resuscitation cart, and reversal drugs should be readily

available. Personnel should be skilled in airway management and patient monitoring and recovery.

PROCEDURE

Appropriate preprocedure history includes allergies to or

adverse effects from anesthetic agents, medical conditions,

and time of last oral intake. Physical exam should include

a thorough airway assessment to predict difficulty with

bag-valve-mask ventilation or endotracheal intubation.

Consider the presence of dentures, neck mobility, obesity,

and Mallampati scale (Figure 4-1). Sedation in the emer ­

gency department should generally be limited to ASA class

I and II patients. A fasting period of 3 hours is recommended; however, studies have shown that a shorter period

does not increase the incidence of aspiration. The urgency

of the procedure often dictates acceptable preprocedure

fasting period. Obtain informed consent and document

the conversation in the record. Many institutions have a

standardized procedural sedation record for recording

consent as well as pertinent history and physical.

Appropriate personnel to perform the procedure,

administer medications, and monitor the patient should

assemble at the bedside. The medications are administered

and titrated to effect. Medication selection is guided by the

type of procedure being performed (Table 4-2). Using a

combination of a sedative/analgesic (eg, midazolam/

fentanyl) generally gives consistent clinical results. Other

commonly used regimens include ketamine alone or with

atropine (0.0 1 mg/kg IV or IM) for pediatric cases,

propofol plus an analgesic (fentanyl), or midazolam plus an

analgesic.

The physician should perform the procedure as a nurse

or other physician monitors the patient. After completion

of the procedure, the patient should be monitored until

mental status returns to baseline. Discharge criteria

include stable vital signs, return to baseline mental status,

Class I Class II

Class Ill Class IV

Figure 4-1. Mallampati classification. (Reprinted with

permission from Vissers RJ. Chapter 30. Tracheal

Intubation and Mechanical Ventilation. In: Tintinalli JE,

Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD,