Basic Emergency Drugs

1. Vasopressors / Cardiac Arrest Drugs

Epinephrine (Adrenaline)

• The cornerstone of ACLS. Alpha and beta-adrenergic agonist.
• Mechanism: Increases coronary and cerebral perfusion pressure during CPR via vasoconstriction (alpha-1); increases heart rate and contractility (beta-1).
• Dose (cardiac arrest): 1 mg IV/IO every 3-5 minutes (adult).
• Pediatric arrest: 0.01 mg/kg IV/IO.
• Also the first-line drug for anaphylaxis (0.3-0.5 mg IM, anterolateral thigh).
• Source: Barash Clinical Anesthesia 9e, Tintinalli's Emergency Medicine

Vasopressin

• Non-adrenergic vasoconstrictor; acts on smooth muscle V1 receptors.
• Dose: 40 U IV/IO (single dose, not repeated).
• Maintains potency in acidosis, unlike catecholamines. However, clinical trials showed it is equivalent but not superior to epinephrine, so it was removed from the standard ACLS algorithm.
• May still be used in prolonged resuscitation or known pre-arrest acidemia.
• Source: Barash Clinical Anesthesia 9e

Atropine

• Anticholinergic; blocks vagal tone.
• Dose: 0.5-1 mg IV; repeat up to 3 mg total.
• Used for symptomatic bradycardia.
• No longer recommended for asystole or PEA (removed from arrest algorithm).
• Source: Morgan & Mikhail's Clinical Anesthesiology 7e, Miller's Anesthesia 10e

2. Antiarrhythmics

Amiodarone

• Class III antiarrhythmic with sodium, potassium, calcium channel blocking AND alpha/beta-adrenergic blocking properties.
• Indications: Shock-refractory VF or pulseless VT (after CPR, defibrillation, and epinephrine); also atrial and ventricular dysrhythmias.
• Dose (arrest): 300 mg IV/IO bolus first dose; 150 mg second dose.
• Side effects: Hypotension, bradycardia (especially with older formulations due to polysorbate-80/benzyl alcohol cosolvents).
• Source: Barash Clinical Anesthesia 9e, Tintinalli's Emergency Medicine

Lidocaine

• Class Ib agent; weak sodium channel blocker preferentially acting on ischemic myocardial tissue.
• Alternative to amiodarone for shock-refractory VF/pulseless VT.
• Dose (VF/pulseless VT): Initial 1-1.5 mg/kg IV; repeat 0.5-0.75 mg/kg every 5-10 min (max 3 mg/kg total).
• Dose (ventricular arrhythmia): 50-100 mg over 2-3 min; maintenance 1-4 mg/min.
• Side effects: CNS toxicity (numbness, somnolence, seizures) - dose-dependent.
• Source: Tintinalli's Emergency Medicine, Barash Clinical Anesthesia 9e

Adenosine

• Temporarily blocks AV node conduction - terminates reentrant SVT.
• Dose: 6 mg rapid IV push (first dose); 12 mg if no response (may repeat once more at 12 mg).
• Must be given as a fast bolus followed immediately by a saline flush.

Procainamide

• Class Ia; increases refractory period, decreases automaticity.
• Dose (stable VT): 20-50 mg/min IV until arrhythmia suppressed; max 17 mg/kg. Maintenance 1-4 mg/min.
• Avoid in QT prolongation or CHF.
• Source: Tintinalli's Emergency Medicine

3. Airway / Anesthesia-Related Emergency Drugs

Succinylcholine

• Depolarizing neuromuscular blocker - ultra-short acting.
• Drug of choice for rapid sequence intubation (RSI).
• Dose: 1-1.5 mg/kg IV.
• Contraindicated in hyperkalemia, burns >24h, crush injuries, rhabdomyolysis, denervation injuries.

Propofol

• IV induction agent; also used to treat bronchospasm, laryngospasm, and emergence delirium.
• Dose: 1-2 mg/kg IV.
• Must have emergency drugs (epinephrine, atropine) ready before induction.
• Source: Barash Clinical Anesthesia 9e

Dantrolene

• Treatment for malignant hyperthermia (MH).
• Inhibits calcium release from the sarcoplasmic reticulum.
• Dose: 2.5 mg/kg IV, repeat as needed.
• A minimum of 12 vials (or equivalent) must be stocked wherever triggering agents (volatile anesthetics, succinylcholine) are used.
• Source: Barash Clinical Anesthesia 9e

4. Reversal Agents / Antidotes

5. Other Key Emergency Drugs

Sodium Bicarbonate

• For metabolic acidosis, hyperkalemia, tricyclic antidepressant overdose.
• Dose: 1 mEq/kg IV initially.

Dextrose 50% (D50W)

• For hypoglycemia.
• Dose: 25-50 g (50-100 mL of D50) IV.
• Always precede with thiamine in suspected alcohol use/malnutrition to prevent Wernicke's encephalopathy.

Thiamine (Vitamin B1)

• Given before dextrose in coma of unknown cause.
• Dose: 100 mg IV/IM.

Magnesium Sulfate

• For torsades de pointes, eclampsia, refractory VF, and severe asthma.
• Dose (torsades): 1-2 g IV over 1-2 min.

Nitroglycerin

• Vasodilator for acute coronary syndromes and hypertensive emergencies with pulmonary edema.
• Dose: 0.4 mg sublingual every 5 min (up to 3 doses).

6. ACLS Drug Summary Table