensive Care
697:
824:
Green, S.M.; Mason, K.P.; Krauss, B.S. (March 2017).
627:
CURRENT Diagnosis & Treatment: Emergency
Medicine
1703:
Australian and New Zealand College of Anaesthetists
16:Sedation and analgesia for non-surgical procedures
999:
944:
559:"BestBets: Procedural Sedation for Cardioversion"
363:are used to suppress pain by acting primarily on
208:Purposeful response to verbal or tactile stimulus
2207:
823:
2015:International Federation for Emergency Medicine
947:"Procedural sedation in the acute care setting"
2019:International Conference on Emergency Medicine
945:Brown TB, Lovato LM, Parker D (January 2005).
1772:
985:
882:
2035:Canadian Association of Emergency Physicians
1365:Intraoperative neurophysiological monitoring
472:Patient being monitored following anesthesia
2141:Care of the Critically Ill Surgical Patient
2030:Australasian College for Emergency Medicine
897:
788:
663:
661:
1779:
1765:
1668:American Association of Nurse Anesthetists
992:
978:
211:Purposeful to repeated or painful stimulus
1713:International Anesthesia Research Society
1320:ASA physical status classification system
841:
757:
403:ASA physical status classification system
2025:American College of Emergency Physicians
1065:Combined spinal and epidural anaesthesia
658:
490:The patient should be properly hydrated.
467:
432:
2045:European Society for Emergency Medicine
1698:Association of Veterinary Anaesthetists
883:Berger, Jessica; Koszela, Keri (2018).
171:
2208:
2055:American Academy of Emergency Medicine
1786:
425:, fiberscope optic, and an intubating
214:Unarousable, even to painful stimulus
1760:
1678:American Society of Anesthesiologists
973:
620:
463:
2050:Asian Society for Emergency Medicine
1683:Anaesthesia Trauma and Critical Care
616:
614:
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604:
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532:
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528:
136:
2135:Advanced Life Support in Obstetrics
2040:Royal College of Emergency Medicine
1708:Australian Society of Anaesthetists
1616:Physicians' assistant (anaesthesia)
1519:Postoperative residual curarization
623:"Procedural Sedation and Analgesia"
350:
162:
13:
1596:Operating department practitioners
450:
338:
278:
14:
2232:
1606:Certified anesthesia technologist
1514:Postoperative nausea and vomiting
1029:Procedural sedation and analgesia
938:
803:10.1016/j.annemergmed.2006.12.017
601:
588:
569:
525:
68:Procedural sedation and analgesia
22:Procedural sedation and analgesia
2188:
2177:
2176:
1832:International emergency medicine
1740:
1731:
1730:
1147:Transverse abdominis plane block
759:10.1111/j.1553-2712.2008.00219.x
683:10.1111/j.1553-2712.2007.00022.x
510:
497:
417:, mouth opening assessment, and
153:
123:during various dental procedures
2189:
2129:Pediatric Advanced Life Support
1842:Pre-hospital emergency medicine
1741:
1647:History of neuraxial anesthesia
1601:Certified anesthesia technician
1423:Double-lumen endobronchial tube
1284:Blood–gas partition coefficient
1117:Intravenous regional anesthesia
891:
876:
858:
817:
81:
2117:Acute Care of at-Risk Newborns
2111:Neonatal Resuscitation Program
1693:Royal College of Anaesthetists
1652:History of tracheal intubation
1299:Minimum alveolar concentration
1236:Anesthesia provision in the US
830:British Journal of Anaesthesia
782:
733:
633:
551:
128:transesophageal echocardiogram
1:
2099:Advanced cardiac life support
2082:Cardiopulmonary resuscitation
1642:History of general anesthesia
1154:Total intravenous anaesthesia
1102:Inferior alveolar nerve block
1048:Continuous wound infiltration
912:10.1016/S0140-6736(06)68230-5
518:
391:
2123:Pediatric basic life support
2105:Advanced trauma life support
2088:Mouth-to-mouth resuscitation
1837:Pediatric emergency medicine
1205:Neuromuscular-blocking drugs
791:Annals of Emergency Medicine
719:. Elsevier Health Sciences.
413:airway exam that includes a
310:
298:
231:Intervention often required
228:Intervention may be required
7:
1540:Critical emergency medicine
746:Academic Emergency Medicine
671:Academic Emergency Medicine
326:
283:
10:
2237:
1807:Emergency medical services
1586:Anesthesiologist assistant
1448:Relative analgesia machine
355:
2171:
2150:
2063:
2005:
1954:
1865:
1794:
1726:
1660:
1624:
1573:
1527:
1494:Local anesthetic toxicity
1461:
1393:
1312:
1276:
1223:
1162:
1011:
885:The Harriet Lane Handbook
205:Normal to verbal stimulus
54:
40:
26:
21:
1982:Epinephrine / Adrenaline
1509:Postanesthetic shivering
1375:Neuromuscular monitoring
1266:Rapid sequence induction
1195:Inhalational anesthetics
629:. McGraw-Hill Education.
621:Stone, C. Keith (2017).
253:Cardiovascular Function
225:No intervention required
1560:Oral sedation dentistry
1550:Intensive care medicine
1504:Perioperative mortality
1360:Guedel's classification
1107:Intercostal nerve block
76:endotracheal intubation
1611:Anaesthetic technician
1499:Malignant hyperthermia
473:
369:central nervous system
248:Frequently inadequate
144:
2163:Injury Severity Score
1934:Nasopharyngeal airway
1907:Intraosseous infusion
1433:Laryngeal mask airway
1277:Scientific principles
1246:Dogliotti's principle
1122:Occipital nerve block
1087:Brachial plexus block
471:
433:Safety and Monitoring
427:Laryngeal mask airway
409:should be completed.
1940:Oropharyngeal airway
1817:Emergency psychiatry
1802:Emergency department
1479:Drug-induced amnesia
1474:Anesthesia awareness
1408:Anesthetic vaporizer
1385:Thyromental distance
1289:Concentration effect
1163:Pharmacologic agents
1132:Pudendal nerve block
458:emergency department
419:Thyromental distance
172:Spectrum of Sedation
1919:Tracheal intubation
1913:Intravenous therapy
1403:Anaesthetic machine
1261:Tracheal intubation
1251:Intravenous therapy
1190:General anesthetics
1142:Sciatic nerve block
1097:Femoral nerve block
1092:Fascia iliaca block
1070:Epidural anesthesia
1036:Twilight anesthesia
717:Miller's Anesthesia
444:supplemental oxygen
197:General Anesthesia
2221:Emergency medicine
2093:Basic life support
1997:Sodium bicarbonate
1795:Emergency medicine
1788:Emergency medicine
1489:Emergence delirium
1469:Allergic reactions
1345:Entropy monitoring
1127:Paracervical block
1112:Interpleural block
1075:Spinal anaesthesia
1060:Neuraxial blockade
843:10.1093/bja/aex004
474:
464:Discharge criteria
365:μ-opioid receptors
262:Usually maintained
259:Usually maintained
2203:
2202:
1992:Magnesium sulfate
1901:Electrocardiogram
1827:Medical emergency
1812:Emergency nursing
1754:
1753:
1591:Nurse anesthetist
1418:Bronchial blocker
1413:Arterial catheter
1304:Second gas effect
1231:Airway management
1200:Local anesthetics
1137:Retrobulbar block
906:(9512): 766–780.
797:(2): 182–187.e1.
726:978-0-323-28011-2
440:oxygen saturation
269:
268:
245:May be inadequate
191:Moderate Sedation
137:Contraindications
90:laceration repair
65:
64:
2228:
2192:
2191:
2180:
2179:
1781:
1774:
1767:
1758:
1757:
1744:
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1734:
1733:
1581:Anesthesiologist
1370:Mallampati score
1330:Bispectral index
1170:Anticholinergics
994:
987:
980:
971:
970:
966:
951:Am Fam Physician
932:
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415:Mallampati score
407:Informed consent
351:Analgesic agents
265:May be impaired
188:Minimal Sedation
183:
182:
163:Difficult airway
58:edit on Wikidata
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2151:Scoring systems
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1185:Benzodiazepines
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752:(10): 877–886.
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589:Frank, Robert.
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451:Aspiration risk
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399:medical history
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373:opioid epidemic
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344:Dexmedetomidine
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339:Dexmedetomidine
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279:Sedative agents
202:Responsiveness
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2069:Life support
1847:Major trauma
1428:Gas cylinder
1313:Measurements
1256:Laryngoscopy
1241:Bronchoscopy
1028:
957:(1): 85–90.
954:
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870:bestbets.org
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236:Ventilation
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107:dislocations
85:
82:Medical uses
71:
67:
66:
1946:Pocket mask
1822:Golden hour
1632:ACE mixture
1574:Professions
1395:Instruments
1340:Capnography
1294:Fink effect
1175:Antiemetics
1082:Nerve block
887:. Elsevier.
548:. Elsevier.
111:performing
42:MedlinePlus
2216:Anesthesia
2210:Categories
2158:NACA score
1967:Amiodarone
1881:Chest tube
1380:Pain scale
1224:Techniques
1001:Anesthesia
900:The Lancet
677:(1): 1–8.
651:2010-10-21
519:References
423:Glidescope
392:Assessment
256:Unaffected
239:Unaffected
222:Unaffected
2077:First aid
1962:Adenosine
1929:Combitube
1903:(ECG/EKG)
1867:Equipment
1555:Obstetric
1545:Geriatric
1215:Sedatives
316:Midazolam
311:Midazolam
304:Etomidate
299:Etomidate
113:endoscopy
105:reducing
101:abscesses
99:draining
95:fractures
2182:Category
2143:(CCrISP)
1987:Naloxone
1977:Dopamine
1972:Atropine
1736:Category
1325:Baricity
1024:Sedation
963:15663030
928:19960762
920:16517277
852:28186265
811:17321006
768:18754820
691:18211306
595:Uptodate
504:sedative
386:Ketamine
379:Fentanyl
332:Ketamine
327:Ketamine
289:Propofol
284:Propofol
273:Ketamine
242:Adequate
93:setting
2194:Outline
2119:(ACoRN)
2065:Courses
1746:Outline
1625:History
1210:Opioids
1053:Topical
1019:General
776:6455843
361:Opioids
356:Opioids
219:Airway
126:during
34:D016292
2137:(ALSO)
2131:(PALS)
2125:(PBLS)
2107:(ATLS)
2101:(ACLS)
1857:Triage
961:
926:
918:
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809:
774:
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689:
48:007409
2113:(NRP)
2095:(BLS)
2084:(CPR)
1955:Drugs
1942:(OPA)
1936:(NPA)
1877:(BVM)
1043:Local
1012:Types
924:S2CID
772:S2CID
318:is a
56:[
1915:(IV)
1909:(IO)
1003:and
959:PMID
916:PMID
848:PMID
807:PMID
764:PMID
721:ISBN
687:PMID
117:for
28:MeSH
1895:ICD
1890:AED
908:doi
904:367
838:doi
834:118
799:doi
754:doi
679:doi
145:Age
72:PSA
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