EMERGENCY SEDATION AND PAIN MANAGEMENT - PART 7 pptx

complications for pediatric fracture reduction than
ketamine/midazolam.
Ketamine and ketamine/midazolam, administered
IV or IM, have been shown to provide safe, effective
procedural sedation and analgesia for pediatric lacera-
tion repair. As mentioned above, ketamine/midazolam
provides better pain control and anxiety relief with less
respiratory complications than midazolam/fentanyl.
However, when ketamine is used, vomiting is more
common, and emergence reactions (mostly mild) will
occur, regardless of the addition of midazolam. In a
randomized, controlled trial comparing IV to IM keta-
mine for fracture reduction, IM ketamine provided
more efficacious sedation but resulted in more frequent
vomiting and longer lengths of sedation.
The shorter acting agents propofol and etomidate have
been used for ED pediatric procedures such as orthopedic
reductions. The properties of sedation, amnesia, and
rapid recovery time make these drugs attractive for ED
use. However, the short duration of action limits their use
for pediatric laceration repair.
Sedation with 50% nitrous oxide effectively decreases
patient distress and is associated with a low rate of
adverse events in children receiving laceration repair.
The use of nitrous oxide is limited by the need for
special delivery and gas scavenger equipment and
patient compliance with holding the face mask in place
to facilitate delivery of the drug.
FOLLOW-UP CONSIDERATIONS
Although delayed adverse events associated with pediatric
procedural sedation have been described, significant

adverse events, such as apnea or oxygen desaturations, are
unlikely to occur greater than 30 min after the last sedation
drug administration. On discharge from the ED, advise
parents and children about other adverse events that they
may still experience (i.e., vomiting, dizziness, emergence
reactions), instruct them about proper wound care, and
direct them to appropriate follow-up care.
SUMMARY
When determining how best to control pain and
patient movement in children with lacerations, consider
patient age and development, the presence of underlying
conditions, and the location and extent of the laceration.
Recognize that nonpharmacologic techniques may be
used effectively to avoid the use of procedural sedation.
Choose sedation drugs to fit the desired depth of seda-
tion and estimate length of time need ed to perform the
repair. Recognize that the properties of sedation drugs
differ, and combinations may be required to provide
sedation, analgesia, and amnesia of the event. Finally, it
is essential to enlist the input of parents or guardians in
the decisions regarding the care of their children.
BIBLIOGRAPHY
1. Singer AJ, Thode HC, Hollandaer JE. National trends in
ED lacerations between 1992 and 2002. Am J Emerg Med
2006;24:183–188.
2. Roback MG, Wathen JE, Bajaj L, Bothner JP. Adverse events
associated with procedural sedation and analgesia in a
pediatric emergency department: A comparison of common
parenteral drugs. Acad Emerg Med 2005;12:508–513.
3. Green SM, Rothrock SG, Lynch EL, et al. Intramuscular

ketamine for pediatric sedation in the emergency depart-
ment: Safety profile in 1,022 cases. Ann Emerg Med
1998;31(6):688–697.
4. Lawrence LM, Wright SW. Sedation of pediatric patients
for minor laceration repair: Effect on length of emergency
department stay and patient charges. Pediatr Emerg Care
1998;14:393–395.
5. Krauss B, Green SM. Procedural sedation and analgesia in
children. Lancet 2006;367:766–780.
6. Loryman B, Davies F, Chavada G. Consigning ‘‘bruta-
caine’’ to history: A survey of pharmacological techniques
to facilitate painful procedures in children in emergency
departments in the UK. Emerg Med J 2006;23:838–840.
7. Sinha M, Christopher NC, Fenn R, et al. Evaluation of
nonpharmacologic methods of pain and anxiety manage-
ment for laceration repair in the pediatric emergency
department. Pediatrics 2006;117:1162–1168.
8. Hawk W, Crockett RK, Ochsenschlager DW. Conscious
sedation of the pediatric patient for suturing: A survey.
Pediatr Emerg Care 1990;6:84–88.
9. Brown ET, Corbett SW, Green SM. Iatrogenic cardiopul-
monary arrest during pediatric sedation with meperidine,
promethazine, and chlorpromazine. Pediatr Emerg Care
2001;17:351–353.
10. Mace SE, Barata IA, Cravero JP, et al. Clinical policy:
Evidence-based approach to pharmacologic agents used in
pediatric sedation and analgesia in the emergency depart-
ment. Ann Emerg Med 2004;44:342–377.
11. Everitt IJ, Barnett P. Comparison of two benzodiazepines
used for sedation of children undergoing suturing of a

laceration in an emergency department. Pediatr Emerg
Care 2002;18:72–74.
12. Theroux MC, West DW, Corddry DH, et al. Efficacy of
intranasal midazolam in facilitating suturing of lacerations
Sedation for Pediatric Laceration Repair 171
in preschool children in the emergency department.
Pediatrics 1993;91:624–627.
13. McGlone R, Fleet T, Durham S, et al. A comparison of
intramuscular ketamine with high dose intramuscular
midazolam with and without intranasal flumazenil in
children before suturing. Emerg Med J 2001;18:34–38.
14. Younge PA, Kendall JM. Sedation for children requiring
wound repair: A randomised controlled double blind
comparison of oral midazolam and oral ketamine. Emerg
Med J 2001;18:30–33.
15. Kanegaye JT, Favela JL, Acosta M, et al. High-dose rectal
midazolam for pediatric procedures: A randomized trial of
sedative efficacy and agitation. Pediatr Emerg Care
2003;19:329–336.
16. Kennedy RM, Porter FL, Miller JP, et al. Comparison
of fentanyl/midazolam with ketamine/midazolam for
pediatric orthopedic emergencies. Pediatrics 1998;
102:956–963.
17. Wathen JE, Roback MG, MacKenzie T, Bothner JP. Does
midazolam alter the clinical effects of intravenous keta-
mine sedation in children? A double-blind, randomized,
controlled emergency department trail. Ann Emerg Med
2000;36:579–588.
18. Roback MG, Wathen JE, MacKenzie T, et al. A random-
ized, controlled trial of IV versus IM ketamine for sedation

of pediatric patients receiving emergency department
orthopedic procedures. Ann Emerg Med 2006;48:
605–612.
19. Luhmann JD, Kennedy RM, Porter FL, et al. A randomized
clinical trial of continuous flow nitrous oxide and
midazolam for sedation of young children during lacera-
tion repair. Ann Emerg Med 2001;137:20–27.
172 Procedural Sedation for the Emergency Patient
27 Procedural Sedation for Pediatric Radiographic
Imaging Studies
Nathan Mick
SCOPE OF THE PROBLEM
CLINICAL ASSESSMENT
PAIN/SEDATION CONSIDERATIONS
PAIN/SEDATION MANAGEMENT
Sedative-Hypnotic Agents
Chloral hydrate
Benzodiazepines
Barbiturates
Propofol
Etomidate
Ketamine
FOLLOW-UP CONSIDERATIONS
SUMMARY
BIBLIOGRAPHY
SCOPE OF THE PROBLEM
In virtually all areas of medicine, including pediatrics, the
use of advanced diagnostic imaging has increased sub-
stantially. Although utilization of all imaging modalities
has increased, the use of computed tomography (CT) has

grown at a particularly brisk rate, specifically in the evalu-
ation and management of the trauma patient.
These increases have implications for physicians in the
emergency department (ED) as procedural sedation is
frequently required to calm and immobilize a child for
these studies. It may be possible to perform many pro-
cedures utilizing behavioral or distraction techniques,
obviating the need for procedural sedation. However, the
stressful, frightening nature of an injury or ED environ-
ment often requires moderate to deep sedation to over-
come these factors and achieve diagnostic imaging goals.
CLINICAL ASSESSMENT
Prior to the administration of any sedative agent, a
careful preprocedure assessm ent should be undertaken.
Special attention should be given to historical features
that may complicate procedural sedation including a
past history of adverse events with sedation or anes-
thesia, medication history, and medication allergies. The
history should also evaluate the patient for seizure
potential and/or the likelihood of a neurological injury/
condition that may result in elevated intracranial pres-
sures, as these considerations will be of importance in
the consideration for the appropriateness of ketamine.
The guidelines of the American Society of Anesthe-
siology recommend delaying sedation for at least 2–3 hr
after the last clear liquids and 4–8 hr after solids or milk.
These recommendations are often not feasible when
applied to the ED and there is a growing body of liter-
ature that shorter fasting times are not associated with
adverse events during procedural sedation.

A thorough examination of the airway should be
performed in every patient prior to sedation with par-
ticular attention given to predictors of difficult airway
management including congenital airway anomalies (i.e.,
the Pierre-Robin sequence or Beckwith-Wiedemann
syndromes) or acquired conditions (i.e., obesity, trauma,
173
or retropharyngeal abscess) that may make endotracheal
intubation or ventilation problematic. The presence of a
difficult airway should alert the clinician that the proce-
dure may be better suited to the more controlled envi-
ronment of the operating room, rather than the ED.
Auscultation of the lungs should be performed as the
presence of active upper respiratory infection or asthma
increases the risk of laryngospasm by as much as fivefold.
A thorough cardiovascular examination should occur
in every patient, particularly in patients with known
underlying heart disease. Volume status assessment is
imperative in all children, especially those with cardiac
disease as most of the agents used for sedation, with the
exception of ketamine, result in vasodilatation and carry
the risk of hypotension in the hypovolemic child.
Minimal monitoring requirements include pulse
oximetry, cardiac monitor, and blood pressure assess-
ment. Airway resuscitation equipment such as bag-valve
mask, suction, and tools for endotracheal intubation
should be readily available. Reversal agents, such as
naloxone and flumazenil, should be on hand if opiates
or benzodiazepines are being employed. End-tidal car-
bon dioxide measurements using capnography may alert

the clinician to apnea and hypoventilation prior to a
drop in oxygen saturati on and this monitoring tech-
nique is being adopted in many institutions.
PAIN/SEDATION CONSIDERATIONS
There are several very important considerations that
impact the planning of procedural sedation for pediatric
diagnostic imaging procedures (Table 27-1). These
include age of the pati ent, the specific imaging proce-
dure that is planned, whether intravenous contrast is
going to be used, and whether there is going to be any
pain associated with the procedure (i.e., hip aspiration
during ultrasonography or contrast injection during
VCUG) (Figure 27-1).
Age of the patient greatly impacts the procedural
sedation strategy as older children may require only
anxiolysis whereas younger children are more likely to
require deeper levels of sedation. The time of day also
plays a role as a child that is tired around naptime or at
night may only require a feeding and be allowed to sleep
naturally rather than undergo sedation for a study such
as CT of the head.
The type of imaging study is also a factor in the choice
of any sedation strategy. Obtaining plain radiographs
or performing an ultrasound rarely requires sedation.
In contrast, magnetic resonance imaging because of
the length of the procedu re, the noise involved, and
the inability to visualize and assess the patient on an
ongoing basis, may require general anesthesia or even
endotracheal intubation.
Children younger than 3 months of age typically can

be bundled and imaged without sedation whereas it may
not be possible to achieve the required degree of immo-
bility for imaging in older infants and toddlers without
moderate to deep sedation. Sedation is often required in
younger, uncooperative children, particularly if intra-
venous contrast is being used. Contrast studies take
longer to perform and the timing of the bolus is critical
to the acquisition of interpretable images. Thus, in
studies involving coordination or precision of timing,
sedation may be needed as the study cannot be ‘‘redone’’
if there is significant patient movement.
Some pediatric radiographic studies are coupled with
diagnostic procedures such as ultrasonography and hip
aspiration for the evaluation of possible septic arthritis
or fluoroscopic-guided lumbar puncture. For these types
of procedures, it is imperative to choose a sedative agent
with analgesic properties (Table 27-2).
PAIN/SEDATION MANAGEMENT
There are a variety of agents available and suitable
for procedural sedation for pediatric imaging studies
Table 27-1. Factors to consider for procedural
sedation during pediatric radiographic procedures
 Age of patient
 Time of day (near sleep or naptime)
 Duration of procedure
 Degree of cooperation or immobility required
 Presence of head injury or risk of elevating
intracranial pressures
 Hemodynamic stability
 Need for analgesia

 Provider training and experience
174 Procedural Sedation for the Emergency Patient
Sedative-Hypnotic Agents
Chloral hydrate
Chloral hydrate is a pure sedative agent without analgesic
properties that has been extensively used for procedural
sedation, particularly for outpatient diagnostic imaging in
children under the age of 3 years.
Chloral hydrate has an excellent safety profile and can
be given either orally or rectally at a dose of 25–100 mg/kg.
The choice of a proper dose for choral hydrate
administration should be adapted to the clinical scenario as
higher doses (75–100 mg/kg) will result in higher rates
of effective sedation when simultaneously prolonging the
sedation period.
Advantages to chloral hydrate include predictable
clinical effects and the fact that intravenous access is not
required for administration. Disadvantages include a
dose-dependent, prolonged duration of action (60–180
min). There have been selected reports of prolonged
after effects associated with chloral hydrate, including
behavioral changes that may last 24 hr.
Benzodiazepines
Midazolam is the benzodiazepine of choice for short
procedures as it provides sedation, anxiolysis, and
amnesia at appropriate doses. Midazolam can be give
through a variety of routes including orally (0.2–0.5 mg/
kg) and intravenously (0.1 mg/kg). Midazolam is often
used in combination with a short-acting opioid such as
fentanyl. Combination use is associated with higher rates

of respiratory depression and adverse hemodynamic
events, though reversal of sedation with flumazenil is
possible.
Some children experience a paradoxical excitatory
response to midazolam. This response can be difficult to
treat as the child will be noted to increase in agitation
and anxiousness with midazolam dosing. Parents should
be warned beforehand of the potential of this effect as it
can be a frustrating experience that may have to be
countered with higher dosing and/or change to another
sedation agent depending upon the clinical circum-
stances.
Barbiturates
Barbiturates, particularly pentobarbital, have been safely
used for sedation during diagnostic procedures for many
years. The advantages of barbiturates include a rapid
onset and brief duration of clinical effects as well as
dose- and route-dependent potent sedative effects. Ide-
ally, these agents are titrated to effect intravenously
though a variety of administration routes exist including
the rectal route .
Rectal administration of methohexital and thiopental
has been described in a number of investigations in the
medical literature. These reports have characterized this
route as efficacious and safe, with a reduced rate of
respiratory depression when compared to intravenous
administration. Administration through the rectal route
is complicated by defecation in as many as one-quarter
of the patients, as a consequence of the irritant effect to
the mucosa. This effect can be reduced by drug dilution

with saline, and a consequent large increase in volume
instilled.
Pentobarbital is a vessel irritant and will often burn
during intravenous administration. This effect can be
attenuated by dilution with normal saline. Dose-
dependent respiratory depression and hypotension can
be observed. Careful titration, particularly in volume-
depleted children, is an important consideration.
Propofol
Propofol is increasingly utilized outside the operating
room environment for sedation for all manner of
procedures, including diagnostic imaging. Propofol is a
powerful sedative hypnotic with characteristics similar
to barbiturates. Propofol is administered intravenously
at an initial dose of 1 mg/kg followed by 0.5 mg/kg
to maintain the sedated state. The extremely short
duration of action and rapid onset make propofol an
ideal agent for b rief procedures. Its rapid metabolism
and distribution may require higher dosing i n younger
patients, approximating 2.0–2.5 mg/kg, to achieve
the depth of sedation often required for imaging
studies.
Disadvantages to propofol use include pain at the
injection site and respiratory depression. Children
should be monitored closely for adequate ventilation
throughout propofol sedation. Monitoring during pro-
pofol sedation should be done by a caregiver skilled in
emergent rescue interventions. The formulation of
propofol also con tains egg proteins and a history of egg
allergy is considered a contraindication to its use.

176 Procedural Sedation for the Emergency Patient
Etomidate
Etomidate is an imidazole, amnestic agent with rapid
onset and brief duration of action. It has been widely
used as an induction agent for rapid sequence intuba-
tion and only recently has begun to be used for proce-
dural sedation. Advantages to etomidate include its
stable hemodynamic profile and cerebroprotective
properties. Adverse events associated with etomidate use
include respiratory depression, myoclonus, and vomit-
ing. Dosages for procedural sedation range from 0.1 to
0.2 mg/kg IV with a duration of action of 8–10 min.
Myoclonus is perhaps the most significant, and unusual,
disadvantage to the use of etomidate occurring in approxi-
mately 20% of patients. Series of children sedated with
etomidate for radiographic imaging have been few to date.
Ketamine
Ketamine is a unique agent that induces a dissociative
state characterized by maintenance of protective airway
reflexes. It is associated with complete amnesia and
analgesia. Ketamine can be give intravenously (1 mg/kg
followed by 0.5 mg/kg for maintenance) and intramus-
cularly (4–5 mg/kg IM) and has the advantage of a stable
hemodynamic profile, even in hypovol emic patients.
Disadvantages to the use of ketamine include an in-
creased risk of laryngospasm in children with active
upper resp iratory infections or asthma and a small risk
of emergence reaction. Emergence reactions in children
sedated with ketamine tend to be relatively mild and
short acting. Ketamine also causes an increase in intra-

cranial pressure, making it ill-suited for many patients
undergoing diagnostic imaging for head injury or with a
significant seizure history.
FOLLOW-UP CONSIDERATIONS
All children undergoing procedural sedation for diag-
nostic imaging should be monitored for respiratory
depression. At discharge, the child should be awake,
alert, and at an age-appropriate baseline level of neu-
rologic function and should be accompanied by a parent
or guardian.
Sedation-specific discharge instructions including
possible complications and signs of respiratory depres-
sion should be given to each patient, as some sedation
agents may have a prolonged duration of action.
SUMMARY
Sedation of children for radiographic imaging studies
is a common practice in many clinical environments.
Pediatric imaging evaluations may require sedation,
particularly longer or more complicated radiographic
assessments or in younger children and those with high
pain levels and/or anxiety.
A number of sedative agents and approaches have
been described as effective for pediatric radiographic
imaging. The specific approach should be determined by
a number of factors including the clinical setting, patient
age, provider experience, specific injury or illnesses
present at the time of the procedure, and the planned
imaging intervention.
BIBLIOGRAPHY
1. Krauss B, Zurakowski D. Sedation patterns in pediatric

and general community hospital emergency departments.
Pediatr Emerg Care 1998;14:99–103.
2. Clinical policy for procedural sedation and analgesia in the
emergency department. American College of Emergency
Physicians. Ann Emerg Med 1998;31:663–677.
3. Practice guidelines for sedation and analgesia by non-
anesthesiologists. Anesthesiology 2002;96:1004–1017.
4. American Academy of Pediatrics Committee on Drugs:
Guidelines for monitoring and management of pediatric
patients during and after sedation for diagnostic and
therapeutic procedures. Pediatrics 1992;89:1110–1115.
5. Krauss B, Green SM. Sedation and analgesia for proce-
dures in children. N Engl J Med 2000;342:938–945.
6. Green SM, Krauss B. Pulmonary aspiration risk during
emergency department procedural sedation – an examina-
tion of the role of fasting and sedation depth. Acad Emerg
Med 2002;9:35–42.
7. Roback MG, Bajaj L, Wathen JE, Bothner J. Preprocedural
fasting and adverse events in procedural sedation and
analgesia in a pediatric emergency department: Are they
related? Ann Emerg Med 2004;44:454–459.
8. McQuillen KK, Steele DW. Capnography during sedation/
analgesia in the pediatric emergency department. Pediatr
Emerg Care 2000;16:401–404.
9. Newman DH, Azer MM, Pitetti RD, Singh S. When is a
patient safe for discharge after procedural sedation? The
timing of adverse effect events in 1367 pediatric procedur-
al sedations. Ann Emerg Med 2003;42:627–635.
10. Malviya S, Voepel-Lewis T, Prochaska G, Tait AR.
Prolonged recovery and delayed side effects of sedation

for diagnostic imaging studies in children. Pediatrics
2000;105:1110–1115.
11. Mace SE, Barata IA, Cravero JP, et al. Clinical policy:
Evidence-based approach to pharmacologic agents used in
Pediatric Radiographic Imaging Studies 177
pediatric sedation and analgesia in the emergency depart-
ment. Ann Emerg Med 2004;44:342–377.
12. Pershad J, Palmisano P, Nichols M. Chloral hydrate: The
good and the bad. Pediatr Emerg Care 1999;15:432–435.
13. Moro-Sutherland DM, Algren JT, Louis PT, et al.
Comparison of intravenous Midazolam with pentobarbital
for sedation for head computed tomography imaging.
Acad Emerg Med 2000;7:1370–1375.
14. Rothermel LK. Newer pharmacologic agents for procedural
sedation of children in the emergency department –
etomidate and propofol. Curr Opin Pediatr 2003;15: 200–203.
15. Ruth WJ, Burton JH, Bock AJ. Intravenous etomidate for
procedural sedation in emergency department patients.
Acad Emerg Med 2001;8:13–18.
16. Bassett KE, Anderson JL, Pribble CG, Guenther E.
Propofol for procedural sedation in children in the
emergency department. Ann Emerg Med 2003;42:
773–782.
17. Green SM, Krauss B. Clinical practice guideline for
emergency department ketamine dissociative sedation in
children. Ann Emerg Med 2004;44:460–471.
178 Procedural Sedation for the Emergency Patient
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
SCOPE OF THE PROBLEM
CLINICAL ASSESSMENT
PAIN/SEDATION CONSIDERATIONS
SEDATION MANAGEMENT
Specific Agents for Sedation/Analgesia during Brief Pediatric Procedures
FOLLOW-UP/CONSULTATION CONSIDERATIONS
SUMMARY
BIBLIOGRAPHY
SCOPE OF THE PROBLEM
The pediatric population accounts for a large percentage
of emergency department (ED) visits annually. Many
of these patie nts will require brief, painful procedures
either in the ED or in another setting such as the
intensive care unit. These procedures also occur fre-
quently in the outpatient clinic or inpatient setting for
children with chronic illnesses. To affect an optimal
procedural experience for these patients, a pediatric
procedure unit or clinical response team of well-trained
caregivers has been a recent trend.
Typical procedures for these patients include lumbar
puncture, bone marrow aspiration, and central venous
catheter placement. These procedures, and other brief
diagnostic and therapeutic procedures in this population,
are similar to the adult population in the intervention
and technique required. They are distinct from their adult
counterparts, however, in that the pediatric patient will
often require sedation and anxiolysis owing to the child’s
fear, in addition to a need to create an experience that is
positive and supportive instead of a recurrent, negative

association with medical care. Younger patients will also
often require a brief period of sedation to optimize
positioning or minimize movement.
It has been previously documented that there is
considerable underuse of analgesia and sedation in
children requiring brief, painful medical interventions.
The goal of procedural sedation in this setting is to
provide sedative, analgesic, and/or dissociative agents to
alter recognition of pain and level of consciousness, at
the same time maintaining airway reflexes in order
to provide symptomatic relief of pain and anxiety.
Over the last decade, there has been a relative increase
in the recognition of the needs of this population
and innovative approaches. These approaches include
pharmacological management, caregiver training, and
individualized approaches toward the needs of each
child.
CLINICAL ASSESSMENT
The assessment of children undergoing procedural
sedation and analgesia (PSA) for brief procedures is
similar to the general sedation assessment. The patient
assessment should include a focused history and physical
examination to identify issues that may interfere with
sedation or increase the risk of adverse sedation events.
Discussion with the patient and family regarding risks
and benefits of sedation should also be routine prior to
179
adoption of a treatment plan. Any patient whose risk of
a serious adverse event outweighs the proposed benefits of
sedation may be better served by delaying the procedure

until a more comprehensive approach can be undertaken,
such as general anesthesia in the operating suite.
A focused assessment should also include any prior
history of seizure, head injury, or active condition that
would place the placement at risk of adverse outcome
with a sedation agent that would mildly elevate intra-
cranial pressure. Ketamine is an agent that has a very
attractive sedation profile for many of these patients
when an intramuscular or intravenous agent is consid-
ered. However, ketamine is unique from other sedation
agents in that it has the potential to elevate intracranial
pressure, cerebral metabolism, and oxygen consump-
tion. Many pediatric patients requiring brief medical
procedures will have concurrent head injury or condi-
tions such as seizures that should motivate a cautious
consideration of the risks associated with ketamine.
Similarly, the clinical assessment should include
consideration of any condition that places the patient at
risk of adverse outcome for a sedation agen t that may
reduce central venous pressure. Many intravenous
agents, such as propofol and methohexital, create the
potential for significant decreases in central venous
return and subsequent hypotension. Children who are
considered hemodynamically unstable, or at substantial
risk for hemodynamic instability, should be approached
with caution when these agents are considered.
PAIN/SEDATION CONSIDERATIONS
Routine patient monitoring during sedation should
includelevel ofconsciousness,respiratory status,vitalsigns,
and oxygen saturation. The most commonly encountered

adverse events during sedation in the pediatric population
are respiratory depression and vomiting. Except in sce-
narios that utilize very light sedation regimes, ventilation
equipment, suction, and intravenous fluid resuscitation
materials should be immediately available to the clinical
team throughout the sedation encounter.
The benefits derived from a procedural sedation
approach include
1. patient experience benefits including anxiolysis,
relaxation, analgesia, and amnesia;
2. improved parental satisfaction;
3. less stressful situation for medical personnel;
4. improved safety of the patient and staff when
performing a medical procedure;
5. ability to satisfactorily complete the needed medical
procedure.
The choice of a sedative and/or analgesic approach should
take into consideration all of these potential benefits
within the context of the specific procedure and patient
(Table 28-1). The caregiver should take into consideration
an assessment of the child’sdistress prior toand anticipated
during the procedure as well as the degree of pain that will
be anticipated during the intervention (Figure 28-1). These
considerations should direct the sedation approach, par-
ticularly with regard to anemphasis on anxiolysis, sedation,
and analgesia.
Many nonpharmacologic approaches may suffice
solely, or in part, to achieve the desired effect for the
patient. These elements might include parental presence
during the procedure as well a medical provider’s

demeanor that is calming to the child with a reassuring,
nonthreatening approach.
SEDATION MANAGEMENT
Multiple agents have been studied for procedural seda-
tion in the pediatric population. Most studies identify-
ing appropriate agents for procedural sedation in the ED
and procedure-focused setting have been described in
populations of pediatric patients und ergoing painful
orthopedic procedures, including joint reduction and
fracture reduction. Few studies have been published
with a focus population of children undergoing painful
procedures other than predomin antly orthopedic and
laceration repair interventions.
Characteristics to consider for any sedation and
analgesia approach in children with brief medical pro-
cedures include painless administration, a rapid onset of
clinical effects, the ability to easily titrate the agent(s) to
a desired level of sedation, a rapid recovery time, and
limited side effects – specifically vomiting, respiratory
depression, hypotension, and emergence reactions.
The most commonly utilized agents in these settings
are nitrous oxide, benzodiazepines (e.g., midazolam),
etomidate, barbiturates (e.g., methohexital), propofol,
180 Procedural Sedation for the Emergency Patient
and ketamine. Each of these agents has specific advan-
tages and disadvantages that may enhance its appro-
priateness for any given patient and procedure
(Table 28-2).
Nonpharmacologic approaches can also be useful in
whole or as part of an adjunctive strategy with other

agents. Additionally, anesthetic agents applied to the
skin, including regional block anesthesia, should be
Table 28-1. Sedation, anxiolysis, and analgesia considerations for brief painful procedures
(e.g., foreign body removal, lumbar puncture, bone marrow aspiration, central venous
catheter placement) in pediatric patients
1. Would the patient benefit from analgesia?
Is the patient currently in pain?
Will the procedure be painful?
Will the patient have pain after the procedure?
2. What form of pain control is appropriate, if necessary? Nonpharmacologic,
topical anesthesia, regional block anesthesia, systemic analgesia
3. Would the patient benefit from anxiolysis?
4. What form of anxiolysis is appropriate? Nonpharmacologic, oral agent
(e.g., a benzodiazepine), inhaled nitrous oxide, systemic anxiolytic agent
5. Would the patient benefit from sedation?
6. What depth of sedation is appropriate? Mild, moderate, deep sedation
Patient needs Depth of sedation Length of analgesia
Sedation only
Sedation,
analgesia
during
procedure
Sedation,
analgesia
during and
after
procedure
Light
Nitrous
Midazolam

None
Moderate
Midazolam
Ketamine
Brief
Fentanyl
Deep
Etomidate
Methohexital
Propofol
Ketamine
Long
Morphine
Figure 28-1. Algorithm for approach to selected brief painful procedures in the pediatric population.
Sedation for Brief Pediatric Procedures 181
considered in the app roach to brief procedures for all
encounters, incl uding pediatric patients.
Specific Agents for Sedation/Analgesia during
Brief Pediatric Procedures
Nitrous oxide has been described in a number of reports
in the medical literature for brief pediatric procedures,
particularly laceration repair. The advantage of nitrous
oxide is the rapid onset and brief duration of clinical
effects following cessation of inhalation.
The analgesic and sedative properties of nitrous oxide
are variable in the pediatric population with up to 20%
of children described as nonresponders. Children
responding well to nitrous administration will generally
have light levels of sedation with few sustaining more
moderate levels of sedation. The analgesic properties of

nitrous oxide are characterized as significant, although
relatively minor compared to intravenous analgesics.
Another advantage of nitrous oxide use in the pedi-
atric population is its minimal effects on the cardio-
vascular system and respiratory effort. Hypoventilation
is quickly resolved with cessation of nitrous inhalation
and patient stimu lus. Given historic concerns for more
substantial levels of sedation associated with prolonged
nitrous inhalation, it is generally recommended that
nitrous be ‘‘self-administered’’ or, at the least, carefully
monitored during assisted administration in younger
pediatric patients.
Midazolam can be used alone or in combination with
opiates for selected procedures. It is typically used alone
if there is increased agitation for a nonpainful proce-
dure; otherwise, midazolam can be combined with
fentanyl for procedures inducing pain.
Intravenous fentanyl or midazolam offer attractive
hemodynamic profiles for sedation patients. Both drugs
have short onset times and short half-live s (although
Table 28-2. Summary of sedation and analgesia considerations for selected pediatric brief
diagnostic and therapeutic procedures
Agent Delivery Advantages Disadvantages
Nitrous oxide Inhaled Rapid onset
Minimal side effects
Analgesic properties
No IV required
Very short acting
Light sedation
Cooperation required

Midazolam Oral
Intranasal
Intravenous
No IV required
Oral and nasal routes
Titratable sedation levels
Longer acting
Less reliable sedation levels
Deep sedation with IV form
Propofol Intravenous Reliable sedation levels
Rapid onset
Short acting
IV required
Deep sedation
Decrease in venous return
Respiratory depression
Etomidate Intravenous Reliable sedation levels
Rapid onset
Short acting
Myoclonus
Deep sedation
Respiratory depression
IV required
Methohexital Intravenous Reliable sedation levels
Rapid onset
Short acting
Deep sedation
Decrease in venous return
Respiratory depression
IV required

Ketamine Intramuscular
Intravenous
Reliable sedation levels
IV not required for IM
Rapid onset
Analgesic properties
Vomiting
Longer acting
Elevation of intracranial
pressure and intraocular pressure
182 Procedural Sedation for the Emergency Patient
midazolam has a longer period of clinical effects than ultra
short-acting drugs such as etomidate or propofol), with
the added benefit of available reversal agents. Caution
should be exercised with the common practice of com-
bining these drugs, as often performed in stable patients
requiring analgesia and sedation for brief procedures. The
combination of these drugs will increase the likelihood
of hemodynamic changes (e.g., hypotension) as well as
clinically significant respiratory depression.
Ketamine is frequently used for pediatric procedures.
It is known as a dissociative anesthetic agent because it
produces a trance-like effect in the patient. Ketamine is
unique in that it has sedative effects with amnestic and
analgesic properties. Typically, patients will maintain
muscle tone, ventilation, and airway reflexes during
ketamine sedation. It has been used for pediatric seda-
tion via multiple routes including intravenous and
intramuscular administration.
Compared with propofol and etomidate, ketamine

effects a longer sedation recovery time for pediatric
patients; however, there is less respiratory and cardio-
vascular adverse risk. Important side effects include
vomiting, which occurs more often with ketamine as
compared to other sedation medications. Anothe r
common side effect of ketamine is an emergence delir-
ium reaction. Emergence reactions are more common in
children under 5 years of age and in adults.
Ketamine should be avoided in the head injured pa-
tient secondary to its sympathomimetic effect and sub-
sequent elevation of systemic blood pressure causing
cerebral vasodilatation leading to increased intracranial
pressure. Laryngospasm is a rare occurrence (<1%)
associated with ketamine usage.
Etomidate has recently been described for a role in
pediatric procedural sedation. Etomidate has minimal
respiratory effects and no cardiovascular adverse out-
comes, making it a consideration for a potentially
hemodynamically unstable patient.
The most common side effect reported for etomidate
is myoclonus, which occurs in approximately 20% of
patients. Reports of etomidate use in pediatric patients
remain few, and the incidence of myoclonus in the pe-
diatric procedural sedation population remains unclear.
Propofol has become increasingly common as an agent
for procedural sedation in the pediatric population
for brief procedures. Propofol is an ultra short-acting
sedative hypnotic. Propofol has a very rapid onset and
brief duration of action, with sedation occurring at less
than 1 min following administration and recovery time

typically described as occurring within 5–15 min.
For brief pediatric procedures, propofol has been typi-
cally administered through bolus intravenously, at a dose
of 1 mg/kg, with repeat boluses of 0.5 mg/kg to maintain
adequate sedation for the procedure. Pediatric patients
generally require larger bolus doses and maintenance
dosing, 25–50% greater, as compared to adult patients,
likely secondary to a larger volume of distribution.
The main adverse effect from propofol administration
is cardiopulmonary depression. Propofol has a relatively
high incidence of respiratory depression that may lead to
hypoxia and apnea. In most cases of respiratory depres-
sion, airway repositioning, suctioning, and supplemental
oxygen correct the hypoventilatory event, although the
use of bag-mask ventilation should be anticipated with
this agent, as with any deep sedation agent.
The clinical use of intravenous barbiturates for brief
pediatric procedures has been characterized as similar to
propofol. Barbiturates have a rapid onset of action with
the most common adverse events noted as respirato ry
depression and dec reased venous return. Given the
advantages associated with ultra short-acting agents
such as propofol, the use of intravenous methohexital
would seem most advantageous compared to other
barbiturates. The characterization in the medical litera-
ture of the use of methohexital for brief pediatric pro-
cedures has been few to date, compared to intravenous
propofol.
FOLLOW-UP/CONSULTATION
CONSIDERATIONS

Discharge instructions for pediatric patients undergoing
sedation for procedures should include procedural
sedation instructions as well as instructions to return to
the ED, or patient care setting, if there are any concerns
following the sedation.
SUMMARY
Pediatric procedural sedation has become increasingly
common within the ED and pediatric procedure settings
for both therapeutic and diagnosti c simple procedures.
Sedation for Brief Pediatric Procedures 183
It is reasonable and safe to use sedation if a procedure is
particularly painful or if the patient is overly anxious. A
diverse range of medications and approaches are avail-
able that should be individualized to the patient’s needs
as well as the patient care providers and setting.
BIBLIOGRAPHY
1. Green MS, Rothrock SG, Lynch EL, et al. Intramuscular
ketamine for pediatric sedation in the emergency depart-
ment: Safety profile of 1,022 patients. Ann Emerg Med
1998;31:688–697.
2. Green MS, Nakamura R, Johnson NE. Ketamine sedation
for pediatric procedures part 1, A prospective series. Ann
Emerg Med 1990;19:1024–1032.
3. Green MS, Johnson NE. Ketamine sedation for pediatric
procedures. Part 2, review and implications. Ann Emerg
Med 1990;19:1033–1046.
4. Wathen JE, Roback MG, Mackenzie T, Bothner JP. Does
midazolam alter the clinical effects of intravenous keta-
mine sedation in children? A double-blind, randomized,
controlled, emergency department trial. Ann Emerg Med

2000;36(6):579–588.
5. Burton JH, Auble TE, Fuchs SM. Effectiveness of 50%
nitrous oxide during laceration repair in young pediatric
patients. Acad Emerg Med 1998;5(2):72–73.
6. Dickinson R, Singer AJ, Carrion W. Etomidate for
pediatric sedation prior to fracture reduction. Acad
Emerg Med 2001;8(1):74–77.
7. Rothermel LK. Newer pharmacologic agents for procedur-
al sedation of children in the emergency department –
etomidate and propofol. Curr Opin Pediatr 2003;15:
200–203.
8. Havel CJ, Strait RT, Hennes H. A clinical trial of propofol
vs. midazolam for procedural sedation in a pediatric
emergency department. Acad Emerg Med 1999;6:989–997.
9. Bassett KE, Anderson JL, Pribble CG, Guenther E.
Propofol for procedural sedation in children in the
emergency department. Ann Emerg Med 2003;42:773–782.
10. Guenther E, Pribble CG, Junkins E, Kadish H, Bassett K,
Nelson D. Propofol sedation by emergency physicians for
elective pediatric outpatient procedures. Ann Emerg Med
2003;42:783–791.
11. Roback MG, Wathe JE, MacKenzie T, Bajaj LA random-
ized controlled trial of IV versus IM ketamine for sedation
of pediatric patients receiving emergency department
pediatric procedures. Ann Emerg Med 2006;48:605–612.
184 Procedural Sedation for the Emergency Patient
29 Procedural Sedation for Adult and Pediatric
Orthopedic Fracture and Joint Reduction
James Miner and John H. Burton
SCOPE OF THE PROBLEM

CLINICAL ASSESSMENT
PAIN/SEDATION MANAGEMENT
PAIN/SEDATION CONSIDERATIONS
FOLLOW UP/CONSULTATION
SUMMARY
BIBLIOGRAPHY
SCOPE OF THE PROBLEM
The closed reduction of fractures and dislocations
presents an excellent situation in which to perform
procedural sedation. Fracture and joint reductions
involve a great deal more pain than the patient feels prior
to or after the reduction. Procedural sedation should
provide analgesia prior to and during the procedure,
sedation, muscle relaxation, and procedural amnesia for
these painful events. Proper sedation for these procedures
has the additional benefit to the medical care provider(s)
by optimizing patient relaxation to facilitate a successful
reduction.
Once a redu ction has been completed, patients often
have less pain than prior to the procedure owing to
stabilization of the bone or joint. The use of long-acting
sedative agents for procedural sedation, in combination
with long-acting analgesics, may lead to patients who
have unnecessarily extended periods of sedation partic-
ularly following the procedure when stimulus and pain
are minimal. Such an extended period may lead to re-
spiratory depression at a time when patient monitoring
has been reduced. This concern, in addition to caregiver
desires to shorten procedural sedation times in order to
reduce the period of moderate or deep sedation and the

duration of extensive staff patient monitoring, has led to
significant changes in medical practice in favor of short-
acting sedation agents.
CLINICAL ASSESSMENT
Both the urgency of the patient’s requirement for frac-
ture or joint reduction and the patient’s current and
preexisting medical conditions must be considered prior
to procedural sedation. The depth and timing of seda-
tion should achieve an optimal balance for the patient’s
needs, risk of the procedure and/or delays to the pro-
cedure, and risk of sedation.
The urgency of a patient’s need for fracture or joint
reduction is determined by the nature of the injury.
Emergent indications for fracture reduction include
fractures causing vascular compromise to the effected
extremity and/or intractable pain and suffering to the
patient. For this reason, the immediate patient clinical
assessment should emphasize the patient’s global he-
modynamic stability and neurological status in addition
to the neurological and vascular status of the affected
extremity. Injuries with concerning clinical findings
should be reduced as quickly as possible to prevent
injuries associated with fracture or joint reduction
delays. This approach should also apply to patients
deemed to have intractable pain and suffering.
Many acute fractures without associated vascular
compromise or extensive patient suffering are injuries in
which the patient may achieve a reasonable comfort
level with simple mechanical immobilization and/or
systemic analgesia. These injuries are best classified as

185
urgent procedures where there is a need for reduction to
be performed; however, no substantial risk is posed
from short delays to allow for more extensive patient
and risk assessment. Fractures that require reduction bu t
are more stable with minimal pain may be classified as
semi-urgent. Nonurgent fracture reductions would in-
clude the placement of orthopedic splints for fractures
that require minimal manipulation or changing splints
for fractures that have already been reduced.
A patient’s risk for procedural sedation should be
assessed prior to sedation. The American Society of
Anesthesiologists’ physical status score is a commonly
utilized tool for this purpose. Patients in good health
with no injury other than an isolated extremity fracture
or dislocation are designated Class 1 with subsequent
lowest anticipated risk for procedural sedation. Patients
with an underlying stable medical condition, such as
asthma or heart disease, are designated Class 2. Patients
with exacerbation of underlying medical conditions are
designated Class 3. Unstable patients (e.g., trauma
patients with multiple injuries, in addition to orthopedic
injuries) are considered Class 4.
It is a fact that many of the conditions that increase the
urgency for injury reduction, such as patient hemody-
namic instability or limb-threatening vascular or neuro-
logic compromise, are also associated with increasing
procedural sedation risk. This consideration poses the
central dilemma in the traditional paradigm of risk as-
sessment for orthopedic injury procedural sedation in the

acutely injured patient. Therefore, provider experience
and judgment are essential components in the assessment
of the risk and benefits associated with procedural seda-
tion for any given clinical scenario, particularly in the
setting of many orthopedic joint and fracture reductions.
PAIN/SEDATION MANAGEMENT
A general approach to procedural sedation and analgesia
for the patient with acute orthopedic injury requiring
reduct ion is summar ized in Figure 29-1 . The unde rlying
principle for the balance between sedation risk and
optimization of conditions for successful injury reduc-
tion relies on a number of factors. Evidence in the
medical literature would suggest that, in addition to
underlying patient risk assessment, adverse sedation
events are more likely to be associated with deeper levels
of sedation, longer sedation periods, and repetitive
dosing of sedative agents.
The selection of an agent or multiple agents for
sedation and/or analgesia during orthopedic injury
reduction should vary with the anticipated complexity
and urgency of the procedu re (Ta ble 29-1 , Figure 29-2 ).
Patients requiring emergent reduction should have
immediate administration of sedation, often undertaken
without prior analgesic therapy or radiographic assess-
ment, and management on the basis of the clinical
assessment alone. For patients with an isolated fracture
or dislocation and urgent indication for reduction,
analgesia should be the first priority. Once the patient has
achieved a reasonable level of comfort, a preprocedure
radiographic assessment should be performed. The

patient can then be sedated with a single bolus of a short-
acting sedative agent, and the fracture reduced.
Propofol 1 mg/kg or methohexital 1 mg/kg are the
first-line agents for such reductions in the adult popula-
tion. These agents have exhibited similar safety, time of
onset, and duration of sedation in comparative studies in
the emergency department population. Additionally, no
agents have been shown to be more safe for moderate or
deep sedation of adult emergency orthopedic patients
with physical status score 1 and 2.
The exact depth of sedation that a given patient will
attain with propofol or methohexital cannot be pre-
dicted in a patient who has not previously received the
medication. However, a deep sedation event should be
anticipated with either of these agents.
In the adult population, etomidate is also an agent
that has been studied for sedation during fracture and
joint reduction. Etomidate appears to be a reasonable
selection for these patients although myoclonus will
often be encountered. Myoclonus will occur in ap-
proximately 20–40% of adult etomidate sedation
encounters. This myoclonus is typically mild and not
associated with muscle damage or myalgias following
the sedation event. Severe myoclonus is uncommon and
typically brief in duration. A severe myoclonus event
may require a brief period of assisted ventilation, par-
ticularly with the assistance of a nasal trumpet or oral
airway as facial/masseter myoclonus may challenge
adequate ventilation with bag-valve mask alone.
For pediatric patients, ketamine likely represents the

best choice as a sedative agent for fracture or joint
186 Procedural Sedation for the Emergency Patient
reduction procedures. In this setting, intravenous keta-
mine is advantageous to intramuscular administration
as venous access allows for analgesic administration as
well as ketamine titration. Propofol has also been well
studied in the pediatric population and offers the
advantage of a shorter duration of action than that
associated with ketamine.
After the fracture is reduced, the patient should be
monitored closely until they have recovered to a pre-
procedure mental status, at whi ch time their pain should
be reassessed and treated accordingly. Once the patient’s
analgesic needs have been addressed, the patient should
undergo repeat radiographic assessment, as needed, to
assess the reduction success. Patients who require repeat
sedation owing to inadequate reduction should have
their second sedation procedure delayed until they have
regained their baseline mental status, if possible.
Critically ill patients who require urgent reduction
(physical status score 3 or 4) should follow a similar
approach as outlined above, except that etomidate should
be strongly considered as the sedation agent with initial
bolus dosing of 0.15 mg/kg. Etomidate sedation has been
demonstrated to be associated with fewer hemodynamic
Propofol
1 mg/kg
Repeat 0.5 mg/kg
Etomidate
0.15 mg/kg

Repeat 0.1 mg/kg
Morphine sulfate 0.1mg/kg
or
fentany l 1–3 mcg/kg
or
hydromorphone 0.015–0.03 mg/kg
Methohexital
1 mg/kg
Choose sedation agent, reduce dosing 25–50% for the following:
- Age: >70 years
- Extended procedure, e.g., hip reduction
- Weight > 100 kg
- ASA status: complicated airway anticipated
- Always consider as deep sedation
- Hypotension risk: select patients with
hemodynamic/hydration stability
- Always consider as deep sedation
- Consider for hemodynamic unstable patient
- Myoclonus approximately 20-40%
- Always consider as deep sedation
- Hypotension risk: select patients with
hemodynamic/hydration stability
Figure 29-1. An approach to intravenous procedural sedation and analgesia for the acutely injured
patient requiring sedation for joint or fracture reduction.
Table 29-1. Selection of short-acting sedation or
analgesic agents based on anticipated procedure
complexity
Simple reductions – one reduction attempt anticipated
Methohexital 1 mg/kg
Propofol 1 mg/kg

Etomidate 0.15 mg/kg
Complex reductions (multiple attempts anticipated or
fluoroscopy)
Propofol 1 mg/mg followed by 0.5 mg/kg as needed
Ketamine 1 mg/kg IV, þ / À midazolam 0.05 mg/kg IV
Simple splinting without reduction
Fentanyl 1.5 ug/kg
Alfentanil 10–15 ug/kg
Sedation for Orthopedic Fracture 187
adverse outcome that may be associated with a delay. In
urgent or semi-urgent procedures, intoxicated patients
may benefit from a delay prior to sedation until such
time the patient has a more predictable and reliable
response to systemic sedation.
FOLLOW UP/CONSULTATION
Patients who will require complex or prolonged reduc-
tions should be considered for general anesthesia in the
operating room. A great deal of the risk associated with
procedural sedation is dependent upon the depth and
the length of the sedation encounter. As these two fac-
tors increase, the patient’s potential to benefit from a
general anesthesia approach increases as well and should
be considered.
The need for a separate practitioner performing the
reduction from the provider performing the sedation
has been a controversial issue with the more frequent
utilization of agents associated with deep sedation
encounters. The current literature is inconclusive on this
issue and lends no substantial support for an evidence-
based con clusion. In general, providers of deep sedation

should consi der the risks and benefits of a practical yet
safe approach to their patients, particularly those re-
quiring fracture or joint reduction. Although relatively
brief and simple reduction encounters may not require
the presence of an additional provider, more complex
and/or extended procedure patients will likely benefit
from a third skilled provider, in addition to the typical
one nurse-one physician approach.
SUMMARY
The brief and painful nature of fracture and joint
reduction techniques make these procedures particularly
amenable to procedural sedation and analgesia. The
approach to the sedation of the orthopedic injury
patient should consider the complexity of the patient’s
injury, the urgency of the reduction, and any concurrent
or preexisting medical conditions.
BIBLIOGRAPHY
1. Anesthesiologists, A.S.O., Physical Status Classification
System. www.asahq.org/clinical/physicalstatus.htm , 2004,
last accessed on July 5, 2007.
2. Bassett KE, Anderson J, Pribble C, Guenther E. Propofol
for procedural sedation in children in the emergency
department. Ann Emerg Med 2003;42:773–782.
3. Burton JH, Bock AJ, Strout TD, Marcolini EG. Etomidate
and midazolam for reduction of anterior shoulder
dislocation: A randomized, controlled trial. Ann Emerg
Med 2002;40:496–504.
4. Burton JH, Miner JR, Shipley ER, Strout TD, Becker C,
Thode HC. Propofol for emergency department proce-
dural sedation and analgesia: A tale of three centers. Acad

Emerg Med 2006;13:24–30.
5. Godambe SA, Elliot V, Matheny D, Pershad J. Comparison
of propofol/fentanyl versus ketamine/midazolam for brief
orthopedic procedural sedation in a pediatric emergency
department. Pediatrics 2003;112:116–123.
6. Green SM, Roback MG, Miner JR, Burton JH, Krauss B.
Fasting and emergency department procedural sedation
and analgesia: A consensus–based clinical practice advi-
sory. Ann Emerg Med 2007;49:454–461.
7. Guenther E, Pribble C, Junkins E, Kadish H, Bassett K,
Nelson D. Propofol sedation by emergency physicians for
elective pediatric outpatient procedures. Ann Emerg Med
2003;42:783–791.
8. Miner JR, Bachman A, Kosman L, Teng B, Heegaard W,
Biros MH. Assessment of the onset and persistence of
amnesia during procedural sedation with propofol. Acad
Emerg Med 2005;12:491–496.
9. Miner JR, Biros M, Krieg S, Johnson C, Heegaard W,
Plummer D. Randomized clinical trial of propofol versus
methohexital for procedural sedation during fracture and
dislocation reduction in the emergency department. Acad
Emerg Med 2003;10:931–937.
10. Miner JR, Biros M, Heegaard W, Plummer D. Bispectral
electroencephalographic analysis of patients undergoing
procedural sedation in the emergency department. Acad
Emerg Med 2003;10:638–643.
11. Miner JR, Danahy M, Moch A, Biros M. Randomized
clinical trial of etomidate versus propofol for procedural
sedation in the emergency department. Ann Emerg Med
2006;49:15–22.

12. Miner JR, Martel ML, Meyer M, Reardon R, Biros MH.
Procedural sedation of critically ill patients in the
emergency department. Acad Emerg Med 2005;12:124–128.
Sedation for Orthopedic Fracture 189
30 Procedural Sedation for Electrical Cardioversion
Christopher J. Freeman
SCOPE OF THE PROBLEM
CLINICAL ASSESSMENT
PAIN CONSIDERATIONS
PAIN MAN AGEMENT
FOLLOW-UP CONSIDERATIONS
SUMMARY
BIBLIOGRAPHY
SCOPE OF THE PROBLEM
The first use of electricity in resuscitation was described
in 1774 by the Royal Humane Society in London for a
near-drowned child. In the late nineteenth century,
treatment of ventricular fibrillation was described in
animals with the use of electricity. In 1947, successful
termination of ventricular fibrillation was described
using AC current in humans. In the 1960s, direct current
cardioversion was described and this ultimately became
the standard for modern-day cardioversion. Cardiover-
sion techniques have been modified and developed
during the past 50 years with different waveforms,
amplitudes, and timing for delivering safe and effective
cardioversion.
The ideal agents and methods to provide procedural
sedation and analgesia (PSA) during the cardioversion
procedure have been less well investigated. Few studies

have evaluated the use of PSA in the emergency depart-
ment (ED) for electrical cardioversion. Additionally,
studies that have addressed this unique problem in the
ED setting have been limited by small sample sizes. As a
consequence, there is a large variation of clinical practice
for PSA during ED cardioversion.
Despite a lack of a uniform approach to PSA during
ED cardioversion, it is clear that electrical cardioversion
as an ED-based procedure is becoming more com-
monplace. This is largely due to an aging population
with elevated risk for arrhythmias.
The largest cohort of ED patients with stable arrhy-
thmias that are candidates for cardioversion is the
new-onset atrial fibrillation and flutter group. Atrial
fibrillation is the most common arrhythmia seen in the
ED and afflicts approximately 0.4% of the population. As
evidence accumulates that supports the use of ED car-
dioversion for recent-onset atrial fibrillation, in addition
to a larger population at risk for atrial fibrillation, the
frequency of ED electrical cardioversion encounters will
increase.
CLINICAL ASSESSMENT
The clinical assessment of the cardiac arrhythmia patient
begins with the question of cardiovascular stability.
Many cardiac arrhythmias have profound effect on car-
diac output causing hypoperfusion, unconsciousness, and
apnea. Conversely, hypoxia, hypercarbia, and apnea can
result in cardiac arrhythmias. Therefore, the first step in
the management of the arrhythmia patient is to stabilize
the patient with regard to cardiovascular and ventilatory

adequacy. Unstable patients require immediate rhythm
recognition and may require immediate cardioversion
if appropriate. If the patient is deemed to be unstable
(Table 30-1), cardioversion is typically performed with-
out concern for PSA prior to the procedure (Figure 30-1).
If the patient is deemed to be stable, a more complete
evaluation should be undertaken including onset of
symptoms, history of similar symptoms/arrhythmias,
190
cardiac history, and evaluation of risk factors for the
arrhythmia. Additional testing that may be beneficial in
these patients includes a chest x-ray, electrolyte profile,
thyroid function studies, and echocardiogram.
Many arrhythmias are amenable to cardioversion.
However, cardioversion is often not the first interven-
tion as many arrhythmias will initially be treated with
agents to attempt chemical (pharmacologic) cardiover-
sion or heart rate control. The arrhythmias amenable to
electrical cardioversion are listed in Table 30-2. Of these
entities, atrial fibrillation/flutter is the most common.
Increasingly, evidence is accumulating that ED atrial
fibrillation cardioversion is a safe and effective proce-
dure. Reported success rates for ED electrical cardio-
version of new-onset, atrial fibrillation patients have
ranged from 86% to 97%. Complication rates have
varied from 0% to 9% with most complications owing
to factors related to procedural sedation. ED cardio-
version of the new-onset, atrial fibrillation patient
appears to allow prompt, effective rhythm management
that is safe to the patient with the potential advantage of

eliminating the added cost of hospital admission.
Cardiac arrhythmia amenable
to electrical cardioversion
*Unstable
*Unstable defined in Table 30-1.
Stable
Procedural Sedation
Etomidate
0.1 mg/kg

Propofol
1.0 mg/kg
Methohexital
1.0 mg/kg
Midazolam
0.04 mg/kg

Electrical Cardioversion
Electrical Cardioversion
Figure 30-1. Clinical approach to sedation and analgesia in the electrical cardioversion patient.
Table 30-1. Definition of the unstable arrhythmia
patient
 Apnea
 Hypoventilation
 Ongoing ischemic chest pain
 Hypotension (SBP< 90)
 Altered mental status owing to any of the above
Table 30-2. New-onset, stable arrhythmias
amenable to ED cardioversion
 Atrial fibrillation

 Atrial flutter
 Superventricular tachycardia
 Ventricular tachycardia
Sedation for Electrical Cardioversion 191
Cardioversion of atrial fibrillation in the ED setting
is typically limited to patients with less than 48 hr of
atrial fibrillation symptoms or those patients who are
therapeutically anticoagulated at the time of their ED
visit. By limiting the population to patients who are
anticoagulated or with symptoms less than 48 hr, there
appears to be an acceptable risk of thromboembolic
events following cardioversion.
In theory, there are multiple benefits to ED electrical
cardioversion. Early cardioversion should decrease the
amount of cardiac remodeling owing to persistent atrial
fibrillation. Additionally, limiting remodeling increases
the likelihood that the patient will maintain sinus
rhythm following cardioversion. ED cardioversion typ-
ically decreases the admission rate for atrial fibrillation –
subsequently decreasing the cost and resources required
for inpatient management. It is currently unclear
whether there is any long-term benefit to rhythm con-
trol in these patients.
PAIN CONSIDERATIONS
The pain considerations for arrhythmias are unique.
The arrhythmia may cause some discomfort to the
patient but is uncommonly described as severely painful.
The need for pain control and sedation during cardio-
version should be understood within the context of a
procedure that is very brief with minimal postprocedure

discomfort.
The ideal agent for procedural sedation in the car-
dioversion setting would have the following attributes:
rapid onset of sedation, rapid recovery from sedation,
minimal cardiovascular effects, minimal respiratory
depression, and an amnestic effect. There is no agent
that meets all of these criteria, but there are man y that
have some if not most of these attributes.
The goal of the clinician should be to find the appro-
priate sedation medication based on the experience of the
provider and the needs of the specific patient. Table 30-3
provides a comparison of agents commonly used for
cardioversion procedural sedation. The four agents most
commonly used as sedative agents for electrical cardio-
version in the ED setting are etomidate, methohexital,
midazolam, and propofol.
Etomidate is a unique sedative hypnotic agent com-
monly used in the ED. The benefits of procedural
sedation with etomidate during cardioversion are its
short duration of action, rapid onset, and lack of
cardiovascular compromise. Etomidate appears to have
the least cardiovascu lar effect of the commonly used
sedative agents, with a slight elevation in heart rate
and a minimal change in blood pressure and cardiac
output.
The use of etomidate during cardioversion is com-
plicated by a high incidence of myoclonus. Myoclonus
during etomidate use is seen in 20–40% of patients. The
myoclonus is typically mild; however, myoclonus may
complicate electrocardiogram interpretation following

Table 30-3. Comparison of procedural sedation agents for electrical cardioversion
Sedative agent Dose Cardiovascular effects Advantages Disadvantages
Etomidate 0.1–0.2 mg/kg
Repeat 0.05 mg/kg
as needed
Small increase in HR
Minimal effects on
BP and CO
Rapid onset and metabolism
Minimal cardiovascular effects
Mild respiratory depression
Myoclonus, nausea, and
vomiting
Methohexital 0.5–1.0 mg/kg
Repeat 0.5 mg/kg as
needed
Decreases in BP and
CO
Rapid onset and metabolism Potential for hypotension
increased in elderly and
hypovolemic
Midazolam 0.03–0.05 mg/kg
Repeat 0.03 mg/kg
as needed
Small decrease in BP
with increase in HR
Reversal agent available
Titratable level of sedation
from light to deep
Longer duration of

actionLighter level of sedation
compared to other agents
Propofol 0.5–1.0 mg/kg
Repeat 0.5 mg/kg as
needed
Decreases in BP and
CO
Rapid onset and metabolism
Antiemetic properties
Potential for hypotension
increased in elderly and
hypovolemic
Note: HR, heart rate; BP, blood pressure; CO, cardiac output.
192 Procedural Sedation for the Emergency Patient
electrical cardioversion. Other complications that are
less of a concern with etomidate are pain at the site of
injection and a brief suppression of the adrenalcorticoid
axis.
Methohexital is a short-acting barbiturate. Barbiturate
use has decreased as benzodiazepines, etomidate, and
propofol have become more popular as sedative agents
in the ED. The benefit of methohexital, compared to
other barbiturates, is that it has a more rapid clearance
and is less likely to result in prolonged sedation at
multiple or high doses.
The greatest concern with the use of methohexital for
cardioversion sedation is the potential for deleterious
cardiac and respiratory effects. Methohexital causes
venous dilatation and a mild decrease in cardiac con-
tractility. Usually the patient will compensate for this with

an increase in heart rate. The decrease in blood pressure
is more pronounced in patients with cardiomyopathy,
coronary artery disease, b-blockade, and hypovolemic
patients.
Midazolam is typically the preferred benzodiazepine
owing to its shorter duration of clinical effects when
compared to other benzodiazepine agents. The benefits
of midazolam, compared to other common sedatives,
include a readily available reversal agent and limited
adverse cardiovascular effects. The disadvantages of
midazolam are primarily longer duration of action and
lighter depth of sedation when compared to metho-
hexital, etomidate, and propofol.
Propofol has become a common agent for ED pro-
cedural sedation. Propofol has a brief half-life and quick
clearance for rapid onset and recovery from sedation.
The most significant disadvantage to propofol use for
ED cardioversion is the potential for cardiovascular and
respiratory depression. Propofol use results in vasodi-
latation and mild decreases in cardiac contractility. The
potential for clinically significant hypotension is most
notable in the elde rly, hypovolemic, or patients on
b-blocker medications.
All of the above sedative agen ts have no intrinsic
analgesic properties. As note d, the electrical cardiover-
sion procedure is one of brief, intense stimuli with
minimal pain following the intervention. Therefore, the
addition of an analgesic agent unnecessarily complicates
the procedure (by adding another agent with the poten-
tial for adverse cardiovascular and respiratory events) and

may lead to a higher incidence of procedural sedation
complications.
Unless there is a specific, unique circumstance to
warrant the addition of an analgesic agent to the plan-
ned sedation, the use of an opiate or similar analgesic
should be avoided during electrical cardioversion in the
ED setting. If the patient has significant pain following
the cardioversion procedure, the pain can be treated
with an analgesic at that time.
PAIN MANAGEMENT
An algorithm for procedural sedation in electrical car-
dioversion is shown in Figure 30-1. Etomidate, metho-
hexital, midazolam, and propofol can be used successfully
for safe ED procedural sedation for electrical cardio-
version.
The choice of a procedural sedation agent for elec-
trical cardioversion is guided by physician experience
and the specific needs of the patient. In an unstable
patient or a patient with less relative cardiovascular
reserve, etomidate is likely the preferred agent. If there is
less concern for hypotension, both methohexital and
propofol are excellent choices. Midazolam, with its
longer duration of action and subsequent prolonged
recovery time, is less of an ideal agent unless a lighter
depth of sedation is desired than that typically associated
with etomidate, propofol, or methohexital.
FOLLOW-UP CONSIDERATIONS
Patients undergoing sedation for an electrical cardio-
version procedure should be observed until they are
alert, awake, and safe to ambulate to discharge from the

clinical setting. If a reversal agent is given during seda-
tion, the patient warrants prolonged ED observation or
admission owing to risk of sedation after the reversal
agent is eliminated.
Follow-up after cardioversion depends on the original
rhythm and specific clinical circumstances. Most
patients successfully cardioverted can be managed as
outpatients, following a routine brief observation during
the postprocedural period, with cardiology follow-up.
Individuals not converted successfully often require
inpatient management to further develop the clinical
options for rhythm management.
Sedation for Electrical Cardioversion 193
SUMMARY
Management of the electrical cardioversion patient
should initially address the clinical stability of the patient.
If the patient is deemed unstable and requires immediate
cardioversion, procedural sedation is typically not uti-
lized.
If the patientis deemed stable,selection ofthe procedural
sedation drug should be guided by the clinical circum-
stances in addition to the physician’s experience with spe-
cific sedation agents. The routine utilization of an analgesic
agent will often increase the potential for an adverse
cardiovascular or respiratory event during procedural
sedation for electrical cardioversion and is best avoided.
BIBLIOGRAPHY
1. Stoneham MD. Anaesthesia for cardioversion. Anaesthesia
1996;55:565–570.
2. Lowen B, Amarasingham R, Neuman J. New method for

terminating cardiac arrhythmias: Use of synchronized
capacitor discharge. JAMA 1962;182:548–555.
3. Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of
rate control and rhythm control in patients with atrial
fibrillation. NEJM 2002;347:1825–1833.
4. Burton JH, Vinson DR, Drummond K, Strout TD, Thode
HC, McInturff JJ. Electrical cardioversion of emergency
department patients with atrial fibrillation. Ann Emerg Med
2004;44:20–30.
5. Lo GK, Fatovich DM, Haig AD. Biphasic cardioversion of
acute atrial fibrillation in the emergency department. Emerg
Med J 2006;23:51–53.
6. Jacoby JL, Cesta M, Heller MB, Salen P, Reed J.
Synchronized emergency department cardioversion of atrial
dysrhythmias saves time, money and resources. J Emerg
Med 2005;28:27–30.
7. Michael JA, Stiell IG, Agarwal S, Mandavia DP. Cardiover-
sion of paroxysmal atrial fibrillation in the emergency
department. Ann Emerg Med 1999;33:379–387.
8. Coll–Vincent B, Sala X, Ferna
´
ndez C, et al. Sedation for
cardioversion in the emergency department: Analysis of
effectiveness in four protocols. Ann Emerg Med
2003;42:767–772.
9. Burton JH, Miner JR, Shipley ER, Strout TD, Becker C,
Thode HC. Propofol for emergency department procedural
sedation and analgesia: A tale of three centers. Acad Emerg
Med 2006;13:24–30.
194 Procedural Sedation for the Emergency Patient

31 Procedural Sedation for Brief Surgical Procedures:
Abscess Incision and Debridement, Tube
Thoracostomy, Nasogastric Tube Placement
Carl Chudnofsky
ABSCESS INCISION AND DEBRIDEMENT
SCOPE OF THE PROBLEM
CLINICAL ASSESSMENT
PAIN/SEDATION CONSIDERATIONS
SEDATION MANAGEMENT
FOLLOW-UP/CONSULTATION CONSIDERATIONS
SUMMARY
TUBE THORACOSTOMY
SCOPE OF THE PROBLEM
CLINICAL ASSESSMENT
PAIN/SEDATION CONSIDERATIONS
SEDATION MANAGEMENT
FOLLOW-UP/CONSULTATION CONSIDERATIONS
SUMMARY
NASOGASTRIC (NG) TUBE PLACEMENT
SCOPE OF THE PROBLEM
CLINICAL ASSESSMENT
PAIN/SEDATION CONSIDERATIONS
PAIN/SEDATION MANAGEMENT
FOLLOW-UP/CONSULTATION CONSIDERATIONS
SUMMARY
BIBLIOGRAPHY
ABSCESS INCISION AND DEBRIDEMENT
SCOPE OF THE PROBLEM
Cutaneous abscesses can originate in any part of the body
through breaks in the skin. Although most abscesses

occur in previously healthy individuals, patients with
diabetes, HIV disease, or other immunocompromising
conditions may be at greater risk, as are parenteral drug
abusers (especially those who ‘‘skin pop’’) owing to the
tendency to develop large cutaneous abscesses. In the
past, most cutaneous abscesses were polymicrobial, with
a predominance of methicillin-sensitive staphylococcus
species. Recently, there has been a disturbing shift in the
microbiology of skin and soft tissue infections with a
large percentage of infections now caused by community-
acquired methicillin-resistant Staphylococcus aureus.
CLINICAL ASSESSMENT
The assessment of patients undergoing procedural seda-
tion and analgesia (PSA) for abscess incision and de-
bridement is similar to the general PSA assessment. The
patient assessment should include a focused history and
physical examination aimed at identifying issues that may
interfere with sedation or increase the risk of adverse
sedation events, discussion with the patient and family
195
regarding risks and benefits of PSA, and close patient
monitoring, including level of consciousness, respiratory
status, vital signs, and oxygen saturation.
The majority of cutaneous abscesses can be drained
in the emergency department (ED). However, some
abscesses may be better managed in the operating suite
unde r general anesth esia (table 31-1 ). for example,
perirectal abscesses may track deep along the rectu m
and, therefore, are seldom drained in the ED. Similarly,
draining an abscess that is close to or that involves

important neurovascular structures may pose undue risk
in the ed setting. Very large or deep abscesses that will
take considerable time may be more efficiently drained
in the operating suite. Any patient whose risk of a
serious adverse event outweighs the proposed benefits
of ED PSA will be better served by having their
abscess drained under general anesthesia in the operat-
ing suite.
Owing to the pain associated with a cutaneous
abscess, most patients are very anxious at the prospect
of incision and debridement. This anxiety is com-
pounded in patients who have undergone previous
drainage procedures without the benefits of PSA. To
help put patients at ease, the clinician should make it
clear that one has an awareness of the pain associated
with draining an abscess and that PSA will provide a
substantial level of comfort during the procedure. It is
also important to be gentle during the examination,
particularly when palpating the abscess and sur-
rounding tissue.
PAIN/SEDATION CONSIDERATIONS
Abscess incision and debridement requires an incision
of the skin overlying the abscess cavity, disruption of
loculated areas, and insertion of gauze packing to facil-
itate continued drainage and prevention of premature
wound closure. These procedures can be excruciatingly
painful, particularly in moderate and large abscesses.
Unfortunately, adequate local anesthesia is often difficult
or impossible to achieve. As a result, PSA is frequently
required.

The skin over the dome of the abscess is usually quite
thin, making skin anesthesia problematic. However,
with careful technique a 25- or 27-gauge needle can be
used to inject local anesthetic subcutaneously into
the skin overlying the dome of the abscess, resulting
in satisfactory anesthesia for the incision. In contrast,
local anesthesia of the abscess cavity is seldom possible
because local anesthetics work poorly in the acidic
environment created by infected tissue. Furthermore,
injection of local anesthetic causes distention of the
already inflamed tissue and is poorly tolerated by most
patients. A regional nerve block can alleviate this
problem, but can only be used if the abscess is in a
location amenable to regional anesthetic block tech-
nique. Alternatively, a field block approach can be uti-
lized but may not provide sufficient anesthesia for a
moderate or large abscess.
Two additional elements to consider when choosing a
PSA regimen for abscess incision and debridement are
the size and location of the abscess. Skin anesthesia and
moderate sedation may be adequate to drain a medium-
sized abscess. Large and/or deep abscesses often require
deep sedation and profound analgesia.
Abscesses on the posterior aspect of the extremities
and thorax, and those located on or around the but-
tocks, usually require the patient to be placed in a prone
position. This position makes monitoring respiratory
effort more difficult and may increase the risk of adverse
respiratory events. This is particularly true in obese
patients, whose weight may reduce chest wall excursion

when lying prone. In these patients, the clinician may
want to choose agents that are easily titrated, can
be reversed, and/or do not affect respiratory effort
(Figu re 31-1 ).
Table 31-1. Abscesses that should be considered
for drainage in the operating suite
 Abscesses in close proximity to or involving important
neurovascular structures (e.g., axillae, antecubital
fossa)
 Large and/or deep abscesses that will require a prolonged
period of time to drain
 Abscesses that, owing to size or location, will require a
degree of patient cooperation best achieved using general
anesthesia
 Deep space abscesses of the hands and feet
 Perirectal abscesses
196 Procedural Sedation for the Emergency Patient
SEDATION MANAGEMENT
For small (i.e., <5 cm) superficial abscesses, subcuta-
neous infiltration of local anesthetic in the overlying
skin, supplemented by a field block and/or administra-
tion of a parenteral opioid will usually result in adequate
analgesia. For patients with small abscesses, who are also
very anxious, the clinician may consider providing light
(i.e., minimal) sedation for the associated anxiolysis. For
moderate and large-sized abscesses, sedation is usually
necessary to assure comp lete drainage and high patient
satisfaction.
A variety of agents may be used to provide PSA for
abscess incis ion and debrideme nt (Fig ure 31-1 ). Since

there have been no studies comparing the effectiveness
of different PSA regimens in this setting, the sedation
selection is usually based on the depth of sedation
required, the expected length of the procedure, the
location of the abscess, the patient’s age, body habitus,
and underlying medical problems, and the physician’s
Regimen Dose Indications Comments
Midazolam Midazolam initial dose: 1.0 mg
Additional doses: 0.5–1.0 to obtain/maintain the
desired level of sedation/anxiolysis
Minimal sedation and
anxiolysis
When used in doses that provide minimal
sedation and anxiolysis, midazolam is very
safe
Use lower doses in elderly patients and those
with underlying COPD
Etomidate and
Fentanyl*



Etomidate initial dose: 0.1 mg/kg
Additional doses: 0.05–0.1 mg/kg to obtain/maintain
the desired level of sedation


Fentanyl dose: 2 - 3 mcg/kg
Moderate or deep sedation
and analgesia

Most often used for deep sedation
Etomidate has minimal cardiovascular effects
Etomidate may be advantageous for patients
with underlying cardiovascular disease or
those at risk for hypotension
Midazolam and
Fentanyl



Midazolam initial dose: 1.0–2.0 mg
Additional doses: 0.5–1.0 to obtain/maintain the
desired level of sedation


Fentanyl initial dose: 50–100 mcg
Additional doses: 50 mcg to obtain/maintain the
desired level of analgesia
Moderate or deep sedation
and analgesia
Easy titration to the desired level of sedation
and analgesia make this combination an
excellent regimen for moderate sedation
Both agents are reversible providing an extra
margin of safety
Use lower doses and titrate more slowly in
elderly patients and those with underlying
COPD
Propofol and
Fentanyl*

Propofol initial dose: 1.0 mg/kg
Additional doses: 0.25–0.5 mg/kg to obtain/maintain
the desired level of sedation



Fentanyl dose: 2–3 mcg/kg
Moderate or deep sedation
and analgesia
Most often used for deep sedation
Propofol may cause a fall in blood pressure
and should be avoided in patients at increased
risk for hypotension
Significant respiratory depression is possible
at doses used for deep sedation
Pretreatment with IV lidocai ne if desired to
prevent/limit injection pain
Ketamine
and
Midazolam



Ketamine initial dose to achieve dissociation: 1.5–2.0
mg/kg
Additional ketamine doses: 0.5–1.0 mg/kg to

obtain/maintain dissociation





Midazolam dose: 1–2 mg
Moderate or deep sedation
and analgesia
Midazolam is given to adults to prevent/limit
emergence reactions
Ketamine causes minimal respiratory
depression and may be advantageous for
patients at risk for respiratory depression
Ketamine inhibits reuptake of catecholamines
leading to cardiovascular excitation – it should
be avoided in patients with coronary artery
diseases (or those possibly at risk for
ischemia) and in patients at risk for elevated
intracranial pressure
Ketamine may be advantageous for patients
with marginal or low blood pressure and those
at risk for hypotension
* When
g
iven in combination with etomidate and
p
rofol, fentan
y
l is

g
enerall
y

g
iven as a sin
g
le bolus to
p
rovide anal
g
esia.
Figure 31-1. Commonly used sedation and analgesia regimens for abscess incision and debridement and tube thoracostomy.
Sedation for Brief Surgical Procedures 197