Emergency Medicine Medication Dosages
The most critical emergency medications with standardized dosing include epinephrine (0.01 mg/kg IV/IO for pediatric cardiac arrest, 1 mg for adults), naloxone (0.1 mg/kg for pediatric opioid overdose, 0.2-2 mg for adults), and calcium chloride (20 mg/kg or 0.2 mL/kg of 10% solution for calcium channel blocker toxicity), with dosing adjustments required for renal impairment and specific clinical scenarios. 1, 2
Cardiac Arrest Medications
Epinephrine
- Adults: 1 mg IV/IO every 3-5 minutes during cardiac arrest 1, 3
- Pediatric: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) IV/IO, maximum 1 mg 1, 2
- Endotracheal route: 0.1 mg/kg (0.1 mL/kg of 1:1000 solution), maximum 2.5 mg 1
- Newborns: 0.01-0.03 mg/kg of 1:10,000 solution IV/IO 2
Important caveat: While epinephrine improves return of spontaneous circulation (ROSC), it does not improve survival with favorable neurologic outcomes 3. Lower doses (0.5 mg) have been studied but show no significant difference in outcomes compared to standard 1 mg dosing 4.
Amiodarone
- Pediatric: 5 mg/kg IV/IO bolus, may repeat twice up to total 15 mg/kg, maximum single dose 300 mg 1
- Monitor ECG and blood pressure; adjust administration rate based on urgency (IV push during cardiac arrest, slower over 20-60 minutes with perfusing rhythm) 1
Atropine
- Pediatric bradycardia: 0.02 mg/kg IV/IO, minimum dose 0.1 mg, maximum single dose 0.5 mg 1
- Adults (for β-blockers, calcium channel blockers, digoxin): 0.5-1.0 mg every 3-5 minutes up to 3 mg 1
- Organophosphate/carbamate poisoning: 1-2 mg (adults) or 0.02 mg/kg (pediatric), doubled every 5 minutes; maintenance infusion 10-20% of loading dose per hour up to 2 mg/h 1
Antidotes for Toxicologic Emergencies
Naloxone (Opioid Overdose)
- Pediatric: 0.1 mg/kg IV/IO/IM 1, 2
- Alternative dosing: <5 years or <20 kg: 0.1 mg/kg; ≥5 years or ≥20 kg: 2 mg 1
- Adults: 0.2-2 mg IV/IO/IM 1
- Maintenance: Two-thirds of the waking dose per hour 1
- For therapeutic opioid-related respiratory depression, use lower doses (1-5 mcg/kg titrated to effect) 1
Flumazenil (Benzodiazepine Overdose)
- Adults: 0.2 mg IV, titrated up to 1 mg 1
- Pediatric: 0.01 mg/kg IV 1
- Critical warning: Multiple contraindications exist, including benzodiazepine tolerance, seizure disorders, and co-ingestion with tricyclic antidepressants 1
Calcium (Calcium Channel Blocker Toxicity)
- Calcium chloride 10%: 20 mg/kg (0.2 mL/kg) IV/IO, maximum 2 g 1
- Calcium gluconate: 60 mg/kg IV/IO 1
- Maintenance: 60-120 mg/kg/h 1
- Titrate to blood pressure; do not exceed serum ionized calcium 1.5-2 times upper limit of normal 1
Digoxin Immune Fab
- Acute overdose: 1 vial for every 0.5 mg digoxin ingested 1
- Chronic poisoning: Dose (vials) = serum digoxin concentration (ng/mL) × weight (kg) / 100 1
- Critically ill with unknown dose: 10-20 vials 1
- Each vial contains 40 mg Fab; lower doses may be equally effective 1
Cardiovascular Medications
Glucagon (β-Blocker/Calcium Channel Blocker Toxicity)
- Adults: 2-10 mg IV/IO bolus 1
- Pediatric: 0.05-0.15 mg/kg IV/IO 1
- Maintenance: 1-15 mg/h (adults) 1
- Anticipate vomiting as common side effect 1
Insulin (High-Dose Insulin Euglycemia Therapy)
- β-blocker/calcium channel blocker toxicity: 1 U/kg IV/IO bolus 1
- Maintenance: 1-10 U/kg/h 1
- Use regular human insulin; monitor closely for hypoglycemia, hypokalemia, and volume overload 1
Lipid Emulsion Therapy
- Local anesthetic toxicity: 1.5 mL/kg (up to 100 mL) IV/IO bolus 1
- Maintenance: 0.25 mL/kg/min for up to 30 minutes 1
- All studies use 20% lipid emulsion 1
Metabolic Emergency Medications
Glucose/Dextrose (Hypoglycemia)
Glucagon (Hypoglycemia)
Sedation and Procedural Medications
Midazolam (Rapid Sequence Intubation)
- Pediatric: 0.2-0.4 mg/kg IV/IO, maximum 20 mg 2
Lidocaine
Other Critical Medications
Adenosine (Supraventricular Tachycardia)
- First dose: 0.1 mg/kg IV/IO, maximum 6 mg 1
- Second dose: 0.2 mg/kg IV/IO, maximum 12 mg 1
- Rapid IV/IO bolus with flush; monitor ECG 1
Magnesium Sulfate (Torsades de Pointes)
- Pediatric: 25-50 mg/kg IV/IO over 10-20 minutes (faster in torsades), maximum 2 g 1
Sodium Bicarbonate
- Pediatric: 1 mEq/kg per dose IV/IO slowly 1
- Administer after adequate ventilation 1
- Critical note: Should not be routinely administered in cardiac arrest 3
Procainamide
- Pediatric: 15 mg/kg IV/IO 1
- Adults: 20 mg/min IV infusion to maximum 17 mg/kg 1
- Monitor ECG and blood pressure; give slowly over 30-60 minutes 1
Dosing Considerations and Safety
Weight Estimation
- Use length-based tapes with precalculated doses when actual weight is unknown 1, 5
- These are more accurate than age-based or observer estimates 1
Route of Administration
- IV/IO preferred: IV is first-line; if unsuccessful, use IO access 3
- Endotracheal route: Only for lipid-soluble drugs (epinephrine, atropine, naloxone—memory aid: LEAN) 2
- Intranasal route: Viable alternative for midazolam, lorazepam, ketamine, fentanyl, naloxone when IV access is challenging 2
Renal Dosing Adjustments
For medications requiring renal adjustment (e.g., tranexamic acid):
- Serum creatinine 1.36-2.83 mg/dL: Reduce to twice daily dosing 6
- Serum creatinine 2.83-5.66 mg/dL: Reduce to once daily dosing 6
- Serum creatinine >5.66 mg/dL: Reduce to every 48 hours or half-dose every 24 hours 6
Common Pitfalls to Avoid
- Calculation errors: Weight-based dosing in pediatrics significantly increases risk for harm; use precalculated dosing aids 5
- Route confusion: Tranexamic acid administered intrathecally instead of IV has caused seizures and cardiac arrhythmias 6
- Endotracheal epinephrine: May cause transient β-adrenergic vasodilation leading to hypotension and reduced coronary perfusion 1
- Flumazenil contraindications: Do not use in benzodiazepine-tolerant patients, seizure disorders, or tricyclic antidepressant co-ingestion 1
- Calcium administration: Must use central line in children to avoid tissue injury 1