Which emergency medications are required in an adult crash cart?

Emergency Drugs Mandatory in Adult Crash Cart

Based on the most recent 2023 American Heart Association guidelines, an adult crash cart must contain epinephrine, atropine, naloxone, sodium bicarbonate, calcium (chloride or gluconate), and amiodarone as core resuscitation medications, supplemented by specific antidotes for toxicologic emergencies. 1

Core Cardiac Arrest Medications

The foundation of crash cart pharmacology centers on Advanced Cardiovascular Life Support (ACLS) drugs:

Primary Resuscitation Agents

• Epinephrine 1 mg (1:10,000 solution): The single most critical medication for cardiac arrest, administered every 3-5 minutes during CPR. For shockable rhythms, give after initial defibrillation attempts fail; for non-shockable rhythms, administer as soon as IV/IO access is established 2

• Amiodarone 300 mg initial dose, 150 mg second dose: For refractory ventricular fibrillation/pulseless ventricular tachycardia after epinephrine and defibrillation 2

• Atropine 0.5-1.0 mg: For symptomatic bradycardia, can repeat every 3-5 minutes up to 3 mg total 1

Critical Supportive Medications

• Sodium bicarbonate 50-150 mEq: Essential for sodium channel blocker toxicity (tricyclic antidepressants, cocaine) and severe metabolic acidosis. Prepare as 150 mEq/L solution 1

• Calcium chloride 2000 mg (20 mL of 100 mg/mL) OR Calcium gluconate 6000 mg (60 mL of 100 mg/mL): For calcium channel blocker toxicity, hyperkalemia, and hypocalcemia. Calcium chloride provides more elemental calcium but requires central access in children 1

Antidotes and Reversal Agents

The 2023 AHA poisoning guidelines significantly expanded antidote recommendations 1:

Opioid Overdose

• Naloxone 0.2-2 mg IV/IO/IM or 2-4 mg intranasal: Titrate to restore respiratory drive, not full consciousness. For respiratory arrest with definite pulse, naloxone administration is reasonable alongside standard BLS/ACLS 2. Critical caveat: During cardiac arrest, high-quality CPR takes absolute priority over naloxone—there is no evidence naloxone improves cardiac arrest outcomes 2

Anaphylaxis

• Epinephrine 50 mcg IV (0.5 mL of 1:10,000) for anesthetized patients, repeated as needed for severe hypotension or bronchospasm. Multiple doses are frequently required 3
• Chlorphenamine 10 mg IV (secondary management) 3
• Hydrocortisone 200 mg IV (secondary management) 3

Toxicologic Emergencies

• Digoxin immune Fab: 10-20 vials for acute overdose when ingested dose unknown 1
• Glucagon 2-10 mg: For beta-blocker or calcium channel blocker toxicity 1
• Insulin (regular) 1 unit/kg bolus: For severe beta-blocker/calcium channel blocker poisoning, with 1-10 units/kg/hr infusion 1
• Flumazenil 0.2 mg titrated to 1 mg: Use with extreme caution—only for pure benzodiazepine overdose in select patients. Contraindicated in seizure disorders, chronic benzodiazepine use, or mixed overdoses due to risk of precipitating seizures and dysrhythmias 1
• Pralidoxime 1-2 g: For organophosphate poisoning 1
• Sodium nitrite 300 mg and Sodium thiosulfate 12.5 g: For cyanide poisoning 1
• Methylene blue 1-2 mg/kg: For methemoglobinemia 1
• Intravenous lipid emulsion (20%) 1.5 mL/kg bolus: For local anesthetic systemic toxicity 1

Essential Bronchodilators and Vasopressors

• Salbutamol (albuterol): For persistent bronchospasm in anaphylaxis 3
• Alternative vasopressors (metaraminol, norepinephrine): When epinephrine infusion fails to restore blood pressure 3

Key Implementation Principles

Route of administration: IV is preferred, but IO access is equally effective when IV access fails—do not delay medication administration 1

Common pitfall: The 2023 guidelines emphasize that antidotes should never delay high-quality CPR. During cardiac arrest, compressions and defibrillation remain the priority; medications are adjunctive 2

Dosing strategy: Most antidotes require repeated dosing and titration to clinical effect rather than fixed protocols. Large doses may be needed to overcome competitive receptor inhibition 1

Monitoring requirements:

• Calcium administration requires monitoring ionized calcium (target 1.5-2× upper limit of normal) 1
• Insulin therapy demands glucose and potassium monitoring 1
• Sodium bicarbonate necessitates watching for hypernatremia, alkalemia, and hypokalemia 1

Evidence quality note: While comprehensive crash cart medication lists exist 4, 5, the 2023 AHA guidelines provide the most authoritative, evidence-based framework for adult resuscitation medications, superseding older institutional practices 1.