Procedural Sedation – Part I

It seems the government and other specialties are trying hard to make sedation as difficult as possible in the ED. We must persevere to provide the best procedural sedation for the maximal comfort and safety for our patients. This brief lecture was originally posted on the defunct EMCrit Lecture Site on 8/7/2009.

I’m reposting it here so I can post part II sometime this week.

This episode, Part I, covers general concepts on sedation as well as ketamine and etomidate/fentanyl.

Part II will cover propofol, ketofol, and dexmedetomidine.

Part III, to be done some time in the future, will cover really difficult sedations.

My friend Reub Strayer has a great PSA checklist as well

Here is the set-up for making your own ETCO2 Nasal Cannulae





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  1. emcrit says

    An anonymous reader wrote:
    Great podcast !

    I have a comment on the procedural sedation talk that was especially good.

    We have a long and successful experience using Etomidate for procedural sedation except we usually use Alfentanil instead of Fentanyl to make duration even shorter when needed. Many people bad-mouth Etomidate because of “Myoclonus” . Many studies also cite frequent Myoclonus with it’s use.
    We rarely see myoclonus and this is why I think that is so.
    In our protocol the nurses are instructed to give it over 90 seconds. In studies I have read there is no mention on how long administration takes so it is probably given much more quickly. In one case of inappropriately getting the etomidate PUSH the patient looked like they were having a grand mal siezure. People should try this approach to be open to using Etomidate for selected short procedures- Cardioversion, Chest tubes, Large abscess (not IVDU). etc.

    Keep up the good work.

  2. Mike says

    Great talk. Here’s my question: I like your idea about the 15 liters Facemask with continous CO2 monitoring. I think that the buffer of oxygen is safe, and I am a total believer in your concept of watching the CO2 – I am amazed that there hasn’t been a national drive to get these everywhere – worked several EDs with none available. (I am currently on a crusade to get this CO2 monitoring in my ED.) What about those patients who are CO2 retainers at baseline, wouldn’t the high flow oxygen prevent their breathing drive. Since I never used these co2 monitors, I wouldnt know how it would play out. theoretically, i would imagine that i would see a climb in their numbers and know why they were becoming goofy. But in summary, how do you manage these COPD patients with CO2 retention who need procedural sedation?

    • says


      These are very high risk patients and probably should be intubated or sedated with an LMA whether that is done by you or by anesthesia depends on your ED.

  3. JAB says


    Great podcast as always! I’ve become apprehensive about etomidate recently because of 2 instances of myoclonus that made a shoulder reduction and a hip much more difficult than they should have been. Is it a question of fast vs SLOW IV push as a previous reader asked?


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