Emergency Medications

Clinical Tip: Always consult an authoritative, current reference about dose, dilution, route and rate of administration, and interactions before administering medications, especially IV medications. Have a second licensed person independently check dose calculations, preparation, original orders, and infusion pump programming.

1.  ACE Inhibitors (Angiotensin-converting Enzyme Inhibitors) (Antihypertensive) Common Agents: Captopril, enalapril, lisinopril, ramipril.

Indications: MI, hypertension (HTN), congestive heart failure (CHF), heart failure without hypotension, ST

segment elevation, left ventricular dysfunction after MI.

Dose: See individual order and drug for route and dosage. Usually not started in emergency department, but within 24 hr after fibrinolytic therapy has been completed and blood pressure (BP) has stabilized. Contraindications: Lactation, pregnancy, angioedema, hypersensitivity to ACE inhibitors, serum potassium

>5 mEq/L.

Side Effects: Tachycardia, dizziness, headache, fatigue, hypotension, hyperkalemia. Precautions: Reduce dose in renal failure.

2.  Adenosine (Adenocard, Adenoscan) (Antiarrhythmic) Indications: Narrow-complex tachycardias and PSVT.

Dose: 6 mg rapid intravenous push (IVP) over 1–3 sec followed by a 20-mL bolus of normal saline. Give 12 mg by IVP in 1–2 min if needed. A third dose of 12 mg IVP may be given in 1–2 min, max. 30 mg.

Contraindications: Hypersensitivity, sick sinus syndrome, 2nd- or 3rd-degree AV block (unless a functional

artificial pacemaker is present), drug- or poison-induced tachycardia.

Side Effects: Flushing, dizziness, bronchospasm, chest pain or tightness, bradycardia, AV block, asystole, ventricular ectopic beats, VF.

Precautions: Ineffective in treating A-fib, A-flutter, or VT. Avoid in patients receiving dipyridamole and in patients with asthma or unstable angina.

3.  Amiodarone (Cordarone, Pacerone) (Antiarrhythmic)

Indications: Wide- and narrow-complex tachycardia, polymorphic VT, shock-refractory VF or pulseless VT, SVT, PSVT.

Dose: Cardiac arrest 300 mg (diluted in 20–30 mL D5W) IVP; consider additional 150 mg IVP in 3–5 min. Wide- and narrow-complex tachycardia (stable) 150 mg IVP over first 10 min (15 mg/min)—may repeat

infusion of 150 mg IVP every 10 min as needed; slow infusion of 360 mg IV over next 6 hr (1 mg/min);

maintenance infusion of 540 mg over next 18 hr (0.5 mg/min). Max. cumulative dose: 2.2 g IV in 24 hr. Contraindications: Bradycardia, hypersensitivity, cardiogenic shock, 2nd- or 3rd-degree AV block.

Side Effects: Vasodilation, hypotension, visual impairment, hepatotoxicity, pulmonary toxicity, CHF; may

prolong QT interval, producing torsade de pointes.

Precautions: Avoid concurrent use with procainamide. Correct hypokalemia and hypomagnesemia if possible before use. Draw up amiodarone through a large-gauge needle to reduce foaming. For slow or maintenance

IV infusion, mix medication only in glass bottle containing D5W and administer through an in-line filter.

4.  Aspirin (Acetylsalicylic Acid) (Antiplatelet)

Indications: Acute coronary syndrome, symptoms suggestive of cardiac ischemia.

Dose: 162–325 mg PO non-enteric coated for antiplatelet effect. Give within minutes of onset. Contraindications: Known allergy to aspirin, pregnancy.

Side Effects: Anorexia, nausea, epigastric pain, anaphylaxis.

Precautions: Active ulcers and asthma, bleeding disorders, or thrombocytopenia.

5.  Atropine (Antiarrhythmic, Anticholinergic)

Indications: Symptomatic sinus bradycardia, asystole, PEA with rate <60 bpm, cholinergic drug toxicity and mushroom poisoning (antidote).

Dose: Cardiac arrest 1 mg IVP every 3–5 min (may give through endotracheal (ET) tube at 2.0–3.0 mg diluted in 10 mL normal saline, max. 0.03–0.04 mg/kg. Bradycardia 0.5–1.0 mg IVP every 3–5 min, max.

0.03–0.04 mg/kg.

Contraindications: A-fib, A-flutter, glaucoma, asthma.

Side Effects: Tachycardia, headache, dry mouth, dilated pupils, VF or VT.

Precautions: Use caution in myocardial ischemia and hypoxia. Avoid in hypothermic bradycardia and in 2nd- degree (Mobitz type II) and 3rd-degree AV block.

6.  Beta Blockers (Antihypertensive)

Common Agents: Atenolol, esmolol, labetalol, metoprolol, propranolol. Indications: MI, unstable angina, PSVT, A-fib, A-flutter, HTN.

Dose: See individual order and drug for route and dosage.

Contraindications: HR <60 bpm, systolic BP <100 mm Hg, 2nd- or 3rd-degree AV block, left ventricular failure.

Side Effects: Hypotension, dizziness, bradycardia, headache, nausea and vomiting.

Precautions: Concurrent use with calcium channel blockers, such as verapamil or diltiazem, can cause hypotension. Use caution in patients with a history of bronchospasm or cardiac failure.

7.  Calcium Chloride (Minerals/Electrolytes/Calcium Salt)

Indications: Hyperkalemia, hypocalcemia, hypermagnesemia; antidote to calcium channel blockers and beta blockers; given prophylactically with calcium channel blockers to prevent hypotension.

Dose: Hyperkalemia and antidote to calcium channel blocker 8–16 mg/kg (usually 5–10 mL) slow IVP, may be repeated as needed. Given prophylactically prior to IV calcium channel blockers 2–4 mg/kg (usually 2 mL)

slow IVP.

Contraindications: Hypercalcemia, VF, digoxin toxicity, renal calculi.

Side effects: Bradycardia, asystole, hypotension, VF, nausea and vomiting. Precautions: Incompatible with sodium bicarbonate.

8.  Digoxin Immune FAB (Fragment Antigen Binding) (Digibind) (Antidote to Digoxin, Digitoxin) Indications: Symptomatic digoxin toxicity or acute ingestion of unknown amount of digoxin.

Dose: Dependent on serum digoxin levels. One 40-mg vial binds to approximately 0.6 mg of digoxin. Dose typically administered over 30 min.

Contraindications: Allergy only, otherwise none known.

Side Effects: Worsening of CHF, A-fib, hypokalemia; increased serum digoxin levels. Precautions: Allergies to sheep proteins or other sheep products.

9.  Digoxin (Lanoxin) (Inotropic, Antiarrhythmic)

Indications: To slow ventricular response in A-fib or A-flutter, as a positive inotrope in CHF, pulmonary edema. May be used as an alternative drug for PSVT.

Dose: Loading dose of 10–15 µg/kg, administered over 5 min. Maintenance dose determined by body size and renal function.

Contraindications: Hypersensitivity, uncontrolled ventricular arrhythmias, AV block, idiopathic hypertrophic

subaortic stenosis (IHSS), constrictive pericarditis.

Side Effects: Arrhythmias, particularly VF and AV block; bradycardia; fatigue; nausea and vomiting; blurred or yellow vision; headache; hypersensitivity; hypokalemia.

Precautions: Avoid electrical cardioversion of stable patients. If the patient's condition is unstable, use lower current settings such as 10–20 J. Use cautiously in elderly patients. Correct electrolyte abnormalities, monitor digoxin levels, monitor for clinical signs of toxicity.

10. Diltiazem (Cardizem) (Calcium Channel Blocker)

Indications: A-fib, A-flutter, PSVT refractory to adenosine with narrow QRS complex and adequate BP. Dose: 15–20 mg (0.25 mg/kg) IVP over 2 min. May repeat in 15 min at 20–25 mg (0.35 mg/kg) IVP over 2 min. Start maintenance drip at 5–15 mg/hr and titrate to HR.

Contraindications: Drug- or poison-induced tachycardia, wide-complex tachycardia of uncertain origin, rapid

A-fib and A-flutter with Wolff-Parkinson-White syndrome, sick sinus syndrome, 2nd- and 3rd-degree AV block

(unless a functional artificial pacemaker is present).

Side Effects: Hypotension, bradycardia (including AV block), chest pain, ventricular arrhythmias. Precautions: Severe hypotension in patients receiving beta blockers, hepatic injury, renal disease.

11. Dopamine (Intropin) (Vasopressor, Inotropic)

Indications: Symptomatic bradycardia and hypotension, cardiogenic shock.

Dose: Continuous infusions (titrate to patient response): Low dose 1–5 µg/kg/min; moderate dose 5–10

µg/kg/min (cardiac doses); high dose 10–20 µg/kg/min (vasopressor doses). Mix 400 mg/250 mL in normal saline, lactated Ringer's solution, or D5W (1600 µg/mL).

Contraindications: Pheochromocytoma, uncorrected tachycardia, cardiogenic shock with CHF.

Side Effects: Tachyarrhythmias, angina, hypotension, palpitations, vasoconstriction, dyspnea, nausea and vomiting.

Precautions: Hypovolemia, MI. Adjust dosage in elderly patients and in those with occlusive vascular

disease. Ensure adequate hydration prior to infusion. Taper slowly. Do not mix with sodium bicarbonate. Use care with peripheral administration; infiltration can cause tissue necrosis. Central line is preferred.

12. Epinephrine (Adrenalin) (Adrenergic Agonist)

Indications: Cardiac arrest: PEA, asystole, pulseless VT, VF; severe hypotension; symptomatic bradycardia;

anaphylaxis; severe allergic reactions.

Dose: Cardiac arrest 1 mg IVP (10 mL of 1:10,000 solution) every 3–5 min; follow each dose with 20 mL IV flush; higher doses (up to 0.2 mg/kg) may be used if 1-mg dose fails. Give 2.0–2.5 mg diluted in 10 mL normal saline if administering by ET tube. For continuous infusion add 30 mg (30 mL of 1:1000 solution) to

250 mL normal saline or D5W, run at 100 mL/hr, and titrate to response. Profound bradycardia or hypotension 2–10 µg/min IV (add 1 mg of 1:1000 solution to 500 mL normal saline or D5W and infuse at 1–5

mL/min). Anaphylaxis/asthma 0.1–0.5 mg SC or IM of 1:1000 solution every 5–15 min, may be followed by

1–4 µg/min continuous infusion.

Contraindications: Hypersensitivity to adrenergic amines, hypovolemic shock, coronary insufficiency.

Side Effects: Angina, HTN, tachycardia, VT, VF, nervousness, restlessness, tremors, weakness, headache, nausea.

Precautions: Use caution in HTN and increasing heart rate (may cause increased myocardial oxygen demand). Higher doses can contribute to postarrest cardiac impairment, but they may be required to treat

poison- or drug-induced shock.

13. Fibrinolytic Agents (Thrombolytic, Fibrinolytic)

Common Agents: Alteplase (Activase, t-PA), anistreplase (Eminase), reteplase (Retavase), streptokinase

(Streptase), tenecteplase (TNKase).

Indications: Within <12 hr from onset of symptoms of acute MI. Alteplase is the only fibrinolytic agent approved for acute ischemic stroke and must be started <3 hr from onset of symptoms.

Dose: See individual order and drug for route and dosage.

Contraindications: Active internal bleeding within 21 days (except menses), neurovascular event within 3 months, major surgery or trauma within 2 weeks, aortic dissection, severe (uncontrolled) HTN, bleeding disorders, prolonged cardiopulmonary resuscitation (CPR), lumbar puncture within 1 week.

Side Effects: Hypotension, reperfusion, arrhythmias, heart failure, headache, increased bleeding time, deep or superficial hemorrhage, flushing, urticaria, anaphylaxis.

Precautions: Use cautiously in patients with severe renal or hepatic disease.

14. Furosemide (Lasix) (Diuretic, Loop Diuretics)

Indications: CHF with acute pulmonary edema, hypertensive crisis, postarrest cerebral edema, hepatic or renal disease.

Dose: 0.5–1.0 mg/kg slow IVP over 1–2 min, may repeat at 2 mg/kg slow IVP over 1–2 min. Contraindications: Hypersensitivity (cross-sensitivity with thiazides and sulfonamides may occur),

uncontrolled electrolyte imbalance, hepatic coma, anuria, hypovolemia.

Side Effects: Severe dehydration, hypovolemia, hypotension, hypokalemia, hyponatremia, hypochloremia, hyperglycemia, dizziness, ototoxicity.

Precautions: Use cautiously in severe liver disease accompanied by cirrhosis or ascites, electrolyte

depletion, diabetes mellitus, pregnancy, lactation, risk for ototoxicity with increased dose or rapid injection. Monitor electrolytes closely.

15. Ibutilide (Corvert) (Antiarrhythmic)

Indications: SVT, including A-fib and A-flutter; most effective for conversion of A-fib or A-flutter of short duration.

Dose: Patients >60 kg 1 mg IVP over 10 min, may repeat same dose in 10 min. Patients <60 kg 0.01 mg/kg

IVP over 10 min, may repeat same dose in 10 min.

Contraindications: Known hypersensitivity, history of ventricular arrhythmias including torsade de pointes. Side Effects: Headache, nausea and vomiting.

Precautions: Monitor ECG for 4–6 hr after administration, with defibrillator nearby. Correct electrolyte

abnormalities prior to use. If A-fib >48 hr, anticoagulation is required before cardioversion with ibutilide.

16. Isoproterenol (Isuprel) (Sympathomimetic, Beta-Adrenergic Agonist)

Indications: Symptomatic bradycardia, refractory torsade de pointes unresponsive to magnesium, bradycardia in heart transplant patients, beta blocker poisoning.

Dose: IV infusion: mix 1 mg/250 mL in normal saline, lactated Ringer's solution, or D5W, run at 2–10 µg/min, and titrate to patient response. In torsade de pointes titrate to increase heart rate until VT is suppressed.

Contraindications: Cardiac arrest, concurrent use with epinephrine (can cause VF or VT), poison- or drug- induced shock (exception: beta blocker poisoning).

Side Effects: Anxiety, tachycardia, palpitations, skin flushing.

Precautions: May increase myocardial ischemia, tachycardia, restlessness. High doses are harmful except in beta blocker overdose.

17. Lidocaine (Xylocaine) (Antiarrhythmic, Anesthetic)

Indications: VF or pulseless VT, stable VT, wide-complex tachycardia of uncertain origin, wide-complex

PSVT.

Dose: Cardiac arrest from VF or VT 1.0–1.5 mg/kg IVP (or 2–4 mg/kg via ET tube), may repeat 0.5–0.75 mg/kg IVP every 5–10 min, max. 3 mg/kg. Stable VT, wide-complex tachycardia of uncertain origin use 0.5–

0.75 mg/kg and up to 1.0–1.5 mg/kg, may repeat 0.5–0.75 mg/kg every 5–10 min; max. total dose 3.0 mg/kg. If conversion is successful, start an IV infusion of 1–4 mg/min (30–50 µg/kg/min) in normal saline or D5W. Contraindications: Prophylactic use in acute MI, advanced AV block, hypotension, Wolff-Parkinson-White

syndrome, hypersensitivity to amide-type local anesthetics.

Side Effects: Confusion, seizures, hypotension, bradycardia, cardiovascular collapse, respiratory arrest. Precautions: CHF, respiratory depression, shock. Reduce maintenance dose (not loading dose) in presence

of impaired liver function or left ventricular dysfunction or in the elderly. Stop infusion if signs of toxicity

(prolonged PR interval, QRS widening, or CNS changes) develop.

18. Magnesium Sulfate (Electrolyte, Antiarrhythmic)

Indications: Torsade de pointes, VF refractory to lidocaine, digoxin-induced VT/VF.

Dose: Cardiac arrest (in hypomagnesemia or torsade de pointes) 1–2 g (2–4 mL of a 50% solution) diluted in

10 mL of D5W IVP.  Digoxin-induced VT or VF 1–2 g IVP. Torsade de pointes (non-cardiac arrest) load with

1–2 g mixed in 50–100 mL of D5W infused over 5–60 min IV, then infuse 0.5–1.0 g/hr IV (titrate to control torsade). Acute MI load with 1–2 g mixed in 50–100 mL of D5W over 5–60 min IV, then infuse 0.5–1.0 g/hr IV for up to 24 hr.

Contraindications: Hypermagnesemia, hypocalcemia, renal disease, AV block, toxemia of pregnancy 2 hr prior to delivery.

Side Effects: Hypotension, bradycardia, cardiac arrest, respiratory depression, altered level of consciousness

(LOC), flushed skin, diaphoresis.

Precautions: Renal insufficiency, occasional fall in BP with rapid administration. Monitor serum magnesium levels.

19. Morphine (Opioid Agonist Analgesic)

Indications: Chest pain unrelieved by nitroglycerin, CHF and dyspnea associated with pulmonary edema. Dose: 2–4 mg IVP (over 1–5 min) every 5–30 min.

Contraindications: Hypersensitivity, heart failure due to chronic lung disease, respiratory depression, hypotension.

Side Effects: Respiratory depression, hypotension, nausea and vomiting, bradycardia, altered LOC, seizures.

Precautions: Administer slowly and titrate to effect. Reverse with naloxone (0.4–2.0 mg IVP). Use caution in cerebral edema and pulmonary edema with compromised respiration.

20. Nitroglycerin (Nitrostat, Nitrolingual Pumpspray) (Antianginal, Nitrate) Indications: Angina, CHF associated with acute MI, hypertensive crisis.

Dose: Sublingual route, 0.3–0.4 mg (1 tablet), repeat every 3–5 min, max. 3 doses/15 min. Aerosol, spray for

0.5–1.0 sec at 3–5 min intervals (provides 0.4 mg/dose), max. 3 sprays/15 min. IVP at 12.5–25.0 µg (if no sublingual or spray used). IV infusion: mix 25 mg/250 mL (100 µg/mL) in D5W, run at 5–20 µg/min, and titrate to desired response.

Contraindications: Hypersensitivity, systolic BP <90 mm Hg; severe bradycardia or severe tachycardia;

sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) within 24 hr; right ventricular infarction. Side Effects: Hypotension with secondary tachycardia, syncope, headache, flushed skin.

Precautions: Do not mix with other medications; titrate IV to maintain systolic BP >90 mm Hg. Mix only in

glass IV bottles and infuse only through tubing provided by manufacturer; standard polyvinyl chloride tubing can bind up to 80% of the medication, making it necessary to infuse higher doses.

21. Oxygen (Gas)

Indications: Cardiopulmonary emergencies with shortness of breath and chest pain, cardiac or respiratory arrest.

Dose: Nasal cannula 1–6 L/min (24%–44% oxygen), Venturi mask 4–8 L/min (24%–40% oxygen), simple mask 5–8 L/min (40%–60% oxygen), partial rebreathing mask 6–15 L/min (35%–60% oxygen),

nonrebreathing mask 6–15 L/min (60%–90% oxygen), bag-valve-mask 15 L/min (up to 100% oxygen).

Contraindications: Emphysema (deliver <35% oxygen unless severely hypoxic), hyperventilation.

Side Effects: Drying of respiratory mucosa, possible bronchospasm if oxygen is extremely cold and dry. Oxygen supports combustion and can fuel a fire.

Precautions: Respiratory arrest in patients with hypoxic drive. Patient needs an airway and adequate ventilation before oxygen is effective.

22. Procainamide (Pronestyl) (Antiarrhythmic)

Indications: Recurrent VT or VF, PSVT refractory to adenosine and vagal stimulation, rapid A-fib with Wolff- Parkinson-White syndrome, stable wide-complex tachycardia of uncertain origin, maintenance after conversion.

Dose: 20 mg/min IV infusion or up to 50 mg/min under urgent conditions, max. 17 mg/kg loading dose. Maintenance IV infusion: mix 1 g/250 mL (4 mg/mL) in normal saline or D5W, run at 1–4 mg/min.

Contraindications: 2nd- and 3rd-degree AV block (unless a functioning artificial pacemaker is in place),

torsade de pointes, hypersensitivity.

Side Effects: Hypotension, widening QRS, headache, nausea and vomiting, flushed skin, seizures, ventricular arrhythmias, AV block, cardiovascular collapse, arrest.

Precautions: Monitor BP every 2–3 min while administering procainamide. If QRS width increases by 50% or more, or if BP decreases to >90 systolic, stop drug. Reduce total dose to 12 mg/kg and maintenance infusion to 1–2 mg/min if cardiac or renal dysfunction is present. Use cautiously in myasthenia gravis and in hepatic

or renal disease and with drugs that prolong QT interval (e.g., amiodarone, sotalol).

23. Sodium Bicarbonate (Alkalizing Agent, Buffer)

Indications: Prolonged resuscitation with effective ventilation; hyperkalemia; diabetic ketoacidosis; cocaine toxicity; tricyclic antidepressant, diphenhydramine, or acetylsalicylic acid overdose; metabolic acidosis; shock associated with severe diarrhea.

Dose: 1 mEq/kg IVP, may repeat 0.5 mEq/kg every 10 min.

Contraindications: Metabolic and respiratory alkalosis, hypocalcemia, renal failure, peptic ulcer, hypertension, convulsions, hypercarbic acidosis.

Side Effects: Hypokalemia, metabolic alkalosis, seizures, tetany.

Precautions: CHF, renal disease, cirrhosis, toxemia, concurrent corticosteroid therapy. Not recommended for routine use in cardiac arrest patients because adequate ventilation and CPR are the major "buffer agents" in

cardiac arrest. Incompatible with many drugs; flush line before and after administration.

24. Vasopressin (Pitressin Synthetic) (Vasopressor, Hormone)

Indications: Vasodilatory (septic) shock, an alternative to epinephrine in shock-refractory VF and pulseless

VT.

Dose: Cardiac arrest 40 units IVP single dose.

Contraindications: Seizures, heart failure, asthma, coronary artery disease (CAD), migraine, allergy to beef or pork protein, chronic renal failure with increased blood urea nitrogen (BUN).

Side Effects: Dizziness, headache, nausea and vomiting, MI, chest pain, abdominal cramps, diaphoresis,

bronchoconstriction, anaphylaxis, coma, convulsions.

Precautions: Coronary artery disease (may precipitate angina or MI), renal impairment; potent peripheral vasoconstrictor.

25. Verapamil (Calan, Isoptin) (Calcium Channel Blocker, Antiarrhythmic, Antihypertensive)

Indications: PSVT (with narrow QRS and adequate BP) refractory to adenosine, rapid ventricular rates in A- fib, A-flutter, or MAT.

Dose: 2.5–5.0 mg slow IVP over 2 min; may give second dose, if needed, of 5–10 mg IVP in 15–30 min, max. dose 20 mg. An alternative second dose is 5 mg IVP every 15 min, max. dose 30 mg. Contraindications: A-fib with Wolff-Parkinson-White syndrome, wide-complex tachycardia of uncertain origin,

2nd- or 3rd-degree AV block (unless a functioning artificial pacemaker is in place), sick sinus syndrome, hypotension, severe CHF, cardiogenic shock.

Side Effects: Hypotension, exacerbation of CHF with left ventricular dysfunction, bradycardia, AV block. Precautions: Concurrent oral beta blockers, CHF, impaired hepatic or renal function; may decrease myocardial contractility. In geriatric patients administer dose slowly over 3 min.

Ref.

BNF 53rd Ed.

Davis's Drug Guide 9th  Ed.

Done By Samhar