Emergency drugs every duty doctor should know
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I now have comprehensive textbook data from Tintinalli's Emergency Medicine, Miller's Anesthesia, Rosen's Emergency Medicine, and multiple pharmacology references. Let me compile the full answer.
Emergency Drugs Every Duty Doctor Should Know
A duty doctor is the last line of defense before specialist backup arrives. Below is a systematic, category-by-category reference based on Tintinalli's Emergency Medicine, Rosen's Emergency Medicine, Miller's Anesthesia, and Goodman & Gilman's Pharmacological Basis of Therapeutics.
1. Cardiac Arrest (ACLS)
Epinephrine (Adrenaline)
- Mechanism: Alpha + beta adrenergic agonist - increases coronary and cerebral perfusion pressure during CPR
- Indication: Pulseless arrest (VF, pVT, PEA, asystole); symptomatic bradycardia; anaphylaxis
- Dose (cardiac arrest): 1 mg IV/IO every 3-5 minutes
- Dose (anaphylaxis): 0.3-0.5 mg IM (1:1000) in anterolateral thigh; repeat q5-15 min
- Dose (bradycardia infusion): 1 mg in 500 mL NS at 2-10 mcg/min
- Note: Standard dose recommended - high-dose (0.1 mg/kg) shows no survival benefit and may worsen neurological outcomes
- Tintinalli's Emergency Medicine, Ch. 21
Amiodarone
- Mechanism: Class III antiarrhythmic (also Classes I, II, IV properties); coronary and peripheral vasodilation
- Indication: Shock-refractory VF/pulseless VT; stable VT; rate control in AF
- Dose (pulseless arrest): 300 mg IV bolus, then 150 mg if no response
- Dose (stable arrhythmia): 150 mg IV over 10-15 min, then 1 mg/min x 6 hr, then 0.5 mg/min x 18 hr
- Key SE: Hypotension, bradycardia - slow infusion or use vasopressors
- Caution: Infusions >2 hr use glass/polyolefin (precipitates in PVC tubing)
- Tintinalli's Emergency Medicine, Ch. 21
Lidocaine (Lignocaine)
- Mechanism: Class Ib antiarrhythmic - reduces automaticity, suppresses ventricular ectopy
- Indication: Alternative to amiodarone for VF/pulseless VT; hemodynamically stable VT
- Dose: 1-1.5 mg/kg IV bolus; second bolus 0.5-0.75 mg/kg if rhythm persists
- Note: Comparable efficacy to amiodarone for out-of-hospital VF/pVT; use when amiodarone unavailable
- Tintinalli's Emergency Medicine, Ch. 21
Atropine
- Mechanism: Muscarinic antagonist - blocks vagal tone, increases heart rate
- Indication: Symptomatic bradycardia; organophosphate poisoning
- Dose (bradycardia): 0.5 mg IV, repeat to max 3 mg total
- Dose (organophosphate): 2-4 mg IV, repeated q5-10 min until secretions dry
- Note: Removed from AHA pulseless arrest algorithm; useful for symptomatic sinus bradycardia and AV block
- Barash's Clinical Anesthesia, 9e
Adenosine
- Mechanism: Transiently blocks AV node conduction
- Indication: First-line for narrow-complex stable SVT (AVNRT, AVRT)
- Dose: 6 mg IV rapid push + 20 mL saline flush; if no conversion: 12 mg, repeat 12 mg
- Key point: Administer into a large proximal vein (antecubital or above) - very short half-life (~10 sec); warn the patient of transient chest tightness/flushing
2. Anaphylaxis & Severe Allergic Reactions
| Drug | Dose | Route | Role |
|---|---|---|---|
| Epinephrine (1:1000) | 0.3-0.5 mg (adult); 0.01 mg/kg child | IM, anterolateral thigh | First-line - no contraindications in anaphylaxis |
| Epinephrine infusion | 1-4 mcg/min IV | IV | Refractory anaphylaxis/shock |
| Diphenhydramine | 25-50 mg | IV/IM | H1 antihistamine (adjunct, not first-line) |
| Ranitidine/famotidine | 50 mg / 20 mg | IV | H2 blocker (adjunct) |
| Methylprednisolone | 80-125 mg IV (2 mg/kg children) | IV | Prevents biphasic reaction; delayed onset |
| Hydrocortisone | 250-500 mg | IV | Alternative to methylprednisolone |
| Salbutamol (albuterol) | 2.5-5 mg nebulized | Inhaled | Bronchospasm refractory to epinephrine |
- Rosen's Emergency Medicine; Tintinalli's Emergency Medicine, Table 14-4
3. Airway Emergencies
Succinylcholine
- Mechanism: Depolarizing neuromuscular blocker
- Indication: Rapid sequence intubation (RSI) - fastest-onset/offset NMB
- Dose: 1.5 mg/kg IV (2 mg/kg in children); 4 mg/kg IM if no IV
- Contraindications: Hyperkalemia, recent burns/crush/denervation, known/suspected myopathy, personal/family history of malignant hyperthermia, prolonged paralysis from pseudocholinesterase deficiency
Rocuronium
- Mechanism: Non-depolarizing NMB (competitive acetylcholine antagonist)
- Indication: RSI when succinylcholine is contraindicated
- Dose: 1.2 mg/kg IV for RSI conditions
- Reversal: Sugammadex 16 mg/kg reverses immediately
Ketamine
- Mechanism: NMDA antagonist - dissociative agent
- Indication: RSI induction (especially in hemodynamically unstable, asthmatic patients); procedural sedation
- Dose (RSI): 1-2 mg/kg IV; 4-6 mg/kg IM
- Advantages: Maintains airway reflexes, bronchodilator, does not cause hypotension - preferred in shocked patients
Midazolam
- Mechanism: Benzodiazepine - GABA-A potentiation
- Indication: Procedural sedation; seizure termination; RSI co-induction
- Dose: 0.05-0.1 mg/kg IV titrated; 0.2 mg/kg IM for seizures
4. Seizures
| Drug | Route | Dose | Notes |
|---|---|---|---|
| Lorazepam | IV | 0.1 mg/kg (max 4 mg) | First-line - longer action than diazepam |
| Diazepam | IV/PR | 0.15-0.2 mg/kg IV; 0.5 mg/kg PR | Rapid onset but shorter effect |
| Midazolam | IM/buccal/IN | 0.1-0.2 mg/kg | Preferred if no IV access |
| Phenytoin/Fosphenytoin | IV | 20 mg PE/kg IV at max 150 mg/min | Second-line; monitor BP and ECG |
| Sodium valproate | IV | 40 mg/kg IV over 10 min | Second-line alternative |
| Levetiracetam | IV | 60 mg/kg IV (max 4500 mg) | Fewer drug interactions |
| Phenobarbital | IV | 20 mg/kg IV at 100 mg/min | Refractory status epilepticus |
| Propofol | IV | 1-2 mg/kg, infusion 2-10 mg/kg/hr | RSE in ICU with airway secured |
5. Poisoning & Overdose Reversal
Naloxone (Narcan)
- Mechanism: Competitive opioid receptor antagonist
- Indication: Opioid overdose - respiratory depression, coma, pinpoint pupils
- Dose: 0.4-2 mg IV/IM/IN; repeat every 2-3 min as needed (duration ~1 hr - shorter than most opioids, so redosing or infusion needed)
- Key point: High-potency opioids (fentanyl analogues) may require repeated large doses (>10 mg cumulative in some cases)
- Miller's Anesthesia 10e; Lippincott Pharmacology
Flumazenil
- Mechanism: Competitive benzodiazepine antagonist
- Indication: Benzodiazepine overdose with respiratory compromise
- Dose: 0.2 mg IV over 15 sec, then 0.1 mg q1min to max 1 mg
- Caution: Precipitates withdrawal seizures in BZD-dependent patients; very short half-life (~1 hr) - rebound sedation common
Activated Charcoal
- Indication: Oral poisoning within 1-2 hr of ingestion if airway protected
- Dose: 1 g/kg (max 50 g) in adults
Sodium Bicarbonate
- Indication: TCA overdose (widened QRS >120 ms); salicylate poisoning; severe metabolic acidosis; hyperkalemia
- Dose (TCA): 1-2 mEq/kg IV bolus; titrate to QRS narrowing and pH 7.45-7.55
Dextrose 50% (D50W)
- Indication: Hypoglycemia (confirmed or suspected); any patient with altered consciousness when glucose cannot be quickly measured
- Dose: 50 mL (25 g) D50W IV; 1-2 mL/kg D25W in children
- Always pair with thiamine 100 mg IV in suspected alcoholism/malnutrition before or with dextrose - prevents precipitating Wernicke's encephalopathy
- Tintinalli's Emergency Medicine, Ch. 215
Thiamine (Vitamin B1)
- Dose: 100 mg IV/IM
- Indication: Alcoholism, malnutrition, Wernicke's risk before dextrose administration
6. Hypertensive Emergency
| Drug | Dose | Mechanism | Notes |
|---|---|---|---|
| Labetalol | 20 mg IV bolus, repeat q10min to 300 mg total; or 0.5-2 mg/min infusion | Alpha+beta blocker | Preferred in most hypertensive emergencies; aortic dissection |
| Hydralazine | 10-20 mg IV q20min | Direct vasodilator | Preferred in eclampsia |
| Nicardipine | 5 mg/hr IV, titrate to 15 mg/hr | CCB | Smooth, predictable control |
| Sodium nitroprusside | 0.3-0.5 mcg/kg/min infusion | NO donor | Immediate effect but cyanide toxicity risk; ICU only |
| Esmolol | 500 mcg/kg bolus, then 50-200 mcg/kg/min | Beta-1 blocker | Aortic dissection; very short-acting |
| GTN (nitroglycerin) | 5-200 mcg/min IV | Nitrate - venodilator | ACS + hypertension; hypertensive pulmonary edema |
7. Acute Coronary Syndrome
| Drug | Dose | Role |
|---|---|---|
| Aspirin | 300 mg chewed (loading) | Antiplatelet - given immediately |
| GTN (glyceryl trinitrate) | 0.4 mg SL q5min x3, then IV | Angina relief, preload reduction |
| Morphine | 2-4 mg IV titrated | Pain/anxiety (use cautiously - may worsen outcomes in NSTEMI) |
| Heparin | 60 U/kg IV bolus (max 4000 U), 12 U/kg/hr | Anticoagulation |
| Clopidogrel/Ticagrelor | 600 mg / 180 mg loading dose | P2Y12 antiplatelet |
| Metoprolol | 25-50 mg PO / 5 mg IV slowly | Heart rate control |
| Thrombolytics (streptokinase/tPA) | Weight-based protocol | STEMI when PCI not available within 120 min |
8. Acute Pulmonary Edema / Heart Failure
| Drug | Dose | Notes |
|---|---|---|
| Furosemide | 40-80 mg IV (or 2.5x oral dose) | Venodilation before diuresis |
| GTN | 0.4 mg SL, then 10-200 mcg/min IV | Rapid preload reduction |
| Morphine | 2-4 mg IV | Anxiolysis, venodilation (use cautiously) |
| CPAP/BiPAP | - | Non-pharmacological - reduces intubation rate significantly |
9. Severe Asthma / COPD Exacerbation
| Drug | Dose | Notes |
|---|---|---|
| Salbutamol (albuterol) | 2.5-5 mg nebulized continuously, or 4-8 puffs MDI | First-line bronchodilator |
| Ipratropium | 0.5 mg nebulized q20min x3 | Anticholinergic - add to salbutamol |
| Hydrocortisone | 100-200 mg IV | IV if oral impossible; onset 4-6 hr |
| Prednisolone | 40-50 mg oral | Equivalent efficacy to IV if patient can swallow |
| Magnesium sulfate | 2 g IV over 20 min | Bronchodilator in severe/life-threatening asthma; one-time dose |
| Epinephrine IM | 0.3 mg IM | Anaphylaxis-associated bronchospasm |
| Heliox | 70:30 mix | Reduces airway resistance in upper obstruction |
10. Shock
| Type | Drug | Dose |
|---|---|---|
| Septic/distributive | Norepinephrine | 0.01-3 mcg/kg/min - first-line vasopressor |
| Septic (add-on) | Vasopressin | 0.03-0.04 U/min - steroid-sparing, spares norepinephrine |
| Cardiogenic | Dobutamine | 2-20 mcg/kg/min - inotrope |
| Any (volume depletion) | Normal saline / Crystalloid | 500 mL bolus, reassess |
| Adrenal/septic | Hydrocortisone | 200 mg/day IV (or 50 mg q6hr) - vasopressor-refractory septic shock |
| Neurogenic | Phenylephrine or norepinephrine | Pure alpha to restore SVR |
11. Metabolic & Electrolyte Emergencies
| Emergency | Drug | Dose |
|---|---|---|
| Hyperkalemia - cardiac stabilization | Calcium gluconate 10% | 10-20 mL IV over 2-5 min - first-line, membrane stabilization |
| Hyperkalemia - shift K+ into cells | Dextrose 50 mL + Insulin 10 U IV | Lowers K+ by 0.5-1 mEq/L over 30-60 min |
| Hyperkalemia - remove K+ | Kayexalate / Patiromer | Oral/rectal (slower onset) |
| Hyponatremia (severe/symptomatic) | 3% NaCl | 100-150 mL bolus IV; correct no faster than 8-10 mEq/L per 24 hr |
| Severe hypomagnesemia/eclampsia | MgSO4 | 4-6 g IV over 15-20 min, then 1-2 g/hr infusion |
| DKA/HHS | Regular insulin + NS | 0.1 U/kg/hr infusion after volume resuscitation |
12. Malignant Hyperthermia
Dantrolene
- Mechanism: Inhibits ryanodine receptor (RYR1) - blocks SR calcium release
- Indication: MH triggered by volatile anaesthetics or succinylcholine
- Dose: 2.5 mg/kg IV bolus, repeat every 5 min to clinical response (max 10 mg/kg)
- Note: Each vial requires 60 mL sterile water; typically need 12+ vials stocked
- Barash's Clinical Anesthesia, 9e; MHAUS protocol
Quick Reference: "Must-Know" Doses at a Glance
| Drug | Key Emergency Dose | Route |
|---|---|---|
| Epinephrine | 1 mg q3-5min (arrest); 0.3-0.5 mg (anaphylaxis) | IV; IM |
| Amiodarone | 300 mg bolus (arrest); 150 mg over 10-15 min (stable) | IV |
| Atropine | 0.5 mg (bradycardia); 2-4 mg (OP poisoning) | IV |
| Adenosine | 6 mg → 12 mg → 12 mg | IV rapid push |
| Naloxone | 0.4-2 mg, repeat q2-3min | IV/IM/IN |
| Flumazenil | 0.2 mg, then 0.1 mg q1min to 1 mg | IV |
| D50W | 50 mL (25 g) | IV |
| Thiamine | 100 mg (before/with dextrose) | IV |
| MgSO4 | 2 g over 20 min (asthma/eclampsia) | IV |
| Calcium gluconate 10% | 10-20 mL over 2-5 min (hyperkalemia/hypocalcemia) | IV |
| Sodium bicarbonate | 1-2 mEq/kg (TCA, severe acidosis) | IV |
| Succinylcholine | 1.5 mg/kg (RSI) | IV |
| Rocuronium | 1.2 mg/kg (RSI) | IV |
| Hydrocortisone | 200 mg/day (septic shock); 100-200 mg (acute asthma) | IV |
| Norepinephrine | Start 0.01 mcg/kg/min, titrate | IV infusion |
Core principle from ACLS and Tintinalli's: Drugs are adjuncts - high-quality CPR, early defibrillation, and securing the airway are always the priorities. No drug substitutes for excellent resuscitation fundamentals.
Sources: Tintinalli's Emergency Medicine (9e), Rosen's Emergency Medicine, Miller's Anesthesia (10e), Barash's Clinical Anesthesia (9e), Goodman & Gilman's Pharmacological Basis of Therapeutics, Lippincott Illustrated Reviews: Pharmacology.
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