Bedside Snapshot

Indications: Painful or distressing procedure: reduction, drainage, cardioversion
Anxiety or agitation that blocks a safe procedure
Patient can keep their airway and has a rescuer present
Contraindications / Abort: No airway-trained clinician, suction or ventilation backup
SpO₂ <90% or apnea: stop, ventilate, reassess
SBP <90 or MAP <65 mmHg: resuscitate before dosing
Known hypersensitivity to the agent
Critical Steps: Document fasting, ASA class and airway check before dosing
EtCO₂ and SpO₂ on before the first dose
Analgesia first; titrate sedative in small steps
Stop and ventilate on any airway concern
Confirm & Monitor: Continuous EtCO₂ waveform and SpO₂ throughout
Response to voice, RR and BP at the set interval
Observe until baseline before discharge or transport

Key Numbers

Sedation for a painful procedure is time-critical only when the patient stops breathing or loses airway control. Have the airway, suction, oxygen and reversal agents ready before the first dose.

Parameter	Value
Midazolam (procedural sedation)	Adult: 1–2.5 mg slow IV, wait 2 min, then titrate; age 60+ or debilitated: start 1–1.5 mg, total usually not over 3.5 mg Peds: 0.05–0.1 mg/kg IV (6 months to 5 years); 0.025–0.05 mg/kg (6 to 12 years, max 10 mg)
Ketamine (dissociative)	Adult: 1–2 mg/kg IV over 60 sec; label range 1–4.5 mg/kg Peds: 1.5–2 mg/kg IV/IO initial (single dose up to 2 mg/kg; repeats per protocol); no sedation under 3 months
Propofol (deep, short)	Adult: 1 mg/kg IV, then 0.5 mg/kg every 3 min, titrated Less and slower if older or frail
Etomidate (induction dose only)	Induction (RSI) 0.3 mg/kg IV over 30–60 sec (label 0.2–0.6 mg/kg); sedation doses are protocol-specific and off-label, so do not extrapolate the induction dose
Fentanyl (analgesia)	Adult: 1 mcg/kg IV slowly (usual 25–100 mcg; max initial 100 mcg), repeat after 5 min Peds: 1 mcg/kg IV/IO (max 100 mcg initial)
Dexmedetomidine (infusion)	Adult: 1 mcg/kg IV over 10 min, then 0.6 mcg/kg/hr (range 0.2–1) Peds: 1.5–2 mcg/kg IV over 10 min, then 0.5–1.5 mcg/kg/hr
Flumazenil (reversal)	0.2 mg IV over 15 sec, repeat every 1 min; max 1 mg Peds (age 1 year and older): 0.01 mg/kg (max 0.2 mg)
Naloxone (opioid reversal)	0.1–0.2 mg IV every 2–3 min to adequate breathing Sedation or postoperative reversal: 0.005–0.01 mg IV increments every 2–3 min to breathing; overdose: 0.01 mg/kg IV, then 0.1 mg/kg (usual max 2 mg)
Stop criteria	SpO₂ <90%, apnea, or RR <10 with a sedated patient: stop, ventilate, then reassess

Most lethal error: Sedating without a ready airway. Depth can turn into apnea within minutes, and a sedation dose is not an airway plan.

Overview & Principles

Procedural sedation and analgesia (PSA) dials down consciousness and pain for a short, painful or distressing procedure. The patient still has the ability to maintain their own airway. Depth runs on a continuum, from minimal sedation all the way to general anesthesia. Patients slip deeper than you intend. Set the rescue plan before the first dose, not after.

Depth of Sedation (ASA continuum)

Depth	Responsiveness	Airway	Ventilation	Cardiovascular
Minimal	Normal response to voice	Unaffected	Unaffected	Unaffected
Moderate	Purposeful response to voice or light touch	Patent; support usually not needed	Adequate spontaneous	Usually maintained
Deep	Purposeful response only after repeated or painful stimulus	May need support	May be inadequate	Usually maintained
General anesthesia	Not arousable, even to painful stimulus	Often needs support	Often needs support	May be impaired

Ketamine is dissociative. The patient can look awake, eyes open, while airway reflexes are partly kept. Don't mistake that for light sedation. It's a separate state, and it needs its own rescue plan.

How It Works

Sedatives and hypnotics: midazolam and propofol turn down consciousness and anxiety. The dose response is steep, and it stacks with opioids.
Dissociatives: At low doses, ketamine keeps airway reflexes and spontaneous breathing. It also pushes heart rate and blood pressure up.
Opioids: Fentanyl gives analgesia, and it slows ventilation. Its effect peaks after the analgesia.
Alpha-2 agonists: Dexmedetomidine depresses breathing less than other agents do. Less is not none. Apnea can still occur, and the heart rate slows.
Reversal agents: Flumazenil reverses benzodiazepines. Naloxone reverses opioids. Propofol, ketamine and dexmedetomidine have no reversal agent.

Where It Fits

PSA fits reductions, drainage, cardioversion, cardioversion-type procedures, and imaging or dental work when a patient cannot hold still. Deep sedation and general anesthesia need a clinician who can manage the airway. Here's the rule: if a sedation dose deepens more than expected, reach for airway support. Don't reach for more drug.

Indications & Contraindications

Indications

Painful or distressing procedure: fracture or dislocation reduction, abscess drainage, chest tube or cardioversion
Anxiety or agitation that blocks a safe procedure. Analgesia is the first goal.
A procedure where the patient keeps their airway, and someone who can rescue it is monitoring

Absolute Contraindications

Known hypersensitivity to the agent. For propofol, that means hypersensitivity to propofol or its components, including a history of anaphylaxis to egg or soy (current label)
No airway-trained clinician, suction or ventilation backup
Uncorrected shock: MAP <65 mmHg or SBP <90 mmHg (resuscitate before dosing)
Ketamine: dangerous rise in blood pressure (aortic dissection, active ischemia)

Relative Contraindications & Cautions

Obstructive sleep apnea, obesity or a difficult airway. Go lower on doses and start capnography sooner.
Older or frail patients. Go smaller and slower with propofol and fentanyl.
Recent oral intake or vomiting. Document it and plan for it. It's not a reason to delay urgent sedation. Weigh the urgency against the depth you are aiming for.
Long-term benzodiazepine use. Flumazenil can trigger seizures.
Ketamine with schizophrenia or psychosis calls for relative caution, because emergence reactions can happen. Plan the sedation and monitoring around that.

Consider an Alternative

Procedure that needs general anesthesia or a secured airway: RSI
Ongoing analgesia alone without sedation: an opioid or regional technique per protocol

Life over contraindication: An unstable patient who needs the procedure now gets stabilized first. You sedate only when the airway and circulation allow it.

Scope & Team Roles

Provider Level	Typical Role	Notes
EMT	Not in scope	Not in national model for procedural sedation
AEMT	Not in scope	Not in national model for procedural sedation
Paramedic	Performs (protocol/credentialing required)	Not in national model; state or agency credentialing
RN (ED/ICU)	Performs (protocol/credentialing required)	Administers under physician order and facility policy
Critical Care Transport (CFRN / CTRN / FP-C / CCP-C)	Performs (protocol/credentialing required)	Same credentialing caveat as Paramedic
Physician / APP	Performs	Orders the sedation and decides on the plan

Team Roles During the Procedure

Sedation clinician: draws, labels and gives each dose; reads back drug and concentration
Airway and oxygen: keeps the airway open, suction ready and ventilation running
Procedure operator: times the stimulus and communicates the next step
Monitor and recorder: watches SpO₂, EtCO₂, heart rate and BP; logs times, doses and responses

Note: Scope varies by state, agency and facility. Follow your local protocols and medical direction.

Pre-Procedure Assessment

Airway Assessment

Component	Assess	Concerning Findings
Mouth opening	Inter-incisor gap, dentition	Small gap or loose teeth: plan a bag-mask and adjunct
Mallampati / neck	Visible structures; neck mobility	Limited neck movement or high Mallampati class
Obstruction risk	Snoring, sleep apnea, obesity, pregnancy, tongue or neck mass	Any of these: smaller doses, capnography, continuous observation

Physiologic Risk & ASA Class

ASA class: Write down the ASA physical status class. ASA I–II is typical for non-anesthesia sedation. ASA III needs extra planning and caution. ASA IV or higher needs anesthesia or ICU-level care under local policy, per ASA 2018 guidance
Hemodynamics: SBP <90 mmHg or MAP <65 mmHg: resuscitate before sedation
Oxygenation: SpO₂ <93% on room air or current oxygen: plan oxygen and capnography before dosing
Fasting: Record the last solid food and the last clear liquid. ACEP 2014 advises against delaying urgent ED sedation for fasting time. Fasting has not been shown to reduce emesis or aspiration. The ASA fasting rules (2023) are written for elective procedures. Apply local policy, and weigh urgency and depth

Site / Device Check

Working IV access with a flush, or IO access if IV fails (per protocol)
Working suction, oxygen source, bag-valve mask and a pulse oximeter with a quick EtCO₂ setup

Pearl: The ASA physical status class estimates risk. It does not define your legal scope. Use it to decide who sedates and where.

Equipment & Preparation

Equipment

Item	Size / Spec	Notes
Suction	Rigid tip and soft catheter	Ready before the first dose
Bag-valve mask	Adult and pediatric masks	Oxygen reservoir; PEEP valve if available
Airway adjuncts	Oropharyngeal airways in sizes by age	Use the pediatric sizing link below
Pulse oximeter	Continuous, with plethysmograph	Waveform for artifact check
EtCO₂ capnography	Nasal cannula or sidestream	Confirms ventilation before SpO₂ falls
Rescue drugs	Flumazenil, naloxone, atropine, epinephrine	Drawn up and labeled before the first dose
Defibrillator	Pads on before sedation	For arrest or unstable rhythm

Sizing

Settle the dosing weight before anything gets drawn up, and write it on the label. The pediatric references hold the weight-based doses and equipment sizes: weight-based dosing, equipment sizing and Broselow.

Patient Positioning & Preparation

Set the patient up so you can reach the airway. Raise the head if the procedure lets you. The team needs to read the monitor from where they stand.

Pre-Procedure ChecklistConsent and time-out completed
Fasting status and ASA class recorded
Airway assessment done and difficulty plan stated
IV access working and flushed
Suction, oxygen, bag-valve mask and airway adjuncts at bedside
Continuous SpO₂ and EtCO₂ on before the first dose
Reversal agents drawn and labeled
Each drug, dose and weight read back by a second clinician

Medications & Settings

Treat these doses as typical adult and pediatric references. Check them against local protocol and the current drug label. Doses vary by protocol; follow local protocols and medical direction.

Procedural sedation and analgesia agents
Drug	Adult Dose	Pediatric Dose	Onset / Duration	Notes
Midazolam	1–2.5 mg slow IV, wait 2 min, titrate (total over 5 mg rarely needed). Age 60 or older or debilitated: 1–1.5 mg over at least 2 min; total usually not over 3.5 mg	IV sedation, 6 mo–5 yr: 0.05–0.1 mg/kg (total up to 0.6 mg/kg; usually ≤6 mg). 6–12 yr: 0.025–0.05 mg/kg (total up to 0.4 mg/kg; usually ≤10 mg)	IV 3–5 min / up to 6 hr	High-alert Respiratory depression; flumazenil reverses it. Boxed warning: opioids add profound sedation and respiratory depression; no rapid IV push in neonates (hypotension, seizures); continuous monitoring
Ketamine	1–2 mg/kg IV over 60 sec, titrate; label range 1–4.5 mg/kg; no fixed max	1.5–2 mg/kg IV/IO initial (single dose up to 2 mg/kg; repeats per protocol) or 4–5 mg/kg IM; none under 3 months	IV 30 sec / 5–10 min	High-alert Laryngospasm and emergence reactions; no reversal agent
Propofol	1 mg/kg IV, then 0.5 mg/kg every 3 min, titrated; no fixed max	ED sedation 1 mg/kg IV, then 0.5 mg/kg every 3 min (off-label)	IV 30–40 sec / ~6 min	High-alert No analgesia and no reversal; hypotension and apnea
Etomidate	Induction (RSI): 0.3 mg/kg IV over 30–60 sec (label 0.2–0.6 mg/kg). Sedation doses are protocol-specific and off-label	Age 10 yr and older: 0.3 mg/kg (max 0.6 mg/kg); under 10 yr not recommended by label	IV <1 min / 3–5 min	High-alert No analgesia; myoclonus can mimic seizure or pain; adrenal suppression for about 6–8 hr (label)
Fentanyl	1 mcg/kg IV slowly (usual 25–100 mcg; max initial 100 mcg), repeat after 5 min	IN (12 months and older): 1.5 mcg/kg (max 75 mcg at 50 mcg/mL); IV/IO 1 mcg/kg (max 100 mcg initial)	IV 1–2 min / 30–60 min	High-alert Respiratory depression peaks after analgesia
Dexmedetomidine	1 mcg/kg IV over 10 min, then 0.6 mcg/kg/hr (range 0.2–1); titrate	1 month–17 yr: 1.5 mcg/kg (under 2 yr) or 2 mcg/kg IV over 10 min, then 0.5–1.5 mcg/kg/hr	IV 15–20 min / variable	High-alert Never bolus fast; bradycardia; no reversal
Flumazenil	0.2 mg IV over 15 sec, repeat every 1 min; max 1 mg	Age 1 yr and older: 0.01 mg/kg IV (max 0.2 mg), up to 4 more doses; total max 0.05 mg/kg or 1 mg, whichever is lower	IV 1–2 min / short-lived	Boxed warning: seizures, especially with long-term benzodiazepine use or cyclic antidepressant overdose
Naloxone	0.1–0.2 mg IV every 2–3 min to adequate breathing (overdose 0.2–2 mg; 2025 AHA Part 10)	Sedation or postoperative reversal: 0.005–0.01 mg IV increments every 2–3 min to breathing. Overdose: 0.01 mg/kg IV, then 0.1 mg/kg (usual max 2 mg)	IV ≤2 min / up to 1–2 hr	Titrate to breathing, not alertness; ventilate first

Paralytics are not in this table: A neuromuscular blocker stops breathing. It does nothing for awareness. Any sedated patient who is paralyzed still needs full sedation and ventilation.

Ketamine concentration: Before every dose, check the strength (10, 50 or 100 mg/mL) and the mL you drew up.

Step-by-Step Procedure

Phase 1: Prepare

Confirm the indication and plan: state the procedure, the sedation depth goal and the rescue plan aloud.
Check fasting and ASA class: record last intake and document the airway assessment.
Place monitors: SpO₂, ECG, BP and a nasal EtCO₂ cannula before the first dose.
Prepare and label drugs: draw up the sedative, the analgesic and reversal agents; read back doses and weights.

Phase 2: Perform

Give the analgesic first: start fentanyl or ketamine before the sedative when the procedure is painful.
Titrate in small steps: give the sedative slowly and wait for the effect before the next dose.
Stop before the depth you need: pause the dosing if the patient is not responding to voice, has a falling SpO₂ or an EtCO₂ rising above the goal.
Time the procedure stimulus: start the procedure only when the patient is at the agreed depth and the monitors are reading.
Keep the airway: jaw thrust and suction are first; bag-valve mask with oxygen is the next step.

Most dangerous step: Dosing a patient who is already deeper than the goal. Pause every sedative and stimulate the airway before you give anything new.

Phase 3: Confirm & Secure

Confirm recovery: return to voice, spontaneous breathing and protective reflexes before moving the patient.
Hand off: state the drugs, total doses, times, reversal given and the next expected sedation effect.

Confirmation & Monitoring

Primary Confirmation

Keep a continuous EtCO₂ waveform and SpO₂ on throughout and after the procedure. A flat or absent capnogram with a normal SpO₂ suggests ventilation has stopped. Check the sampling line and the patient first. A displaced cannula, or mouth-breathing through a nasal sampler, can flatten the trace too. Under ACEP 2014 and ASA 2018 guidance, capnography is an adjunct to clinical monitoring.

One normal capnogram breath with baseline (inspiration) and expiration phases; EtCO₂ is read at the end of the plateau — **Figure 1:** One normal breath. Labels are in Dutch: 1 is inspiration (baseline), 2 is expiration (upstroke and plateau). EtCO₂ is read at the end of the plateau. Source: Wikimedia Commons, Rschiedon (Dutch Wikipedia), CC BY-SA 3.0

Secondary Confirmation

Chest rise and breath sounds with each breath
Response to voice or touch at the agreed sedation depth
Stable heart rate and BP within the expected range for the drug

Finding	Expected	Concerning / Action
EtCO₂ waveform	Regular plateau; rate matches breathing	Flat or falling trace: stimulate, jaw thrust, BVM
SpO₂	At or above the target for the patient	<90%: stop dosing, ventilate, reassess
Level of response	Responds to voice or light touch	No response to voice: deep sedation, airway support
Heart rate / BP	Within expected range for the drug	HR <50/min on dexmedetomidine: reduce rate; bradycardia with hypotension: stop

Ongoing Monitoring

Continuous SpO₂, ECG and EtCO₂ until the patient is at baseline
Respiratory rate, level of response and BP at the interval set by local policy
Resedation can come back after reversal. Watch for delayed respiratory depression after midazolam or opioids.

False reassurance: Oxygen can keep the SpO₂ looking normal for a while, even as the patient hypoventilates. The flat EtCO₂ trace is the earlier sign.

Troubleshooting

Problem	Likely Cause	Fix
Apnea or falling EtCO₂	Drug depth, opioid plus sedative, obstruction	Stimulate, jaw thrust, suction, bag-valve mask with oxygen
Airway obstruction	Tongue or soft tissue; head position	Head tilt or jaw thrust; oral or nasal airway if tolerated
Laryngospasm	Light depth, secretions, blood or vomit in airway	Stop stimulation; Larson maneuver (jaw thrust with bilateral pressure at the laryngospasm notch) and 100% oxygen; CPAP or PEEP; small propofol bolus per protocol; succinylcholine per protocol for complete spasm, with airway rescue (see RSI)
Hypotension	Propofol, dexmedetomidine, volume depletion	Pause the drug; fluids; vasopressor per protocol
Bradycardia	Dexmedetomidine or deep sedation	Stop the infusion; atropine per protocol; pacing if unstable
Emergence agitation or reaction	Ketamine; inadequate analgesia	Reassure, add analgesia; benzodiazepine per protocol
Oversedation after reversal	Short-acting reversal wears off before the sedative	Repeat reversal per label; observe until baseline

If It Still Fails

Ventilate: bag-valve mask with oxygen and a two-person technique if needed.
Reverse: flumazenil or naloxone per the table, one dose at a time, reassessing after each.
Escalate: failed bag-valve mask ventilation moves to advanced airway; see RSI.

Complications

Complication	Recognition	Prevention	Management
Immediate: apnea and hypoxia	Falling EtCO₂, SpO₂ <90%	Titrate slowly; monitor EtCO₂ from start	Ventilate, reverse, then reassess the plan
Immediate: airway obstruction or laryngospasm	Noisy breathing, paradoxical chest motion; complete obstruction is silent, so EtCO₂ goes flat	Adequate depth for the stimulus; suction	Stop stimulation; Larson maneuver, 100% oxygen, CPAP or PEEP, suction; succinylcholine per protocol for complete spasm
Immediate: hypotension	BP drop from baseline	Fluids; avoid rapid propofol bolus	Pause drug; fluids; vasopressor per protocol
Immediate: bradycardia	HR <50/min or pauses	Slow dexmedetomidine loading; monitor ECG	Stop infusion; atropine per protocol
Delayed: resedation	Drowsiness hours after reversal or midazolam	Observe until baseline	Repeat reversal; keep monitors on
Rare: aspiration	Vomiting or wet gurgling during sedation	Document intake; weigh urgency and depth; antiemetic per protocol	Suction, head-down position, airway support

Apnea With Hypoxia

Stop all sedatives: pause every infusion and syringe.
Ventilate: bag-valve mask with oxygen until SpO₂ and EtCO₂ recover.
Reverse and call for help: flumazenil for benzodiazepine excess, naloxone for opioid excess.

Special Populations

Pediatrics

Pediatric sedation runs on weight-based doses, and each one has an explicit maximum. The table gives the age limits from the label or protocol. Midazolam starts at 6 months. Flumazenil starts at age 1 year. Etomidate starts at age 10 years. Ketamine is not for sedation under 3 months. Dexmedetomidine starts at 1 month.

Use the pediatric weight-based and equipment references linked in Equipment & Preparation.
Chart a dosing weight and read it back before each pediatric dose.
Use pediatric airway and pediatric vascular access references for the rescue plan.

Older Adults

Go smaller and slower with doses. Titrate propofol, and dose it at the low end.
Hypotension and delayed respiratory depression both need close watching

Pregnancy

Aspiration risk rises and airway reserve drops from mid-pregnancy. Set the airway plan early, and use aspiration precautions.
Past about 20 weeks, tilt the patient left. That relieves aortocaval compression.
Monitor the fetal heart rate. Bring in obstetric care per local protocol.
Ketamine, propofol and fentanyl are the common choices. Minimize benzodiazepines when alternatives exist. Follow local OB protocol.

Physiologically Difficult Patients

Shock or sepsis: Resuscitate first, and avoid propofol boluses. If you need an induction agent, use etomidate or ketamine per protocol, dosed to hemodynamics. Etomidate is hemodynamically neutral. Its label notes insufficient data in hypovolemia. Adrenal suppression lasts about 6–8 hr
Obesity or sleep apnea calls for capnography and a head-up position

Opioid-Tolerant or Benzodiazepine-Dependent Patients

Expect higher doses, and expect withdrawal risk. Flumazenil can trigger seizures in long-term benzodiazepine users.
Naloxone reverses opioids, but it may trigger withdrawal. Titrate to breathing.

Post-Procedure Care & Transport

Immediate Aftercare

Return to voice, spontaneous breathing and protective reflexes before moving the patient
Keep oxygen and suction in place until recovery is clear

Ongoing Maintenance

Observe for resedation and respiratory depression for the duration of the longest-acting drug given
Discharge or transfer only to the local recovery criteria; a short-acting sedative can outlast the procedure

Transport Considerations

Reassess after every move; keep EtCO₂ and SpO₂ on through transfer
Monitor noise and vibration can hide alarms: watch the waveform, not only the alarm

Document & Hand OffProcedure, time started and time ended
Each drug, dose, weight basis, route and time
Sedation depth goal, depth reached and response
Airway events, reversal given and the response
Last recorded vitals and the recovery status

Clinical Pearls & Pitfalls

Pearls

Analgesia first: Treat the pain before you add sedation. Many procedures need analgesia more than depth.
Waveform over number: A steady EtCO₂ trace tells you about ventilation before SpO₂ falls.
Titrate, wait, then dose: Let the last dose work before you give another.
Know the reversal: Flumazenil for benzodiazepines. Naloxone for opioids. Most of the others have none.
Confirm the concentration: Ketamine and midazolam vials come in different strengths.

Common Pitfalls

Dosing a sleepy patient: Let the depth settle before the next dose
Relying on SpO₂ alone: Add EtCO₂ before the first dose
Using an induction dose for sedation: Etomidate's labeled dose is for induction. Sedation doses are protocol-specific. And etomidate gives no analgesia
Bolusing dexmedetomidine: The loading dose runs over 10 min, on a pump

Education & Skill Maintenance

Skill Maintenance

Every quarter, rehearse airway rescue and the stop-ventilate-reverse sequence in simulation
Walk through the pre-procedure checklist with a second clinician who reads back each dose
After every sedation event, debrief the depth, the timing and how the rescue went
At the start of every shift, check the equipment and the reversal agents

References

Godwin SA, Burton JH, Gerardo CJ, Hatten BW, Mace SE, Silvers SM, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Annals of Emergency Medicine. 2014;63(2):247–258. https://doi.org/10.1016/j.annemergmed.2013.10.015
American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia. Practice guidelines for moderate procedural sedation and analgesia 2018. Anesthesiology. 2018;128(3):437–479. https://doi.org/10.1097/ALN.0000000000002043
American Society of Anesthesiologists. 2023 American Society of Anesthesiologists Practice Guidelines for Preoperative Fasting: carbohydrate-containing clear liquids with or without protein, chewing gum, and pediatric fasting duration. Anesthesiology. 2023;138:132–151. https://doi.org/10.1097/ALN.0000000000004381
Coté CJ, Wilson S; American Academy of Pediatrics; American Academy of Pediatric Dentistry. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures. Pediatrics. 2019;143(6). https://doi.org/10.1542/peds.2019-1000
Green SM, Roback MG, Bhatt M, Andolfatto G, Caperell K, Poonai N, et al. Unscheduled procedural sedation multidisciplinary Delphi consensus guidelines, part 2: clinical practice (ACEP policy statement). Annals of Emergency Medicine. 2026;88:346–361. https://doi.org/10.1016/j.annemergmed.2026.06.039
Par Health. Ketalar (ketamine hydrochloride) injection: full prescribing information; revised 03/2026. U.S. Food and Drug Administration. https://www.accessdata.fda.gov/drugsatfda_docs/label/2026/016812s057lbl.pdf
Pfizer. Naloxone hydrochloride injection: dosage and administration (pediatric overdose and postoperative opioid depression). Pfizer Medical Information, accessed October 15, 2026. https://www.pfizermedical.com/naloxone/dosage-admin
Hospira, Inc. Midazolam injection, USP CIV: prescribing information. DailyMed, U.S. National Library of Medicine; 2026. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=1abda8b8-48a8-4995-af86-39220d1aa240

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Procedural Sedation and Analgesia (PSA)