By Guhan Rammohan, MD, and Julia Bonanno, DO
EXECUTIVE SUMMARY
- Emergency department sedation is used for the tranquilizing of acutely agitated patients and for procedural sedation and analgesia (PSA) during painful or anxiety-provoking interventions.
- Preprocedural fasting is not always required. Informed consent, appropriate staffing, and resuscitation equipment should be available.
- Choice of sedative should be individualized based on patient factors, procedure type, and desired depth of sedation. Common agents include ketamine, propofol, etomidate, opioids, and benzodiazepines.
- Alternative options to procedural sedation, such as nerve or intraarticular blocks, can be considered when feasible to decrease the risk of unfavorable events.
- Risks associated with sedation include vomiting, respiratory suppression, aspiration, and laryngospasm (typically seen with ketamine usage).
- Continuous monitoring of airway, breathing, circulation, and level of consciousness is essential. Capnography, pulse oximetry, and cardiac monitoring are recommended during emergency department sedation.
- Pediatric and geriatric patients require tailored dosing and agent selection because of differing pharmacodynamics and risk profiles.
- In children, intranasal sedatives and analgesics may be a good option for anxiolysis or short procedures such as a small laceration repair. In addition, distraction techniques and usage of child life specialists may help with preprocedural anxiety.
- In general, discharge criteria should be based on recovery of baseline mental status and stable vital signs after an appropriate recovery phase.
Case
A 73-year-old man with past medical history significant for hypertension, diabetes, and stroke two months ago presents to a single-coverage emergency department via ambulance at 3 a.m. after falling. Vital signs show heart rate 82 beats/min, blood pressure 147/95 mmHg, oxygen saturation 95%, temperature 98.7°F, respiratory rate 22 breaths/min, and weight 65 kg. The patient has no other apparent injuries but is unable to flex his left leg at the hip. His leg appears shortened and rotated, but he has good distal pulses and sensation remains intact. X-ray shows a hip dislocation without any visible fracture. The vital signs remain stable while in the emergency department, and a decision is made to use procedural sedation to address his injury.
Introduction
Procedural sedation is included in the American Council for Graduate Medical Education (ACGME) list of 15 required procedures for residents to perform.1 Certain procedures, including fracture or dislocation reductions, suturing children, and cardioversion, are time-sensitive and require patient cooperation for successful completion. As with anything in the emergency department, efficiency also is important. Procedural sedation can allow for these procedures to be completed quickly and safely. The American Board of Emergency Medicine has created a practice advance position statement on procedural sedation that includes pharmacologic options, improved safety protocols, and a focus on individualized care.2
Many different medications are available to use in these cases, and this article will discuss agent selection for specific circumstances to empower the emergency practitioner to make the best choice for their patient.
Indications
Sedation in the emergency department can be used for various reasons and procedures. It is used commonly for orthopedic injuries, such as dislocations and fractures, as well as for complex lacerations and even abscess drainage. Sedation also may be required for chest tubes, lumbar punctures, or even for having examinations or obtaining imaging studies in patients who cannot follow commands well. This population may include children, older adult patients, or patients with altered mental status. The duration of sedation often will vary. For example, shorter-acting sedation methods often are used for patients needing cardioversion, while initial and then continued long-term sedation is needed for patients who are being intubated.
Contraindications
Outside of patient refusal and patient allergy to the available sedative options, there are no established absolute contraindications to performing sedation. However, there are several factors that providers should consider before sedating patients. In general, only providers who can manage all of the possible complications, including need for intubation or possibly cricothyrotomy, should be performing the sedation. Therefore, sedation should only be performed when in an environment where definitive airway equipment is available. Certain procedures are more easily treated with short sedation, while complicated procedures that require surgical intervention should not be attempted in the emergency department. Lastly, patients with American Society of Anesthesiologists (ASA) scores of III or higher (https://www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system) should be optimized as much as possible prior to sedation, and only necessary procedures should be performed.3
Alternatives
While procedural sedation generally is well tolerated by patients in the emergency department, there still are risks associated with it. Providers can minimize adverse events with an understanding of the potential complications and risk-mitigating techniques. These risks are particularly true for the special populations and unhealthy patients with high ASA scores. For any procedure, the risk and benefits should be weighed and alternatives should be discussed with the patient. The primary reason and anticipated outcome for the sedation should be considered when thinking about alternatives. For example, is sedation being done because the patient is likely to be in pain during the procedure or is the patient having anxiety about the procedure, as is common in children. In these cases, alternative methods for completing the desired task may be considered. For example, shoulder reductions can be painful, and sometimes a nerve block or intraarticular analgesia can be used instead of sedation.4,5 For children who are nervous about receiving stitches, often topical lidocaine and distraction can be enough, and sedation can be avoided altogether.
Pre-Procedure
The ASA Physical Status Classification System (https://www.asahq.org/standards-and-practice-parameters/statement-on-asa-physical-status-classification-system) is a generally accepted method to measure a patient’s procedural risk based on underlying health conditions. Patients who fall into ASA class 1 or 2 generally will tolerate procedural sedation well, and for class 4 or 5 patients procedural sedation usually is not recommended.3 All patients regardless of class should be optimized as much as possible prior to administration of sedatives to minimize potential complications.
One of the major risks associated with procedural sedation is the risk of aspiration. Certain types of patients are believed to be at higher risk for aspiration, such as those who have a full stomach, intoxicated patients, patients who are pregnant, and patients taking glucagon-like peptide 1 agonists (GLP-1) like semaglutide.6
There is limited evidence that specific fasting times prior to emergency department procedural sedation reduce the risk of aspiration or respiratory complications. Therefore, sedation may not need to be delayed for certain patients depending on their fasting status.3,7 However, the provider should consider the individual risk assessment in the timing of sedation. For example, providers can consider delaying sedation in non-urgent procedures to minimize the potential risk of aspiration in higher risk populations. A Mallampati score also should be obtained to evaluate for features that could cause difficulty with airway management should it be needed.3
Often, sedation is being performed for painful conditions such as fractures or dislocations. A patient’s pain should be addressed prior to starting sedation, since giving additional pain medications during sedation is associated with increased risk of adverse events and provides little benefit to the patient.8 If opioids are given for pain prior to the sedation, it is important that the provider wait until the peak effect of the medicine has passed before starting sedation so that the risk of respiratory depression is reduced.
As with all procedures being performed in the emergency department, consent should be obtained. The clinician should thoroughly discuss the risks and benefits of sedation, as well as any available alternatives, with patients or their families. Time-outs also should be used prior to starting the procedure so that providers can make sure that all necessary equipment is available, patients are being monitored appropriately, and proper medications and dosages are being administered.
Monitoring/Setup
Procedural monitoring is used so that physiological changes can be detected early and intervened on to prevent adverse events from occurring. Each emergency department has different resources available, including how much staff is available to perform monitoring. Ideally, two providers should be available during the procedure: one to perform the procedure and one to monitor the patient and manage the sedation.3 In tertiary or academic centers, it can be easy to have two providers in the room. However, in a single-coverage setting or stand-alone emergency department, resources are relatively limited, making procedure setup and monitoring even more important. Even if only one physician is available, a nurse or other trained person should be available to continuously monitor the patient.7 This individual should carefully observe the patient to make sure the patient is breathing and has no signs of airway obstruction. Skin temperature also can be used as an early detector for decreased respiratory function, since increased CO2 leads to vasodilation and warmer-feeling skin.8 Increased respiratory rate, and subsequent low CO2, can be detected as cooler skin and is a possible early sign of aspiration.8
The individual focused on monitoring the patient also should frequently assess the patient’s level of consciousness. Simply asking the patient their name or tapping two fingers on the center of their forehead can assess if the patient is under moderate sedation.8 If deeper sedation is necessary or if a patient becomes apneic and needs to be stimulated, then a painful stimulus may need to be provided to the patient, such as by applying pressure to the mandible just below the ear.8
Continuous mechanical monitoring often is used during procedural sedation, although its use has been debated.9 Cardiac monitoring is standard even though tachycardia is a nonspecific sign that could mean impending adverse events but also could suggest that the patient is in pain. Certain medications, such as propofol, are more commonly associated with hypotension, and therefore blood pressure should be checked frequently so that further sedation can be held or the patient can receive a fluid bolus if they would tolerate it. Pulse oximetry also is commonly used despite brief episodes of hypoxia not routinely causing changes in pulse oximetry.10 Patients often are placed on supplemental oxygen, which makes them less likely to develop hypoxia, and therefore makes the use of pulse oximetry even less useful.8 Capnography also often is used as a sensitive monitor of patients’ work of breathing and can quickly detect airway obstructions as well as apnea. Increased end-tidal CO2 may be associated with hypoventilation and over-sedation, while large decreases are associated with airway obstruction.8 However, capnography has limitations and can cause problems if it is misinterpreted.11
Besides having these monitoring capabilities set up and functioning in the patient room, several other pieces of equipment are recommended. Supplemental oxygen by both nasal cannula as well as bag valve mask ventilation should be readily available at the bedside and ready for use. In addition, having suction equipment available is important, especially in patients at risk for aspiration, but also in case intubation becomes required. An airway cart or tray with a laryngoscope, endotracheal tube, stylet, bougie, oral airway, nasal airway, and laryngeal mask airway also should be available in the room.8 If the sedation being used has a reversal agent, that agent should be available in case of any adverse reaction or if the procedure needs to be stopped quickly, as should the medications that may be required for intubation.
Level of Sedation
The risk of adverse events generally increases with increased depth and longer use of sedation. Most sedations in the emergency department fall into the moderate/conscious sedation category. (See Table 1.) This ideally has little effect on patients’ respiratory or cardiovascular functioning, while allowing them to be sedated enough that they do not interfere with, or remember, the procedure being performed.
Table 1. Level of Sedation |
Minimal (anxiolysis) Responsiveness: normal to verbal stimuli Eyes: open Commands: follow simple Airway: unaffected Spontaneous ventilation: unaffected Cardiovascular function: unaffected Indications: imaging, lumbar puncture, wound care Moderate (conscious sedation) Responsiveness: purposeful response to verbal/tactile Eyes: closed but open easily to light touch/voice Airway: no intervention Spontaneous ventilation: adequate Cardiovascular function: usually adequate Indications: bronchoscopy, wound care, fracture/dislocation reduction Dissociative Eyes: open Commands: unable to follow Airway: no intervention Spontaneous ventilation: adequate Cardiovascular function: usually adequate Deep Responsiveness: purposeful response to repeated/painful Eyes: closed Commands: not able to follow Airway: may need intervention Spontaneous ventilation: sometimes inadequate Cardiovascular function: usually adequate Indications: cardioversion, intubation General Anesthesia Responsiveness: unarousable Eyes: closed Commands: not able to follow Airway: intervention usually required Spontaneous ventilation: often inadequate Cardiovascular function: sometimes impaired Indications: open surgery |
Sources: Benzoni T, Agarwal A, Cascella M. Procedural Sedation. In: StatPearls. StatPearls Publishing; March 22, 2025. Homma Y, Norii T, Kanazawa T, et al. A mini-review of procedural sedation and analgesia in the emergency department. Acute Med Surg. 2020;7(1):e574. Miner J, Paetow G. Procedural Sedation. In: Swadron S, Nordt S, Mattu A, and Johnson W, eds. CorePendium. 5th ed. CorePendium, LLC. Updated April 23, 2025. https://www.emrap.org/corependium/chapter/recCvtWt5In5h4fLJ/Procedural-Sedation#h.g7yrtt9p4mb |
Medications
Multiple medication choices exist for procedural sedation. Ideally medications should provide sedation, analgesia, and amnesia for patients. This often requires a combination of multiple medications, such as a benzodiazepine (sedative) with an opioid (analgesic). It also is ideal to have medications with quick onset of action and relatively short duration so that patients do not require prolonged periods of monitoring after the sedation is complete and can be safely discharged from the emergency department in a timely manner. The type of medication also depends on whether the patient has intravenous access. (See Table 2.)
Table 2. Medications for Sedation |
Propofol
Midazolam
Ketamine
Ketofol
Fentanyl
Etomidate
Dexemedetomidine
Methohexital
|
IV: intravenous; IN: intranasal; IM: intramuscular Sources: Homma Y, Norii T, Kanazawa T, et al. A mini-review of procedural sedation and analgesia in the emergency department. Acute Med Surg. 2020;7(1):e574. Pansini V, Curatola A, Gatto A, Lazzareschi I, Ruggiero A, Chiaretti A. Intranasal drugs for analgesia and sedation in children admitted to pediatric emergency department: a narrative review. Ann Transl Med. 2021;9(2):189. Miner J, Paetow G. Procedural Sedation. In: Swadron S, Nordt S, Mattu A, and Johnson W, eds. CorePendium. 5th ed. CorePendium, LLC. Updated April 23, 2025. https://www.emrap.org/corependium/chapter/recCvtWt5In5h4fLJ/Procedural-Sedation#h.g7yrtt9p4mb |
Propofol
Propofol is one of the most used medications for procedural sedation. It is short acting and easily titratable to achieve the desired effect and length of sedation. As a downside, it must be administered intravenously and provides no analgesia to patients. It also is associated with increased risk of apnea, bradycardia, hypotension, and, if used long term, can be associated with hypertriglyceridemia and propofol infusion syndrome. Using propofol does allow for deeper levels of sedation and complete relaxation in patients, which is particularly important when performing procedures such as hip reductions, since any level of alertness in the patient can impede the provider’s ability to perform a successful reduction. The typical starting dose for propofol is 0.5 mg/kg to 1.0 mg/kg with an additional 0.25 mg/kg to 0.5 mg/kg every two to three minutes as needed.
Midazolam
Midazolam is a short-acting benzodiazepine that also is highly used during procedural sedations. It provides sedative, amnestic, and anxiolytic effects, but just like propofol also provides no analgesia to patients. Unlike propofol, though, midazolam can be given intranasally as well, which is especially helpful when working with children. It often is given as a premedication in pediatrics.12 Unfortunately, it also is associated with apnea, which can lead to hypoxia, especially when combined with other medications. If administered intravenously, initial dosing is 0.5 mg to 2.5 mg, with additional doses administered every two to five minutes as needed, typically not exceeding 5 mg total. When administered this way, it works within one to five minutes, has a peak effect in five to 10 minutes, and lasts up to an hour. If administered intranasally, dosing is 0.1 mg/kg, with a maximum of 10 mg. This works within 10 minutes and lasts for 20-25 minutes, so it typically is administered 15 minutes prior to performing procedures. If administered in this route, it is important to divide the dosage evenly between each nostril and not administer more than 1 mL per nostril. Midazolam also has an antidote, flumazenil, which can be used if patients become hypoxic or have other complications. However, if used, it is important to remember that the duration of flumazenil is shorter than midazolam, so it can wear off prior to the midazolam being metabolized, and the patient can become sedated again without any additional midazolam being administered. Flumazenil also should not be given to any patient on long-term benzodiazepines since it can precipitate seizures.
Ketamine
Ketamine is another commonly used medication, particularly for patients at risk for hypotension or with concerns for airway compromise because it is less likely to cause respiratory depression.13 It provides sedative, amnestic, and analgesic effects, and can be administered without an IV if needed. However, ketamine also is associated with some side effects. Most commonly, patients can experience an emergence reaction as the medication is wearing off, where they have hallucinations, vivid dreams, and sometimes become agitated. Therefore, it generally is not advised to use ketamine for sedation in patients with psychotic behavior or severe agitation. Giving a benzodiazepine or dexmedetomidine toward the end of sedation can significantly mitigate this side effect, especially in children.14 Ketamine also is associated with nausea, vomiting, and transient risk of laryngospasm. It also is associated with causing increases in heart rate and blood pressure, which can be beneficial in some patients, but can be detrimental to patients with cardiac disease since it can cause increased myocardial oxygen demands. It also has no effect on intracranial pressure, so if a patient is hypotensive or bradycardic, or has a traumatic brain injury, it may be the best choice for sedation. When administered intravenously, the starting dose is 1 mg/kg to 2 mg/kg, with an additional 0.5 mg/kg to 1.0 mg/kg every five to 10 minutes as needed. Onset when given this way is within 30 seconds, but duration typically is only five to 10 minutes, making it more appropriate for shorter procedures. If administered intramuscularly, the typical starting dose is 3 mg/kg to 5 mg/kg, with additional 2 mg/kg to 5 mg/kg if needed. Providing ketamine intramuscularly has a slower onset of action at three to four minutes and can have a longer duration of 10-25 minutes. Ketamine also can be administered intranasally, particularly in children, with doses of 0.5 mg/kg to 4 mg/kg.
“Ketofol”
While often debated, the combination of ketamine and propofol, also known as “ketofol,” is used in emergency departments. This combination is associated with decreased vomiting and emergence reactions compared to ketamine, but less hypotension than when propofol is administered alone.15 The dose of each medication is debated, but some sources recommend giving a combination of 0.3 mg/kg to 1 mg/kg ketamine with 0.4 mg/kg to 1 mg/kg propofol.16 Ideally, these medications would be administered in two separate syringes so that additional doses can be titrated based on the patient’s specific needs.
Fentanyl
Fentanyl does not offer any sedation but is highly used for its analgesic properties. It can cause hypotension, bradycardia, confusion, and respiratory suppression, so it should be used carefully when given in conjunction with the medications listed earlier. It also should not be used for relatively painless, quick procedures like electrical cardioversion, since doing so is associated with increased adverse events.17 Fentanyl can be administered both intravenously or intranasally. When given intravenously, the typical dosing is 0.5 mcg/kg to 1 mcg/kg every two to three minutes. This takes effect quickly in roughly one to two minutes and lasts for 30-60 minutes. If given intranasally, the dose is adjusted to 2 mcg/kg to 5 mcg/kg, or 1.5 mcg/kg to 2 mcg/kg in children.
Etomidate
Etomidate is a short-acting sedative medication with no analgesic properties that often is used for quick procedures such as endotracheal intubation and some orthopedic reductions. It also has less effect on blood pressure and cardiopulmonary function than other sedatives, and can be preferred for short procedures in hemodynamically unstable patients. It can cause myoclonus as well as adrenal suppression, which may be detrimental if used for intubation in patients experiencing septic shock.18 The typical dosing for etomidate is 0.1 mg/kg to 0.2 mg/kg IV, with additional 0.05 mg/kg every three to five minutes. Onset typically is quick, within 30 seconds to one minute, but it also only lasts for two to five minutes.
Dexmedetomidine
One of the less frequently used medications for sedation is dexmedetomidine. Even though it provides sedation, analgesia, and anxiolysis, it often is combined with additional medications. It also is less likely to cause respiratory depression and is a good option for patients with concern for possible airway complications. The dose given usually is 1 mcg/kg bolus followed by an infusion of 0.2 mcg/kg/h. This medication takes roughly three to five minutes to take effect and peaks around 15-30 minutes. Some studies have shown that this is a good option for children when a short time for sedation is needed.19
Methohexital
Methohexital is a barbiturate that is less commonly used but has been shown to be just as safe and effective as ketamine or propofol for musculoskeletal procedures.20 Outside of the emergency department, methohexital has gained favor as a sedative option for electroconvulsive therapy.21 This medication cannot be used in patients with acute intermittent porphyria, and in other patients it is associated with bronchospasm, headache, pain, and hypotension. If administered, the typical starting dose is 0.75 mg/kg to 1 mg/kg, repeated every two to five minutes. It has a rapid onset of 15-30 seconds, with a short duration of five to 15 minutes, making it another option for quick procedures such as electrical cardioversion.
Nitrous Oxide
Nitrous oxide is not as widely available in emergency departments, making some providers less comfortable with using it. It does provide sedation, anxiolysis, analgesia, and amnesia, and commonly is used in dentistry, as well as in pediatric patients. It has a rapid onset with fast recovery and can be administered easily by placing a mask over a patient. Typically, patients will be started on 100% oxygen at 5 L/min to 6 L/min and then the nitrous oxide level can be titrated up to roughly 50% as needed. This should not be used in first trimester pregnancy or in patients with emotional disturbances or drug dependency.
Post-Sedation
Patients should have their vital signs frequently reassessed and be continually monitored until they are back to their baseline mental status, respond to voice, and until vitals have returned to pre-procedural levels.8 For certain sedative agents, especially ketamine, patients may become confused and agitated as sedation wears off. Keeping the patient calm and in a room with low stimulation is helpful, but if needed benzodiazepines may be administered as well. Most adverse effects of procedural sedation occur within 30 minutes after medication is administered, so patients should be monitored closely during this time.7
Complications
Respiratory depression is the most common complication of procedural sedation, with some studies showing an incidence of 78.5 per 1,000 sedations.15 As previously discussed, monitoring should be in place to detect this complication early. The first treatment for this is withholding additional sedative medication as well as repositioning the patient and stimulating them. In addition, if the patient’s airway becomes obstructed, a jaw thrust may be used. If those measures fail, then bagging with a bag-valve mask can be used to support the patient until they begin breathing appropriately on their own.2 Nausea, vomiting, and hypotension also are common complications.3,15 These complications can be treated with anti-emetics as well as intravenous fluids.
Laryngospasm is the most common severe adverse event and occurs in roughly three to four per 1,000 sedations, particularly those in which ketamine is used.7,22 If laryngospasm is going to occur, it typically occurs at the onset of sedation with the patient developing inspiratory stridor but quickly can progress to airway obstruction. To treat laryngospasm, one of the first interventions consists of using the Larson maneuver. The Larson maneuver is a technique whereby bilateral pressure is applied at the laryngospasm notch (soft spot behind the earlobe, where the jaw meets the skull) and a simultaneous jaw thrust is used. It is thought that this maneuver relaxes the vocal cords, opens the airway, and distracts from the pain of laryngospasm. If this does not work, intermittent positive pressure ventilation can be tried, and if this also fails, paralysis with intubation or bag-valve mask ventilation may be required.23-25
Aspiration is the second most common serious adverse event and affects roughly 1.2 per 1,000 sedations. The risk is worsened in people who are intoxicated, pregnant, or taking GLP-1 agonists. Increasing levels of sedation also are associated with increased risk of aspiration. If there is concern for aspiration, the provider should attempt to use the minimum required sedation to complete the task or stimulate the patient to wake them up. If the procedure allows, patients also can be placed in a more upright or lateral position, and if not, then repositioning or suctioning the airway can be helpful as well. In cases of severe aspiration and subsequent hypoxia, intubation may be necessary.
Any of the aforementioned adverse events can lead to the patients requiring intubation and mechanical ventilation, which affects roughly 1.6 per 1,000 sedations.7 Preparation is key and whenever a patient is being sedated, intubation supplies, including medications that may be required, should be available. While they are relatively uncommon, these serious adverse events quickly can become life-threatening if they are not managed appropriately and expeditiously. Having appropriately trained personnel with proper equipment available and a plan of action is paramount for patient safety during these procedures.
Special Populations
Sedation in children is seen as a low-frequency, high-stakes procedure. Depending on the age of the child, they may have significant anxiety associated with procedures, including placement of IVs, and may not be able to follow commands. Children younger than 2 years of age are most commonly sedated for laceration repairs, while those older than 2 years of age are more commonly sedated for orthopedic reductions.26 Keeping parents in the room when possible can help ease some of their anxiety, although this is not always possible, especially for sterile procedures. Amnesia also is important in these cases so that children are less likely to become fearful for future procedures or healthcare interactions in general.8,27 Children also often require more sedation than adults, and ketamine and propofol generally are regarded as safe options.8,28,29 Intranasal formulations also can be better tolerated than giving intravenous or intramuscular medications, and often have almost immediate effects.12 Oral medications also can be used but require some patient cooperation and have a slower onset of action.12 Monitoring children prior to procedures also can be complicated and anxiety-provoking, and sometimes continuous monitoring may have to wait until the patient is already sedated and, therefore, more cooperative with having monitoring devices placed. Whenever possible, alternatives to sedation should be used. This can include options such as placing the patient in a papoose (Velcro restraint), using topical lidocaine or glue instead of sutures, and using child life specialists, although access to this resource may be limited.28 The general consensus typically recommends against restraints in children when possible. Since sedation in children may not be as frequently encountered for the emergency practitioner, increasing provider knowledge is paramount. Studies have shown that using checklists as well as intermittent simulation training improves the knowledge, confidence, and skill of providers performing sedation.30 However, while sedation checklists may be helpful, they are not shown to reduce the rate of serious adverse events.3,31
Older adult patients also are treated slightly different during sedations. These patients often have increased comorbidities and limited physiological reserve.7,8 For these patients, a smaller amount of medication often can be administered and should be titrated slowly until the desired effect is achieved so that the likelihood of adverse events can be decreased.3 These patients often take longer to clear medications as well and may take longer to return to baseline after sedation.7,8,32 Unlike children, older adult patients often are fairly cooperative and may require only pain control. If feasible and the provider is appropriately trained, nerve blocks can be used for fracture and dislocation reductions instead of sedation.
There are other patient populations in whom medication dosing needs to be adjusted. For example, patients with chronic alcohol or drug use often develop altered responses to pain and stress, and their bodies may metabolize these medications differently. Similarly, patients with impaired renal or hepatic function also may metabolize various sedatives and analgesics differently. Care must be taken with agent selection in these patients to avoid adverse effects, such as respiratory suppression or prolonged sedation. In these cases, it may be challenging to predict how much medication the patient may need to achieve the desired level of sedation.8 Medication dosing also is based on a standard-sized patient with a standard amount of body fat. This may cause mid-dosing in patients with obesity where ideal or adjusted body weights provide better approximations.3,8 Lastly, critically ill patients are more likely to develop hypotension or respiratory depression as a result of procedural sedation. In these patients, resuscitation followed by preemptive intubation often may be safer.8
Continued Sedation
While most of the sedations performed in the emergency department are relatively quick, after a patient is intubated they should be adequately sedated in the emergency department. Awareness with paralysis can occur if patients are paralyzed but not appropriately sedated, or sedation wears off while paralytics still are in effect. There may be a delayed administration of continued sedation and analgesia after patients are intubated, with one study showing these times to be 47 minutes and 63 minutes, respectively.33 While this happens in a minority of patients, the risk of severe long-term psychological morbidity is devastating for the patients it affects.34
Benzodiazepines and propofol commonly are used to sedate patients in the intensive care unit, but dexmedetomidine is a viable alternative.35 Dexmedetomidine is associated with a lower risk of delirium but is associated with an increased incidence of bradycardia and hypotension, so it should be used with caution in patients at risk for those conditions.35 It also is important to consider what medications are readily available in a particular emergency department and the amount of time it may take for these medications to be prepared and become available at the bedside. Often, propofol is an easy medication to start with because it is often readily available in the emergency department and can be titrated quickly to achieve the desired level of sedation.
Sedation of Agitated Patients
Agitation is a common occurrence in emergency departments, and care needs to be taken for both patients as well as hospital staff. For mild agitation, diphenhydramine is well-tolerated and has few adverse events. In more agitated patients, haloperidol commonly is used as a first-line agent, and second-generation antipsychotics are used as second-line agents. A combination of benzodiazepines and antipsychotics may have a synergistic effect in obtaining deeper sedation for the agitated patient who does not respond to either agent alone. However, the risk of respiratory depression may be higher when administered in combination, and special care must be taken to monitor respiratory status, end tidal CO2, and hypoxia. Special consideration should be taken for agitated patients who also are pregnant since this increased level of distress can harm both the patient and the fetus.36 It is important to avoid medications like benzodiazepines and ketamine, since these have been associated with adverse fetal effects.36
Case Resolution
The patient has a hip dislocation and stable vital signs, so propofol was thought to be the ideal agent for procedural sedation. This medication allowed for full relaxation of the patient, which is essential when performing hip reductions. Since the procedure was being performed in a single-coverage emergency department, particular attention was used in the setup and monitoring. A properly trained nurse was assigned to monitor the patient’s vital signs and administer any supplemental oxygen/bag-valve mask ventilation as needed. Given that hypotension is a potential complication of propofol, normal saline was given as a maintenance fluid at the rate of 100 cc/hr. The patient was given 1 mg/kg (65 mg) of propofol as a bolus, and then two repeated doses of 30 mg five minutes apart were given. This allowed the practitioner to reduce the hip without any issue. The patient remained hemodynamically stable throughout the procedure with no episodes of apnea or oxygen desaturation. The patient had a repeat hip X-ray showing a successful reduction of the hip. The patient was monitored for one hour post-sedation and was discharged home with orthopedic followup.
Conclusion
Procedural sedation is an important and required skill for emergency medicine providers. Performing procedural sedation allows providers to safely perform multiple procedures, such as reductions, suturing, and cardioversion. Multiple agents can be used for procedural sedation and should be chosen based on desired length of sedation and comorbidities, as well as the physician’s level of comfort. Prior to sedation, the room should be prepared to include proper monitoring as well as reversal agents (if applicable), and tools necessary for possible definitive airway placement. During sedation, the patient should have frequent assessment of vital signs, including respirations as well as level of sedation. Once the sedation is complete, the patient should be monitored until they return back to their baseline. If continued sedation is required, as in the case of intubated patients, continued sedation and analgesia should be started as soon as possible, and patients should be closely monitored while they remain in the emergency department.
Guhan Rammohan, MD, is Assistant Chief, Emergency Medicine/Critical Care Faculty, St. Luke’s University Health Network, Bethlehem, PA.
Julia Bonanno, DO, is Chief Resident, St. Luke’s Bethlehem Emergency Medicine Residency, Bethlehem, PA.
References
1. Accreditation Council for Graduate Medical Education. Emergency Medicine Defined Key Index Procedure Minimums. November 2017. https://www.acgme.org/globalassets/pfassets/programresources/em_key_index_procedure_minimums_103117.pdf
2. Wolf S. Adult procedural sedation in the emergency department. My EM Cert Key Advances Practice Advance. American Board of Emergency Medicine. July 2024. https://www.abem.org/wp-content/uploads/2024/10/Key-Advances_Practice-Advance_-Procedural-Sedation-Adult.pdf
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Procedural sedation is an important and required skill for emergency medicine providers. Performing procedural sedation allows providers to safely perform multiple procedures, such as reductions, suturing, and cardioversion. Multiple agents can be used for procedural sedation and should be chosen based on desired length of sedation and comorbidities, as well as the physician’s level of comfort.
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