Conscious Sedation: Medications That Make It Work

Conscious sedation relaxes patients for procedures like cardioversion, resetting broken bones, or pediatric stitching, while keeping them responsive and breathing independently. In the ER, managing sedation is part of the job. Here's a quick guide to the most common medications used, their benefits, and when to choose them.

1. Etomidate

• Typical Dose: 0.1–0.3 mg/kg IV
• Benefits:
  • Rapid onset and short duration of action.
  • Minimal effects on cardiovascular stability, making it a great choice for patients with heart issues.
  • Produces excellent sedation with limited respiratory depression.
• Why Choose Etomidate?
  Etomidate is often used for patients at risk of hypotension because it has minimal impact on blood pressure. It’s a go-to option in emergency or critical care settings for quick procedures.

2. Propofol

• Typical Dose: 1–2 mg/kg IV bolus followed by an infusion at 25–75 mcg/kg/min (if required).
• Benefits:
  • Rapid onset with a smooth, predictable recovery.
  • Provides both sedation and amnesia.
  • Anti-nausea properties, making it ideal for patients prone to post-procedure nausea.
• Why Choose Propofol?
  Propofol is preferred for its versatility and ease of titration. However, it can cause hypotension and respiratory depression, so it’s used cautiously in patients with cardiovascular concerns.

3. Ketamine

• Typical Dose: 1–2 mg/kg IV or 4–5 mg/kg IM
• Benefits:
  • Preserves airway reflexes and respiratory drive.
  • Provides sedation, analgesia, and amnesia in one agent.
  • Minimal effect on cardiovascular function, sometimes even increasing heart rate and blood pressure.
• Why Choose Ketamine?
  Ketamine is an excellent choice for pediatric patients, patients with asthma, or those at risk of hypotension. Its dissociative effects make it especially useful for painful procedures.

4. Midazolam (Versed)

• Typical Dose: 1–2 mg IV, titrated to effect.
• Benefits:
  • Provides excellent amnesia and anxiolysis.
  • Short-acting benzodiazepine with a quick onset and predictable recovery.
  • Can be reversed with flumazenil if necessary.
• Why Choose Midazolam?
  Midazolam is ideal for patients who are anxious about their procedure. It’s often paired with the other agents listed above. For instance, it's often used prior to the procedure to calm the patient. When I'm having procedures, I enjoy a dose of this great medicine. 

The Bottom IV Line

Each medication has its strengths. Choosing the right one ensures patients stay comfortable and safe, whether it’s for a cardioversion or calming a scared child. A doctor’s ability to master these choices is key to providing effective conscious sedation in the ER.