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Emergency medicine duty doctor should know

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This is a very rich section from Rosen's Emergency Medicine. Let me compile a comprehensive answer from what I've found, supplemented by my medical knowledge.

Essential Medicines Every Emergency Duty Doctor Should Know

Based on Rosen's Emergency Medicine, Tintinalli's Emergency Medicine, and established emergency pharmacology, here is a structured reference of the most critical drugs an ED doctor must know:

1. Cardiac Arrest & Resuscitation (ACLS Drugs)

Drug	Dose	Indication
Epinephrine (Adrenaline)	1 mg IV/IO every 3-5 min	VF/pVT/PEA/Asystole
Amiodarone	300 mg IV bolus, then 150 mg	Refractory VF/pVT
Lidocaine	1-1.5 mg/kg IV	Alternative to amiodarone in VF/pVT
Atropine	0.5 mg IV (max 3 mg)	Symptomatic bradycardia
Adenosine	6 mg rapid IV push, then 12 mg	SVT (narrow-complex tachycardia)
Magnesium sulfate	1-2 g IV	Torsades de pointes, hypomagnesemia
Sodium bicarbonate	1 mEq/kg IV	Hyperkalemia, TCA overdose
Calcium chloride	1 g IV	Hyperkalemia, calcium channel blocker OD, hypocalcemia

2. Airway & RSI (Rapid Sequence Intubation)

Drug	Dose	Use
Etomidate	0.3 mg/kg IV	Induction agent - hemodynamically neutral
Ketamine	1-2 mg/kg IV	Induction, bronchospasm, procedural sedation
Propofol	1-2 mg/kg IV	Induction (avoid if hypotensive)
Succinylcholine	1.5 mg/kg IV	Depolarizing neuromuscular blocker (RSI)
Rocuronium	1.2 mg/kg IV	Non-depolarizing NMB (RSI, if succinylcholine contraindicated)
Sugammadex	16 mg/kg IV	Reversal of rocuronium
Midazolam	0.1 mg/kg IV	Sedation, pre-medication

Contraindications for succinylcholine: hyperkalemia, crush injury >72h, burns, denervation injury, rhabdomyolysis.

3. Analgesia & Sedation

Drug	Dose	Use
Morphine	0.1 mg/kg IV	Moderate-severe pain
Fentanyl	1-2 mcg/kg IV	Rapid-onset analgesia, hemodynamically stable
Ketamine (sub-dissociative)	0.3 mg/kg IV	Pain, procedural sedation
Ketorolac	15-30 mg IV/IM	NSAID analgesia (renal colic, musculoskeletal)
Acetaminophen (IV)	1 g IV over 15 min	Pain, fever
Naloxone	0.4-2 mg IV/IM/intranasal	Opioid reversal

4. Anaphylaxis & Allergy

Drug	Dose	Use
Epinephrine	0.3-0.5 mg IM (1:1000)	Anaphylaxis - FIRST LINE
Diphenhydramine	25-50 mg IV/IM	H1 blocker
Ranitidine/Famotidine	50 mg IV / 20 mg IV	H2 blocker
Methylprednisolone	125 mg IV	Prevent biphasic reaction
Salbutamol (Albuterol)	2.5 mg nebulized	Bronchospasm in anaphylaxis

5. Stroke & Neurological Emergencies

Drug	Dose	Use
tPA (Alteplase)	0.9 mg/kg IV (max 90 mg)	Ischemic stroke (within 4.5h of onset)
Lorazepam	0.1 mg/kg IV	Status epilepticus - first line
Diazepam	0.15 mg/kg IV	Status epilepticus
Levetiracetam	60 mg/kg IV (max 4.5 g)	Second-line seizure control
Phenytoin/Fosphenytoin	20 mg/kg IV	Second-line seizure control
Mannitol	0.5-1 g/kg IV	Raised ICP, cerebral herniation
Hypertonic saline (3%)	150 mL IV	Raised ICP, severe hyponatremia

6. Sepsis & Critical Care

Drug	Use
Norepinephrine	Vasopressor of choice in septic shock
Vasopressin	Second-line vasopressor (0.03-0.04 units/min)
Dopamine	Alternative vasopressor; cardiogenic shock at low dose
Hydrocortisone	200 mg/day IV - refractory septic shock
Broad-spectrum antibiotics	Piperacillin-tazobactam, meropenem (give within 1 hour)

7. Chest Pain / ACS (Acute Coronary Syndrome)

Drug	Use
Aspirin	300 mg PO/chew - immediate antiplatelet
Nitroglycerin	0.4 mg SL - chest pain, acute pulmonary edema
Heparin	Anticoagulation in NSTEMI/STEMI
Clopidogrel/Ticagrelor	Dual antiplatelet therapy
Metoprolol	Rate control, MI - avoid if bradycardia or acute HF
Streptokinase/Tenecteplase	Thrombolysis if PCI unavailable

8. Respiratory Emergencies

Drug	Use
Salbutamol (Albuterol)	Bronchodilator - asthma/COPD exacerbation
Ipratropium bromide	Anticholinergic bronchodilator (combine with salbutamol)
Budesonide (nebulized)	Inhaled steroid - severe asthma, croup
Methylprednisolone	1-2 mg/kg IV - severe asthma
Magnesium sulfate	2 g IV - severe asthma not responding to bronchodilators
Heliox	Severe upper airway obstruction/asthma
Furosemide	40-80 mg IV - acute pulmonary edema

9. Toxicology & Antidotes

Poison/Overdose	Antidote	Dose
Opioids	Naloxone	0.4-2 mg IV/IM/IN
Benzodiazepines	Flumazenil	0.2 mg IV (caution - may precipitate seizures)
Organophosphate	Atropine + Pralidoxime	Atropine 2-4 mg IV (titrate to dry secretions)
Paracetamol (Acetaminophen)	N-Acetylcysteine (NAC)	150 mg/kg IV over 1h then infusion
Beta-blocker OD	Glucagon	3-10 mg IV
Calcium channel blocker OD	Calcium chloride + High-dose insulin	CaCl 1g IV; Insulin 1 unit/kg bolus
Cyanide	Hydroxocobalamin	5 g IV
Digoxin	Digoxin-specific Fab	Based on serum level
TCA overdose	Sodium bicarbonate	1-2 mEq/kg IV
Warfarin/anticoagulant	Vitamin K + FFP/PCC	Vitamin K 10 mg IV
Methanol/Ethylene glycol	Fomepizole (or ethanol)	15 mg/kg IV loading
Heparin	Protamine sulfate	1 mg per 100 units heparin

10. Obstetric Emergencies

Drug	Use
Magnesium sulfate	4-6 g IV loading - eclampsia seizure prevention/treatment
Labetalol / Hydralazine	Severe hypertension in pregnancy
Oxytocin	Postpartum hemorrhage management
Dexamethasone	Fetal lung maturity (24-34 weeks)

11. Hypoglycemia & Metabolic

Drug	Use
Dextrose 50% (D50W)	50 mL IV - acute hypoglycemia
Glucagon	1 mg IM - hypoglycemia if no IV access
Thiamine (B1)	100 mg IV - always before dextrose in alcoholics (Wernicke's prevention)
Insulin (regular)	Hyperkalemia, DKA

Key Emergency Mnemonics

MONA for ACS: Morphine, Oxygen, Nitroglycerin, Aspirin
STEMI thrombolysis if no PCI: Streptokinase / Tenecteplase
RSI pretreatment: Atropine (in kids <1yr), Lidocaine (TBI), Fentanyl
Anaphylaxis: Epinephrine FIRST - never delay for antihistamines
Status epilepticus: Benzodiazepine → Levetiracetam/Phenytoin → Phenobarbitone → Propofol/Thiopentone

Sources: Rosen's Emergency Medicine (9780323757898), Tintinalli's Emergency Medicine (9781260019933), Plum & Posner's Diagnosis and Treatment of Stupor and Coma, Harriet Lane Handbook (Pediatric Resuscitation).

This covers the core pharmacological knowledge every emergency duty doctor should have at their fingertips. Would you like a deeper dive into any specific category - such as pediatric doses, specific drug mechanisms, or a particular emergency scenario?

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Excellent - I now have detailed, authoritative content directly from Tintinalli's and Miller's Anesthesia. Here is the comprehensive deep-dive:

Cardiac Arrest & ACLS Drugs - Deep Dive

Sources: Tintinalli's Emergency Medicine, Braunwald's Heart Disease, Miller's Anesthesia (2020 AHA Guidelines)

The Core Principle First

"Good CPR, ventilation, and early defibrillation are the cornerstones of management. Drugs are an adjunct. The effectiveness of standard resuscitative drugs on survival to hospital discharge has not been well demonstrated." - Tintinalli's Emergency Medicine

This is critical: never delay CPR or defibrillation to give a drug.

Drug Administration During Arrest - Key Rules

Use a proximal peripheral vein (not central - too long, slower delivery)
Flush with 20 mL normal saline after every drug bolus
Continue CPR for 30-60 seconds after drug before next defibrillation
Optimal IV fluid = normal saline (NOT dextrose, Ringer's, or bicarb)
Endotracheal drug route is no longer recommended - poor absorption in pulmonary edema
IO access is equivalent to IV for drug doses

1. EPINEPHRINE (Adrenaline)

Class: Endogenous catecholamine

Mechanism:

Alpha effects (beneficial): Peripheral vasoconstriction → increases coronary perfusion pressure + cerebral blood flow during CPR
Beta effects (controversial): Increase myocardial work, may reduce subendocardial perfusion

Doses:

Route	Dose	Indication
IV/IO	1 mg (10 mL of 1:10,000)	Cardiac arrest (VF, pVT, PEA, Asystole)
Repeat	Every 3-5 minutes	No maximum dose
IV infusion	2-10 mcg/min	Cardiogenic shock / symptomatic bradycardia

Timing matters:

Non-shockable rhythms (PEA/Asystole): Give epinephrine EARLY - associated with increased ROSC and neurologically intact survival
Shockable rhythms (VF/pVT): Give after defibrillation attempts; optimal timing less clear

What NOT to do:

High-dose epinephrine (2-5 mg) is NOT recommended - no benefit in long-term survival
Do NOT add to alkaline solutions (bicarbonate inactivates it)
After 20 minutes of arrest, epinephrine may worsen myocardial ischemia and induce VT

Evidence: A 2018 UK RCT showed improved 30-day survival (3.2% vs 2.4%) with epinephrine, BUT survivors had higher rates of severe neurologic disability. Epinephrine helps the heart restart but may worsen brain outcomes.

2. AMIODARONE

Class: Vaughan-Williams Class III - but has properties of ALL 4 classes (Na+, K+, Ca++ channel blockade + beta blockade)

Mechanism: Prolongs action potential duration and refractory period; causes coronary and peripheral vasodilation

Doses:

Indication	Dose
Pulseless VT / VF (after defib + epinephrine)	300 mg IV bolus (flush with D5W/saline 20 mL)
Second dose if no response	150 mg IV bolus
Hemodynamically stable VT/SVT	150 mg over 10-15 min, then 1 mg/min x 6 hrs, then 0.5 mg/min x 18 hrs

Other uses beyond arrest:

Hemodynamically stable VT / wide-complex tachycardia
Pharmacologic cardioversion of atrial fibrillation
Rapid ventricular rate in pre-excitation SVT (WPW)

Adverse effects:

Hypotension and bradycardia (most common with infusion) - slow the rate, give fluids
IV solution precipitates in plastic tubing after 2 hours - use glass/polyolefin bottles

Important: A large 2016 multicenter trial (ALPS trial) failed to show survival-to-discharge benefit of amiodarone or lidocaine vs placebo for shock-refractory VF/pVT. Both drugs were better than placebo only in bystander-witnessed arrest for hospital admission.

3. LIDOCAINE

Class: Vaughan-Williams Class IB antiarrhythmic

Mechanism: Sodium channel blocker; suppresses ventricular ectopy; raises VF threshold

Doses:

Indication	Dose
Pulseless VT / VF (alternative to amiodarone)	1-1.5 mg/kg IV bolus
Repeat bolus (if no response)	0.5-0.75 mg/kg every 5-10 min
Maximum total dose	3 mg/kg
Maintenance infusion	1-4 mg/min

When to prefer lidocaine over amiodarone:

Acute transmural MI as the cause of arrest
When amiodarone is unavailable
Either drug is acceptable per 2020 AHA guidelines (no one drug proven superior)

Note: Evidence shows benefit only with IV administration - NOT intraosseous (IO) for improving outcomes.

4. MAGNESIUM SULFATE

Doses:

Indication	Dose
Torsades de Pointes (polymorphic VT with long QT)	1-2 g IV over 5-20 min
Severe refractory asthma (bronchospasm)	2 g IV
Eclampsia	4-6 g IV loading dose

Key point: Routine use of magnesium for VF/pVT is NOT recommended in adults per AHA 2020 guidelines - only for Torsades de Pointes.

5. ATROPINE

Class: Anticholinergic - muscarinic receptor antagonist

Mechanism: Blocks cholinergic (vagal) slowing of SA node and AV conduction → increases heart rate

Doses:

Indication	Dose
Symptomatic bradycardia	0.5 mg IV every 3-5 min
Max total dose	3 mg (complete vagal blockade)

Important caveats:

NOT used in cardiac arrest (removed from PEA/Asystole algorithm in 2010 AHA guidelines)
Doses <0.5 mg may cause paradoxical bradycardia (avoid!)
If atropine fails → use transcutaneous pacing, dopamine, or epinephrine infusion
May cause myocardial ischemia at high heart rates (use cautiously in known IHD)

6. ADENOSINE

Class: Endogenous purine nucleoside

Mechanism: Activates K+ channels in AV node → transient AV nodal blockade → interrupts re-entry circuits

Doses:

Indication	Dose	Route
SVT (narrow-complex regular tachycardia)	6 mg rapid IV push	Proximal vein + 20 mL flush FAST
Repeat if no effect (after 1-2 min)	12 mg IV	Same
Third dose if needed	12 mg IV	Same

Critical technique: Must be given as a RAPID bolus through a proximal (antecubital or above) vein, immediately followed by a fast 20 mL saline flush. It has a half-life of <10 seconds.

Do NOT use in:

Pre-excited AF/flutter (WPW with AF) - may cause VF
Wide-complex tachycardia of uncertain origin unless certain it is SVT with aberrancy
Significant asthma (can cause bronchospasm)

7. SODIUM BICARBONATE

Doses: 1 mEq/kg IV bolus

When it IS indicated:

Hyperkalemia with cardiac effects
TCA (tricyclic antidepressant) overdose - widened QRS
Salicylate overdose - urinary alkalinization
Pre-existing metabolic acidosis before arrest
Prolonged resuscitation (>10-15 min) with arterial blood gas guidance

When it is NOT indicated:

Routine use in cardiac arrest - NOT recommended (no improvement in ROSC or neurologic outcome)
pH-guided use only when pH < 7.1 or bicarbonate < 10 mEq/L

8. CALCIUM CHLORIDE / CALCIUM GLUCONATE

Drug	Dose	Notes
Calcium chloride 10%	1 g (10 mL) IV	3x more bioavailable; central/large vein preferred (caustic)
Calcium gluconate 10%	3 g (30 mL) IV	Safer for peripheral vein

Indications:

Hyperkalemia with ECG changes
Hypocalcemia (massive transfusion, dialysis patients)
Calcium channel blocker overdose
Beta-blocker overdose (adjunct to glucagon)
Hypermagnesemia

NOT recommended for routine use during CPR even if ionized Ca++ levels are low.

ACLS Algorithm at a Glance

CARDIAC ARREST
     ↓
CPR + Rhythm check
     ↓
┌─────────────────────────────────────────────┐
│ SHOCKABLE (VF / pVT)    NON-SHOCKABLE (PEA/Asystole)
│                              ↓
│ DEFIBRILLATE           Epinephrine 1mg IV ASAP
│ → CPR 2 min            (repeat q 3-5 min)
│ → Epinephrine 1mg      → Treat reversible causes (H's & T's)
│   (after 1st or 2nd shock)
│ → CPR 2 min
│ → Amiodarone 300mg (after 3rd shock)
│   or Lidocaine 1-1.5 mg/kg
│ → Continue cycles
└─────────────────────────────────────────────┘

The H's and T's - Reversible Causes of Cardiac Arrest

H's	T's
Hypovolemia	Tension pneumothorax
Hypoxia	Tamponade (cardiac)
Hydrogen ion (acidosis)	Toxins/overdose
Hypo/Hyperkalemia	Thrombosis (pulmonary - PE)
Hypothermia	Thrombosis (coronary - MI)

Treat these simultaneously - no drug will work if the reversible cause is not corrected.

Post-ROSC (Return of Spontaneous Circulation) Care

Action	Drug/Target
Avoid hypoxia	SpO2 94-98%
Avoid hypotension	MAP >65 mmHg - use norepinephrine
Targeted Temperature Management	32-36°C for 24 hours if comatose
Treat seizures	Levetiracetam or valproate
Treat underlying cause	PCI if STEMI/OHCA

Sources: Tintinalli's Emergency Medicine (9781260019933), Miller's Anesthesia 10e (9780323935920), Braunwald's Heart Disease (9780323722193), AHA 2020 Guidelines for CPR and ECC.

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