What are the frequently used medicines in the emergency room?

Frequently Used Medicines in the Emergency Room

Cardiovascular Emergency Medications

For hypertensive emergencies, labetalol and nicardipine are the essential first-line agents that should be stocked in every emergency department, as they can safely manage most hypertensive crises and are widely available throughout Europe and recommended for hospital essential drug lists 1.

Hypertensive Crisis Management

• Labetalol is the first-line treatment for malignant hypertension, hypertensive encephalopathy, acute ischemic stroke with severe hypertension (>220/120 mmHg), and acute hemorrhagic stroke with systolic BP >180 mmHg 1.
• Nicardipine serves as the primary alternative when labetalol is contraindicated or ineffective 1.
• Nitroprusside or nitroglycerin are preferred for acute cardiogenic pulmonary edema and acute coronary events, with target systolic BP <140 mmHg 1.
• For acute aortic dissection, esmolol combined with nitroprusside or nitroglycerin achieves the aggressive targets of systolic BP <120 mmHg and heart rate <60 bpm 1.

Acute Coronary Syndrome Medications

• Aspirin is fundamental for ACS management, with an initial loading dose of 160-325 mg followed by maintenance doses of 75-150 mg daily 1, 2.
• Nitroglycerin is first-line for acute coronary events with target systolic BP <140 mmHg 1.
• Antiplatelet therapy prevents approximately 25% of serious vascular events in patients with prior occlusive vascular events 3.

Resuscitation Medications

Epinephrine is the cornerstone resuscitation drug, with specific dosing protocols that differ dramatically between cardiac arrest and anaphylaxis 4, 5.

Cardiac Arrest

• Epinephrine 0.01 mg/kg of 1:10,000 solution IV/IO (maximum 1 mg), repeated every 3-5 minutes for pediatric cardiac arrest 4.
• For neonatal resuscitation, dosing is 0.01-0.03 mg/kg of 1:10,000 solution IV/IO 4.

Anaphylaxis

• Epinephrine 0.01 mg/kg of 1:1000 solution IM/SC (maximum 0.3-0.5 mg), repeated every 5-20 minutes as needed 4.
• Note the critical difference: 1:1000 concentration for anaphylaxis versus 1:10,000 for cardiac arrest 5.

Bradycardia Management

• Atropine 0.02 mg/kg IV/IO for symptomatic bradycardia, with maximum single dose of 0.5 mg for children and 1.0 mg for adolescents, repeated every 5 minutes to maximum total dose of 1 mg (children) or 2 mg (adolescents) 4, 6.
• The 2015 guidelines eliminated the previous 0.1 mg minimum dose requirement for neonates 6.

Sedation and Procedural Medications

Emergency departments must stock multiple sedation agents to accommodate different procedural needs and patient conditions 1.

Commonly Used Sedatives

• Midazolam 0.2-0.4 mg/kg IV/IO (maximum 20 mg) for rapid sequence intubation 4.
• Ketamine provides dissociative sedation with minimal respiratory depression 1.
• Propofol offers rapid onset and offset for procedural sedation 1.
• Etomidate is preferred when hemodynamic stability is critical 1.
• Fentanyl and remifentanil provide opioid analgesia during procedures 1.

Neuromuscular Blocking Agents

• Rocuronium and atracurium for paralysis during intubation 1.
• Suxamethonium for rapid sequence intubation when short duration is needed 1.

Antidotes and Reversal Agents

Naloxone is the absolute priority antidote that must be immediately available in all emergency settings 4, 7.

Essential Antidotes

• Naloxone 0.1 mg/kg IV/IO/IM for pediatric opioid overdose, with adult dosing of 0.2-2 mg IV/IM 4, 7.
• Multiple doses may be required as naloxone has shorter duration than many opioids 7.
• Flumazenil 0.01-0.02 mg/kg (maximum 0.2 mg) for benzodiazepine overdose, repeated at 1-minute intervals to maximum cumulative dose of 0.05 mg/kg or 1 mg 4.

Critical pitfall: Flumazenil should NOT be used routinely due to risk of precipitating refractory seizures and life-threatening withdrawal in chronic benzodiazepine users 7.

Respiratory Emergency Medications

Acute Asthma Management

• Short-acting beta-2 agonists (albuterol, levalbuterol) are the treatment of choice for acute symptoms and the only appropriate quick-relief medication 1.
• Ipratropium bromide provides additive benefit to SABA in moderate or severe exacerbations in the emergency setting 1.
• Systemic corticosteroids are used for moderate and severe exacerbations to speed recovery and prevent recurrence 1.

Important caveat: Regular scheduled daily use of SABA is not recommended; increasing use indicates inadequate asthma control requiring anti-inflammatory therapy 1.

Pain Management in Emergency Settings

Trauma Pain Control

• Acetaminophen (paracetamol) administered intravenously every 6 hours is effective and not inferior to NSAIDs for minor musculoskeletal trauma 1.
• Opioids (morphine, fentanyl, ketamine) are the cornerstone for moderate to severe trauma pain 1.
• Ketamine shows favorable safety profile with oxygenation assistance required in only 0.05% of patients versus 0.02% with fentanyl 1.

Critical consideration for elderly patients: NSAIDs require caution due to acute kidney injury and gastrointestinal complications; if used, co-prescribe proton pump inhibitors 1.

Anticonvulsant Medications

• Benzodiazepines (midazolam, lorazepam) for acute seizure management 1.
• Levetiracetam as anti-epileptic maintenance 1.
• Thiopentone for refractory status epilepticus 1.

Metabolic Emergency Medications

Hypoglycemia Management

• Dextrose 0.5-1.0 g/kg: D10W (5-10 mL/kg), D25W (2-4 mL/kg), or D50W (1-2 mL/kg) 4.
• Glucagon 0.03 mg/kg (maximum 1 mg), repeated every 15 minutes up to 3 doses if needed 4.
• Thiamine must be administered before glucose in suspected alcohol-related presentations to prevent Wernicke's encephalopathy 7.

Calcium for Overdoses

• Calcium chloride 20 mg/kg IV (0.2 mL/kg of 10% solution) for calcium channel blocker overdose 4.

Brain Injury Transfer Medications

For safe transfer of brain-injured patients, a specific medication kit must accompany the patient 1.

Required Transfer Medications

• Hypnotics: propofol or midazolam 1.
• Opioid analgesics: alfentanil, fentanyl, or remifentanil infusion 1.
• Vasopressors: ephedrine, metaraminol, noradrenaline, labetalol 1.
• Mannitol 20% or hypertonic saline for elevated intracranial pressure 1.
• Resuscitation drugs as per hospital resuscitation protocols 1.
• Intravenous fluids (0.9% saline preferred) 1.

Alternative Administration Routes

When IV access is challenging, intranasal and endotracheal routes provide viable alternatives for specific medications 4.

• Intranasal route: midazolam, lorazepam, ketamine, fentanyl, and naloxone 4.
• Endotracheal route: epinephrine, atropine, and naloxone (memory aid: LEAN) when IV/IO access is unavailable 4.