EMERGENCY MEDICATIONS AND DOSAGES

(Books used: Nancy Caroline, Emergency Care in The Streets. ACLS, PALS)

Seizures
 Diazepam (Valium) – Potentiates effects of inhibitory neurotransmitters. Raises seizure
threshold. Induces amnesia and sedation. CONTRINDICATIONS- narrow angle glaucoma,
myasthenia gravis, respiratory insufficiencies, coma, head injury.
ADULT
o Seizure activity 5-10 mg IV q10-15 *MAX dose 30 mg

PEDIATRICS

o 0.2 mg/kg to 0.5 mg/kg slow IV q 2-5 minutes up to 5 mg (maximum dose 10 mg/kg).
 Lorazepam (Ativan) – Benzodiazepine, short/immediate acting: sedative, anticonvulsant,
schedule IV drug. - Suppresses propagation of seizure activity produced by foci in cortex,
thalamus, and limbic areas. CONTRAINDICATIONS – Acute narrow-angle glaucoma, coma, shock,
suspected drug abuse.
ADULT
o 2-4 mg slow IM at 2mg/min may repeat in 15-20 min * MAX dose 8mg
o 2-4 mg diluted in equal amount of sterile water or saline IV/IO slow 2mg/min * MAX
dose 8mg

PEDIATRICS

o0.05 – 0.20 mg/kg slow IV/IO/IM over 2 minutes. May be repeated once in 5-20
minutes. Maximum dose of 0.2 mg/kg
 Midazolam Hydrochloride (Versed) – Reversibly interacts with GABA receptors in the CNS
causing sedative, anxiolytic, and hypnotic effects. CONTRAINDICATIONS- Acute narrow-angle
glaucoma, shock, coma, alcohol intoxication, overdose, depressed vital signs, concomitant use
with barbiturates, alcohol, narcotics, or other depressants.

ADULT

o 2-2.5 mg slow IV over 2-3 min *MAX dose 0.1 MG/KG

PEDIATRICS

o 0.1-0.3 mg/kg IV/IO (maximum single dose: 10 mg).

 Phenobarbital (Luminal)- Believed to reduce neuronal excitability by increasing the motor cortex
threshold to electrical stimulation. CONTRAINTICATIONS- Severe liver or Respiratory Disease,
Porphyria, history of sedative or hypnotic addiction.

ADULT

o 100-250 mg slow IV or IM. May repeat as needed in 20-30 minutes.

PEDIATRICS
 o 10-20 mg/kg slow IV/IO/IM. Repeat as needed in 20-30 minutes.

Seizures of eclampsia (toxemia of pregnancy)

 Magnesium Sulfate- Electrolyte, anti-inflammatory – Reduces striated muscle contractions and
blocks peripheral neuromuscular transmission by reducing acetylcholine release at the
myoneural junction. Manages seizures in toxemia of pregnancy. Induces uterine relaxation. Can
cause bronchodilation after beta-agonists and anti-cholinergic have been administered.
CONTRAINDICATIONS- Heart block, myocardial damage.
ADULT
o Seizure activity associated with pregnancy: 1-4 grams of a 10% solution IV/IO over 3
minutes; MAX dose of 30-40 grams/day

Seizure of unknown origin, Status Epilepticus

 Dextrose- Rapidly increases serum glucose levels, short term osmotic diuresis.
CONTRINDICATIONS- Intracranial Hemorrhage.

ADULT

o 12.5-25 grams of a 50% solution slow IV push. May be repeated as necessary.

PEDIATRICS

o 1 year and older; 0.5-1 g/kg of a 25% solution slow IV/IO push. May be repeated as
necessary.
o Neonates and infants: 200-500 mg/kg of a 10-25% solution slow IV push (see below).
May be repeated as necessary. Maximum concentration of 12.5% (vasculature
extremely sensitive to high concentrations).

Coma of Unknown Origin

 Thiamine (Betaxin)- Combines with ATP to form thiamine pyrophosphate coenzyme, which is a
necessary component for carbohydrate metabolism. The brain is extremely sensitive to thiamine
deficiency. CONTRAINDICATIONS- None
ADULT
o 100 mg slow IV or IM
PEDIATRICS
o 10-25 mg slow IV or IM.
 Dextrose- Rapidly increases serum glucose levels, short term osmotic diuresis.
CONTRAINDICATIONS- Intracranial Hemorrhage.
ADULT
o 12.5-25 grams of a 50% solution slow IV push. May be repeated as necessary.
PEDIATRICS
o 1 year and older; 0.5-1 g/kg of a 25% solution slow IV/IO push. May be repeated as
necessary.
 o Neonates and infants: 200-500 mg/kg of a 10-25% solution slow IV push (see below).
May be repeated as necessary. Maximum concentration of 12.5% (vasculature
extremely sensitive to high concentrations).
 Naloxone Hydrochloride (Narcan)- a Competitive inhibition at narcotic receptor sites. Reverses
respiratory depression secondary to opiate drugs. Completely inhibits the effect of morphine.
CONTRAINDICATIONS- Use in caution with neonates of narcotic-addicted mothers, use in
caution with narcotic dependent patients.
ADULT
o 0.4-2 mg IV/IM/IO/SQ/ET/Intranasal MINIMUM single dose recommend 2 mg
MAXIMUM dose 10 mg. Repeat at 5 minute intervals
PEDIATRICS
o 0.1 mg/kg/dose IV/IO/IM/SQ every 2 minutes as needed. Maximum total dose of 2 mg.
If no response in 10 minutes, administer an additional 0.1 mg/kg/dose.

Premedication for Cardioversion

 Diazepam (Valium) – Potentiates effects of inhibitory neurotransmitters. Raises seizure
threshold. Induces amnesia and sedation. CONTRAINDICATIONS-
ADULT
o 5-15 mg IV over 5-10 minutes prior to cardioversion.

Difficulty Breathing
 Albuterol (Proventil, Ventolin) – Selective beta-2 agonist that stimulates adrenergic receptors of
the sympathomimetic nervous system. Smooth muscle relaxation in the bronchial tree and
peripheral vasculature. INDICATIONS- Treatment of bronchospasm in patients with reversible
obstructive airway disease (COPD, asthma). Prevention of exercise induced bronchospasm.
CONTRAINDICATIONS- Tachycardia, dysrhythmias
ADULT
o Administer 2.5 mg dilute in 0.5 mL of 0.5% solution for inhalation with 2.5 mL normal
saline in nebulizer and administered over 10-15 minutes.
PEDIATRIC
o <20 kg (44 pounds): 1.25 mg/dose via handheld nebulizer or mask over 20 minutes. >20
kg (44 pounds): 2.5 mg/dose via handheld nebulizer or mask over 20 minutes. Repeat
once in 20 mins
 Ipratropium (Atrovent) – Anticholinergic, bronchodilator- Inhibits interaction of acetylcholine at
receptor sites of bronchial smooth muscle, resulting in decreased cyclic guanosine
monophosphate and bronchodilation. CONTRAINDICATIONS- hypersensitivity to ipratropium,
atropine, alkaloids, peanuts.
ADULTS
o 250-500 mcg via inhalation with hand held nebulizer every 20 minutes up to 3 times.
***PEDIATRIC DOSE IS SAME AS ADULT***
 Epinephrine (Adrenaline)- Sympathomimetic- Direct acting alpha and beta agonist. Alpha:
vasoconstriction. Beta1: positive inotropic, dromotropic and chronotropic effects. Beta2:
 bronchial smooth muscle relaxation and dilation of skeletal vasculature. Blocks histamine
receptors.

ADULT

o Mild allergic reactions and asthma: 0.3-0.5 mg (0.3-0.5 mL 1:1000) SC.

Anaphylaxis: 0.1 mg (1 mL) of 1:10,000 solution IV.

PEDIATRIC

o Mild allergic reactions and asthma: 0.01 mg/kg of a 1,000 solution SC (MAX 0.3 mg)
Anaphylaxis/ severe status asthmaticus 0.01 mg/kg IM of a 1:1,000 solution (MAX single
dose 0.3 mg)
 Methylprednisolone Sodium Succinate (Solu-Medrol)- Highly potent synthetic glucocorticoid
that suppresses acute and chronic inflammation; potentiates vascular smooth muscle relaxation
by beta-adrenergic agonists.

ADULT
o Asthma, COPD, anaphylaxis: 1-2 mg/kg IV
PEDIATRIC
o Status asthmaticus/anaphylaxis: 2 mg/kg/dose IV/IO/IM to a maximum dose of 60 mg.
 Levalbuterol (Xopenex)- Stimulates Beta-2 receptors resulting in smooth muscle relaxation of
bronchial tree and peripheral vasculature.

ADULT
o 1.25-2.5 mg in 3 mL administered by nebulizer every 20 minutes to a maximum of 3
doses.
PEDIATRIC
o 0.075 mg/kg (minimum of 1.25 mg) administered by nebulizer every 20 minutes to a
maximum of 3 doses
 Metaproterenol Sulfate (Alupent)- Acts directly on bronchial smooth muscle causing relaxation
of the bronchial tree and peripheral vascular.
ADULT
o Metered-dose inhaler 2-3 inhalations q3-4 hours (2 minutes between inhalations)
PEDIATRIC
o Metered-dose inhaler: Not recommended.
o Inhalation solution 5%: Age 6-12 years: 0.1-0.2 mL of a 5% solution diluted in 3 mL saline
 Magnesium Sulfate- Electrolyte, anti-inflammatory – Reduces striated muscle contractions and
blocks peripheral neuromuscular transmission by reducing acetylcholine release at the
myoneural junction. Manages seizures in toxemia of pregnancy. Induces uterine relaxation. Can
cause bronchodilation after beta-agonists and anti-cholinergic have been administered.
CONTRAINDICATIONS- Heart block, myocardial damage.
PEDIATRICS –
o STATUS ASTHMATICUS: 25-50 mg/kg IV/IO of a 10% solution over 15-30 minutes to a
MAX of 2 grams.
Bronchial Asthma/Prevention of Bronchospasm/Croup/Laryngeal edema/Laryngotracheobronchitis

 Epinephrine Racemic (Micronefrin) – Sympathomimetic- Stimulates beta-2 receptors in the

lungs; bronchodilation with relaxation of bronchial smooth muscles; Reduces airway resistance.
Useful in treating laryngeal edema; inhibits histamine release. CONTRAINDICATIONS –
Hypertension, underlying cardiovascular disease, epiglottitis.
ADULT
o MDI: 2-3 inhalations, repeat every 5 minutes PRN. Solution: dilute 5 mL in 5 mL saline,
administer over 15 minutes.

PEDIATRIC

o Solution : dilute 0.25 mL in 2.5 mL saline (if less than 20 kg): dilute in 0.5 mL in 2.5 mL
saline (if 20-40 kg): dilute in 0.75 mL in 2.5 mL saline (if more than 40 kg)

Chest Pain

 Nitroglycerin (Nitrostat, Nitro-Bid, Tridil) – Smooth muscle relaxant acting on vasculature,

bronchial, uterine, intestinal smooth muscle. Dilation of arterioles and veins in the periphery.
Reduces preload and afterload, decreasing workload of the heart and thereby myocardial
oxygen demand.
o Tablet: 0.3-0.4 mg sublingually; may repeat in 5 minutes to a maximum of 3 doses.
NTG spray: 1-2 sprays for 0.5 -1 second at 5 minute intervals to a max of 3 doses
NTG IV infusion: Begin at 10 mcg/min; increase by 10 mcg/min every 3-5 minutes until
desired effects.
 Aspirin (ASA, Bayer, Ecotrin, St.Joseph, and others) - Prevents platelets from clumping together,
or aggregating, and forming emboli.
o 160- 324 mg PO. Chewing is preferable to swallowing.
 Morphine Sulfate (Roxanol, MS Contin) – Alleviates pain through CNS action. Suppresses fear
and anxiety centers in the brain. Depresses brainstem respiratory centers. Increases peripheral
venous capacitance and decreases venous return. Decreases preload and afterload, which
decreases myocardial oxygen demand.

ADULT
o STEMI initial dose: 2-4 mg slow IV (over 1-5 minutes). Repeat dose: 2-8 mg at 5-15
minutes intervals.
NSTEMI/Unstable angina: 1-5 mg IV push if symptoms not relieved by nitrates.
 Oxygen- Confirmed or expected hypoxemia, ischemic chest pain, respiratory insufficiency,
prophylactically during air transport, confirmed or suspected carbon monoxide poisoning, all
other causes of decreased tissue oxygenation, decreased level of consciousness.
o Cardiac arrest and carbon monoxide poisoning: 100%

Hypoglycemia

 Oral Glucose (Insta-glucose)- After absorption in the G.I. tract, glucose is distributed to the
tissues providing an increase in circulating blood glucose levels.
ADULT
 o15-45 grams PO in patients with an intact gag reflex and the ability to manage their own
secretions.
PEDIATRIC
o 5-45 g PO in patients with an intact gag reflex and the ability to manage their own
secretions.
 Dextrose- rapidly increases serum serum glucose levels. Short term osmotic diuresis.
CONTRAINDICATIONS – Intracranial hemorrhage
ADULT
o 12.5-25 grams of a 50% solution slow IV push. May be repeated as necessary.

PEDIATRICS

o 1 year and older: 0.5- 1g/kg of a 25% solution slow IV/IO push May be repeated as
necessary
o Neonates and infants: 200-500 mg/kg of a 10- 25% SOLUTION SLOW iv PUSH. May be
repeated as necessary. MAXIMUM concentration of 12.5%
 Glucagon (GlucaGen)- increases blood glucose levels by stimulating glycogenolysis. Unknown
mechanism of stabilizing cardiac rhythm in beta blocker overdose. Minimal positive inotropic
and chronotropic response. Decreases gastrointestinal motility and secretions.
CONTRAINDICATIONS – Hyperglycemia, Hypersensitivity
ADULT
o Hypoglycemia- 0.5-1 mg IM; may repeat in 7-10 minutes
PEDIATRICS
o Hypoglycemia- 0.03-0.1 mg/kg IM, IO, SQ slow IV. May repeat in 20 minutes
Supraventricular Tachycardia

 Adenosine- Slows conduction through the AV node; can interrupt re-entrant pathways; slows
heart rate by acting directly on the sinus pacemaker cells by slowing impulse formation. Can be
used diagnostically for stable, wide- complex tachycardia of unknown origin after two doses of
lidocaine. CONTRAINDICATIONS – 2nd or 3rd degree block, SSS, Bronchoconstrictive or
bronchospastic lung disease, poison or drug induced tachycardia.
ADULT
o 6 mg rapid IV bolus over 1-3 seconds, followed by a 20 mL saline flush and elevate
extremity. If no response after 1-2 minutes…….
12 mg rapid IV bolus over 1-3 seconds, followed by a 20 mL saline flush and elevate
extremity.

PEDIATRIC

o 0.1 mg/kg rapid IV/IO push (MAX first dose 6 mg), followed by a 5 to 10 mL flush
Second dose 0.2 mg/kg rapid IV/IO push (MAX second dose 12 mg), followed by a 5 to
10 mL flush
 Metoprolol Tartrate (Lopressor)- Decreases heart rate, conduction velocity, myocardial
contractility, and cardiac output. Considered second line drug after adenosine, diltiazem, or
digitalis derivative. (Beta blocker, Beta 1 selective; antihypertensive, antidysrhythmic)
o 5 mg slow IV push at 5 minute intervals to a total of 15 mg.
 Safety Not established in Pediatrics

 Diltiazem (Cardizem)- Calcium Channel Blocker - slow calcium channel blocker that blocks
calcium ion influx during depolarization of cardiac and vascular smooth muscle. Decreases
peripheral vascular resistance and causes relaxation of the vascular smooth muscle, resulting in
a decrease of both systolic and diastolic blood pressure. Reduces preload and afterload. Reduces
myocardial oxygen demand.
o Initial dose- 0.25 mg/kg IV over 2 minutes. If inadequate response, may rebolus in 15
minutes
Secondary dose- 0.35 mg/kg IV over 2 minutes
o Maintenance infusion- 5-15 mg/h titrated to physiologically appropriate heart rate.

Not Recommended in Pediatrics

Atrial Fibrillation/ Atrial Flutter

 Diltiazem (Cardizem)- Calcium Channel Blocker ! - slow calcium channel blocker that blocks
calcium ion influx during depolarization of cardiac and vascular smooth muscle. Decreases
peripheral vascular resistance and causes relaxation of the vascular smooth muscle, resulting in
a decrease of both systolic and diastolic blood pressure. Reduces preload and afterload. Reduces
myocardial oxygen demand.
o Initial dose- 0.25 mg/kg IV over 2 minutes. If inadequate response, may rebolus in 15
minutes
Secondary dose- 0.35 mg/kg IV over 2 minutes
o Maintenance infusion- 5-15 mg/h titrated to physiologically appropriate heart rate.
 Atenolol (Tenormin)- Decreases heart rate, myocardial contractility, and cardiac output. Inhibits
dilation of bronchial smooth muscle.
o 5 mg slow IV over 5 minutes
Not Recommended in Pediatrics
 Metoprolol Tartrate (Lopressor)- Beta Blocker ! Decreases heart rate, conduction velocity,
myocardial contractility, and cardiac output. Considered second line drug after adenosine,
diltiazem, or digitalis derivative. (Beta blocker, Beta 1 selective; antihypertensive,
antidysrhythmic)
o 5 mg slow IV push at 5 minute intervals to a total of 15 mg.

Cardiogenic Shock

 Norepinephrine Bitartrate (Levophed)- Potent alpha-agonist resulting in intense peripheral

vasoconstriction, positive chronotropic and increased inotropic effect (from 10% beta effect)
with increased cardiac output. Alpha-adrenergic activity resulting in peripheral vasoconstriction
and beta- adrenergic activity leading to inotropic stimulation of the heart and coronary artery
vasodilation.
ADULT
o 4mg in 250 mL of D5W. Infuse by IV piggyback at 0.1-0.5 mcg/kg/min titration to patient
response.
PEDIATRICS
 o Begin at 0.1-2 µg/kg/min IV infusion, adjust rate to achieve desired change in blood
pressure and systemic perfusion. Titrated to patient response
 Dobutamine Hydrochloride (Dobutrex) – Sympathomimetic, inotropic agent – Synthetic
catecholamine. Increased myocardial contractility, stroke volume, and increase cardiac output.
Minimal chronotropic activity. Increases renal blood flow. CONTRAINDICATIONS-
Tachydysrhythmias, severe hypotension, idiopathic hypertrophic subaortic stenosis (IHSS),
suspected or known drug/poison induced shock.
ADULT
o IV infusion at 2-20 micrograms/kg/min titrated to desired effect.
MAX dose 40 microgram/kg/min.
PEDIATRIC
o IV infusion at 2-20 microgram/kg/min titrated to desired effect (NOT recommended)

 Dopamine Hydrochloride (Intropin) – Sympathomimetic, vasopressor, inotropic agent-

Second line drug for Bradycardia. Immediate metabolic precursor to nor-epinephrine.
Produces positive inotropic and chronotropic effects. Dilates renal and splanchnic
vasculature. Constricts systemic vasculature, increasing blood pressure and preload.
Increases myocardial contractility and stroke volume. CONTRAINDICATIONS- Hypovolemic
shock, pheochromocytoma, tachydysrhythmia, ventricular fibrillation.
ADULT
o IV/IO infusion at 2-20 microgram/kg/min. Slowly titrate to patient response
PEDIATRIC
o IV/IO infusion at 2-20 microgram/kg/min. Slowly titrate to patient response

Hypovolemic Shock

 Dopamine Hydrochloride (Intropin) – Sympathomimetic, vasopressor, inotropic agent- Second

line drug for Bradycardia. Immediate metabolic precursor to nor-epinephrine. Produces positive
inotropic and chronotropic effects. Dilates renal and splanchnic vasculature. Constricts systemic
vasculature, increasing blood pressure and preload. Increases myocardial contractility and
stroke volume. CONTRAINDICATIONS- Hypovolemic shock, pheochromocytoma,
tachydysrhythmia, ventricular fibrillation.

ADULT

o IV/IO infusion at 2-20 microgram/kg/min. Slowly titrate to patient response

PEDIATRIC

o IV/IO infusion at 2-20 microgram/kg/min. Slowly titrate to patient response

Septic Shock

 Dopamine Hydrochloride (Intropin) – Sympathomimetic, vasopressor, inotropic agent- Second

line drug for Bradycardia. Immediate metabolic precursor to nor-epinephrine. Produces positive
inotropic and chronotropic effects. Dilates renal and splanchnic vasculature. Constricts systemic
 vasculature, increasing blood pressure and preload. Increases myocardial contractility and
stroke volume. CONTRAINDICATIONS- Hypovolemic shock, pheochromocytoma,
tachydysrhythmia, ventricular fibrillation.

ADULT

o IV/IO infusion at 2-20 microgram/kg/min. Slowly titrate to patient response

PEDIATRIC

o IV/IO infusion at 2-20 microgram/kg/min. Slowly titrate to patient response

Hypotension

 FOR SEVERE HYPOTENSION <70 mm Hg Norepinephrine Bitartrate (Levophed)- Potent alpha-

agonist resulting in intense peripheral vasoconstriction, positive chronotropic and increased
inotropic effect (from 10% beta effect) with increased cardiac output. Alpha-adrenergic activity
resulting in peripheral vasoconstriction and beta- adrenergic activity leading to inotropic
stimulation of the heart and coronary artery vasodilation.
ADULT
o 4mg in 250 mL of D5W. Infuse by IV piggyback at 0.1-0.5 mcg/kg/min titration to patient
response.
PEDIATRIC
o Begin at 0.1-2 µg/kg/min IV infusion, adjust rate to achieve desired change in blood
pressure and systemic perfusion. Titrated to patient response.

Nausea

 Ondansetron Hydrochloride (Zofran)- Blocks action of serotonin, which is a natural substance

that causes nausea and vomiting.
ADULT
o 4 mg IV/IM may repeat in 10 minutes
PEDIATRIC
o 0.1 mg/kg IV/IM
Overdoses

 Tricyclic antidepressant, aspirin, and phenobarbital overdoses

 Sodium Bicarbonate- Buffers metabolic acidosis and lactic acid build up in the body caused by
anaerobic metabolism secondary to severe hypoxia by reacting with hydrogen ions to form
water and carbon dioxide.
ADULT
o 1 mEq/kg slow IV, IO push may repeat at 0.5 mEq/kg every 10 minutes
PEDIATRICS
o 1 mEq/kg slow IV, IO push (Dilute in small children to 4.2%)

 Opiate overdose, complete or partial reversal of CNS depression induced by opiates.

 Naloxone Hydrochloride (Narcan)- a Competitive inhibition at narcotic receptor sites. Reverses
respiratory depression secondary to opiate drugs. Completely inhibits the effect of morphine.
ADULT
o 0.4-2 mg IV/IM/IO/SQ/ET/Intranasal MINIMUM single dose recommend 2 mg
MAXIMUM dose 10 mg. Repeat at 5 minute intervals
PEDIATRIC
o 0.1 mg/kg/dose IV/IO/IM/SQ every 2 minutes as needed. Maximum total dose of 2 mg.
If no response in 10 minutes, administer an additional 0.1 mg/kg/dose.

 Beta Blocker or Calcium Channel Blocker Overdoses

 Atropine Sulfate – Anticholinergic agent – Inhibits the action of acetylcholine at postganglionic
parasympathetic neuroeffector sites. Increases heart rate in life threatening bradydysrhythmias.
CONTRAINDICATIONS – Tachycardia, unstable cardiovascular status in acute hemorrhage with
myocardial ischemia, narrow angle glaucoma, hypothermic bradycardia.

ADULT

o Extremely Large doses 2-4 mg or higher may be needed

 Glucagon (GlucaGen)- increases blood glucose levels by stimulating glycogenolysis. Unknown
mechanism of stabilizing cardiac rhythm in beta blocker overdose. Minimal positive inotropic
and chronotropic response. Decreases gastrointestinal motility and secretions.
CONTRAINDICATIONS – Hyperglycemia, Hypersensitivity
ADULTS
o 3-10 mg IV slowly over 3-5 minutes initially; followed by a 3-5 mg/hr infusion as
necessary
PEDIATRICS
o 0.05-0.15 mg/hr IV/IO over 3-5 minutes followed by a 0.03-0.10 mg/kg/h infusion rate
as necessary

 Epinephrine (Adrenaline)- Sympathomimetic- Direct acting alpha and beta agonist. Alpha:
vasoconstriction. Beta1: positive inotropic, dromotropic and chronotropic effects. Beta2:
bronchial smooth muscle relaxation and dilation of skeletal vasculature. Blocks histamine
receptors. CONTRAINDICATIONS- hypertension, hypothermia, pulmonary edema, myocardial
ischemia, hypovolemic shock.
ADULT
o Profound hypotension/bradycardia due to CCB/BB overdose - 0.2 mg/kg
 Benzodiazepine overdose
 Flumazenil (Romazicon)- Benzodiazepine antagonist, antidote- Antagonizes the action of
benzodiazepines on the central nervous system, reversing the sedative effects.
CONTRAINDICATIONS- Hypersensitivity, tricyclic antidepressant overdose, seizure prone
patients, coma of unknown etiology.
o Adult- First dose 0.2 mg IV/IO over 15 seconds. Second dose 0.3 mg may be given over
30 seconds. If no response repeat dose every minute until adequate response or a total
of 3 mg is given.
Ventricular Fibrillation

 Amiodarone (Cordarone, Paceron) - Antidysrhythmic – Blocks sodium channels and myocardial

potassium channels, delaying repolarization and increasing the duration of action potential.
CONTRAINDICATIONS- Cardiogenic shock, sinus bradycardia, 2nd or 3rd degree AV Block, severe
sinus node dysfunction.
ADULT
o Ventricular fibrillation/ pulseless V Tach: 300 mg IV/IO push. Initial dose can be followed
in 3 to 5 minutes at 150 mg IV/IO push.
o Recurrent life threatening ventricular dysrhythmias: 150 mg IV/IO over 10 minutes
(15mg/per minute) May repeat infusion.

PEDIATRIC

o Refractory V Fib/Pulseless V tach: 5 mg/kg IV/IO bolus. Can repeat up to 15 mg/kg per
24 hours. MAX single dose 300 mg
o Perfusing SVT and V Tach: loading dose 5 mg/kg IV/IO over 20-60 minutes. MAX single
dose 300 mg.

Torsades de Pointes

 Magnesium Sulfate- Electrolyte, anti-inflammatory – Reduces striated muscle contractions and

blocks peripheral neuromuscular transmission by reducing acetylcholine release at the
myoneural junction. Manages seizures in toxemia of pregnancy. Induces uterine relaxation. Can
cause bronchodilation after beta-agonists and anti-cholinergic have been administered.
CONTRAINDICATIONS- Heart block, myocardial damage.
ADULT-
o With a pulse- Loading dose of 1-2 grams in 50-100 mL of D5W over 5-60 minutes IV.
Follow with 0.5-1 gram/hour IV (titrate dose to control torsades)

PEDIATRICS

o Torsades de Pointes with a pulse/hypomagnesaemia: 25-50 mg/kg IV/IO of a 10%

solution over 10-20 minutes to a MAX dose of 2 grams.

Bradycardia

 Atropine Sulfate – Anticholinergic agent – Inhibits the action of acetylcholine at postganglionic

parasympathetic neuroeffector sites. Increases heart rate in life threatening bradydysrhythmias.
CONTRAINDICATIONS – Tachycardia, unstable cardiovascular status in acute hemorrhage with
myocardial ischemia, narrow angle glaucoma, hypothermic bradycardia.
ADULT
o Unstable Bradycardia: 0.5 mg IV/IO every 3-5 minutes as needed. Not to exceed total
dose of 0.04 mg/kg (MAX 3 mg total)

PEDIATRIC

o Unstable bradycardia: 0.02 mg/kg IV/IO (minimum dose: 0.1 mg). May repeat once.
Maximum single dose: Child: 0.5 mg. Adolescent: 1 mg.
 Maximum total dose: Child: 1 mg. Adolescent: 3 mg.
 Dopamine Hydrochloride (Intropin) – Sympathomimetic, vasopressor, inotropic agent- Second
line drug for Bradycardia. Immediate metabolic precursor to nor-epinephrine. Produces
positive inotropic and chronotropic effects. Dilates renal and splanchnic vasculature. Constricts
systemic vasculature, increasing blood pressure and preload. Increases myocardial contractility
and stroke volume. CONTRAINDICATIONS- Hypovolemic shock, pheochromocytoma,
tachydysrhythmia, ventricular fibrillation.
ADULT
o IV/IO infusion at 2-20 microgram/kg/min. Slowly titrate to patient response

PEDIATRIC

o IV/IO infusion at 2-20 microgram/kg/min. Slowly titrate to patient response

 Epinephrine (Adrenaline)- Sympathomimetic- Direct acting alpha and beta agonist. Alpha:
vasoconstriction. Beta1: positive inotropic, dromotropic and chronotropic effects. Beta2:
bronchial smooth muscle relaxation and dilation of skeletal vasculature. Blocks histamine
receptors. CONTRAINDICATIONS- hypertension, hypothermia, pulmonary edema, myocardial
ischemia, hypovolemic shock.
ADULT
o Profound Bradycardia -2-20 micrograms/minute titrated to patient response

PEDIATRIC

o Sympathomatic bradycardia- IV/IO dose of 0.01 mg/kg of a 1:10,000 solution

o Infusion rate: Begin with Rapid infusion then
titrate to response at 0.1-1 micrograms/min

Rapid Sequence Intubation for Pediatrics

 Atropine Sulfate – Anticholinergic agent – Inhibits the action of acetylcholine at postganglionic

parasympathetic neuroeffector sites. Increases heart rate in life threatening bradydysrhythmias.
CONTRAINDICATIONS – Tachycardia, unstable cardiovascular status in acute hemorrhage with
myocardial ischemia, narrow angle glaucoma, hypothermic bradycardia.
o 0.01 – 0.02 mg/kg IV/IO (minimum dose 0.1 mg , maximum dose 0.5 mg)
 Etomidate (Amidate)- Nonbarbiturate hypnotic, anesthesia induction agent – Short acting
hypnotic that acts at the level of the reticular activating system. CONTRAINDICATIONS-
Hypersensitivity, labor/delivery.

PEDIATRICS

o 0.2-0.4 mg/kg IV/IO over 30-60 seconds for RSI (OLDER THAN 10 YEARS OLD) 1 time
only. MAX dose 20 mg
 Lidocaine Hydrochloride (Xylocaine) – Antidysrhythmic – Decreases automaticity by slowing the
rate of spontaneous phase 4 depolarization. CONTRAINDICATIONS- Hypersensitivity, 2 or 3rd AV
 block in the absence of an artificial pacemaker, Stokes-Adams syndrome, prophylactic use in
MAI, wide complex ventricular escape beats with bradycardia.
PEDIATRICS
o 1-2 mg/kg IV/IO one time only.

Rapid Sequence Intubation for Adults

 Etomidate (Amidate)- Nonbarbiturate hypnotic, anesthesia induction agent – Short acting
hypnotic that acts at the level of the reticular activating system. CONTRAINDICATIONS-
Hypersensitivity, labor/delivery.
ADULT
o 0.2-0.6 mg/kg IV over 30-60 seconds (typical adult dose is 20 mg)
 Rocuronium bromide (Zemuron) - Nondepolarizing neuromuscular blocker - Antagonizes
acetylcholine at the motor end plate producing skeletal muscle paralysis CONTRAINDICATIONS –
Known sensitivity to bromides. Use in caution in heart and liver disease
ADULT
o 0.6-1.2 mg/kg IV, IO
 Succinylcholine chloride (Anectine) - Neuromuscular blocker, depolarizing; skeletal muscle
relaxant -Ultra-short-acting depolarizing skeletal muscle relaxant that mimics acetylcholine as it
binds with the cholinergic receptors on the motor end plate, producing a phase 1 block as
manifested by fasciculations CONTRAINDICATIONS -Acute narrow-angle glaucoma ,Penetrating
eye injuries, Malignant hyperthermia, Acute injury after multisystem trauma, major burns, or
extensive muscle injury,Inability to control airway or support ventilations with oxygen and
positive pressure.
ADULT
o 1-1.5 mg/kg rapid IV. Repeat once if needed.

Organophosphate poisoning / Nerve Agent Exposure

 Pralidoxime (2-PAM, Protopam) – Cholinesterase reactivator, antidote - Reactivates
cholinesterase to effectively act as an antidote to organophosphate and pesticide poisonings.
This action allows for destruction of accumulated acetylcholine at the neuromuscular junction
resulting in reversal of respiratory paralysis and paralysis of skeletal muscle.
CONTRAINDICATIONS- Reduce dose in patients with impaired renal function, patients with
myasthenia gravis, or inorganic phosphates poisoning.
ADULT
o Initial dose of 1-2 g as an IV infusion over 30-60 minutes after atropine administration.
Dose can be repeated in 1 h if muscle paralysis is still present. 600 mg IM repeat twice
more at 15-minute intervals as needed. Anticholinesterase overdose: 1-2 g as an IV
infusion over 30-60 minutes. Repeat at 250 mg every 5 minutes as needed.

PEDIATRIC
 o 20-40 mg/kg as IV infusion over 15-30 minutes. Dose may be repeated in 1 h if muscle
paralysis is still present. If IV administration is not feasible, IM or SC injection may be
used.
 Atropine Sulfate – Anticholinergic agent – Inhibits the action of acetylcholine at postganglionic
parasympathetic neuroeffector sites. Increases heart rate in life threatening bradydysrhythmias.
CONTRAINDICATIONS – Tachycardia, unstable cardiovascular status in acute hemorrhage with
myocardial ischemia, narrow angle glaucoma, hypothermic bradycardia.
ADULT
o Extremely large doses (2-4 mg or higher) may be needed

Congestive Heart Failure / Pulmonary Edema

 Bumetanide (Bumex) – loop diuretic- A potent loop diuretic with a rapid onset and short
duration of action. Inhibits the reabsorption of sodium and chloride in the ascending loop of
henle. CONTRAINDICATIONS- hypovolemia, anuria, electrolyte deficiencies, hepatic coma
ADULT
o 0.5 – 1 mg IV slowly over 1 to 2 minutes
 Dobutamine Hydrochloride (Dobutrex) – Sympathomimetic, inotropic agent – Synthetic
catecholamine. Increased myocardial contractility, stroke volume, and increase cardiac output.
Minimal chronotropic activity. Increases renal blood flow. CONTRAINDICATIONS-
Tachydysrhythmias, severe hypotension, idiopathic hypertrophic subaortic stenosis (IHSS),
suspected or known drug/poison induced shock.
ADULT
o IV infusion at 2-20 micrograms/kg/min titrated to desired effect.
MAX dose 40 microgram/kg/min.
 Furosemide (Lasix)- Loop diuretic – Blocks the absorption of sodium and chloride at the distal
and proximal tubules and the loop of Henle, causing an increase of urine output.
CONTRAINDICATIONS- Hypovolemia, anuria, hypotension, hypersensitivity, hepatic coma,
suspected electrolyte imbalances.
ADULT
o 0.5-1 mg/kg IV over 1-2 minutes. If no response double the dose to 2 mg/kg
slowly over 1-2 minutes

PEDIATRICS

o 1 mg/kg IV/IO

HyperKalemia/ HypoCalemia/ Hypermagnesemia

 Calcium Chloride – Electrolyte (anion) – Increases cardiac contractile state (positive inotropic
effect). May enhance ventricular automaticity. CONTRAINDICATIONS- hypercalcemia, v-fib,
digitalis toxicity.
ADULT
o Calcium channel blocker overdose and hyperkalemia: 500 mg to 1,000 mg IV
push. May repeat as needed.

PEDIATRIC
 oCalcium channel blocker and hyperkalemia: 20 mg/kg (0.2 mL/kg) slow IV/IO
push. MAXIMUM 1 gram dose may repeat in ten minutes.
 Calcium Gluconate – Electrolyte – Counteracts the toxicity if hyperkalemia by stabilizing the
membranes of the cardiac cells, reducing the likelihood of fibrillation.
ADULT
o Hyperkalemia: 500 mg to 1,000 mg IV/IO push (1-1.5 mL/minute) to a maximum
of 3 grams
o Calcium channel blocker and beta blocker overdose: 3-6 grams (30-60 mL) IV/IO
followed by an hourly continuously hourly dose.

PEDIATRIC

o Hyperkalemia: 60 to 100 mg/kg IV/IO slowly over 5 to 10 minutes to maximum of 3 grams.

o Beta blocker and calcium channel blocker overdose: 60 mg/kg (0.6 mL/kg) IV/IO followed by a
continuous hourly infusion of the same dose.

Allergic Reaction/Anaphylaxis
 Diphenhydramine (Benadryl) – Antihistamine, anticholinergic – Blocks cellular histamine
receptors; decreases vasodilation; decreases motion sickness. Reverses extrapyramidal
reactions. CONTRAINDICATIONS- Asthma, glaucoma, pregnancy, hypertension, narrow angle
glaucoma, infants, patients taking MAOIs
ADULT
o 25-50 mg IM, IV, PO

PEDIATRICS

o 1-2 mg/kg IV, IO slowly or IM

o 5 mg/kg/24hr PO
 Epinephrine (Adrenaline)- Sympathomimetic- Direct acting alpha and beta agonist. Alpha:
vasoconstriction. Beta1: positive inotropic, dromotropic and chronotropic effects. Beta2:
bronchial smooth muscle relaxation and dilation of skeletal vasculature. Blocks histamine
receptors. CONTRAINDICATIONS- hypertension, hypothermia, pulmonary edema,
myocardial ischemia, hypovolemic shock.

ADULT

o Mild allergic reactions and asthma: 0.3-0.5 mg (0.3-0.5 mL 1:1000) SC.

Anaphylaxis: 0.1 mg (1 mL) of 1:10,000 solution IV.
PEDIATRIC
o Mild allergic reactions and asthma: 0.01 mg/kg of a 1,000 solution SC (MAX 0.3 mg)
o Anaphylaxis/ severe status asthmaticus 0.01 mg/kg IM of a 1:1,000 solution (MAX
single dose 0.3 mg) every 15 minutes as needed
 Hydrocortisone Sodium Succinate (Solu-Cortef) – Adrenal glucocorticoid- Anti-inflammatory;
immunosuppressive with salt retaining actions.
ADULT
o 4 mg/kg slow IV bolus
 PEDIATRICS

o 2 mg/kg slow IV bolus MAX dose 100 mg

CARDIAC ARREST
 Epinephrine (Adrenaline)- Sympathomimetic- Direct acting alpha and beta agonist. Alpha:
vasoconstriction. Beta1: positive inotropic, dromotropic and chronotropic effects. Beta2:
bronchial smooth muscle relaxation and dilation of skeletal vasculature. Blocks histamine
receptors. CONTRAINDICATIONS- hypertension, hypothermia, pulmonary edema,
myocardial ischemia, hypovolemic shock.
ADULT
o IV/IO push of 1 mg 1:10,000 solution followed by a 20-mL saline flush. May repeat
every 3-5 minutes during resuscitation.
o Continuous infusion: Add 1 mg of 1:1,000 solution to a 250-mL bag of normal saline
or D5W at an initial infusion rate of 1 micrograms/minute titrate to effect (typical
dose is 2-20 micrograms/min)

PEDIATRIC

o IV/IO push of 0.01 mg/kg of a 1:10,000 solution every 3-5 minutes during arrest.
Followed by a 5-10 mL saline flush. MAX single dose 1 mg
o Drip rate 0.1-1 mcg/kg/min of a 1:1,000 solution in a 250 mL saline bag
o ET Tube dose 0.1 mg/kg of a 1:1,000 solution mixed in 3-5 mL saline until IV/IO
accesses is achieved.
 Amiodarone (Cordarone, Paceron) - Antidysrhythmic – Blocks sodium channels and
myocardial potassium channels, delaying repolarization and increasing the duration of
action potential. CONTRAINDICATIONS- Cardiogenic shock, sinus bradycardia, 2nd or 3rd
degree AV Block, severe sinus node dysfunction.
ADULT
o Ventricular fibrillation/ pulseless V Tach: 300 mg IV/IO push. Initial dose can be
followed in 3 to 5 minutes at 150 mg IV/IO push.
o Recurrent life threatening ventricular dysrhythmias: 150 mg IV/IO over 10 minutes
(15mg/per minute) May repeat infusion.

PEDIATRIC

o Refractory V Fib/Pulseless V tach: 5 mg/kg IV/IO bolus. Can repeat up to 15

mg/kg per 24 hours. MAX single dose 300 mg
o Perfusing SVT and V Tach: loading dose 5 mg/kg IV/IO over 20-60 minutes. MAX
single dose 300 mg.
 Lidocaine Hydrochloride (Xylocaine) – Antidysrhythmic – Decreases automaticity by slowing the
rate of spontaneous phase 4 depolarization. CONTRAINDICATIONS- Hypersensitivity, 2 or 3rd AV
 block in the absence of an artificial pacemaker, Stokes-Adams syndrome, prophylactic use in
MAI, wide complex ventricular escape beats with bradycardia.
ADULT
o Cardiac arrest/pulseless ventricular tachycardia/ventricular fibrillation:
Initial dose: 1-1.5 mg/kg IV/IO. Repeat dose: 0.5-0.75 mg/kg IV/IO repeated in 5-10
minutes. MAX total dose 3 mg/kg

PEDIATRICS

o IV/IO dose: 1 mg/kg rapid IV/IO push. MAX dose 100 mg.
o Infusion rate : 20-50 micrograms/kg/min. Repeat bolus dose (1mg/kg) when infusion is
initiated if bolus has not been given within previous 15 minutes.

 Magnesium Sulfate- Electrolyte, anti-inflammatory – Reduces striated muscle contractions and

blocks peripheral neuromuscular transmission by reducing acetylcholine release at the
myoneural junction. Manages seizures in toxemia of pregnancy. Induces uterine relaxation. Can
cause bronchodilation after beta-agonists and anti-cholinergic have been administered.
CONTRAINDICATIONS- Heart block, myocardial damage.
ADULT-
o CARDIAC ARREST DUE TO HYPOMAGNESAEMIA or TORSADES DE POINTES: 1 to 2 grams
of a 10% solution IV/IO over 5-20 minutes.

PEDIATRICS

o PULSELESS V TACH with TORSADES DE POINTES: 25-50 mg/kg IV/IO bolus of a 10%
solution up to MAX 2 grams.

Pain Management

 Fentanyl Citrate (Sublimaze) – Opioid analgesic, schedule II narcotic- Binds to opiate

receptors, producing analgesia and euphoria. CONTRAINDICATIONS – Known
hypersensitivity, use in caution on patients with traumatic brain injury.
ADULT
o 50 to 100 micrograms (1 micrograms/kg) IM or IV, IO slow push over 1-2 minutes to a
MAX of 150 micrograms

PEDIATRICS

o 1-2 micrograms/kg IM, IV or IO slow push over 1-2 minutes. The safety and efficacy in
children younger than 2 years old has not been established.
 Ketorolac Tromethamine (Toradol) – Nonsteroidal anti-inflammatory (NSAIDS) analgesic- Potent
analgesic that does not possess any sedative or anxiolytic activities by inhibiting prostaglandin
synthesis. CONTRAINDICATIONS – Allergy to salicylates or other nonsteroidal anti-inflammatory
drugs. Patient with asthma, bleeding disorders (especially GI related illness such as peptic ulcers)
renal failure.
ADULT
o Adult 30-60 mg IM
NOT RECOMMENDED IN PEDIATRICS
Psychotic Episodes

 Haloperidol Lactate (Haldol)- Tranquilizer, antipsychotic- Inhibits central nervous system

catecholamine receptors; strong antidopaminergic and weak anticholinergic. Acts on CNS to
depress subcortical areas, mid-brain, and ascending reticular activating system in the brain.
CONTRAINDICATIONS- Parkinson’s disease, depressed mental status, agitation secondary to
shock and hypoxia, hypersensitivity.
ADULT
o 2-5 mg IM ONLY every 30-60 seconds until sedation is achieved.
Not recommended in pediatrics

PEDIATRIC

o Unstable bradycardia: 0.02 mg/kg IV/IO (minimum dose 0.1 mg) MAXIMUM single
doses: Child 0.5 mg: Adolescent 1 mg , MAXIMUM total dose Child 1 mg: Adolescent 3 mg