What are the most commonly used emergency department medications for adult patients without specific comorbidities, including their indications, initial doses, and dosing intervals?

Most Common Emergency Department Medications

Analgesics

Opioids

For acute pain management in the ED, start with short-acting oral opioids at the lowest effective dose, with hydrocodone/acetaminophen 5-10 mg or oxycodone 5-10 mg every 4-6 hours as needed being first-line options. 1

• Hydrocodone/APAP: 5-15 mg PO every 4-6 hours PRN (Schedule III) 1
• Oxycodone/APAP: 5-15 mg PO every 4-6 hours PRN (Schedule II) 1
• Morphine: 15-30 mg PO every 4-6 hours PRN (Schedule II) 1
• Hydromorphone: 2-4 mg PO every 4-6 hours PRN (Schedule II) 1
• Codeine/APAP: 30-60 mg PO every 4-6 hours PRN (Schedule III) 1

Critical pitfall: Never prescribe long-acting or extended-release opioids (OxyContin, MS Contin, fentanyl patches) for acute pain—these are for opioid-tolerant chronic pain patients only. 1

NSAIDs

• Ibuprofen: 800 mg PO provides equivalent analgesia to ketorolac 60 mg IM for acute pain 2
• Ketorolac: 60 mg IM (though not superior to oral ibuprofen 800 mg) 2

Cardiac Arrest & Resuscitation

Epinephrine 1 mg IV/IO every 3-5 minutes is the cornerstone of cardiac arrest management and should be continued throughout resuscitation efforts. 3

• Epinephrine: 1 mg IV/IO every 3-5 minutes during cardiac arrest 3
• Atropine: 0.5-1.0 mg IV every 3-5 minutes up to 3 mg total for bradycardia 3

Anaphylaxis Management

Intramuscular epinephrine 0.3-0.5 mg (1:1000 concentration) into the anterolateral thigh must be given immediately as first-line treatment—never delay for antihistamines. 4, 3

• Epinephrine: 0.3-0.5 mg IM (1:1000) into anterolateral thigh as first-line 4, 3
• Diphenhydramine: 25-50 mg IV/IM as adjunctive therapy after epinephrine 3
• Famotidine: 20 mg IV as adjunctive therapy after epinephrine 4, 3

Critical pitfall: H2-antagonists like famotidine have a 1-hour onset and should never replace or delay epinephrine administration. 4

Acute Coronary Syndrome Anticoagulation

For unstable angina/NSTEMI, enoxaparin 1 mg/kg SC every 12 hours is preferred over unfractionated heparin based on superior outcomes. 1

• Enoxaparin: 1 mg/kg SC every 12 hours (minimum 48 hours) 1
• UFH: 60-70 units/kg IV bolus (max 5000 units), then 12-15 units/kg/hour infusion 1

Acute Agitation Management

For the acutely agitated undifferentiated patient, use either a benzodiazepine (lorazepam or midazolam) or a conventional antipsychotic (droperidol or haloperidol) as effective monotherapy. 1

• Lorazepam: 2-4 mg IV as first-line for seizures or agitation 1, 3
• Midazolam: 5 mg IM as first-line for seizures 3
• Haloperidol: 5 mg IM (often combined with lorazepam 2 mg) 1
• Droperidol: Preferred over haloperidol when rapid sedation required 1

For cooperative agitated patients: Combine oral lorazepam with oral risperidone for synergistic effect. 1

Respiratory Emergencies

• Albuterol: 2.5-5 mg in 3 mL normal saline via nebulizer for bronchospasm 3
• Ipratropium bromide: 0.5 mg combined with albuterol via nebulizer 3
• Magnesium sulfate: 1-2 g IV over 5-15 minutes for severe asthma or torsades de pointes 3

Overdose Antidotes

For opioid overdose, titrate naloxone to reversal of respiratory depression, not full consciousness—this prevents acute withdrawal and agitation. 3

• Naloxone: 0.2-2 mg IV/IO/IM, titrated to respiratory reversal 3
• Flumazenil: 0.2 mg IV, titrated up to 1 mg maximum for benzodiazepine reversal 3
• Atropine: 1-2 mg IV, doubled every 5 minutes for organophosphate poisoning 3

Critical pitfall: Never give flumazenil without screening for contraindications (seizure history, chronic benzodiazepine use, tricyclic antidepressant co-ingestion). 3

Metabolic Emergencies

• 50% Dextrose: 25-50 mL (12.5-25 g) IV push for hypoglycemia 3
• Sodium bicarbonate: 1 mEq/kg IV for severe metabolic acidosis or tricyclic antidepressant overdose 3

Special Population Considerations

For patients ≥65 years old, reduce opioid and benzodiazepine starting doses by 50% as elevated doses are frequently administered inappropriately, especially to the 65-69 age group. 5

• Patients aged 65-69 receive very high opioid doses 8.28 times more frequently than those ≥85 years 5
• Men receive elevated benzodiazepine doses 2.12 times more frequently than women 5
• Thiazides, antidepressants, benzodiazepines, and anticonvulsants are commonly associated with drug-related ED visits in elderly patients with non-specific complaints 6

Most Frequently Used Medication Categories in ED

Based on MET activation data, the most common medication categories are: 7

1. Cardiac system agents (35.6% of medications used) 7
2. Intravenous electrolytes (12.9%) 7
3. Opioid analgesics (9.4%) 7
4. Oxygen (most common overall at 16.3% in mass casualty incidents) 8
5. Crystalloids (6.9% in mass casualty incidents) 8