PSA is the use of analgesics, sedatives, and dissociative agents to perform urgent painful and emotionally challenging procedures on patients in a humane, safe and controlled fashion.
What makes PSA possible in the ED is the comfort of EM docs with a host of sedative agents and the ability to prepare for and handle any complications stemming from sedation.
For quick reference we’ve distilled the most commonly used PSA meds their doses and some of their nuances.
|Sedative Medication||Intial Dose||Maintinence Dose||Comments||Contraindications|
|Propofol||0.5-1.0 mg/kg||0.5 mg/kg every 1-2 min prn||Very short acting, favor in short procedures, muscle relaxation, no analagsia, may worsen hypotension||Soy, egg allergy|
|Ketamine||1.5 to 2.0 mg/kg IV in children 1.0-1.5 mg/kg IV in adults, administered over 30 to 60 seconds 4-5mg/kg IM||0.5 to 1.0 mg/kg for longer procedures||Favor for longer procedures, maintence of airway reflexes; avoid if hypertension or tachycardia are a concern||Age under 3 months|
|Etomidate||0.1-0.15 mg/kg IV||0.05 mg/kg q2-3 min prn||Fast acting, myoclonus, hypertonicity common, associated with post-procedure emesis|
|Dexmedetomidine||1 mcg/kg over
|0.6 mcg/kg/hr infusion; titrate to effect with 0.2-1 mcg/kg/hr||Can be stimulated while sedated; can cause bradycardia, hypotension||Bradycardia|
|Midazolam||0.05 mg/kg IV||0.05 mg/kg q3-5 min prn||Relatively slower onset, potent anterograde amnesia|
Vital to safe and effective PSA is preparation. Checklists are an indispensible tool to help methodically ready our patients, our collegues, our environment and ourselves to perform vigalent and controlled PSA. Ruben Strayer From emupdates.com has prepared the PSA checklist that we find the most compelling.
For a deep dive into PSA check out Dr. Strayer’s PSA Screencast Trilogy and Scott Weingart’s take a look at EMCrit
Part one covers how to think about and prepare for PSA, including a discussion of fasting guidelines.
Part two describes how patients are harmed during PSA and how to prevent patients from being harmed during PSA.
Part three discusses contemporary PSA pharmacology.
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