At the Bedside

  • Pre-sedation assessment:
  • Confirm indication, urgency, fasting status if known, and whether delay is acceptable. Lack of ideal NPO time is not an absolute contraindication in urgent ED care.
  • Focused airway assessment:
  • Prior difficult airway/sedation history
  • Mallampati if feasible
  • Mouth opening, dentition, neck mobility
  • Obesity, OSA, facial trauma, stridor, active vomiting
  • Review comorbidities:
  • Severe cardiopulmonary disease
  • Pregnancy
  • Liver/renal disease
  • Neuromuscular disease
  • Substance/alcohol use, chronic opioids/benzodiazepines
  • Baseline vitals, mental status, cardiopulmonary exam.
  • Monitoring and setup:
  • Cardiac monitor, pulse oximetry, frequent BP checks.
  • Capnography is strongly recommended; ETCO2 often changes before hypoxemia.
  • Oxygen, suction, bag-valve-mask, airway adjuncts, RSI/intubation equipment at bedside.
  • IV access preferred for moderate/deep sedation.
  • Dedicated personnel: one clinician performing sedation and one focused on procedure/monitoring per local policy.
  • Common ED sedative strategies:
  • Painful procedure: ketamine, propofol, ketofol, etomidate; add analgesia if agent is not analgesic.
  • Short orthopedic reduction: propofol or ketamine are common.
  • Cardioversion: etomidate or propofol commonly used.
  • Elderly/frail: reduce dose substantially and titrate.
  • Agent selection by patient phenotype:
  • Hypotensive/fragile hemodynamics: ketamine or etomidate often favored.
  • Severe hypertension/tachycardia/psychosis: avoid ketamine if sympathetic surge is undesirable.
  • Bronchospasm/asthma: ketamine can help.
  • High aspiration risk or active emesis: proceed cautiously; ensure airway-readiness.
  • Immediate complications to anticipate and treat:
  • Airway obstruction/apnea: jaw thrust, repositioning, airway adjunct, BVM, stop sedatives, prepare to intubate if not rapidly reversible.
  • Hypoxemia: oxygen, ventilation, capnography-guided reassessment.
  • Hypotension: fluids, reduce agent, vasopressor support if needed.
  • Laryngospasm (especially ketamine): jaw thrust + CPAP/BVM with PEEP; deepen sedation with propofol if needed; paralyze/intubate if refractory.
  • Emergence reaction: low-dose benzodiazepine if needed.
  • Vomiting/aspiration: suction, lateral positioning, airway protection.
  • Recovery/disposition:
  • Return to baseline mental status, stable vitals, tolerating secretions, pain controlled, able to be discharged with responsible supervision if outpatient.
  • Admit/observe if prolonged sedation, hypoxia, aspiration concern, hemodynamic instability, significant comorbidity, or procedure-related issue.
A Classic Presentation
A 28-year-old man presents with anterior shoulder dislocation after basketball. He is in severe pain but otherwise healthy, with normal vitals and no airway risk factors. After consent, airway equipment and capnography are prepared. He receives ketamine 1 mg/kg IV with supplemental oxygen and continuous monitoring. During sedation he develops brief partial airway obstruction that resolves with jaw thrust. Closed reduction is successful, post-reduction films confirm alignment, he returns to baseline within 30 minutes, and is discharged with sling, neurovascularly intact exam, and ortho follow-up.

Study Directive

  • Build a one-page sedation checklist from memory: preassessment, equipment, monitoring, rescue plan, recovery criteria.
  • Practice choosing a sedative for 5 scenarios: cardioversion, fracture reduction, pediatric laceration, hypotensive trauma, severe asthma.
  • Memorize standard adult doses for ketamine, propofol, etomidate, fentanyl, and midazolam.
  • Watch or review one airway rescue video/session focused on jaw thrust, OPA/NPA, BVM, and laryngospasm management.
  • After your next ED sedation, debrief: what was the intended depth, earliest sign of effect, and backup airway plan?

Recent Literature