EMERGENCY SEDATION AND PAIN MANAGEMENT - PART 1 pot

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EMERGENCY SEDATION AND PAIN MANAGEMENT
Procedural sedation and analgesia represents one of the great advances in the maturation
of emergency medicineas a discrete specialtywithin medicine.Oncetheexclusive domain
of the anesthesiologist, sedation and pain management procedures are now a routine part
of all emergency department practices.
Emergency Sedation and Pain Management is a comprehensive medical text
addressing emergency sedation and analgesia with specific emphasis on treatment of
the emergency department patient. The easi ly accessible, clinically oriented format
allows the reader fast and efficient access to the key points in each chapter.
The text presents a clinical approach to the treatment of pain in emergency
patients, including pediatric and adult populations. Analgesia, sedation, and
anesthetic techniques are presented in an informative, authoritative, and concise
format – written and edited by physicians with extensive research as well as clinical
emergency medicine expertise. The chapters are richly supplemented with tables,
photographs, and step-by-step illustrations.
john h. burton, md, has been the Resi dency Program Director in Emergency
Medicine and a Professor of Emergency Medicine at Albany Medical College in
Albany, NY, since 2006. From 1999 to 2003, Dr. Burton was the Medical Director for
Maine Emergency Medical Services and, from 1995 to 2006, he worked in the
Department of Emergency Medicine at the Maine Medical Cente r in Portland. He
was the founding Research Director in the Department of Emergency Medicine at
Maine Medical Center.
Dr. Burton’s areas of research interest are procedural sedation and analgesia,
emergency medical services, and management of cardiovascular emergencies. He has
published extensively in the emergency medicine literature on thes e and related
topics. He has received awards and peer recognition throughout his academic career
noting a commitment to the specialty of emergency medicine.
Dr. Burton completed medical school at the University of North Carolina at Chapel
Hill in 1992 and residency training at the University of Pittsburgh Affiliated Residency

in Emergency Medicine in 1995.
james miner, md, facep, has been the Director of Performance Improvement
and the Associate Research Director in the Department of Emergency Medicine at
Hennepin County Medical Center since 1999 and is an Associate Professor of
Emergency Medicine at the University of Minnesota Medical School.
Dr. Miner has performed extensive research in the areas of pain management and
procedural sedation in the Emergency Department and has publishe d numerous
manuscripts on these topics. He is an associate editor of Academic Emergency
Medicine.
Dr. Miner completed medical school at Mayo Medical School in 1996 and residency
training at the Hennepin County Medical Center in Emergency Medicine in 1999.

Emergency Sedation
and Pain Management
Edited by
JOHN H. BURTON
Albany Medical College
JAMES MINER
University of Minnesota School of Medicine
CAMBRIDGE UNIVERSITY PRESS
Cambridge, New York, Melbourne, Madrid, Cape Town, Singapore, São Paulo
Cambridge University Press
The Edinburgh Building, Cambridge CB2 8RU, UK
First published in print format
ISBN-13 978-0-521-87086-3
ISBN-13 978-0-511-37133-2
© John H. Burton and James Miner 2008
Every effort has been made in preparing this book to provide accurate and up-to-date
information that is in accord with accepted standards and practice at the time of
publication. Nevertheless, the authors, editors, and publisher can make no warranties that

the information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors, editors,
and publisher therefore disclaim all liability for direct or consequential damages resulting
from the use of material contained in this book. Readers are strongly advised to pay careful
attention to information provided by the manufacturer of any drugs or equipment that
they plan to use.
2007
Information on this title: www.cambridge.org/9780521870863
This publication is in copyright. Subject to statutory exception and to the provision of
relevant collective licensing agreements, no reproduction of any part may take place
without the written
p
ermission of Cambrid
g
e University Press.
ISBN-10 0-511-37133-0
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for external or third-party internet websites referred to in this publication, and does not
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uarantee that any content on such websites is, or will remain, accurate or a
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ro
p
riate.
Published in the United States of America by Cambridge University Press, New York
www.cambridge.org
hardback
eBook (NetLibrary)
eBook (NetLibrary)

hardback
Contents
Acknowledgments page ix
List of Contributors xi
SECTION ONE. OVERVIEW AND PRINCIPLES IN EMERGENCY
ANALGESIA AND PROCEDURAL SEDATION
1
1 Emergency Analgesia Principles
James Miner and John H. Burton 1
2 Emergency Procedural Sedation Principles
John H. Burton and James Miner 5
3 Analgesic and Procedural Sedation Principles Unique
to the Pediatric Emergency Department
Susan Fuchs 11
4 Pain and Analgesia in the Infant
Michelle P. Tomassi 18
5 Provider Bias and Patient Selection for Emergency
Department Procedural Sedation and Analgesia
Knox H. Todd 25
6 Federal and Hospital Regulatory Oversight in Emergency
Department Procedural Sedation and Analgesia
Sharon Roy 30
7 Nursing Considerations in Emergency Department
Procedural Sedation and Analgesia
Tania D. Strout and Dawn B. Kendrick 38
SECTION TWO. ANALGESIA FOR THE EMERGENCY PATIENT 43
8 Pharmacology of Commonly Utilized Analgesic Agents
Eustacia Jo Su 43
9 Patient Assessment: Pain Scales and Observation in
Clinical Practice

Tania D. Strout and Dawn B. Kendrick 55
10 Pathways and Protocols for the Triage Patient with Acute Pain
Paula Tanabe 67
v
11 Patients with Acute Pain: Patient Expectations and
Desired Outcomes
David E. Fosnocht, Robert L. Stephen, and Eric R. Swanson 75
12 Analgesia for the Adult and Pediatric Multitrauma
Patient
Wayne Triner 79
13 Analgesia for the Emergency Department Isolated
Orthopedic Extremity Trauma Patient
Michael A. Tur turro 87
14 Analgesia for Selected Emergency Eye and
Ear Patients
Matthew G. Dunn 91
15 Analgesia for the Emergency Headache Patient
James Miner 96
16 Analgesia for the Emergency Chest Pain Patient
Carl A. Germann and Andrew D. Perron 103
17 Analgesia for the Emergency Back Pain Patient
Donald Jeanmonod 109
18 Analgesia for the Acute Abdomen Patient
Martha L. Neighbor 120
19 Analgesia for the Renal Colic Patient
Allan B. Wolfson and David H. Newman 127
20 Analgesia for the Biliary Colic Patient
Allan B. Wolfson and David H. Newman 131
21 Analgesia for the Chronic Pain Patient
James Miner 135

22 Outpatient Analgesia following Acute Musculoskeletal
Injury
John C. Southall 141
SECTION THREE. PROCEDURAL SEDATION FOR THE EMERGENCY
PATIENT
147
23 Patient Assessment and Preprocedure Considerations
Baruch Krauss and Steven M. Green 147
24 Monitoring for Procedural Sedation
Baruch Krauss 152
vi Contents
25 Pharmacology of Commonly Utilized Sedative Agents
Eustacia Jo Su 159
26 Procedural Sedation for Pediatric Laceration Repair
Mark G. Roback 168
27 Procedural Sedation for Pediatric Radiographic Imaging
Studies
Nathan Mick 173
28 Procedural Sedation for Brief Pediatric Procedures:
Foreign Body Removal, Lumbar Puncture,
Bone Marrow Aspiration, Central Venous Catheter
Placement
Michael Ciccarelli and John H. Burton 179
29 Procedural Sedation for Adult and Pediatric Orthopedic
Fracture and Joint Reduction
James Miner and John H. Burton 185
30 Procedural Sedation for Electrical Cardioversion
Christopher J. Freeman 190
31 Procedural Sedation for Brief Surgical Procedures:
Abscess Incision and Debridement, Tube Thoracostomy,

Nasogastric Tube Placement
Carl Chudnofsky 195
SECTION FOUR. TOPICAL, LOCAL, AND REGIONAL ANESTHESIA
APPROACH TO THE EMERGENCY PATIENT
205
32 Selected Topical, Local, and Regional Anesthesia
Techniques
Douglas C. Dillon and Michael Gibbs 205
33 Topical Anesthesia Considerations for Pediatric Peripheral
Intravenous Catheter Placement
William T. Zempsky 224
34 Regional Anesthesia for Adult and Pediatric Orthopedic
Fracture and Joint Reduction
Douglas C. Dillon and Michael Gibbs 230
35 Regional Anesthesia for Dental Pain
Kip Benko 237
36 Local Anesthesia for Laceration Repair
Joel M. Bartfield 250
Contents vii
SECTION FIVE. SPECIAL CONSIDERATIONS FOR EMERGENCY
PROCEDURAL SEDATION AND ANALGESIA
255
37 Sedation and Analgesia for the Prehospital Emergency
Medical Services Patient
Michael Dailey and David French 255
38 Induction Agents for Rapid Sequence Intubation of the
Emergency Department Patient
Joseph Clinton and Arleigh Trainor 260
39 Sedation and Analgesia for the Critical Care Patient
Richard Riker and Gilles L. Fraser 268

Index 277
viii Contents

Gilles L. Fraser
Maine Medical Center
Portland, ME 04102
Email:
Christopher J. Freeman
Department of Emergency Medicine
Albany Medical College
43 New Scotland Avenue, MC 139
Albany, NY 12208-3479
Email:
David French
Department of Emergency Medicine
Albany Medical College
43 New Scotland Avenue, MC 139
Albany, NY 12208-3479
Email:
Susan Fuchs
Professor of Pediatrics
Feinberg School of Medicine
Northwestern University
Division of Pediatric Emergency Medicine
Associate Director
Children’s Memorial Hospital
Chicago, IL 60614
Email:
Carl A. Germann
Maine Medical Center

Department of Emergency Medicine
22 Bramhall Street
Portland, ME 04102-3175
Email:
Michael Gibbs
Department of Emergency Medicine
Maine Medical Center
Portland, ME 04102
Email:
Steven M. Green
Loma Linda University Medical Center
Department of Emergency Medicine A-108
11234 Anderson Street
Loma Linda, CA 92354
Email:
Donald Jeanmonod
Department of Emergency Medicine
Albany Medical Center
43 New Scotland Avenue
Albany, NY 12208
Email:
Dawn B. Kendrick
Division of Emergency Medicine
Department of Pediatrics
University of Alabama at Birmingham
MTC 205
1600 7th Avenue South
Birmingham, AL 35233-1711
Email:
Baruch Krauss

Children’s Hospital Boston
Division of Emergency Medicine
300 Longwood Avenue
Boston, MA 02115
Email:
Nathan Mick
Department of Emergency Medicine
47 Bramhall Street
Maine Medical Center
Portland, ME 04102
Email:
James Miner
Department of Emergency Medicine
Hennepin Medical Center
701 Park Avenue South
Minneapolis, MN 55415
Email:
Martha L. Neighbor
1 Hawks Hill Court
Lafayette, CA 94549-1900
Email:
David H. Newman
Director of Clinical Research
Assistant Professor of Clinical Medicine
Department of Emergency Medicine
St Luke’s/Roosevelt Hospital Center
1111 Amsterdam Avenue
New York, NY 10025
Email:
xii List of Contributors

Andrew D. Perron
Department of Emergency Medicine
Maine Medical Center
Portland, ME 04102
Richard Riker
Chest Medicine Associates
335 Brighton Avenue, Suite 200
Portland, ME 04102-2354
Email:
Mark G. Roback
Professor, Department of Pediatrics
University of Minnesota Medical School
Associate Director, Division of Pediatric
Emergency Medicine
University of Minnesota Children’s Hospital/Fairview
76 Variety Club Research Center
MMC 814, 420 Delaware Street SE
Minneapolis, MN 55455
Email:
Sharon Roy
Department of Emergency Medicine
Hennepin County Medical Center
701 Park Avenue South
Minneapolis, MN 55415
Email:
John C. Southall
Chief of Emergency Services
Mercy Hospital
144 State Street
Portland, ME 04101

Email:
Robert L. Stephen
Division of Emergency Medicine
University of Utah
30 North 1900 East Rm AC218
Salt Lake City, UT 84132
Tania D. Strout
Maine Medical Center
Department of Emergency Medicine
Research Nurse
321 Brackett Street
Portland, ME 04102
Email:
Eustacia Jo Su
Chief, Pediatric Emergency Medicine Section
Associate Professor, Emergency Medicine
and Pediatrics
Oregon Health Sciences University
3181 SW Sam Jackson Park Road
CDW-EM
Portland, OR 97201
Email:
Eric R. Swanson
Division of Emergency Medicine
University of Utah
30 North 1900 East Rm AC218
Salt Lake City, UT 84132
Tim Sweeney
Department of Emergency Medicine
Maine Medical Center

Portland, ME 04102
Email:
Paula Tanabe
Department of Emergency Medicine and the
Institute for Healthcare Studies
Northwestern University
259 E. Erie, Suite 100
Chicago IL 60611
Email:
Knox H. Todd
Professor of Emergency Medicine
Director, Pain and Emergency Medicine Institute
Department of Emergency Medicine
Beth Israel Medical Center
Albert Einstein College of Medicine
First Avenue at 16th Street
New York, NY 10003
Email:
Michelle P. Tomassi
Department of Emergency Medicine
Albany Medical Center
43 New Scotland Avenue, A-139
Albany, NY 12208-3478
Email:
List of Contributors xiii
Arleigh Trainor
Department of Emergency Medicine
Hennepin County Medical Center
Minneapolis, MN 55415
Wayne Triner

Department of Emergency Medicine
Albany Medical College
43 New Scotland Avenue, MC 139
Albany, NY 12208
Michael A. Turturro
Clinical Professor of Emergency Medicine
University of Pittsburgh School of Medicine
Vice Chair and Director of Academic Affairs
Department of Emergency Medicine
The Mercy Hospital of Pittsburgh
1400 Locust Street
Pittsburgh, PA 15219
Email:
Allan B. Wolfson
Professor of Emergency Medicine
230 McKee Place, Suite 500
Pittsburgh, PA 15213
Email:
William T. Zempsky
Associate Director, Pain Relief Program
Connecticut Children’s Medical Center
282 Washington Street
Hartford, CT 06106
Email:
xiv List of Contributors
but these signs are often absent. As a consequence,
patient pain assessment remains an indirect estimation
by the treating physician. It is, therefore, important to
use a consistent vocabulary in describing an assessment
of a patient’s pain. This process will allow patient

findings to be communicated accurately and precisely
while a systematic treatment practice is implemented.
Because pain is assessed almost completely through
patient report, patients who have difficulty communi-
cating are at risk of oligoanalgesia due to under-
appreciation of their pain. Groups at risk include infants
and children, patients whose cultural background differs
significantly from the treating physician’s, and patients
who are developmentally delayed, cognitively impaired,
under severe emotional stress, or mentally ill.
Unfamiliar or unrecognized attempts by the patient to
express pain may be misinterpreted by the physician,
leading to a poor interaction and an unclear assessment
of the patient’s pain (Table 1-2). The accurate assessment
of pain in the face of cultural differences is a difficult, yet
important challenge to overcome in order to treat pain
adequately.
It should a l so be noted th at many physicians h ave
encountered pati ents who h ave altered a prescription,
have lost pain medications, seem to have pain out of
proportion to their illness or injury, o r who ignore follow-
up clinic appointments and return to the ED repeatedly.
These experiences can make it e asy to view a patient’s
report of pain with skepticism. Such observations and
experiences, lik e the physician’s as s essment of pat ient
pain, are significantly dependent on verbal and nonverbal
subjective communication between the physician and
patient. This reality creates a substantial potential for
inaccurate interpretations of patient motives in clinical
conditions where the patient pain experience is largely

subjective (e.g., back pain) with minimal opportunity
for objective clinical assessment with modalities such as
radiographic imaging or laboratory testing.
Table 1-1. Opioid receptors, activities, and subsequent endorphin responses to acute pain
Receptor Activity Endorphin
Mu1 Euphoria, supraspinal analgesia Beta-endorphin
Mu2 Respiratory depression, CV, and GI effects Beta-endorphin
Delta Spinal analgesia Enkephalin
Kappa Spinal analgesia, sedation, feedback inhibition Dynorphin
Epsilon Hormone Beta-endorphin
Gamma Psychomimetic effects, dysphioria
Table 1-2. Pathway/barriers to effective pain assessment and treatment
Phase Barrier
Complaint/assessment Patient communication
Physician bias
Patient and physician concerns about the consequences
of treatment
Treatment Patient medical condition
Physician knowledge of treatment modalities
Adverse events
Plan for ongoing
treatment
Physician knowledge of treatment modalities
Patient compliance
Adverse effects of medications
2 Overview and Principles in Emergency Analgesia and Procedural Sedation
PAIN CONSIDERATIONS
Acute pain follows injury and usually resolves as the
injury heals. Acute pain may be, but is not always, asso-
ciated with objective physical signs of autonomic nervous

system activity such as tachycardia, hypertension, dia-
phoresis, mydriasis, and pallor. When the cause of acute
pain is uncertain, establishing a diagnosis is the priority of
the emergency physician. Symptomatic treatment of pain
should be initiated while the diagnostic evaluation is
proceeding. In general, it is inappropriate to delay anal-
gesic use until a diagnosis has been made. It is unlikely,
and unproven in medical literature, that treatment with
0.1 mg/kg of morphine, or another analgesic equivalent,
will mask signs or symptoms of progressive disease such
that the effective treatment of pain will confound the
diagnostic approach.
Chronic pain is pain that has persisted after the usual
time of tissue healing has passed. This is clearly a vague
definition with a great deal of ambiguity between acute and
chronic p ain states. Chronic pain is uncommonly a ssoci-
ated with signs of s ympathetic nervous system ac tivity.
The treatment of acute and chronic pain is different,
and confusion between the two leads to poor manage-
ment of patients. Acute pain should be approached with
the intention of providing relief to a limited degree,
individualized to each patient, with a plan to taper
medications as symptoms improve. Chronic pain
assumes a baseline level of pain that is best treated with a
consistent approach to minimize baseline discomfort
and minimize the adverse effects of both pain and pain
treatment on the patient’s lifestyle.
ED personnel commonly identify patie nts who are
thought to seek pai n medications, usually opioids, for
illegitimate purposes. Drug addiction and prescription

abuse occur throughout medicine specialties, and the
true prevalence of addiction and drug-seeking behaviors
in the ED population is unknown.
When patients are undergoing treatment with opioid
medications, the physician should be aware of the
Opioids
Sedation/anesthesia
Peripheral nerve blocks as
appropriate
Nonpharmacologic
measures
– assurance
– stabilize situation

Oral/IM opioids
– nonsevere pain
– titration unlikely
– quantity of pain
medication required
established
IV opioids
– titration required
– severe pain
– unknown quantity of pain
medications required
Intractable pain
– Sedation/anesthesia
Brief procedural pain
– procedural sedation
Nonselective NSAIDS,

COX-2 inhibitors, tramadol
Acetaminophen
Pain assessment
Figure 1-1. A generalized approach to the treatment of acute pain.
Emergency Analgesia Principles 3
potential for development of physical dependence and/
or tolerance. The clinician should be cautious, however,
not to label the patient as an ‘‘addict’’ who is merely
physically dependent or tolerant of medications. Such
scenarios have been characterized with the term iatro-
genic pseudoaddiction. The se patients have opioid doses
that are either too low or spaced too far apart to relieve
pain, and subsequently develop behavior resembling
psychological dependence.
PAIN MANAGEMENT
A generalized approach to the treatm ent of acute pain
should be consistently applied to patient encounters
(Figure 1-1). Such an approach will optimize the
potential for effective analgesia across a broad range of
painful conditions.
For injured patients whose pain progresses past the
initial acute phase and in patients with chronic pain,
close follow-up with a single practitioner can be an
important aspect of their ongoing care. This practice
allows for the adoption of consistent approaches and the
systematic trial of various strategies to determine a
strategy that best suits a given patient.
It is common for patients in the midst of ongoing
primary care to present with pain in the ED, or for
patients who have conditions warranting follow-up with

a single practitioner to seek care from multiple sources
including the ED. If possible, these patients should be
provided with a short course of medication and have
close follow-up arranged. In patients who are unwilling
or unable to obtain follow-up with a single physician,
the clinician should emphasize the development of a
consistent patient analgesic strategy with clear expecta-
tions to minimize both undertreatment and the adverse
effects of long-term opioid use.
SUMMARY
Pain is the most common complaint in the ED. Having a
consistent, integrated, and well-planned approach will
optimize the experience for patients as well as medical
providers.
BIBLIOGRAPHY
1. Pain management in the emergency department. Ann
Emerg Med 2004;44(2):198.
2. Rupp T, Delaney KA. Inadequate analgesia in emergency
medicine. Ann Emerg Med 2004;43(4):494–503.
3. Fosnocht DE, Swanson ER, Barton ED. Changing attitudes
about pain and pain control in emergency medicine.
Emerg Med Clin North Am 2005;23(2):297–306.
4. Jones JS, Johnson K, McNinch M. Age as a risk factor for
inadequate emergency department analgesia. Am J Emerg
Med 1996;14(2):157–160.
5. Friedland LR, Kulick RM. Emergency department analge-
sic use in pediatric trauma victims with fractures. Ann
Emerg Med 1994;23(2):203–207.
6. Green CR, et al. The unequal burden of pain: Confronting
racial and ethnic disparities in pain. Pain Med 2003;4

(3):277–294.
7. Miner J, et al. Patient and physician perceptions as risk
factors for oligoanalgesia: A prospective observational
study of the relief of pain in the emergency department.
Acad Emerg Med 2006;13(2):140–146.
8. Bartfield JM, et al. Physician and patient factors influencing
the treatment of low back pain. Pain 1997;73(2):209–211.
9. Cooper-Patrick L, et al. Race, gender, a nd partnership in the
patient–physician relationship. JAMA 1999;282(6):583–589 .
10. Merskey H. The taxonomy of pain. Med Clin North Am
2007;91(1):13–20.
11. Thomas SH, et al. Effect s of morphi ne analgesia on
diagnostic accu racy in Emergency Dep artment patients
with abdominal pain: A prospective, randomized trial.
JAmCollSurg2003;196(1):18–31.
12. Bijur PE, Kenny MK, Gallagher E J. Intravenous m orphine at
0.1 mg/kg is not effec tive for controlling severe acute pain in
the m ajority of patients. Ann Emerg Med 2005;46(4):362–367.
13. Weissman DE, Haddox JD. Opioid pseudoaddiction – an
iatrogenic syndrome. Pain 1989;36(3):363–366
4 Overview and Principles in Emergency Analgesia and Procedural Sedation
PSA VS CONSCIOUS SEDATION
The term ‘‘procedural sedation and analgesia’’ has sup-
planted the often misused and misinterpreted historical
expression ‘‘conscious sedation.’’ In clinical practice, the
concepts implied with the use of PSA are less misleading
to both the patient and the medical provider. In addition,
the use of the term PSA in clinical practice more accu-
rately captures the intent of this practice: sedation and/or
analgesia for an acute medical intervention with the depth

of sedation and analgesia largely dependent on factors
dictated by the patient’s needs.
Locations for PSA Practice
There are many locations within health-care facilities
where PSA may take place. The areas with greatest
activity are typically located within the hospital and
would include the ED, outpatient surgery units, radiol-
ogy, gastroenterology, and the intensive care unit (ICU).
Each PSA site will have its unique patient population
and procedures in addition to a unique set of caregivers
delivering care within this setting. The principles for
PSA practice should not be fluid across any collection of
health-care sites. Rather, procedural sedation practice
should be promulgated within a predetermined set of
clinical guidelines and requirements that emphasizes
patient PSA needs, patient safety, and provide r training
specific to the intended level of consciousness depth as
well as the procedure (Table 2-1). PSA practice policies
should specifically address provider credentialing, doc-
umentation, patient consent, monitoring, and discharge
criteria for PSA patients in all areas.
The PSA Depth of Consciousness Spectrum
Many health-care locations will organize PSA clinical
practice guidelines based on categorical assessments of
expected sedation depth. PSA practitioners should rec-
ognize that a spectrum exists for the depth of patient
sedation during any PSA encounter. This spectrum can
be categorically characterized with levels that would
typically include minimal, moderate, and deep sedation
(Figure 2-1). The distant end of the sedation depth

spectrum would be occupied by a general anesthesia
level of consciousness.
Minimal sedation generally refers to a patient who
retains a near-baseline level of alertness with the ability
to follow commands in an age-appropriate fash ion.
Minimal sedation is usually performed for procedures
that require complianc e but are typically less painful
with the use of local anesthesia. Typical light sedation
procedures might include procedures such as lumbar
puncture, evidentiary exams, simple fracture reductions
in combination with local anesthesia, and abscess inci-
sion and drainage. During minimal sedation, cardio-
vascular and ventilatory functions are usually
maintained, although patients should be monitored for
inadvertent oversedation to deeper levels with oxygen
saturation monitors and close nursing supervision.
Agents typically utilized for minimal sedation include
fentanyl, midazolam, and low-dose ketamine.
As one progresses along the sedation continuum to a
moderate sedation depth, levels of impaired conscious-
ness progress with the onset of eyelid ptosis, slurred
speech, and delayed or altered responses to verbal sti-
muli. Moderate sedation is performed on patients who
Table 2-1. PSA practice policy components
 Medical provider scope of practice and credentialing
 Patient PSA consent
 Standardized patient assessment, monitoring, and preparation practices
for intended depth of consciousness
 Suggested PSA drug dosing strategies
 Patient history and physical examination documentation prior to procedure

 Documentation of medical procedure and patient monitoring data
 Discharge criteria following PSA
 Standards for routine reporting of adverse PSA-related events
6 Overview and Principles in Emergency Analgesia and Procedural Sedation
would benefit from either a deeper level of sedation to
augment the procedure or would benefit from amnesia
of the event. Patients usually have an intact airway and
maintain ventilatory function without support. As with
minimal sedation, inadvertent oversedation to deeper
levels can occur and appropriate monitoring including
oxygen saturation, cardiac, and blood pressure assess-
ments should be done throughout the sedation with
direct observation of the patient’s airway throughout the
procedure. Agents used for moderate sedation in the ED
include propofol, etomidate, ketamine, and the combi-
nation of fentanyl and midazolam.
As patient depth of consciousness progresses into a
deep sedation, the patient response to verbal commands
is substantially impaired with preservation of response
to painful stimuli as well as preservation of airway
protective reflexes. Deep sedation is performed on
patients who would benefit from a deeper level of
sedation in order to complete the procedure for which
they are receiving sedation . Amnesia of the procedure is
similar between moderate and deep sedation , and it is
not necessary to sedate patients to a deep level only to
obtain amnesia of the procedure. Deep sedation gener-
ally is achieved in the ED with the same agents as
moderate sedation – the difference being the intended
level of sedation. Monitoring for deep sedation is the

same as for moderate with oxygen saturation, cardiac,
and blood pressure assessments augmented by direct
observation of the airway.
End tidal carbon dioxide (ETCO
2
) has also been
described in ED PSA, but its utility over direct ventila-
tion observation remains unclear. Deeply sedated
patients can develop respiratory depression but generally
maintain a patent airway and adequate ventilation.
Patients sedated to this level can progre ss to a level of
sedation consistent with anesthesia and there is some
evidence that this may occur more frequently in patients
intended to undergo deep sedation than in patients who
are going to undergo moderate sedation.
A categorization of general anesthesia depicts a
patient unresponsive to all stimuli as well as the absence
of airway protective reflexes. Although it is acknowl-
edged that deep sedation can inadvertently result in a
level of sedation consist ent with anesthesia, this is not
typically the goal of ED PSA. Patients who pro gress to an
unintended level of sedation consistent with anesthesia
are unable to be aroused with verbal or painful stimuli.
The ability to independently maintain ventilatory
Light Moderate Deep
General
anesthesia
Clinical signs
Awake Responds to voice Responds to pain No response
Relaxed Lid ptosis No gag reflex

Slurred speech No speech

Adverse event risk

Pain Hypoventilation Apnea
Aspiration
Emesis
Hypoxia
Hypotension
Airway obstruction
Figure 2-1. The depth of consciousness spectrum for procedural sedation.
Emergency Procedural Sedation Principles 7
function is usually impaired, and patients often require
assistance in maintaining a patent airway. Since patients
can quickly progress to this level using the agents typical
of moderate and deep sedation, physicians performing
moderate and deep sedation must be prepared to pro-
vide ventilatory support until the patient has regained
consciousness.
Recent work with bispectral (BIS) monitoring has
added an objec tive assessment to the traditional un-
derstanding of the sedation depth spectrum during PSA
and general anesthesia. Although much insight has been
attained for the application of BIS findings to the general
anesthesia patient, the implications and adaptability of
this work to the PSA patient are less clear. Precise levels
of consciousness captured by the BIS monitor have
varying degrees of correlation with clinically observed
moderate to deep levels of consciousness. As a conse-
quence, the application of BIS monitoring technology to

PSA practice remains investigative.
CLINICAL ASSESS MENT
PSA guidelines should include a history of present illness
and physical examination for each patient. The pre-
procedure assessment should include consideration of
the patient age and any comorbidity that would impact
the selection of agents or dosing.
The patient assessment should include consideration
of the baseline airway status, including the American
Society of Anesthesiologists’ (ASA) classification of the
patient as potentially uncomplicated or complicated
(Table 23-1 ). The ASA classificati on and the patie nt’s
age may prompt consideration for a more conservative
agent selection and/or dosing strategy. The Mallampati
score is often employed as an assessment guide to assess
the potential for airway complications (discussed in
Chapter 23).
An informed consent document should be routinely
used for encounters where the expected depth of con-
sciousness will exceed minimal sedation. As PSA consent
is obtained, the patient should be informed of any
possible risks of the pro cedure, including potential
adverse complications and specific alternatives to the
treatment plan. The PSA consent should also assist the
patient in understanding that PSA for any given patient
may or may not me et the patient’s expectations for pain
relief, anxiolysis, event amnesia, and sedation. The PSA
intervention should be characterized as one with an
emphasis on the balance between the intended benefits
and the potential for PSA-related complications for any

given encounter allowing for the potential that many
patients may experience discomfort despite the use of a
PSA-augmented approach.
Patient monitoring should be a standardized process
for all PSA encounters. Moderate sedation and deep
sedation encounters should routinely include blood
pressure, heart rate, hemoglobin-oxygen saturation, re-
spiratory rate, and depth of sedation monitoring. Many
practices have also begun routine ven tilation monitoring
with capnography. Capnography offers the benefit of
more precise and sensitive monitoring of ventilation
depth and rate through ETCO
2
detection.
Depth of sedation is best monitored utilizing a stan-
dardized sedation asses sment scale (see Figure 2-1). The
most common and clinically relevant complications
during PSA encounters are adverse respiratory events
such as apnea, hypoxemia, and airway obstruction.
Therefore, the greatest emphasis for health-care provider
training and patient monitoring should be directed
toward the prevention, detection, and treatment of
adverse respiratory events.
PAIN/SEDATION CONSIDERATIONS
With the exception of ketamine, ED PSA sedative
medications have minimal to no inherent analgesic
properties. As the majority of sedation procedures will
involve a substantial amount of pain, most PSA
encounters should offer a standardized analgesic
approach to ensure proper attention to patient pain

prior to, during, and after any ED procedure.
The dosing of analgesic agents should be standardized
in a weight-based fashion. A typical approach should
include initial dosing of an analgesic agent based upon
the patient’s preprocedural pain. Typical analges ic
agents will include morphine sulfate, hydromorphone,
and fentanyl (Table 2-2). Selection of a specific analgesic
should take into consideration the patient’s prior
experience with similar analgesics as well as the desired
duration of clinical affects.
Patients who require longer periods of analgesia, such
as those with fractures, will benefit from strategies
8 Overview and Principles in Emergency Analgesia and Procedural Sedation
emphasizing longer-acting agents, such as morphine or
hydromorphone. These patients may also benefit from
integration of patient-controlled elem ents such as
patient-controlled analgesia (PCA) pumps. Regardless of
the analgesic agent selected, the analgesia approach
should be a continuous observational pro cess with
titration of additional medication in accordance with
the ongoing patient needs.
The ongoing titration of an analgesic agent during
sedation procedures should be approached with caution.
Intravenous analgesics have inherent risks for ventilatory
depression as well as hemody namic compromise. The
simultaneous titration of an analgesic and sedative agent
adds a compounded risk of these events during pro ce-
dural sedation as well as an element of confusion as to
the agent or combination of agents responsible should
an adverse event occur.

Selected procedures such as cardioversion or foreign
body removal may be viewed as events in which the
addition of an analgesic agent is of limited benefit. In
such events, the PSA approach is simplified significantly
by the reduction of agents that place the patient at risk
for adverse hemodynamic or resp iratory events.
PAIN/SEDATION MANAGEMENT
Typical PSA procedures in the adult and pediatric
population might include incision and drainage of
abscess, fracture and/or dislocation reduction, laceration
repair, and foreign body removal. Electrical cardiover-
sion is a procedure commonly undertaken in the adult
population. In the ED setting, the most comm on PSA
procedures will be painful fracture and/or dislocation
reduction maneuve rs. These procedures typify encoun-
ters where optimum patient relaxation and analgesia are
a benefit to patients as well as providers.
The selection of a proper PSA agent should rely upon
the consideration of a number of patient and procedure-
related factors. The anticipated degree of muscle relax -
ation and analgesia required for the procedure should be
contemplated. The expected duration of the procedure
is of critical importance. Any anticipated positioning or
maneuvering of the patient may lend certain agent
selections more appropriate. Finally, the expectations of
the patient and medical consultants taking part in the
procedure should be considered as well.
There remains a great deal of variance in ED PSA agent
selection and dosing strategies. Provider experience as
well as institution or medical consultant preferences may

substantially influence individual approaches. An ‘‘evi-
dence-based’’ approach is now possible in clinical practice
given the many reviews and investigations published in
the medical literature.
Common ED PSA Agents
Agents commonly utilized for adult and pediatric ED
PSA include midazolam, etomidate, propofol, ketamine,
and methohexital (Table 2-2).
Until recently, midazolam has been the PSA agent
that clinicians are most familiar with. Midazolam offers
the benefit of a rapid onset and low incidence of car-
diovascular complications in the ED PSA population.
However, the utilization of shorter-acting sedative
agents has increased substantially, largely as a conse-
quence of physician familiar ity with these medications
as induction agents in addition to many published
investigations in the medical literature.
Short-acting sedative agents, specifically methohex-
ital, etomidate, and propofol, have consistently been
demonstrated to confer similar or, in many cases ,
improved patient and provider experiences in the ED
PSA setting. Adverse event rates associated with these
latter agents have not been characterized as substantially
higher than the risk traditionally attributed to mid-
azolam. The current medical evidence has demonstrated
safety profiles associated with these agents comparable
to midazolam.
Table 2-2. Commonly utilized agents
for ED PSA
Analgesia agents

 Fentanyl
 Morphine sulfate
 Hydromorphone
Sedation agents
 Midazolam
 Propofol
 Methohexital
 Etomidate
 Ketamine
Emergency Procedural Sedation Principles 9
An advantage of midazolam compared to short-acting
sedative agents is the relatively light levels of sedation
produced with low-dose midazolam. In contrast,
methohexital, etomidate, and propofol will confer
moderate or deep sedation levels for nearly all encoun-
ters. Since most ED-based PSA encounters require levels
of sedation in the moderate to deep range, this argument
in favor of midazolam likely has little clinical application
to the majority of ED patients.
Common arguments expressed in favor of shorter-
acting sedative agents promote the view that shorter
periods of impaired levels of consciousness confer less
relative risk for adverse respiratory events, at the same
time offering the benefit of substantially reduced moni-
toring times. The latter issue has gained a great deal of
favor and pertinence with increasing ED patient volumes
placing great demands on fixed ED personnel resources.
FOLLOW-UP/CONSULTATION
CONSIDERATIONS
A diverse medical provider group should be responsible

for development, maintenance, and ongoing review of
ED PSA practices for any given site. This approach is of
particular importance in locations where moderate and
deep levels of patient sedation are frequently utilized.
Consultants routinely include providers with expertise
in anesthesiology, pediatric, and radiology services.
Additional contributing services might include indivi-
duals with orthopedics, plastics/reconstructive surgery,
and cardiology expertise. The goal of such a multi-
disciplined group should be to enable a process of
ensuring patient safety as well as ongoing performance
and evolution of PSA practices.
Selected patients may be deemed inappropriate for
ED PSA. These individuals may be considered to have an
elevated risk for adverse events to such a degree that an
alternate approach of delaying or relocating the inter-
vention and sedation to an alternate time or location
may be deemed in the patient’s best interests. General
guidelines and participation in a planned approach to
these patients is another benefit of a multidisciplined
oversight process for ED PSA.
SUMMARY
ED providers and patients benefit from standardized
institutional and ED PSA practices. Concerns for patient
safety should remain foremost in the provision of ED
PSA services. Medical providers responsible for PSA
practice encounters, particularly practices that routinely
confer levels of deep sedation, should be vigilant in their
training and preparation for adverse hemodynamic and
respiratory events.

BIBLIOGRAPHY
1. American Society of Anesthesiologists, Task Force on
Sedation and Analgesia by Non-Anesthesiologists. Practice
guidelines for sedation and analgesia by non-anesthesiologists.
Anesthesiology 2002;96:1004–1017.
2. American Academy of Pediatrics. Committee on Drugs,
Section of Anesthesiology. Guidelines for monitoring and
management of pediatric patients during and after sedation
for diagnostic and therapeutic procedures. PEDS
1992;89:1110–1115.
3. Clinical policy for procedural sedation and analgesia in the
emergency department. American college of emergency
physicians. Ann Emerg Med 1998; 663–677.
4. Green SM, Krauss B. Procedural sedation terminology:
Moving beyond ‘‘conscious sedation.’’ Ann Emerg Med
2002;39(4):433–435.
5. Agrawal D, Manzi SF, Gupta R, Krauss B. Preprocedural
fasting state and adverse events in children undergoing
procedural sedation and analgesia in a pediatric emergency
department Ann Emerg Med 2003;42:636–646.
6. Joint Commission on Accreditation of Healthcare Organi-
zation. Standards for moderate and deep sedation and
anesthesia hospital accreditation standards. Oakbrook Ter-
race, Illinois, 2002; Tx:2–Tx.2.4. 1, pp. 108–111.
7. Miner JR, Biros MH, Seigel T, Ross K. The utility of
bispectral index in procedural sedation with propofol in
the emergency department. Acad Emerg Med 2005;12:
190–196.
10 Overview and Principles in Emergency Analgesia and Procedural Sedation
nondisplaced fracture, anxiolysis to decrease apprehension

of venipuncture, sedation for a painless procedure such
as a CT scan, and sedation for a painful procedure such as
a displaced fracture reduction. The appropriate selection
of agents is dependent upon the level of anxiolysis,
sedation, or pain relief required for the individual
clinical encounter.
Presedation Assessment
A focused history and physical examination should
include questions about past medical history, medica-
tions, allergies, and prior sedation/analgesia or anes-
thesia experiences. The time of the last solid food intake,
oral intake, and clear liquids should be determined, and
decisions made about method and timing of sedation
may need to be adjusted.
A thorough assessment of the airway for potential pro-
blems should be performed. This assessment should
include evaluation for a small mandible, large tongue,
short neck, loose teeth, or limited neck mobility. A physical
status classification, such as that developed by the ASA,
may serve to categorize the pediatric patient with regard to
ongoing illnesses and medical problems that would suggest
a cautious approach toward PSA encounters.
Consent for PSA should be obtained from the parent or
guardian. The method of drug administration, the actions
of the drug(s), risks, as well as adverse events during and
after PSA should be routinely explained beforehand.
PAIN/SEDATION CONSIDERATIONS
Pain Assessment in Pediatric Patients
One of th e most important aspects of providing pain relief
to children is to understand how to assess the presence

and severity of p ain a nd the relief of pain in infant s and
children. Pain can be assess ed in children using physio-
logic or behavioral observation as well as self-report.
Since pain is a subjective experience, self-repo rting is
favored. Even children as young as 3 years old can use
self-reports by the use of pain-rating tools. Observa-
tional pain assessment is used when the child cannot
self-report, or it can be used to supplement physiologic
measures and self-reporting.
It should be noted that health-care professionals
consistently underestimate a child’s pain, as do parents,
yet the parents are closer to the child’s own pain rating.
One concern with observational assessment is it is often
difficult to determine if the behavio r is owing to pain or
distress/agitation.
Physiologic measurements of pain include tachycar-
dia, pupil dilatation, diaphores is, and peripheral vaso-
constriction. However, these can also occur because of
fear, anxiety, or crying. Although a change of 10–20% in
heart rate, respiratory rate, or blood pressure is associ-
ated with pain, no pain assessment tool relies solely on
these parameters. For children less than 3 years of age,
the FLACC score is an observational pain assessment
tool that is commonly utilized (Figure 3-1).
For children of age 3 and above, the ‘‘FACES’’ scales
have been found to be an easy, well-accepted, reliable, and
valid method of pain self-reporting. The Wong-Baker
FACES Pain Rating Scale is often used for children between
the ages of 3 and 18, and consists of 6 faces ranging from
smiling to crying (Figure 3-2). This scale can be used with

brief age-appropriate verbal explanations and has been
interpreted in several languages. The smiling face is scored
as zero, whereas the crying face is scored as 5.
Another reliable and valid scale is the Bieri Scale, used
for children 3–12 years of age. This scale consists of
seven faces, showing a neutral expression (scored as 0)
to a face with a painful expression (sco red as 6). One
concern with using a scale with a happy smiling face as
compared to one with a neutral face is that the pain
score is higher with the former. No matter which scale is
used, the key point is that the same scale should be used
in the ED and throughout the hospital.
For older children as well as adults, a visual analog
scale (VAS) is commonly used (Figure 3-3). The VAS
consists of a horizontal or vertical line with a description
of pain at each end (usually no pain on one end with the
worst pain on the other). Marks are present on the scale
at equal intervals, typically at 1 cm inte rvals, with each
mark corresponding to a number along the scale.
Studies have shown that when using a 10 cm VAS with
children, a change of 10 mm is interpreted by the patient
as clinically significant.
The Pediatric-Friendly ED as a Method of
Distraction
Because anxiety and fear may play a large role in any
child’s ED experience, simple methods of distraction
can be built into the ED or made readily available
12 Overview and Principles in Emergency Analgesia and Procedural Sedation
Categories Scoring
0 1 2

Faces No particular
expression or
smile
Occasional
grimace or
frown,
withdrawn,
disinterested
Frequent to
constant
quivering chin,
clenched jaw
Legs Normal position
or relaxed
Uneasy, restless,
tense
Kicking, or legs
drawn up
Activity Lying quietly,
normal position,
moves easily
Squirming,
shifting back
and forth, tense
Arched, rigid or
jerking
Cry No crys (awake
or asleep)
Moans or
whimpers;

occasional
complaint
Crying steadily,
screams or sobs,
frequent
complaints
Consolability Content, relaxed Reassured by
occasional
touching,
hugging or being
talked to,
Difficult to
console or
comfort
distractable
Note: Each of the five cate
g
ories is scored from 0–2, with a total score between zero and ten.
Figure 3-1. FLACC Scale.
0
0
NO HURT HURTS
LITTLE BIT
HURTS
LITTLE MORE
HURTS
EVEN MORE
HURTS
WHOLE LOT
HURTS

WORST
Alternate
coding
2
1
4
2
6
3
8
4
10
5
Figure 3-2. Wong-Baker FACES Scale. (From Hockenberry MJ. Wong’s essentials of pediatric nursing, 7th edn. St. Louis, MO: Mosby,
2005, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission.)
Sedation in the Pediatric Department 13
aspiration of gastric contents. The AAP and ASA agree
that there should be no oral intake of clear liquids for
2 hr prior to the procedure for any age infant or child.
These ASA guidelines assert that the length of NPO
status should be 6 hr after infant formula or a light meal,
and 4 hr after breast milk, whereas the AAP guidelines
advise that infants 5 months and under should have no
milk or solids for 4 hr, infants 6–36 months no milk or
solids for 6 hr preprocedure, and those older than 36
months should NPO for 8 hr. Of note, the Canadian
Anesthesiologists’ Society has indicated that an N PO
rule of no fluid intake for periods beyond 3 hr prior to
surgery is unnecessary.
The extrapolation of elective procedure practices to the

emergency setting and population remains a point of
contention. The primary issue in the ED is that one is
often faced with an emergency procedure, such as a
fracture reduction, yet the child does not meet the fasting
guidelines owing to the nature of the unplanned event.
There have been several recent studies considering
preprocedural fasting and adverse events in pediatric PSA.
Three studies, from 3 different institutions with 3,420
patients of ages ranging from 5 days to 32 years, have
demonstrated that there appears to be no association
between a preprocedural fasting state and adverse events
intheEDsetting.
Ultimately, the routine preprocedural assessment
should include a query regarding time of last food and
liquid intake. The implications of this history should be
evaluated against the risks and benefits of the planned
depth of sedation and the urgency of the situation.
Children with Special Health-Care Needs
Children with special health-care needs represent a
growing number of patients seen in the ED, especially in
tertiary care institutions. Although the initial assessment
of these children is no different when compared to the
nonspecial needs population, some of these children will
have comorbidities and illnesses suggesting significant
risk for analgesic and sedation practices.
Information regarding the patients’ current medica-
tion is important to predict any adverse drug interac-
tions. Asking the parents about prior experiences with
sedation can be beneficial, as these may provide infor-
mation revealing agents that have previously been used

for success or complications.
The pain as sessment o f the special health-care
needs child should be adjusted for a developmental
Figure 3-5. Toys can serve as visual distracters to allow for a less-threatening examination for children in the ED. (For color
reproduction, see Color Plate 3.5.)
Sedation in the Pediatric Department 15