Monday, May 13, 2013

Need to know medications for EM residents (both MD/DO and PharmD)

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.


Meds to know for ED Residents
Epinephrine
Anaphylaxis: 0.3mg IM
(Peds): 0.01mg/kg IM
Cardiac arrest: 1mg IV/IO
(Peds): 0.01mg/kg IV/IO
Starting infusion rate: 2-10 mcg/min
Norepinephrine
Starting infusion rate: 0.5-30mcg/min
Phenylephrine
Bolus: 50-200 mcg IVP
Starting infusion rate:40-100 mcg/min
Dopamine
Inotropic: 10mcg/kg/min
Pressor: 15mcg/kg/min
Etomidate
RSI: 0.3mg/kg
Procedural sedation: 0.1mg/kg
Succinylcholine
1.5mg/kg
(peds) 2.0mg/kg
Rocuronium
1.0-1.2 mg/kg
Vecuronium
Defasciculating dose: 0.01 mg/kg
RSI: 0.1mg/kg
Propofol
Procedural sedation: 0.75mg/kg
Sedation (mechanically ventilated): 1-2mg/kg bolus, 5mcg/kg/min infusion
Midazolam
0.035mg/kg
Lorazepam
0.1mg/kg (status epilepticus)
Diazepam
0.1-0.3mg/kg
Phenytoin
15-20mg/kg Load IV and PO (max PO dose 400mg, must space by at least 2 hours)
Naloxone
0.04mg – 0.4 mg
IV NAC
LD: 150mg/kg over 1 hour, 2nd dose 50mg/kg over 4 hours, 3rd dose 100mg/kg over 16 hours
Hydroxocobalamin
5g IV q15min x2
Alteplase (tPA)
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
Ketamine
Procedural sedation: 1mg/kg
RSI: 2mg/kg
Haloperidol
5mg IVP
Dexamethasone
0.15mg/kg
Nitroglycerin
5-20 mcg/min
Esmolol
500 mcg/kg bolus, 50mcg/kg/hr
Labetalol
10-20mg IVP
Nicardipine
5mg/hr, max 15mg/hr
Diltiazem
0.25mg/kg, 0.35mg/kg (new data suggests 0.1mg/kg just as effective)
Adenosine
6mg, 12mg, 12mg (3mg though central line, or on dipyridamole)
Amiodarone
300mg IV bolus (no pulse)
150mg IV bolus (with a pulse)
Fentanyl
1 mcg/kg
Morphine
0.1mg/kg, max single dose 8mg
Vitamin K (phytonadione)
Life threatening bleed on warfarin: 10mg IVPB
Mannitol
Intracrantial edema, impending herniation: 1g/kg bolus
Hypertonic Saline (3% NaCl)
TBI: 250mL IV over 15 min (adults)
Digoxin
LD: 1mg or 0.5 mg: 50% inititally, then 25% q6h for 2 doses
Glucagon
0.5 mcg/kg or 2-10 mg
Octreotide
Sulfonylurea: 50 mcg SQ
GI bleed (varacies): 50mcg IV bolus, 50mcg/hr infusion
Insulin
Hyperkalemia: 10 units
DKA: 0.1 units/kg LD then 0.05-0.1 units/kg/hr
HIET: 1 unit/kg

6 comments:

  1. 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/3826809
    http://www.ncbi.nlm.nih.gov/pubmed/9094065

    Just food for thought. Keep up the good work!

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    1. 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.

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    2. Thanks for reading and thank for the comment!

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  2. 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.

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  3. 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?

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    Replies
    1. 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.

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