Procedural Sedation and Analgesia in the Emergency Department (Pharmacology CME) -
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Publication Date: June 2022 (Volume 24, Number 6)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-A or 2-B CME credits. CME expires 06/01/2025.

Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 2 Pharmacology CME credit, subject to your state and institutional approval.

Authors

Joshua Kern, MD

Assistant Professor, Department of Emergency Medicine, University of Texas-Southwestern, Dallas, TX

Alexander Guinn, MD

Department of Emergency Medicine, University of Texas-Southwestern, Dallas, TX

Prayag Mehta, MD

Assistant Professor, Department of Emergency Medicine, University of Texas-Southwestern, Dallas, TX

Peer Reviewers

Jennifer Maccagnano, DO, FACEP, FACOEP

Assistant Professor, NYIT College of Osteopathic Medicine, Old Westbury, NY; Attending Emergency Physician, Maimonides Medical Center, Brooklyn, NY

Mark Silverberg, MD

Director of Disaster Preparedness, Department of Emergency Medicine, Kings County Hospital, Brooklyn, NY

Abstract

Procedural sedation is a common procedure performed in the emergency department and is a fundamental skill for emergency clinicians. With a wide variety of procedures and patient populations, procedural sedation can be systematically tailored to individual patients‘ needs, in order to optimize safety and efficacy. This evidence-based review distinguishes the various levels of sedation, provides insight on which patients are appropriate for procedural sedation, lists adjuncts that should be used, and reviews considerations for special populations. The differences between the most frequently utilized medications are presented, as well as a discussion of documentation requirements and discharge criteria.

Case Presentations

CASE 1

A 30-year-old man with no past medical history presents to the ED after falling off a ladder, landing on his right shoulder…

You perform a 3-view shoulder x-ray and find that his right shoulder is anteriorly dislocated.
The patient states that he had eaten lunch just prior to this event. The patient is in pain and very resistant to any manipulation.
You know that procedural sedation will be needed, but you wonder if he is eligible since he just ate . . .

CASE 2

An 80-year-old man with a past medical history of congestive heart failure, hypertension, and diabetes presents to the ED with chest pain…

His initial ECG demonstrates ventricular tachycardia. He has lower extremity edema with bibasilar rales on exam. He is hypotensive, with a blood pressure of 85/52 mm Hg.
You make the decision that cardioversion with procedural sedation is indicated, but you wonder what would be the best drug(s) to use, given his comorbidities, and whether his ASA physical status class impacts your decision . . .

CASE 3

A 56-year-old obese woman with a history of alcohol abuse, obstructive sleep apnea, and diabetes presents with multiple deep lacerations…

She states that she was intoxicated and trying to jump over a wire fence when her leg got caught on the edge and she fell backwards, suffering large lacerations on her right leg as well as her face.
Both wounds appear to be contaminated. She is hysterical and unable to cooperate with your attempts to irrigate and repair her wounds. She asks for medication to help reduce her pain and anxiety, so you decide to perform procedural sedation.
Given her comorbidities and presentation, what agent(s) would be safest to use in this patient? What adjuncts would be best for these procedures? What are some expected complications and how can you best prepare for them?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.