Emergency Medicine Hub / Pediatrics & Obstetrics • 3 min read • 3 sections

Pediatric Procedural Sedation & Analgesia (PSA)

Comprehensive emergency evaluation and protocolized execution of pediatric procedural sedation and analgesia (PSA): presedation risk stratification (ASA physical status, NPO guidelines, Mallampati and LEMON airway anatomy), agent selection (Ketamine dissociative state, Propofol, 'Ketofol', Dexmedetomidine, Intranasal Fentanyl/Midazolam), depth of sedation monitoring with continuous capnography (EtCO2), airway rescue maneuvers (Larson's point jaw thrust, positive pressure ventilation), and management of ketamine-induced laryngospasm.

Resuscitation Quick Actions • First 2 Minutes

High-Acuity

Ketamine IV Dosing

1 to 2 mg/kg IV push over 30–60 seconds (administer slowly to prevent transient apnea); repeat 0.5–1.0 mg/kg if needed

Ketamine IM Dosing

4 to 5 mg/kg IM once for uncooperative or unvascularized children; onset within 3–5 minutes, duration 30–45 minutes

Continuous Capnography

Continuous sidestream end-tidal CO2 (EtCO2) is MANDATORY; identifies hypoventilation/apnea 60–90 seconds before SpO2 drops

Laryngospasm Larson Point

Apply forceful bilateral pressure in the laryngospasm notch (behind condyle of mandible) with vigorous jaw-thrust + CPAP via BVM

Succinylcholine Rescue

Low-dose Succinylcholine 0.1 to 0.5 mg/kg IV (pediatric 1–2 mg/kg IM) breaks refractory laryngospasm without total paralysis

NPO Emergency Rule

In emergency settings, do NOT delay urgent procedural sedation based solely on NPO status; evidence shows no link to aspiration

Bottom-Line Clinical Pearl

Pediatric procedural sedation requires meticulous preparation, pre-sedation risk assessment, and continuous end-tidal CO2 (capnography) monitoring to detect hypoventilation long before pulse oximetry desaturation occurs. Ketamine (1–2 mg/kg IV or 4–5 mg/kg IM) is the single most versatile and safe dissociative agent in pediatric emergency medicine: it provides profound analgesia, amnesia, and sedation while preserving airway reflexes and spontaneous respiratory drive. Laryngospasm occurs in ~0.4% of ketamine sedations; manage immediately with the 'Larson maneuver' (firm bilateral pressure at the laryngospasm notch behind the earlobes while subluxing the jaw anteriorly) and high-flow 100% O2 positive pressure via bag-valve-mask. If refractory, administer low-dose Succinylcholine (0.1–0.5 mg/kg IV).

1. Presedation Risk Stratification & NPO Status

Before initiating pediatric procedural sedation, evaluate the child's American Society of Anesthesiologists (ASA) physical status classification, underlying respiratory pathology (recent URI, asthma, obstructive sleep apnea), and craniofacial anatomy. While elective surgical guidelines recommend 2 hours for clear liquids and 6 hours for solid foods, ACEP and AAP emergency clinical policies state that urgent emergency procedural sedation should NOT be delayed based on fasting time alone, as large multicenter registries demonstrate zero correlation between fasting intervals and pulmonary aspiration events during emergency procedural sedation.

2. Sedative Pharmacopoeia for Pediatric Emergency Care

Agent & Mechanism	Pediatric Dosing & Route	Onset/Duration	Clinical Advantages & Adverse Effects
Ketamine (NMDA receptor antagonist)	IV: 1 to 2 mg/kg<br>IM: 4 to 5 mg/kg	IV: 1 min/15–30 min<br>IM: 3–5 min/30–45 min	Gold Standard for painful procedures (fracture reductions, extensive lacerations, abscess I&D). Preserves airway reflexes and spontaneous respiration; causes bronchodilation. Adverse effects: Sialorrhea (drooling), emergence agitation, laryngospasm (0.4%).
Propofol (GABA-A agonist)	IV: 1 mg/kg bolus, then 0.5 mg/kg q2–3 min titrated to effect	IV: 30 sec/5–10 min	Rapid onset, ultra-short duration, antiemetic properties. Ideal for non-painful imaging (CT/MRI) or brief painless procedures (lumbar puncture, cardioversion). Adverse effects: Dose-dependent respiratory depression and hypotension; lacks analgesic properties.
'Ketofol' (1:1 Ketamine & Propofol mixture)	IV: 0.5 mg/kg of each drug (mixed in single syringe or co-administered)	IV: 1 min/10–15 min	Combines the profound analgesia of ketamine with the smooth, anti-emetic sedation of propofol; mitigates propofol hypotension and ketamine emergence delirium.
Dexmedetomidine (Selective alpha-2 agonist)	IN: 2 to 3 mcg/kg intranasally OR IV: 1 mcg/kg over 10 min	IN: 20 min/45–60 min	Preserves respiratory drive completely; mimics natural sleep. Excellent for non-painful scans (MRI/CT). Can cause mild bradycardia.

3. Management of Ketamine-Induced Laryngospasm

Laryngospasm is a sudden, involuntary muscular spasm of the true and false vocal cords that produces partial or complete upper airway obstruction. Follow this stepwise abortive algorithm:

Step Number	Intervention & Technique	Physiologic Rationale
Step 1: Oxygen & Suction	Clear oropharynx of secretions with soft suction; apply 100% $FiO_2$ via non-rebreather mask	Removes irritant triggers from the glottis.
Step 2: Larson's Maneuver & CPAP	Apply firm, continuous forward pressure bilaterally in the laryngospasm notch (between the mastoid process and the ramus of the mandible) while subluxing the jaw forward, combined with gentle continuous positive airway pressure (CPAP) using a tight-fitting BVM	Stimulates the periosteum of the styloid process and cranial nerve VII/IX, reflexively breaking vocal cord adduction in $> 90\%$ of cases.
Step 3: Low-Dose Succinylcholine	Succinylcholine 0.1 to 0.5 mg/kg IV (pediatric: 1.0–2.0 mg/kg IM)	A fraction of the full intubating dose relaxes the vocal cords and terminates laryngospasm without causing total diaphragmatic paralysis or requiring prolonged mechanical ventilation.

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