PSA PictureCase Writer:  Brent Thoma, MD MA
Case Editors: Teresa Chan, MD and Nikita Joshi, MD

This procedural sedation simulation case can be used to teach, evaluate or reinforce the skills needed to safely perform procedural sedation. It presents a new format for the ALiEM Sim Case Series: Teresa Chan (@TChanMD) has worked magic to amalgamate all of the materials into a cohesive, organized, easy to follow format that also happens to be pretty. The freely downloadable PDF below includes:

  1. Teacher’s Guide – Provides the information needed for a facilitator to determine if the case is feasible and meets appropriate objectives
  2. Milestones – Lists the ACGME Milestones that this case addresses
  3. Case Flow Sheet – Displays a high-level colour-coordinated overview of the case
  4. Pre-Sedation Patient Information Cards – Displays an outline of the patient’s history and physical exam
  5. X-ray – Displays the x-ray for the case
  6. Ketamine Scenario Case Sheet – Lists the changes and complications that will occur if ketamine is used
  7. Propofol Scenario Case Sheet – Lists the changes and complications that will occur if propofol is used
  8. Achievement Checklist – Provides a checklist of critical actions that should be taken at each step of the procedural sedation along with pre-written debrief questions to use, if an action is missed.

PSA Picture

Download the ALiEM Procedural Sedation Simulation Case

Teachers Guide

Keywords: Procedural Sedation and Analgesia (PSA), Disclosure of Complications

Educational Objectives


  • Understand the characteristics of sedation agents and select appropriate medication
  • Perform focused pre-PSA physical exam
  • Ensure cardiorespiratory monitoring during and following PSA
  • Recognize and treat common PSA complications


  • Acquire informed consent for the PSA
  • Respond to nursing challenge regarding the selection of PSA medication
  • Communicate effectively as an interdisciplinary team

Case Synopsis

A 62 year old female bent over to tie her shoe and felt her left hip “pop out.” She had a total left hip arthroplasty 4 months ago for progressive arthritis and dislocated it in a similar fashion 2 months ago. It was reduced successfully at that time. She had significant pain initially but now rates it 3/10 and calls it “more of a discomfort.” She has no other complaints and wants the physician to “put the goshdarn thing back” so she can get back to her grandchildren. Her last meal was 6 hours ago and she last drank water 4 hours ago. Your emergency physician colleague has asked for your assistance in sedation so that he can reduce the hip.

Critical Actions

  1. Complete an appropriate airway assessment.
  2. Ensure appropriate cardiorespiratory monitoring prior, during, and post procedure.
  3. Identify and intervene to prevent complications specific for agents administered.

Target Learners


  • Emergency Medicine
  • Anesthesia
  • Critical care
  • Orthopedic


  • Medical
  • Pharmacy


ED resuscitation bay


62 year old female

Equipment –

  • Advanced airway equipment
  • Airway adjuncts (if requested)
  • Cardiac monitor
  • EtCO2 monitor (if requested)
  • IV fluid
  • Sedation agent
  • Syringes


Manikin with Street Clothing


  • Emergency physician colleague – Gives the patient’s history and requests sedation. Attempts to reduce the hip.
  • ED nurse – Completes and executes all orders provided. Raises concerns regarding choice of PSA agent with learner.
  • Orthopedics attending (voice) – Requests that EP sedate and reduce the hip and call if they have trouble. Agrees to followup as an outpatient.
  • Anesthesia attending (voice) – Suggests that patient is appropriate for an ED PSA. Unavailable to assist as there is an urgent case in the OR.

Supporting Files / Media

  • Hip x-ray – included in PDF


BP = blood pressure
ED = emergency department
EP = emergency physician
HR = heart rate
IV = intravenous
LOC = loss of consciousness
PSA = procedural sedation & analgesia
RR = respiratory rate

Brent Thoma, MD MA
ALiEM Associate Editor
Emergency Medicine Research Director at the University of Saskatchewan
Editor/Author at
Brent Thoma, MD MA