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EmergencyDepartmentNitrousOxideProtocol

AlexisM.LaPietra,DO,FACEP

Background

NitrousOxide(N2O)isatastelesscolorlessgasadministeredincombinaFonwithoxygenviainhalaFonasananalgesicandsedaFveagent.N2Oisrapidlyabsorbedviathepulmonaryvasculatureintothebloodstream,anddoesnotcombinewithhemoglobinorotherbodyFssues.N2Orapidlyreachesthecentralnervoussystemwithinminutes.AdministraFonofN2Ocanachievesimilaranalgesiaascomparedtoopioidanalgesia,withtheaddedbenefitofnoninvasiveadministraFon,andtheabilitytoFtrateupanddowntoachieverapidonsetandeliminaFon.Ithasanimpeccablesafetyrecordwithfewsideeffectsandrequiresonlyminimalmonitoringduringuse.

IndicaFons

• ReducFonofjointdislocaFons

• AdjuncttootheranalgesiainfracturereducFon

• SplinFng

• AdjuncttolocalanestheFcforlaceraFonrepair

• AdjuncttolocalanestheFcforincisionanddrainageofsoRFssue/bartholin’sabscesses

• Advancedwoundorburncare

• Foreignbodyremoval

• AdjuncttolocalanestheFcforCentralVenousAccess

• PeripheralVenousAccess

• AdjuncttolocalanestheFcforLumbarPuncture

• FecalDisimpacFon

ContraindicaFons

Nitrousoxidehas15FmeshighersolubilityraFoascomparedtonitrogen,andinhighdosescancausegaseousexpansioninenclosedairspaces.AddiFonally,inpaFentswhobreatheviaahypoxemicdrive

secondarytolungdiseasemayhaverespiratorycompromisewiththeadministraFonofhighconcentraFonsofN2O.

• InflammaFonorobstrucFonofnasalpassages(eg-upperrespiratoryinfecFon/sinusiFs)

• COPD

• 1stand2ndtrimesterpregnancy

• Severeasthma

• Alteredlevelofcomprehensionsecondarytopsychiatricdisease,intoxicaFon,orheadinjury

• Complexadvancedcardiacdisease

• HighsuspicionofoFFsmedia

• HighsuspicionofbowelobstrucFon

Maintanence/Servicing/Storage

Nitrousoxidewillbestoredandmaintainedbyrespiratorytherapy.ApplyafacemasksuitableforthepaFent’sfacesize;sizesincludesmall,medium,andlarge.PosiFonpaFentasneededforprocedureoranalgesia.

AdministraFon

N2OisadministeredalongwithoxygenatvaryinglevelsofconcentraFon.ThemaximumsafeconcentraFonisa70%N2O:30%mixtureoxygen.TitraFonofthemixtureshouldstartat10%N2O:90%oxygen.TheopFmalconcentraFonofnitrousoxidetoachievedesiredanalgesiaorsedaFonwillvarywitheachpaFent,andcanvaryinthesamepaFentpresenFngwithdifferentpainorsedaFonneeds.TheoperatorcanassesswhenthecorrectlevelofanalgesiaismetbyusingaverbalpainscaleorwhenthepaFentnolongeradverselyresponsestothepainfulsFmulibutissFllabletocommunicate.ThecorrectlevelofsedaFoncanbeassessedwhenthepaFentappearssedated,hasminimaltonoresponsetopainfulsFmuli,butisabletocommunicatewithoutsignificantsFmulaFon.

SpecialConsideraFonsinpediatrics-thereisanincreaserateofemesisinyoungerchildrenpost-administraFon.Theriskincreaseswithyoungerage,increasedconcentraFon,andincreasedduraFonofadministraFon.Forcomplicatedlengthy(>30minutes)proceduresprophylacFctreatmentwithananF-emeFcisrecommended.

• Setthemixturedialto100%oxygenandallowthepaFenttobreathethroughtheirnoseforoneminute

• Turnthemixturedialto70%oxygen(30%nitrousoxide)andallowpaFenttobreathethroughtheirnoseforapproximatelyoneminute

• Turnthemixturedialto50%oxygen(50%nitrousoxide)andallowpaFenttobreathethroughtheirnoseforapproximatelyoneminute

• ConFnuetoFtrateoxygenleveldown(allowingthenitrousoxideconcentraFontorise)unFldesiredlevelofanalgesiaorsedaFonisachieved.Beawarethatthemixturewillnotgobelow30%oxygenor70%nitrousoxide

• ConFnueadministraFonofgasatthedesiredconcentraFonthroughoutprocedureorasneededforanalgesia.IfatanypointthepaFentbecomesover-sedatedFtrateoxygenconcentraFonbackup.TheoperatormayconFnuetoFtratethegasmixtureupanddownasneeded.TheeffectsofchangingthenitrousoxideconcentraFonshouldbeapparentwithinonetotwominutes.

• OncetheprocedureiscompletedorthepaFent’sanalgesicneedshavebeenmettheoperatorshouldturnthedialbackdownto100%oxygenandallowthepaFenttobreathethroughtheirnosefor2-5minutesbeforeremovingthefacemask.

• AllowthepaFenttoremaininachairorthebedforanaddiFonal2-5minuteswhilebreathingroomairbeforesafelydischarging.

• PaFentswillnotrequireanyrestricFononacFvityordrivingifonlynitrousoxidewasadministered.