Can you provide a comprehensive list of emergency medications with their dosages, indications, adverse effects, and contraindications?

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Emergency Medications: Comprehensive Reference Guide

This is a comprehensive list of critical emergency medications based on the 2023 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care, organized by clinical indication with specific dosing, adverse effects, and contraindications. 1

CARDIAC ARREST & RESUSCITATION

Epinephrine

  • Indication: Cardiac arrest (all rhythms), anaphylaxis, severe bradycardia
  • Dosage:
    • Cardiac arrest: 1 mg IV/IO (1:10,000 solution) every 3-5 minutes
    • Anaphylaxis: 0.2-0.5 mg IM (1:1000 solution) every 5-15 minutes 2
    • Anaphylactic shock with IV access: 0.05-0.1 mg IV (1:10,000 solution) 2
    • Continuous infusion: 0.1-1.0 mcg/kg/min, titrate to effect 3
  • Adverse Effects: Tachyarrhythmias, hypertension, myocardial ischemia, tissue necrosis with extravasation
  • Contraindications: None in cardiac arrest; relative contraindication in cocaine-induced chest pain
  • Critical Pitfall: Ensure correct concentration—1:10,000 for IV/IO, 1:1000 for IM to avoid 10-fold dosing errors 3

POISONING & TOXICOLOGY ANTIDOTES

Naloxone (Opioid Reversal)

  • Indication: Opioid-induced respiratory depression/arrest
  • Dosage:
    • Adult: 0.2-2 mg IV/IO/IM, titrate to restore respiratory drive 1
    • Intranasal: 2-4 mg, repeat every 2-3 minutes 1
    • Pediatric: 0.1 mg/kg 1
    • Continuous infusion: Two-thirds of waking dose per hour 1
  • Adverse Effects: Acute opioid withdrawal (agitation, hypertension, tachycardia, pulmonary edema), seizures in neonates
  • Contraindications: None in life-threatening situations
  • Key Point: Titrate to reversal of respiratory depression, NOT full consciousness—over-reversal precipitates severe withdrawal 1

Flumazenil (Benzodiazepine Reversal)

  • Indication: Pure benzodiazepine overdose with respiratory depression in select low-risk patients 1
  • Dosage:
    • Adult: 0.2 mg IV, titrate up to 1 mg total 1
    • Pediatric: 0.01 mg/kg 1
  • Adverse Effects: SEIZURES, ventricular dysrhythmias, acute benzodiazepine withdrawal
  • Contraindications (ABSOLUTE):
    • Chronic benzodiazepine use/dependence
    • Seizure disorder
    • Suspected co-ingestion with tricyclic antidepressants or other proconvulsants
    • Cardiac arrest 1
  • Critical Warning: Administer naloxone FIRST if combined opioid/benzodiazepine poisoning suspected—flumazenil has worse safety profile 1

High-Dose Insulin (Beta-Blocker/Calcium Channel Blocker Poisoning)

  • Indication: Hypotension refractory to vasopressors from beta-blocker or CCB poisoning 1
  • Dosage:
    • Bolus: 1 unit/kg regular insulin IV 1
    • Infusion: 1-10 units/kg/hour 1
    • Must co-administer dextrose: Start D50W 25-50 g IV, then continuous dextrose infusion
  • Adverse Effects: Hypoglycemia (monitor glucose every 30 min), hypokalemia, volume overload
  • Contraindications: None in life-threatening poisoning
  • Mechanism: Improves myocardial inotropy in cardiogenic shock 1

Calcium (Calcium Channel Blocker Poisoning)

  • Indication: CCB-induced hypotension/bradycardia 1
  • Dosage:
    • Calcium chloride: 2000 mg (20 mL of 10% solution) IV 1
    • Calcium gluconate: 6000 mg (60 mL of 10% solution) IV 1
    • Infusion: Calcium chloride 20-40 mg/kg/hour OR calcium gluconate 60-120 mg/kg/hour 1
    • Pediatric: 20 mg/kg calcium chloride or 60 mg/kg calcium gluconate 1
  • Adverse Effects: Bradycardia, tissue necrosis with extravasation (especially calcium chloride)
  • Contraindications: Digoxin toxicity (relative)
  • Key Point: Titrate to blood pressure; do NOT exceed ionized calcium 1.5-2× upper limit of normal. Calcium chloride MUST be given via central line in children 1

Glucagon (Beta-Blocker/CCB Poisoning)

  • Indication: Bradycardia or hypotension from beta-blocker or CCB poisoning 1
  • Dosage:
    • Bolus: 2-10 mg IV 1
    • Pediatric: 0.05-0.15 mg/kg 1
    • Infusion: 1-15 mg/hour (adult) 1
  • Adverse Effects: Vomiting (anticipate and protect airway), hyperglycemia, hypokalemia
  • Contraindications: Pheochromocytoma
  • Mechanism: Increases cardiac contractility independent of beta-receptors 1

Sodium Bicarbonate (Sodium Channel Blocker Poisoning)

  • Indication: QRS widening from tricyclic antidepressants, cocaine, or other sodium channel blockers 1
  • Dosage:
    • Bolus: 50-150 mEq IV (1-3 ampules) 1
    • Pediatric: 1-3 mEq/kg 1
    • Infusion: Prepare 150 mEq/L solution, infuse at 1-3 mL/kg/hour 1
  • Adverse Effects: Hypernatremia, alkalemia, hypokalemia, hypochloremia, volume overload
  • Contraindications: None in life-threatening poisoning
  • Target: Serum pH 7.50-7.55 and QRS narrowing 1

Digoxin Immune Fab

  • Indication: Life-threatening digoxin toxicity (dysrhythmias, hyperkalemia >5.5 mEq/L, cardiac arrest) 1
  • Dosage:
    • Acute overdose: 1 vial per 0.5 mg digoxin ingested 1
    • Chronic toxicity: Dose (vials) = [serum digoxin (ng/mL) × weight (kg)] / 100 1
    • Unknown dose, critically ill: 10-20 vials 1
    • Pediatric: Same formula as adult 1
  • Adverse Effects: Hypokalemia (as digoxin redistributes), allergic reactions, loss of inotropic support
  • Contraindications: None in life-threatening toxicity
  • Note: Each vial contains 40 mg Fab and binds ~0.5 mg digoxin 1

Atropine (Organophosphate/Carbamate Poisoning)

  • Indication: Cholinergic crisis from organophosphate or carbamate poisoning 1
  • Dosage:
    • Adult: 1-2 mg IV, double every 5 minutes until bronchorrhea/bronchospasm resolves 1
    • Pediatric: 0.02 mg/kg, double every 5 minutes 1
    • Infusion: 10-20% of total loading dose per hour (up to 2 mg/hour in adults) 1
  • Adverse Effects: Tachycardia, hyperthermia, delirium, urinary retention
  • Contraindications: None in life-threatening poisoning
  • Endpoint: Titrate to reversal of bronchorrhea, bronchospasm, bradycardia—NOT pupil size or heart rate alone 1

Pralidoxime (Organophosphate Poisoning)

  • Indication: Organophosphate poisoning (reactivates acetylcholinesterase) 1
  • Dosage:
    • Adult: 1-2 g IV over 30 minutes 1
    • Pediatric: 20-50 mg/kg 1
    • Infusion: 400-600 mg/hour (adult) or 10-20 mg/kg/hour (pediatric) 1
  • Adverse Effects: Hypertension, tachycardia, muscle rigidity
  • Contraindications: Carbamate poisoning (not effective, may worsen)
  • Key Point: Must be given WITH atropine; most effective if started within 24-48 hours of exposure 1

Intravenous Lipid Emulsion (ILE)

  • Indication: Local anesthetic systemic toxicity (LAST) with cardiac arrest or severe cardiovascular collapse 1
  • Dosage:
    • Bolus: 1.5 mL/kg of 20% lipid emulsion (up to 100 mL) 1
    • Infusion: 0.25 mL/kg/min for up to 30 minutes 1
    • Pediatric: Same as adult 1
  • Adverse Effects: Pancreatitis, fat embolism, interference with laboratory tests
  • Contraindications: None in life-threatening LAST
  • Evidence: NOT beneficial for beta-blocker poisoning 1

Cyanide Antidotes

  • Hydroxocobalamin:

    • Dosage: 5 g IV over 15 minutes (adult); 70 mg/kg (pediatric) 1
    • Adverse Effects: Red discoloration of skin/urine, hypertension, laboratory interference
    • Preferred agent—safe in smoke inhalation with CO poisoning 1

  • Sodium Nitrite + Sodium Thiosulfate:

    • Sodium nitrite: 300 mg IV (adult); 6 mg/kg (pediatric) 1
    • Sodium thiosulfate: 12.5 g IV (adult); 250 mg/kg (pediatric) 1
    • Adverse Effects: Methemoglobinemia, hypotension
    • Contraindication: DO NOT use in smoke inhalation—worsens oxygen delivery 1

Methylene Blue

  • Indication: Methemoglobinemia, vasodilatory shock from CCB poisoning 1
  • Dosage:
    • Methemoglobinemia: 1-2 mg/kg IV over 5 minutes, repeat every hour if needed 1
    • Vasodilatory shock: 1 mg/kg/hour infusion 1
    • Maximum: 5-7 mg/kg total 1
  • Adverse Effects: Serotonin syndrome (with SSRIs), hemolysis in G6PD deficiency, blue-green urine
  • Contraindications: G6PD deficiency (absolute), concurrent serotonergic agents (relative)

CARDIOVASCULAR EMERGENCIES

Atropine (Bradycardia)

  • Indication: Symptomatic bradycardia, beta-blocker/CCB/digoxin poisoning 1
  • Dosage:
    • Adult: 0.5-1.0 mg IV every 3-5 minutes (maximum 3 mg) 1
    • Pediatric: 0.02 mg/kg (minimum 0.1 mg, maximum single dose 0.5 mg) 1
  • Adverse Effects: Tachycardia, paradoxical bradycardia with doses <0.5 mg, urinary retention
  • Contraindications: None in emergency situations
  • Note: May be ineffective for beta-blocker poisoning—consider glucagon or pacing 1

Vasopressors (General)

  • Dopamine:

    • Dosage: 2-20 mcg/kg/min IV infusion 3
    • Effects: Dose-dependent (dopaminergic at 1-5 mcg/kg/min, beta-adrenergic at 5-10, alpha-adrenergic >10)
    • Adverse Effects: Tachyarrhythmias, tissue necrosis with extravasation
    • Antidote for extravasation: Phentolamine 0.1-0.2 mg/kg (up to 10 mg) diluted in 10 mL NS, inject intradermally 3

  • Norepinephrine:

    • Dosage: 0.1-2 mcg/kg/min IV infusion
    • Indication: Distributive shock, beta-blocker poisoning 1

SEIZURES & NEUROLOGICAL EMERGENCIES

Benzodiazepines (Status Epilepticus)

  • Lorazepam: 0.1 mg/kg IV (maximum 4 mg per dose)
  • Midazolam: 0.2 mg/kg IM (maximum 10 mg) or 0.2 mg/kg IV
  • Diazepam: 0.15-0.2 mg/kg IV (maximum 10 mg)
  • Adverse Effects: Respiratory depression, hypotension, paradoxical agitation
  • Contraindications: None in status epilepticus

RAPID SEQUENCE INTUBATION

Etomidate

  • Dosage: 0.2-0.4 mg/kg IV (maximum 20 mg) 3
  • Advantages: Minimal hemodynamic effects, lowers ICP
  • Adverse Effects: Myoclonic activity, adrenal suppression with prolonged use
  • Indication: Preferred for head injury, multisystem trauma, hypotension 3

Ketamine

  • Dosage: 0.2-0.4 mg/kg IV (maximum 20 mg) 3
  • Advantages: Maintains respiratory drive, bronchodilation
  • Adverse Effects: Increased secretions, emergence reactions, theoretical ICP elevation
  • Indication: Asthma, hemodynamic instability

ANTIEMETICS

Ondansetron

  • Indication: Nausea/vomiting in emergency department 4, 5
  • Dosage: 4-8 mg IV/PO
  • Adverse Effects: QT prolongation (rare), constipation, headache
  • Contraindications: Congenital long QT syndrome
  • Evidence: First-line agent—as effective as promethazine without sedation or akathisia 4

Metoclopramide

  • Dosage: 10 mg IV (slow infusion over 15 minutes)
  • Adverse Effects: Akathisia (can occur up to 48 hours post-dose), extrapyramidal symptoms, tardive dyskinesia
  • Treatment of akathisia: Diphenhydramine 25-50 mg IV 4

Prochlorperazine

  • Dosage: 5-10 mg IV (slow infusion)
  • Adverse Effects: Akathisia, extrapyramidal symptoms, sedation, hypotension
  • Note: More effective than metoclopramide but higher akathisia risk 4

ANALGESIA & FEVER

Acetaminophen (Paracetamol)

  • Dosage: 1000 mg PO/IV every 6 hours (maximum 4 g/day) 6
  • Indication: Fever, mild-moderate pain
  • Adverse Effects: Hepatotoxicity with overdose (>150 mg/kg or >7.5 g in adults)
  • Antidote for overdose: N-acetylcysteine (see below)

N-Acetylcysteine (Acetaminophen Overdose)

  • Indication: Acetaminophen overdose 7
  • Dosage (IV protocol):
    • Loading: 150 mg/kg in 200 mL D5W over 1 hour
    • Second infusion: 50 mg/kg in 500 mL D5W over 4 hours
    • Third infusion: 100 mg/kg in 1000 mL D5W over 16 hours
  • Adverse Effects: Anaphylactoid reactions (flushing, bronchospasm), nausea
  • Key Point: Most effective if started within 8 hours of ingestion; still beneficial up to 24 hours 7

SPECIAL POPULATIONS & CONSIDERATIONS

Geriatric High-Risk Medications to AVOID 8:

  1. Benzodiazepines (falls, delirium, respiratory depression)
  2. Skeletal muscle relaxants (sedation, falls)
  3. First-generation antihistamines (anticholinergic effects, delirium)
  4. First-generation antipsychotics (extrapyramidal symptoms, falls)
  5. Barbiturates (respiratory depression, dependence)
  6. Hypnotic Z-drugs (falls, cognitive impairment)
  7. Metoclopramide (extrapyramidal symptoms, tardive dyskinesia)
  8. Sulfonylureas (prolonged hypoglycemia)

Reasonable exceptions: Seizure disorders, benzodiazepine/ethanol withdrawal, end-of-life care, severe generalized anxiety, allergic reactions 8

CRITICAL SAFETY PRINCIPLES

  1. Medication Reconciliation: Always review home medications before prescribing—drug interactions and inappropriate discontinuation are major sources of harm 9

  2. Polypharmacy: Average emergency patient receives 10 drugs per encounter—each additional drug exponentially increases interaction risk 5

  3. Antidote Availability: Hospitals providing emergency care must stock adequate antidotes based on hazard vulnerability assessment (local industries, indigenous fauna, referral patterns) 7

  4. Dosing Errors: Double-check pediatric weight-based dosing and concentration of high-alert medications (epinephrine, insulin, opioids) 3

  5. Route Matters: IM epinephrine for anaphylaxis (NOT IV unless shock), IV calcium chloride via central line in children, intranasal naloxone for field use 2, 1

References

6
Research

Treatment of fever and associated symptoms in the emergency department: which drug to choose?

European review for medical and pharmacological sciences, 2023

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