Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship

Common Scenarios

* Cardioversion* Orthopedic reductions* Painful procedures

Three Step Approach to Procedural Sedation

* Step 1: Risk stratify the patient* Mallampati score (aka “How visible is the uvula?”)* Level 1: Can visualize THE WHOLE uvula* Level 2: Can visualize MOST of the uvula* Level 3: Can visualize SOME of the uvula* Level 4: Can NOT visualize the uvula* ASA (aka “How healthy are they?”)* Level 1: Healthy* Level 2: Mild illness* Hypertension* Hyperlipidemia* Anemia* Level 3: Major illness* Diabetes* Coronary disease* COPD* Chronic renal disease* Level 4: Extremely unhealthy* Dialysis patient* Severe heart failure* Chronically debilitated* Level 5: Dying* Patient needs operation to live* Intracranial hemorrhage with midline shift* Ruptured aortic aneurysm* Ruptured papillary muscle with cariogenic shock* Dissecting aortic aneurysm* Step 2: Informed consent* Patients sign a GENERAL CONSENT to treat when registering to the department* Many emergency scenarios require physician to operate with IMPLIED CONSENT* Many patients have an ADVANCED DIRECTIVE* In stable patients and higher risk procedures, separate WRITTEN CONSENT is often required* Varies by hospital* Typically required for procedural sedation in stable patients* Step 3: Gather supplies* Nurse and nursing supplies* IV* Cardiac monitor* Respiratory therapy and respiratory supplies* Capnography* Bag-valve mask* Airway box

Top 5 Procedural Sedation Medications

* Midazolam (“Versed”) – 0.02 mg/kg IV* Reduces anxiety prior to procedure* Provides no analgesia* Fentanyl – 1 mcg/kg IV* Reduces pain* Useful for painful procedures* Incision and drainage* Simple reductions* Propofol – 0.5-1mg/kg IV* General anesthetic* Best given “low and slow”* Short acting* Causes respiratory depression and hypotension* Etomidate – 0.15 mg/kg IV* General anesthetic* Less hypotension than propofol* Can cause myoclonus* Ketamine – 1-2mg/kg IV* “Dissociative”* Provides both amnesia AND analgesia* Can cause emergence reactions* Can cause laryngospasm and secretions

Additional Reading

* Mallampati Score (Wikipedia)* ASA Physical Status Classification (Wikipedia)