Welcome to the third and final post about PSA. Now you know what PSA is and which medications you will be using, so what’s next?
What else do I need to perform PSA?
Signed consent form (if non-emergent)
BVM
Oxygen source and delivery system
End tidal capnography
Vital signs monitor
Intubation equipment
Supraglottic airway
Airway adjuncts
PSA agent(s)
Paralytic (should you need to intubate)
Easily accessible reversal agent (if applicable)
At least 2 providers: One person must be dedicated to monitoring the PSA, watching the monitor and watching the patient to look for changes in respiration. This person should have an unobstructed view of the monitor, patient’s face and chest. Second person to perform whatever procedure you are doing the PSA for.
Here is a great checklist to go through before every PSA: https://emupdates.com/perm/PSAChecklistv2emupdates.com_screen.pdf
Additional notes/tips:
Most important job of the EP performing the PSA is to watch the patient, especially changes in respiratory rate and depth
Do not delay procedural sedation based on fasting time. There is no evidence to support that fasting for any duration reduces the risk of emesis or aspiration with PSA.
If providing supplemental O2, be aware that this can delay recognition of respiratory suppression, especially if looking at the SpO2. It can take an additional 4-5 minutes for you to see a drop in the pulse oximetry reading while the patient is apneic.
Capnography is a great adjunct to help you detect airway or respiratory compromise. Note the end-tidal CO2 prior to administering the sedative. If there is a significant consistent change in this number (>10mmHg) or if you notice that the waveform plateaus, begin addressing possible airway/respiratory compromise. Here is a great resource to practice interpreting capnography: https://www.medtronic.com/content/dam/covidien/library/us/en/product/capnography-monitoring/capnostream-tutorial-quiz/tutorial.html
Do not discharge the patient until she has returned to her baseline mental status. Make sure to provide the proper discharge instructions. Adverse effects of sedation are rare once patients have returned to baseline mental status but they should be instructed to return to the ED if they begin experiencing difficulty breathing or vomiting.