Emergency department (ED) procedural sedation and analgesia is widely and routinely performed; serious complications are rare. We describe the first reported case of aspiration during procedural sedation in the ED. Although our patient required endotracheal intubation and critical care admission, there was no adverse long-term outcome. Given that there were no apparent predisposing factors, we believe it is crucial for emergency physicians to routinely anticipate the possibility of such a complication during each sedation event.