What are the essential emergency medicines and their respective doses?

Essential Emergency Medications and Doses

Emergency departments and hospitals should maintain immediate access to core resuscitation medications including epinephrine, vasopressors, sedatives, analgesics, antiarrhythmics, and antidotes, with specific dosing protocols established for both adult and pediatric populations. 1

Core Resuscitation Medications

Epinephrine

• Cardiac arrest (adults): 1 mg IV/IO of 1:10,000 solution, repeated every 3-5 minutes 2, 3
• Cardiac arrest (pediatric): 0.01 mg/kg IV/IO of 1:10,000 solution (maximum: 1 mg), repeated every 3-5 minutes 2
• Anaphylaxis: 0.01 mg/kg IM/SC of 1:1000 solution (maximum: 0.3-0.5 mg for children; 0.5 mg for adults), repeated every 5-20 minutes as needed 2
• Endotracheal route (when IV/IO unavailable): 2-2.5 times the IV dose diluted in 5-10 mL normal saline 2, 4

Atropine

• Bradycardia: 0.02 mg/kg IV/IO for pediatrics, doubled every 5 minutes as needed 2
• Adult bradycardia/cardiac arrest: 0.5-1 mg IV, repeated every 3-5 minutes 1, 5
• Organophosphate poisoning: 2-3 mg IV initially, repeated every 20-30 minutes 5

Vasopressors

• Norepinephrine, epinephrine, dopamine: Essential for hemodynamic support during resuscitation and shock states 1
• Administered via continuous IV infusion with dose titration based on blood pressure response 1

Cardiovascular Emergency Medications

Antiarrhythmics

• Amiodarone: First-line for refractory ventricular fibrillation/pulseless ventricular tachycardia 3
• Lidocaine: Alternative antiarrhythmic when amiodarone unavailable 3
• Both agents carried as basic resuscitation drugs for sudden cardiac arrest 1

Calcium

• Calcium chloride: 20 mg/kg IV (0.2 mL/kg of 10% solution) for calcium channel blocker overdose, hyperkalemia, or hypocalcemia 2
• Should not be routinely administered in cardiac arrest without specific indication 3

Nitroglycerin

• Sublingual tablets for acute coronary syndromes and chest pain 1
• IV formulation for hypertensive emergencies with cardiac involvement 6

Sedatives and Analgesics

Benzodiazepines

• Midazolam: 0.2-0.4 mg/kg IV/IO (maximum: 20 mg) for rapid sequence intubation sedation 2
• Diazepam: For seizure control and sedation 1
• Available via intranasal route when IV access challenging 2

Opioid Analgesics

• Morphine: Essential for pain management in critically ill patients 1
• Fentanyl: Alternative analgesic, available via intranasal route 2

Neuromuscular Blocking Agents

• Required for intubation and mechanical ventilation 1

Antidotes and Reversal Agents

Naloxone

• Opioid overdose (pediatric): 0.1 mg/kg IV/IO/IM 2
• Opioid overdose (adult): 0.4-2 mg IV/IM, repeated as needed 1
• Can be administered endotracheally when IV/IO unavailable 2, 4

Flumazenil

• Benzodiazepine overdose: 0.01-0.02 mg/kg (maximum: 0.2 mg); repeat at 1-minute intervals to maximum cumulative dose of 0.05 mg/kg or 1 mg, whichever is lower 2

Metabolic Emergency Medications

Dextrose

• Hypoglycemia treatment:
  • D10W: 5-10 mL/kg (0.5-1.0 g/kg) 2
  • D25W: 2-4 mL/kg (0.5-1.0 g/kg) 2
  • D50W: 1-2 mL/kg (0.5-1.0 g/kg) 2

Glucagon

• Hypoglycemia (when IV access unavailable): 0.03 mg/kg up to maximum of 1 mg; repeat every 15 minutes up to 3 doses if needed 2

Respiratory Emergency Medications

Bronchodilators

• Albuterol: Nebulizer treatments for bronchospasm and respiratory distress 1, 7
• Among the most frequently used emergency medications, accounting for significant proportion of prehospital interventions 7

Hypertensive Emergency Medications

Intravenous Agents (for true emergencies with end-organ damage)

• Labetalol: 0.25-0.5 mg/kg IV bolus, followed by 2-4 mg/min continuous infusion until goal BP reached, then 5-20 mg/h 6, 8
• Nicardipine: Initial dose 5 mg/h, increasing every 5 minutes by 2.5 mg/h to maximum of 15 mg/h 6
• Clevidipine, nitroglycerin, sodium nitroprusside: Alternative first-line IV agents 8

Oral Agents (for hypertensive urgency without end-organ damage)

• Captopril, labetalol, extended-release nifedipine: First-line oral options 6, 8
• Target: Reduce SBP by no more than 25% within first hour, then aim for <160/100 mmHg over next 2-6 hours 6, 8

Additional Essential Medications

Antimicrobials

• Broad-spectrum antibiotics for sepsis and infection 1

Antivirals

• Neuraminidase inhibitors for influenza-related critical illness 1

Steroids

• Dexamethasone and other corticosteroids for specific indications 1

Prophylactic Medications

• Thromboembolism prophylaxis: Heparin or low-molecular-weight heparin 1
• GI hemorrhage prophylaxis: Proton pump inhibitors or H2 blockers 1

IV Fluids

• Normal saline and other crystalloids: Essential for resuscitation 1

Alternative Administration Routes

When IV/IO access is unavailable or delayed, alternative routes can be life-saving:

• Intranasal (IN): Midazolam, lorazepam, ketamine, fentanyl, naloxone 2
• Endotracheal (ET): Epinephrine, atropine, naloxone, lidocaine (memory aid: LEAN) 2, 4
• Intramuscular (IM): Epinephrine for anaphylaxis, naloxone for opioid overdose 2, 9

Critical Pitfalls to Avoid

• Never use short-acting nifedipine for hypertensive emergencies due to risk of uncontrolled BP drops causing stroke and death 6, 8
• Do not routinely administer sodium bicarbonate or calcium in cardiac arrest without specific indication 3
• Avoid rapid BP reduction in hypertensive emergencies as this causes further complications 6, 8
• Do not use beta-blockers first in sympathomimetic intoxication or pheochromocytoma 8
• Ensure adequate stockpiles as medication shortages remain ongoing challenge, particularly for epinephrine 0.1 mg/mL, morphine, and dextrose 10% 10

Stockpiling Recommendations

Hospitals with ICUs should prepare to deliver emergency mass critical care at three times their usual ICU capacity for up to 10 days, requiring proportional medication stockpiles 1