Background: Several efforts have been made to assure and to improve the quality of procedural sedation and analgesia (PSA) performed by emergency physicians (EPs) in The Netherlands. This study investigated the current PSA practice and competences of EPs in both adult and paediatric patients. In particular, if residency and current training, awareness of guidelines is sufficient for registered EPs to adequately perform PSA and if the availability of both adult and paediatric PSA in the ED is adequate. Methods: A cross-sectional nationwide survey was performed amongst Dutch EPs (n = 463) in June 2016. We collected data on background, training, practice, and competencies of both adult and paediatric PSA. We investigated guideline adherence, reasons for not performing PSA, and desired improvements. Results: The respondents (n = 191) represented 84.6% hospitals with EPs and 41.3% of all EPs in The Netherlands. Nearly all EPs (97.8%) performed PSA in adult patients compared to only 59.1% who performed PSA in paediatric patients (p < 0.001). The major reason for not performing paediatric PSA was caused by a lack of exposure during the training-program (74.1%). PSA-guideline knowledge (98.3%) and PSA related adverse event registration (98.3%) were excellent. Lack of 24/7-availability of both adult and paediatric emergency department PSA was mainly caused by a shortage of EPs. Self-reflection indicated that EPs feel less competent in performing paediatric PSA when compared to adult PSA. Conclusion: This nationwide survey demonstrates that there is still a significant gap between the performance of adult and paediatric PSA even though guideline adherence and registration of PSA-related adverse events appear to be adequate. Enhancement of paediatric PSA training in combination with an increase of EP-staffing can help improve the availability of adult and paediatric PSA in the emergency department.