Procedural Sedation

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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

• Mallampati Score (Wikipedia)
• ASA Physical Status Classification (Wikipedia)