Medications in Emergency Medicine

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Latest content: 03/22/24 Fibrinolytics Summary Table New Edition and Update with more references

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. 


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Activated charcoal

- 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)

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


Adult single dose of AC for acute poisoning / drug overdose


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Albuterol (salbutamol) #full_description_published

- 5 mg/ml inhalation solution vials (nebulization).

- 90 and 100 ug/spray, aerosol metered (oral inhalation).

Executive Summary

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.


Adult dose for moderate to severe acute bronchoconstriction


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Aspirin

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

Executive Summary
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 and other acute vascular conditions.


Adult dose for acute coronary syndromes


Adult dose for acute ischemic stroke, transient ischemic attack
Delay antiplatelet therapy for at least 24 hours in patients who have undergone IV fibrinolysis (alteplase or tenecteplase) and have had a control CT scan to rule out hemorrhagic conversion. Standard of care should involve consulting a vascular neurologist to guide treatment.

When hemorrhagic stroke has been ruled out in patients not eligible for fibrinolytic therapy, initiate aspirin therapy as soon as possible.


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Atropine  #new_summary
- 0.4 mg/ml and 1 mg/ml vials (IV)

- 1 mg/10 ml prefilled syringe (IV)

Executive Summary
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 certain symptomatic bradyarrhythmias and to counteract cholinergic symptoms such as respiratory secretions and bronchospasm in the case of muscarinic toxicity (cholinergic toxidrome). 


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



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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.


Adult dose for paroxysmal supraventricular tachycardia

“6-12-12 mg”


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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). 


Acute Coronary Syndrome with ST elevation (<12 hours)

US-FDA approved

Adult dose:

 

Acute Ischemic Stroke (<4.5 hours)

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

 

Pulmonary Embolism

US-FDA approved. 

Adult dose


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Amiodarone
- 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.


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):


Adult dose for stable ventricular tachycardia


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Calcium gluconate
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.

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).


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Cyclobenzaprine
- 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. 

 

Adult dose for acute painful musculoskeletal spasms

Immediate release formulation*


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


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Dobutamine

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. 


Adult dose for cardiogenic shock

2-20 ug/kg/min


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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. 

 

Adult dose for undifferentiated agitation in the ED

5-10mg IM


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

1.25-2.5mg IV or IM


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Etomidate
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. 

 

Pharmacology for a single bolus administration:

 

Adult dose for rapid sequence intubation:  

0.3mg/kg IV (total body weight).


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Epinephrine
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. 

 

*ROSC: Return of Spontaneous Circulation


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

 

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


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Epinephrine racemic (racepinephrine)
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. 

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.


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Fentanyl
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.

Adult dose for moderate to severe pain:

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


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Flavoxate
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.

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

100-200mg every 6 to 8 hours PO

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Heparin, unfractionated
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.

Adult dose for pulmonary embolism


Adult dose for ST-segment elevation myocardial infarction (STEMI)


*Percutaneous coronary intervention


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Hypertonic saline
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. 


Adult dose for acute intracranial hypertension caused by TBI

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


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Ibuprofen
- 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)

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.


Adult dose for pain or fever

400-800 mg IV or PO over 30 min every 6-8 hours as needed (maximum 3200 mg/day).


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Ketamine

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

Executive Summary

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.


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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Ketorolac
- 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. 


Adult dose for acute moderate to severe pain


*adults ≥65 years: max 60mg/day

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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); 


Adult dose for status epilepticus

Adult dose for post-traumatic seizure prophylaxis in severe TBI


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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. 


Adult dose for local anesthesia

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


Adult dose for ventricular tachycardia (8, 9)

1-1.5mg/kg IV.

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Lipid emulsion

- Lipid emulsion 20%, 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).


Adult dose for Local Anesthetic Systemic Toxicity (LAST)

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

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Lorazepam

- 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:

Onset (IV): 5-10 minutes*

Peak Effect (IV): 30 minutes

Duration (IV): 2-6 hours

(*shorter to terminate seizures)

Onset (IM) 15 minutes

Peak Effect (IM) 60 minutes

Duration (IM) 6-8 hours


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


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


Acute anxiety disorder:


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Magnesium sulfate #new_summary

Magnesium sulfate 50%, 25%, 15%, 8%, and 4% ampoules, vials or bags (IV, IM). 

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

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


Adult dose for seizure prevention 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.

Comment: MgSO₄ prevents eclampsia seizures from recurring but does not treat the seizure episode directly. In cases resistant to MgSO₄, standard ED seizure management is required (e.g. lorazepam).


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Nitroglycerin

- 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). 

Nitroglycerin (NTG) is a nitrate prodrug of nitric oxide (NO), which primarily produces vasodilation as its main cardiovascular effect.

Adult dose for acute cardiogenic pulmonary edema

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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Naloxone

- 0.4 mg/1 ml vials (IV, IM, subcutaneous)

- 2 and 4 mg/spray (intranasal spray)

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

Adult dose for opioid overdose


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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


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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. 


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


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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.


Adult dose for peptic ulcer bleeding


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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.


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


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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). 


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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. 


Cautions summary


Adult dose for rapid sequence intubation (RSI) (25)

1.5 mg/kg IV bolus.


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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)

 

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

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


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Rocuronium

50 mg/5 ml vials (IV)

Executive Summary

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


Adult dose for rapid sequence intubation

1.5mg/kg IV


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Tenecteplase

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):

 

Acute Ischemic Stroke (AIS <4.5hrs)

Not FDA approved. 

Adult dose (IV ,bolus):

 

Pulmonary Embolism (PE)

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

Adult dose (IV, bolus):


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Tetanus Immune Globulin

250 unit prefilled syringes (IM)

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

Adult dose for tetanus treatment and prophylaxis


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Thiamine (Vitamin B1)

- 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


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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. 

 

Adult dose for trauma with risk of significant hemorrhage

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


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Opioids for pain management