Moderate or conscious sedation is a common procedure used in the emergency room to reduce dislocations or fractures in patients. I have seen this procedure frequently on dislocated hip prostheses (like the image above) and shoulders after the patient has experienced some kind of trauma or fall. This procedure allows patients to tolerate typically unpleasant procedures. Meaning that this type of sedation allows the patient to be in a depressed conscious state with the ability to still respond to verbal or tactile stimulation, the ability to protect their airway and have adequate ventilation and the ability to maintain their cardiovascular function and circulation.
Preprocedure
- Obtain any pertinent imaging needed for evaluation, start an intravenous line for medications, place patient on 2L nasal cannula for extra oxygen support prior to procedure, have the patient on continuous vital and cardiac monitoring with blood pressure cycling every five minutes.
- Obtain proper consent from the patient for the procedure, ensuring that the procedure, risks, and benefits have fully been explained to the patient by the doctor or licensed medical professional that will be performing the procedure.
- Make sure all needed materials for sedation are at bedside if usage is needed such as code cart with emergency medications, reversal medications such as Naloxone (reversal for opioids) or Flumazenil (reversal for benzodiazepines), respiratory therapy to assist with airway and any supplies needed for possible intubation.
- Check IV patency, airway patency, and patient allergies.
- Document preprocedure vitals and Aldrete score, including level of consciousness and mental status.
- Do a time out to confirm correct patient and procedure, with correct limb, if applicable identified.
Aldrete Score Table
| Activity | Score |
| Able to move 4 extremities voluntarily or on command | 2 |
| Able to move 2 extremities voluntarily or on command | 1 |
| Able to move 0 extremities voluntarily or on command | 0 |
| Respiration | Score |
| Able to breathe deeply and cough freely | 2 |
| Dyspnea or limited breathing | 1 |
| Apneic | 0 |
| Consciousness | Score |
| Fully awake | 2 |
| Arousable on calling | 1 |
| Not responding | 0 |
| Circulation | Score |
| BP + 20% of preanesthetic level | 2 |
| BP + 20% to 49% of preanesthetic level | 1 |
| BP + 50% of preanesthetic level | 0 |
| O2 Saturation | Score |
| Able to maintain O2 saturation >92% room air | 2 |
| Needs O2 to maintain O2 saturation >92% room air | 1 |
| O2 saturation <90% even with O2 supplement | 0 |
Intraprocedure
- Administer sedation medications under supervision of the licensed medical professional. The medications most often used for moderate sedation are Versed, Fentanyl, Morphine, Ketamine, Propfol, Etomidate or Nitrous Oxide. Many physicians also like to use a combination of the medications as well. Make sure that you are licensed to bolus the medications because many places restrictions on what nurses are able to bolus for sedation procedures.
- Assist the provider in the reduction if needed. For hip reduction for example the nurse may need to help stabilize the pelvis while the medical provider flexes, rotates and adducts the hip to allow the femoral head to enter the acetabulum.
- Monitor the patient during the procedure including level of consciousness, Aldrete score, respiratory rate, pulse oximetry, cardiac rhythm and rate, blood pressure, and capnography.
- Document assessments and vital signs every five minutes or per your institutions guidelines. Watch out for any decreased level of consciousness into deep sedation, adverse reactions to medications, and difficulty of the patient to maintain airway or oxygen saturation.
- Have X-ray tech on standby for repeat imaging to make sure the dislocation has been properly reduced.
Postprocedure
- Once the dislocation has been reduced continue to monitor patient vitals every five minutes until patient’s pre-sedation level of consciousness and functioning is achieved.
- If your patient is to be discharged make sure that the patient has a ride home that will be able to watch them over the next couple of hours post sedation, make sure that the patient can tolerate oral intake, and that they are able to ambulate on their own.
- Provide the patient with education materials on sedation and reduction procedures.
Moderate sedation in the emergency room allows patients with dislocations the ability to have their ailment fixed quickly and provides the patient with pain relief faster than having to wait for a OR suite to open. Additionally it saves the patient from costly inpatient stays or anesthesiology consults! I personally love doing moderate sedation because it is so cool to watch the medical providers do a few simple moves to reduce a dislocation and provide the patient with instant pain relief, plus the before and after X-rays are pretty awesome to look at too!
If anyone has questions or experience with moderate sedation comment below!
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