Unfortunately not every ED has a pharmacist (yet), and most of the graduating EM residents will be leaving for institutions without pharmacists in the ED. To make sure that the residents will be prepared, I was asked to compile a list of medications and doses that the they must know without looking at a reference or asking a pharmacist. While trying to stick to 25-30 meds, below is what I came up with. I would love input from everyone in the FOAMed universe for their must know lists.
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Meds to know for ED Residents
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Epinephrine
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Anaphylaxis: 0.3mg IM
(Peds): 0.01mg/kg IM
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Cardiac arrest: 1mg IV/IO
(Peds): 0.01mg/kg IV/IO
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Starting infusion rate: 2-10 mcg/min
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Norepinephrine
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Starting infusion rate: 0.5-30mcg/min
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Phenylephrine
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Bolus: 50-200 mcg IVP
Starting infusion rate:40-100 mcg/min
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Dopamine
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Inotropic: 10mcg/kg/min
Pressor: 15mcg/kg/min
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Etomidate
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RSI: 0.3mg/kg
Procedural sedation: 0.1mg/kg
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Succinylcholine
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1.5mg/kg
(peds) 2.0mg/kg
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Rocuronium
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1.0-1.2 mg/kg
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Vecuronium
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Defasciculating dose: 0.01 mg/kg
RSI: 0.1mg/kg
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Propofol
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Procedural sedation: 0.75mg/kg
Sedation (mechanically ventilated): 1-2mg/kg bolus, 5mcg/kg/min infusion
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Midazolam
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0.035mg/kg
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Lorazepam
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0.1mg/kg (status epilepticus)
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Diazepam
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0.1-0.3mg/kg
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Phenytoin
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15-20mg/kg Load IV and PO (max PO dose 400mg, must space by at least 2 hours)
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Naloxone
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0.04mg – 0.4 mg
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IV NAC
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LD: 150mg/kg over 1 hour, 2nd dose 50mg/kg over 4 hours, 3rd dose 100mg/kg over 16 hours
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Hydroxocobalamin
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5g IV q15min x2
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Alteplase (tPA)
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Stroke: 0.9mg/kg (10% as bolus, 90% over 1 hour)
PE: 100mg over 2 hours
Cardiac arrest: 50mg bolus, repeat 50mg in 15 min
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Ketamine
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Procedural sedation: 1mg/kg
RSI: 2mg/kg
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Haloperidol
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5mg IVP
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Dexamethasone
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0.15mg/kg
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Nitroglycerin
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5-20 mcg/min
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Esmolol
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500 mcg/kg bolus, 50mcg/kg/hr
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Labetalol
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10-20mg IVP
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Nicardipine
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5mg/hr, max 15mg/hr
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Diltiazem
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0.25mg/kg, 0.35mg/kg (new data suggests 0.1mg/kg just as effective)
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Adenosine
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6mg, 12mg, 12mg (3mg though central line, or on dipyridamole)
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Amiodarone
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300mg IV bolus (no pulse)
150mg IV bolus (with a pulse)
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Fentanyl
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1 mcg/kg
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Morphine
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0.1mg/kg, max single dose 8mg
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Vitamin K (phytonadione)
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Life threatening bleed on warfarin: 10mg IVPB
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Mannitol
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Intracrantial edema, impending herniation: 1g/kg bolus
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Hypertonic Saline (3% NaCl)
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TBI: 250mL IV over 15 min (adults)
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Digoxin
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LD: 1mg or 0.5 mg: 50% inititally, then 25% q6h for 2 doses
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Glucagon
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0.5 mcg/kg or 2-10 mg
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Octreotide
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Sulfonylurea: 50 mcg SQ
GI bleed (varacies): 50mcg IV bolus, 50mcg/hr infusion
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Insulin
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Hyperkalemia: 10 units
DKA: 0.1 units/kg LD then 0.05-0.1 units/kg/hr
HIET: 1 unit/kg
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Nice list! I'm a huge fan of the peripheral brain.Can I possibly challenge your comment about maximum oral phenytoin doses? Assuming you're okay with a delayed peak effect, a larger loading dose has been evaluated:http://www.ncbi.nlm.nih.gov/pubmed/3826809http://www.ncbi.nlm.nih.gov/pubmed/9094065Just food for thought. Keep up the good work!
I think dependent on the indication, phenytoin could be dosed higher as long as a therapeutic trough isn't needed right now. In patients who's level can wait 12-24 hours, givin a gram at a time (ideally suspension, not capsules) is acceptable.
Thanks for reading and thank for the comment!
Your Naloxone dose is on the low side if you truly have a good history of acute opioid intoxication and are getting set to intubate otherwise; 1-2 mg is fine in a comatose patient if there is no response to the 0.4 mg. Propofol sedation drip rate is also at the low end, but if you are giving a bolus, that is likely about right; often we end up in the 30-50 mcg/kg/min range once we have achieved a nice, steady sedation, but to start off at that level after a bolus will probably cause hypotension. Good list.
Nice list, any strategies for memorization?Also, I noticed that you had vecuronium dosing for defasciculation. When I was on rotation in the ED, both the pharmacists there agreed that defasciculation was not necessary or commonly used anymore for succinylcholine. Any thoughts?
Don't memorize. Get out there and apply this information. Application, review and repetition is the best way to learn it.As for defasciculation dose vec, I agree that it may not be necessary. However, I also do not have evidence to say that it harms patients particularly when we are appropriately timing administration of paralytics and sedative agents.