A Safety Comparison of Single-Agent Methohexital, Ketamine, or Propofol for Musculoskeletal Procedural Sedation in the Emergency Department

The use of sedative and analgesic agents is required for procedural sedation in the emergency department (ED). Agents such as ketamine and propofol are commonly used for procedural sedation. This is likely due to clinical experience with these agents, as well as optimal pharmacologic properties when used in combination with one another. Methohexital, a barbiturate, is less frequently used due to concerns for adverse events associated with this drug class.The objective of this study is to evaluate the safety of methohexital in comparison with ketamine and propofol when used for procedural sedation in musculoskeletal procedures.A retrospective chart review was conducted to evaluate adult ED patients who received ketamine, propofol, or methohexital for procedural sedation from January 1, 2014 to June 30, 2020.Overall, a total of 43 procedures were included in the study. Procedures included shoulder relocation, elbow relocation, hip relocation, ankle reduction, radius/ulnar reduction, mandibular relocation, patellar relocation, and wrist reduction. There was a 90.6% overall procedural success rate, which was similar between groups. Overall adverse events occurred in 34.8% of patients. Respiratory depression occurred in 9.3% of patients. No incidence of respiratory depression was observed in the methohexital group, compared with 2 patients receiving ketamine and 4 receiving propofol (p = 0.44).Methohexital is a safe and effective option for procedural sedation for musculoskeletal procedures in the ED when compared with ketamine and propofol.