Emergency Medications & Resuscitation Formulary

Rapid Doser

Rapid Sequence Intubation (RSI) Doser

Weight:

Etomidate (0.3 mg/kg) 21 mg

Ketamine (1.5–2 mg/kg) 105–140 mg

Rocuronium (1.2 mg/kg) 84 mg

Succinylcholine (1.5–2) 105–140 mg

*Administer induction agent immediately followed by high-dose paralytic. Verify no hyperkalemia or denervation before succinylcholine.

Code Arrest Doses

ACLS Code Cart Quick Push

Epi (1:10,000): 1 mg IV/IO q3–5m
Amiodarone: 300 mg bolus, then 150 mg
Lidocaine: 1–1.5 mg/kg, then 0.75 mg/kg
Calcium Chloride: 1 g IV push (Hyperkalemia)
Sodium Bicarb: 50 mEq (1 amp) IV (TCA / Acidosis)

Bedside Pharmacopeia 41 Critical Dosing Guides

Emergency Medications & Critical Infusions

Bedside push-dose pressors, RSI induction agents, rapid paralytics, ACLS emergency cart infusions, toxicology antidotes, reversal agents, and empiric antimicrobial regimens with precise adult and pediatric dosing.

Push-Dose & Pressor

Epinephrine (Push-Dose)

Adrenaline

Adult Dose: 5–20 mcg (0.5–2 mL of 10 mcg/mL) IV push q2–5m titrated to MAP > 65

Pediatric Dose: 0.1–1 mcg/kg IV push q2–5m (titrate cautiously)

Route: IV / IO Push

Kinetics: Onset: 1 min | Peak: 2–5 min | Duration: 5–10 min

Prep Recipe: Take 1 mL Epinephrine 1:10,000 (100 mcg) + 9 mL NS flush = 10 mcg/mL

Clinical Pearls & Red Flags:

Potent alpha-1 + beta-1/2 agonist. Increases HR, SVR, and inotropy. Bridge to central line infusion. Never push 1:1,000 IV.

Push-Dose & Pressor

Phenylephrine (Push-Dose)

Neo-Synephrine

Adult Dose: 50–200 mcg (0.5–2 mL of 100 mcg/mL) IV push q2–5m titrated to MAP > 65

Pediatric Dose: 5–20 mcg/kg IV push q2–5m

Route: IV / IO Push

Kinetics: Onset: 1 min | Peak: 2–3 min | Duration: 10–20 min

Prep Recipe: Take 1 mL Phenylephrine (10 mg/mL) and add to 100 mL NS bag = 100 mcg/mL

Clinical Pearls & Red Flags:

Pure alpha-1 agonist. Increases SVR without increasing HR. Ideal for tachycardic hypotension (e.g. post-intubation shock with rapid AF).

Push-Dose & Pressor

Norepinephrine Infusion

Levophed

Adult Dose: 2–30 mcg/min IV infusion (start 5–10 mcg/min, titrate q2–5m to MAP >= 65)

Pediatric Dose: 0.05–0.5 mcg/kg/min IV infusion

Route: IV Infusion (Central line preferred; peripheral safe for initial hours)

Kinetics: Onset: 1–2 min | Duration: 2–10 min after stop

Prep Recipe: 4 mg in 250 mL D5W or NS (16 mcg/mL)

Clinical Pearls & Red Flags:

First-line vasopressor for septic shock, cardiogenic shock with low SVR, and neurogenic shock. Alpha-1 > beta-1.

Push-Dose & Pressor

Vasopressin Infusion

Pitressin

Adult Dose: 0.03 units/min fixed IV infusion (do not titrate)

Pediatric Dose: 0.0003–0.002 units/kg/min

Route: IV Infusion (Central line preferred)

Kinetics: Onset: Rapid | Duration: 20 min

Prep Recipe: 20 units in 100 mL NS (0.2 units/mL)

Clinical Pearls & Red Flags:

Second-line pressor added to Norepi in refractory septic shock. Works at V1 receptors independent of adrenergic receptors.

RSI Induction & Paralytics

Etomidate

Amidate

Adult Dose: 0.3 mg/kg IV push (typically 20–30 mg)

Pediatric Dose: 0.3 mg/kg IV push

Route: IV / IO Push

Kinetics: Onset: 15–30 sec | Duration: 3–8 min

Prep Recipe: 2 mg/mL ready-to-use ampule/vial

Clinical Pearls & Red Flags:

Hemodynamically neutral induction agent. Ideal for trauma, sepsis, and shock. Causes transient adrenal suppression (clinical significance debated).

RSI Induction & Paralytics

Ketamine (RSI Induction)

Ketalar

Adult Dose: 1.5–2 mg/kg IV push (or 4–5 mg/kg IM)

Pediatric Dose: 1.5–2 mg/kg IV push

Route: IV / IO Push (or IM)

Kinetics: Onset: 30–60 sec IV (3–5 min IM) | Duration: 10–20 min

Prep Recipe: 10 mg/mL, 50 mg/mL, or 100 mg/mL vials

Clinical Pearls & Red Flags:

Dissociative anesthetic. Bronchodilator (drug of choice for status asthmaticus intubation). Sympathomimetic preserves airway reflexes and BP.

RSI Induction & Paralytics

Propofol

Diprivan

Adult Dose: 1.5–2.5 mg/kg IV push; Sedation: 5–50 mcg/kg/min

Pediatric Dose: 1.5–2.5 mg/kg IV push

Route: IV / IO Push / Infusion

Kinetics: Onset: 15–30 sec | Duration: 3–10 min

Prep Recipe: 10 mg/mL emulsion

Clinical Pearls & Red Flags:

Potent bronchodilator and anticonvulsant. Causes significant myocardial depression and vasodilation; AVOID in hypotensive or shock patients.

RSI Induction & Paralytics

Rocuronium

Zemuron

Adult Dose: 1.2 mg/kg IV push (high RSI dose for 60s paralysis)

Pediatric Dose: 1.2 mg/kg IV push

Route: IV / IO Push

Kinetics: Onset: 45–60 sec | Duration: 45–75 min

Prep Recipe: 10 mg/mL vial

Clinical Pearls & Red Flags:

Non-depolarizing paralytic of choice. No hyperkalemia risk. Fully reversible at any time with Sugammadex (16 mg/kg for immediate rescue).

RSI Induction & Paralytics

Succinylcholine

Anectine

Adult Dose: 1.5–2 mg/kg IV push (or 3–4 mg/kg IM)

Pediatric Dose: 2 mg/kg IV push (infants 3 mg/kg)

Route: IV / IO Push (or IM)

Kinetics: Onset: 30–45 sec | Duration: 5–10 min

Prep Recipe: 20 mg/mL vial

Clinical Pearls & Red Flags:

Depolarizing paralytic. CONTRAINDICATIONS: Hyperkalemia, major burns/crush injuries > 48h, denervating disease, malignant hyperthermia history.

RSI Induction & Paralytics

Sugammadex

Bridion

Adult Dose: 16 mg/kg IV push (immediate reversal of Rocuronium 1.2 mg/kg)

Pediatric Dose: 16 mg/kg IV push for emergent reversal

Route: IV Push

Kinetics: Onset: < 2 min | Full reversal in 3 min

Prep Recipe: 100 mg/mL vial

Clinical Pearls & Red Flags:

Encapsulates rocuronium and vecuronium. 'Cannot intubate, cannot oxygenate' reversal rescue. Inactivates oral contraceptives for 7 days.

ACLS & Antiarrhythmics

Epinephrine 1:10,000 (ACLS)

Adrenaline

Adult Dose: 1 mg IV/IO push q3–5m during CPR

Pediatric Dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO q3–5m

Route: IV / IO Push

Kinetics: Onset: 1–2 min | Duration: 3–5 min

Prep Recipe: Pre-filled syringe 1 mg / 10 mL (0.1 mg/mL)

Clinical Pearls & Red Flags:

ACLS cornerstone. Administer immediately in non-shockable rhythms (Asystole/PEA); administer after 2nd shock in shockable rhythms (VF/pVT).

ACLS & Antiarrhythmics

Amiodarone

Cordarone

Adult Dose: Cardiac arrest: 300 mg IV push, then 150 mg; Stable VT: 150 mg IV over 10 min

Pediatric Dose: 5 mg/kg IV/IO bolus (max 300 mg) for arrest

Route: IV / IO Push / Infusion

Kinetics: Onset: Variable IV | Long half-life (40–55 days)

Prep Recipe: 50 mg/mL vial

Clinical Pearls & Red Flags:

Class III antiarrhythmic. For shock-refractory VF/pVT after 3rd shock. Can cause hypotension and bradycardia; monitor QT interval.

ACLS & Antiarrhythmics

Adenosine

Adenocard

Adult Dose: 6 mg rapid IV push, then 12 mg rapid IV push if no conversion

Pediatric Dose: 0.1 mg/kg (max 6 mg), then 0.2 mg/kg (max 12 mg)

Route: Rapid IV Push via antecubital vein + immediate 20 mL flush

Kinetics: Onset: 10–20 sec | Half-life: < 10 sec

Prep Recipe: 3 mg/mL vial

Clinical Pearls & Red Flags:

Slows AV node conduction. First-line for stable narrow-complex SVT. Warn patient of impending sense of doom / transient asystole. Contraindicated in heart transplant / WPW with AF.

ACLS & Antiarrhythmics

Atropine Sulfate

Atropine

Adult Dose: 1 mg IV push q3–5m (max 3 mg total) for symptomatic bradycardia

Pediatric Dose: 0.02 mg/kg IV/IO (minimum 0.1 mg, max 0.5 mg)

Route: IV / IO Push

Kinetics: Onset: 1–2 min | Duration: 2–4 hours

Prep Recipe: 0.1 mg/mL pre-filled syringe (1 mg / 10 mL)

Clinical Pearls & Red Flags:

Anticholinergic. Reverses vagal tone. Ineffective in Mobitz II or 3rd degree AV block with wide QRS (requires transcutaneous pacing).

ACLS & Antiarrhythmics

Magnesium Sulfate

Magnesium

Adult Dose: Torsades de Pointes: 2 g IV push over 1–2 min; Eclampsia/Asthma: 2–4 g IV over 15–20 min

Pediatric Dose: 25–50 mg/kg IV (max 2 g)

Route: IV / IO Push / Infusion

Kinetics: Onset: Immediate | Duration: 30 min

Prep Recipe: 50% solution (500 mg/mL)

Clinical Pearls & Red Flags:

Stabilizes cardiac membrane in Torsades de Pointes (polymorphic VT with prolonged QT). Bronchodilator in severe acute asthma. Anticonvulsant for eclampsia.

ACLS & Antiarrhythmics

Calcium Chloride (10%)

Calcium Chloride

Adult Dose: 1 g (10 mL of 10%) IV push over 2–5 min

Pediatric Dose: 20 mg/kg (0.2 mL/kg of 10%) IV/IO

Route: IV / IO Push (central line preferred; CaCl3 contains 3x elemental Ca of gluconate)

Kinetics: Onset: 1–3 min | Duration: 30–60 min

Prep Recipe: 100 mg/mL pre-filled syringe (1 g / 10 mL)

Clinical Pearls & Red Flags:

Membrane stabilization in critical hyperkalemia (wide QRS / sine wave) and calcium channel blocker overdose. Extravasation causes tissue necrosis.

Analgesia & Procedural Sedation

Fentanyl

Sublimaze

Adult Dose: 50–100 mcg (1–2 mcg/kg) IV push q30–60m

Pediatric Dose: 1–2 mcg/kg IV/IO (or 1.5–2 mcg/kg intranasal)

Route: IV / IO / Intranasal

Kinetics: Onset: 1–2 min | Duration: 30–60 min

Prep Recipe: 50 mcg/mL vial

Clinical Pearls & Red Flags:

Synthetic opioid. Rapid onset, short duration, minimal histamine release (no hypotension). Rapid high-dose push can cause chest wall rigidity.

Analgesia & Procedural Sedation

Hydromorphone

Dilaudid

Adult Dose: 0.5–1 mg IV push q2–3h (equivalent to 4–7 mg morphine)

Pediatric Dose: 0.015 mg/kg IV push

Route: IV / SubQ

Kinetics: Onset: 5 min | Peak: 15–30 min | Duration: 3–4 hours

Prep Recipe: 1 mg/mL or 2 mg/mL vial

Clinical Pearls & Red Flags:

Potent semisynthetic opioid (7x morphine potency). Safe in renal impairment (less toxic metabolite accumulation than morphine).

Analgesia & Procedural Sedation

Ketorolac

Toradol

Adult Dose: 15 mg IV push (or 30 mg IM) q6h prn (max 5 days)

Pediatric Dose: 0.5 mg/kg IV (max 15 mg)

Route: IV / IM

Kinetics: Onset: 10–15 min | Peak: 1–2 hours | Duration: 4–6 hours

Prep Recipe: 15 mg/mL or 30 mg/mL vial

Clinical Pearls & Red Flags:

Analgesic ceiling is 10–15 mg IV (30 mg IV provides NO extra analgesia, only increased renal/GI toxicity). First-line for renal colic and migraine.

Analgesia & Procedural Sedation

Ketamine (Analgesic Dose)

Ketalar Sub-Dissociative

Adult Dose: 0.1–0.3 mg/kg IV piggyback over 15 min (or 0.5 mg/kg intranasal)

Pediatric Dose: 0.1–0.2 mg/kg IV (or 0.5–1 mg/kg IN)

Route: IV Piggyback in 100 mL NS over 15m (prevents dysphoria)

Kinetics: Onset: 5 min | Duration: 60–90 min

Prep Recipe: Dilute in 100 mL NS

Clinical Pearls & Red Flags:

NMDA receptor antagonist. Opioid-sparing analgesia for acute sickle cell crises, severe burns, and refractory acute pain. Zero respiratory depression.

Toxicology Antidotes

Naloxone

Narcan

Adult Dose: 0.04–0.4 mg IV (titrate to restore spontaneous breathing, NOT full alertness); Arrest: 2 mg IV/IM/IN

Pediatric Dose: 0.01–0.1 mg/kg IV/IN

Route: IV / IM / SubQ / Intranasal

Kinetics: Onset: 1–2 min IV (2–5 min IN) | Duration: 30–90 min

Prep Recipe: 0.4 mg/mL or 4 mg/0.1 mL nasal spray

Clinical Pearls & Red Flags:

Pure mu-opioid antagonist. Goal is ventilation, not awake withdrawal agitation. Duration (30–90m) is shorter than methadone/fentanyl patches; watch for renarcotization.

Toxicology Antidotes

N-Acetylcysteine (NAC)

Acetadote

Adult Dose: 21-hour IV protocol: 150 mg/kg over 1h, then 50 mg/kg over 4h, then 100 mg/kg over 16h

Pediatric Dose: Same weight-based protocol (use cautious fluid volumes)

Route: IV Infusion (or Oral: 140 mg/kg load, then 70 mg/kg q4h x 17 doses)

Kinetics: Onset: Rapid intracellular glutathione replenishment

Prep Recipe: 200 mg/mL (20%) solution diluted in D5W

Clinical Pearls & Red Flags:

Acetaminophen toxicity antidote. 100% hepatoprotective if started within 8 hours of acute ingestion. Safe in pregnancy. Check Rumack-Matthew nomogram.

Toxicology Antidotes

20% Lipid Emulsion

Intralipid (LAST)

Adult Dose: Bolus: 1.5 mL/kg IV over 1 min (~100 mL for 70 kg), then infusion: 0.25 mL/kg/min

Pediatric Dose: 1.5 mL/kg IV bolus, then 0.25 mL/kg/min

Route: IV Push / Infusion

Kinetics: Onset: Immediate 'lipid sink' and metabolic rescue

Prep Recipe: 20% intravenous fat emulsion bag

Clinical Pearls & Red Flags:

First-line antidote for Local Anesthetic Systemic Toxicity (LAST, e.g. bupivacaine, lidocaine). Also effective in severe lipophilic drug OD (CCBs, BBs, TCAs).

Toxicology Antidotes

Digoxin Immune Fab

DigiFab

Adult Dose: Empiric arrest / life-threatening: 10–20 vials IV push; Known level: Vials = (Serum Digoxin x Weight in kg) / 100

Pediatric Dose: Calculate using formula or 1–2 vials empiric

Route: IV Push in arrest / over 30 min if stable

Kinetics: Onset: 15–30 min | Full reversal in 2–4 hours

Prep Recipe: Lyophilized powder 40 mg/vial (binds 0.5 mg digoxin)

Clinical Pearls & Red Flags:

Indications: Ventricular arrhythmias, symptomatic bradycardia unresponsive to atropine, or K+ > 5.0 mEq/L in acute digoxin toxicity.

Toxicology Antidotes

Fomepizole

Antizol

Adult Dose: Load: 15 mg/kg IV over 30 min, then 10 mg/kg q12h x 4 doses, then 15 mg/kg q12h

Pediatric Dose: 15 mg/kg IV loading dose

Route: IV Infusion in 100 mL NS/D5W over 30 min

Kinetics: Onset: Immediate alcohol dehydrogenase inhibition

Prep Recipe: 1 g/mL vial

Clinical Pearls & Red Flags:

Blocks alcohol dehydrogenase (ADH) preventing toxic metabolite formation in Ethylene Glycol (glycolic/oxalic acid) and Methanol (formic acid) poisoning.

Toxicology Antidotes

Hydroxocobalamin

Cyanokit

Adult Dose: 5 g IV infusion over 15 min (may repeat once up to 10 g)

Pediatric Dose: 70 mg/kg IV (max 5 g)

Route: IV Infusion

Kinetics: Onset: Immediate binding of cyanide to form cyanocobalamin (Vit B12)

Prep Recipe: 2.5 g vials reconstituted with 100 mL NS each

Clinical Pearls & Red Flags:

First-line for Cyanide poisoning (smoke inhalation victim with soot in mouth and unexplained lactic acidosis > 8 mmol/L). Causes harmless red skin/urine discoloration.

Reversal & Hemostasis

4-Factor PCC

Kcentra / Beriplex

Adult Dose: INR 2–<4: 25 units/kg (max 2500); INR 4–6: 35 units/kg (max 3500); INR > 6: 50 units/kg (max 5000) + Vitamin K 10 mg IV

Pediatric Dose: 25–50 units/kg IV based on INR

Route: IV Infusion over 10–15 min

Kinetics: Onset: < 15 min | Duration: 12–24 hours

Prep Recipe: Vials containing Factors II, VII, IX, X, Protein C & S

Clinical Pearls & Red Flags:

Urgent reversal of Warfarin in life-threatening bleeding or intracranial hemorrhage (ICH). Far superior to FFP (immediate INR correction, zero fluid overload).

Reversal & Hemostasis

Tranexamic Acid (TXA)

Cyklokapron

Adult Dose: Trauma (CRASH-2): 1 g IV over 10 min, then 1 g infusion over 8 hours; Postpartum hemorrhage: 1 g IV over 10m

Pediatric Dose: 15–20 mg/kg IV loading dose

Route: IV Infusion / Topical

Kinetics: Onset: 5–15 min | Duration: 3 hours

Prep Recipe: 100 mg/mL vial (dilute 1 g in 100 mL NS)

Clinical Pearls & Red Flags:

Antifibrinolytic (lysine analog). MUST be given within 3 hours of trauma injury (mortality increases if given > 3h!). Also used topically for epistaxis.

Reversal & Hemostasis

Idarucizumab

Praxbind

Adult Dose: 5 g IV (administered as two consecutive 2.5 g boluses)

Pediatric Dose: Safety not established in pediatrics

Route: IV Push / Rapid Infusion

Kinetics: Onset: Immediate (< 5 min) complete reversal of dabigatran

Prep Recipe: Two 2.5 g / 50 mL vials

Clinical Pearls & Red Flags:

Monoclonal antibody fragment specifically binding Dabigatran (Pradaxa) with 350x higher affinity than thrombin. Zero procoagulant effect.

Reversal & Hemostasis

Protamine Sulfate

Protamine

Adult Dose: 1 mg per 100 units of Unfractionated Heparin (max 50 mg single dose) slow IV push over 10 min

Pediatric Dose: 1 mg per 100 units heparin

Route: Slow IV Push over 10 minutes

Kinetics: Onset: 30–60 sec | Duration: 2 hours

Prep Recipe: 10 mg/mL vial

Clinical Pearls & Red Flags:

Neutralizes heparin by forming salt complex. Rapid infusion causes severe catastrophic hypotension and anaphylactoid reaction. Reverses ~60% of Lovenox.

Seizure & Agitation

Lorazepam

Ativan

Adult Dose: 4 mg IV push over 2 min (repeat once at 5–10 min if seizing)

Pediatric Dose: 0.1 mg/kg IV/IO (max 4 mg single dose)

Route: IV / IO Push

Kinetics: Onset: 2–3 min | Duration: 4–6 hours

Prep Recipe: 2 mg/mL or 4 mg/mL vial

Clinical Pearls & Red Flags:

First-line benzodiazepine for status epilepticus (0–5 min). Longer effective central nervous system duration than diazepam due to lower lipid solubility.

Seizure & Agitation

Midazolam (IM/IN)

Versed

Adult Dose: Seizure without IV access: 10 mg IM (or 0.2 mg/kg IN); Excited Delirium: 5–10 mg IM

Pediatric Dose: 0.2 mg/kg IM/IN (max 10 mg)

Route: IM / Intranasal / IV

Kinetics: Onset: 3–5 min IM/IN | Duration: 1–2 hours

Prep Recipe: 5 mg/mL vial

Clinical Pearls & Red Flags:

First-line for status epilepticus when IV access is NOT immediately established (RAMPART trial proved 10 mg IM midazolam superior to 4 mg IV lorazepam due to zero access delay).

Seizure & Agitation

Levetiracetam

Keppra

Adult Dose: 60 mg/kg IV infusion over 10–15 min (max 4,500 mg)

Pediatric Dose: 60 mg/kg IV (max 4,500 mg)

Route: IV Infusion in 100 mL NS over 10–15 min

Kinetics: Onset: Rapid brain penetration within 15 min

Prep Recipe: 100 mg/mL vial

Clinical Pearls & Red Flags:

Second-line status epilepticus therapy (ESETT trial: equal efficacy to fosphenytoin and valproate with fewer cardiorespiratory adverse effects).

Seizure & Agitation

Haloperidol

Haldol

Adult Dose: 5–10 mg IM/IV (often combined with Lorazepam 2 mg + Benadryl 50 mg = '5-2-50')

Pediatric Dose: 0.05–0.15 mg/kg/day divided

Route: IM / IV

Kinetics: Onset: 15–30 min IM (5–10 min IV) | Duration: 4–6 hours

Prep Recipe: 5 mg/mL vial

Clinical Pearls & Red Flags:

First-generation typical antipsychotic (D2 blocker). Watch for QTc prolongation and extrapyramidal symptoms / dystonia (treat with Diphenhydramine 50 mg IV).

Cardio & Hypertensive

Nicardipine

Cardene

Adult Dose: Start 5 mg/h IV infusion; titrate by 2.5 mg/h q5–15m (max 15 mg/h) to target BP

Pediatric Dose: 0.5–1 mcg/kg/min IV infusion

Route: IV Infusion

Kinetics: Onset: 5–15 min | Duration: 4–6 hours after stop

Prep Recipe: 25 mg in 250 mL NS (0.1 mg/mL)

Clinical Pearls & Red Flags:

Dihydropyridine calcium channel blocker. Drug of choice for acute stroke blood pressure management (target SBP < 140 in ICH; < 185 before tPA).

Cardio & Hypertensive

Labetalol

Trandate

Adult Dose: 10–20 mg slow IV push over 2 min; repeat 20–80 mg q10m (max 300 mg) OR infusion 1–2 mg/min

Pediatric Dose: 0.2–1 mg/kg IV (max 20 mg initial)

Route: IV Push / Infusion

Kinetics: Onset: 2–5 min | Duration: 2–4 hours

Prep Recipe: 5 mg/mL vial

Clinical Pearls & Red Flags:

Combined alpha-1 and non-selective beta-blocker (1:7 alpha-to-beta ratio). First-line for acute aortic dissection (target HR < 60, SBP < 120) and preeclampsia.

Cardio & Hypertensive

Nitroglycerin (IV / SL)

Nitrostat / Tridil

Adult Dose: SL: 0.4 mg tab/spray q5m x3; IV: start 20–40 mcg/min, rapidly titrate up to 200–400 mcg/min for flash pulmonary edema

Pediatric Dose: 0.25–0.5 mcg/kg/min

Route: Sublingual / IV Infusion

Kinetics: Onset: 1–2 min | Duration: 3–5 min after stop

Prep Recipe: 0.4 mg SL tablets; 50 mg in 250 mL D5W (200 mcg/mL)

Clinical Pearls & Red Flags:

Venodilator at low doses; arteriolar dilator at high doses (> 100 mcg/min). CONTRAINDICATION: Sildenafil/vardenafil use in 24h, tadalafil in 48h, RV infarction.

Empiric Antimicrobials

Septic Shock Empiric Regimen

Vancomycin + Cefepime

Adult Dose: Vancomycin: 25–30 mg/kg IV load (max 2 g) + Cefepime: 2 g IV over 30 min

Pediatric Dose: Vanc: 15–20 mg/kg + Cefepime: 50 mg/kg

Route: IV Infusion

Kinetics: Administer STAT within 60 min of recognition

Prep Recipe: Administer within 1 hour of triage in septic shock

Clinical Pearls & Red Flags:

Broad MRSA + Pseudomonas coverage. If severe penicillin anaphylaxis, substitute Cefepime with Aztreonam 2 g IV or Levofloxacin 750 mg IV.

Empiric Antimicrobials

Bacterial Meningitis Regimen

Vanc + Ceftriaxone + Amp + Dex

Adult Dose: Ceftriaxone 2 g IV + Vancomycin 25 mg/kg IV + Dexamethasone 10 mg IV (+ Ampicillin 2 g IV if age > 50 or immunocompromised)

Pediatric Dose: Ceftriaxone 50 mg/kg + Vanc 15 mg/kg + Dex 0.15 mg/kg

Route: IV Infusion / Push

Kinetics: Immediate priority; do not delay for CT or lumbar puncture!

Prep Recipe: Administer Dexamethasone 10 mg IV PRIOR TO or CONCURRENTLY with 1st antibiotic dose

Clinical Pearls & Red Flags:

Dexamethasone reduces hearing loss and mortality in Streptococcus pneumoniae meningitis. Ampicillin covers Listeria monocytogenes in > 50 yo and immunocompromised.

Empiric Antimicrobials

Severe CAP / Pneumonia Regimen

Ceftriaxone + Azithromycin

Adult Dose: Ceftriaxone: 1–2 g IV daily + Azithromycin: 500 mg IV daily (or Doxycycline 100 mg IV/PO)

Pediatric Dose: Ceftriaxone 50 mg/kg + Azithromycin 10 mg/kg

Route: IV Infusion

Kinetics: Administer in ED prior to admission

Prep Recipe: Standard inpatient pneumonia coverage

Clinical Pearls & Red Flags:

Covers typical pathogens (Strep pneumoniae, Haemophilus) plus atypicals (Legionella, Mycoplasma). Add Vancomycin or Cefepime if MRSA / Pseudomonas risk.

Empiric Antimicrobials

Open Fracture Prophylaxis

Cefazolin +/- Gentamicin

Adult Dose: Gustilo I & II: Cefazolin 2 g IV q8h (3 g if > 120 kg); Gustilo III: Cefazolin 2 g IV + Gentamicin 5 mg/kg IV (+ Penicillin G 4m units if farm/soil)

Pediatric Dose: Cefazolin 30 mg/kg IV (max 2 g)

Route: IV Infusion

Kinetics: Urgent; every hour delay increases osteomyelitis risk

Prep Recipe: Administer STAT within 3 hours of trauma (ideally < 1h)

Clinical Pearls & Red Flags:

Every open fracture requires immediate sterile dressing, splinting, and antibiotics. Add clostridial coverage (Penicillin G) for barnyard/soil contamination.

Medication & Brand	Category	Adult Dose	Pediatric Dose	Route & Kinetics	Clinical Pearls
Epinephrine (Push-Dose) Adrenaline	Push-Dose & Pressor	5–20 mcg (0.5–2 mL of 10 mcg/mL) IV push q2–5m titrated to MAP > 65	0.1–1 mcg/kg IV push q2–5m (titrate cautiously)	IV / IO Push Onset: 1 min \| Peak: 2–5 min \| Duration: 5–10 min	Potent alpha-1 + beta-1/2 agonist. Increases HR, SVR, and inotropy. Bridge to central line infusion. Never push 1:1,000 IV.
Phenylephrine (Push-Dose) Neo-Synephrine	Push-Dose & Pressor	50–200 mcg (0.5–2 mL of 100 mcg/mL) IV push q2–5m titrated to MAP > 65	5–20 mcg/kg IV push q2–5m	IV / IO Push Onset: 1 min \| Peak: 2–3 min \| Duration: 10–20 min	Pure alpha-1 agonist. Increases SVR without increasing HR. Ideal for tachycardic hypotension (e.g. post-intubation shock with rapid AF).
Norepinephrine Infusion Levophed	Push-Dose & Pressor	2–30 mcg/min IV infusion (start 5–10 mcg/min, titrate q2–5m to MAP >= 65)	0.05–0.5 mcg/kg/min IV infusion	IV Infusion (Central line preferred; peripheral safe for initial hours) Onset: 1–2 min \| Duration: 2–10 min after stop	First-line vasopressor for septic shock, cardiogenic shock with low SVR, and neurogenic shock. Alpha-1 > beta-1.
Vasopressin Infusion Pitressin	Push-Dose & Pressor	0.03 units/min fixed IV infusion (do not titrate)	0.0003–0.002 units/kg/min	IV Infusion (Central line preferred) Onset: Rapid \| Duration: 20 min	Second-line pressor added to Norepi in refractory septic shock. Works at V1 receptors independent of adrenergic receptors.
Etomidate Amidate	RSI Induction & Paralytics	0.3 mg/kg IV push (typically 20–30 mg)	0.3 mg/kg IV push	IV / IO Push Onset: 15–30 sec \| Duration: 3–8 min	Hemodynamically neutral induction agent. Ideal for trauma, sepsis, and shock. Causes transient adrenal suppression (clinical significance debated).
Ketamine (RSI Induction) Ketalar	RSI Induction & Paralytics	1.5–2 mg/kg IV push (or 4–5 mg/kg IM)	1.5–2 mg/kg IV push	IV / IO Push (or IM) Onset: 30–60 sec IV (3–5 min IM) \| Duration: 10–20 min	Dissociative anesthetic. Bronchodilator (drug of choice for status asthmaticus intubation). Sympathomimetic preserves airway reflexes and BP.
Propofol Diprivan	RSI Induction & Paralytics	1.5–2.5 mg/kg IV push; Sedation: 5–50 mcg/kg/min	1.5–2.5 mg/kg IV push	IV / IO Push / Infusion Onset: 15–30 sec \| Duration: 3–10 min	Potent bronchodilator and anticonvulsant. Causes significant myocardial depression and vasodilation; AVOID in hypotensive or shock patients.
Rocuronium Zemuron	RSI Induction & Paralytics	1.2 mg/kg IV push (high RSI dose for 60s paralysis)	1.2 mg/kg IV push	IV / IO Push Onset: 45–60 sec \| Duration: 45–75 min	Non-depolarizing paralytic of choice. No hyperkalemia risk. Fully reversible at any time with Sugammadex (16 mg/kg for immediate rescue).
Succinylcholine Anectine	RSI Induction & Paralytics	1.5–2 mg/kg IV push (or 3–4 mg/kg IM)	2 mg/kg IV push (infants 3 mg/kg)	IV / IO Push (or IM) Onset: 30–45 sec \| Duration: 5–10 min	Depolarizing paralytic. CONTRAINDICATIONS: Hyperkalemia, major burns/crush injuries > 48h, denervating disease, malignant hyperthermia history.
Sugammadex Bridion	RSI Induction & Paralytics	16 mg/kg IV push (immediate reversal of Rocuronium 1.2 mg/kg)	16 mg/kg IV push for emergent reversal	IV Push Onset: < 2 min \| Full reversal in 3 min	Encapsulates rocuronium and vecuronium. 'Cannot intubate, cannot oxygenate' reversal rescue. Inactivates oral contraceptives for 7 days.
Epinephrine 1:10,000 (ACLS) Adrenaline	ACLS & Antiarrhythmics	1 mg IV/IO push q3–5m during CPR	0.01 mg/kg (0.1 mL/kg of 1:10,000) IV/IO q3–5m	IV / IO Push Onset: 1–2 min \| Duration: 3–5 min	ACLS cornerstone. Administer immediately in non-shockable rhythms (Asystole/PEA); administer after 2nd shock in shockable rhythms (VF/pVT).
Amiodarone Cordarone	ACLS & Antiarrhythmics	Cardiac arrest: 300 mg IV push, then 150 mg; Stable VT: 150 mg IV over 10 min	5 mg/kg IV/IO bolus (max 300 mg) for arrest	IV / IO Push / Infusion Onset: Variable IV \| Long half-life (40–55 days)	Class III antiarrhythmic. For shock-refractory VF/pVT after 3rd shock. Can cause hypotension and bradycardia; monitor QT interval.
Adenosine Adenocard	ACLS & Antiarrhythmics	6 mg rapid IV push, then 12 mg rapid IV push if no conversion	0.1 mg/kg (max 6 mg), then 0.2 mg/kg (max 12 mg)	Rapid IV Push via antecubital vein + immediate 20 mL flush Onset: 10–20 sec \| Half-life: < 10 sec	Slows AV node conduction. First-line for stable narrow-complex SVT. Warn patient of impending sense of doom / transient asystole. Contraindicated in heart transplant / WPW with AF.
Atropine Sulfate Atropine	ACLS & Antiarrhythmics	1 mg IV push q3–5m (max 3 mg total) for symptomatic bradycardia	0.02 mg/kg IV/IO (minimum 0.1 mg, max 0.5 mg)	IV / IO Push Onset: 1–2 min \| Duration: 2–4 hours	Anticholinergic. Reverses vagal tone. Ineffective in Mobitz II or 3rd degree AV block with wide QRS (requires transcutaneous pacing).
Magnesium Sulfate Magnesium	ACLS & Antiarrhythmics	Torsades de Pointes: 2 g IV push over 1–2 min; Eclampsia/Asthma: 2–4 g IV over 15–20 min	25–50 mg/kg IV (max 2 g)	IV / IO Push / Infusion Onset: Immediate \| Duration: 30 min	Stabilizes cardiac membrane in Torsades de Pointes (polymorphic VT with prolonged QT). Bronchodilator in severe acute asthma. Anticonvulsant for eclampsia.
Calcium Chloride (10%) Calcium Chloride	ACLS & Antiarrhythmics	1 g (10 mL of 10%) IV push over 2–5 min	20 mg/kg (0.2 mL/kg of 10%) IV/IO	IV / IO Push (central line preferred; CaCl3 contains 3x elemental Ca of gluconate) Onset: 1–3 min \| Duration: 30–60 min	Membrane stabilization in critical hyperkalemia (wide QRS / sine wave) and calcium channel blocker overdose. Extravasation causes tissue necrosis.
Fentanyl Sublimaze	Analgesia & Procedural Sedation	50–100 mcg (1–2 mcg/kg) IV push q30–60m	1–2 mcg/kg IV/IO (or 1.5–2 mcg/kg intranasal)	IV / IO / Intranasal Onset: 1–2 min \| Duration: 30–60 min	Synthetic opioid. Rapid onset, short duration, minimal histamine release (no hypotension). Rapid high-dose push can cause chest wall rigidity.
Hydromorphone Dilaudid	Analgesia & Procedural Sedation	0.5–1 mg IV push q2–3h (equivalent to 4–7 mg morphine)	0.015 mg/kg IV push	IV / SubQ Onset: 5 min \| Peak: 15–30 min \| Duration: 3–4 hours	Potent semisynthetic opioid (7x morphine potency). Safe in renal impairment (less toxic metabolite accumulation than morphine).
Ketorolac Toradol	Analgesia & Procedural Sedation	15 mg IV push (or 30 mg IM) q6h prn (max 5 days)	0.5 mg/kg IV (max 15 mg)	IV / IM Onset: 10–15 min \| Peak: 1–2 hours \| Duration: 4–6 hours	Analgesic ceiling is 10–15 mg IV (30 mg IV provides NO extra analgesia, only increased renal/GI toxicity). First-line for renal colic and migraine.
Ketamine (Analgesic Dose) Ketalar Sub-Dissociative	Analgesia & Procedural Sedation	0.1–0.3 mg/kg IV piggyback over 15 min (or 0.5 mg/kg intranasal)	0.1–0.2 mg/kg IV (or 0.5–1 mg/kg IN)	IV Piggyback in 100 mL NS over 15m (prevents dysphoria) Onset: 5 min \| Duration: 60–90 min	NMDA receptor antagonist. Opioid-sparing analgesia for acute sickle cell crises, severe burns, and refractory acute pain. Zero respiratory depression.
Naloxone Narcan	Toxicology Antidotes	0.04–0.4 mg IV (titrate to restore spontaneous breathing, NOT full alertness); Arrest: 2 mg IV/IM/IN	0.01–0.1 mg/kg IV/IN	IV / IM / SubQ / Intranasal Onset: 1–2 min IV (2–5 min IN) \| Duration: 30–90 min	Pure mu-opioid antagonist. Goal is ventilation, not awake withdrawal agitation. Duration (30–90m) is shorter than methadone/fentanyl patches; watch for renarcotization.
N-Acetylcysteine (NAC) Acetadote	Toxicology Antidotes	21-hour IV protocol: 150 mg/kg over 1h, then 50 mg/kg over 4h, then 100 mg/kg over 16h	Same weight-based protocol (use cautious fluid volumes)	IV Infusion (or Oral: 140 mg/kg load, then 70 mg/kg q4h x 17 doses) Onset: Rapid intracellular glutathione replenishment	Acetaminophen toxicity antidote. 100% hepatoprotective if started within 8 hours of acute ingestion. Safe in pregnancy. Check Rumack-Matthew nomogram.
20% Lipid Emulsion Intralipid (LAST)	Toxicology Antidotes	Bolus: 1.5 mL/kg IV over 1 min (~100 mL for 70 kg), then infusion: 0.25 mL/kg/min	1.5 mL/kg IV bolus, then 0.25 mL/kg/min	IV Push / Infusion Onset: Immediate 'lipid sink' and metabolic rescue	First-line antidote for Local Anesthetic Systemic Toxicity (LAST, e.g. bupivacaine, lidocaine). Also effective in severe lipophilic drug OD (CCBs, BBs, TCAs).
Digoxin Immune Fab DigiFab	Toxicology Antidotes	Empiric arrest / life-threatening: 10–20 vials IV push; Known level: Vials = (Serum Digoxin x Weight in kg) / 100	Calculate using formula or 1–2 vials empiric	IV Push in arrest / over 30 min if stable Onset: 15–30 min \| Full reversal in 2–4 hours	Indications: Ventricular arrhythmias, symptomatic bradycardia unresponsive to atropine, or K+ > 5.0 mEq/L in acute digoxin toxicity.
Fomepizole Antizol	Toxicology Antidotes	Load: 15 mg/kg IV over 30 min, then 10 mg/kg q12h x 4 doses, then 15 mg/kg q12h	15 mg/kg IV loading dose	IV Infusion in 100 mL NS/D5W over 30 min Onset: Immediate alcohol dehydrogenase inhibition	Blocks alcohol dehydrogenase (ADH) preventing toxic metabolite formation in Ethylene Glycol (glycolic/oxalic acid) and Methanol (formic acid) poisoning.
Hydroxocobalamin Cyanokit	Toxicology Antidotes	5 g IV infusion over 15 min (may repeat once up to 10 g)	70 mg/kg IV (max 5 g)	IV Infusion Onset: Immediate binding of cyanide to form cyanocobalamin (Vit B12)	First-line for Cyanide poisoning (smoke inhalation victim with soot in mouth and unexplained lactic acidosis > 8 mmol/L). Causes harmless red skin/urine discoloration.
4-Factor PCC Kcentra / Beriplex	Reversal & Hemostasis	INR 2–<4: 25 units/kg (max 2500); INR 4–6: 35 units/kg (max 3500); INR > 6: 50 units/kg (max 5000) + Vitamin K 10 mg IV	25–50 units/kg IV based on INR	IV Infusion over 10–15 min Onset: < 15 min \| Duration: 12–24 hours	Urgent reversal of Warfarin in life-threatening bleeding or intracranial hemorrhage (ICH). Far superior to FFP (immediate INR correction, zero fluid overload).
Tranexamic Acid (TXA) Cyklokapron	Reversal & Hemostasis	Trauma (CRASH-2): 1 g IV over 10 min, then 1 g infusion over 8 hours; Postpartum hemorrhage: 1 g IV over 10m	15–20 mg/kg IV loading dose	IV Infusion / Topical Onset: 5–15 min \| Duration: 3 hours	Antifibrinolytic (lysine analog). MUST be given within 3 hours of trauma injury (mortality increases if given > 3h!). Also used topically for epistaxis.
Idarucizumab Praxbind	Reversal & Hemostasis	5 g IV (administered as two consecutive 2.5 g boluses)	Safety not established in pediatrics	IV Push / Rapid Infusion Onset: Immediate (< 5 min) complete reversal of dabigatran	Monoclonal antibody fragment specifically binding Dabigatran (Pradaxa) with 350x higher affinity than thrombin. Zero procoagulant effect.
Protamine Sulfate Protamine	Reversal & Hemostasis	1 mg per 100 units of Unfractionated Heparin (max 50 mg single dose) slow IV push over 10 min	1 mg per 100 units heparin	Slow IV Push over 10 minutes Onset: 30–60 sec \| Duration: 2 hours	Neutralizes heparin by forming salt complex. Rapid infusion causes severe catastrophic hypotension and anaphylactoid reaction. Reverses ~60% of Lovenox.
Lorazepam Ativan	Seizure & Agitation	4 mg IV push over 2 min (repeat once at 5–10 min if seizing)	0.1 mg/kg IV/IO (max 4 mg single dose)	IV / IO Push Onset: 2–3 min \| Duration: 4–6 hours	First-line benzodiazepine for status epilepticus (0–5 min). Longer effective central nervous system duration than diazepam due to lower lipid solubility.
Midazolam (IM/IN) Versed	Seizure & Agitation	Seizure without IV access: 10 mg IM (or 0.2 mg/kg IN); Excited Delirium: 5–10 mg IM	0.2 mg/kg IM/IN (max 10 mg)	IM / Intranasal / IV Onset: 3–5 min IM/IN \| Duration: 1–2 hours	First-line for status epilepticus when IV access is NOT immediately established (RAMPART trial proved 10 mg IM midazolam superior to 4 mg IV lorazepam due to zero access delay).
Levetiracetam Keppra	Seizure & Agitation	60 mg/kg IV infusion over 10–15 min (max 4,500 mg)	60 mg/kg IV (max 4,500 mg)	IV Infusion in 100 mL NS over 10–15 min Onset: Rapid brain penetration within 15 min	Second-line status epilepticus therapy (ESETT trial: equal efficacy to fosphenytoin and valproate with fewer cardiorespiratory adverse effects).
Haloperidol Haldol	Seizure & Agitation	5–10 mg IM/IV (often combined with Lorazepam 2 mg + Benadryl 50 mg = '5-2-50')	0.05–0.15 mg/kg/day divided	IM / IV Onset: 15–30 min IM (5–10 min IV) \| Duration: 4–6 hours	First-generation typical antipsychotic (D2 blocker). Watch for QTc prolongation and extrapyramidal symptoms / dystonia (treat with Diphenhydramine 50 mg IV).
Nicardipine Cardene	Cardio & Hypertensive	Start 5 mg/h IV infusion; titrate by 2.5 mg/h q5–15m (max 15 mg/h) to target BP	0.5–1 mcg/kg/min IV infusion	IV Infusion Onset: 5–15 min \| Duration: 4–6 hours after stop	Dihydropyridine calcium channel blocker. Drug of choice for acute stroke blood pressure management (target SBP < 140 in ICH; < 185 before tPA).
Labetalol Trandate	Cardio & Hypertensive	10–20 mg slow IV push over 2 min; repeat 20–80 mg q10m (max 300 mg) OR infusion 1–2 mg/min	0.2–1 mg/kg IV (max 20 mg initial)	IV Push / Infusion Onset: 2–5 min \| Duration: 2–4 hours	Combined alpha-1 and non-selective beta-blocker (1:7 alpha-to-beta ratio). First-line for acute aortic dissection (target HR < 60, SBP < 120) and preeclampsia.
Nitroglycerin (IV / SL) Nitrostat / Tridil	Cardio & Hypertensive	SL: 0.4 mg tab/spray q5m x3; IV: start 20–40 mcg/min, rapidly titrate up to 200–400 mcg/min for flash pulmonary edema	0.25–0.5 mcg/kg/min	Sublingual / IV Infusion Onset: 1–2 min \| Duration: 3–5 min after stop	Venodilator at low doses; arteriolar dilator at high doses (> 100 mcg/min). CONTRAINDICATION: Sildenafil/vardenafil use in 24h, tadalafil in 48h, RV infarction.
Septic Shock Empiric Regimen Vancomycin + Cefepime	Empiric Antimicrobials	Vancomycin: 25–30 mg/kg IV load (max 2 g) + Cefepime: 2 g IV over 30 min	Vanc: 15–20 mg/kg + Cefepime: 50 mg/kg	IV Infusion Administer STAT within 60 min of recognition	Broad MRSA + Pseudomonas coverage. If severe penicillin anaphylaxis, substitute Cefepime with Aztreonam 2 g IV or Levofloxacin 750 mg IV.
Bacterial Meningitis Regimen Vanc + Ceftriaxone + Amp + Dex	Empiric Antimicrobials	Ceftriaxone 2 g IV + Vancomycin 25 mg/kg IV + Dexamethasone 10 mg IV (+ Ampicillin 2 g IV if age > 50 or immunocompromised)	Ceftriaxone 50 mg/kg + Vanc 15 mg/kg + Dex 0.15 mg/kg	IV Infusion / Push Immediate priority; do not delay for CT or lumbar puncture!	Dexamethasone reduces hearing loss and mortality in Streptococcus pneumoniae meningitis. Ampicillin covers Listeria monocytogenes in > 50 yo and immunocompromised.
Severe CAP / Pneumonia Regimen Ceftriaxone + Azithromycin	Empiric Antimicrobials	Ceftriaxone: 1–2 g IV daily + Azithromycin: 500 mg IV daily (or Doxycycline 100 mg IV/PO)	Ceftriaxone 50 mg/kg + Azithromycin 10 mg/kg	IV Infusion Administer in ED prior to admission	Covers typical pathogens (Strep pneumoniae, Haemophilus) plus atypicals (Legionella, Mycoplasma). Add Vancomycin or Cefepime if MRSA / Pseudomonas risk.
Open Fracture Prophylaxis Cefazolin +/- Gentamicin	Empiric Antimicrobials	Gustilo I & II: Cefazolin 2 g IV q8h (3 g if > 120 kg); Gustilo III: Cefazolin 2 g IV + Gentamicin 5 mg/kg IV (+ Penicillin G 4m units if farm/soil)	Cefazolin 30 mg/kg IV (max 2 g)	IV Infusion Urgent; every hour delay increases osteomyelitis risk	Every open fracture requires immediate sterile dressing, splinting, and antibiotics. Add clostridial coverage (Penicillin G) for barnyard/soil contamination.