Procedural sedation in ED

Last Updated on by frcemuser

Indication in ED

  • reduction of a fracture or dislocation
  • incision and drainage of an abscess,
  • laceration repair,
  • lumbar puncture,
  • change of burns dressings
  • cardioversion

Contraindicated in the ED

  • Appropriately trained personnel are not available to perform the sedation.
  • Patients have an American Society of Anesthesiologists (ASA) classification of unstable class II or class IV and above (unless requiring immediate intervention, e.g. ventricular tachycardia)
  • Appropriate monitoring and resuscitation equipment are not available.
  • A general anaesthetic would be more appropriate.
  • The patient has an allergy or hypersensitivity to the relevant medications.
  • There is a high risk of aspiration e.g. acute alcohol intoxication.

Risk assessment

Class Description Examples
I Normal, healthy patient
II Mild systemic disease Asthma, controlled diabetes
III Moderate systemic disease Stable angina, diabetes with hyperglycaemia, moderate chronic obstructive pulmonary disease
IV Severe systemic disease Unstable angina, diabetic ketoacidosis
V Moribund


Clinical assessment

Airway assessment procedures for sedation and analgesia


  • Previous problems with anaesthesia or sedation (look in the hospital and ED records if possible)
  • Stridor, snoring or sleep apnoea
  • Advanced rheumatoid arthritis
  • Chromosomal abnormality (e.g. trisomy 21)

Physical Examination:

  • Habitus
    • Significant obesity (especially involving the neck and facial structure)
  • Head and neck
    • Short neck, limited neck extension, decreased hyoid-mental distance (<3cm in an adult),
    • neck mass, cervical spine disease or trauma, tracheal deviation, dysmorphic facial features
    • (e.g. Pierre-Robin syndrome), excessive facial hair
  • Mouth
    • Small opening (<3cm in an adult, edentulous, protruding incisors, high arched palate, macroglossia, tonsillar hypertrophy and nonvisibule uvula)
  • Jaw
    • Micrognathia, retrognathia, trismus and significant malocclusion

Requirements for effective procedural sedation

  • Analgesia
  • Anxiolysis
  • Sedation
  • Amnesia

Depths of sedation

Level of sedationParameter Minimal sedation
Moderate Sedation
(Conscious Sedation)
Deep Sedation General Anaesthesia
Responsiveness Normal response to verbal stimulation Purposeful* response to verbal or tactile stimulation Purposeful* response after repeated or painful stimulation Unrousable even with painful stimulus
Unaffected No intervention required Intervention may be required Intervention often required
Spontaneous ventilation Unaffected Adequate May be inadequate Frequently inadequate
Unaffected Usually maintained Usually maintained May be impaired


Requirements for procedural sedation and analgesia in the ED

Minimum staffing levels

  • Minimal sedation with Entonox: One physician or Emergency Nurse Practitioner (ENP)
  • Moderate sedation/analgesia with intravenous agents: One physician as seditionist and one physician or ENP as operator and one nurse (total of 3)
  • Deep sedation/analgesia and dissociative sedation using ketamine: 3 practitioners as for moderate sedation, with the seditionist accredited to Royal College of Anaesthetists initial assessment of competence standards.

Location and facilities

  • Resuscitation room facilities


  • ECG, NIBP, pulse oximetry
  • The use of continuous quantitative capnography is recommended for conscious sedation and mandatory for deep and dissociative sedation

Pre-procedure checks

  • ASA grading
  • Pre-procedural assessment including prediction of difficulty in airway management
  • Pre-procedural fasting and risk benefit assessment
    • Fasting is not needed for minimal sedation, sedation with nitrous oxide (in oxygen) alone, or moderate sedation where verbal contact is maintained
    • For procedures using all other sedation techniques (deep sedation, dissociative sedation and moderate sedation where the patient might not maintain verbal contact with the healthcare professional), apply the fasting rule used for general anaesthesia: two hours for clear fluids and six hours for solids
    • For an emergency procedure in someone who is not fasted, base the decision to proceed with sedation on the urgency of the procedure and the target depth of sedation
  • Consent and documentation
  • Drug selection and preparation: benzodiazepine/opioid combinations, propofol, ketamine

Procedural Sedation: Drugs

Drug Propofol Midazolam Ketamine
Mode of action Positive modulation of GABA inhibitory neurotransmission Short-acting benzodiazepine NMDA-receptor antagonist
Effects Sedation and amnesia Sedation and amnesia Dissociative sedation, amnesia, analgesia
Side effects Hypotension, respiratory depression, pain at site of injection Respiratory depression, hypotension, paradoxical disinhibition and agitation at low doses in children, accumulates in adipose tissue which can prolong sedation (elderly, obese and patients with hepatic or renal disease at risk) Tachycardia, hypertension, laryngospasm, hallucinations, nausea and vomiting, hypersalivation, increased intracranial and intraocular pressure
Route IV IV IV
Initial onset time 30 sec – 1 min 1 – 2 min 30 sec – 1 min
Peak effect time 1 – 2 min 3 – 4 min 1 – 2 min
Initial dose
  • Adult: 0.5 – 1 mg/kg
  • Elderly: 10 – 20 mg
  • Adult: 1 – 2 mg
  • Elderly: 0.5 mg
  • Adult: 1 mg/kg
  • Elderly: 10 – 30 mg
  • IM: 4 – 5 mg/kg
Repeat dose
  • Adult: 0.5 mg/kg every 3 – 5 mins
  • Elderly: 10 – 20 mg
  • Adult: 1 – 2 mg after 2 – 5 mins
  • Elderly: 0.5 mg
  • Adult/Elderly: 0.25 – 0.5 mg/kg every 5 – 10 min
  • IM: 2 – 2.5 mg/kg every 5 – 10 min


All patients who have received sedation should continue to be managed in a clinical area that provides the same level of facilities and monitoring as those required during the procedure until the level of consciousness and other vital signs have returned to pre-procedure baseline levels.

Discharge status

Discharge criteria are as follows:

  • The patient has returned to their baseline level of consciousness
  • Vital signs are within normal limits for that patient
  • Respiratory status is not compromised
  • Nausea, vomiting, pain, and discomfort have been adequately addressed
  • Patients should be discharged in the presence of a responsible adult who will accompany them home and be able to report any post-procedure complications.
  • They should be provided with verbal and written instruction about post-procedure diet, medication, and a phone number to call in the event of an emergency

More Reading:

Adult Procedural Sedation

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