What are the 20 essential drugs routinely stocked for adult emergency care, including their usual initial adult doses and typical indications?

Essential Emergency Medications: Core Drug List with Dosing and Indications

The 20 most essential emergency medications for adult care include resuscitation drugs (epinephrine, atropine), antidotes (naloxone, flumazenil), cardiovascular agents (adenosine, nitroglycerin), airway medications (albuterol), anticonvulsants (lorazepam, midazolam), metabolic agents (dextrose, glucagon), and critical antidotes for poisoning (acetylcysteine, pralidoxime), with specific dosing protocols that prioritize immediate life-saving interventions. 1, 2

Cardiac Arrest & Resuscitation Drugs

Epinephrine

• Cardiac arrest: 1 mg IV/IO every 3-5 minutes throughout resuscitation efforts 1, 2
• Anaphylaxis: 0.3-0.5 mg IM (1:1000 concentration) into anterolateral thigh as first-line treatment 1
• Critical pitfall: Never delay epinephrine for antihistamines in anaphylaxis—epinephrine must be given first 1

Atropine

• Bradycardia: 0.5-1.0 mg IV every 3-5 minutes up to 3 mg total 1
• Organophosphate poisoning: 1-2 mg IV initially, doubling every 5 minutes until bronchorrhea, bronchospasm, and bradycardia resolve; typical requirements are 10-20 mg in first 2-3 hours 1, 3
• Atropine-induced tachycardia is NOT a contraindication to continued dosing in organophosphate poisoning 3

Antidotes for Overdose

Naloxone

• Opioid overdose: 0.2-2 mg IV/IO/IM, titrated to reversal of respiratory depression (not full consciousness) 1
• Always give naloxone first in suspected combined opioid-benzodiazepine overdose 1

Flumazenil

• Benzodiazepine overdose: 0.2 mg IV initially, titrated up to 1 mg maximum 1
• Critical pitfall: Never give flumazenil without screening for contraindications (chronic benzodiazepine use, seizure history, tricyclic antidepressant co-ingestion) 1

Acetylcysteine

• Acetaminophen overdose: 22 g IV over 8 hours for a 100 kg patient (loading dose 150 mg/kg over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours) 4
• Administer intravenously for hepatic failure 4

Pralidoxime

• Organophosphate poisoning: 1-2 g IV loading dose over 15-30 minutes, followed by continuous infusion of 400-600 mg/hour 3
• Must be given early before enzyme "aging" occurs; for nerve agents like soman, aging happens within minutes 3
• Always administer concurrently with atropine—pralidoxime reverses nicotinic effects while atropine controls muscarinic toxicity 3

Anticonvulsants

Lorazepam

• Status epilepticus: 2-4 mg IV as first-line treatment 1
• Acute agitation: 2-4 mg IV/IM (often combined with haloperidol 5 mg) 1

Midazolam

• Seizures: 5 mg IM as first-line treatment when IV access unavailable 1
• Rapid sequence intubation: 0.2-0.4 mg/kg IV (maximum 20 mg) 2

Respiratory Emergency Medications

Albuterol

• Bronchospasm: 2.5-5 mg in 3 mL normal saline via nebulizer 1
• Often combined with ipratropium bromide 0.5 mg for enhanced bronchodilation 1

Ipratropium Bromide

• Bronchospasm: 0.5 mg combined with albuterol via nebulizer 1

Cardiovascular Medications

Adenosine

• Supraventricular tachycardia: 6 mg rapid IV push, followed by 12 mg if no response, then 12 mg again if needed 4
• Must be given as rapid push followed immediately by saline flush 4

Nitroglycerin

• Acute coronary syndrome/hypertensive emergency: 0.4 mg sublingual every 5 minutes up to 3 doses, or IV infusion starting at 5-10 mcg/min 1

Labetalol

• Hypertensive emergency: First-line treatment for malignant hypertension, hypertensive encephalopathy, and acute stroke with severe hypertension 2

Metabolic Emergency Medications

Dextrose 50%

• Hypoglycemia: 25-50 mL (12.5-25 g) IV push 1
• D50 as initial treatment may be followed by additional dextrose at lower concentrations 4

Glucagon

• Hypoglycemia (when IV access unavailable): 1 mg IM/SC, repeat every 15 minutes up to 3 doses if needed 2
• Beta-blocker or calcium channel blocker overdose: 90-250 mg total dose 4

Sodium Bicarbonate

• Severe metabolic acidosis or tricyclic antidepressant overdose: 1 mEq/kg IV 1
• 63-84 g needed to treat one 100 kg patient over 8-24 hours 4

Magnesium Sulfate

• Torsades de pointes: 1-2 g IV over 5-15 minutes 1
• Severe asthma: 1-2 g IV over 5-15 minutes 1

Calcium Preparations

Calcium Chloride

• Calcium channel blocker overdose: 20 mg/kg IV (0.2 mL/kg of 10% solution) 2
• Critical pitfall: Never give calcium chloride through peripheral IV in children—must use central venous route if possible 4, 1
• Do not administer calcium chloride subcutaneously 4

Calcium Gluconate

• Hyperkalemia, hypocalcemia, hydrofluoric acid exposure: 30 g for 100 kg patient over 8-24 hours 4
• May be given by IV or subcutaneous routes (unlike calcium chloride) 4

Anaphylaxis Adjuncts

Diphenhydramine

• Anaphylaxis (adjunctive): 25-50 mg IV/IM after epinephrine 1

Famotidine

• Anaphylaxis (adjunctive): 20 mg IV after epinephrine 1

Anticoagulation Reversal

Digoxin Immune Fab

• Digoxin toxicity: 15 vials for 100 kg patient 4

Protamine Sulfate

• Heparin reversal: 400 mg to 1.2 g for 100 kg patient 4

Critical Stocking Recommendations

• Hospitals providing emergency care should stock 8-hour supplies of all essential antidotes, with 24-hour supplies preferred for high-risk facilities 4
• Oxygen was the most commonly administered medication in mass-casualty incidents (16.3%), followed by crystalloids (6.9%) and narcotic analgesics (3.2%) 5
• Endotracheal administration is acceptable for epinephrine, atropine, and naloxone when IV/IO access is unavailable (memory aid: LEAN—Lidocaine, Epinephrine, Atropine, Naloxone) 2, 6

Route-Specific Considerations

• Intranasal (IN) route is viable for midazolam, lorazepam, ketamine, fentanyl, and naloxone when IV access is challenging 2
• Avoid succinylcholine and mivacurium in organophosphate poisoning—these neuromuscular blockers are metabolized by cholinesterase 3