child at the time of the visit, and determine the need for and choice of medications for sedation and analgesia The parents’ or caregiver’s assessment of the child’s anticipated emotional response is useful in defining the best approach for the procedure Despite an apparent lack of response to usual vocal or calming techniques, many children still well if their caregivers stay near, and if it seems to them that there is less change occurring in their surroundings The route of administration is also an important consideration, in that some children have a strong aversion to manipulation of certain body parts If the child is taking medications already, drug interactions must be considered when choosing a procedural sedative However, if the child’s initial medication has sedative properties (e.g., those found in phenobarbital or benzodiazepines), then simply adding or increasing a dose may be all that is needed Despite the potential for paradoxical reactions in children with emotional disorders, benzodiazepines used in the correct dosage result in better cooperation for procedures In fact, the situation may be worsened by having too little medication to initiate anxiolysis or sedation Propofol has been used successfully for PSA in children with autism spectrum disorder (ASD) with no increase in adverse events compared to children without ASD Ketamine may also cause a severe emotional response in emotionally reactive children A small case series of successful PSA with IM dexmedetomidine (4 mcg/kg) for children with ASD makes this an intriguing option that warrants further study COMPLICATIONS AND ERRORS Most children who receive sedation and analgesia in the ED have a good outcome and benefit from the efforts to reduce pain and anxiety during a procedure However, administration of sedative and analgesic agents to children in the ED always carries some risk to the patient and potential liability for the provider Even with proper patient screening, preparation, and care, adverse events can still occur The overall adverse event rate for PSA in children is less than 10%, and the majority of these are minor, such as hypoxia requiring brief administration of oxygen The serious adverse event rate, such as those requiring a more significant intervention, is even lower, around 3% or less depending on the agent Nonetheless, it is essential that the PSA provider adheres to proper protocol, be thoughtful about the