EM · Procedural & diagnostic ED skills
Procedural sedation in the emergency department
Also known as Procedural sedation and analgesia · PSA · Conscious sedation · Dissociative sedation · ED sedation
Procedural sedation in the ED — the indications (fracture reduction, dislocation reduction, abscess drainage, cardioversion, paediatric procedures), the pre-sedation assessment (fasting status, ASA physical status, the airway, the Mallampati), the monitoring (ECG, pulse oximetry, capnography, BP), the drugs (propofol 1 to 2 mg/kg, ketamine 1 to 2 mg/kg IV or 4 to 5 mg/kg IM, midazolam 0.05 to 0.1 mg/kg, fentanyl 1 to 2 mcg/kg), the antagonists (flumazenil, naloxone — titrated per local protocol, resedation trap), the rescue airway, and the complications (hypoventilation, hypotension, hypoxia, emesis, laryngospasm). ACEM-primary, globally tagged.
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- The primary survey (ABCDE) — the trauma assessment framework
- Upper airway obstruction in the emergency department
- Paediatric trauma — the modified approach
- Acute severe asthma
- Tachyarrhythmias in the emergency department
- Bradyarrhythmias and atrioventricular block in the emergency department
- Wound assessment and management
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Red flags
- Capnography is the standard of care — waveform ETCO2 detects apnoea minutes before the oxygen saturation falls, especially on supplemental oxygen
- NPO status alone must not delay an urgent procedure — the clinical urgency overrides the fasting interval, with the airway managed as for a full stomach
- Never co-administer a benzodiazepine, an opioid and propofol blindly — the synergy is respiratory arrest
- Laryngospasm under ketamine is an airway emergency — 100 per cent oxygen, jaw thrust, the Larson manoeuvre, and a paralysing dose of succinylcholine if refractory
- The reversal agents have a shorter half-life than the drugs they reverse — resedation is the trap, observe beyond the apparent recovery
Meet the patient
A 4-year-old, 16 kg boy is carried in at 11 pm after a fall onto an outstretched hand. He has a displaced, angulated both-bone forearm fracture with skin tenting, he is screaming, and two attempts at intravenous access have failed. He last ate a sandwich two hours ago. The decision is to reduce this in the resuscitation bay under procedural sedation — and the drug, the airway plan, and the monitor all have to be right before the first aliquot. [1]
The two questions that decide his next ten minutes are the two that decide every PSA: does he need sedation at all? (a regional block or sub-dissociative ketamine may serve him better) and can I recover his airway if the drug goes deeper than I intend? (the airway assessment and the rescue kit answer that). [1]
References13ShowHide
- [1]Green SM, Roback MG, Krauss B, et al. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children Ann Emerg Med, 2009.PMID 19201064
- [2]Green SM, Roback MG, Krauss B, et al. Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient data meta-analysis of 8,282 children Ann Emerg Med, 2009.PMID 19501426
- [3]Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial Ann Emerg Med, 2010.PMID 19783324
- [4]Rath S, Alsabri M, Tawfik AM, et al. Seeing beyond the numbers: capnography as a vital tool in pediatric emergency care Int J Emerg Med, 2026.PMID 41507776
- [5]Gharavifard M, Boroumand Reza Zadeh B, Zamani Moghadam H A Randomized Clinical Trial of Intravenous and Intramuscular Ketamine for Pediatric Procedural Sedation and Analgesia Emergency (Tehran), 2015.PMID 26495383
- [6]Blumer JL Clinical pharmacology of midazolam in infants and children Clin Pharmacokinet, 1998.PMID 9673833
- [7]Soysal S, Karcioglu O, Demircan A, et al. Comparison of meperidine plus midazolam and fentanyl plus midazolam in procedural sedation: a double-blind, randomized controlled trial Adv Ther, 2004.PMID 15727400
- [8]Messenger DW, Murray HE, Dungey PE, et al. Subdissociative-dose ketamine versus fentanyl for analgesia during propofol procedural sedation: a randomized clinical trial Acad Emerg Med, 2008.PMID 18754820
- [9]Motov S, Rockoff B, Cohen V, et al. Intravenous Subdissociative-Dose Ketamine Versus Morphine for Analgesia in the Emergency Department: A Randomized Controlled Trial Ann Emerg Med, 2015.PMID 25817884
- [10]Shannon M, Albers G, Burkhart K, et al. Safety and efficacy of flumazenil in the reversal of benzodiazepine-induced conscious sedation. The Flumazenil Pediatric Study Group J Pediatr, 1997.PMID 9386663
- [11]Andolfatto G, Abu-Laban RB, Zed PJ, et al. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial Ann Emerg Med, 2012.PMID 22401952
- [12]Bassett KE, Anderson JL, Pribble CG, et al. Propofol for procedural sedation in children in the emergency department Ann Emerg Med, 2003.PMID 14634602
- [13]US Food and Drug Administration (DailyMed) Succinylcholine chloride injection — prescribing information: dosage for intramuscular use DailyMed, US National Library of Medicine, 2026.Source