The June issue of Emergency Medicine Practice is on the topic of Procedural Sedation and Analgesia in the Emergency Department. It includes an exhaustive review of both adult and pediatric procedural sedation. Table 2 of the publication is reproduced below for your rapid reference.
Table 2: Routinely Available Agents and Dosages for Emergency Department Procedural Sedation1
| Agent | Starting Dosage, Adult and Pediatric Patients | Onset (min) | Duration (min) | Advantages | Disadvantages |
|---|---|---|---|---|---|
| Fentanyl | 1 mcg/kg IV | 1-2 | 30-40 | •Rapid onset •Short duration •Minimal CV effects | •Chest wall rigidity (when given rapidly in large doses) •Analgesic properties only |
| Remifentanil | 0.05-0.1 mcg/kg/ min IV infusion with supplemental 0.5-1 mcg/kg IV boluses | <1-3 | 3-10 | •Short duration •Can be titrated | •Respiratory depression •Analgesic properties only |
| Midazolam | 0.05-0.1 mg/kg IV | 1.5 | 60-120 | •Rapid onset •Short duration •Multiple routes | •Respiratory depression •Moderate duration •Sedative properties only |
| Nitrous Oxide | 30%-70% concentration | 1-2 | 3-5 | •Rapid onset •Minimal CV effects | •Emesis •Expansion of gas-filled structures |
| Propofol | 0.5-1 mg/kg IV | <1 | 3-10 | •Rapid onset •Antiemetic •Short duration | •Hypotension •Respiratory depression •Injection pain •Sedative properties only |
| Ketamine | •1-1.5 mg/kg IV •4-5 mg/kg IM •6-9 mg/kg IN (adults only) | ~1 (IV) ~5 (IM) | 10-15 (IV) 15-30 (IM) | •Preserved airway reflexes •Predictable •Provides analgesia and sedation | •Emergence phenomena •Emesis •Laryngospasm •Hypertension •Tachycardia •Increased secretions |
| Ketofol Ketamine + Propofol (adult patients only) | 1.1 admixture dosing 0.5 mg/kg ketamine IV and 0.5 mg/kg propofol IV administered simultaneously | 1-3 | 10-15 | •Airway preservation •Hemodynamic stability •Rapid recovery •Use together offsets hemodynamic effects of each individual agent •Provides analgesia and sedation | Same as for each individual |
| Etomidate | 0.15 mg/kg IV | <1 | 5-10 | •Rapid onset •Minimal CV effects | •Respiratory depression •Myoclonus •Sedative properties only |
Source: Kern J, Guinn A, Mehta P. Procedural sedation and analgesia in the emergency department. Emerg Med Pract. 2022 Jun;24(6):1-24. Epub 2022 Jun 1. PMID: 35616493.
Further Reading
Procedural Sedation and Analgesia in the Emergency Department (Pharmacology CME)
Date Release: Jun 2022
Procedural sedation and analgesia are essential in emergency medicine. This issue reviews how to choose the optimal agents and procedures, individualized for each patient.
Date Release: May 2022
This issue discusses materials, methods, and monitoring for pediatric patients undergoing nerve blocks in the emergency department. Recognition and management of local anesthetic systemic toxicity syndrome and special considerations for pediatric patients are also reviewed.
Listen to the Podcast
References
- Godwin SA. Procedural sedation and analgesia. In: Walls RM, Hockberger RS, Gausche-Hill M, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. Ninth ed. Philadelphia, PA: Elsevier; 2018
- Kern J, Guinn A, Mehta P. Procedural sedation and analgesia in the emergency department. Emerg Med Pract. 2022 Jun;24(6):1-24. Epub 2022 Jun 1. PMID: 35616493.
Last Updated on January 25, 2023
Sam Ashoo, MD, FACEP, is board certified in emergency medicine and clinical informatics. He serves as EB Medicine’s editor-in-chief of interactive clinical pathways and FOAMEd blog, and host of EB Medicine’s EMplify podcast. Follow him below for more…
