Procedural sedation and analgesia facilitator - Expanded scope role for paramedics in the emergency department

Introduction: Procedural sedation and analgesia (PSA) is accepted as a standard of care in emergency departments (ED). PSA requires careful monitoring of a patient's cardio-respiratory status, and an ability to act immediately and appropriately in the event of any untoward event. The knowledge and skills necessary for this are a natural extension of the expertise of Advanced Care Paramedics (ACP). We report a series of PSA's conducted by ACPs over a 19 month period at a busy teaching hospital. Methods: This is a retrospective descriptive study presenting data from a registry recording details of all cases of ACP-facilitated PSA conducted in our ED between August 1, 2004 and February 28, 2006. Baseline characteristics, indication for the procedure, medications used and adverse events are reported. Results: 1334 ACP-facilitated PSAs were conducted during the period. According to definitions used by this study, 'desaturation'- a SaO₂ of < 90% at any time during the procedure in patients with an initial SaO₂ of ≥ 95% occurred in only 11 (0.9%) patients, and 'hypotension' - systolic blood pressure (SBP) < 85 mm Hg in patients with an initial SBP > 100 mm Hg occurred in 0.6% of patients. One significant adverse event was recorded, that of pulmonary aspiration. Medications used for PSA included fentanyl (94.1%of cases), propofol (65.5%), midazolam (36.7%) and ketamine (2.2%). Conclusions: PSA conducted in the ED by specifically trained ACPs is not associated with a significant number of adverse effects. This role should be recognized and subjected to further study.