Scope of Application
This guideline is intended for physicians working in emergency departments.

Inclusion Criteria
This guideline is intended for patients of all ages in the emergency department who have emergent or urgent conditions that require pain and/or anxiety management to successfully accomplish an interventional or diagnostic procedure and for high-risk patients (eg, those with underlying cardiopulmonary disorders, multiple trauma, head trauma, who have ingested a central nervous system depressant such as alcohol), with the understanding that these patients are at increased risk of complications from procedural sedation and analgesia.

Exclusion Criteria
This guideline is not intended for patients receiving inhalational anesthetics, patients who receive analgesia for pain control without sedatives, patients who receive sedation solely for the purpose of managing anxiolysis and behavioral emergencies, and patients who are intubated.

Critical Questions

1. In patients undergoing procedural sedation and analgesia in the emergency department, does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration?
   
   Level B Recommendation:
   
   Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.
   
   
   
2. In patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events?
   
   Level B Recommendation:
   
   Capnography* may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone in patients undergoing procedural sedation and analgesia in the ED. *Capnography includes all forms of quantitative exhaled carbon dioxide analysis.
   
   
   
3. In patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications?
   
   Level C Recommendation:
   
   During procedural sedation and analgesia, a nurse or other qualified individual should be present for continuous monitoring of the patient, in addition to the provider performing the procedure. Physicians who are working or consulting in the ED should coordinate procedures requiring procedural sedation and analgesia with the ED staff.
   
   
   
4. In patients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil, and remifentanil be safely administered?
   
   Level A Recommendation:
   
   Ketamine can be safely administered to children for procedural sedation and analgesia in the ED. Propofol can be safely administered to children and adults for procedural sedation and analgesia in the ED.
   
   Level B Recommendation:
   
   Etomidate can be safely administered to adults for procedural sedation and analgesia in the ED. A combination of propofol and ketamine can be safely administered to children and adults for procedural sedation and analgesia.
   
   Level C Recommendation:
   
   Ketamine can be safely administered to adults for procedural sedation and analgesia in the ED. Alfentanil can be safely administered to adults for procedural sedation and analgesia in the ED. Etomidate can be safely administered to children for procedural sedation and analgesia in the ED.
   
   
   

Disclaimer
Recommendations offered in this policy are not intended to represent the only diagnostic and management options that the emergency physician should consider. ACEP recognizes the importance of the individual physician's judgment and patient preferences.