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.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Emergency Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Godwin SA
        • Burton JH
        • Gerardo CJ
        • et al.
        Clinical policy: procedural sedation and analgesia in the emergency department.
        Ann Emerg Med. 2014; 63 (e18): 247-258
        • Jalili M
        • Bahreini M
        • Doosti-Irani A
        • Masoomi R
        • Arbab M
        • Mirfazaelian H.
        Ketamine-propofol combination (ketofol) vs propofol for procedural sedation and analgesia: systematic review and meta-analysis.
        Am J Emerg Med. 2016; 34: 558-569
        • Yan JW
        • McLeod SL
        • Iansavitchene A.
        Ketamine-propofol versus propofol alone for procedural sedation in the emergency department: a systematic review and meta-analysis.
        Acad Emerg Med. 2015; 22: 1003-1013
        • Newton A
        • Fitton L
        Intravenous ketamine for adult procedural sedation in the emergency department: a prospective cohort study.
        Emerg Med J. 2008; 25: 498-501
        • Gresham C
        • LoVecchio F
        in: Tintinalli JE Stapczynski J Ma O Yealy DM Meckler GD Cline DM Tintinalli's emergency medicine: a comprehensive study guide. 8th edn. McGraw-Hill, New York2016 (Available at) (Accessed January 25, 2020)
        • Lerman B
        • Yoshida D
        • Levitt A.
        Prospective evaluation of the safety and efficacy of methohexital in the emergency department.
        Am J Emerg Med. 1996; 14: 351-354
        • Miner JR
        • Biros M
        • Krieg S
        • Johnson C
        • Heegaard W
        • Plummer D.
        Randomized clinical trial of propofol versus methohexital for procedural sedation during fracture and dislocation reduction in the emergency department.
        Acad Emerg Med. 2003; 10: 931-937
        • Austin T
        • Vilke GM
        • Nyheim E
        • Kelly D
        • Chan TC.
        Safety and effectiveness of methohexital for procedural sedation in the ED.
        J Emerg Med. 2003; 24: 315-318
        • Bono JV
        • Rella JG
        • Zink BJ
        • Reilly KM.
        Methohexital for orthopedic procedures in the emergency department.
        Orthop Rev. 1993; 22: 833-838
        • Zink BJ
        • Darfler K
        • Salluzzo RF
        • Reily KM.
        Efficacy and safety of methohexital in the emergency department.
        Ann Emerg Med. 1991; 20: 1293-1298