Medications in
Emergency Medicine

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  • 600 mg effervescent tablets and oral capsules (PO).
  • 6 gr/60 ml (100 mg/ml) oral solution (PO).
  • 6 gr/30 ml (200 mg/ml) vials (IV).

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N-Acetylcysteine (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 (also known as paracetamol, or APAP) overdose.
  • US-FDA approved formulations include IV, oral solution, and effervescent tablets.

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

  • Loading dose: 140 mg/kg PO.
  • Dose 2 to 17: repeated doses every 4 hours of 70 mg/kg PO.
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  • 25 gr/120 ml and 50 gr/240 ml suspension (PO).
  • 10 gr, 28 gr (1 Oz) and other presentations of powder for dilution (PO).

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Activated charcoal (AC) is a nonspecific adsorbent extensively used in EDs to reduce the absorption and prevent the enterohepatic recirculation of various toxic substances and drug overdoses.

  • There is a tendency to use it in a more rational fashion, balancing potential benefits with risks. Ideally, it should be administered within 1 hour of ingestion; however, this limit may vary in cases involving extended-release forms of ingested xenobiotics and other exceptions.

    • AC is indicated for toxic doses of acetaminophen, aspirin, antidepressants, antipsychotics, antiepileptic drugs, calcium channel blockers, beta-blockers, etc.

  • Cautions: evaluate the level of consciousness and airway to prevent aspiration; secure the airway before administration if necessary. Activated charcoal is contraindicated in cases of gastrointestinal obstruction or perforation.

    • Not useful in acids, alkali, alcohols, hydrocarbons, heavy metals, pesticides, etc.

Adult single dose of AC for acute poisoning / drug overdose

  • 1 gr/kg PO.

  • Dilute in water or flavored juice.

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  • 6 mg/2 ml and 12 mg/4 ml vials and pre-filled syringes (for rapid IV bolus).

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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. For unstable PSVT consider electric cardioversion among other interventions.
  • 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.

Learn more about PSVT and dosing details in the full description.

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  • 20%, 50 ml (200 mg/ml, total of 10 gr) vials (IV)
  • 20%, 100 ml (200 mg/ml, total of 100 gr) vials (IV)
  • 5%, 250 ml (50 mg/ml, total of 12.5 gr) vials (IV)
  • 5%, 500 ml (50 mg/ml, total of 25 gr) vials (IV)
  • Other presentations may be available such as 4 and 25%.

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Albumin is the most abundant protein in plasma (50%). It is produced by hepatocytes at a rate of 10-15 gr/day, with normal serum levels of 3.5-5 gr/dL.

  • Function

    • Albumin is the primary component of intravascular oncotic pressure (80%).

    • It also plays a role in the transport of hormones and various molecules, acid-base balance among many other physiological functions.

  • Usage

    • In the ED, albumin has several indications where proven benefits exist, such as decompensated chronic liver disease with spontaneous bacterial peritonitis, hepatorenal syndrome, and large-volume paracentesis.

    • In addition, it is the most commonly used colloid for volume replacement in circulatory failure (both as an adjunct and in refractory shock), with evidence suggesting that its use could be beneficial in certain conditions (sepsis, hypovolemia, major burns).

    • Hypoalbuminemia is associated with increased mortality, especially in critically ill patients. Nonetheless, routine replacement has not shown consistent benefits. Considering its high cost and potential risks, understanding its indications is crucial for appropriate use.

Adult dose for large volume paracentesis in cirrhotic patients

  • 8 gr of albumin every 1 liter of ascitic fluid evacuated, initiating albumin when more than 5 liters have been drained.

Notes:

  • The purpose of albumin is to prevent Post Paracentesis Circulatory Dysfunction (PPCD).
  • Example: when 5 liters have been evacuated, start an infusion of 40 gr of albumin, and add 8 gr for every additional liter drained.

Read the full description for other indications and doses (spontaneous bacterial peritonitis, hepatorenal syndrome, shock).

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  • 5 mg/ml inhalation solution vials (nebulization).
  • 90 and 100 ug/spray, aerosol metered (oral inhalation).

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Albuterol is a short-acting adrenergic β-2 receptor agonist (SABA), which is a fundamental treatment for bronchoconstriction crises typically caused by acute bronchitis, acute asthmatic exacerbations, and acutely decompensated COPD patients.

  • Bronchodilators are indicated for symptomatic patients exhibiting signs and symptoms of airflow obstruction, such as wheezing, rhonchi, and prolonged expiration.

  • For mild to moderate obstructive crises, aerosol-metered vs continuous nebulization show similar efficacy. However, for the severely distressed, continuous nebulization is advised for practical reasons.

  • In the initial 4 hours of acute asthma exacerbation treatment, guidelines and experts do not stipulate a maximum prescribed dosage.

  • Albuterol is also used as adjuvant therapy for moderate to severe hyperkalemia.

  • Cautions: For most cases tachycardia is not a contraindication for using albuterol during a bronchoconstriction crisis, as it is usually well tolerated and self-limited.

    • Caution is advised in severe tachycardia; consider alternatives such as anticholinergic bronchodilators.

    • Avoid albuterol in moderate to severe hypokalemia.

    • Go to ⚠ Cautions for more information.

Adult dose for moderate to severe acute bronchoconstriction

  • Nebulized: 2.5-5 mg every 20 minutes for the first hour.

  • Metered-dose inhaler: 4-8 puffs every 20 minutes, repeated 3 times.

Read the full description for other indications and doses (hyperkalemia management).

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  • 50 and 100 mg lyophilized powder (IV).

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Highlights

  • Alteplase is a fibrin-specific Tissue Plasminogen Activator (tPA; fibrinolytic) that 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 for 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).

  • Go to Fibrinolytics Table

Acute Coronary Syndrome with ST elevation (< 12 hours)

US-FDA approved

Adult dose:
  • > 67 kg: 15 mg bolus + 50 mg over 30 min, then 35 mg over 60 min IV
  • ≤ 67 kg: 15 mg bolus + 0.75 mg/kg over 30 min IV, then 0.5 mg/kg over the next 60 min.
Patient Weight Intravenous Bolus First 30 min Next 60 min
> 67 kg 15 mg 50 mg 35 mg
≤ 67 kg 15 mg 0.75 mg/kg 0.50 mg/kg

Acute Ischemic Stroke (< 4.5 hours)

US-FDA approved for use within <3 hours after symptom onset; universally accepted for use within <4.5 hours.

Adult dose:

  • < 100 kg: 0.9 mg/kg total (max 90 mg).

    • 10% bolus over 1 min.
    • 90% infused over 60 min.

  • ≥ 100 kg: 9 mg bolus + 81 mg infused over 60 min.

Pulmonary Embolism

US-FDA approved.

Adult dose:

  • Intermediate risk: 50 mg infused over 2 hrs.

  • High risk: 100 mg infused over 2 hrs.

  • Cardiac arrest: 50 mg bolus.

    • If no ROSC within 15 minutes, administer an additional 50 mg.
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  • 150 mg/3 ml, 450 mg/9 ml and 900 mg/18 ml vials (IV).
  • 100, 200 and 400 mg tablets (PO).

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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.

  • During acute use, it primarily blocks Na+ and Ca2+ channels, and exhibits beta-blockade effects. Its influence on K+ channels is primarily attributed to its metabolite, desethylamiodarone.

  • 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)
    • Monomorphic and polymorphic 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.

Read the full description for other indications and doses (stable ventricular tachycardia, rate control of atrial fibrillation/flutter).

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  • 75, 81, 100, 325 and 500 mg tablets (PO).

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Acetylsalicylic acid (ASA), also known as aspirin, is an NSAID with analgesic and anti-inflammatory effects that inhibit platelet aggregation. It is frequently prescribed in EDs worldwide as part of the standard treatment for acute coronary syndromes, ischemic stroke, and transient ischemic attack.

  • To date, ASA is not commonly utilized as an analgesic or anti-inflammatory agent. Other NSAID alternatives, such as ibuprofen, exhibit significantly lower effects on platelet anti-aggregation and pose a lower risk of bleeding. An exception is observed in patients with coronary artery disease experiencing acute pericarditis.

  • ⚠ Cautions:

    • Increased risk of bleeding, kidney injury and peptic ulcer disease.
    • Adverse effects usually manifest at analgesic doses (300-600 mg every 4-6 hours), and rarely at lower antiaggregatory doses (≈100 mg/day).

Adult dose for acute coronary syndromes

  • Loading dose: 162 to 325 mg PO.

  • Maintenance dose (beginning on the next day): 75 to 100 mg/day PO.

Read the full description for other indications and doses ( acute ischemic stroke, transient ischemic attack, acute pericarditis)

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  • 0.4 mg/ml (1 ml) and 1 mg/ml (1 ml) vials (IV)
  • 1 mg/10 ml prefilled syringe (IV)
  • 1 mg/0.7 ml and 2 mg/0.7 ml autoinjector (IM)

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Atropine is a competitive antagonist of peripheral and central muscarinic receptors, with no effect on nicotinic receptors. In emergency medicine, it is commonly indicated for the initial management of symptomatic bradyarrhythmias and to counteract cholinergic symptoms such as respiratory secretions and bronchospasm in the case of muscarinic toxicity (cholinergic toxidrome).

  • Cautions:

    • Consider critical and reversible bradycardia differentials, especially in the unstable patient (hypoxemia, electrolyte disturbances, ischemia).

    • There are no absolute contraindications to atropine. Relative contraindications are COPD or asthma, acute glaucoma, coronary heart disease, obstructive uropathy, bowel obstruction and myasthenia gravis. Use with caution.

Adult dose for the treatment of symptomatic sinus bradycardia or AV block

  • 0.5-1 mg IV, repeated every 3-5 min to a maximum of 3 mg.
  • Caution: less than 0.5 mg in adults is NOT recommended as it may cause paradoxical bradycardia.

Read the full description for other indications and doses (cholinergic syndrome).

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  • 1000 mg/10 ml ampoules (IV).

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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.

  • Also consider administering IV calcium to patients with hemorrhagic shock who are subject to a massive transfusion protocol.

  • It contains roughly one-third the concentration of calcium ions compared to calcium chloride at equivalent concentrations.

  • 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).

Adult dose in hemorrhagic shock / massive transfusion protocol

  • 3 gr IV every 4 units of citrated blood products.
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  • 5, 7.5 and 10 mg immediate release tablets (PO)
  • 10, 15 and 30 mg extended release tablets (PO)

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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. In an analysis of a large number of cyclobenzaprine overdoses, there were no reports of widened QRS, ventricular arrhythmias, or seizures.

Adult dose for acute painful musculoskeletal spasms

Immediate release formulation
  • 5 mg TID with one dose at night.
  • Maximum 30 mg/day, up to 2-3 weeks.

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

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  • 4 mg/ml, 8 mg/ml and 10 mg/ml vials (IV, IM).
  • 0.5, 0.75, 1, 1.5, 2, 4, 6 mg tablets (PO).

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Dexamethasone is a long-acting glucocorticoid with significant anti-inflammatory effects, sharing similar properties to betamethasone. It has been thoroughly studied for numerous emergent and non-emergent conditions and is likely one of the most extensively prescribed corticosteroids in the emergency department.

  • Common ED Indications: Acute obstructive airway conditions, including asthma exacerbation and croup; allergic reactions; acute bacterial meningitis; cerebral edema; migraine headache; severe pneumonia; septic shock; acute pharyngitis; and others.

  • Cautions: Most adverse effects are associated with prolonged exposure to glucocorticoids and are typically not a major concern in emergency medicine, where they are usually prescribed for short durations, often less than a week.

    • Use <7 days: hyperglycemia, hypertension, cardiovascular decompensations (e.g. acute heart failure in patients with pre-existing cardiac conditions), insomnia. Transient perineal irritation.
    • Use <30 days: Increased rates of sepsis, venous thromboembolism, and fractures. HPA-axis suppression.
    • Use >30 days: Osteoporosis and fractures, HPA-axis suppression, cushingoid appearance, weight gain, hyperglycemia/diabetes, cardiovascular disease and dyslipidemia, myopathy, cataracts and glaucoma, psychiatric disturbances, immunosuppression, fungal and other opportunistic infections, and various gastrointestinal and dermatologic events.

Adult dose for acute pharyngitis, tonsillitis

  • 10 mg PO or IM, single dose.
    • Dose may be repeated once the next day.

Adult dose for acute bacterial meningitis

  • 10 mg every 6 hours IV for 4 days.
    • Timing: For maximum benefit, dexamethasone should be administered early—either minutes before or immediately after antibiotics.
    • Expert consensus suggests that dexamethasone treatment can still be initiated up to 4-12 hours after starting antibiotic therapy.
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  • 400 μg/100 ml, 1,000 μg/250 ml, 200 μg/50 ml, and 200 μg/2 ml vials (IV)

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Dexmedetomidine (DEX) is a selective and potent alpha-2 adrenergic agonist with a dose-dependent sedative effect.

  • Its use has increased over the past decade in critical care settings and is gaining popularity in the emergency department for indications such as procedural sedation and analgesia (PSA), psychomotor agitation, and facilitating compliance with non-invasive ventilation (NIV).

  • DEX has sedative, anxiolytic, and analgesic effects

  • Its unique property is that it induces so-called "arousable" or "cooperative" sedation with minimal respiratory depression.

  • Cautions:

    • Adverse effects: hypotension, bradycardia, respiratory depression.
    • Evidence for ED use is limited, requiring more data to establish solid recommendations.. Expertise and familiarity with DEX properties are crucial for safe use.

Adult dose for procedural sedation

  • 0.2 to 0.7 μg/kg/hr, IV continuous infusion.

    • A bolus of 0.5 to 1 μg/kg over 10 minutes may be administered prior to continuous infusion.
    • Titrate dose as needed.
    • Monitor cardiovascular and respiratory parameters closely.
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  • 250 mg/20 ml vials (IV).

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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 . 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 (𝛽-1 and 𝛽-2), 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 μg/kg/min
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  • 5 mg/2 ml ampoules (IV, IM).

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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.

    • Droperidol or olanzapine are considered first-line medications to treat acute severe agitation in psychiatric patients, and both can be used in combination with benzodiazepines.

  • Its use differs amongst geographical locations, clinicians and ED protocols. Some EDs do indicate it on a daily basis, others do not; this phenomena is explained to a great degree because of the US-FDA Black Box Warning issued in 2001 . This warning has been deeply questioned , this is why droperidol 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

  • 5-10 mg IM

Read the full description for other indications and doses (migraine, acute vertigo, nausea/vomiting, cannabinoid hyperemesis).

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

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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.
    • To this date, it is the only established therapy to treat this condition with proven efficacy.

  • Cardiac arrest

    • Current guidelines include epinephrine as part of standard treatment during cardiac arrest 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.
    • Benefits of epinephrine predominate in an early administration (<10 minutes) of non-shockable cardiac arrest.
    • *ROSC: Return of Spontaneous Circulation

  • Severe asthma crisis

    • Consider IV or IM epinephrine in the crashing asthmatic patient to deliver a systemic 𝛽-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.

Adult dose for anaphylaxis

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

    • Can be repeated every 5-15 min if necessary.
    • If no response, consider a continuous IV infusion of epinephrine.

Adult dose for cardiac arrest

  • 1 mg every 3 to 5 minutes IV or IO.
    • In shockable rhythms early defibrillation should be perform as soon as possible, before any other resuscitation interventions (with the exception of chest compressions while preparing defibrillation).
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  • Racepinephrine 2.25%, 0.5 ml vials (11.5 mg/0.5 ml)(nebulization).

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  • 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.

    • Epinephrine (L isomer) is a powerful non-selective agonist of α and β adrenergic receptors, with prominent activity on cardiac and vascular muscle.

    • Racepinephrine is less active than pure L-epinephrine and is labeled to be administered via nebulization, whereas standard epinephrine is not. 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.
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  • 20 mg/10 ml ampoules (IV).

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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 (RSI).

  • Etomidate acts on GABA receptors moderating the activity of chloride channels; it makes neurons less excitable without any major cardiovascular impact. This feature suits etomidate for the great majority of emergency scenarios in which advanced airway management is required.

  • Its use in sepsis has been challenged because of the dose-dependent adrenal inhibition of corticosteroid synthesis, therefore only a single bolus dose is recommended for induction –not as a continuous infusion– but to minimize adrenal suppression.

  • Myoclonic movements are a common adverse effect; they are observed for 1 to 3 minutes and cease spontaneously. In practice, the movements usually stop shortly after neuromuscular blockage and lack any clinical significance.

Pharmacology for a single bolus administration:
Onset 15-45 sec
Time to Peak Effect 45 sec
Duration of hypnotic effect 3-12 min
Half life 2-5 hrs

Adult dose for rapid sequence intubation

  • 0.3 mg/kg IV (total body weight).
    • Consider a lower dose of 0.2 mg/kg in profound shock.
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  • 0.1 mg/2 ml and 0.5 mg/10 ml vials (IV, IM).
  • 0.1, 0.2 mg (oral transmucosal)
  • 0.05, 0.1 and 0.2 mg/dose (nasal spray)
  • 0.1, 0.2, 0.3, 0.4 mg tablets (sublingual)

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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. It is primarily administered intravenously (IV).

  • 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.

  • Other frequent indications include fentanyl as the analgesic component for analgosedation during painful procedures and mechanical ventilation.

  • 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. Providers should also be aware that alterations in respiratory rate and ventilation may last longer than the analgesic effects.

    • High risk of addiction and overdose (black box warning; 21): 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 μg/kg/dose (usually 50-100 μg) 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).
    • IV Time to peak effect: 5 min.
    • Duration of analgesia: 30-60 min.
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  • 100 and 200 mg tablets (PO).

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Flavoxate is a synthetic muscarinic antagonist (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.

  • While there is solid evidence regarding alleviating urgency for overactive bladder, and has a better safety profile than other antispasmodics, there is limited reassuring evidence to support its usage in genitourinary infections.

Adult dose for symptomatic relief of urinary urgency, suprapubic pain secondary to urinary tract infections (UTIs)

  • 100-200 mg every 6 to 8 hours PO
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  • 0.5 mg/5 ml, and 1 mg/10 ml vials (IV)

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Flumazenil is a competitive benzodiazepine (BDZ) receptor antagonist with a short half-life.

  • The ideal setting for its use involves BDZ-naive patients who have overdosed solely on a confirmed BDZ or those undergoing procedural sedation without BDZ dependence.

  • Monitor patients for hypoxia and hypoventilation. Flumazenil does not reliably reverse respiratory depression, and there is a risk of inadvertent re-sedation.

  • ⚠ Cautions:

    • Seizures and arrhythmias may occur in patients with co-ingestion of pro-convulsant agents or benzodiazepine dependence.
    • Contraindications: known hypersensitivity to flumazenil or BDZ, patients under BDZ for control of potential life-threatening conditions, evidence of TCA toxicity. Avoid use in epileptic patients or recent seizures.

Adult dose for reversing benzodiazepine effects

  • 0.1-0.5 mg IV every 1 min until awake.
  • Notes
    • Slow administration (0.1 mg/min) is associated with less adverse effects.
    • Titrate dose as needed.
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  • 25.000 IU/ml multidose vials (IV, subcutaneous).

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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, ease of administration, and monitoring advantages.

  • Preference of UFH over LMWH:

    • High-risk pulmonary embolism.

    • Myocardial infarction with ST segment elevation.

    • Severely impaired renal function (creatinine clearance <30 ml/min).

  • Caution: High-alert medication . Always evaluate the hemorrhagic risk before initiating anticoagulant therapy.

Adult dose for pulmonary embolism

  • 80 U/kg bolus IV followed by a 18 U/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-elevation myocardial infarction

Primary PCI (percutaneous coronary intervention)

  • 60-70 U/kg bolus IV (max 5000 U).

  • Notes

    • Routine post-procedural anticoagulant therapy is not indicated after primary PCI, unless there is a separate indication for its use.
    • Dose based on the 2023 ESC guidelines. The 2025 AHA guidelines show a slight difference (see Adult Dose section).

Fibrinolysis

The 2023 ESC and 2025 AHA guidelines recommend anticoagulation with enoxaparin over UFH to patients eligible to fibrinolytic therapy. If UFH is selected:

  • 60 U/kg bolus IV (max 4000 U) followed by 12 U/kg/hr infusion (max 1000 U/hr).

  • Continue anticoagulation until PCI has been performed.

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  • 3%, 10% and 23.4%, 100 ml ampoules (IV).

Executive Summary

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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.

  • Other causes of cerebral edema that leads to acute IH when HTS usage can be considered includes subarachnoid hemorrhage, hemorrhagic and ischemic stroke and hepatic encephalopathy.

  • 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 over 15 minutes
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  • 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

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Ibuprofen is the most extensively studied NSAIDs for the treatment of acute pain and is prescribed worldwide in EDs for both pediatric 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:

    • Usual 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 to 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.

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  • 500 mg/10 ml, 1000 mg/10 ml, and 200 mg/20 ml vials (IV).

Executive Summary

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Ketamine, a dissociative and analgesic agent, has seen a notable surge in its usage within the ED over the past decade. It is employed as an induction agent for endotracheal intubation, procedural analgosedation, management of agitation, and acute pain relief.

  • Ketamine may be considered as an alternative to etomidate as an induction agent for hemodynamically unstable patients, but it is associated with a higher incidence of peri-intubation hypotension compared to etomidate.

  • Low-dose ketamine (0.2-0.5 mg/kg IV) has been found to be equally effective as morphine in the management of acute pain within the ED, demonstrating comparable safety profiles.

  • A thorough understanding of ketamine's pharmacological properties and potential adverse effects is essential for its appropriate usage. Continuous monitoring is imperative during its administration.

  • Cautions: respiratory depression, neuropsychiatric symptoms, hypertension and tachycardia, hypotension, laryngospasm, and potential dependence with prolonged use.

Adult dose for endotracheal intubation induction

  • 1.5-2 mg/kg IV.

Adult dose for procedural sedation and analgesia

  • 0.3-1 mg/kg IV.
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  • 30 mg/ml vials, (IV, IM).
  • 10 mg and 30 mg tablets (PO, sublingual).
  • 0.5% drops (ophthalmic), 15.75 mg/spray (intranasal).

Executive Summary

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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.

  • There are many formulations available, including oral, sublingual, intravenous, intramuscular, intranasal and ophthalmic.

  • 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 reduces opioid requirements , and it may have a similar potency than meperidine and morphine in certain doses, sparing the opioids adverse effects. .

  • CMax: 40-45 min. Time to peak effect: 1 to 2 hours.

Adult dose for acute moderate to severe pain

  • IV: 10 to 30 mg every 6 hours IV (max 120 mg/day)*

  • PO: 10 mg every 6 hours PO (max 40 mg/day)

  • Nasal spray: 31.5 mg SPRIX (one 15.75 mg spray in each nostril) every 6 to 8 hours (max 126 mg/day –four doses–).

Dosing considerations:

  • For adults ≥65 years: 10-15 mg every 6 hours (max 60 mg/day).

  • Ketorolac can be administered as a bolus injection.

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  • 500 mg/5 ml vial (IV).
  • 500 mg tablets (PO) and 100 mg/ml oral solution (PO).

Executive Summary

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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 the evidence regarding the usage of LEV for seizure prophylaxis in subarachnoid hemorrhage.

Adult dose for status epilepticus

  • Loading dose of 60 mg/kg IV (max 4.500mg) in 15 min.

  • Maintenance dose of 1 gr every 12 hrs IV or PO (up to a maximum of 3 gr/day)

Read the full description for other indications and doses (seizure prophylaxis in severe traumatic brain injury).

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  • 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

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  • 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

  • A recent double-blinded, randomized controlled trial discouraged use of IV lidocaine for renal colic as it did not show better outcomes than IV ketorolac.

Adult dose for local anesthesia

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

  • Dosing calculator: MDCalc® - Local Anesthetic Dosing Calculator

Adult dose for ventricular tachycardia

  • 1-1.5 mg/kg IV.
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  • Lipid emulsion 20%, 100 ml vials and 500 ml bags (IV).

Executive Summary

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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):

  • It has had favorable results in animal studies –mostly with bupivacaine–.

  • Multiple case reports have shown promising results in treating LAST caused by lidocaine. There have been 147 case reports published until 2016, many more have been published to this date, the majority with good outcomes.

  • 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).

  • Emergency physicians, toxicologists and anesthesiologists recommend that IVLE should be stocked in emergency departments in close proximity to resuscitation rooms and areas where local nerve blocks are performed.

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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  • 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

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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 2-4 mg dose

Intravenous
Onset (IV) 5-10 min (shorter to terminate seizures)
Peak Effect (IV) 30 min
Duration (IV) 2-6 hrs

Intramuscular
Onset (IM) 15 min
Peak Effect (IM) 60 min
Duration (IM) 6-8 hrs

Adult dose for seizures / status epilepticus

  • 0.1 mg/kg IV (max 4 mg/dose).

  • Repeat every 5-10 min until the crisis has ceased.

  • Consider initiating an antiepileptic drug if a second lorazepam dose is required.

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  • 50%, 25%, 15%, 8%, and 4% ampoules, vials or bags (IV, IM).
  • Note: MgSO4 has a wide variety of formulations. It is critically important to be familiar with the formulation available.

Common formulations:

  • MgSO4 50%, 2 and 10 ml vials (0.5 gr/2 ml, and 5 gr/10 ml)(IV, IM).
  • MgSO4 25%, 5 ml vials (1.25 gr/5 ml)(IV, IM).
  • MgSO4 15%, 500 ml bags (20 gr/500 ml)(IV, IM).

Executive Summary

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Magnesium sulfate (MgSO4) is an essential inorganic salt used for a variety of conditions in the ED.

  • Its most proven efficacy and benefit are observed in the treatment of hypertensive emergencies during pregnancy. Included on the World Health Organization’s list of essential medicines.

  • Established drug for the management of Torsades de Pointes (subtype of polymorphic ventricular tachycardia).

  • Adjuvant treatment in selected cases of acute exacerbated asthma and COPD, acute rate control of atrial fibrillation, and migraine. Caution is advised for those indications.

  • Cautions

    • Increased risk of hypotension in rapid administration.
    • Continuous infusion, particularly in pregnant patients, requires vigilant oversight for potential hypermagnesemia toxicity and fetal distress. Crucial aspects include fetal monitoring and recognizing maternal signs such as hypotension, loss of deep tendon reflexes, altered mental status, and respiratory depression. This vigilance is essential to ensure the safe use of MgSO4 in the ED.
    • Despite the association of prolonged use with newborn bone abnormalities, short-term infusions for pregnancy hypertension emergencies are deemed safe and constitute a standard of care. Emergency clinicians should be familiar with treatment initiation, and immediate OB/GYN consultation is crucial for management guidance.

Dose for seizure prevention and control in severe preeclampsia and eclampsia (hypertensive emergencies of pregnancy)

  • 4-6 gr IV over 20-30 min, followed by an infusion of 1-2 gr/hr.

    • Eclampsia: if seizures recur during the infusion administration, an additional 2-4 gr may be administered IV over 5 min.

    • Consider labetalol or other antihypertensive agents for severe hypertension despite MgSO4 treatment.

    • OB/GYN consultation is needed for management guidance.

Read the full description for other indications and doses (Torsades de Pointes, severe bronchoconstriction, atrial fibrillation rate control).

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  • 0.4 mg/1 ml vials (IV, IM, subcutaneous).
  • 2 and 4 mg/spray (intranasal spray).

Executive Summary

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Naloxone is an opioid receptor antagonist extensively used in prehospital settings and EDs to reverse respiratory depression and coma in opioid-intoxicated patients.

  • An intranasal spray formulation is also available for domestic and bystander administration, aimed at reducing preventable deaths associated with the ongoing public health issue of opioid abuse.

  • Cautions: a "standard dose" may induce severe withdrawal symptoms in opioid-dependent patients, especially during IV administration. A lower dosing approach is recommended if opioid-dependence is suspected.

  • In the ED, it is crucial to prioritize the effective evaluation, assessment, and treatment of patients with coma and/or respiratory depression. Critical, time-dependent differentials include shock states, neurological disorders, toxic-metabolic conditions, and more. Proficiency in airway management is indispensable.

Adult dose for opioid overdose

Non-opioid-dependent patients

  • 0.4 mg IV every 2 to 3 minutes until adequate spontaneous ventilation is achieved, up to a maximum of 10 mg.

  • If the patient requires more than one dose or is at risk of further episodes of respiratory depression, a continuous infusion should be considered, or repeat doses every 1 to 2 hours.

Opioid-dependent patients

  • 0.04 mg IV every 3 to 5 minutes until adequate spontaneous ventilation is achieved, up to a maximum of 2mg.

  • A significantly lower dose of naloxone should be considered to reverse hypoventilation and avoid withdrawal syndrome.

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  • 50 mg/250 ml of 5% dextrose solution, 200 μg/ml (IV).
  • 50 mg/10 ml vials (IV).
  • 0.4 mg tablets and spray (sublingual).

Executive Summary

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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 syndrome.

  • 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).
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  • 4 mg/4 ml ampoules (IV).

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Norepinephrine (NE) is an endogenous catecholamine that plays a prominent role in the management of circulatory failure in the emergency department and critically ill patients.

  • It is extensively used for hemodynamic support, frequently as a first-line vasopressor, with the exception of anaphylaxis, were epinephrine is preferred).
  • Norepinephrine is widely accepted as the first-line vasopressor for septic shock.
  • Consider using norepinephrine in combination with inodilator agents in cases of cardiogenic shock.

Adult dose for shock

  • 0.01-0.3 ug/kg/min IV
    • Usually started at 0.05 ug/kg/min IV
    • Calculate with total body weight
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  • 5 mg and 10 mg tablets (sublingual).
  • 10 mg lyophilized powder (IM).

Executive Summary

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Olanzapine is a second generation (atypical) antipsychotic with a potent antagonism of serotonin 5-HT2A, 5-HT2C, dopamine D1-4, histamine H1 and alpha1-adrenergic receptors. It also has a moderate antagonism of muscarinic M1-5 receptors, as well as a weak agonism to GABA-A, BZD and beta-adrenergic receptors.

  • In the ED, olanzapine is frequently indicated as a first-line antipsychotic for acute agitation associated with psychiatric disorders (US FDA and EMA approved for agitation in individuals with schizophrenia and bipolar disorder).

  • Agitation in the ED is a very complex situation that includes a variety of dissimilar scenarios with a wide range of therapeutic options.

  • Many clinical guidelines have been proposed with substantial differences between them; as emergency physicians, it is of great importance to be familiarized with the available therapeutic arsenal for agitation, such as haloperidol, droperidol, benzodiazepines, propofol, ketamine, etc.

Adult dose for severe agitation

  • 5 to 10 mg IM, repeated every 20 min if necessary
    • Maximum of 30 mg/day for intramuscular administration.
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  • 40 mg lyophilized vial (IV).

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

Executive Summary

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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, including gastrointestinal bleeding, gastroesophageal reflux disease, dyspepsia, etc. Nevertheless, 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.

  • PPIs are frequently initiated in the ED as prophylaxis for stress peptic ulcer disease in critically ill patients with favorable outcomes.

  • The acute management of upper gastrointestinal bleeding in the ED typically involves the empiric administration of an IV PPI bolus (such as omeprazole) followed by continuous infusion or intermittent boluses. 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

Intermittent dosing

  • 80 mg IV, followed by 40 mg every 6 hours IV.
  • Therapy is usually started empirically in upper GI bleeding before endoscopic visualization.
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  • 4 mg/2 ml and 8 mg/4 ml ampoules (IV, IM).
  • 4 mg and 8 mg tablets (PO, oral disintegrating tablets).

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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.

  • Usually ondansetron is considered a first-line antiemetic for most patients in the ED.

  • Disintegrating tablets offer a practical advantage over other antiemetic formulations because they are easier to administer.
  • 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 8 mg PO or IV.
    • Repeat every 4-8 hours if necessary.
    • A maximum cumulative daily dose of 24 mg may be a conservative approach for ensuring safety.
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  • 10 mg/1 ml vials (subcutaneous).
  • 5 mg lyophilized powder (subcutaneous).

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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).
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  • 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).

Executive Summary

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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. It may be considered a first-line induction agent for status epilepticus.

  • Propofol has no analgesic effects, and its amnestic effects are variable.

Cautions summary

  • Circulatory 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.

  • CNS and respiratory depression: 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 is formulated in an oil-in-water emulsion that can potentially lead to Propofol-Related Infusion Syndrome (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)

  • 1.5 mg/kg IV bolus.

    • Other induction agents, such as etomidate or ketamine, may be more appropriate for hemodynamically unstable and elderly patients. If propofol is selected, consider administering a reduced dose of 0.5-1 mg/kg.
    • Onset of action: 15-45 sec.
    • Duration of effect: 5-10 min.
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  • 50 mg/5ml and 250 mg/25 ml vials (IV)

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Protamine is a rapidly acting antidote that forms complexes with unfractionated heparin (UFH), effectively reversing its anticoagulant effects. It also provides partial reversal of low molecular weight heparins (LMWHs).

  • Recommended for patients experiencing hemorrhagic emergencies with active bleeding in the context of heparin treatment or overdose.

  • Not recommended in patients with abnormal coagulation parameters without active bleeding. Exceptions may apply in anticipation of high-risk procedures or surgeries.

  • ⚠ Cautions:

    • Close monitoring is essential. Severe reactions have been reported, including hypotension, bradycardia, ARDS, pulmonary hypertension, and cardiovascular collapse.
    • In patients with an ongoing indication for anticoagulation, the decision to reverse heparin should be carefully individualized, weighing the risk of thrombosis against the urgency of bleeding control.

Adult dose for reversal of heparin anticoagulation

Unfractionated heparin reversal

  • 1 mg for every 100 IU of UFH administered in the last 90 minutes.
    • Maximum dose of 50 mg.
  • ⚠ Infuse slowly over 10 to 15 min to avoid rate-related adverse effects.
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  • 300 UI/1 ml, 900 UI/3 ml and 1500 UI/5 ml vials (IM).

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Rabies immune globulin (RIG) consists of virus-neutralizing antibodies against the rabies virus, indicated for use alongside the rabies vaccine as post-exposure prophylaxis (PEP) in select cases. It provides passive immunity until endogenous antibody production begins.

  • Highly effective in reducing mortality from confirmed exposures.

  • Unnecessary if the exposed individual has received prior rabies vaccination.

  • Must be administered as soon as possible within 7 days of the first rabies vaccine dose.
  • ⚠ Cautions
    • RIG is generally considered safe. Severe adverse effects, such as anaphylaxis, are rare, while adverse reactions are usually mild and self-limited.
    • Overdosage may lead to partial suppression of antibody production; do not exceed the recommended dose.
    • RIG may carry a risk of transmitting infectious agents; however, this risk is minimized through stringent production standards.

Adult dose for post-exposure prophylaxis (PEP)

  • 20 IU/kg, single dose infiltration and/or IM injection (human-derived RIG).

    • Infiltrate the full dose of RIG thoroughly in the area around and into the wound(s), if anatomically feasible.
    • Inject the remainder, if any, intramuscularly at an anatomical site distant from the site of rabies vaccine administration (different muscle group). Preferably thigh or deltoid.

Notes:

  • If using equine-derived RIG, administer a single dose of 40 IU/kg (instead of 20 IU/kg for human-derived RIG), following the same principles as for human RIG

  • Avoid infiltration of the gluteal muscles due to risk of sciatic nerve damage

  • Do not exceed the recommended dose of RIG, otherwise the active production of rabies antibodies may be particularly suppressed.

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  • Single-dose 1 ml and 0.5 ml vials, both equivalent to 1 vaccination dose (IM).

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Rabies is a zoonotic disease caused by the rabies virus (RABV). It is one of the most lethal viral infections, with a mortality rate of nearly 100%.

  • The rabies vaccine is remarkable, as its effectiveness approaches nearly 100% in preventing death after viral exposure. The high survival rate can also be attributed to the use of rabies immunoglobulin (RIG) in selected cases.

  • >99% of global human deaths are attributed to exposure to infected dogs. Vaccination of pets and wildlife is an effective measure to reduce outbreaks.

  • Knowledge of local epidemiological trends, animal bite protocols, and current rabies vaccination guidelines is crucial for appropriate rabies prevention.

Adult and pediatric vaccination for Post-Exposure Prophylaxis (PEP)

Modified Essen Regimen

  • 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 28

  • Prior rabies immunization

    • 2 doses IM, days 0 and 3

Read the full description for more detailed information.

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  • 50 mg/5 ml vials (IV).

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Neuromuscular blockade is an essential component of rapid sequence intubation. 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.

  • While rocuronium is a valid alternative for continuous neuromuscular blockade in critically ill patients with early ARDS (Acute Respiratory Distress Syndrome) and severe asthma, it should be used with caution in carefully selected cases.

  • 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.

  • Caution: The only contraindication is a prior anaphylactic reaction to rocuronium.

Adult dose for rapid sequence intubation

  • 1.5 mg/kg IV
    • Time to intubation level paralysis: 60 sec
    • Duration of paralysis: 40-60 min
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  • 100 mg/5 ml and 200 mg/10 ml vials

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Succinylcholine (or suxamethonium) is a depolarizing neuromuscular blocking agent. Its effect is exerted through non-competitive agonism at nicotinic and muscarinic receptors, with its most relevant action occurring at the neuromuscular junction.

  • Its clinical relevance lies in its rapid onset of action, profound blockade, and short duration of effect, making it a good alternative for rapid sequence intubation in prehospital, emergency department, and critical care settings.

  • Doses higher than those specified by the manufacturer are commonly used for rapid sequence intubation (RSI) to ensure complete paralysis and improve intubation conditions.

  • ⚠ Absolute contraindications

    • Personal or family history of malignant hyperthermia.
    • More than 72 hours after major injuries such as significant burns or crush injuries, and other conditions leading to immobility.
    • Myopathies (e.g., muscular dystrophy).
    • Moderate to severe preexisting hyperkalemia.

Adult dose for rapid sequence intubation

  • 1.5 mg/kg IV bolus.
    • Calculate using total body weight (TBW)
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  • 25 and 50 mg lyophilized powder (IV).

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Tenecteplase (TNK) is a modified form of the Tissue Plasminogen Activator alteplase, with enhanced fibrin affinity, diminished fibrinogenolysis (greater fibrin-specificity) and Plasminogen Activator Inhibitor-1 (PAI-1) resistance. These properties prolong its half-life permitting administration as a single bolus which is remarkably useful in emergency medicine.

  • Myocardial infarction: fibrinolytic of preference for acute myocardial infarction with ST segment elevation within 12 hours of symptoms (preferably <4 hours) if time to percutaneous coronary intervention will exceed 120 minutes.

  • Acute ischemic stroke: Recently approved by the US-FDA. Guidelines and experts support its use as an alternative to alteplase

  • ⚠ Cautions:

    • Fibrinolysis is a critical and high risk treatment that should not be taken lightly. This intervention must be decided -or at least supported- by a specialist (eg. emergency medicine, neurologist, cardiologist, intensivist).
    • Evaluate for individual risk of hemorrhage. Rule out relative and absolute contraindications with checklists (see contraindications).

  • Learn more about fibrinolysis in Fibrinolytics Table and Alteplase.

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

Indicated when anticipated STEMI diagnosis to Percutaneous Coronary Intervention-mediated reperfusion time is >120 min and onset of MI is <12 hrs

Intravenous, bolus
<60 kg 30 mg
60 to <70 kg 35 mg
70 to <80 kg 40 mg
80 to <90 kg 45 mg
≥90 kg 50 mg (max dose)

Note: reduce dose to half in patients ≥75 years of age

Adult dose for Acute Ischemic Stroke

Intravenous, bolus
Less than 60 kg 15 mg
60 kg to less than 70 kg 17.5 mg
70 kg to less than 80 kg 20 mg
80 kg to less than 90 kg 22.5 mg
90 kg or more 25 mg

For both eligible or ineligible patients to undergo mechanical thrombectomy, dosing over 0.25 mg/kg is not recommended

Adult dose for Pulmonary Embolism (PE)

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

Intravenous, bolus
<60 kg 30 mg
60 to <70 kg 35 mg
70 to <80 kg 40 mg
80 to <90 kg 45 mg
≥90 kg 50 mg (max dose)
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  • 1 mg/5 ml and 1 mg/10 ml vials (IV)
  • Note: clinicians are mostly familiar with doses of terlipressin acetate. 1 mg of terlipressin acetate is equivalent to 0.85 mg of terlipressin. Companies may manufacture vials of terlipressin 0.85 mg instead of terlipressin acetate 1 mg.

Executive Summary

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Terlipressin is a synthetic vasopressin receptor agonist that reduces portal pressure and has known benefits for treating certain complications of chronic liver disease.

  • It has been used for decades in Europe and Latin America for the treatment of:

    • Upper gastrointestinal bleeding of variceal origin to improve survival and bleeding control.
    • Hepatorenal syndrome (HRS) to improve kidney function.

  • In 2022, the US-FDA approved its use for HRS, positioning terlipressin as the first US-FDA-approved agent indicated to improve kidney function in adults with HRS.

  • Cautions

    • As a vasopressor, it is associated with ischemic and cardiovascular events. Use with caution.
    • Black box warning: terlipressin may cause serious or fatal respiratory failure. Patients with volume overload or with acute-on-chronic liver failure (ACLF) grade 3 are at increased risk.

Adult dose for upper gastrointestinal bleeding (confirmed or suspected variceal origin)

  • 2 mg every 4 hours IV during the first 48 hours, followed by 1 mg every 4 hours for a total of 3 to 5 days.

Note: at EMDrugs, we refer to the "terlipressin" dose in reference to "terlipressin acetate."

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  • 250 units/1 ml prefilled syringes (IM).

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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

  • 500 units IM with part of the dose infiltrated close to the source wound.

  • Up to 6000 units can be used.

Adult dose for tetanus prophylaxis
  • 250 units IM (single dose ).
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  • 30 mg/ml and 200 mg/2 ml vials (IV, IM).
  • 10, 50, 100 and 250 mg tablets (PO).

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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 treatment

  • 500 mg IV every 8 hours for 3-5 days, then 250 mg IV daily for 3-5 days, then indefinitely PO supplementation
  • Consider magnesium supplementation (2 gr MgSO4 daily)
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  • 1000 mg/10 ml ampoules (IV).

Executive Summary

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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.

  • Later on TXA was studied in acute traumatic brain injury (TBI). It was found to have a limited potential benefit in reducing head injury associated deaths in mild to moderate TBI. Nonetheless TXA was recently indicated and included for TBI in combat medical guidelines .

Adult dose for trauma with risk of significant hemorrhage

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