Procedural Sedation
EM Clerkship
Zack Olson, MD ; Mike Estephan, MD ; Maddie Watts, MD
4.9 • 816 Ratings
🗓️ 19 February 2017
⏱️ 10 minutes
🧾️ Download transcript
Summary
Procedural sedation is one of the core procedures in Emergency Medicine. You WILL see this during your clerkship
Common Scenarios
* Cardioversion* Orthopedic reductions* Painful procedures
Three Step Approach to Procedural Sedation
* Step 1: Risk stratify the patient* Mallampati score (aka “How visible is the uvula?”)* Level 1: Can visualize THE WHOLE uvula* Level 2: Can visualize MOST of the uvula* Level 3: Can visualize SOME of the uvula* Level 4: Can NOT visualize the uvula* ASA (aka “How healthy are they?”)* Level 1: Healthy* Level 2: Mild illness* Hypertension* Hyperlipidemia* Anemia* Level 3: Major illness* Diabetes* Coronary disease* COPD* Chronic renal disease* Level 4: Extremely unhealthy* Dialysis patient* Severe heart failure* Chronically debilitated* Level 5: Dying* Patient needs operation to live* Intracranial hemorrhage with midline shift* Ruptured aortic aneurysm* Ruptured papillary muscle with cariogenic shock* Dissecting aortic aneurysm* Step 2: Informed consent* Patients sign a GENERAL CONSENT to treat when registering to the department* Many emergency scenarios require physician to operate with IMPLIED CONSENT* Many patients have an ADVANCED DIRECTIVE* In stable patients and higher risk procedures, separate WRITTEN CONSENT is often required* Varies by hospital* Typically required for procedural sedation in stable patients* Step 3: Gather supplies* Nurse and nursing supplies* IV* Cardiac monitor* Respiratory therapy and respiratory supplies* Capnography* Bag-valve mask* Airway box
Top 5 Procedural Sedation Medications
* Midazolam (“Versed”) – 0.02 mg/kg IV* Reduces anxiety prior to procedure* Provides no analgesia* Fentanyl – 1 mcg/kg IV* Reduces pain* Useful for painful procedures* Incision and drainage* Simple reductions* Propofol – 0.5-1mg/kg IV* General anesthetic* Best given “low and slow”* Short acting* Causes respiratory depression and hypotension* Etomidate – 0.15 mg/kg IV* General anesthetic* Less hypotension than propofol* Can cause myoclonus* Ketamine – 1-2mg/kg IV* “Dissociative”* Provides both amnesia AND analgesia* Can cause emergence reactions* Can cause laryngospasm and secretions
Additional Reading
* Mallampati Score (Wikipedia)* ASA Physical Status Classification (Wikipedia)
Transcript
Click on a timestamp to play from that location
| 0:00.0 | Hello, med students. My name is Zach Olson, and thank you for downloading this episode of the EM |
| 0:08.7 | Clerkship Podcast. Today, we are talking about one of the core medical procedures in emergency medicine. |
| 0:24.9 | Procedural sedation. This is the procedure that we do with every other procedure. This is how we reduce fractures, cardiovert hearts, even things like |
| 0:30.9 | popping, abscesses and doing lumbar punctures without the patient losing their minds and freaking out. |
| 0:36.3 | And so what we are going to do today is first cover a super quick three-step approach to procedural sedation. |
| 0:46.0 | And then we are going to go through the five medicines that you will see attendings use for procedural sedation during your clerkship. |
| 0:55.5 | We've got lots to cover today, so let's get moving. |
| 0:58.6 | Here's a quick three-step approach. |
| 1:01.4 | Step one, you need to channel your inner anesthesiologist and record their two favorite scores. the Malampati score and the ASA. |
| 1:17.6 | First, determine a Malampati Airway score. |
| 1:22.8 | From easy to hard, just like in video games. |
| 1:25.7 | Level one is you can see the whole uvula just |
| 1:28.8 | dangling there. Level two, you can still see most of it. Level three, now you can barely |
| 1:34.0 | see it. Level four, not even visible. Very hard airway. You also need to determine the |
| 1:42.7 | ASA score, which is basically how healthy they are. |
| 1:46.9 | Again, just like in video games, there's easy to hard. |
| 1:50.2 | Level one is really healthy. |
| 1:53.0 | Two is some mild illness like high blood pressure. |
| 1:57.3 | ASA 3 is a lot of illnesses. |
| 1:59.5 | So diabetes, COPD, heart disease, ASA 4 is sick and dying, |
| 2:06.0 | in stage renal disease, advanced cancer, that kind of thing. |
| 2:09.0 | And ASA 5 is basically dead. |
... |
Please login to see the full transcript.
Disclaimer: The podcast and artwork embedded on this page are from Zack Olson, MD ; Mike Estephan, MD ; Maddie Watts, MD, and are the property of its owner and not affiliated with or endorsed by Tapesearch.
Generated transcripts are the property of Zack Olson, MD ; Mike Estephan, MD ; Maddie Watts, MD and are distributed freely under the Fair Use doctrine. Transcripts generated by Tapesearch are not guaranteed to be accurate.
Copyright © Tapesearch 2026.