Procedural Sedation in Emergency Medicine 2020

Author: Gavin Lloyd / Editors: Steve Fordham, Gavin Lloyd / Reviewer: Mehdi Teeli / Code: / Published: 11/03/2021

This module should help you to: 

Discuss the indications for procedural sedation
Identify at risk patients
Decide which pharmacological agent is most appropriate
Ensure that your practice is safe
Consider modifications to your practice for children

Duration: 60 mins


  1. Curriculum
  2. 2012 CEM report
  3. Green SM, Roback MG, et al. Fasting and Emergency Department Procedural Sedation and Analgesia: A Consensus-Based Clinical Practice Advisory: Ann Emerg Med 2007:49:454-461
  4. Mallampati SR, Gatt SP, Gugina LD, et al. A clinical sign to predict difficult intubation: a prospective study. Can Anesth Soc J 1985;32:429
  5. ACEP 2014 policy
  6. Newman DH et al. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1,367 paediatric procedural sedations. Ann Emerg Med 2003; 42:627-635
  7. Godwin SA, Caro DA, et al. Clinical Policy: Procedural Sedation and Anaesthesia in the Emergency Department. Ann Emerg Med: 2005;45:177-196
  8. Opp DR. Local anaesthesia in minor lacerations: topical TAC vs lidocaine infiltration. Ann Emerg Med 1980:9:568-571
  9. Bonadio WA, Wagner B. Efficacy of TAC topical anaesthetic for repair of paediatric lacerations. AmJ Dis Child. 1988;142:203-205
  10. Anderson AB et al. Local anaesthesia in paediatric patients: topical TAC vs lidocaine. Ann Emerg Med1990;19:519-522
  11. Hegenbarth MA. Comparison of topical tetracaine, adrenaline, and cocaine anaesthesia with lidocaine infiltration for repair of lacerations in children. Ann Emerg Me.1990;19:63-68
  12. Menegazzi JJ, Paris PM, Kersteen CH et al. A randomised controlled trial of the use of music during laceration repair. Ann Emerg Med 199: 20:348-350
  13. Erwin DM. Emergency room hypnosis for the burnt patient. Am J Clin. Hypnosis 1986;27:7-12
  14. Zelter L, LeBaron S. Hypnosis and non-hypnotic techniques for reduction of pain and anxiety during painful procedures in children and adolescents with cancer. Paediatrics 1982;101:1032-1035
  15. Kuttner L. Management of young childrens acute pain an anxiety during invasive medical procedures. Paediatrician 1989;16:39-44
  16. French GM et al. Blowing away shot pain; a technique for pain management during immunisation. Paediatrics 1994;93:384-388
  17. Harrison A. Preparing children for venous blood sampling. Pain 1991;45:299-306
  18. Kendall JM, Reeves BC, Latter VS. Multicentre randomised controlled trial of nasal diamorphine for analgesia in children and teenagers with clinical fractures. BMJ 2001; 322: 261 265
  19. Green SM, Krauss B, et al. Clinical practice guideline for emergency department ketamine dissociative sedation in children. Ann Emerg Med 2004 44:5; 460-471
  20. Green SM, Rothrock S, Lynch E, et al.   Intramuscular Ketamine for Pediatric Sedation in the Emergency Department: Safety Profile in 1,022 Cases. Ann Emerg Med 1998; 31:688-697
  21. Agrawal D, Shannon F. Manzi, Gupta R, Krauss B, et al. Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a paediatric emergency department. Ann Emerg Med 2003; 42:636-646
  22. Wathen JE, Roback MG, Mackenzie T, et al. Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double-blind, randomized, controlled emergency department study. Ann Emerg Med 2000; 36: 7988.
  23. Sherwin TS, Green SM, Khan A, et al. Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomized, double-blind, placebo- controlled trial. Ann Emerg Med 2000; 35: 22938
  24. Green SM, Roback MG, Krauss B et al. Predictors of Airway and Respiratory Adverse Events with Ketamine Sedation in the Emergency Department; An Individual-Patient Data Meta-analysis of 8,282 Children. Ann Emerg Med 2009;54:158-168
  25. Reid, C. Larygospasm after Ketamine. Resus Me. 2012
  26. Heinz P, Greelhoed GC, Wee C, et al. Is atropine needed with ketamine sedation? A prospective, randomised, double blind study. Emergency Medicine Journal 2006;23:206-209
  27. Brown L, Green SM, Sherwin TS, et al. Ketamine with and without atropine; whats the risk of excessive salivation? Acad Emerg Med 2000:10:482-483
  28. The Royal College of Emergency Medicine. Ketamine Procedural Sedation for Children in the Emergency Department. Revised Feb 2020
  29. The Royal College of Emergency Medicine. Pharmacological Agents for Procedural Sedation and Analgesia in the Emergency Department. March 2019 (Revised)
  30. Canders Caleb P., Tong Gregory E. and El Fawal Nadine. Procedural Sedation in the Emergency Department. ReliasMedia June, 2019.
  31. ACEP 2017 Policy
  32. The Royal College of Emergency Medicine, Ketamine Procedural Sedation for Children in the Emergency Department. revised Feb 2020.
  33. The Royal College of Emergency Medicine, Pharmacological Agents for Procedural Sedation and Analgesia in the Emergency Department, revised March 2019.
  34. Canders C P, Tong G E, Fawal N El, Procedural Sedation and Analgesia in the Emergency Department. Monograph, ReliasMedia 2019.

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