Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Study Objectives: Three of the most commonly used agents for conscious sedation in the Emergency Department (ED) are ketamine, fentanyl/versed, and propofol. In this study, we measured and compared the total times spent in the ED with each of these agents. Our objective was to determine whether the use of propofol for conscious sedation was associated with a shorter length of ED stay as compared to the other two agents. Methods: This was a consecutive case series. All patients who required procedural conscious sedation who presented to the ED at University of California, Irvine Medical Center from January 2003 through April 2004 were included in the study. The attending ED physician evaluated the patient and determined which medication(s) would be administered. All patients underwent procedural sedation according to the ED’s standardized sedation protocol. The times and dosages of administered medications and the sedation/ consciousness level (SCL) scores were recorded by ED nurses at 3-5 minute intervals. Data was abstracted prospectively. The time to sedation (first dose of agent to SCL score of 2 or less) and time to recovery (last dose of agent to SCL score of 4) of the different regimens were then analyzed and compared. Results: Thirty-eight patients received propofol, 38 received ketamine, and 14 received fentanyl/versed. The mean times to sedation (minutes) were: propofol 4.5 (95% CI: 3.3-5.7), ketamine 10.6 (95% CI: 5.8 –15.4), fentanyl/versed 11.5 (95% CI: 3.5-19.4). The mean times to recovery were: propofol 21.6 (95% CI: 16.1-27.1), ketamine 55.4 (95% CI: 46.2-64.5), fentanyl/versed 59.9 (95% CI: 20.3-99.5). Propofol had a statistically significant shorter time to sedation than both ketamine (p<.001) and fentanyl/versed (p=.022). Propofol also produced shorter recovery times than both ketamine (p<.001) and fentanyl/versed (p=.002). Conclusion: In this study, sedation and recovery times were shorter with propofol than with ketamine or fentanyl/versed. The use of propofol for conscious sedation in this non-randomized study was associated with a shorter ED length of stay.

A young man presented to the emergency room in extremis and deteriorated into a state of pulseless electrical activity. Bedside echocardiography by emergency medicine physicians was crucial to the clinical decision to implement thrombolytic therapy for suspected massive pulmonary embolus.