Procedural Sedation Protocol for the Emergency Department
Emergency physicians who have completed appropriate training should be credentialed to perform all levels of procedural sedation (minimal, moderate, deep, and dissociative) in the ED, with a two-person team model consisting of a sedation provider and a dedicated monitor. 1
Personnel Requirements and Roles
Sedation Provider (Emergency Physician)
The procedural sedation provider must possess specific cognitive and technical competencies 1:
Cognitive requirements: Understanding of airway/respiratory/cardiovascular physiology, sedative pharmacology (pharmacokinetics, pharmacodynamics, dosing, contraindications, adverse events), patient risk stratification, and how the specific procedure impacts sedation risk 1
Monitoring capabilities: Ability to monitor airway patency, identify obstruction and distinguish obstructive from central apnea, assess ventilatory adequacy through chest wall observation plus pulse oximetry and capnography, and evaluate cardiovascular stability 1
Rescue skills: Must be able to relieve airway obstruction (head tilt, chin lift, nasal/oral airway placement), perform bag-mask ventilation, and initiate resuscitation for hypoxia, apnea, laryngospasm, hypotension, bradycardia, anaphylaxis, or cardiac arrest 1
Sedation Monitor (Registered Nurse or Respiratory Therapist)
A dedicated licensed healthcare professional whose principal role is continuous monitoring and documentation 1:
Must be familiar with airway/respiratory/cardiovascular physiology, monitoring equipment interpretation (cardiac rhythm, pulse oximetry, capnography, blood pressure), and the sedative drugs being used 1
Can assist with minor, interruptible tasks only if they don't interfere with effective monitoring 1
Must be able to assist the sedation provider in resuscitation and rapidly summon additional help 1
Credentialing and Privileging
Competencies should be defined by specific sedation skill sets rather than specialty training 1. Emergency physicians trained in procedural sedation should receive comprehensive privileges covering all sedation levels, including dissociative sedation 1. For providers who don't regularly intubate, focus rescue skills training on airway repositioning, bag-mask ventilation, and oral/nasal airway placement rather than requiring intubation competency 1.
Pharmacologic Agent Selection
The emergency physician should select sedative agents based on individual patient factors without institutional restrictions 1. Commonly used agents include 1, 2:
- Opioids and benzodiazepines
- Ketamine (dissociative sedation)
- Propofol (deep sedation) 3
- Etomidate
- Dexmedetomidine
- Remifentanil and alfentanil
Emergency physicians must be familiar with the agents they use and prepared to manage potential complications 1.
Pre-Procedural Evaluation and Preparation
Perform patient evaluation focusing on 1, 2:
- Factors that increase sedation risk (airway anatomy, cardiovascular status, respiratory disease)
- Appropriate drug selection and dosing for the individual patient
- Note: While preprocedural fasting is addressed in guidelines, the 2014 ACEP clinical policy found insufficient evidence that fasting reduces emesis or aspiration risk during ED procedural sedation 2
Monitoring Requirements
Continuous monitoring must include 1:
- Cardiac rhythm monitoring
- Pulse oximetry
- Capnography (routine use recommended to detect respiratory depression early) 2
- Blood pressure monitoring
- Continual observation of airway patency and chest wall motion 1
Documentation Requirements
Document throughout the sedation process 1, 4:
- Pre-sedation patient evaluation and risk assessment
- Informed consent
- Medications administered (drug, dose, route, time)
- Continuous monitoring parameters
- Level of sedation achieved
- Adverse events and interventions
- Recovery and discharge criteria met
Discharge Criteria
Establish clear criteria for patient discharge after sedation 1, 4:
- Return to baseline mental status
- Stable vital signs
- Adequate pain control
- Ability to ambulate (if age-appropriate)
- Responsible adult escort available
Quality Improvement
Institutional guidelines must include 1:
- Provider credentialing and competency verification
- Patient selection and preparation protocols
- Equipment and monitoring requirements
- Staff training and competency verification
- Continuous quality improvement programs
Common Pitfalls to Avoid
- Inadequate monitoring: Never allow the sedation monitor to be distracted by tasks that interfere with continuous patient observation 1
- Insufficient rescue skills: Ensure all sedation providers can perform bag-mask ventilation, as this is the most common rescue intervention needed 1
- Restrictive credentialing: Don't limit privileges based solely on specialty training rather than demonstrated competency 1