Procedural sedationMANAGEMENT

SYSTEMIC AND MISCELLANEOUS PRESENTATIONS · 12 SECTIONS

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567 items

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Cardiovascular Presentations71▾

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Neurological Presentations83▾

Gastrointestinal Presentations74▾

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Infectious Disease Presentations148▾

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Toxicologic Presentations80▾

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Pediatric-Specific Presentations19▾

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Systemic and Miscellaneous Presentations17▾

Allergic Transfusion Reaction Anaphylaxis Angioedema Benedikt's Syndrome Cannabis-induced hyperemesis Eczema (acute flare)Gradenigo's Syndrome Horner's Syndrome (Acute)Huntington's Disease (Acute Presentation)Kanavel's Signs Lemierre's Syndrome Procedural sedation Radiation exposure Retained products of conception Sever's Disease Urticaria Venous air embolism

01Approach to the Critical Patient/attcp84

Pre-sedation assessment and risk stratification

›Pre-sedation risk stratification

›Airway assessment

›Mallampati class, thyromental distance, neck mobility, mouth opening

›LEMON screen for anticipated difficult airway

›Prior difficult intubation or difficult mask ventilation history

›ASA physical status classification

›ASA I healthy patient

›ASA II mild systemic disease

›ASA III severe systemic disease

›ASA IV severe systemic disease that is a constant threat to life

›ASA V moribund patient not expected to survive without the operation

›ASA class III or higher predicts increased risk of sedation-related adverse events

›Fasting status stated honestly

›Traditional elective fasting targets are 2 hours for clear liquids, 4 hours for breast milk, 6 hours for infant formula or a light meal, and 8 hours for a fried or fatty meal

›ED evidence does not show a clear association between fasting duration and aspiration or emesis during procedural sedation

›Fasting status alone should not delay an urgent or emergent procedure

›Risk should be individualized on airway anatomy, level of consciousness, injury pattern, and the depth of sedation planned rather than on fasting time alone

›Recent full meal or unknown fasting status favors a lighter target depth and a shorter procedure rather than automatic deferral

›Patients who should be sedated outside the ED

›Anticipated difficult airway with anticipated deep sedation

›ASA IV or V physical status

›Severe obstructive sleep apnea with morbid obesity

›Active vomiting or hemodynamic instability at baseline

›Anticipated prolonged deep sedation or general anesthesia requirement

›Route to operating room anesthesia or interventional sedation service instead of ED procedural sedation

Personnel, equipment, and monitoring readiness

›Readiness bundle before the drug is drawn

›Personnel requirements

›One clinician responsible only for sedation and airway, distinct from the proceduralist

›Trained nurse or second provider for monitoring and drug administration

›Immediate availability of a clinician credentialed in advanced airway management

›Equipment checklist

›Suction tested and within reach

›Bag-valve-mask sized correctly and oxygen source confirmed

›Airway adjuncts including oral and nasal airways at bedside

›Advanced airway equipment and rescue supraglottic device immediately available

›Reversal agents drawn up or immediately accessible

›Defibrillator or code cart accessible

›Monitoring equipment

›Continuous pulse oximetry

›Continuous capnography

›Continuous cardiac monitor

›Automated blood pressure cycling

›IV access secured before sedative administration

Iatrogenic harm review of routine ED interventions

›Walk the routine intervention list before sedating

›Intubation

›Not a routine step of procedural sedation and should remain a bailout, not the plan

›Converting an unplanned sedation failure into an emergent intubation carries higher aspiration and hypoxia risk than a controlled elective airway

›Sedation itself

›Stacking a sedative-hypnotic with an opioid analgesic is the single most common route to clinically significant respiratory depression

›Redosing before the prior dose has taken full effect risks unintentional deep sedation

›Fluid loading

›Pre-treatment crystalloid bolus can reduce propofol-associated hypotension in the volume-depleted patient

›Fluid loading in decompensated heart failure or renal failure risks pulmonary edema and should be avoided

›Oxygen

›Preoxygenation and passive apneic oxygenation extend the safe apnea window

›Supplemental oxygen delays the fall in pulse oximetry after hypoventilation begins, masking the earliest sign of a deteriorating airway

›Vasopressors

›Push-dose phenylephrine or ephedrine may be needed transiently for propofol- or dexmedetomidine-induced hypotension

›Routine pre-treatment with a vasopressor is not indicated and delays recognizing hypovolemia as the true cause of hypotension

›Mechanical circulatory support including intra-aortic balloon pump

›Not applicable to routine procedural sedation

›Relevant only when sedation is being provided to facilitate a cannulation or device placement procedure, in which case hemodynamic goals are set by the proceduralist and cardiology

›Anticoagulation

›Anticoagulated patients have increased bleeding and hematoma risk with the procedure itself, not with the sedation

›Anticoagulation status does not change drug selection for sedation but should be reviewed before an invasive procedure under sedation

›Fibrinolysis

›A patient sedated shortly after fibrinolytic therapy carries elevated bleeding risk from any concurrent invasive procedure

›Defer non-urgent procedural sedation for an invasive procedure until the fibrinolytic bleeding risk window has passed when feasible

›Analgesia

›Opioid analgesia is frequently combined with sedation and is the component most responsible for synergistic respiratory depression

›Treat pain before and during the procedure rather than relying on sedation depth alone to blunt a painful stimulus

Immediate escalation triggers during sedation

›Time-critical deterioration

›Airway and ventilation

›Sustained apnea beyond 20 seconds

›Loss of capnography waveform

›Stridor or inability to move air

›Circulation

›Sudden severe hypotension

›New arrhythmia on continuous monitor

›Escalation pathway

›Stop drug administration and stimulate the patient

›Jaw thrust and 100 percent oxygen by bag-valve-mask

›Call for airway-credentialed clinician immediately if not already present

›Activate resuscitation team for cardiac arrest or refractory hypoxia

02History/hx36

Focused pre-sedation history

›Procedure and prior sedation context

›Procedure indication and expected duration

›Painful versus non-painful procedure

›Anticipated need for immobility

›Prior sedation or anesthesia history

›Prior adverse reaction to sedation or anesthesia

›Family history of malignant hyperthermia

›Prior emergence delirium or paradoxical reaction

›Allergies and medication use

›Egg, soy, or propofol allergy history

›Chronic opioid or benzodiazepine use raising tolerance

›Current sedating medications, alcohol use, or recreational drug use

Fasting status and aspiration risk history

›Aspiration risk assessment

›Time and content of last oral intake

›Clear liquids versus solid or fatty food

›Time since last intake relative to traditional 2, 4, 6, and 8 hour targets

›Factors that increase aspiration risk independent of fasting time

›Active nausea or vomiting

›Reduced level of consciousness at baseline

›Bowel obstruction or ileus

›Pregnancy beyond the first trimester

›Severe gastroesophageal reflux disease

Comorbidities affecting agent selection

›Comorbidity review

›Cardiopulmonary disease

›Obstructive sleep apnea

03Physical Exam/exam23

Airway assessment

›Airway examination

›Anatomic predictors of difficulty

›Mallampati class III or IV

›Thyromental distance under 3 fingerbreadths

›Limited neck extension

›Small mouth opening under 3 fingerbreadths

›Dentition and airway hazards

›Loose or missing teeth

›Facial or mandibular trauma

›Baseline airway sounds

›Stridor at rest

›Snoring pattern suggesting obstructive sleep apnea

Baseline cardiopulmonary and neurologic exam

›Baseline exam

›Vital signs before any drug is given

›Baseline SpO2 on room air

›Baseline blood pressure and heart rate

›Baseline respiratory rate and pattern

›Cardiopulmonary exam

›Breath sounds for wheeze or crackles

›Cardiac auscultation for murmur suggesting valvular disease

›Baseline neurologic and mental status

›Baseline level of consciousness for later comparison

›Baseline motor and sensory exam when the procedure involves a limb

04Differential Diagnosis/ddx23

Differential for intra-procedural deterioration

›Desaturation during sedation

›Hypoventilation from sedative-opioid synergy

›Airway obstruction from tongue or soft tissue collapse

›Laryngospasm

›Aspiration

›Hypotension during sedation

›Direct vasodilation and myocardial depression from propofol

›Alpha-2 agonist effect from dexmedetomidine

›Underlying hypovolemia unmasked by sedation

›Vasovagal response to the procedure itself

›Altered behavior after sedation

›Expected residual sedative effect

›Ketamine emergence reaction

›Paradoxical reaction to a benzodiazepine

›Hypoglycemia as a reversible mimic

›Hypoxia as a reversible mimic

Coding anchors

›Standardized coding

›ICD-10 T41 category, adverse effect of general anesthetics, includes propofol and ketamine

›ICD-10 T42 category, adverse effect of sedatives and hypnotics, includes benzodiazepines

›ICD-10 T40 category, adverse effect of opioids, includes fentanyl

›ICD-10 T88 category, other complications of surgical and medical care, includes anesthesia-related laryngospasm and hypoventilation

›SNOMED CT concept procedural sedation

›SNOMED CT concept laryngospasm

05Laboratory Tests/lt16

Pre-sedation laboratory testing

›Selective testing, not routine

›Point-of-care glucose

›When the patient is lethargic, poorly feeding, or diabetic

›Pregnancy test

›When pregnancy status is unknown and drug selection or imaging would change

›Renal or hepatic function

›When a drug with renal or hepatic clearance dependence is planned in a patient with known organ dysfunction

›Routine complete blood count and coagulation studies are not required for sedation alone

Laboratory evaluation after a sedation complication

›Post-complication labs

›Venous or arterial blood gas

›Hypercapnia confirms hypoventilation when capnography is unavailable

›Interpretation trap, a normal pH early in hypoventilation does not exclude a rapidly rising PCO2 that will decompensate minutes later

›Lactate

›Interpretation trap, ketamine-induced catecholamine release can raise heart rate and blood pressure without true hypoperfusion, and lactate should be interpreted alongside perfusion exam rather than in isolation

›Troponin

›Consider only when chest pain or new arrhythmia accompanies hypotension, since sedation alone does not routinely elevate troponin

06Diagnostic Tests/dt42

Scoring Systems

›Airway and risk classification

›ASA physical status classification

›Used to stratify baseline risk before drug selection

›Mallampati classification

›Class I to IV correlating with anticipated difficulty of laryngoscopy

›LEMON airway assessment

›Look externally, evaluate 3-3-2 rule, Mallampati, obstruction, neck mobility

›STOP-BANG obstructive sleep apnea screen

›Snoring, tiredness, observed apnea, blood pressure, BMI, age, neck circumference, gender

›Higher scores associated with increased airway and respiratory depression risk during sedation

›Depth-of-sedation continuum

›Minimal sedation, anxiolysis, patient responds normally to verbal commands

›Moderate sedation, conscious sedation, purposeful response to verbal or light tactile stimulation, airway and spontaneous ventilation adequate

›Deep sedation, purposeful response only after repeated or painful stimulation, airway or ventilatory support may be required

›General anesthesia, unarousable even with painful stimulation, airway and ventilatory support usually required

›The continuum is a spectrum rather than fixed drug-specific states, and any patient can drift one level deeper than intended

›Recovery scoring

›Modified Aldrete score

›Activity, respiration, circulation, consciousness, and oxygen saturation each scored

›A total score of 9 or higher is commonly used to indicate readiness for discharge from monitored recovery

MRI

›MRI-specific sedation considerations

›Indications

›Pediatric patients unable to remain still

›Severe claustrophobia

›Monitoring limitations in the scanner environment

›MRI-compatible monitoring equipment required

07Disposition/dispo22

Setting selection and referral criteria

›Level of care selection

›Appropriate for ED procedural sedation

›ASA I to II, and selected stable ASA III

›Anticipated moderate sedation depth

›Requires escalation to operating room or anesthesia-supported sedation

›Anticipated difficult airway with anticipated deep sedation

›ASA IV or V

›Severe obstructive sleep apnea with morbid obesity

›Active vomiting or hemodynamic instability

›Transfer criteria for a non-tertiary ED

›Anticipated need for pediatric anesthesia not locally available

›Anticipated need for prolonged deep sedation beyond local monitoring capacity

Recovery and discharge criteria

›Recovery pathway

›Monitoring duration

›Continuous monitoring until the patient returns to baseline mental status

›Extended monitoring after reversal agent use because reversal duration may be shorter than the sedative's duration

›Discharge criteria

›Return to baseline level of consciousness and orientation

›Stable vital signs without supplemental oxygen requirement

›Adequate hydration and ability to tolerate oral intake when appropriate

›Modified Aldrete score of 9 or higher

›Reliable adult escort and supervision for the next several hours arranged before discharge

08Treatment/t228

Pre-procedure preparation and equipment checklist

›Preparation sequence

›Informed consent documented

›Time-out confirming patient, procedure, and site

›Baseline vitals recorded before first drug given

›IV access secured

›Preoxygenation with supplemental oxygen before sedative administration

›Suction, airway equipment, and reversal agents confirmed at bedside immediately before the drug is drawn up

Continuous monitoring during sedation

›Monitoring during administration

›Capnography

›Earliest detector of hypoventilation because it reflects ventilation directly rather than oxygenation

›A rising end-tidal CO2 or a flattening waveform precedes any fall in pulse oximetry

›Pulse oximetry

›Lags behind hypoventilation, especially on supplemental oxygen, because a well-oxygenated reservoir delays the fall in SpO2 despite rising CO2 and progressive apnea

›Should never be relied on as the sole respiratory monitor during moderate or deep sedation

›Monitoring cadence

›Continuous pulse oximetry and capnography throughout

›Blood pressure and heart rate at least every 5 minutes during active sedation and immediately after any bolus dose

›More frequent reassessment during and immediately after redosing or when titrating a continuous infusion

›Personnel during monitoring

›The clinician monitoring the airway performs no other procedural task

›Verbal or tactile reassessment of responsiveness at intervals consistent with the intended sedation depth

Agent selection overview

›Matching agent to clinical situation

›Painful procedure requiring dissociation and preserved airway reflexes favors ketamine

›Brief painful procedure requiring rapid onset and rapid recovery favors propofol, alone or combined with an opioid

›Anxiolysis without significant analgesia favors midazolam

›Procedure with a significant painful component favors adding fentanyl to a sedative-hypnotic

›Single very brief painful procedure such as cardioversion favors etomidate for hemodynamic stability

›Minor procedure in a cooperative patient able to self-titrate favors nitrous oxide

›Prolonged procedure or need to preserve respiratory drive favors dexmedetomidine

›Combined analgesia and amnesia with reduced total dose of either agent favors the ketamine-propofol combination

Dissociative and induction agents

›Ketamine

›Dosing

›IV 1 to 1.5 mg/kg over 1 to 2 minutes

›Titration, repeat half the initial dose every 5 to 10 minutes if inadequate dissociation

›Maximum total dose per procedure typically 3 to 4 mg/kg unless prolonged procedure requires redosing under continuous monitoring

›IM 4 mg/kg

›Titration, additional 2 to 4 mg/kg IM if inadequate effect after 10 minutes

›Maximum single IM dose typically capped at 5 mg/kg

›Onset and duration

›IV onset within 1 minute, dissociation lasting 10 to 20 minutes

›IM onset within 3 to 5 minutes, dissociation lasting 20 to 30 minutes

›Mechanism and rationale

›NMDA receptor antagonism produces dissociative anesthesia while typically preserving airway reflexes and spontaneous respiration

›Sympathomimetic catecholamine release typically raises heart rate and blood pressure rather than causing hypotension

›Specific hazards

›Laryngospasm, uncommon but the airway-specific hazard requiring immediate rescue

›Emergence phenomena including vivid dreams, hallucinations, or agitation on recovery

›Hypersalivation that can contribute to airway irritation

›Braking and caveats

›Co-administer a small dose of a benzodiazepine only if emergence reaction occurs, not routinely pre-treated

›Slower IV push reduces respiratory depression and apnea risk compared with rapid bolus

›Etomidate

›Dosing

›IV 0.1 to 0.15 mg/kg over 30 to 60 seconds

›Titration, repeat 0.05 mg/kg if additional brief sedation needed

›Maximum single dose typically 20 mg for brief procedural use

›Onset and duration

›Onset within 30 to 60 seconds, duration 3 to 5 minutes

›Mechanism and rationale

›Potentiates GABA-A receptor activity with minimal effect on sympathetic tone, producing hemodynamic stability favored for cardioversion or a hemodynamically fragile patient

›Specific hazards

›Myoclonus from disinhibition of subcortical motor pathways, can be mistaken for seizure activity

›Adrenal suppression through 11-beta-hydroxylase inhibition, dose- and repeat-dose-dependent, a caution for repeat dosing or use in septic or critically ill patients

›No clinically significant analgesia, painful procedures need a separate analgesic

›Braking and caveats

›Avoid repeated or prolonged dosing when adrenal suppression risk is a concern, such as septic shock

›Propofol

›Dosing

›IV bolus 0.5 to 1 mg/kg over 1 to 2 minutes for procedural sedation

›Titration, repeat 0.25 to 0.5 mg/kg every 1 to 2 minutes to effect

›Deceleration step, once light sedation is achieved switch to smaller 0.25 mg/kg increments rather than continuing full boluses to avoid overshoot

›IV infusion for longer procedures 25 to 75 microg/kg per minute after an initial bolus

›Titration, adjust by 5 to 10 microg/kg per minute every 3 to 5 minutes to target depth

›Onset and duration

›Onset within 30 to 60 seconds, single-bolus duration 4 to 8 minutes

›Mechanism and rationale

›Potentiates GABA-A receptor activity producing rapid-onset, rapid-offset sedation without analgesia

›Specific hazards

›Apnea, dose- and speed-of-injection-dependent, the defining respiratory hazard of this agent

›Hypotension from direct myocardial depression and vasodilation, more pronounced in the volume-depleted or elderly patient

›Braking and caveats

›Bolus-omission caveat, if hypotension risk is high, omit the bolus and begin a lower infusion rate with slower titration instead

›No inherent analgesic effect, add an opioid or use the ketamine-propofol combination for a painful procedure

Sedative and analgesic adjuncts

›Midazolam

›Dosing

›IV 0.02 to 0.05 mg/kg, typically 1 to 2 mg increments in an adult

›Titration, repeat every 2 to 3 minutes to effect

›Maximum total dose typically 0.1 mg/kg in a single sedation episode outside a critical care setting

›Onset and duration

›Onset within 1 to 2 minutes IV, duration 30 to 60 minutes with a longer duration in the elderly

›Mechanism and rationale

›Benzodiazepine site potentiation of GABA-A receptor activity producing anxiolysis and amnesia without analgesia

›Specific hazards

›Dose-dependent respiratory depression, markedly amplified when combined with an opioid

›Paradoxical reaction with agitation or disinhibition, more common at the extremes of age

›Braking and caveats

›Reduce dose by roughly half when co-administering an opioid because of synergistic respiratory depression

›Fentanyl

›Dosing

›IV 0.5 to 1 microg/kg

›Titration, repeat 0.5 microg/kg every 2 to 3 minutes to analgesic effect

›Maximum total dose typically 3 microg/kg for procedural analgesia outside a critical care infusion protocol

›Onset and duration

›Onset within 1 to 2 minutes, analgesic duration 30 to 60 minutes

›Mechanism and rationale

›Mu-opioid receptor agonism providing potent, short-acting analgesia without inherent sedative-hypnotic amnesia

›Specific hazards

›Chest wall rigidity, a rare but specific hazard from rapid high-dose administration that can make bag-valve-mask ventilation impossible, treated with naloxone or, if refractory, neuromuscular blockade and intubation

›Respiratory depression that is markedly amplified when combined with a sedative-hypnotic

›Braking and caveats

›Slow administration over at least 1 to 2 minutes reduces chest wall rigidity risk

›Reduce the sedative-hypnotic dose when fentanyl is co-administered rather than dosing each agent as if given alone

›Nitrous oxide

›Dosing

›Inhaled 30 to 70 percent nitrous oxide in oxygen, self-titrated or clinician-titrated by mask or nasal hood

›Titration, adjust the inhaled concentration in 10 percent increments to effect

›Onset and duration

›Onset within 2 to 5 minutes, offset within minutes of discontinuation

›Mechanism and rationale

›NMDA receptor antagonism and GABA modulation producing anxiolysis and mild analgesia with rapid reversibility

›Specific hazards

›Diffusion into closed air spaces, contraindicated with pneumothorax, bowel obstruction, or recent intraocular gas

›Diffusion hypoxia at emergence, mitigated by a brief period of 100 percent oxygen after discontinuation

›Braking and caveats

›Requires a patient able to cooperate with a mask or nasal hood, limiting use in young children or the uncooperative patient

›Dexmedetomidine

›Dosing

›IV loading 0.5 to 1 microg/kg over 10 minutes

›Infusion start 0.2 to 0.7 microg/kg per hour

›Titration, adjust by 0.1 to 0.2 microg/kg per hour every 10 to 15 minutes to target sedation depth

›Bolus-omission caveat, omit the loading bolus and begin at the low end of the infusion range in the hypotension-prone or bradycardia-prone patient

›Onset and duration

›Onset within 5 to 10 minutes, effect resolving over 30 to 60 minutes after infusion stop

›Mechanism and rationale

›Central alpha-2 adrenergic agonism producing sedation resembling natural sleep with relatively preserved respiratory drive

›Specific hazards

›Bradycardia and hypotension, dose-dependent

›Slower onset makes it poorly suited as the sole agent for a brief painful procedure

Combination sedation and synergistic respiratory depression

›Ketamine-propofol combination

›Dosing

›Mixed in the same syringe or given sequentially, ketamine 0.5 mg/kg IV plus propofol 0.5 mg/kg IV

›Titration, repeat propofol 0.25 to 0.5 mg/kg alone for additional depth once dissociation is established

›Onset and duration

›Onset within 1 minute, duration 10 to 15 minutes with the combination typically allowing a lower total propofol dose

›Mechanism and rationale

›Ketamine's sympathomimetic and analgesic properties offset propofol's hypotension and lack of analgesia, while propofol blunts ketamine's emergence phenomena and hypersalivation

›Specific hazards

›Combined respiratory depression risk still present despite the lower individual doses of each agent

›Braking and caveats

›Population-specific caution, use a lower starting ratio favoring ketamine in the patient with borderline hemodynamics

›Opioid-sedative synergistic respiratory depression

›The defining hazard of combination procedural sedation

›An opioid and a sedative-hypnotic each individually well tolerated can produce apnea in combination at doses that would be safe if either drug were given alone

›This synergy, not either drug's toxicity in isolation, is the commonest route to a serious adverse event in procedural sedation

›Mitigation

›Give the opioid first, wait for peak analgesic effect, then titrate the sedative-hypnotic slowly against the combined effect rather than dosing each to its usual solo target

›Reduce each individual drug's dose ceiling when the other class is on board

›Heightened capnography vigilance for at least 5 minutes after any combined redosing

Airway and respiratory complications

›Apnea and hypoventilation

›Recognition

›Loss of the capnography waveform or a rising end-tidal CO2 trend

›Reduced respiratory rate or paradoxical chest wall movement

›Management

›Stimulate the patient and reposition the airway

›Jaw thrust with head-tilt-chin-lift if no cervical spine concern

›Assisted ventilation with bag-valve-mask and 100 percent oxygen if apnea persists beyond 20 seconds

›Reduce or hold further sedative dosing until ventilation is restored

›Airway obstruction

›Recognition

›Snoring respirations or paradoxical breathing without stridor

›Management

›Jaw thrust and repositioning

›Nasal or oral airway adjunct placement

›Escalate to bag-valve-mask ventilation if obstruction does not resolve

›Laryngospasm

›Recognition

›High-pitched stridor progressing to a silent chest with paradoxical chest wall movement and no air movement

›Management

›Larson's maneuver, firm bilateral inward and anterior pressure at the laryngospasm notch behind the earlobe, at the base of the skull just posterior to the mandibular condyle

›Continuous positive pressure with 100 percent oxygen by bag-valve-mask

›If unresolved, propofol 0.5 to 1 mg/kg IV to deepen sedation and break the spasm

›If refractory and desaturating, succinylcholine IV 0.1 to 0.2 mg/kg, or 4 mg/kg IM if no IV access, to relax the vocal cords and permit ventilation or intubation

›Prepare for immediate bag-valve-mask ventilation and intubation once relaxation is achieved

›Hyperkalemia and peaked T waves are a recognized risk of succinylcholine in the burn, crush injury, or chronic neuromuscular disease patient, and the cardiac monitor should be watched through this rescue sequence

Hemodynamic and other complications

›Hypotension

›Recognition

›Systolic blood pressure under 90 mmHg in the adult, with the target adjusted upward in a patient whose baseline is chronically hypertensive and downward in normal pregnancy physiology

›Management

›IV crystalloid bolus if volume depletion is suspected

›Reduce or pause further propofol or dexmedetomidine dosing

›Push-dose phenylephrine or ephedrine for persistent symptomatic hypotension

›Aspiration

›Recognition

›Witnessed regurgitation or new hypoxia and wheeze after the procedure

›Management

›Immediate suctioning and lateral positioning if not contraindicated

›Avoid routine prophylactic antibiotics unless a specific aspiration pneumonitis develops

›Paradoxical reaction

›Recognition

›Agitation, disinhibition, or worsened combativeness after a benzodiazepine, most common at the extremes of age

›Management

›Stop further benzodiazepine dosing

›Consider flumazenil only when benzodiazepine effect is clearly reversible and the patient is not benzodiazepine-dependent

›Emergence delirium

›Recognition

›Agitation, vivid dreaming, or dissociative distress on recovery, most associated with ketamine

›Management

›Quiet, low-stimulation recovery environment

›Small dose of a benzodiazepine for a distressing emergence reaction

›Reassurance and reorientation as the primary intervention for a mild reaction

Reversal agents and troubleshooting

›Naloxone

›Dosing

›IV 0.04 to 0.1 mg titrated to reverse respiratory depression while preserving analgesia

›Higher dose 0.4 to 2 mg IV if profound respiratory depression or arrest, repeat every 2 to 3 minutes as needed

›Duration mismatch caveat

›Naloxone's duration is shorter than fentanyl's, and re-sedation with recurrent respiratory depression can occur once naloxone wears off, requiring extended monitoring

›Flumazenil

›Dosing

›IV 0.2 mg over 15 seconds, repeat 0.2 mg every minute to a typical maximum of 1 mg

›Duration mismatch and seizure caveat

›Flumazenil's duration is shorter than midazolam's, and resedation can recur

›Avoid in the benzodiazepine-dependent patient or when a co-ingested pro-convulsant is suspected, because reversal can precipitate seizures

›Therapy-not-working troubleshooting

›If the patient remains inadequately sedated despite reaching the stated maximum titration steps, reassess the diagnosis before exceeding the dose ceiling

›Consider tolerance from chronic alcohol, benzodiazepine, or opioid use

›Consider an alternate agent class rather than continuing to escalate the same drug

›Consider that persistent agitation may reflect uncontrolled pain rather than inadequate sedation, and treat the pain directly

›If oxygenation or ventilation is not improving despite airway repositioning and bag-valve-mask ventilation, escalate immediately to advanced airway management rather than repeating the same maneuver

09Special Populations/sp44

Pregnancy

›Pregnancy considerations

›Aspiration risk

›Increased aspiration risk beyond the first trimester from delayed gastric emptying and lower esophageal sphincter tone

›Agent selection

›Propofol and fentanyl have the largest reported experience in pregnancy when procedural sedation is required

›Ketamine can be used but its sympathomimetic effect warrants blood pressure monitoring in the preeclamptic patient

›Nitrous oxide is generally avoided for prolonged exposure but brief use is not an absolute contraindication

›Benzodiazepine use should be minimized and limited to the lowest effective dose given a theoretical neonatal sedation and floppy infant concern with late third-trimester exposure

›Hemodynamic target adjustment

›Baseline blood pressure is physiologically lower in pregnancy, so the hypotension threshold should be interpreted against the patient's own baseline rather than a fixed non-pregnant number

›Monitoring

›Left lateral tilt positioning when feasible to avoid aortocaval compression

›Fetal heart rate monitoring when gestational age is viable and the procedure or sedation duration warrants it

Geriatric

›Older adult considerations

›Pharmacokinetic and pharmacodynamic changes

›Reduced drug clearance and increased sensitivity to sedative-hypnotics and opioids

›Start at the low end of the adult dose range and titrate more slowly than in a younger adult

›Increased complication risk

›Higher risk of hypotension with propofol due to reduced cardiovascular reserve

›Higher risk of paradoxical reaction and delirium with benzodiazepines

›Longer drug duration than expected from standard adult onset and duration figures

›Airway and comorbidity review

›Higher baseline prevalence of obstructive sleep apnea and chronic lung disease that shifts the SpO2 target and monitoring threshold

›Polypharmacy increasing the risk of unrecognized drug interaction with home sedatives or opioids

Pediatrics

›Pediatric considerations

10Background/b21

Epidemiology

›Epidemiologic notes

›Serious adverse events, defined as apnea, laryngospasm, or the need for airway intervention, occur in roughly 1 percent of ED procedural sedations

›Aspiration during ED procedural sedation is rare, reported in a small fraction of a percent of cases across large registries

›Ketamine is associated with vomiting in roughly 5 to 10 percent of pediatric sedations, more common than with other single agents

›Laryngospasm with ketamine occurs in under 1 percent of administrations but is the airway-specific complication most attributed to this agent

Pathophysiology

›Mechanisms

›Respiratory depression mechanism

›GABA-A agonists and opioids each reduce central respiratory drive and upper airway muscle tone by distinct receptor mechanisms, and their effects are additive to synergistic when combined

›Laryngospasm mechanism

›Reflex adduction of the vocal cords triggered by airway irritation during a light plane of anesthesia, most likely during induction or emergence rather than at a stable deep plane

›Dissociative anesthesia mechanism

›Functional dissociation between the thalamocortical and limbic systems from NMDA receptor blockade, producing a trance-like state with preserved airway reflexes and spontaneous ventilation in most patients

Therapeutic Considerations

›Treatment rationale

›Matching depth to procedure

›Targeting the minimum sedation depth that permits the procedure reduces respiratory and hemodynamic risk compared with routinely targeting deep sedation

›Single-agent versus combination strategy

›A single well-chosen agent, such as ketamine for a painful procedure requiring dissociation, can avoid the additive respiratory depression risk of combining an opioid with a sedative-hypnotic

›Monitoring investment

›Capnography adoption is associated with earlier detection of respiratory depression and has been incorporated into major society sedation guidelines

›Individualized fasting risk

›Practice has moved from a rigid fasting-time requirement toward individualized risk assessment based on the evidence that fasting duration alone poorly predicts aspiration in the ED setting

11Patient Discharge Instructions/pdi19

Copy discharge instructions

›Discharge instructions

›Expected course

›Mild drowsiness or unsteadiness can persist for several hours after sedation

›Vivid dreams or brief confusion can occur after ketamine and typically resolve within a few hours

›Activity restrictions

›No driving, operating machinery, or making important decisions for 24 hours after sedation

›Adult supervision required for the rest of the day

›Pain and fever control

›Acetaminophen PO 500 to 1000 mg every 6 hours as needed, maximum 3000 to 4000 mg per day

›Ibuprofen PO 400 to 600 mg every 6 to 8 hours as needed if no contraindication

›Return to ED immediately

›Trouble breathing or persistent drowsiness that does not improve

›Blue lips or fingertips

›Temperature above 38.3 degrees Celsius

›Persistent vomiting or inability to keep fluids down

›New confusion, severe headache, or fainting

›Follow-up

›Follow up with the ordering or procedural service as directed

›Contact primary care if any new symptoms develop over the following days

12References/r9

Guidelines and key sources

›Reference list

›American College of Emergency Physicians clinical policy on procedural sedation and analgesia in the emergency department

›American Society of Anesthesiologists practice guidelines for moderate procedural sedation and analgesia

›American Society of Anesthesiologists practice guidelines for preoperative fasting

›Society for Pediatric Sedation consensus guidance on pediatric procedural sedation

›Green and colleagues clinical practice guideline for emergency department ketamine dissociative sedation

›Evidence base for capnography monitoring during procedural sedation and its association with earlier detection of respiratory depression

›Evidence base for individualized fasting risk assessment in emergency department procedural sedation

›Clinical management system generator instructions

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed September 13, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.