Procedural Sedation


If less cardiorespiratory reserve, difficult airway, and less urgent - consider other options (regional/local anesthetic, operating room, or intubation prior to sedation)

  • Monitors
    • BP, HR, RR, Cardiac
    • ETCO2 + SPO2 ideal
  • Position for intubation
  • IV, fluids
  • Nasal cannula + high flow O2 by face mask
  • Airway management
    • Suction
    • BVM + O2
    • Oral/nasal airway
    • Blade
    • ETT, stylet, syringe
    • Medications
      • Sedation
      • Reversal meds
      • Epinephrine

Intervention sequence

  • Detect hypoventilation
  • Stop drugs
  • Position, jaw thrust
  • Suction
  • Laryngospasm "Larsons" notch pressure
    • Behind the earlobe, between mastoid process and condyle of mandible – bilateral, firm pressure medially and cephalad (up and in)
  • Bag slowly and gently
  • LMA/Oral airway
  • Consider deeper sedation (propofol 0.5mg/kg IV push)
  • Consider paralytic/intubation (succinylcholine 1.5mg/kg or rocuronium 1mg/kg)


Propofol 0.5-1mg/kg IV then 0.5mg/kg q1 min PRN

  • Onset 1 minute, duration 6mins
  • Egg/soy allergy not contraindication
  • Consider in orthopedics (muscle relaxation)
  • Consider lidocaine, fentanyl or ketamine pre-treatment for analgesia
  • Consider risk of hypotension

Ketamine 1-2mg/kg IV over 60 sec or 4mg/kg IM, repeat half-dose PRN

  • Onset immediate, duration 10-20mins
  • Consider midazolam 0.05mg/kg IV slowly over 2 mins prior to prevent "emergence reactions"
  • Commonly used in pediatrics
  • Consider risk of hypertension/tachycardia

Etomidate 0.1-0.15 mg/kg IV, then 0.05 mg/kg q3 min prn

  • Consider in cardioversion
  • Consider risk of myoclonus, adrenal suppression, vomiting

Fentanyl 1-2mcg/kg IV, then 0.05mg/kg q2 min PRN

  • Can combine with midazolam or before propofol/etomidate

Midazolam 0.05mg/kg or 1mg IV q3mins PRN


Use Mucosal Atomization Device briskly divided between both nostrils, generally twice the IV dose, avoid in nasal congestion

Consider distraction, sucrose or oral medication

  • Fentanyl 1-2mcg/kg (max 100mcg) q2-3mins
  • Midazolam 0.2mg/kg (max 10mg), onset 10 mins


Naloxone 0.01-0.1 mg/kg IV or IM (typical 0.4 mg, max 2mg)

Flumazenil 0.01 mg/kg IV (typical 0.2 mg, max 1mg) over 20 seconds

  • Only use in benzodiazepine naïve patient

Glycopyrrolate 4-10mcg/kg (max 100mcg) over 15 mins for hypersalivation (eg. in Ketamine)

Ondansetron 0.15mg/kg (max 8mg) for vomiting, can be given 30 mins prior to sedation as prophylaxis

Phenylephrine 1mcg/kg or Epinephrine for hypotension

Succinylcholine 1.5mg/kg IV for laryngospasm