Medications in Emergency Medicine
Acetylcysteine
- 600 mg effervescent tablets, capsules (PO)
- 6 gr/60 ml (100 mg/ml) solution (PO)
- 6 gr/30 ml (200 mg/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.
Loading dose: 140mg/kg PO.
Dose 2 to 17: repeated doses every 4 hours of 70mg/kg PO.
Adenosine
6 mg/2 ml and 12 mg/4 ml vials and pre-filled syringes (for rapid IV bolus)
Executive Summary
Adenosine is an endogenous nucleoside present in all human cells. It is categorized as a “class V” or “miscellaneous” antiarrhythmic agent, as it does not meet the criteria for inclusion in antiarrhythmic classes I, II, III, or IV.
Adenosine is the first-line medication for stable paroxysmal supraventricular tachycardia (PSVT) unresponsive to vagal maneuvers, commonly used in EDs worldwide.
It decreases conduction through the AV node, thereby terminating the PSVT in 90% of cases.
Always administer adenosine in the resuscitation room with continuous monitoring and a defibrillator at hand.
⚠ Cautions:
Contraindications: 2nd or 3rd AV block, sinus node disease and symptomatic bradycardia, and irregular wide-complex tachycardia as it may trigger ventricular fibrillation.
Interactions: use with extreme caution if the patient has received other antiarrhythmics or AV blocking agents.
Adverse effects: flushing, dizziness, shortness of breath, chest pain or discomfort, transient hypotension, etc. Various self-limited arrhythmias, AV blocks, or prolonged sinus pause at the time of sinus conversion. It may cause bronchoconstriction.
Adult dose for paroxysmal supraventricular tachycardia
“6-12-12 mg”
Initial dose: 6 mg IV given as a rapid bolus, immediately followed by a vigorous flush of normal saline.
If a second dose is needed: 12 mg IV as a rapid bolus.
If a third dose is needed: 12 mg IV as a rapid bolus.
Consider other cardioversion strategies and alternative diagnoses if 3 doses of adenosine do not work.
Alteplase
50 mg 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).
In emergency medicine it is also used in intermediate-high risk PE and cardiac arrest when there is a high suspicion of MI or PE as the cause, in both scenarios the decision should be taken cautiously and in very selected cases.
Always seriously consider the contraindications and balance the risk of intracranial and other major bleeding events versus the benefit of the therapy. Fibrinolysis is an intervention that should be decided -or at least supported- by a specialist (emergency medicine, neurologist, cardiologist, intensivist).
Acute Coronary Syndrome with ST elevation (<12 hours)
US-FDA approved
Adult dose:
≤67kg: 15mg bolus + 0.75mg/kg in next 30 min
>67kg: 15 mg bolus + 50 mg in 30 min + 35 mg in 60 min
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:
<100kg: 0.9mg/kg total (max 90mg)
10% bolus over 1 min
90% infusion over 60 min
≥100kg: 9mg bolus + 81mg 60min
Pulmonary Embolism
US-FDA approved.
Adult dose:
Intermediate risk: 50mg in 2 hrs
High risk: 100mg in 2 hrs
Cardiac arrest: 50mg bolus + 50mg if no ROSC in 15 min
Go to Full Drug Description
Go to Fibrinolytics Summary Table
Amiodarone #full_description_released
- 150 mg/3 ml, 450 mg/9 ml and 900 mg/18 ml vials (IV).
- 100, 200 and 400 mg tablets (PO).
- 150 mg/3 ml, 450 mg/9 ml and 900 mg/18 ml vials (IV).
- 100, 200 and 400 mg tablets (PO).
Executive Summary
Amiodarone is classified as a class III antiarrhythmic, affecting all phases of the action potential by inhibiting K+ efflux channels, Na+ channels, and L-type Ca2+ channels. Furthermore, it exhibits a non-competitive blockade action on beta receptors, resulting in a potent antiarrhythmic effect.
Most ED use involves the treatment of ventricular and supraventricular arrhythmias. In-depth knowledge of these conditions and alternative effective treatments beyond amiodarone is necessary:
Cardiac arrest (VF and pulseless VT)
Ventricular tachycardia (VT)
Atrial fibrillation/flutter
Electrical storm
⚠ Cautions summary:
Hypotension, bradydysrhythmias, and QT interval prolongation are the most common and relevant adverse reactions associated with acute use. Additionally, it has several long-term and chronic complications, including pulmonary, hepatic, thyroid and ocular issues.
It should not be used in patients with atrial fibrillation who have not been previously anticoagulated and in whom atrial thrombi have not been ruled out due to the risk of periprocedural cardioversion embolization and stroke, with a risk as high as 3-6%.
Adult dose for cardiac arrest with shockable rhythms (VF and Pulseless VT (pVT))
It is only recommended in cases of persistent VF/pVT despite defibrillation attempts and the administration of epinephrine (see ACLS algorithm):
Initial dose: 300 mg of amiodarone IV or IO for patients who remain in VF or pVT after three defibrillation attempts.
Additional dose: 150 mg IV or IO if persistent VF/pVT after a total of five shocks.
Adult dose for stable ventricular tachycardia
Loading dose: 150 mg IV diluted in 100 ml 5% dextrose over 30 min.
Continuous infusion: after loading dose, initiate infusion of 1 mg/min for 6 hr, then 0.5 mg/min for 18 hr.
After initial IV administration, consider initiation of 400 mg every 8-12 hours for 1-2 weeks, then 300–400 mg daily; reduce dose to 200 mg daily if possible.
Consider procainamide as the first-line antiarrhythmic for monomorphic VT.
Calcium gluconate
1000 mg/10 ml ampoules (IV)
1000 mg/10 ml ampoules (IV)
Executive Summary
Calcium gluconate is the calcium salt of gluconic acid. It is used intravenously to rapidly increase the blood calcium levels, as it plays a crucial role in various physiological processes such as heart function and nerve impulse conduction.
In the ED, calcium gluconate is mainly used for the acute management of symptomatic severe hypocalcemia and in patients with severe hyperkalemia, as both of these conditions carry a high risk of arrhythmias.
⚠ Cautions: contraindicated in hypercalcemia. Caution in hyperphosphatemia. May increase digoxin toxicity.
Adult dose for acute severe hypocalcemia
1-2 gr IV over 10 min, may be repeated every 10-60 min if necessary.
Adult dose for severe/emergent hyperkalemia
1-2 gr IV over 2-5 min, may be repeated every 15-30 min if needed (persistent EKG signs of hyperkalemia, AV blockade, etc).
Cyclobenzaprine
- 5, 7.5 and 10 mg tablets (PO, immediate release)
- 10, 15 and 30 mg tablets (PO, extended release)
- 5, 7.5 and 10 mg tablets (PO, immediate release)
- 10, 15 and 30 mg 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.
Limited data supports its use in the short term for treating acute muscle spasm, acute low back pain, fibromyalgia and temporomandibular disorder.
Muscle relaxants including cyclobenzaprine have significant adverse effects on the central nervous system (sedation, drowsiness, dizziness), therefore, they should be prescribed with caution and their benefits need to be balanced with their risks; experts differ on whether they should be used or not.
It has a similar structure to tricyclic antidepressants such as amitriptyline, thus it can cause serious anticholinergic effects, but no direct cardiotoxicity has been reported in cases of overdose (eg. sodium channel blockade and QRS complex widening).
Adult dose for acute painful musculoskeletal spasms
Immediate release formulation*
5mg TID with one dose at night.
Maximum 30mg/day, up to 2-3 weeks.
*Many clinicians start at a low dose at night (5mg) and then titrate up if it is strictly necessary.
Dobutamine
250 mg/20 ml 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.
USA and European guidelines recommend norepinephrine as first-line vasopressor to manage hypotension in CS (3, 6). Subsequently, if needed, an inotrope and/or mechanical cardiovascular support (MCS) may be added to improve perfusion and facilitate definitive intervention.
It has inodilator properties as a beta-receptors agonist (𝛽1 and 𝛽2), with subsequent positive chronotropism, inotropism and mild peripheral vasodilation. This may provoke myocardial ischemia, arrhythmias and severe cardiovascular events. Use with extreme caution.
Dobutamine is preferred over epinephrine for CS, as the latter is associated with an increased risk of refractory shock, lactic acidosis and mortality.
Adult dose for cardiogenic shock
2-20 ug/kg/min
Droperidol
5 mg/2 ml 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.
It has a significant potential role in the ED because of its efficacy to treat a variety of clinical conditions, including undifferentiated agitation, migraine, vertigo, nausea, vomiting, cannabinoid hyperemesis, and pain.
The US-FDA issued a Black Box Warning in 2001, but has been deeply questioned. This is why the drug has been regaining popularity and its use has been increasing over the last decade. Nonetheless it should not be used on patients with long QT syndrome or at an increased risk of QT prolongation.
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
Etomidate
20 mg/10 ml ampoules (IV)
20 mg/10 ml 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.
Etomidate acts on GABA receptors moderating the activity of chloride channels; it makes neurons less excitable without any major cardiovascular impact.
It causes an adrenal inhibition of corticosteroid synthesis, therefore only a single bolus dose is recommended for induction to minimize adrenal suppression.
Pharmacology for a single bolus administration:
Onset: 15-45 seg
Time to Peak Effect: 45 seg
Duration of hypnotic effect: 3-12 min
Adult dose for rapid sequence intubation:
0.3mg/kg IV (total body weight).
Consider a lower dose of 0.2mg/kg in profound shock.
Epinephrine
1 mg/1 ml ampoules (IV, IM, IO, nebulization, subcutaneous)
1 mg/1 ml 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.
Anaphylaxis
Epinephrine acts on several pathophysiological pathways that cause anaphylaxis . It is the only established therapy to treat this condition.Cardiac arrest (CA)
Current guidelines include epinephrine as part of standard treatment during CA in children and adults, being the only recommended drug regardless of initial rhythm mainly because it is associated with an increased rate of ROSC* and short-term survival.Severe asthma crisis
Consider IV or IM epinephrine in the crashing asthmatic patient to deliver a systemic Beta-2 agonist agent (when inhaled bronchodilators have trouble getting into the lower airway). Give as a push-dose if administered IV, and an equivalent anaphylaxis dose for IM administration.
*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.
Can be repeated every 5-15 min if necessary.
If there is no response, consider a continuous IV infusion of epinephrine.
Adult dose for cardiac arrest
1mg every 3 to 5 minutes IV or IO
In shockable rhythms early defibrillation should be performed as soon as possible, before any other resuscitation interventions
Epinephrine racemic (racepinephrine)
Racepinephrine 2.25%, 0.5 ml vials (11.5 mg/0.5 ml)(nebulization)
Racepinephrine 2.25%, 0.5 ml vials (11.5 mg/0.5 ml)(nebulization)
Executive Summary
Racepinephrine is a mixture of epinephrine's L- and D- isomers. It is used nebulized as an effective and safe treatment for croup (acute laryngotracheitis) in pediatric patients, acting as a local vasoconstrictor to alleviate swelling and edema.
While L-epinephrine has been proven safe and effective when administered via nebulization for croup, racepinephrine is considered by many experts and institutions as the first-line inhaled vasoconstrictor agent for the treatment of moderate to severe croup.
Comparing racepinephrine with L-epinephrine, evidence has shown that there is no difference in croup score after 30 minutes of treatment. On the contrary, a better outcome has been observed after 120 minutes, favoring L-epinephrine.
Pediatric dose for moderate to severe croup (acute laryngotracheitis)
Nebulization of 0.05 ml/kg per dose (max 0.5 ml), diluted to 3 ml with normal saline.
Same dose may be repeated every 15 to 20 minutes as needed.
Fentanyl
0.1 mg/2 ml and 0.5 mg/10 ml vials (IV, IM)
0.1 mg/2 ml and 0.5 mg/10 ml 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.
In the ED is usually preferred over other opioids (eg. morphine) due to its higher potency, faster onset of action, and shorter duration of action. This makes it useful to precisely titrate dosing in the acute setting. Additionally, it has a safer hemodynamic profile than morphine, causing less hypotension or cardiac instability.
⚠ Cautions summary:
High risk of respiratory depression (black box warning) and other adverse effects; it should be used with caution, monitoring closely for respiratory depression, hypotension, sedation and other adverse effects.
High risk of addiction and overdose (black box warning): Its use should be limited to the management of short-term acute pain and critical care support.
Adult dose for moderate to severe pain:
1 mcg/kg/dose (usually 50-100 mcg) IV.
Repeat in 1 to 2 hours as needed (label recommendation).
Consider repeat doses in 5-10 min in cases of excruciating pain (emergency medicine practice).
Flavoxate
100 and 200 mg tablets (PO)
100 and 200 mg 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.
It does not have antibiotic properties, and should never be used as a replacement for appropriate antimicrobials.
It should not be prescribed to patients with an increased risk of intestinal obstruction, ileus, or urinary retention, or any other conditions that may be aggravated by anticholinergic agents.
Adult dose for symptomatic relief of urinary urgency, suprapubic pain secondary to UTIs
100-200mg every 6 to 8 hours PO
Go to Full Drug Description
Ketorolac
- 30 mg/ml vials, (IV, IM)
- 30 mg/ml vials, (IV, IM)
- 10 mg and 30 mg 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.
The US-FDA labeling recommends usage only for moderate to severe pain (defined as requiring analgesia at the opioid level), and for a short period of time of no more than 5 days to reduce NSAIDs adverse effects.
Ketorolac, as well as other NSAIDs, reduces opioid requirements for acute pain.
Adult dose for acute moderate to severe pain
IV: 10 to 30mg every 6 hours IV (max 120mg/day)*
PO: 10mg every 6 hours PO (max 40mg/day)
*adults ≥65 years: max 60mg/day
Go to Full Drug Description
Heparin, unfractionated
25.000 IU/ml multidose vials (IV, subcutaneous)
25.000 IU/ml multidose vials (IV, subcutaneous)
Executive Summary
Unfractionated heparin (UFH) is an endogenous anticoagulant that enhances antithrombin, ultimately preventing the conversion of fibrinogen to fibrin. It can be reversed by protamine.
UFH and other anticoagulants are extensively used in the ED for many thrombotic-related events, such as venous thromboembolism (VTE) – including acute pulmonary embolism (PE) and deep venous thrombosis (DVT) – acute coronary syndrome, acute limb ischemia, mesenteric thrombosis, etc.
There has been a clear tendency to replace UFH with low molecular weight heparins (LMWH) due to their predictable effects, easier administration, and monitoring advantages.
Preference of UFH over LMWH:
High-risk pulmonary embolism.
Myocardial infarction with ST segment elevation.
Severely impaired renal function.
⚠ Always evaluate the hemorrhagic risk before initiating anticoagulant therapy.
Adult dose for pulmonary embolism
80 IU/kg bolus IV followed by a 18 IU/kg/hr infusion.
UFH is preferred over LMWH for high-risk PE. For low and intermediate-risk PE, consider LMWH or oral anticoagulation alternatives.
Adult dose for ST-segment elevation myocardial infarction (STEMI)
Primary PCI*:
70 IU/kg bolus IV (max 5000 IU).Fibrinolysis:
60 IU/kg bolus IV (max 4000 IU) followed by 12 IU/kg/hr infusion (max 1000 IU/hr), continue until PCI.
*Percutaneous coronary intervention
Hypertonic saline
3%, 10% and 23.4%, 100 ml vials (IV)
3%, 10% and 23.4%, 100 ml vials (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.
Recent reviews comparing mannitol versus HTS tend to favor the latter with a weak level of evidence.
Ideally HTS should be administered through a central venous access, but in emergency situations, peripheral infusions have been determined to be a safe short-term alternative, but a close monitoring of the clinical response and sodium levels is warranted to guide subsequent doses.
Adult dose for acute intracranial hypertension caused by TBI
NaCl 3%, 2 ml/kg IV in 15 minutes bolus
Ibuprofen #new_summary
- 200, 400 and 600 mg tablets (PO)
- 200, 400 and 600 mg tablets (PO)
- 100 mg/5 ml, 200 mg/5 ml suspension (PO)
- 600 mg/ 100 ml, 800 mg/8 ml vials (IV)
Executive Summary
Ibuprofen is probably the most studied NSAID for the treatment of acute pain and is prescribed worldwide in the ED for both children and adult patients.
It is the only intravenous NSAID approved by the US-FDA for the treatment of both fever and pain (while other IV NSAIDs are approved solely for pain management). IV ibuprofen has the disadvantage of requiring a slow 30-min infusion.
Pediatrics: with acetaminophen, it is considered a first-line analgesic for this population.
The US-FDA has approved the use of intravenous ibuprofen starting at the age of 3 months and oral formulations starting from 6 months of age.
⚠ Cautions:
NSAIDS adverse effects: cardiovascular thrombotic events, gastrointestinal bleeding (ulceration, perforation), heart failure, renal toxicity, etc.
Fetal toxicity: premature closure of fetal ductus arteriosus, neonatal renal impairment (avoid in pregnancy).
Adult dose for pain or fever
400-800 mg IV or PO every 6-8 hours as needed (maximum 3200 mg/day).
When given IV it should be infused over 30 min.
Individual doses of 400 mg and a cumulative daily dose of 1200-2400 may be the analgesic ceiling for acute pain management.
Go to Full Drug Description (coming soon)
Levetiracetam
- 500 mg/5 ml vial (IV)
- 500 mg tablets (PO) and 100 mg/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);
It modulates neuronal activity through GABA and high-voltage-dependent calcium channels, by unknown molecular mechanisms.
In children and adults, compared with other AED, LEV has a similar efficacy treating SE, with an excellent safety profile (most studies comparing it with phenytoin).
EMDrugs is currently reviewing evidence regarding LEV usage for seizure prophylaxis in subarachnoid hemorrhage.
Adult dose for status epilepticus
Loading dose of 60 mg/kg IV (max 4,500 mg) in 15 minutes.
Maintenance dose of 1 gr every 12 hours IV or PO (up to a maximum of 3 gr/day).
Adult dose for post-traumatic seizure prophylaxis in severe TBI
Loading dose of 1000 mg IV.
Maintenance of 500 to 1000 mg every 12 hours (IV or PO).
Lidocaine
- 2%, 5 ml (20 mg/ml, 100 mg 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.
Lidocaine has a wide variety of specific applications in the ED:
Antiarrhythmic for ventricular tachycardia
Local and regional anesthesia for wound repair and fracture closed reductions
Pain management for severe painful conditions such as renal colic and headache
Topical –spray or gel– anesthesia for awake intubation and other procedures such as bladder catheterization
Symptomatic treatment of cough
Transdermal patches to alleviate post-herpetic neuralgia and rib fractures
Adult dose for local anesthesia
Up to 4.5 mg/kg (max 300mg per dose) subcutaneous infiltration within 2 hours.
Dosing calculator: MDCalc® - Local Anesthetic Dosing Calculator
Adult dose for ventricular tachycardia (8, 9)
1-1.5mg/kg IV.
Go to Full Drug Description
Lipid emulsion
- Lipid emulsion 20%, 100 ml vials* and 500 ml 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).
In conjunction with advance cardiovascular and neurocritic support, toxicologists and AHA guidelines consider IVLE as a valid therapeutic option to treat LAST, particularly in severe cases (eg. cardiovascular collapse / arrest).
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.
Go to Full Drug Description
Lorazepam
- 4 mg/2 ml, 4 mg/1 ml and 2 mg/1 ml ampoules (IV, IM)
- 0,5 mg, 1 mg and 2 mg 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:
Intravenous
Onset (IV): 5-10 minutes*
Peak Effect (IV): 30 minutes
Duration (IV): 2-6 hours
(*shorter to terminate seizures)
Intramuscular
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).
Repeat every 5-10 min until the crisis has ceased.
Consider initiating an antiepileptic if a second lorazepam dose is required.
Adult dose for undifferentiated agitation:
2-4mg sublingual, IV or IM as needed (if severely agitated, IM route is prefered).
Repeat every 20-30 min if necessary.
The BDZ of choice to treat severe undifferentiated agitation is considered to be midazolam IM for its faster onset of action.
Acute anxiety disorder:
0.5-2mg sublingual, PO or IV as needed.
Repeat every 20-30 minutes if necessary.
Nitroglycerin
- 50 mg/250 ml of 5% dextrose solution, 100 μg/ml (IV).
- 50 mg/10 ml vials (IV).
- 0.4 mg tablets and spray (sublingual).
Nitroglycerin (NTG) is a nitrate prodrug of nitric oxide (NO), which primarily produces vasodilation as its main cardiovascular effect.
It is used sublingually and intravenously to treat angina pectoris secondary to coronary artery disease. In the ED, it is commonly indicated in hypertensive emergencies, particularly acute cardiogenic pulmonary edema (ACPE) and acute coronary syndromes.
NTG use in ACPE is associated with a shorter hospital length of stay, lower intubation rates, and decreased ICU admissions.
Vasodilatory effects: venous > arterial. Arterial vasodilation and afterload reduction are correlated with higher doses.
⚠ Cautions: NTG may cause severe hypotension. Contraindicated if the patient has used PDE-5 inhibitors (eg. sildenafil) within the previous 48 hours.
Adult dose for acute cardiogenic pulmonary edema
Only consider NTG in hypertensive acute heart failure.
Intravenous
Start IV infusion at 0.5-0.7 μg/kg/min (approx. 30-50 μg/min for an adult) and titrate every 3-5 min with increases of 20-50 μg/min. Max dose of 400 μg/min.
In severely symptomatic and hypertensive patients, consider high-dose boluses of 500 - 1000 μg every 3-5 min, followed by a continuous infusion.
Sublingual and oral spray
400 μg, repeat every 5 min if needed.
Adult dose for angina and hypertension in acute coronary syndrome
5-10 μg/min infusion, titrate as needed (max 400 μg/min).
Go to Full Drug Description
Norepinephrine
4 mg/4 ml 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 μg/kg/min IV
Usually started at 0.05 μg/kg/min IV
Calculate with total body weight
Olanzapine
- 5 mg and 10 mg tablets (sublingual)
- 10 mg lyophilized powder (IM)
Executive Summary
Olanzapine is a second generation (atypical) antipsychotic with a potent antagonism of serotonin, dopamine, histamine and alpha1-adrenergic receptors.
In the ED, olanzapine is frequently indicated as a first-line antipsychotic for acute agitation associated with psychiatric disorders.
Agitation in the ED is a very complex situation that includes a variety of dissimilar scenarios with a wide range of therapeutic options. It is of great importance to be familiarized with the available therapeutic arsenal for agitation, such as droperidol, benzodiazepines, ketamine, etc.
Adult dose for severe agitation:
5 to 10mg IM, repeated every 20 min if necessary
Maximum of 30mg/day for intramuscular administration.
Omeprazole
- 40 mg lyophilized vial (IV)
- 10 mg, 20 mg and 40 mg 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.
Globally, PPIs are commonly prescribed and administered in the ED for a variety of conditions, but there is no need to initiate PPI therapy within the first hours of emergency care, and no benefit has been proven in providing acute symptomatic relief in the ED.
The acute management of upper gastrointestinal bleeding in the ED typically involves the empiric administration of an IV PPI bolus. However, the benefits of emergent administration are questionable, as it does not reduce mortality, rebleeding, use of hemoderivatives, or need for surgery. On the other hand, it has been associated with a reduced incidence of high-risk stigmata of hemorrhage.
Resuscitation and bleeding control of hemorrhagic shock should be prioritized, and the administration of omeprazole should not delay upper endoscopy or standard management for severe hemorrhage (eg., administration of hemoderivatives).
Adult dose for peptic ulcer bleeding
80 mg IV, followed by 40 mg every 6 hours IV.
Ondansetron
- 4 mg/2 ml and 8 mg/4 ml ampoules (IV, IM)
- 4 and 8 mg 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.
Its use in the ED has increased significantly in the past decade, due to its effectiveness and fewer adverse effects than other antiemetic drugs.
When using multiple doses of ondansetron, a major concern is the risk of QT interval prolongation and subsequent potential arrhythmia. Patients with a history of prolonged QT interval or those at risk for it should be closely monitored.
Adult dose for nausea and/or vomiting
4 to 8mg PO or IV.
Repeat every 4-8 hours if necessary.
A maximum cumulative daily dose of 24mg may be a conservative approach for ensuring safety.
Phentolamine (for extravasated vasopressors)
- 10 mg/1 ml vials (subcutaneous)
- 5 mg 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:
5-10 mg diluted in 10-20 ml of NaCl 0.9% subcutaneous immediately after extravasation (use within 12 hours).
Propofol
- 1%: 100 mg /10 ml, 200 mg/20 ml, 500 mg/50 ml and 1000 mg/100 ml vials (IV).
- 2%: 1000 mg/50 ml and 2000 mg/100 ml vials (IV).
(August 31 2023)
Propofol is a hypnotic agent that enhances the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) in the brain through NMDA and GABA-A receptors, resulting in sedation and unconsciousness. It is the third most commonly used induction agent in the ED, following etomidate and ketamine.
It has a fast onset of action and an extremely short half-life, which makes it suitable for various situations in the ED, particularly for patients requiring short-term sedation (3). It may be considered a first-line induction agent for status epilepticus.
⚠ Cautions summary:
Circulatory, CNS and respiratory depression: reduction in blood pressure due to vasodilation and direct myocardial depression mandates extremely cautious use in unstable patients. Etomidate or ketamine are often preferred for hemodynamically unstable patients. High risk medication that should be used with extreme caution, especially when other CNS depressants are used concomitantly.
Allergies: the manufacturer’s label contraindicates propofol in patients allergic to soybean or eggs. This concern has been discredited by multiple studies, experts, and societies in the fields of anesthesia, emergency medicine and immunology.
PRIS (Propofol-Related Infusion Syndrome): propofol is formulated in an oil-in-water emulsion that can potentially lead to PRIS –characterized by acidosis, rhabdomyolysis, refractory bradycardia and eventually organ failures and death–. Prolonged and high-dose infusions pose a major risk.
Adult dose for rapid sequence intubation (RSI) (25)
1.5 mg/kg IV bolus.
Consider a reduced dose (0.5-1 mg/kg) in hemodynamically unstable or elderly patients. Other inductors agents may be more appropriate (eg. etomidate or ketamine).
Onset of action: 15-45 sec.
Duration of effect: 5-10 min.
Rabies Vaccine
Single-dose 1 ml and 0,5 ml 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)
Immunocompetent without prior rabies immunization:
4 doses IM, days 0-3-7 and 14*Immunocompromised without prior rabies immunization:
5 doses IM, days 0-3-7-14 and 28Prior rabies immunization**:
2 doses IM, days 0 and 3
*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).
Rocuronium
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).
Studies have shown that there are no significant differences in intubation conditions when using rocuronium at a dose ≥1.2 mg/kg compared to succinylcholine 1.5 mg/kg for RSI.
Non-depolarizing NMBAs can be reversed with sugammadex at any point, or with neostigmine when significant recovery has been achieved (40% approx).
In the ED, NMBA reversal is not an option in the vast majority of cases and is not included in most Emergency Medicine difficult airway algorithms.
⚠ The only contraindication is a prior anaphylaxis to rocuronium.
Adult dose for rapid sequence intubation
1.5mg/kg IV
Time to intubation level paralysis: 60 sec
Duration of paralysis: 40-60 min
Tenecteplase
50 mg 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):
<60 kg 30mg
60 - 69 kg 35mg
70 - 79 kg 40mg
80 - 89 kg 45mg
≥90 kg 50mg
Acute Ischemic Stroke (AIS <4.5hrs)
Not FDA approved.
Adult dose (IV ,bolus):
AIS eligible for mechanical thrombectomy
0.25mg/kg bolus (max 25mg)
AIS with minor neurological impairment uneligible for a mechanical thrombectomy
Under revision due to NOR-TEST 2 trial results (2022)
Pulmonary Embolism (PE)
Not FDA approved. Prefer alteplase for PE fibrinolytic therapy. If unavailable, consider tenecteplase.
Adult dose (IV, bolus):
<60 kg 30mg
60 - 69 kg 35mg
70 - 79 kg 40mg
80 - 89 kg 45mg
≥90 kg 50mg
Go to Full Drug Description
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
Tetanus treatment
500 units IM with part of the dose infiltrated close to the source wound.Up to 6000 units can be used.
Tetanus prophylaxis:
250 units IM (single dose).
Thiamine (Vitamin B1)
- 30 mg/ml and 200 mg/2 ml vials (IV, IM)
- 10, 50, 100 and 250 mg 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
WK prevention
100-250mg IV daily for 3-5 days, then consider daily PO supplementation
WK treatment
500mg IV every 8 hours for 3-5 days, then 250mg IV daily for 3-5 days, then indefinitely daily PO supplementation
Always supplement with magnesium (2gr MgSO4 daily)
Tranexamic Acid (TXA)
1000 mg/10 ml 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.
The most validated usage is in patients with acute trauma with a suspected severe hemorrhage. Currently it is an established component of “damage control resuscitation”.
All-cause mortality reduction was proven by the game-changer CRASH-2 trial –a strong double-blind RCT that compared TXA versus a placebo in trauma, based on the uncertainty principle (attending physician not being sure if TXA was beneficial or not)–. Afterwards other studies have documented improved survival rates.
Adult dose for trauma with risk of significant hemorrhage
1gr in 10 min IV + 1gr in 8 hrs IV.
Neuromuscular Blocking Agents Summary Table
Practice guidance - clinical guidelines, recommendations and more open access content
Latest additions:
August 2023, Myocardial Infarction (STEMI)
June 2023, Hyperglycemic Emergencies
May 2023, Asthma
#Articles in Emergency Medicine and Critical Care Pharmacology
Highlights:
September 2023 - Comparison of acetaminophen, ketamine, or ketorolac versus morphine in the treatment of acute renal colic: A network meta-analysis.
Alghamdi YA, Morya RE, Bahathiq DM, et al. Comparison of acetaminophen, ketamine, or ketorolac versus morphine in the treatment of acute renal colic: A network meta-analysis [published online ahead of print, 2023 Aug 19]. Am J Emerg Med. 2023;S0735-6757(23)00447-3. doi:10.1016/j.ajem.2023.08.029
August 2023 - Acute Coronary Syndromes ESC Guidelines #must_read
Byrne RA, et al. 2023 ESC Guidelines for the management of acute coronary syndromes: Developed by the task force on the management of acute coronary syndromes of the European Society of Cardiology (ESC), European Heart Journal, 2023;, ehad191, https://doi.org/10.1093/eurheartj/ehad191
European Heart Journal (Open Access)July 2023 - Vasopressin in septic shock, narrative review
Sacha GL, Bauer SR. Optimizing Vasopressin Use and Initiation Timing in Septic Shock: A Narrative Review [published online ahead of print, 2023 Jul 19]. Chest. 2023;S0012-3692(23)01032-2. doi:10.1016/j.chest.2023.07.009
Pubmed
TIMELINE & LATEST UPDATES!
2023
09/22/23 New content Amiodarone full description published
09/17/23 New content Ibuprofen executive summary
08/31/23 New content Propofol for induction and more, full description published
08/29/23 Adenosine for PSVT and more, full description published
08/25/23 2023 ESC Guidelines for Acute Coronary Syndromes added to Articles
08/08/23 Calcium gluconate for hyperkalemia, hypocalcemia, and more
07/31/23 Racepinephrine for croup
07/14/23 Unfractionated heparin
07/05/23 Walls Emergency Medicine Airway 6th Ed (2022) added to Books of Interest
06/27/23 Nitroglycerin
06/20/23 Levetiracetam update - new section on seizure prophylaxis in severe TBI and more (8 new references added)
06/11/23 New content added to Articles: must-read tranexamic acid trials: CRASH-2 (trauma with significant haemorrhage) and CRASH-3 (traumatic brain injury)
06/01/23 Omeprazol
05/26/23 Asthma Practice Guidance
05/11/23 Rocuronium
05/02/23 Fentanyl
04/20/23 Neuromuscular Blocking Agents for Rapid Sequence Intubation Summary Table
04/14/23 Procedural sedation and analgesia Practice Guidance (RCEM 2020)
04/11/23 Flavoxate for urinary symptoms alleviation
04/05/23 Droperidol update (3 sections and 9 references added)
04/04/23 Ondansetron for nausea and vomiting
03/27/23 Anaphylaxis added to Practice Guidance
03/24/23 Benzodiazepines Summary Table
03/18/23 Cardiogenic Shock added to Practice Guidance
03/17/23 Dobutamine for cardiogenic shock
03/11/23 Post Cardiac Arrest Care added to Practice Guidance
03/09/23 Ketorolac for moderate to severe acute pain
03/07/23
The diagnosis and Management of Agitation (Zeller 2017), added to books of interest
The Resuscitation Crisis Manual (Borshoff - Weingart 2018) added to book books of interest
03/03/23 Antidote Stocking in the ED - Royal College of Emergency Medicine and National Poisons Information Service - Guidelines 2022
03/01/23 Australian Pregnancy Risk Labeling
02/25/23: IM Medications for severe agitation (table)
02/23/23 New section dedicated to Practice Guidance (summaries, algorithms and more)
02/15/23 Lipid emulsion for LAST
02/12/23 Update - Epinephrine for the crashing asmathic
Update - Droperidol vs pregnancy/lactation02/09/23 Lidocaine for infiltrative anesthesia and ventricular arrhythmias
02/02/23 Epinephrine pathophysiology update
01/31/23 Pharmacology open access resources
Basic pharmacology concepts
Drug classification
Orange and Purple Books (U.S. FDA)
01/28/23 Levetiracetam for status epilepticus
01/20/23 Droperidol for agitation and more!
01/15/23 Recommended Resources about drug use during Pregnancy and Lactation
01/13/23 Epinephrine for anaphylaxis and cardiac arrest
01/11/23 Tenecteplase update based on NOR-TEST 2 trial results
01/05/23 Canadian Association of Emergency Medicine (CAEP) Clinical Practice Guidelines added to links of interest
Recommended articles:
2022
12/21/22 Hypertonic saline (3%, 10% and 23.4%) for acute intracranial hypertension and symptomatic severe hyponatremia
12/14/22 Institute for Safe Medication Practices (ISMP) added to links of interest
12/01/22 Articles in EM and Crit Care Pharmacotherapy new section in "Resources"
11/30/22 Tranexamic acid in trauma
11/25/22 "Books of interest" new section in "Resources"
11/10/22 Thiamine for Wernicke-Korsakoff treatment and prevention
11/03/22 Lorazepam update (use in agitation)
10/31/22 Cyclobenzaprine
05/22/22 Rabies Vaccine
04/09/22 Inductors Summary Table
04/09/22 References added to fibrinolytics summary table
2021
11/27/21 Etomidate
11/19/21 Lorazepam
10/01/21 Acetylcysteine for acetaminophen overdose
09/05/21 Olanzapine for the agitated patient
08/15/21 Fibrinolytics Summary Table
08/10/21 Tenecteplase
07/29/21 Alteplase
07/17/21 Phentolamine (for vasopressor extravasation treatment)
06/14/21 Norepinephrine
06/11/21 Tetanus Immune Globulin
04/24/21 EMDrugs go for launch!
Links of interest:
ISMP - Institute for Safe Medication Practices
https://www.ismp.org/WHO - World Health Organization Model List of Essential Medicines 2021
https://www.who.int/(...)US FDA - Approved Drugs Orange Book 2023
https://www.fda.gov/(...)EMA - European Medicines Agency - Medicines Information
https://www.ema.europa.eu/(...)ACEP - American College of Emergency Physicians - Clinical Policies
https://www.acep.org/(...)AAEM - American Academy of Emergency Medicine - Clinical Practice Statements
https://www.aaem.org/(...)CAEP - Canadian Association of Emergency Physicians - Clinical Practice Guidelines
https://caep.ca/(...)EUSEM - European Society for Emergency Medicine - Guidelines for the management of acute pain in emergency situations 2020
https://eusem.org/(...)RCEM - The Royal College of Emergency Medicine - Clinical Guidance
https://www.rcem.ac.uk/(...)ASHP - American Society of Health-System Pharmacists - Guidelines on Emergency Medicine Pharmacist Services
https://www.ashp.org/(...)
® 2023 EMDrugs. All rights reserved.
contact@emdrugs.com
DISCLAIMER
⚠ This website provides general information and discussion about medications, health, and related subjects. The words and other content provided in this website, and in any linked materials, are not intended and should not be construed as medical advice. If the reader or any other person has a medical concern, he or she should consult with an appropriately-licensed physician or other legally accredited health care worker in the country that resides or is visiting.
Please do not delay your medical concerns and potential health emergencies by searching information in this website, instead look out for medical opinion in the services that exist with that specific purpose and work under the respective local health-care regulations.
The views expressed on this blog and website have no relation to those of any academic, hospital, practice or other institution with which the authors are affiliated.
For other instances, the authors of this website do not have any conflict of interest with any institution or pharmaceutical company in particular, and do not receive any compensation about any licenced drug mentioned in the website. In the same matter, the website is not intended to recommend any specific patented medication.
EMDrugs Team