Procedural sedation was traditionally the domain of anaesthesiologists in operating theatres. As emergency departments increasingly needed to perform painful procedures — fracture reductions, abscess drainage, cardioversion — the question arose whether emergency physicians could safely administer sedation agents like propofol and ketamine outside the OR environment.

Proof

Landmark RCTs and pivotal trials that established the evidence base

Miner (2007) published a seminal prospective study of propofol for ED procedural sedation in 113 patients, demonstrating excellent safety with 0% intubation rate and rapid recovery. Green's 2009 meta-analysis synthesised 8,282 paediatric ketamine sedations, establishing an adverse event rate below 4% with no fatalities. Andolfatto (2012) conducted an RCT comparing ketofol (ketamine-propofol combination) to propofol alone in 284 patients, showing comparable efficacy with potentially fewer respiratory adverse events.

Miner 20072007Landmark

0% intubation rate; median recovery time 14 minutes

CJEMProspective observationalN=113

Green 20092009Landmark

Overall adverse event rate <4%; emesis most common; no fatalities

Annals of emergency medicineMeta-analysisN=8,282

Andolfatto 20122012Landmark

Similar sedation quality; trend toward fewer respiratory events with ketofol

Annals of emergency medicineRCTN=284

Guidelines

Integration into clinical practice guidelines and recommendations

ACEP clinical policies (2014, 2018) endorsed propofol for ED procedural sedation, establishing that emergency physicians can safely administer it without anaesthesiologist supervision. The 2018 ACEP guideline specifically affirmed propofol safety in the ED setting, ending the debate over whether non-anaesthesiologists could use this agent.

ACEP Clinical Policy on Procedural Sedation

Propofol recommended for ED procedural sedation (Level B)

ACEP Propofol Guideline

Propofol safe for use by emergency physicians for procedural sedation

Now

Current standard of care and ongoing research directions

Procedural sedation is now a core competency for emergency physicians. Propofol and ketamine (individually or as ketofol) are the dominant agents. Discharge criteria are well-established. Current research explores intranasal and intramuscular routes for needle-averse patients, nitrous oxide for brief procedures, and shared sedation protocols between emergency and procedural teams.

Landmark Trials in This Story

Miner 20072007Landmark

Efficacy, safety and patient satisfaction of propofol for procedural sedation and analgesia in the emergency department: a prospective study

0% intubation rate; median recovery time 14 minutes

CJEMProspective observationalN=113

Green 20092009Landmark

Predictors of emesis and recovery agitation with emergency department ketamine sedation: an individual-patient data meta-analysis of 8,282 children

Overall adverse event rate <4%; emesis most common; no fatalities

Annals of emergency medicineMeta-analysisN=8,282

Andolfatto 20122012Landmark

Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial

Similar sedation quality; trend toward fewer respiratory events with ketofol

Annals of emergency medicineRCTN=284

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Frequently Asked Questions

Is propofol safe for use in the emergency department?+

Yes. Multiple studies and ACEP clinical policies have established that propofol is safe for ED procedural sedation when administered by trained emergency physicians. Miner's 2007 study showed a 0% intubation rate, and the 2018 ACEP guideline affirmed its safety outside the operating room.

What is ketamine sedation and when is it used in the ED?+

Ketamine is a dissociative anaesthetic widely used for ED procedural sedation, particularly in paediatric patients. Green's 2009 meta-analysis of 8,282 paediatric sedations showed an adverse event rate below 4% with no fatalities. Ketamine is favoured for its preservation of airway reflexes and respiratory drive, making it safer in non-fasted patients.