Emergency Medicine is Hard

Procedural Sedation

Levels of Sedation

Equipment

  • Cardiac monitor
  • BVM
  • Oral / Nasal airways; supplemental oxygen
  • Capnography – etCO2 >50 mmHg, or an increase in etCO2 >10 mmHg indicates hypoventilation
  • Intubation equipment
  • Defibrillator
  • IVF

Pre-procedural Analgesics

  • Fentanyl 1-2 mcg/kg

Wait 2-3 minutes for peak effect of the opioid to minimize risk of respiratory depression and apnea

Procedural Sedation Agents

Propofol

  • Dosing: 1 mg/kg; repeat dosing 0.25-0.5 mg/kg (Based on ideal body weight)
  • Onset: 10-50s
  • Duration: <10 min
  • Advantages: Rapid onset, short duration of action, good for orthopedic reductions (Provides moderate to deep sedation)
  • Disadvantages: No analgesic effect, respiratory depression, hypotension

Ketamine

  • Dosing: 1-1.5 mg/kg (administer slowly); pediatrics usually requires higher 1.5 mg/kg dosing; repeat dosing 0.5-1 mg/kg
  • Onset: 30-40s
  • Duration: 5-10 min
  • Advantages: Provides sedation, analgesia, and cardiorespiratory stability; useful for longer procedures; useful for patients at risk for bronchospasms
  • Disadvantages: Emergence reaction (can pretreat with Zofran and versed), avoid in psychotic or schizophrenic patients

Etomidate

  • Dosing: 0.1 mg/kg; repeat dosing; repeat dosing 0.05 mg/kg
  • Onset: 10-20s
  • Duration: 2-3 min for 0.15 mg/kg dose
  • Advantages: Hemodynamically neutral agent; Minimal cardiovascular and respiratory depression; ideal for short procedures, cardioversion
  • Disadvantages: Myoclonus, adrenal suppression in the critically ill

Ketofol

  • Dosing: 0.5mg/kg Ketamine + 0.5mg/kg propofol
  • Onset: <1 min
  • Duration: <10 min
  • Advantages: Ketamine adds analgesia without opioids and blunts propofol induced hypotension
  • Disadvantages: Higher ketamine:propofol ratios lead to longer recovery

Midazolam

  • Dosing: 1 – 2.5 mg OR 0.1 mg/kg (0.05 mg/kg in the elderly)
  • Onset: 3-5 minutes
  • Duration: 30-80 minutes
  • Advantages: Use during longer procedures requiring deep sedation
  • Disadvantages: Provides no analgesia, and can cause cardiovascular and respiratory depression when combined with opioids

Fentanyl

  • Dosing: 0.5-1.5 mcg/kg
  • Onset: 3-5 min
  • Duration: 30-60 minutes
  • Advantages: Monotherapy can be used for minimal sedation; provides analgesia
  • Disadvantages: Respiratory depression

Dexmedetomidate (Precedex)

  • Dosing: 1 mcg/kg over 10 min then maintain infusion of 0.6 mcg/kg/hr
  • Onset: 4-5 min
  • Duration: 45-90 min
  • Advantages: Useful for cooperation in a patient experiencing respiratory depression (Sedation without respiratory depression)
  • Disadvantages: Hypotension; blunts sympathetic response

Dosing Considerations

Obesity

  • Etomidate, ketamine, fentanyl and propfol are highly lipophilic and protein bound and should be dosed according to ideal body weight
  • Benzodiazepines i.e. Midazolam have a volume of distribution that correlates with excess fat tissue and should be dosed according to total body weight

Pregancy

  • Consider using propofol or fentanyl, but consult OB if able regarding the best PSA agent
Alex Yang

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