Learn About Procedural Sedation in the Emergency Department Guidelines

procedural sedation in the emergency department guidelines Procedural sedation (PS) is used to relieve pain and anxiety associated with therapeutic or diagnostic procedures while maintaining full cardiorespiratory function. It is routinely performed in the emergency department (ED) and has been proven safe when performed by a trained emergency physician.  

Learning about procedural sedation in the emergency department guidelines can lower its associated risks. Explore the subject with experts from Hospital Procedures Consultants.

Procedural Sedation: What Is It Used For?

Procedural sedation is indicated for various hospital procedures, including:

  • Biopsy or I&D procedures
  • Bone marrow biopsy and aspiration
  • Extensive burn debridement
  • Foreign body removal CT or MRI scan sedation
  • Fracture reductions
  • Laceration repair
  • Synchronized DC cardioversion
  • Shoulder, elbow, or hip dislocations
  • Chest tube placement

It can also used for deep line placement.

Understanding the Levels of Sedation 

There are 3 levels of intravenous sedation:

  • Anxiolysis: Patient is drowsy but still responsive to verbal speech. 
  • Moderate Sedation (conscious sedation): Abnormally drowsy, but the patient responds to light tactile stimulation. 
  • Deep Sedation: Asleep, but noxious stimuli evokes a purposeful reaction.

Capnography can detect respiratory depression 17.6 times better than standard monitoring. It also reduces serious sedation-related adverse events due to inadequate oxygenation.

A Step-by-step Guide to Procedural Sedation 

Based on procedural sedation in the emergency department guidelines, here are the steps you need to follow:

Document Medical History

Inquire about the patient’s medical history concerning fever, GERD, heart disease, hypertension, liver disease, lung disease, nausea, renal disease, rhinorrhea, seizures, and stroke/CNS disease. You can also use the STOP-BANG questionnaire for obstructive sleep apnea (OSA).

Ensuring Suitability 

Refer to the American Society of Anesthesiologists (ASA) classification to identify their health status and predict perioperative risks for morbidity and mortality. Avoid PS if the patient has hemodynamic instability or exhibits respiratory distress.  

Assessing Airway 

A study established that patients with Mallampati scores of III and IV were 3.7 times more likely to experience difficult intubation. The same score was 77% sensitive and 96% specific in predicting difficult intubation in children.

You can also use the 3-3-2 Rule to assess jaw opening, chin length and thyromental distance and assess neck extension (≥ 70 degrees is normal). as markers of a possible anatomically difficult airway

Get Consent 

Brief the patient on the procedure’s benefits, risks, and alternatives. Document evidence of their consent. Without documentation and a proper briefing, PS is contraindicated unless medical records show a lack of mental capacity.

You should also speak to them about peri-procedural fasting guidelines.

Remain updated in this area. Recommendations by ACEP suggest PS can be safely performed on adults and children without preprocedural fasting.

Monitor Vital Signs 

All patients receiving procedural sedation in the emergency department must have the following monitored:

  • BP
  • ETCO2 
  • Rhythm
  • SpO2

Ideally, a separate certified provider should monitor sedation.

Have Basic Equipment Nearby

Procedural sedation requires:

  • Bag-valve mask equipment
  • Crash cart
  • Nasal cannula or face mask for oxygen
  • Oral airway and nasal trumpet
  • Suction equipment

Using the Right Medications 

Here are the preferred medications for PS. Select sedatives with the least effect on hemodynamics. The level of sedation must preserve protective reflexes and respiratory function. However, it should be potent enough to offer amnesia, relaxation, and analgesia. 


Benzodiazepines increase the efficacy of the interaction between GABA, its receptor, and the chloride channel. It is often co-administered with opioids as they have similar pharmacokinetic profiles (rapid onset and offset). 

Midazolam and lorazepam are commonly used for this procedure. 

Paradoxical reactions are rare with this class of drugs, occurring in less than 1% of the general population. For oversedation with benzodiazepines, you can reverse the action of benzodiazepines with flumazenil UNLESS the patient has a history of seizures or may experience seizures due to chronic benzodiazepine use; these would be reasons to NOT administer Flumazenil to reverse benzodiazepine’s effects. since it can lead to status epilepticus.

Note that elderly patients, those with renal failure or cirrhosis and debilitated patients may exhibit greater sensitivity to systemic benzodiazepines; therefore, would decrease doses by at least 50% in these patients. 


Thanks to its rapid onset (5 to 15 seconds) and rapid recovery (5 to 15 minutes), etomidate is the optimal sedative-hypnotic for rapid sequence intubation in the ED at a dose of 0.3 mg/kg IVP (up to 20 mg). For PS, typical doses are 0.1-0.15 mg/kg (up to 10 mg) IVP. However, it can cause apnea and has been shown to have adverse effects like myoclonus (30% to 60% incidence), postoperative nausea and vomiting, and biochemical adrenocortical suppression.  Patients typically do not develop etomidate-induced clinical adrenal insufficiency.


Intravenous ketamine is safe and effective for procedural sedation in the emergency department. 

Avoid administering it to patients with the following characteristics:

  • Active psychosis
  • Acute coronary syndrome
  • Decompensated CHF
  • Glaucoma or acute globe injury
  • Uncontrolled hypertension

It is also contraindicated in children younger than three months of age.


Ketofol, prepared with a 5-mg/mL concentration of ketamine and propofol, is dissociative anesthetic

It often preserves muscle tone and maintains protective airway reflexes and spontaneous respiration. It has been associated with less hypotension, better sedation, and increased patient comfort and safety than propofol alone. 

But it can bring sympathomimetic reactions, aggravate laryngospasm, increase intracranial pressures, and worsen postoperative nausea and vomiting.


Opioids induce sedation, anxiolysis, and systemic analgesia while controlling procedure-induced discomfort. They’re often used with other drugs but are typically administered before benzodiazepines. 

Morphine’s peak effect occurs in less than 5 minutes. If you’re looking for a more potent alternative that doesn’t compromise peak effect, use  hydromorphone. It is approximately 2 to 8 times more potent than morphine. Alternatively, you can consider fentanyl, which has a peak effect of 1 to 2 minutes and is typically 50 to 100 times more potent.

Note that elderly patients, those with renal failure or cirrhosis and debilitated patients may exhibit greater sensitivity to systemic opioids; therefore, would decrease doses by at least 50% in these patients. 


Propofol, also called “milk of amnesia”, is a non-opioid agent that provides sedation and amnesia without analgesia. It also has antiemetic effects on the brain, which helps reduce postoperative nausea and vomiting.

Clinicians noticed a marked reduction in hypotension during induction if fentanyl was administered 5 minutes before propofol AND the dose of propofol was decreased by 50%.

Incidence of Adverse Events 

A systematic review and meta‐analysis on procedural sedation in the ED noted these adverse events:

  • Hypoxia, incidence of 40.2 per 1,000 sedations
  • Vomiting, incidence of 16.4 per 1,000 sedations
  • Hypotension, incidence of 15.2 per 1,000 sedations

It also recorded one case of aspiration in 2,370 sedations (1.2 per 1,000) and one case of laryngospasm in 883 sedations (4.2 per 1,000).

Among pediatric populations, oxygen desaturation and vomiting have been identified as major issues.

To keep patients from deteriorating post-procedure, pulse oximetry monitoring is non-negotiable. Clinicians can use the Aldrete Scoring System to evaluate the patients’ physiological recovery from anesthesia before discharging them.

Reducing the Need for Sedation with Topical Anesthetics

Topical anesthesia can be used on patients who cannot tolerate injectable anesthetics.  

EMLA Cream

EMLA contains a mixture of 2 amide-type local anesthetics, lidocaine and prilocaine. Combined with 1% mepivacaine infiltration, it is effective for pain reduction during venipuncture and superficial surgery.

LET Cream

LET cream is 4% lidocaine, 0.05% epinephrine, and 0.5% tetracaine. It offers significant pain reduction and can significantly reduce the number of patients requiring infiltrative analgesia.

J-Tip Injector 

J-tip is a single-use device that allows an intradermal needle-free jet injection of 1% buffered lidocaine. During a double-blinded trial involving infants younger than 3 months, it reduced pain and length of cry.


Procedural sedation in the emergency department guidelines requires specific training and advanced skills to master upper airways, ventilation, and circulation. 

Our procedural sedation course will familiarize you with the ins and outs of the medical technique so you can improve the quality of care you deliver. 


Bellolio, M. F. Gilani, W. I. Barrionuevo, P. Murad, M. H. Erwin, P. J. Anderson, J. R. Miner, J. R. Hess, E. P. Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta‐analysis. Acad Emerg Med. 2016 Feb; 23(2): 119–134. Published online 2016 Jan 22. doi: 10.1111
Hinkelbein, J. Lamperti, M. Akeson, J. Santos, J. Costa, J. De Robertis, E. Longrois, D. Novak-Jankovic, V. Petrini, F. Struys, M. M. R. F. Veyckemans, F. Fuchs-Buder, T. Fitzgerald, R. European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults. Review Eur J Anaesthesiol. 2018 Jan;35(1):6-24. doi: 10.1097
Hinkelbein, J. Schmitz, J. Lamperti, M. Fuchs-Buder, T. Procedural sedation outside the operating room. Review Curr Opin Anaesthesiol. 2020 Aug;33(4):533-538. doi: 10.1097
Green, S. M. Leroy, P. L. Roback, M. G. Irwin, M. G. Andolfatto, G. Babl, F. E. Barbi, E. Costa, L. R. Absalom, A. Carlson, D. W. Krauss, B. S. Roelofse, J. Yuen, V. M. Alcaino, E. Costa, P. S. Mason, K. P. An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children. Review Anaesthesia. 2020 Mar;75(3):374-385. doi: 10.1111

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