Acetylcysteine
- 600mg effervescent tablets, capsules (PO)
- 6gr/60ml (100mg/ml) solution (PO)
- 6gr/30ml (200mg/ml) vials (IV)
Executive Summary
N-Acetylcisteine (NAC) is a mucolytic, antioxidant and a glutathione-inducer. It is positioned as the cornerstone antidote for the prevention and treatment of liver toxicity secondary to acetaminophen (APAP) overdose, with US-FDA approval for IV, PO and effervescent tablets administration.
Adult and Pediatric dose for acetaminophen overdose: oral administration, 18 doses total.
Loading dose: 140mg/kg PO.
Dose 2 to 17: repeated doses every 4 hours of 70mg/kg PO.
Alteplase
50mg lyophilized powder (IV)
Executive Summary
Alteplase, a fibrin-specific Tissue Plasminogen Activator (fibrinolytic) is widely accepted for emergency revascularization in acute myocardial infarction (MI), high risk acute pulmonary embolism (PE), and acute ischemic stroke (AIS).
In emergency medicine it is also used in intermediate-high risk PE and cardiac arrest when there is a high suspicion of MI or PE as the cause, in both scenarios the decision should be taken cautiously and in very selected cases.
Always seriously consider the contraindications and balance the risk of intracranial and other major bleeding events versus the benefit of the therapy. Fibrinolysis is an intervention that should be decided -or at least supported- by a specialist (emergency medicine, neurologist, cardiologist, intensivist).
Acute Coronary Syndrome with ST elevation (<12 hours)
US-FDA approved
Adult dose:
≤67kg: 15mg bolus + 0.75mg/kg in next 30 min
>67kg: 15 mg bolus + 50 mg in 30 min + 35 mg in 60 min
Acute Ischemic Stroke (<4.5 hours)
US-FDA approved for <3 hours after symptom onset (1996), Universally accepted use in <4.5 hours.
Adult dose:
<100kg: 0.9mg/kg total (max 90mg)
10% bolus over 1 min
90% infusion over 60 min
≥100kg: 9mg bolus + 81mg 60min
Pulmonary Embolism
US-FDA approved.
Adult dose:
Intermediate risk: 50mg in 2 hrs
High risk: 100mg in 2 hrs
Cardiac arrest: 50mg bolus + 50mg if no ROSC in 15 min
Go to Full Drug Description
Go to Fibrinolytics Summary Table
Cyclobenzaprine
- 5, 7.5 and 10mg tablets (PO, immediate release)
- 10, 15 and 30mg tablets (PO, extended release)
- 5, 7.5 and 10mg tablets (PO, immediate release)
- 10, 15 and 30mg tablets (PO, extended release)
Executive Summary
Ciclobenzaprine is a centrally acting skeletal muscle relaxant widely prescribed to relieve acute painful musculoskeletal conditions as an adjunct treatment to physical therapy and rest. It is also used as a temporary adjuvant medication along with non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen.
Limited data supports its use in the short term for treating acute muscle spasm, acute low back pain, fibromyalgia and temporomandibular disorder.
Muscle relaxants including cyclobenzaprine have significant adverse effects on the central nervous system (sedation, drowsiness, dizziness), therefore, they should be prescribed with caution and their benefits need to be balanced with their risks; experts differ on whether they should be used or not.
It has a similar structure to tricyclic antidepressants such as amitriptyline, thus it can cause serious anticholinergic effects, but no direct cardiotoxicity has been reported in cases of overdose (eg. sodium channel blockade and QRS complex widening).
Adult dose for acute painful musculoskeletal spasms
Immediate release formulation*
5mg TID with one dose at night.
Maximum 30mg/day, up to 2-3 weeks.
*Many clinicians start at a low dose at night (5mg) and then titrate up if it is strictly necessary.
Dobutamine #latest_content!
250mg/20ml vials (IV)
Executive Summary
Dobutamine, a synthetic catecholamine, is one of the most studied and used inotropic agents in cardiovascular critical care for the treatment of cardiogenic shock (CS), with approval of the US-FDA for that condition.
USA and European guidelines recommend norepinephrine as first-line vasopressor to manage hypotension in CS. Afterwards an inotrope and/or mechanical cardiovascular support (MCS) is added if needed, in order to improve perfusion towards a definite intervention.
It has inodilator properties as a beta-receptors agonist (𝛽1 and 𝛽2), with subsequent positive chronotropism, inotropism and mild peripheral vasodilation. This may provoke myocardial ischemia, arrhythmias and severe cardiovascular events. Use with extreme caution.
Dobutamine is preferred over epinephrine for CS, as the latter is associated with an increased risk of refractory shock, lactic acidosis and mortality.
Adult dose for cardiogenic shock
2-20 ug/kg/min
Droperidol
5mg/2ml ampoules (IV, IM)
Executive Summary
Droperidol is a first generation antipsychotic (so-called typical antipsychotics, same class as haloperidol) that acts as a D2 dopamine receptor antagonist. Droperidol also has some histamine and serotonin antagonist properties.
It has a significant potential role in the ED because of its efficacy to treat a variety of clinical conditions, including undifferentiated agitation, migraine, vertigo, nausea, vomiting, cannabinoid hyperemesis, and pain.
The US-FDA issued a Black Box Warning in 2001, but has been deeply questioned. This is why the drug has been regaining popularity and its use has been increasing over the last decade. Nonetheless it should not be used on patients with long QT syndrome or at an increased risk of QT prolongation.
Adult dose for undifferentiated agitation in the ED
5-10mg IM
Adult dose for migraine, acute vertigo, nausea or vomiting and cannabinoid hyperemesis
1.25-2.5mg IV or IM
Etomidate
20mg/10ml ampoules (IV)
20mg/10ml ampoules (IV)
Executive Summary
Etomidate is an ultrashort-acting, non-barbiturate hypnotic intravenous anesthetic agent. Is one of the most used and preferred hypnotic agents in the ED for Rapid Sequence Intubation.
Etomidate acts on GABA receptors moderating the activity of chloride channels; it makes neurons less excitable without any major cardiovascular impact.
It causes an adrenal inhibition of corticosteroid synthesis, therefore only a single bolus dose is recommended for induction to minimize adrenal suppression.
Pharmacology for a single bolus administration:
Onset: 15-45 seg
Time to Peak Effect: 45 seg
Duration of hypnotic effect: 3-12 min
Adult dose for rapid sequence intubation:
0.3mg/kg IV (total body weight).
Consider a lower dose of 0.2mg/kg in profound shock.
Epinephrine
1mg/1ml ampoules (IV, IM, IO, nebulization, subcutaneous)
1mg/1ml ampoules (IV, IM, IO, nebulization, subcutaneous)
Executive Summary
Epinephrine is an endogenous catecholamine non-selective agonist of all adrenergic receptors with a major role in emergency medicine on a variety of different diagnoses.
Anaphylaxis
Epinephrine acts on several pathophysiological pathways that cause anaphylaxis . It is the only established therapy to treat this condition.Cardiac arrest (CA)
Current guidelines include epinephrine as part of standard treatment during CA in children and adults, being the only recommended drug regardless of initial rhythm mainly because it is associated with an increased rate of ROSC* and short-term survival.Severe asthma crisis
Consider IV or IM epinephrine in the crashing asthmatic patient to deliver a systemic Beta-2 agonist agent (when inhaled bronchodilators have trouble getting into the lower airway). Give as a push-dose if administered IV, and an equivalent anaphylaxis dose for IM administration.
*ROSC: Return of Spontaneous Circulation
Adult dose for anaphylaxis
0.01mg/kg (max 0.5mg per dose) IM into the anterolateral aspect of the thigh.
Can be repeated every 5-15 min if necessary.
If there is no response, consider a continuous IV infusion of epinephrine.
Adult dose for cardiac arrest
1mg every 3 to 5 minutes IV or IO
In shockable rhythms early defibrillation should be performed as soon as possible, before any other resuscitation interventions
Hypertonic saline #recent_update
3%, 10% and 23.4%, 100ml ampoules (IV)
3%, 10% and 23.4%, 100ml ampoules (IV)
Executive Summary
Hypertonic saline solutions (HTS) are electrolyte concentrates of NaCl (over 0.9%) and considered to be high alert medications that are cautiously used to treat symptomatic hyponatremia and acute intracranial hypertension (IH) secondary to multiple causes, but mainly to traumatic brain injury.
Recent reviews comparing mannitol versus HTS tend to favor the latter with a weak level of evidence.
Ideally HTS should be administered through a central venous access, but in emergency situations, peripheral infusions have been determined to be a safe short-term alternative, but a close monitoring of the clinical response and sodium levels is warranted to guide subsequent doses.
Adult dose for acute intracranial hypertension caused by TBI
NaCl 3%, 2 ml/kg IV in 15 minutes bolus
Ketorolac
- 30mg/ml vials, (IV, IM)
- 30mg/ml vials, (IV, IM)
- 10mg and 30mg tablets (PO, sublingual)
- 0.5% drops (ophthalmic), 15.75mg/spray (intranasal)
Executive Summary
Ketorolac is an NSAID with a potent analgesic effect that is very frequently indicated in the ED worldwide to treat moderate to severe acute pain.
The US-FDA labeling recommends usage only for moderate to severe pain (defined as requiring analgesia at the opioid level), and for a short period of time of no more than 5 days to reduce NSAIDs adverse effects.
Ketorolac, as well as other NSAIDs, reduces opioid requirements for acute pain.
Adult dose for acute moderate to severe pain
IV: 10 to 30mg every 6 hours IV (max 120mg/day)*
PO: 10mg every 6 hours PO (max 40mg/day)
*adults ≥65 years: max 60mg/day
Go to Full Drug Description
Levetiracetam
- 500mg/5ml vial (IV)
- 500mg tablets (PO) and 100mg/ml oral solution (PO)
Executive Summary
Levetiracetam (LEV) is a second generation antiepileptic drug (AED) that has gained popularity in the ED for the treatment of status epilepticus (with a conjunction of benzodiazepines, usually IV lorazepam or IM midazolam);
It modulates neuronal activity through GABA and high-voltage-dependent calcium channels, by unknown molecular mechanisms.
In children and adults, compared with other AED, LEV has a similar efficacy treating SE, with an excellent safety profile (most studies comparing it with phenytoin).
EMDrugs is currently reviewing evidence regarding LEV usage for seizure prophylaxis in traumatic brain injury and subarachnoid hemorrhage.
Adult dose for status epilepticus
Loading dose of 60mg/kg IV (max 4,500mg) in 15 minutes.
Lidocaine
- 2%, 5ml (20mg/ml, 100mg total) ampoules (subcutaneous, IV)
- 4% spray (mucosa, topical), 5% patches (transdermal), 2% drops (ophthalmic, otic)
Executive Summary
Lidocaine is a synthetic local anesthetic, and one of the most frequently used drugs in the ED. It has a reversible blocking effect on voltage-gated sodium channels, resulting in two main clinical usages: (i) interrupting nerve impulse propagation to achieve local or regional anesthesia, and (ii) inhibition of cardiac ion channels as a class IB antiarrhythmic drug.
Lidocaine has a wide variety of specific applications in the ED:
Antiarrhythmic for ventricular tachycardia
Local and regional anesthesia for wound repair and fracture closed reductions
Pain management for severe painful conditions such as renal colic and headache
Topical –spray or gel– anesthesia for awake intubation and other procedures such as bladder catheterization
Symptomatic treatment of cough
Transdermal patches to alleviate post-herpetic neuralgia and rib fractures
Adult dose for local anesthesia
Up to 4.5 mg/kg (max 300mg per dose) subcutaneous infiltration within 2 hours.
Dosing calculator: MDCalc® - Local Anesthetic Dosing Calculator
Lipid emulsion
- Lipid emulsion 20%, 100ml vials* and 500ml bags* (IV)
*Intralipid® and Smoflipid® formulations
Executive Summary
Intravenous lipid emulsion (IVLE) is a nutritional supplement approved by the US-FDA for parenteral nutrition, that have promising results for the treatment of lipophilic agents toxicity, mostly for local anesthetic systemic toxicity (LAST).
In conjunction with advance cardiovascular and neurocritic support, toxicologists and AHA guidelines consider IVLE as a valid therapeutic option to treat LAST, particularly in severe cases (eg. cardiovascular collapse / arrest).
Adult dose for Local Anesthetic Systemic Toxicity (LAST)
Intralipid® 20%, 1,5 ml/kg IV bolus over 1 minute (approximately 100ml in adults), followed by an infusion of 0.25ml/kg/min IV over the next 30-60 minutes.
Go to Full Drug Description
Lorazepam
- 4mg/2ml, 4mg/1ml and 2mg/1ml ampoules (IV, IM)
- 0,5mg, 1mg and 2mg tablets (PO, sublingual)
Executive Summary
Lorazepam is an intermediate acting benzodiazepine (BDZ) –a GABA receptor enhancer– with CNS depressant effects including sedative, hypnotic, skeletal muscle relaxing and anticonvulsant activity. It can be administered either by intravenous, intramuscular, sublingual or oral routes. Along with midazolam and clonazepam, lorazepam is one of the most frequently indicated BDZs in the ED.
Sedation timing with single 2-4mg dose:
Intravenous
Onset (IV): 5-10 minutes*
Peak Effect (IV): 30 minutes
Duration (IV): 2-6 hours
(*shorter to terminate seizures)
Intramuscular
Onset (IM) 15 minutes
Peak Effect (IM) 60 minutes
Duration (IM) 6-8 hours
Adult dose for status epilepticus:
0.1mg/kg IV (max 4mg/dose).
Repeat every 5-10 min until the crisis has ceased.
Consider initiating an antiepileptic if a second lorazepam dose is required.
Adult dose for undifferentiated agitation:
2-4mg sublingual, IV or IM as needed (if severely agitated, IM route is prefered).
Repeat every 20-30 min if necessary.
The BDZ of choice to treat severe undifferentiated agitation is considered to be midazolam IM for its faster onset of action.
Acute anxiety disorder:
0.5-2mg sublingual, PO or IV as needed.
Repeat every 20-30 minutes if necessary.
Norepinephrine
4mg/4ml ampoules (IV)
Executive Summary
Norepinephrine (NE) is used for hemodynamic support frequently as a first-line vasopressor with the exception of anaphylaxis (epinephrine) and post cardiac arrest care (epinephrine). Consider using noradrenaline in combination with inodilator drugs in 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
Olanzapine
- 5mg and 10mg tablets (sublingual)
- 10mg lyophilized powder (IM)
Executive Summary
Olanzapine is a second generation (atypical) antipsychotic with a potent antagonism of serotonin, dopamine, histamine and alpha1-adrenergic receptors.
In the ED, olanzapine is frequently indicated as a first-line antipsychotic for acute agitation associated with psychiatric disorders.
Agitation in the ED is a very complex situation that includes a variety of dissimilar scenarios with a wide range of therapeutic options. It is of great importance to be familiarized with the available therapeutic arsenal for agitation, such as droperidol, benzodiazepines, ketamine, etc.
Adult dose for severe agitation:
5 to 10mg IM, repeated every 20 min if necessary
Maximum of 30mg/day for intramuscular administration.
Phentolamine (for extravasated vasopressors)
- 10mg/1ml vials (subcutaneous)
- 5mg lyophilized powder (subcutaneous)
Executive Summary
Phentolamine is a vasodilator used to prevent tissue necrosis caused by extravasated catecholamine infusions (epinephrine, norepinephrine, dopamine, etc). Available in the US. Limited stock in Canada. Unavailable in Chile.
Adult dose for vasopressor extravasation:
5-10mg diluted in 10-20ml of NaCl 0.9% subcutaneous immediately after extravasation (use within 12 hours).
Rabies Vaccine
Single-dose 1ml and 0,5ml vials, both equivalent to 1 vaccination dose (IM)
Executive Summary
Rabies is a zoonotic disease positioned as one of the most lethal viral infections; mortality approaches 100%. It is also preventable in nearly 100% of expositions when vaccination has been properly administered.
Adult and pediatric vaccination regimen for post-exposure prophylaxis (PEP)
Immunocompetent without prior rabies immunization:
4 doses IM, days 0-3-7 and 14*Immunocompromised without prior rabies immunization:
5 doses IM, days 0-3-7-14 and 28Prior rabies immunization**:
2 doses IM, days 0 and 3
*Some regions and their local guidelines still recommend a universal 5-dose regimen for PEP as previously was recommended by the US-CDC, and currently some manufacturers.
**Complete 4 doses of PEP scheme or 3 doses of PrEP (pre-exposure prophylaxis).
Tenecteplase
50mg lyophilized powder (IV)
Executive Summary
Acute Myocardial Infarction with ST elevation (STEMI <12hrs)
FDA approved, 2000. Indicated when anticipated STEMI diagnosis to Percutaneous Coronary Intervention-mediated reperfusion time is >120min.
Adult dose (IV ,bolus):
<60 kg 30mg
60 - 69 kg 35mg
70 - 79 kg 40mg
80 - 89 kg 45mg
≥90 kg 50mg
Acute Ischemic Stroke (AIS <4.5hrs)
Not FDA approved.
Adult dose (IV ,bolus):
AIS eligible for mechanical thrombectomy
0.25mg/kg bolus (max 25mg)
AIS with minor neurological impairment uneligible for a mechanical thrombectomy
Under revision due to NOR-TEST 2 trial results (2022)
Pulmonary Embolism (PE)
Not FDA approved. Prefer alteplase for PE fibrinolytic therapy. If unavailable, consider tenecteplase.
Adult dose (IV, bolus):
<60 kg 30mg
60 - 69 kg 35mg
70 - 79 kg 40mg
80 - 89 kg 45mg
≥90 kg 50mg
Go to Full Drug Description
Go to Fibrinolytics Summary Table
Tetanus Immune Globulin
250 unit prefilled syringes (IM)
Executive Summary
Tetanus Immune Globulin (TIG) is indicated for tetanus disease treatment and prophylaxis (the latter in individuals without updated or an unknown tetanus immunization who have suffered a contaminated or a tetanus-prone wound).
Adult dose for tetanus treatment and prophylaxis
Tetanus treatment
500 units IM with part of the dose infiltrated close to the source wound.Up to 6000 units can be used.
Tetanus prophylaxis:
250 units IM (single dose).
Thiamine (Vitamin B1)
- 30mg/ml and 200mg/2ml vials (IV, IM)
- 10, 50, 100 and 250mg tablets (PO)
Executive Summary
Thiamine (vitamin B1) is a water-soluble vitamin that is essential in the creation and utilization of cellular energy related to aerobic glycolysis in the citric acid cycle. Its deficiency leads to cardiovascular (heart failure) and neurologic disease (Wernicke - Korsakoff syndrome, "WK"). In the ED thiamine is frequently indicated in the prevention and treatment of WK, mainly in patients with ethanol dependence and/or malnutrition.
Adult dose for WK prevention and treatment
WK prevention
100-250mg IV daily for 3-5 days, then consider daily PO supplementation
WK treatment
500mg IV every 8 hours for 3-5 days, then 250mg IV daily for 3-5 days, then indefinitely daily PO supplementation
Always supplement with magnesium (2gr MgSO4 daily)
Tranexamic Acid (TXA)
1000mg/10ml ampoules (IV)
Executive Summary
The antifibrinolytic agent tranexamic acid (TXA) is a synthetic lysin derivative that binds plasminogen and plasmin, blocking their interaction with fibrin. It is indicated extensively in the ED for a variety of bleeding scenarios.
The most validated usage is in patients with acute trauma with a suspected severe hemorrhage. Currently it is an established component of “damage control resuscitation”.
All-cause mortality reduction was proven by the game-changer CRASH-2 trial –a strong double-blind RCT that compared TXA versus a placebo in trauma, based on the uncertainty principle (attending physician not being sure if TXA was beneficial or not)–. Afterwards other studies have documented improved survival rates.
Adult dose for trauma with risk of significant hemorrhage
1gr in 10 min IV + 1gr in 8 hrs IV.
Medications to treat agitation
Practice guidance - clinical guidelines, recommendations and more open access content #new
TIMELINE & LATEST UPDATES!
2023
03/18/23 Newest content Cardiogenic Shock added to Practice Guidance
03/17/23 Dobutamine for cardiogenic shock
03/11/23 Post Cardiac Arrest Care added to Practice Guidance
03/09/23 Ketorolac for moderate to severe acute pain
03/07/23
The diagnosis and Management of Agitation (Zeller 2017), added to books of interest
The Resuscitation Crisis Manual (Borshoff - Weingart 2018) added to book books of interest
03/03/23 Antidote Stocking in the ED - Royal College of Emergency Medicine and National Poisons Information Service - Guidelines 2022
03/01/23 Australian Pregnancy Risk Labeling
02/25/23: IM Medications for severe agitation (table)
02/23/23 New section dedicated to Practice Guidance (summaries, algorithms and more)
02/15/23 Lipid emulsion for LAST
02/12/23 Update - Epinephrine for the crashing asmathic
Update - Droperidol vs pregnancy/lactation02/09/23 Lidocaine for infiltrative anesthesia and ventricular arrhythmias
02/02/23 Epinephrine pathophysiology update
01/31/23 Pharmacology open access resources
Basic pharmacology concepts
Drug classification
Orange and Purple Books (U.S. FDA)
01/28/23 Levetiracetam for status epilepticus
01/20/23 Droperidol for agitation and more!
01/15/23 Recommended Resources about drug use during Pregnancy and Lactation
01/13/23 Epinephrine for anaphylaxis and cardiac arrest
01/11/23 Tenecteplase update based on NOR-TEST 2 trial results
01/05/23 Canadian Association of Emergency Medicine (CAEP) Clinical Practice Guidelines added to links of interest
Recommended articles:
2022
12/21/22 Hypertonic saline (3%, 10% and 23.4%) for acute intracranial hypertension and symptomatic severe hyponatremia
12/14/22 Institute for Safe Medication Practices (ISMP) added to links of interest
12/01/22 Recent Articles in EM and Crit Care Pharmacotherapy new section in "Resources"
11/30/22 Tranexamic acid in trauma
11/25/22 "Books of interest" new section in "Resources"
11/10/22 Thiamine for Wernicke-Korsakoff treatment and prevention
11/03/22 Lorazepam update (use in agitation)
10/31/22 Cyclobenzaprine
05/22/22 Rabies Vaccine
04/09/22 Inductors for rapid sequence intubation summary table
04/09/22 References added to fibrinolytics summary table
2021
11/27/21 Etomidate
11/19/21 Lorazepam
10/01/21 Acetylcysteine for acetaminophen overdose
09/05/21 Olanzapine for the agitated patient
08/15/21 Fibrinolytics
08/10/21 Tenecteplase
07/29/21 Alteplase
07/17/21 Phentolamine (for vasopressor extravasation treatment)
06/14/21 Norepinephrine
06/11/21 Tetanus Immune Globulin
04/24/21 EMDrugs go for launch!
Links of interest:
ISMP - Institute for Safe Medication Practices
https://www.ismp.org/WHO - World Health Organization Model List of Essential Medicines 2019
https://www.who.int/(...)US FDA - Approved Drugs Orange Book 2021
https://www.accessdata.fda.gov/(...)EMA - European Medicines Agency - Covid-19 Updates 2023
https://www.ema.europa.eu/(...)ACEP - American College of Emergency Physicians - Clinical Policies
https://www.acep.org/(...)AAEM - American Academy of Emergency Medicine - Clinical Practice Statements
https://www.aaem.org/(...)CAEP - Canadian Association of Emergency Physicians - Clinical Practice Guidelines
https://caep.ca/(...)EUSEM - European Society for Emergency Medicine - Guidelines for the management of acute pain in emergency situations 2020
https://eusem.org/(...)RCEM - The Royal College of Emergency Medicine - Clinical Guidance
https://www.rcem.ac.uk/(...)ASHP - American Society of Health-System Pharmacists - Guidelines on Emergency Medicine Pharmacist Services
https://www.ashp.org/(...)
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EMDrugs Team