Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship

Common Scenarios

  • Cardioversion
  • Orthopedic reductions
  • Painful procedures

Three Step Approach to Procedural Sedation

  • Step 1: Risk stratify the patient
    • Mallampati score (aka “How visible is the uvula?”)
      • Level 1: Can visualize THE WHOLE uvula
      • Level 2: Can visualize MOST of the uvula
      • Level 3: Can visualize SOME of the uvula
      • Level 4: Can NOT visualize the uvula
    • ASA (aka “How healthy are they?”)
      • Level 1: Healthy
      • Level 2: Mild illness
        • Hypertension
        • Hyperlipidemia
        • Anemia
      • Level 3: Major illness
        • Diabetes
        • Coronary disease
        • COPD
        • Chronic renal disease
      • Level 4: Extremely unhealthy
        • Dialysis patient
        • Severe heart failure
        • Chronically debilitated
      • Level 5: Dying
        • Patient needs operation to live
          • Intracranial hemorrhage with midline shift
          • Ruptured aortic aneurysm
          • Ruptured papillary muscle with cariogenic shock
          • Dissecting aortic aneurysm
  • Step 2: Informed consent
    • Patients sign a GENERAL CONSENT to treat when registering to the department
    • Many emergency scenarios require physician to operate with IMPLIED CONSENT
    • Many patients have an ADVANCED DIRECTIVE
    • In stable patients and higher risk procedures, separate WRITTEN CONSENT is often required
      • Varies by hospital
      • Typically required for procedural sedation in stable patients
  • Step 3: Gather supplies
    • Nurse and nursing supplies
      • IV
      • Cardiac monitor
    • Respiratory therapy and respiratory supplies
      • Capnography
      • Bag-valve mask
      • Airway box

Top 5 Procedural Sedation Medications

  • Midazolam (“Versed”) – 0.02 mg/kg IV
    • Reduces anxiety prior to procedure
    • Provides no analgesia
  • Fentanyl – 1 mcg/kg IV
    • Reduces pain
    • Useful for painful procedures
      • Incision and drainage
      • Simple reductions
  • Propofol – 0.5-1mg/kg IV
    • General anesthetic
    • Best given “low and slow”
    • Short acting
    • Causes respiratory depression and hypotension
  • Etomidate – 0.15 mg/kg IV
    • General anesthetic
    • Less hypotension than propofol
    • Can cause myoclonus
  • Ketamine – 1-2mg/kg IV
    • “Dissociative”
    • Provides both amnesia AND analgesia
    • Can cause emergence reactions
    • Can cause laryngospasm and secretions

Additional Reading