Practice Therapeutics

Procedural sedation and analgesia for adults in the emergency department

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2965 (Published 08 May 2014) Cite this as: BMJ 2014;348:g2965

This article has a correction. Please see:

  1. Paul Atkinson, professor12,
  2. James French, assistant professor1,
  3. C Andrew Nice, clinical assistant professor34
  1. 1Department of Emergency Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, NB, Canada, E2L 4L4
  2. 2Discipline of Emergency Medicine, Memorial University of Newfoundland, Saint John Regional Hospital, Saint John, NB, Canada
  3. 3Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Saint John Regional Hospital, Saint John, NB, Canada
  4. 4Discipline of Anesthesia, Memorial University of Newfoundland, Saint John Regional Hospital, Saint John, NB, Canada
  1. Correspondence to: P Atkinson Paul.atkinson{at}dal.ca

A 59 year old woman presents to the emergency department with an isolated anterior dislocation of her left shoulder after a fall. Other than controlled asthma, she is healthy. Her last meal was four hours before the injury. After adequate analgesia using intravenous fentanyl, and despite an initial attempt to reduce her dislocation using relaxation techniques, it becomes evident that she needs sedation to complete the procedure successfully.

What drugs are used for procedural sedation and analgesia?

Patients in the emergency department often need to undergo painful, distressing, or unpleasant diagnostic and therapeutic procedures as part of their care. The use of various analgesic, sedative, and anaesthetic agents has been outlined in several well referenced guidelines.1 2 3 4 The American Society of Anesthesiologists (ASA) describes four levels of non-dissociative sedation—from minimal sedation to general anaesthesia—in addition to dissociative sedation (box).2 In practice, prolonged deep sedation or general anaesthesia is rarely used in the emergency department in the absence of a clinician with appropriate training in anaesthesia.

Levels of sedation as described by the American Society of Anesthesiologists2

Non-dissociative sedation
  • Minimal sedation and analgesia: essentially mild anxiolysis or pain control. Patients respond normally to verbal commands. Example of appropriate use: changing burns dressings

  • Moderate sedation and analgesia (formerly known as “conscious sedation”): patients are sleepy but also aroused by voice or light touch. Although their airway and respiration are self maintained, these may be suppressed with deeper levels of sedation (which is a continuum). Example of appropriate use: direct current cardioversion

  • Deep sedation and analgesia: patients require painful stimuli to evoke a purposeful response. Airway or ventilator support (or both) may be needed. Example of appropriate use: major joint reduction (dislocated hip prosthesis)

  • General anaesthesia: patient has no purposeful response to even repeated painful stimuli. Airway and ventilator support is usually required. Cardiovascular function may also be impaired. Example of appropriate use: not appropriate for general use in the emergency …

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