Procedural sedation and analgesia in the emergency department: a review of current practices and clinical implications

Abstract This review provides an evidence-based overview of procedural sedation and analgesia (PSA) practices in emergency department settings, addressing pharmacologic agent selection, monitoring strategies, pediatric- and adult-specific considerations, and current guideline recommendations to support safe and effective PSA across diverse clinical scenarios. Literature published between 2014 and 2024 was reviewed using PubMed, Cochrane Library, Embase, Scopus, and Web of Science, with inclusion limited to English-language, full-text human studies of methodological quality and clinical relevance. Ketamine, propofol, midazolam, and fentanyl remain the most commonly used agents, often administered in combination to balance efficacy and adverse effects, while newer agents such as remimazolam, esketamine, and ciprofol are emerging but lack robust evidence in emergency settings. In pediatric populations, noninvasive administration routes and age-appropriate dosing are emphasized, and adherence to guidelines is consistently associated with improved procedural standardization and patient safety. Point-of-care ultrasound has gained increasing prominence in monitoring strategies, complementing established practices. Overall, when guided by appropriate patient selection, careful pharmacologic planning, and adherence to evidence-based protocols, PSA can be safely and effectively performed in emergency care, and the integration of standardized training, clinical guidelines, and novel monitoring tools will be critical for optimizing outcomes across diverse patient populations.