Emergency & Toxicology

Procedural sedation: drug selection and monitoring

Clinical Overview and When to Suspect Need for Procedural Sedation

— Minimal (anxiolysis): normal response to voice, airway/ventilation/CV unaffected

— Moderate ("conscious sedation"): purposeful response to voice/touch, spontaneous ventilation adequate

— Deep: purposeful response only to repeated or painful stimulation, ventilation may be impaired

— General anesthesia: unarousable, often requires airway support

— Orthopedic reductions (shoulder, hip, ankle, Colles)

— Abscess I&D in sensitive areas, complex laceration repair in children

— Cardioversion (synchronized) for stable SVT/AFib/AFlutter

— Tube thoracostomy, central line in agitated patient, LP in uncooperative child

— Foreign body removal, burn debridement

— Procedure pain exceeds what local infiltration controls

— Patient anxiety or movement would compromise success/safety

— Pediatric patients unable to cooperate

— Anticipated difficult airway with high aspiration risk

— Hemodynamic instability uncorrected

— Procedure duration likely >30–60 min or deep general anesthesia required

— ASA class IV–V without resuscitation/airway backup

Step 3 management: Before any PSA, document a focused pre-sedation assessment including ASA class, Mallampati, last oral intake, allergies, prior anesthesia issues, and a time-out informed consent. The decision to sedate in the ED rather than book OR time hinges on airway risk, hemodynamics, and expected sedation depth — not simply procedure type.

Definition: Procedural sedation and analgesia (PSA) is the administration of sedatives, analgesics, or dissociative agents to permit a painful or anxiety-provoking procedure while preserving cardiopulmonary function and (usually) protective airway reflexes.

ASA continuum of sedation depth:

Common ED indications:

When to consider PSA over local/regional alone:

When to NOT do PSA in the ED — defer to OR/anesthesia:

Pre-procedure must-haves (the "SOAP-ME" mnemonic): Suction, Oxygen, Airway equipment, Pharmacy (reversal drugs), Monitors, Equipment (defib, IV).

Presentation Patterns and Key History

— Allergies (especially eggs/soy → propofol caution historically, though current evidence permits use; true anaphylaxis is rare)

— Medications (chronic opioids → tolerance; benzodiazepines → cross-tolerance; MAOIs → meperidine contraindicated)

— Past medical history: OSA, COPD, CHF, pulmonary HTN, hepatic/renal disease, seizure disorder, CAD, prior adverse sedation reaction, malignant hyperthermia family history

— Last meal (fasting status)

— Events leading to need for sedation

— + Substance use: alcohol, opioids, stimulants — alters dosing and risk

— ASA traditional: 2 hr clears, 4 hr breast milk, 6 hr light meal, 8 hr fatty meal

— ACEP position: recent food intake is NOT an absolute contraindication to emergent/urgent PSA; weigh aspiration risk vs procedural urgency

— Emergent procedures (reduction of dislocation with neurovascular compromise, cardioversion of unstable patient): proceed regardless of NPO

— Prior difficult intubation, OSA on CPAP, neck radiation, RA with cervical instability, micrognathia, large tongue, morbid obesity

— Schizophrenia or active psychosis → relative caution with ketamine (emergence reactions)

— Severe HTN/CAD/aortic dissection → avoid ketamine (sympathomimetic surge)

— Egg/soy allergy with prior reaction → historically flagged for propofol, but anaphylaxis rare and not absolute contraindication

— Porphyria → avoid etomidate and barbiturates

Board pearl: A stem mentioning "shoulder dislocation 30 min ago, ate lunch 1 hour ago, neurovascular intact" is testing whether you'll inappropriately delay PSA for NPO status. Per ACEP, recent oral intake alone does not mandate delay — proceed with appropriate agent selection and aspiration precautions.

Pre-sedation history is the single most important risk-stratifier — board stems will embed the red flag in the HPI.

Targeted "AMPLE+" history:

NPO status — current guidance:

Airway red flags in history:

Drug-specific history pearls:

Physical Exam Findings and Pre-Sedation Airway Assessment

— Look externally: facial trauma, beard, large tongue, micrognathia, short neck

— Evaluate 3-3-2: 3 fingerbreadths mouth opening, 3 fingerbreadths mentum-to-hyoid, 2 fingerbreadths hyoid-to-thyroid notch

— Mallampati: I (full uvula/pillars visible) to IV (only hard palate); III–IV predict difficult intubation

— Obstruction: stridor, peritonsillar mass, epiglottitis, hematoma

— Neck mobility: c-collar, RA, ankylosing spondylitis, prior fusion

— Vital signs including SpO2 on room air and end-tidal CO2 if available

— Auscultate for wheezing (bronchospasm risk with ketamine in active asthma is debated but generally safe), rales (CHF), murmurs

— Mental status baseline — needed to detect post-sedation delirium

— I: healthy

— II: mild systemic disease (controlled HTN, mild asthma)

— III: severe systemic disease (poorly controlled DM, stable CAD)

— IV: severe disease that is constant threat to life

— V: moribund

— ED PSA generally appropriate for ASA I–II; ASA III with caution; ASA IV–V → anesthesia consultation

Key distinction: Mallampati predicts intubation difficulty; MOANS predicts BVM difficulty. Both matter for PSA because rescue ventilation may be needed if oversedation occurs. Document both before pushing any sedative.

The pre-sedation exam is essentially an airway and cardiopulmonary risk assessment — failure to document this is a board-favorite safety lapse.

Airway exam — "LEMON":

Bag-mask ventilation difficulty — "MOANS": Mask seal (beard), Obesity/Obstruction, Age >55, No teeth, Stiff lungs (asthma/COPD/ARDS)

Cardiopulmonary baseline:

ASA Physical Status classification:

Pediatric considerations: larger occiput, smaller mandible, larger tongue, more anterior larynx → position with shoulder roll, not neck extension.

Monitoring Setup — Equipment, Personnel, and Capnography

— Continuous pulse oximetry

— Continuous ECG (especially for deep sedation, cardioversion, cardiac history)

— Blood pressure every 3–5 minutes

— Continuous waveform capnography (end-tidal CO2) — now standard of care for moderate-to-deep sedation

— Level of consciousness assessed and documented at intervals

— Detects hypoventilation/apnea 30–60 seconds before pulse oximetry desaturation, especially in patients on supplemental O2

— Loss of waveform = apnea; rising ETCO2 with preserved waveform = hypoventilation; falling ETCO2 = also concerning (low CO/apnea)

— Reduces incidence of hypoxia in multiple RCTs

— One provider performing the procedure

— A separate qualified provider whose sole responsibility is monitoring sedation (cannot be doing the procedure)

— Nursing support for medication administration

— Respiratory therapy availability ideal for deep sedation

— Suction (working Yankauer)

— Oxygen with nasal cannula and non-rebreather

— Airway: BVM, oral/nasal airways, supraglottic device, intubation kit, video laryngoscope

— Pharmacy: reversal agents (naloxone, flumazenil), vasopressors, code drugs

— Monitors: as above

— Equipment: defibrillator, IV access ×1 (preferably ×2)

CCS pearl: In a CCS case requiring procedural sedation, orders should include: "continuous pulse oximetry," "continuous cardiac monitoring," "end-tidal CO2 monitoring," "IV access," "supplemental oxygen," and "bedside airway equipment" — before ordering the sedative itself. Skipping monitoring orders is a documented scoring penalty.

Required monitoring during PSA (ACEP/ASA standards):

Why capnography matters:

Personnel requirements:

Equipment at bedside ("SOAP-ME"):

Supplemental O2: Pre-oxygenation with nasal cannula 2–4 L or NRB during sedation is standard; but O2 supplementation can mask hypoventilation on pulse ox alone — reinforces need for capnography.

Diagnostic and Pre-Procedure Workup

— ECG: patients with cardiac history, syncope, electrolyte abnormalities, or undergoing cardioversion; check QTc if using droperidol or methadone

— CBC: if anemia or bleeding suspected

— BMP: chronic diuretic use, CKD, suspected dehydration (affects drug distribution)

— LFTs: known hepatic disease (affects metabolism of midazolam, propofol, ketamine)

— Pregnancy test: women of reproductive age before sedation/radiation/procedure

— Glucose: diabetics, altered mental status

— Correct patient, correct procedure, correct site

— Informed consent documented (for both procedure and sedation, unless emergent)

— Allergies reconciled

— IV access patent

— Monitors applied and baseline vitals recorded

— Reversal agents drawn up and at bedside

— Airway equipment checked

— STOP-BANG for OSA risk: Snoring, Tired, Observed apnea, Pressure (HTN), BMI >35, Age >50, Neck >40 cm, Gender male — ≥3 = intermediate risk, ≥5 = high risk → consider deferring deep sedation or use lower doses with capnography

— Mallampati class III–IV + obesity + short neck → flag for anesthesia consultation

— Pre-sedation assessment with ASA class

— Informed consent

— Intra-procedure flowsheet (vitals, meds, depth of sedation q5 min)

— Recovery vitals and discharge readiness score (e.g., Aldrete score ≥9)

Board pearl: Routine pre-PSA labs in a healthy ASA I–II patient for a shoulder reduction are low-yield and not required. A pregnancy test in a reproductive-age woman is the most defensible "selective" test. Don't order a CBC, BMP, and coags reflexively — boards penalize unnecessary workup.

Routine labs are NOT required for most healthy patients undergoing brief PSA — a focused H&P suffices.

Selective testing based on comorbidities:

Pre-procedure checklist (time-out):

Risk scores worth knowing:

Documentation requirements (Joint Commission / CMS):

Drug Selection Logic — Matching Agent to Procedure

— Is the procedure painful, anxiety-provoking, or both?

— How long will it take?

— What is the patient's age and comorbidity profile?

— Short + painful (joint reduction, abscess I&D): ketamine (peds), propofol + fentanyl, or ketofol (adults)

— Short + non-painful but anxiety/movement (CT in child, cardioversion): propofol, etomidate, or midazolam

— Long + painful (complex laceration, burn debridement): ketamine infusion, or repeated boluses of propofol + fentanyl

— Cardioversion (electrical) in stable patient: etomidate or propofol (brief, hemodynamically tolerated)

— Hypotensive/hypovolemic: etomidate or ketamine (preserve BP); avoid propofol bolus

— Hypertensive/CAD: propofol or midazolam; avoid ketamine (sympathomimetic surge)

— Reactive airway disease: ketamine (bronchodilator) preferred over propofol

— Sedatives without analgesia (propofol, etomidate, midazolam) → add an opioid (fentanyl) for painful procedures

— Ketamine provides BOTH analgesia and dissociation → no opioid needed

— Local anesthetic infiltration should still be used when feasible regardless of sedative

— Midazolam + fentanyl is particularly risky in elderly — synergistic respiratory depression

— Propofol + opioid → titrate opioid first, then propofol slowly

Step 3 management: The classic "ketofol" combination (ketamine + propofol, often 1:1 mixed in same syringe) leverages ketamine's hemodynamic and analgesic properties to offset propofol's hypotension and respiratory depression, while propofol blunts ketamine's emergence reactions and nausea. It's a board-favorite answer for the adult shoulder reduction.

Three core questions drive drug selection:

Procedure × drug pairing:

Hemodynamic considerations:

Analgesic vs sedative split:

Avoid drug combinations that synergize respiratory depression unless prepared to manage apnea:

Pharmacotherapy — Individual Agent Profiles

— Onset 30–60 sec, duration 5–10 min

— Sedative/hypnotic only — no analgesia

— Side effects: hypotension, respiratory depression, apnea, injection pain

— Anti-emetic effect, anticonvulsant

— Avoid in hemodynamic instability

— Onset 30–60 sec IV, duration 10–20 min

— Dissociative: provides analgesia, amnesia, sedation while preserving airway reflexes and respiratory drive

— Side effects: emergence reactions (give midazolam 0.03 mg/kg if occurs), hypersalivation, laryngospasm (rare), HTN, tachycardia, vomiting (peds), transient nystagmus

— Contraindicated: age <3 months, schizophrenia (active); relative: severe HTN, CAD, increased ICP (controversial—newer data show safe), globe injury

— Onset 30 sec, duration 5–10 min

— Hemodynamically neutral — best for cardiac patients, hypotension

— Side effects: myoclonus (can mimic seizure), adrenal suppression (single dose clinically insignificant for PSA), nausea, no analgesia

— Onset 2–3 min, duration 30–60 min (longer than other agents)

— Anxiolysis, amnesia; no analgesia

— Reversed by flumazenil (caution in benzo-dependent patients → seizures)

— Synergistic respiratory depression with opioids

— Onset 1–2 min, duration 30–60 min

— Analgesic; paired with sedatives for painful procedures

— Side effects: respiratory depression, chest wall rigidity (rapid high-dose push), reversed by naloxone

Board pearl: Etomidate causes myoclonus that can be mistaken for seizure during cardioversion or LP — warn the team and don't push benzodiazepines reflexively. The myoclonus is self-limited.

Propofol (1–2 mg/kg IV bolus, then 0.5 mg/kg q1–3 min):

Ketamine (1–2 mg/kg IV or 4–5 mg/kg IM):

Etomidate (0.1–0.15 mg/kg IV):

Midazolam (0.02–0.05 mg/kg IV, max 2 mg initial):

Fentanyl (1–2 mcg/kg IV):

Dexmedetomidine (alpha-2 agonist): less common in ED PSA; preserves respiration but causes bradycardia/hypotension; used for awake fiberoptic intubation, ICU sedation

Procedural Execution and Titration Strategy

— Pre-oxygenate 3–5 min with NC or NRB

— Confirm IV access, monitors on, capnography waveform present

— Time-out: patient, procedure, site, allergies, consent

— Administer analgesic first (if separate from sedative): e.g., fentanyl 1 mcg/kg, wait 2 min

— Titrate sedative to target depth: start low, repeat boluses q1–3 min for propofol/ketamine

— Perform procedure once target depth achieved

— Monitor continuously; redose as needed

— Document depth, vitals, response q5 min

— Apnea/hypoventilation (loss of capnography waveform): stimulate patient, jaw thrust, chin lift, BVM if no response, consider reversal

— Hypoxia (SpO2 <90%): increase O2, jaw thrust, BVM, suction; if persistent → escalate to intubation

— Hypotension: fluid bolus 500 mL NS, reduce further dosing, vasopressor if refractory

— Laryngospasm (ketamine, especially peds): jaw thrust with firm pressure at "Larson's point" (posterior to ear), positive pressure ventilation, succinylcholine 0.5–1 mg/kg if persists

— Emergence reaction (ketamine): low-stimulus environment, midazolam 1–2 mg IV

— Bradycardia (fentanyl, dexmedetomidine): atropine 0.5 mg if symptomatic

— Naloxone 0.04–0.4 mg IV titrated (avoid full reversal of analgesia)

— Flumazenil 0.2 mg IV; avoid in chronic benzodiazepine users (precipitates seizures)

— Activity, respiration, circulation, consciousness, O2 saturation

— Return to baseline mental status, stable vitals, tolerating PO (if appropriate), ambulating if pre-procedure baseline

CCS pearl: In a CCS case, after sedation order, you must order: "reassess vital signs q5 min," "document level of consciousness," and "discharge when Aldrete score ≥9" — these are scored items. Don't discharge a sedated patient on first post-procedure vital set.

Step-by-step PSA execution:

Recognizing and managing common intra-procedural events:

Reversal agents — use sparingly:

Recovery criteria — Modified Aldrete score (≥9 of 10):

Special Populations — Elderly and Renal/Hepatic Impairment

— Reduced volume of distribution, decreased hepatic/renal clearance, increased brain sensitivity

— Dose reduction of 25–50% for nearly all sedatives

— Increased risk of: hypotension (propofol), prolonged sedation (midazolam), delirium (benzodiazepines), aspiration

— Avoid midazolam when possible — on Beers criteria; causes prolonged sedation, falls, delirium

— Etomidate is hemodynamically favored

— Slower titration intervals (q3–5 min vs q1–2 min)

— Lower threshold for capnography and prolonged observation

— Morphine → active metabolite (M6G) accumulates → avoid; use fentanyl

— Meperidine → normeperidine accumulates → seizures; avoid entirely

— Midazolam → active metabolite (alpha-hydroxymidazolam) accumulates in ESRD → prolonged sedation

— Propofol, etomidate, ketamine: largely safe, no dose adjustment needed

— Fentanyl: preferred opioid; minimal renal accumulation

— Reduced metabolism of midazolam, propofol, fentanyl, ketamine

— Reduce doses 25–50% and lengthen dosing intervals

— Etomidate: relatively preserved metabolism

— Avoid prolonged propofol infusion (rare propofol infusion syndrome)

— Dose by lean body weight for most agents (propofol bolus by total body weight, then LBW for redosing)

— Higher OSA risk → mandatory capnography, consider deferring if STOP-BANG ≥5

— Difficult BVM and intubation — anticipate

— Pre-oxygenate longer; consider 25–30° head-up position

— Assess functional status; frail elderly may decompensate even with "safe" doses

— Use the lowest effective dose; avoid combinations

Step 3 management: In an 82-year-old with CKD needing shoulder reduction, the best choice is etomidate (hemodynamic stability, renal-safe) or low-dose ketamine with reduced dosing — not midazolam + fentanyl (Beers criteria, synergistic respiratory depression, renal accumulation).

Elderly (>65 years):

Renal impairment (CKD/ESRD):

Hepatic impairment:

Obesity:

Frailty:

Special Populations — Pediatrics and Pregnancy

— Ketamine is the workhorse agent in pediatric ED PSA

— Dose: 1–2 mg/kg IV or 4–5 mg/kg IM

— Preserves airway, respiratory drive, hemodynamics

— Contraindicated <3 months (high laryngospasm risk)

— Co-administer ondansetron 0.15 mg/kg to reduce post-procedure vomiting (~5–10% incidence)

— Routine atropine/glycopyrrolate NOT required (was previously used for hypersalivation)

— Intranasal midazolam (0.3–0.5 mg/kg) or intranasal fentanyl (1.5 mcg/kg) for anxiolysis and brief procedures without IV

— Nitrous oxide (50–70% blend) for minor procedures (laceration repair, IV access) in cooperative children

— Propofol safe in peds but requires deeper monitoring and is more often used by anesthesia

— Larger occiput → shoulder roll, not neck hyperextension

— Higher metabolic rate → desaturate faster

— Smaller functional residual capacity → less reserve

— Use length-based (Broselow) tape for equipment sizing

— Forearm fracture reduction → ketamine IV

— Laceration repair, cooperative child → intranasal midazolam ± local

— Laceration, uncooperative toddler → ketamine IM if no IV

— CT/MRI requiring stillness → propofol (with anesthesia) or pentobarbital

— Defer elective sedation; for urgent procedures, use lowest effective doses

— Fentanyl preferred opioid (category C, short-acting)

— Propofol acceptable in single doses

— Midazolam crosses placenta — use sparingly, especially near term

— Ketamine raises BP, may decrease uterine blood flow at high doses — use cautiously

— Left lateral decubitus tilt after 20 weeks to avoid aortocaval compression

— Fetal monitoring if viable gestation and procedure duration warrants

Board pearl: A 4-year-old with a forearm fracture for closed reduction in the ED: IV ketamine 1–2 mg/kg with ondansetron prophylaxis is the gold-standard answer. Atropine is NOT routinely needed; benzodiazepine prophylaxis for emergence is NOT routine in young children (lower incidence than adults).

Pediatric PSA — key principles:

Pediatric airway considerations:

Common pediatric PSA scenarios:

Pregnancy:

Complications and Adverse Outcomes

— Hypoventilation/apnea (incidence 5–10% with propofol, lower with ketamine): managed with stimulation, jaw thrust, BVM; rarely requires intubation

— Hypoxia (SpO2 <90%): brief desaturation common, sustained desaturation requires intervention

— Laryngospasm (ketamine, peds): rare but life-threatening; jaw thrust + Larson's maneuver + positive pressure; succinylcholine if refractory

— Aspiration: rare (<0.1% in ED PSA); risk factors include full stomach, deep sedation, GERD, obesity, pregnancy

— Hypotension (propofol most common): fluid bolus, reduce dose, vasopressor rarely needed

— Hypertension/tachycardia (ketamine): usually self-limited; avoid in CAD, dissection, severe HTN

— Bradycardia (fentanyl, dexmedetomidine): atropine if symptomatic

— Dysrhythmia: rare; monitor ECG continuously

— Emergence phenomena (ketamine adults 10–20%): vivid dreams, hallucinations, agitation; midazolam treats

— Prolonged sedation (midazolam, especially elderly/hepatic)

— Myoclonus (etomidate): benign, self-limited, can confuse with seizure

— Paradoxical agitation (midazolam in children/elderly): treat with flumazenil

— Injection pain (propofol): pre-treat with lidocaine 20–40 mg IV or use larger vein

— Nausea/vomiting (ketamine, opioids): ondansetron 4 mg IV

— Allergic reactions: rare; true propofol egg/soy anaphylaxis is exceedingly uncommon

— Propofol infusion syndrome: with prolonged high-dose infusions (>4 mg/kg/hr >48 hr) — not a PSA risk

— Unrecognized esophageal intubation, undetected apnea (especially on supplemental O2 without capnography), medication error with concentrated propofol

Key distinction: Hypoventilation is detected by capnography 30–60 seconds before hypoxia on pulse oximetry, especially in patients receiving supplemental O2. This is why capnography is now standard — not optional — for moderate-to-deep PSA.

Respiratory complications (most common):

Cardiovascular complications:

CNS complications:

Other:

Sentinel events:

When to Escalate Care — ICU, Anesthesia, or OR

— ASA class IV–V

— Anticipated difficult airway (Mallampati IV, prior difficult intubation, neck immobility, facial trauma)

— STOP-BANG ≥5 with high-risk procedure

— Pulmonary hypertension, severe COPD on home O2

— Severe aortic stenosis, decompensated heart failure

— Malignant hyperthermia history

— Pediatric patient <6 months for non-emergent procedures

— Anticipated need for deep general anesthesia or paralysis

— Open fractures requiring extensive irrigation/debridement

— Procedures >30–60 min anticipated duration

— Need for muscle relaxation

— Concurrent surgical procedures

— Required intubation during procedure

— Failure to return to baseline mental status

— Aspiration event with hypoxia

— Hemodynamic instability requiring vasopressors

— Significant cardiac event (arrhythmia, ischemia)

— Persistent somnolence despite reversal

— Recurrent hypoxia in recovery

— Inadequate analgesia control

— Procedure complication requiring further intervention

— Social: no responsible adult for discharge home

— Sustained SpO2 <85% despite BVM

— Pulseless arrest

— Refractory hypotension despite fluids and vasopressor

— Inability to ventilate or intubate ("CICO" — cricothyrotomy preparation)

Step 3 management: A patient with OSA on CPAP, STOP-BANG 7, BMI 45, scheduled for elective shoulder reduction is NOT an ED PSA candidate — refer to anesthesia/OR. Recognizing the limits of ED-level sedation is a board-favorite "what is the BEST next step" answer, distinguished from "what is the next step."

Indications for anesthesia consultation BEFORE attempting PSA in ED:

Indications for OR rather than ED:

Indications for post-PSA ICU admission:

Indications for prolonged ED observation (not discharge):

Code activation criteria during PSA:

Differential — Other Sedation/Analgesia Strategies

— Lidocaine 1% (max 4.5 mg/kg, 7 mg/kg with epinephrine), bupivacaine 0.25–0.5% for longer duration

— First-line for simple lacerations, abscess I&D in non-sensitive areas

— Buffer with sodium bicarbonate (1:10) to reduce burning

— Hematoma block for distal radius fracture reduction (lidocaine into fracture site)

— Intra-articular lidocaine for shoulder reduction — alternative to PSA in select patients

— Bier block (IV regional) for forearm/hand procedures

— Ultrasound-guided peripheral nerve blocks (femoral, fascia iliaca for hip fracture; interscalene for shoulder; forearm blocks): increasingly favored, opioid-sparing, avoid systemic sedation entirely

— Digital blocks for finger procedures

— LET gel (lidocaine-epinephrine-tetracaine) for pediatric lacerations on face/scalp

— EMLA cream for IV starts, LP in children (requires 30–60 min)

— Oral midazolam or intranasal midazolam for cooperative but anxious patients undergoing minor procedures with local

— Nitrous oxide 50–70% for minor pediatric procedures

— Child life specialists, video distraction, parental presence

— Effective for minor procedures (IV starts, simple lacerations)

— Simple laceration on extremity → local only

— Hip fracture in elderly → fascia iliaca block (avoids PSA risks)

— Forearm fracture in child → ketamine PSA (block not feasible/cooperative)

— Shoulder dislocation, healthy adult → ketofol PSA or intra-articular lidocaine

Board pearl: For a frail 88-year-old with hip fracture awaiting OR, the analgesic of choice is a fascia iliaca compartment block under ultrasound — NOT IV opioids (delirium risk) and NOT PSA. This is the modern, board-favored geriatric pain answer.

Local infiltration anesthesia:

Regional/nerve blocks:

Topical anesthesia:

Minimal sedation/anxiolysis alone:

Distraction and non-pharmacologic:

Comparison framework — when to choose what:

Differential — Procedural Indications That Look Like PSA But Aren't

— Goal: secure airway, NOT preserve protective reflexes

— Uses induction agent (etomidate, ketamine, propofol) + paralytic (succinylcholine, rocuronium)

— Continuous post-intubation sedation in ICU

— Different consent paradigm, different monitoring requirements

— Ketamine "dissociative dose" 1.5 mg/kg given for pre-oxygenation in agitated hypoxic patient, then paralytic later

— Hybrid technique — not classic PSA

— For anticipated difficult airway

— Topical anesthesia + dexmedetomidine or low-dose ketamine

— Patient remains breathing spontaneously throughout

— Propofol, dexmedetomidine, fentanyl infusions

— Different titration goals (RASS −1 to −2), different duration

— Daily sedation interruption ("SAT") part of ABCDEF bundle

— Typically outpatient with established sedation protocols

— Often involves anesthesia or trained sedation nurses

— Goal: relief of refractory suffering at end of life

— Different ethical framework, requires informed consent and often ethics consult

— Midazolam infusion typical agent

— Droperidol, haloperidol, ketamine 4 mg/kg IM for severe agitation

— Goal is behavioral control, not procedural facilitation

— Same monitoring principles apply post-administration

Key distinction: RSI uses paralytics and intentionally abolishes protective reflexes; PSA never uses paralytics and aims to preserve them. Boards may try to trick you by listing succinylcholine in a "procedural sedation" answer choice — that's always wrong.

Rapid Sequence Intubation (RSI) — NOT procedural sedation:

Delayed Sequence Intubation (DSI):

Awake fiberoptic intubation:

Sedation for mechanical ventilation (ICU):

Conscious sedation for chronic painful procedures (chemo port access, dressing changes):

End-of-life palliative sedation:

Treatment of acute agitation / "chemical restraint":

Post-Sedation Care and Discharge Planning

— Continued monitoring (pulse ox, HR, BP, mental status) until discharge criteria met

— Minimum observation period varies by agent and dose

— Ketamine: ~60 min after last dose

— Propofol: 30 min after return to baseline

— Midazolam: 60–120 min (longer half-life)

— Document level of consciousness and vitals q15 min during recovery

— Activity (able to move all extremities)

— Respiration (deep breath, cough freely)

— Circulation (BP within 20% of baseline)

— Consciousness (fully awake, oriented)

— O2 saturation (>92% on room air)

— Return to baseline mental status

— Tolerating oral fluids (if relevant to procedure)

— Pain controlled with oral analgesics

— Ambulating at baseline (if applicable)

— Responsible adult escort — patient cannot drive home or operate machinery for 24 hr

— Written discharge instructions including who to call for complications

— Analgesia: acetaminophen + NSAID first-line; short course (3–5 days) of low-dose opioid (e.g., oxycodone 5 mg) only if severe

— Avoid benzodiazepine prescriptions at discharge

— Address procedure-specific needs (antibiotics, splint care, wound care)

— No driving, machinery, important decisions

— No alcohol or additional sedatives

— Have a responsible adult present

— Resume normal activities when fully alert

— Procedure-specific (orthopedics for fracture, primary care for wound check)

— Return precautions: severe pain, fever, bleeding, breathing difficulty, persistent vomiting

CCS pearl: Before discharge after PSA, CCS orders should include "oral intake as tolerated," "ambulate with assistance," "discharge with responsible adult escort," and "written discharge instructions including 24-hr driving restriction." Failure to document the escort/driving restriction is a common scoring miss.

Recovery phase requirements:

Discharge criteria — Modified Aldrete score ≥9:

Additional discharge requirements:

Discharge prescriptions:

24-hour restrictions to counsel:

Follow-up:

Follow-Up, Quality Metrics, and Counseling

— Expected residual drowsiness for 4–8 hours

— Possible mild nausea, dizziness — usually resolves in 24 hr

— Vivid dreams may occur post-ketamine (especially adults) — typically benign

— Avoid driving, signing legal documents, childcare alone for 24 hr

— Drink fluids, eat lightly when alert

— Persistent vomiting >24 hr

— Difficulty breathing, persistent cough

— Confusion or excessive drowsiness beyond 12 hr

— Severe pain at procedure site, signs of infection

— Chest pain, palpitations

— Orthopedic reductions: ortho follow-up within 1 week, repeat imaging

— Cardioversion: cardiology follow-up, anticoagulation continuation, rhythm monitoring

— Abscess I&D: wound check 48–72 hr, packing change as indicated

— Pediatric: parental observation overnight, normal activity by next day

— Adverse event rate (hypoxia, apnea, aspiration, unplanned intubation)

— Time to discharge after procedure

— Patient satisfaction scores

— Documentation compliance (consent, time-out, monitoring)

— Reversal agent usage rates (high rate may indicate dosing issues)

— Most institutions require ACLS, PALS (for peds), airway management skills, demonstrated competency

— Periodic re-credentialing with simulation, M&M review

— Capnography training mandatory

— M&M review of any adverse event (apnea requiring BVM >30 sec, aspiration, unplanned admission, reversal agent use)

— Root cause analysis for sentinel events

Board pearl: Counsel ALL post-PSA patients on the 24-hour rule: no driving, no machinery, no legal decisions, no childcare alone. This applies even when the patient feels "back to normal" because subtle cognitive impairment persists beyond subjective recovery.

Patient/family counseling at discharge:

Red flags to return for:

Procedure-specific follow-up:

Department quality metrics for PSA programs:

Provider credentialing and competency:

Continuous quality improvement:

Ethical, Legal, and Patient Safety Considerations

— Separate consent typically required for sedation in addition to procedure consent

— Must include: risks (respiratory depression, aspiration, allergic reaction, prolonged sedation, rare death), benefits, alternatives (local only, regional block, OR with anesthesia)

— Capacity assessment before consent — patient must demonstrate understanding

— Emergent procedures (unstable cardioversion, dislocation with vascular compromise): implied consent under emergency exception when patient cannot consent and harm from delay outweighs intervention risks

— Parental consent required; assent from older children (typically ≥7 years) when feasible

— Court order or hospital ethics committee for refused parental consent in life-threatening pediatric emergencies

— Intoxicated patient with dislocation: may lack capacity — document attempt to obtain consent, proceed under emergency exception if procedure cannot wait, involve surrogate when possible

— Jehovah's Witness: PSA itself doesn't involve blood products, but document discussion if procedure carries bleeding risk

— Surrogate decision-maker required for incapacitated adult patients

— Two-provider rule: separate provider for sedation monitoring vs procedure

— Time-out before every PSA — universal protocol

— Medication safety: read-back of doses, concentrated propofol stored separately (look-alike with other lipid emulsions)

— Capnography mandatory for moderate-deep sedation

— Never sedate without functioning IV, suction, O2, and reversal agents at bedside

— Pre-sedation ASA class, Mallampati, NPO status, consent

— Time-stamped vital signs and depth of sedation

— Adverse events and response

— Discharge criteria met, escort identified

— Patient transferred from ED to floor or home before fully recovered: handoff must include sedation timing, agents, total doses, any complications, monitoring needs

— Sentinel events (death, anoxic injury, wrong-patient procedure) reportable to Joint Commission and state agencies

Step 3 management: A 22-year-old intoxicated patient with shoulder dislocation refusing PSA — assess capacity. If lacking capacity due to intoxication and dislocation requires timely reduction (neurovascular compromise), proceed under emergency doctrine with documentation. If neurovascularly intact, await sobriety for capacitated consent.

Informed consent for PSA:

Pediatric consent:

Special consent situations:

Patient safety priorities:

Documentation as legal protection:

Transition-of-care risk:

Mandatory reporting:

High-Yield Associations and Rapid-Fire Clinical Facts

— Propofol → hypotension, apnea, injection pain

— Ketamine → emergence reactions, laryngospasm (peds), HTN, hypersalivation, vomiting

— Etomidate → myoclonus, adrenal suppression (single dose insignificant for PSA), no analgesia

— Midazolam → prolonged sedation, paradoxical agitation, synergistic respiratory depression

— Fentanyl → chest wall rigidity (high-dose push), respiratory depression

— Naloxone → opioids (start 0.04 mg, titrate)

— Flumazenil → benzodiazepines (avoid in chronic users)

— No reversal for propofol, etomidate, ketamine — supportive care only

— Loss of waveform → apnea

— Rising ETCO2 with preserved waveform → hypoventilation

— Falling ETCO2 → low cardiac output, ROSC failure, apnea

— I: full uvula visible

— II: partial uvula

— III: soft palate only

— IV: hard palate only (predicts difficult intubation)

— Brief, painful → etomidate or propofol (short-acting, hemodynamically tolerated)

— Avoid midazolam alone (slow onset, prolonged recovery)

— Ketamine + ondansetron is the standard combo

— IM ketamine 4–5 mg/kg if no IV

— Atropine NOT routinely indicated

— Laryngospasm → Larson's point + jaw thrust

— Hypotensive → ketamine or etomidate

— Hypertensive/CAD → propofol or midazolam (avoid ketamine)

— Reactive airway → ketamine (bronchodilator)

— Adult shoulder reduction → ketofol or propofol + fentanyl

— Pediatric forearm fracture → IV ketamine

— Elderly hip dislocation → etomidate or fascia iliaca block

— Cardioversion in stable AFib → etomidate

— Abscess I&D in toddler → IM ketamine

Board pearl: "Ketamine is the airway agent" — preserves respiratory drive, protective reflexes, hemodynamics, and provides analgesia. When the stem describes a hypotensive trauma patient or asthmatic needing PSA, ketamine is almost always the answer.

Drug-side effect pairings (rapid recall):

Reversal agent pairings:

Capnography findings:

Mallampati class:

Cardioversion sedation:

Pediatric pearls:

Hemodynamic agent selection:

Common scenarios:

Beers criteria avoidance in elderly: midazolam, meperidine, prolonged benzos

Board Question Stem Patterns

— Hypotensive trauma patient → ketamine or etomidate

— Severe HTN with aortic dissection → propofol or midazolam (NOT ketamine)

— Active asthma exacerbation needing PSA → ketamine (bronchodilator)

— Elderly with CAD needing cardioversion → etomidate

— Apnea on propofol with capnography loss → stimulate, jaw thrust, BVM

— Pediatric laryngospasm post-ketamine → jaw thrust + Larson's maneuver + positive pressure

— Emergence agitation post-ketamine → midazolam 1–2 mg IV

— Etomidate myoclonus mimicking seizure → observe, self-limited (NOT benzodiazepine)

— Chronic benzodiazepine user with oversedation → supportive care, NOT flumazenil

— Best monitor to detect hypoventilation early → capnography (ETCO2)

— Required personnel → separate sedation provider from procedurist

— Recent oral intake + urgent reduction → proceed (ACEP: NPO not absolute)

— STOP-BANG 7, BMI 50, elective procedure → defer to anesthesia/OR

— Unstable VT requiring cardioversion → proceed immediately, emergency doctrine

— Forearm fracture in 4-year-old → IV ketamine + ondansetron

— Laceration in cooperative 6-year-old → LET gel + local lidocaine ± intranasal midazolam

— Awake, alert, vitals stable, ambulating, has escort → discharge with 24-hr restrictions

— Still somnolent 2 hr after midazolam → continue observation, consider flumazenil if respiratory compromise

— Intoxicated patient refusing PSA for emergent procedure → emergency doctrine, document, proceed

— Pediatric patient, parent refusing for life-threatening need → ethics consult, court order

— Elderly hip fracture → fascia iliaca block (not IV opioids, not PSA)

— Distal radius fracture in cooperative adult → hematoma block

Key distinction: Stems that emphasize "82 years old" or "BMI 45 with OSA" are testing recognition of when ED PSA is wrong — the answer is often a regional block or anesthesia consultation, not a different sedative.

Pattern 1 — "Which agent for this hemodynamic profile?"

Pattern 2 — "What's the next step after adverse event?"

Pattern 3 — "What's the appropriate monitoring?"

Pattern 4 — "Should we proceed or defer?"

Pattern 5 — "Which pediatric agent and adjunct?"

Pattern 6 — "Discharge readiness?"

Pattern 7 — "Capacity and consent?"

Pattern 8 — "Best alternative to PSA?"

One-Line Recap

Procedural sedation in the ED is a structured, monitored continuum of pharmacologic depth tailored to procedure pain/duration and patient comorbidity — with agent selection driven by hemodynamics and airway risk, mandatory capnography for moderate-deep sedation, a dedicated monitoring provider, reversal agents and airway equipment ready, and recovery to baseline before discharge with a responsible adult escort.

— Adult shoulder reduction (healthy) → ketofol or propofol + fentanyl

— Pediatric fracture reduction → IV ketamine + ondansetron (IM if no access)

— Hypotensive patient or cardioversion → etomidate (hemodynamically neutral)

— Asthmatic or analgesia-priority → ketamine (bronchodilator + analgesic)

— Elderly hip pain → fascia iliaca block, not PSA

— Continuous pulse oximetry + ECG + capnography (ETCO2) + q3–5 min BP

— Separate provider monitoring sedation distinct from the proceduralist

— SOAP-ME at bedside (Suction, Oxygen, Airway, Pharmacy/reversal, Monitors, Equipment)

— Capnography detects hypoventilation 30–60 sec before SpO2 drops, especially on supplemental O2

— Avoid midazolam in elderly (Beers); avoid meperidine in renal disease; avoid ketamine in severe HTN/CAD

— Recent oral intake is NOT an absolute contraindication per ACEP — weigh urgency vs aspiration risk

— Etomidate myoclonus ≠ seizure; ketamine emergence treated with low-dose midazolam

— Aldrete ≥9, return to baseline mental status, tolerating PO, ambulating

— Responsible adult escort, no driving/machinery/legal decisions × 24 hr

— Written instructions with red-flag return precautions and procedure-specific follow-up

Board pearl: The single highest-yield ED PSA principle for Step 3 is: match the agent to the patient's hemodynamics and the procedure's pain profile, monitor with capnography, and document a responsible escort before discharge — these three decisions cover the majority of vignette stems.

Drug-to-scenario shortlist:

Monitoring non-negotiables:

Safety pearls:

Discharge essentials: