Emergency Procedural Sedation and Analgesia

Introduction: Injuries and painful medical conditions are common among children presenting to the emergency department (ED). Some medical conditions may require a procedure which itself may be painful or require a child to be absolutely still. ED physicians are obligated to manage pain appropriately and safely, and ensure that procedures are performed under conditions that limit harm to the patient. Performing procedural sedation and analgesia (PSA), when indicated, is a necessary skill for the ED physician, and is essential to providing comfort and quality care to children and their families. Procedural Sedation and Analgesia Definitions: When discussing PSA, it is useful to review terminology, which is most accurately categorized by the intended effects, rather than by the specific medications used. Analgesia refers to an agent that reduces or eliminates pain in response to a normally painful stimulus. Sedation refers to a state of drug-induced depressed level of consciousness. Certain medications may have one or both of these properties and are used to that effect. For example, topical lidocaine for a laceration repair is an analgesic, but will not affect consciousness. Midazolam causes an alteration in level of consciousness, but does not take away pain. Ketamine is an example of a medication that has both analgesic and sedative properties. PSA has replaced conscious sedation in the lexicon of emergency medical treatment of ill or injured patients. The American College of Emergency Physicians (ACEP) defines PSA as "techniques of administering sedatives or dissociative agents with or without analgesia to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function." The now outdated term conscious sedation is no longer acceptable as it does not allow for describing the depth of sedation desired or achieved. The Joint Commission accepts the continuum of depth of sedation proposed by the American Society of Anesthesiologists (ASA) in ۱۹۹۹. It is important to focus on the word continuum as it highlights the essential point that a patient can easily move from one depth of sedation to another. There are four defined depths of PSA: minimal sedation (or anxiolysis), moderate sedation, deep sedation, and general anesthesia. It is important to note that ketamine, a commonly used dissociative agent, does not fit neatly on this continuum. In the ED, the depth of PSA desired depends on the child and the situation. For example, a clinician may choose to administer mild sedation to an anxious