EDAITUTOR
ED Procedures · 04 v0.1 · illustrated Educational use only

Procedural
Sedation

Safe, depth-controlled sedation for brief, painful or distressing ED procedures in adults and children — assess, plan one level deeper, monitor, and be ready to rescue the airway.

Patient receiving inhalational sedation via face mask with monitoring

🔴 Before you start

Sedation is a continuum — you cannot reliably stay at one point, so plan, staff and equip for one level deeper than you intend. You need a dedicated sedationist whose only job is the airway and the patient, and a separate proceduralist — never sedate solo. Resus bay, full monitoring (including waveform capnography), a checked airway trolley and reversal drugs ready before the first dose.

Depth of sedation — it is a continuum, not a switch (ANZCA PS09)

Minimal

Anxiolysis. Responds normally to voice. Airway & ventilation unaffected.

e.g. low-dose midazolam · N₂O

Moderate

"Conscious" sedation. Purposeful response to voice ± touch. Airway maintained, breathing adequate.

e.g. titrated opioid + benzo

Dissociative

Ketamine. Trance-like cataleptic state; reflexes & breathing usually preserved. Sits outside the continuum.

e.g. ketamine ≥1 mg/kg IV

Deep

Purposeful response only to repeated / painful stimulus. Airway may need support; ventilation may be inadequate.

e.g. propofol bolus

General anaesthesia

Unrousable, even to pain. Airway & ventilation support required. Not a target for ED PSA.

rescue: BVM → LMA → ETT

⚪ key principleYou cannot reliably hold a patient at one point on the continuum. Plan, staff and equip for one level deeper than your target depth, and titrate slowly to effect. Source: ANZCA PS09 · ACEP procedural sedation policy.

University of Michigan Sedation Scale (UMSS)

ScoreStateResponse
0Awake / alertNormal
1Minimally sedatedTired / sleepy, appropriate response to voice
2Moderately sedatedSomnolent, easily roused by light touch / voice
3Deeply sedatedRoused only by significant physical stimulus
4UnrousableNo response — manage as GA

Use it to record baseline, depth during the procedure, and recovery. Discharge when back to the pre-sedation UMSS. Source: Malviya / UMSS (validated paediatric & adult sedation scale).

Good candidates / indications
  • Fracture & joint reductions (Colles', ankle)
  • Shoulder / hip / patella dislocation relocation
  • Incision & drainage of abscess
  • Lumbar puncture (esp. children)
  • DC cardioversion (brief, deep)
  • Complex laceration repair · burns dressing
  • Foreign-body / tube removal · paraphimosis
  • Imaging or a procedure needing the child to stay still
⚪ consensusBest for short, painful or distressing procedures where the patient is otherwise well and the airway is reassuring.
🟢 ACEM · LITFL · RCH · DFTB
Don't / department stop-criteria
  • No second clinician — can't staff a sedationist + proceduralist
  • Inadequate monitoring or no resus space
  • Predicted difficult airway without a backup plan
  • Haemodynamic instability · undifferentiated sepsis
  • High aspiration risk + the procedure can wait
  • ASA IV–V / significant comorbidity
  • Skill mix / experience inadequate for the depth needed
  • Better done in theatre / by anaesthetics
⚪ stopIf any of these are present, pause: defer, escalate, or move to a controlled environment. "Can this wait?" is always a fair question.
🟡 ACEM · ANZCA PS09 · LITFL
Pre-sedation assessment — history, risk, airway, fasting

AMPLE + focused

  • Allergies (incl. egg/soy, prior agents)
  • Medications (opioids, sedatives, anticoagulants)
  • Past history — cardioresp disease, OSA, reflux, prior sedation / anaesthetic & any adverse event
  • Last meal (note, don't be ruled by it)
  • Events — current illness, intoxication, the procedure & expected duration

Examine the airway and cardioresp system. Weigh urgency vs risk.

ASA physical status

OK in ED — ASA I–II

Healthy, or mild well-controlled systemic disease.

Maybe OK — ASA III

Severe but stable disease — senior decision, plan for rescue, lighter target.

Not in ED — ASA IV–V

Defer, or do it with anaesthetics / in a controlled environment.

Predict the difficult airway

  • LEMON — Look · Evaluate 3-3-2 · Mallampati · Obstruction · Neck mobility
  • Upper-lip-bite test — can't cover upper lip with lower incisors = predicts difficulty
  • Beard, obesity, short/large neck, small mouth, retrognathia, prior difficult airway
🟡 evidenceThe upper-lip-bite test is the single strongest bedside predictor (class III, +LR ≈ 14); Mallampati 3–4 +LR ≈ 4. Source: Detsky ME et al. JAMA 2019 (Rational Clinical Examination).
🟡 fastingFasting status alone should not be a barrier to, or reason to delay, ED procedural sedation. ASA fasting rules were written for elective GA and are not validated for emergency PSA — there is no good evidence that fasting reduces aspiration in this setting. Balance urgency, planned depth and aspiration risk, and document the reasoning. Source: Green SM et al. Ann Emerg Med 2019 · ACEP.
Increased risk of negative outcome
  • Extremes of age — the very young & the elderly
  • Difficult facial or neck anatomy — anticipated difficult BVM ventilation or intubation
  • Patients with significant underlying disease states
  • Previous anaesthetic / sedation difficulty
⚪ cautionThese features warrant extra caution and early senior involvement. Keep a low threshold for GA in theatre over ED procedural sedation, or to defer until the situation is optimised.
🟡 ACEM · ANZCA PS09 · LITFL
Preparation & monitoring — set up before the first dose

Team & space

Resus bay. Dedicated sedationist (airway only) + separate proceduralist. Trained assistant. Shared plan / time-out.

🟢 ANZCA PS09 · ACEM

EtCO₂SpO₂NIBP

Monitoring

Continuous SpO₂ + waveform capnography, ECG, NIBP q3–5 min, conscious level (UMSS). EtCO₂ detects apnoea earliest.

🟢 ANZCA · ACEP

SOAP-ME

Airway trolley — SOAP-ME

Suction · Oxygen + BVM · Airways (OPA/NPA, LMA, ETT, laryngoscope) · Pharmacy · Monitors · Equipment / IV.

🟢 LITFL · EMCrit

Drugs ready

IV access & flush. Reversal: naloxone, flumazenil. Rescue: suxamethonium, atropine, adrenaline, IV fluids. Antiemetic drawn up.

🟢 ANZCA PS09

🟢 monitoringAdd waveform capnography to standard monitoring: it detects hypoventilation / apnoea before SpO₂ falls — particularly valuable under drapes or for deep sedation. Pre-oxygenate and give supplemental O₂. Source: ANZCA PS09 · ACEP · EMCrit.
Agents — drug-of-choice by scenario

Reductions / dislocations

Ketamine (dissociative) — first-line in children; or propofol + fentanyl in adults.

deep, brief, very painful

Needs stillness (LP, I&D, imaging)

Propofol titrated, or ketamine — choose by haemodynamics & analgesia need.

moderate–deep

Minor / short (lacerations)

Nitrous oxide 50–70% ± local anaesthetic. Rapid on/off, child-friendly.

minimal–moderate

DC cardioversion

Propofol or ketamine — very brief deep sedation; pre-oxygenate, anticipate apnoea.

brief deep

⚪ principleThere is no single "best" agent — match the drug to the depth, duration and analgesia needed, the patient's physiology, and your familiarity. Titrate slowly; combinations (e.g. propofol + opioid) compound respiratory depression.
Ketamine
Dose
  • Dissociative: 1–1.5 mg/kg IV over 1–2 min
  • IM (no IV): 4–5 mg/kg
  • Top-up: 0.5 mg/kg IV q5–10 min to maintain
  • Sub-dissociative analgesia: 0.1–0.3 mg/kg IV
🟢 LITFL · RCH · ACEPPreserves airway reflexes & spontaneous ventilation; bronchodilator; cardiostable. The paediatric work-horse.
Cautions
  • Age < 3 months (higher airway risk)
  • Active psychosis / schizophrenia (relative)
  • Emergence phenomena — commoner in adults; calm environment, treat distress with low-dose midazolam (not routine prophylaxis, esp. in children)
  • Hypersalivation — anti-sialagogue (atropine/glycopyrrolate) not routinely needed
  • Antiemetic: ondansetron 0.15 mg/kg (max 8 mg) IV reduces vomiting
🟢 RCH · DFTB · LITFL · ACEP
Propofol
Dose
  • Induction: 0.5–1 mg/kg IV over 1–2 min
  • Titration: 0.5 mg/kg IV q1–3 min to effect
  • Reduce dose in the elderly & haemodynamically marginal
🟡 cautionDose-dependent apnoea & hypotension. No analgesia — pair with local or an opioid. Pre-oxygenate & titrate.
Notes
  • Rapid on/off — ideal for brief deep sedation & cardioversion
  • Pain on injection (lignocaine co-administration helps)
  • PRIS (propofol infusion syndrome) — a concern with prolonged high-dose infusions, not single ED boluses, but be aware
  • Egg/soy allergy — modern formulations low risk
🟢 LITFL · RCH · Deranged Physiology
Midazolam
Dose
  • IV: 0.02–0.05 mg/kg, titrated slowly (wait 1–2 min between doses)
  • Anxiolysis & amnesia — minimal analgesia
🔴 reversalFlumazenil 0.01 mg/kg (max 0.2 mg) IV, repeat to ~1 mg max. Caution: may precipitate seizures in benzo-dependence / co-ingestion — use selectively, not routinely.
🟡 synergyProfound additive respiratory depression with opioids — give smaller doses, slower, and watch capnography.

Note: RCH paediatric conscious-sedation protocols may titrate to 0.1 mg/kg (max 2.5–5 mg) — confirm against your local protocol.

🟢 LITFL · RCH
Nitrous oxide (N₂O)
Dose
  • 50–70% inhaled (Entonox = fixed 50/50; up to 70% via blender)
  • Self-administered demand valve where able; scavenging required
🟢 RCH · DFTBMinimal–moderate sedation + analgesia, rapid on/off — excellent for minor / short procedures and cooperative children.
Exclusions
  • Pneumothorax · bowel obstruction
  • Recent diving · middle-ear / sinus disease · pneumocephalus
  • Recent intra-ocular gas
  • Cannot cooperate · first-trimester pregnancy (staff exposure)
🟢 RCH · DFTB · ACEM
Opioids (fentanyl / morphine)
Dose
  • Fentanyl 0.5–1 mcg/kg IV, titrated (rapid, short)
  • Morphine 0.05–0.1 mg/kg IV (slower onset, longer)
🟡 cautionAnalgesia, not sedation. Additive respiratory depression with propofol / midazolam — go slow, smaller doses.
🔴 reversalNaloxone 0.4 mg IV titrated (adult); 0.1 mg/kg (max 0.4 mg) paeds. Short half-life — re-dose / observe for re-sedation.
🟢 LITFL · RCH
Rescue / adjunct drugs
  • Suxamethonium (laryngospasm) — 1–2 mg/kg IV, or 3–4 mg/kg IM if no IV
  • Atropine 0.02 mg/kg IV (max ~0.5–0.6 mg) for bradycardia
  • Ondansetron 0.15 mg/kg (max 8 mg) IV — antiemetic
  • Naloxone — opioid reversal (see opioid card)
  • Flumazenil — benzodiazepine reversal (see midazolam card)
  • Adrenaline & IV fluids — for anaphylaxis / hypotension
⚪ have-readyDraw up rescue drugs & calculate weight-based doses before sedation — not during the crisis.
🟢 LITFL · DFTB · RCH
Paediatric specifics — ketamine country

Principles

  • Ketamine is first-line for paediatric PSA — wide safety margin, preserves the airway
  • No routine midazolam prophylaxis — emergence phenomena are uncommon in children and prophylactic benzo may increase adverse events / vomiting
  • Nitrous needs cooperation — generally ≥ 1 yr for delivered N₂O; self-administration usually ≥ 5 yr; caution < 2 yr; max 70%
  • Everything is weight-based; use the smallest effective dose
  • Non-pharmacological first (distraction, parents, topical/local anaesthetic)
  • Atropine 0.02 mg/kg only if bradycardic — not a routine pre-med

Paediatric quick doses

AgentDose
Ketamine IV1–1.5 mg/kg over 1–2 min; top-up 0.5 mg/kg
Ketamine IM4 mg/kg (RCH; some quote 4–5)
Propofol IV0.5–1 mg/kg then 0.5 mg/kg titration
Midazolam IV0.05–0.1 mg/kg (max 2.5 mg) titrated
Nitrous oxide50–70% inhaled (cooperation needed)
Ondansetron IV0.15 mg/kg (max 8 mg)

Always confirm against the RCH / local weight-based guideline before drawing up.

🟢 paeds sourceDoses anchored to the RCH Clinical Practice Guidelines (Ketamine & Procedural Sedation) and Don't Forget the Bubbles. Verify the current local protocol — paediatric dosing is updated periodically.
Intranasal dexmedetomidine (paediatric)
🟢 what it isSelective α₂-adrenoceptor agonist — sedation + anxiolysis with minimal respiratory depression. Increasingly used in paediatric ED for minimally painful or distressing procedures, imaging (CT / MRI), EEG, and as premedication. Particularly useful in anxiety, autism spectrum disorder, and children at risk of emergence delirium.
Dose — intranasal
  • 1–4 microgram/kg (max 200 microgram) as a single dose via mucosal atomisation device (MAD)
  • Give 30–60 min before the procedure; onset ~30–45 min
  • For children ≥ 10 kg and ≥ 1 year
  • Divide between both nostrils if volume > 1 mL (> 100 microgram)
🟡 cautionNot an analgesic — add analgesia for painful procedures. Slow onset — plan ahead; not for time-critical sedation.
Watch & precautions
  • Bradycardia & hypotension — usually mild / self-limiting after intranasal use, but monitor
  • Significant bradycardia / heart block
  • Ventricular dysfunction / CHF · hypovolaemia · hepatic impairment
  • Drugs affecting cardiac conduction — digoxin, β-blockers, calcium-channel blockers, amiodarone
🔴 IV = ICU onlyIV dexmedetomidine is critical-care only (loading 0.5–1 microgram/kg over ≥ 15 min; maintenance 0.1–1.4 microgram/kg/hr) — not routine ED procedural sedation.
⚪ monitoringDedicated nurse / doctor, continuous SpO₂ + HR, baseline obs + UMSS, then 15-minutely obs until back to baseline.
🟢 PCH (CAHS WA) · RCH · DFTB
Complications & rescue — anticipate, detect early, act

Laryngospasm

Larson's notch (laryngospasm notch) — pressure point behind the ear lobe

Signs: stridor, ↓SpO₂, paradoxical / tracheal-tug effort, silent chest if complete.
Manage: stop the stimulus → 100% O₂ → jaw thrust + CPAP → Larson's manoeuvre (firm pressure in the notch behind each earlobe, between mastoid & mandibular ramus). If it persists → suxamethonium 1–2 mg/kg IV. If no IV access → suxamethonium 3–4 mg/kg IM injected into the tongue (intralingual); intraosseous is an alternative if available. Add atropine 0.02 mg/kg if bradycardic; ventilate / prepare to intubate. Laryngospasm may recur as the neuromuscular blockade wears off — keep watching.

Apnoea · hypotension · vomiting

  • Apnoea / hypoventilation — capnography detects it first; stimulate, jaw thrust, BVM, reduce dosing; reverse if opioid/benzo
  • Hypotension — usually propofol; IV fluids, reduce dose, reassess, leg-raise
  • Vomiting / aspiration — suction ready, position, ondansetron (esp. ketamine), suction & reposition if it occurs
  • Bradycardia — atropine 0.02 mg/kg IV
⚪ tipDesaturation? Look at the patient and the capnograph first — reposition the airway before reaching for drugs.

Airway rescue ladder

  • 1. Reposition — head-tilt / jaw-thrust, OPA / NPA
  • 2. 100% O₂ + two-person BVM
  • 3. Supraglottic airway (LMA)
  • 4. Intubate (RSI if needed)
  • 5. Can't intubate, can't oxygenate → front-of-neck access

Most events are transient and respond to basic airway support & time. Stop, oxygenate, reassess — escalate only as needed.

🟢 evidenceSerious adverse events are uncommon and the great majority are managed with simple airway manoeuvres and oxygen. Early detection (capnography) and a prepared team are what keep it safe. Source: LITFL · DFTB · EMCrit · ACEP.
Recovery / discharge criteria
  • Back to pre-sedation UMSS / conscious level, oriented
  • Airway reflexes intact; vitals at baseline, SpO₂ maintained on room air
  • Tolerating oral fluids without nausea
  • Pain controlled
  • Ambulating at pre-sedation baseline (age-appropriate)
  • Adequate observation period completed
⚪ consensusRecover in a monitored area until criteria are met — recovery time tracks the agent's offset, not the procedure length.
🟢 ACEM · ANZCA PS09 · RCH
Safe discharge
  • Discharge into the care of a responsible adult
  • Written advice — who/when to call, red flags
  • No driving, operating machinery, alcohol or important decisions for ~24 h
  • Children — supervise closely; expect some drowsiness / ataxia after ketamine
  • Document agent(s), doses, depth, monitoring, adverse events & recovery
⚪ safetyDo not discharge alone after sedation. If criteria aren't met, keep observing — late re-sedation can occur (esp. long-acting opioids after naloxone wears off).
🟢 ACEM · ANZCA PS09 · RCH

ED AI Tutor — ED Procedures Series · v0.1 · For clinician education only. Not a substitute for clinical judgement, local guidelines or senior oversight. Always verify drug doses, contraindications and discharge criteria against current institutional protocols.