The Cheese - Procedural Sedation in the Emergency Department

Procedural sedation is a unique skill that is frequently utilized by Emergency Medicine (EM) trained physicians. Depending on the indication and patient’s clinical status, it can be both stressful and time consuming, but ultimately a procedure that must be mastered to facilitate safe and effective care for our patients. Let’s start with the basic steps and setup and finish with some article reviews.

The Basics 

Generally, procedural sedation should be considered for any prolonged and/or painful procedure in the Emergency Department (ED) to may benefit from enhanced pain control and amnesia. Most often, it is used for fracture and dislocation reductions, though it may also used for complex laceration repairs, incision and drainages, and other procedures that are difficult for patients to tolerate. Managing a patient’s pain is crucial, as untreated pain can lead to long-term increases in pain symptoms and other negative physiological effects (1).

The Setup 

• IV access: Don’t forget to verify high-fidelity access for administration of medications.

• The medications: Most commonly, ketamine or propofol is used, or a combination of the two. Fentanyl, midazolam, and etomidate are also options. Please refer to Figure 1 for more information regarding options, doses, and classes (analgesia vs amnesia).

• Airway: Have everything ready and available in the event the patient needs to be intubated (video laryngoscope, extra blades, bougie, tube with stylet, suction, bag-valve mask and oral adjuncts, supraglottic airways, etc.).

• Cardiac, pulse-ox, and end-tidal CO2 monitoring.

• Nursing: Coordinate timing with the nursing staff (they are vital to success for administration of the medications, as well as having adequate supply on hand in case of needing to re-dose any medications).  

• Paperwork: Make sure to fill out the pre-sedation form, which includes Mallampati, ASA scores, and NPO time, among other items, as well as an informed consent form signed by both the physician and patient.

The Complications 

• Laryngospasm: Rare (~1 in 1000) complication of ketamine use, more common in pediatric patients. The physician may hear stridor or note apnea or oxygen desaturation. Untreated laryngospasm can lead to hypoxia and possible cardiac arrest. Treatment begins with bagging the patient. If unsuccessful, the next step is to increase sedation with propofol (1 to 2 mg/kg), which resolves 80% of all cases. Rarely, these patients will need to be intubated (2).

• Other obstruction: The patient may have a large body habitus with anatomy causing obstruction. Again, begin by attempting to reposition the airway, perform respiratory stimulation techniques, perform a jaw thrust, and proceed with more invasive airway support if no improvement.

• Apnea: May note a decrease in end tidal CO2 or respiratory rate prior to oxygen desaturation.

• Hemodynamic changes: Propofol can induce hypotension, so give intravenous fluids if hypotension is persistent. Ketamine often causes hypertension and tachycardia, so use with caution in patients with hypertensive or cardiac histories.

• Aspiration: Consider PO time and delay or avoid procedural sedation if the patient has had a recent significant intake. Have suction ready for an increase in secretions, as well (optimally 4-6 hours NPO).

Rescue Techniques 

• Patients with apnea or respiratory distress should be repositioned with a jaw thrust as the first step of management.

• If the patient remains persistently apneic or is desaturating, increase supplemental O2 supply and attempt to provide oxygenation via bag-valve mask. Gentle positive pressure can help relieve obstruction or resolve laryngospasm.

• If you are not able to ventilate, do not panic. Consider additional repositioning and adjunct airways, such as an oral airway, nasal trumpet, or laryngeal mask airway (LMA).

• The last resort is to intubate the patient if they cannot otherwise be properly ventilated. It is a rare complication, but be prepared with all the necessary airway equipment and appropriate rapid-sequence intubation (RSI) medications.

Should we actually place end-tidal CO2? 

• Some studies have shown no reduction in adverse events when using end-tidal CO2 monitoring, and a cost analysis points out a significant cost burden with potentially very limited benefit (3,4). However, many studies show faster time to recognition of desaturation and better patient safety outcomes (4,5). Therefore, for now, continue to use end-tidal CO2 monitoring during procedural sedation.

 Which medications should we use? 

• Medication choice is often made in discussion with nursing and pharmacy colleagues to the specific patient in question, his or her comorbidities, and the procedure being performed while the patient is sedated.

• Propofol with ketamine vs fentanyl: A randomized control trial (RCT) looked at 63 patients requiring procedural sedation for orthopedic fracture/dislocation reduction or abscess drainage and noted that propofol in combination with ketamine had fewer hypoxic events and more favorable hemodynamics than when propofol was combined with fentanyl (7).

• Etomidate: One study reviewed three observational studies and 5 prospective RCTs. It demonstrated that etomidate has an adequate efficacy and favorable hemodynamics, as well as low risk for respiratory adverse events (8). A separate RCT with approximately 200 patients from Hennepin County ED demonstrated that propofol and etomidate had similar safety profile. However, etomidate had a lower rate of procedural success (9).

Authored by Kathryn McGregor, MD; Taylor Wahrenbrock, MD; and Eric Leser, MD.

Sources 

1. Miner J, Paetow G. Procedural Sedation. In: Johnson W, Nordt S, Mattu A and Swadron S, eds. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recCvtWt5In5h4fLJ/Procedural-Sedation#h.g7yrtt9p4mb. Updated March 1, 2024. Accessed January 24, 2025.

2. MacLean, A., & Sehgal, N. (2023, January 30). Oh Snap! Ketamine-induced Laryngospasm in an Adult Patient. EMRA. https://www.emra.org/emresident/article/laryngospasm-january-2023/

3. Dewdney C, MacDougall M, Blackburn R, Lloyd G, Gray A. Capnography for procedural sedation in the ED: a systematic review. Emerg Med J. 2017 Jul;34(7):476-484. doi: 10.1136/emermed-2015-204944. Epub 2016 Aug 26. PMID: 27565194. 

4.  NM, Stoltze A, Ahmed A, Kiscaden E, Shane D. Using continuous quantitative capnography for emergency department procedural sedation: a systematic review and cost-effectiveness analysis. Intern Emerg Med. 2018 Jan;13(1):75-85. doi: 10.1007/s11739-016-1587-3. Epub 2016 Dec 28. PMID: 28032265. 

5. Saunders R, Struys MMRF, Pollock RF, Mestek M, Lightdale JR. Patient safety during procedural sedation using capnography monitoring: a systematic review and meta-analysis. BMJ Open. 2017 Jun 30;7(6):e013402. doi: 10.1136/bmjopen-2016-013402. PMID: 28667196; PMCID: PMC5734204. 

6. 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 Mar;55(3):258-64. doi: 10.1016/j.annemergmed.2009.07.030. Epub 2009 Sep 24. PMID: 19783324. 

7. Messenger, D.W., Murray, H.E., Dungey, P.E., Van Vlymen, J. and Sivilotti, M.L.A. (2008), Subdissociative-dose Ketamine versus Fentanyl for Analgesia during Propofol Procedural Sedation: A Randomized Clinical Trial. Academic Emergency Medicine, 15: 877-886. https://doi.org/10.1111/j.1553-2712.2008.00219. 

8. Falk J, Zed PJ. Etomidate for procedural sedation in the emergency department. Ann Pharmacother. 2004 Jul-Aug;38(7-8):1272-7. doi: 10.1345/aph.1E008. Epub 2004 Jun 1. PMID: 15173551. 

9. Miner JR., Danahy M, Moch A, Biros M. Randomized Clinical Trial of Etomidate Versus Propofol for Procedural Sedation in the Emergency Department. 2007, Annals of Emergency Medicine