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child at the time of the visit, and determine the need for and choice of
medications for sedation and analgesia.
The parents’ or caregiver’s assessment of the child’s anticipated emotional
response is useful in defining the best approach for the procedure. Despite an
apparent lack of response to usual vocal or calming techniques, many
children still do well if their caregivers stay near, and if it seems to them that
there is less change occurring in their surroundings. The route of
administration is also an important consideration, in that some children have
a strong aversion to manipulation of certain body parts. If the child is taking
medications already, drug interactions must be considered when choosing a
procedural sedative. However, if the child’s initial medication has sedative
properties (e.g., those found in phenobarbital or benzodiazepines), then
simply adding or increasing a dose may be all that is needed. Despite the
potential for paradoxical reactions in children with emotional disorders,
benzodiazepines used in the correct dosage result in better cooperation for
procedures. In fact, the situation may be worsened by having too little
medication to initiate anxiolysis or sedation. Propofol has been used
successfully for PSA in children with autism spectrum disorder (ASD) with
no increase in adverse events compared to children without ASD. Ketamine
may also cause a severe emotional response in emotionally reactive children.
A small case series of successful PSA with IM dexmedetomidine (4 mcg/kg)
for children with ASD makes this an intriguing option that warrants further
study.

COMPLICATIONS AND ERRORS
Most children who receive sedation and analgesia in the ED have a good
outcome and benefit from the efforts to reduce pain and anxiety during a
procedure. However, administration of sedative and analgesic agents to
children in the ED always carries some risk to the patient and potential
liability for the provider. Even with proper patient screening, preparation,
and care, adverse events can still occur. The overall adverse event rate for

PSA in children is less than 10%, and the majority of these are minor, such
as hypoxia requiring brief administration of oxygen. The serious adverse
event rate, such as those requiring a more significant intervention, is even
lower, around 3% or less depending on the agent. Nonetheless, it is essential
that the PSA provider adheres to proper protocol, be thoughtful about the