Acetylcysteine

- 600mg effervescent tablets, capsules (PO)

- 6gr/60ml (100mg/ml) solution (PO)

- 6gr/30ml (200mg/ml) vials (IV)

Executive Summary
N-Acetylcisteine (NAC) is a mucolytic, antioxidant and a glutathione-inducer. It is positioned as the cornerstone antidote for the prevention and treatment of liver toxicity secondary to acetaminophen (APAP) overdose, with US-FDA approval for IV, PO and effervescent tablets administration.


Adult and Pediatric dose for acetaminophen overdose: oral administration, 18 doses total. 


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Alteplase

50mg lyophilized powder (IV)

Executive Summary
Alteplase, a fibrin-specific Tissue Plasminogen Activator (fibrinolytic) is widely accepted for emergency revascularization in acute myocardial infarction (MI),  high risk acute pulmonary embolism (PE), and acute ischemic stroke (AIS). 


Acute Coronary Syndrome with ST elevation (<12 hours)

US-FDA approved

Adult dose:

 

Acute Ischemic Stroke (<4.5 hours)

US-FDA approved for <3 hours after symptom onset (1996), Universally accepted use in <4.5 hours.
Adult dose:

 

Pulmonary Embolism

US-FDA approved. 

Adult dose


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Go to Fibrinolytics Summary Table

Cyclobenzaprine
- 5, 7.5 and 10mg tablets (PO, immediate release)
- 10, 15 and 30mg tablets (PO, extended release)

Executive Summary
Ciclobenzaprine is a centrally acting skeletal muscle relaxant widely prescribed to relieve acute painful musculoskeletal conditions as an adjunct treatment to physical therapy  and rest. It is also used as a temporary adjuvant medication along with non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen. 

 

Adult dose for acute painful musculoskeletal spasms

Immediate release formulation*


*Many clinicians start at a low dose at night (5mg) and then titrate up if it is strictly necessary.


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Dobutamine

250mg/20ml vials (IV)

Executive Summary

Dobutamine, a synthetic catecholamine, is one of the most studied and used inotropic agents in cardiovascular critical care for the treatment of cardiogenic shock (CS), with approval of the US-FDA for that condition. 


Adult dose for cardiogenic shock

2-20 ug/kg/min


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Droperidol

5mg/2ml ampoules (IV, IM)

Executive Summary

Droperidol is a first generation antipsychotic (so-called typical antipsychotics, same class as haloperidol) that acts as a D2 dopamine receptor antagonist. Droperidol also has some histamine and serotonin antagonist properties. 

 

Adult dose for undifferentiated agitation in the ED

5-10mg IM


Adult dose for migraine, acute vertigo, nausea or vomiting and cannabinoid hyperemesis

1.25-2.5mg IV or IM


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Etomidate
20mg/10ml ampoules (IV)

Executive Summary
Etomidate is an ultrashort-acting, non-barbiturate hypnotic intravenous anesthetic agent. Is one of the most used and preferred hypnotic agents in the ED for Rapid Sequence Intubation. 

 

Pharmacology for a single bolus administration:

 

Adult dose for rapid sequence intubation:  

0.3mg/kg IV (total body weight).


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Epinephrine
1mg/1ml ampoules (IV, IM, IO, nebulization, subcutaneous)

Executive Summary

Epinephrine is an endogenous catecholamine non-selective agonist of all adrenergic receptors with a major role in emergency medicine on a variety of different diagnoses. 

 

*ROSC: Return of Spontaneous Circulation


Adult dose for anaphylaxis
0.01mg/kg (max 0.5mg per dose) IM into the anterolateral aspect of the thigh.

 

Adult dose for cardiac arrest
1mg every 3 to 5 minutes IV or IO


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Fentanyl
- 0.1mg/2ml and 0.5mg/10ml vials (IV, IM)

Executive Summary
Fentanyl is a potent opioid pain medication that is extensively used in the ED to manage severe acute pain and as premedication to intubation preparation.

Adult dose for moderate to severe pain:

1 mcg/kg/dose (usually 50-100 mcg) IV.


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Flavoxate
100 and 200mg tablets (PO)

Executive Summary

Flavoxate is a synthetic anticholinergic with urinary tract spasmolytic activity that is used for symptomatic alleviation in genitourinary conditions such as lower urinary tract infection, prostatitis, and urethritis.

Adult dose for symptomatic relief of urinary urgency, suprapubic pain secondary to UTIs 

100-200mg every 6 to 8 hours PO

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Hypertonic saline
3%, 10% and 23.4%, 100ml ampoules (IV)

Executive Summary

Hypertonic saline solutions (HTS) are electrolyte concentrates of NaCl (over 0.9%) and  considered to be high alert medications that are cautiously used to treat symptomatic hyponatremia and acute intracranial hypertension (IH) secondary to multiple causes, but mainly to traumatic brain injury. 


Adult dose for acute intracranial hypertension caused by TBI

NaCl 3%, 2 ml/kg IV in 15 minutes bolus


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Ketorolac
- 30mg/ml vials, (IV, IM)

- 10mg and 30mg tablets (PO, sublingual)

- 0.5% drops (ophthalmic), 15.75mg/spray (intranasal)

Executive Summary

Ketorolac is an NSAID with a potent analgesic effect that is very frequently indicated in the ED worldwide to treat moderate to severe acute pain. 


Adult dose for acute moderate to severe pain


*adults ≥65 years: max 60mg/day

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Levetiracetam

- 500mg/5ml vial (IV)

- 500mg tablets (PO) and 100mg/ml oral solution (PO)

Executive Summary

Levetiracetam (LEV) is a second generation antiepileptic drug (AED) that has gained popularity in the ED for the treatment of status epilepticus (with a conjunction of benzodiazepines, usually IV lorazepam or IM midazolam); 


Adult dose for status epilepticus

Loading dose of 60mg/kg IV (max 4,500mg) in 15 minutes. 


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Lidocaine 

- 2%, 5ml (20mg/ml, 100mg total) ampoules (subcutaneous, IV)

- 4% spray (mucosa, topical), 5% patches (transdermal), 2% drops (ophthalmic, otic)

Executive Summary
Lidocaine is a synthetic local anesthetic, and one of the most frequently used drugs in the ED.  It has a reversible blocking effect on voltage-gated sodium channels, resulting in two main clinical usages: (i) interrupting nerve impulse propagation to achieve local or regional anesthesia, and (ii) inhibition of cardiac ion channels as a class IB antiarrhythmic drug. 


Adult dose for local anesthesia

Up to 4.5 mg/kg (max 300mg per dose) subcutaneous infiltration within 2 hours.


Adult dose for ventricular tachycardia (8, 9)

1-1.5mg/kg IV.

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Lipid emulsion

- Lipid emulsion 20%, 100ml vials* and 500ml bags* (IV)

  *Intralipid® and Smoflipid® formulations

Executive Summary

Intravenous lipid emulsion (IVLE) is a nutritional supplement approved by the US-FDA for parenteral nutrition, that have promising results for the treatment of lipophilic agents toxicity, mostly for local anesthetic systemic toxicity (LAST).


Adult dose for Local Anesthetic Systemic Toxicity (LAST)

Intralipid® 20%, 1,5 ml/kg IV bolus over 1 minute (approximately 100ml in adults), followed by an infusion of 0.25ml/kg/min IV over the next 30-60 minutes.

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Lorazepam

- 4mg/2ml, 4mg/1ml and 2mg/1ml ampoules (IV, IM)

- 0,5mg, 1mg and 2mg tablets (PO, sublingual)

Executive Summary
Lorazepam is an intermediate acting benzodiazepine (BDZ) –a GABA receptor enhancer– with CNS depressant effects including sedative, hypnotic, skeletal muscle relaxing and anticonvulsant activity. It can be administered either by intravenous, intramuscular, sublingual or oral routes. Along with midazolam and clonazepam, lorazepam is one of the most frequently indicated BDZs in the ED. 


Sedation timing with single 2-4mg dose:

Onset (IV): 5-10 minutes*

Peak Effect (IV): 30 minutes

Duration (IV): 2-6 hours

(*shorter to terminate seizures)

Onset (IM) 15 minutes

Peak Effect (IM) 60 minutes

Duration (IM) 6-8 hours


Adult dose for status epilepticus:
0.1mg/kg IV (max 4mg/dose).


Adult dose for undifferentiated agitation:
2-4mg sublingual, IV or IM as needed (if severely agitated, IM route is prefered).


Acute anxiety disorder:


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Norepinephrine

4mg/4ml ampoules (IV)

Executive Summary
Norepinephrine (NE) is used for hemodynamic support frequently as a first-line vasopressor with the exception of anaphylaxis (epinephrine) and post cardiac arrest care (epinephrine). Consider using norepinephrine in combination with inodilator drugs in cardiogenic shock


Adult dose for shock:
0.01-0.3 ug/kg/min IV


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Olanzapine

- 5mg and 10mg tablets (sublingual)
- 10mg lyophilized powder (IM)

Executive Summary
Olanzapine is a second generation (atypical) antipsychotic with a potent antagonism of serotonin, dopamine, histamine and alpha1-adrenergic receptors. 


Adult dose for severe agitation:
5 to 10mg IM, repeated every 20 min if necessary


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Omeprazole #new! (full description released!)

- 40mg lyophilized vial (IV)

- 10mg, 20mg and 40mg standard and extended release capsules, tablets (PO)

Executive Summary
Omeprazole is the most prescribed proton pump inhibitor (PPI) worldwide. It reduces gastric acid secretion by irreversibly blocking the H+/K+ ATPase enzyme within the gastric parietal cells.


Adult dose for peptic ulcer bleeding


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Ondansetron

- 4mg/2ml and 8mg/4ml ampoules (IV, IM)

- 4 and 8mg tablets (PO, oral disintegrating tablets)

Executive Summary

Ondansetron is a selective serotonin receptor antagonist (5HT-3) with proven antiemetic properties, used in both children and adults to treat nausea and vomiting caused by a variety of conditions; such as chemotherapy, gastroenteritis, migraine, traumatic brain injury, etc.


Adult dose for nausea and/or vomiting
4 to 8mg PO or IV.


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Phentolamine (for extravasated vasopressors)

- 10mg/1ml vials (subcutaneous)
- 5mg lyophilized powder (subcutaneous)

Executive Summary
Phentolamine is a vasodilator used to prevent tissue necrosis caused by extravasated catecholamine infusions (epinephrine, norepinephrine, dopamine, etc). Available in the US. Limited stock in Canada. Unavailable in Chile. 


Adult dose for vasopressor extravasation:
5-10mg diluted in 10-20ml of NaCl 0.9% subcutaneous immediately after extravasation (use within 12 hours). 


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Rabies Vaccine

Single-dose 1ml and 0,5ml vials, both equivalent to 1 vaccination dose (IM)

Executive Summary
Rabies is a zoonotic disease positioned as one of the most lethal viral infections; mortality approaches 100%. It is also preventable in nearly 100% of expositions when vaccination has been properly administered. 


Adult and pediatric vaccination regimen for post-exposure prophylaxis (PEP)

 

*Some regions and their local guidelines still  recommend a universal 5-dose regimen for PEP as previously was recommended by the US-CDC, and currently some manufacturers. 

**Complete 4 doses of PEP scheme or 3 doses of PrEP (pre-exposure prophylaxis).


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Rocuronium #new

50 mg/5 ml vials (IV)

Executive Summary

Rocuronium is becoming the most commonly used non-depolarizing neuromuscular blocking agent (N-NMBA) in the emergency department due to its ability to create excellent intubating conditions compared to other NMBAs, and its superior safety profile over succinylcholine for a variety of clinical conditions when the latter is contraindicated (NMBA table). 


Adult dose for rapid sequence intubation

1.5mg/kg IV


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Tenecteplase

50mg lyophilized powder (IV)

Executive Summary


Acute Myocardial Infarction with ST elevation (STEMI <12hrs)

FDA approved, 2000. Indicated when anticipated STEMI diagnosis to Percutaneous Coronary Intervention-mediated reperfusion time is >120min. 

Adult dose (IV ,bolus):

 

Acute Ischemic Stroke (AIS <4.5hrs)

Not FDA approved. 

Adult dose (IV ,bolus):

 

Pulmonary Embolism (PE)

Not FDA approved. Prefer alteplase for PE fibrinolytic therapy. If unavailable, consider tenecteplase.

Adult dose (IV, bolus):


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Go to Fibrinolytics Summary Table

Tetanus Immune Globulin

250 unit prefilled syringes (IM)

Executive Summary
Tetanus Immune Globulin (TIG) is indicated for tetanus disease treatment and prophylaxis (the latter in individuals without updated or an  unknown tetanus immunization who have suffered a contaminated or a  tetanus-prone wound).

Adult dose for tetanus treatment and prophylaxis


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Thiamine (Vitamin B1)

- 30mg/ml and 200mg/2ml vials (IV, IM)

- 10, 50, 100 and 250mg tablets (PO)

Executive Summary
Thiamine (vitamin B1) is a water-soluble vitamin that is essential in the creation and utilization of cellular energy  related to aerobic glycolysis in the citric acid cycle. Its deficiency leads to cardiovascular (heart failure) and neurologic disease (Wernicke - Korsakoff syndrome, "WK"). In the ED thiamine is frequently indicated in the prevention and treatment of WK, mainly in patients with ethanol dependence and/or malnutrition. 

 

Adult dose for WK prevention and treatment


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Tranexamic Acid (TXA)

1000mg/10ml ampoules (IV)

Executive Summary

The antifibrinolytic agent tranexamic acid (TXA) is a synthetic lysin derivative that binds plasminogen and plasmin, blocking their interaction with fibrin. It is indicated extensively in the ED for a variety of bleeding scenarios. 

 

Adult dose for trauma with risk of significant hemorrhage

1gr in 10 min IV + 1gr in 8 hrs IV.


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Neuromuscular Blocking Agents Summary Table

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