65 common BLS and ALS prehospital medications with indications, contraindications, dosing, routes, and clinical notes.
Acetaminophen (Tylenol)
Analgesic / Antipyretic · BLS · analgesic
Centrally inhibits prostaglandin synthesis and modulates serotonergic descending pain pathways — analgesic and antipyretic with minimal anti-inflammatory or antiplatelet effect.
Adult: PO/PR: 650–1000 mg q4–6h (max 4 g/24 hr). IV (Ofirmev): 1 g over 15 min q6h. Pediatric: PO/PR: 15 mg/kg q4–6h (max 75 mg/kg/24 hr). IV: 15 mg/kg q6h (≥ 2 yr).
Route: PO, PR, IV (where carried) · Onset: PO: 30–60 min; IV: 5–10 min · Duration: 4–6 hours
Clinical pearls: Often carried by both BLS and ALS for fever and mild pain control, especially pediatrics. Pairs well with ibuprofen for febrile children. Avoid in patients already nearing the 4 g/24 hr ceiling. IV formulation (Ofirmev) is increasingly common in IFT and critical-care transport.
Activated Charcoal
Adsorbent / Antidote · ALS · toxicology
Adsorbs ingested toxins in the GI tract, preventing systemic absorption.
Indications
Oral poisoning / overdose (within 1–2 hours of ingestion)
Intentional ingestion of toxic substances
Contraindications
Unprotected airway / altered LOC (aspiration risk)
Caustic ingestion (acids/alkalis)
Hydrocarbons
Heavy metals (iron, lithium)
Intestinal obstruction
Dosing and administration
Adult: 25–100 g PO or via NG tube (typical 50 g for adult) Pediatric: < 12 yrs: 1 g/kg PO (max 50 g); mix with water into slurry
Route: PO, NG tube · Onset: Immediate (binds toxin in GI tract) · Duration: While in GI tract
Clinical pearls: Only effective for medications/drugs it can adsorb. Patient must have intact gag reflex or protected airway. Does NOT work for: iron, lithium, alcohols, caustics, or hydrocarbons. Coordinate with medical control and poison control.
Adenosine
Antiarrhythmic · ALS · cardiac
Slows AV node conduction, terminates reentry SVT.
Indications
SVT
Stable narrow-complex tachycardia
Contraindications
2nd/3rd degree AV block
Sick sinus syndrome
WPW with atrial flutter/fib
Dosing and administration
Adult: 6 mg rapid IV push; repeat 12 mg x2 if no effect Pediatric: 0.1 mg/kg IV (max 6 mg); repeat 0.2 mg/kg (max 12 mg)
Route: IV — rapid push at AC or above, flush immediately · Onset: Seconds · Duration: 10–30 seconds
Clinical pearls: Must be given FAST with immediate NS flush. Warn patient of brief chest pressure/flushing.
Clinical pearls: May cause tachycardia. Monitor HR and SpO2. MDI: 4–8 puffs via spacer.
Alteplase (tPA)
Fibrinolytic / Tissue Plasminogen Activator · ALS · cardiac
Recombinant tPA — converts plasminogen to plasmin, dissolving fibrin clots in acute thromboembolic events.
Indications
Acute ischemic stroke (within 3–4.5 hr window per protocol)
Massive pulmonary embolism with hemodynamic instability
STEMI when PCI unavailable (rare in EMS)
Contraindications
Active internal bleeding
Recent intracranial/spinal surgery or trauma (< 3 mo)
History of intracranial hemorrhage
SBP > 185 or DBP > 110 (stroke)
Bleeding diathesis / INR > 1.7
Recent major surgery (< 14 days)
Suspected aortic dissection
Dosing and administration
Adult: Stroke: 0.9 mg/kg IV (max 90 mg); 10% as bolus over 1 min, remainder over 60 min. PE: 100 mg IV over 2 hr. Pediatric: Rarely used in prehospital pediatrics — per medical control
Route: IV infusion (dedicated line — do not co-infuse) · Onset: Minutes (clot lysis begins immediately) · Duration: Fibrinolytic effect persists hours after infusion
Clinical pearls: Almost exclusively a critical-care transport / IFT medication — most EMS systems do not initiate. Maintain SBP < 180 / DBP < 105 during and 24 hr after infusion. Monitor for bleeding (gums, IV sites, neuro changes). Avoid IM injections, arterial sticks, and NG tubes during transport.
Adult: 500–1000 mg (5–10 mL of 10% solution) IV slow push. Repeat per protocol. Pediatric: 20 mg/kg IV slow push (max 1 g)
Route: IV slow push (over 2–5 min) — central or large-bore peripheral preferred · Onset: 1–3 minutes · Duration: 30–60 minutes
Clinical pearls: Calcium chloride has 3× more elemental calcium than calcium gluconate. Vesicant — extravasation causes tissue necrosis; use a large vein. Flush line well before and after — incompatible with NaHCO3 and phosphates.
Calcium Gluconate
Electrolyte / Cardioprotective Agent · ALS · metabolic
Provides ionized calcium that stabilizes the cardiac membrane in hyperkalemia and reverses calcium channel blocker / magnesium toxicity. Contains roughly one-third the elemental calcium of calcium chloride but is far less irritating to peripheral veins.
Do not co-administer with sodium bicarbonate (precipitates — flush line between)
Dosing and administration
Adult: 1–3 g (10–30 mL of 10% solution) IV over 5–10 min. Repeat per protocol. Pediatric: 60 mg/kg IV slow push (max 3 g)
Route: IV slow push — peripheral acceptable (less vesicant than CaCl2) · Onset: 1–3 minutes · Duration: 30–60 minutes
Clinical pearls: Preferred over calcium chloride when only peripheral access is available — extravasation risk is much lower. Three grams of calcium gluconate ≈ 1 g calcium chloride for elemental calcium. Always flush line before/after — do not mix with bicarbonate.
Dexamethasone (Decadron)
Corticosteroid (Long-Acting Glucocorticoid) · ALS · respiratory
Binds glucocorticoid receptors to suppress inflammation, reduce capillary permeability, and stabilize cell membranes. Long half-life (36–72 hr) and minimal mineralocorticoid activity.
Indications
Croup (viral laryngotracheobronchitis)
Acute asthma / COPD exacerbation (alternative to methylprednisolone)
Route: IV, IM, PO · Onset: 1–2 hours (clinical effect) · Duration: 36–72 hours
Clinical pearls: Drug of choice for croup — single dose lasts the entire illness course. Single-dose alternative to a multi-day prednisone burst for asthma. Long half-life means repeat dosing in EMS is rarely needed. PO and IV doses are essentially equivalent.
Dextrose (D50/D25/D10)
Carbohydrate / Glucose · ALS · metabolic
Rapidly restores blood glucose levels.
Indications
Hypoglycemia (BGL < 60 mg/dL)
Altered mental status with confirmed hypoglycemia
Contraindications
Hyperglycemia
Use with caution in CVA/stroke (hyperglycemia worsens outcome)
Dosing and administration
Adult: 25 g (50 mL of D50) IV — titrate to effect Pediatric: 0.5–1 g/kg of D25 (2–4 mL/kg) IV/IO slowly
Clinical pearls: Confirm hypoglycemia with glucometer first. D50 is vesicant — ensure good IV access. Use D25 for pediatrics.
Diltiazem (Cardizem)
Calcium Channel Blocker (Non-Dihydropyridine) · ALS · cardiac
Blocks L-type calcium channels in the AV node, slowing conduction and ventricular rate.
Indications
Atrial fibrillation with rapid ventricular response (rate control)
Atrial flutter (rate control)
Stable SVT (refractory to adenosine — per protocol)
Contraindications
SBP < 90 mmHg
WPW with A-fib/flutter (accelerates accessory pathway — may cause VF)
2nd/3rd degree AV block without pacemaker
Wide-complex tachycardia of unknown origin
Concurrent IV beta-blockers (risk of complete heart block)
Dosing and administration
Adult: 0.25 mg/kg IV over 2 min (typical 15–25 mg). May repeat 0.35 mg/kg in 15 min. Infusion: 5–15 mg/hr. Pediatric: Not commonly used in peds EMS
Route: IV slow push, IV infusion · Onset: 2–7 minutes · Duration: 1–3 hours
Clinical pearls: Monitor BP closely — may cause hypotension. Have calcium available as antidote. Preferred over verapamil in EMS for rate control. Avoid in WPW — this is critical and potentially fatal.
Symptomatic bradycardia (refractory to atropine — per protocol)
Contraindications
Uncorrected tachyarrhythmias
Pheochromocytoma
Hypovolemia not yet corrected
Dosing and administration
Adult: 2–20 mcg/kg/min IV infusion — titrate to effect. Start at 5 mcg/kg/min. Pediatric: 2–20 mcg/kg/min IV infusion
Route: IV infusion (dedicated line — irritant) · Onset: 2–4 minutes · Duration: 10 minutes (after stopping infusion)
Clinical pearls: Vesicant — extravasation causes tissue necrosis. Use largest available vein. Infusion pump required for accuracy. Tachycardia and arrhythmias are dose-limiting. Norepinephrine now preferred for septic shock per current guidelines.
Droperidol (Inapsine)
Butyrophenone Antipsychotic / Antiemetic · ALS · neurological
Dopamine D2 receptor antagonist with additional alpha-adrenergic blockade — produces sedation, antiemesis, and reduction of agitation. Similar profile to haloperidol with faster onset and shorter duration.
Adult: Agitation: 2.5–5 mg IM/IV. Nausea / migraine: 0.625–1.25 mg IV slow push. Pediatric: 0.05–0.06 mg/kg IM (rare in EMS — per medical control)
Route: IM (preferred), IV slow push · Onset: IM: 3–10 min; IV: 3–5 min · Duration: 2–4 hours
Clinical pearls: FDA black box warning for QT prolongation / torsades — obtain a 12-lead when feasible, especially with higher doses. Returned to widespread EMS use after the 2001 black box curtailed it; now favored for fast-acting chemical restraint and antiemesis at low doses. Onset is meaningfully faster than haloperidol and duration is shorter, allowing easier neuro reassessment in the ED. Watch for hypotension and extrapyramidal symptoms.
DuoDote / Mark I Auto-Injector
Nerve Agent Antidote (Atropine + Pralidoxime) · ALS · toxicology
Clinical pearls: Designed for self/buddy administration in mass casualty. Triple-dose all three injectors immediately for severe symptoms (seizures, apnea, unconsciousness). Add CANA (diazepam) auto-injector if seizing. Decontamination is critical BEFORE/DURING treatment — protect rescuers with PPE. Document number of doses given and time of each.
Clinical pearls: Drug of choice for RSI in most patients — preserves BP and HR unlike propofol. Single dose causes transient adrenal suppression (cortisol) — ongoing infusions contraindicated. Myoclonus (muscle twitching) is common but benign. Always pair with a paralytic for RSI.
Fentanyl
Opioid Analgesic · ALS · analgesic
Mu-opioid receptor agonist — potent analgesia with rapid onset.
Route: IV, IO, IM, IN (intranasal) · Onset: IV: 1–2 min; IN: 5–10 min · Duration: 30–60 minutes
Clinical pearls: Monitor respiratory status. Have naloxone available. Rapid IV push can cause chest wall rigidity.
Flumazenil (Romazicon)
Benzodiazepine Antagonist · ALS · toxicology
Competitive antagonist at the benzodiazepine binding site of the GABA-A receptor — reverses benzodiazepine-induced sedation and respiratory depression.
Indications
Reversal of benzodiazepine-induced sedation (procedural sedation)
Suspected pure benzodiazepine overdose with respiratory depression
Contraindications
Chronic benzodiazepine use / dependence (precipitates withdrawal seizures)
Known seizure disorder controlled by benzodiazepines
Mixed overdose with TCA or pro-convulsant agents
Increased ICP
Hypersensitivity
Dosing and administration
Adult: 0.2 mg IV over 15 sec; may repeat 0.2 mg q1 min (max total 1 mg in EMS, 3 mg over 1 hr). Pediatric: 0.01 mg/kg IV (max 0.2 mg/dose); may repeat to max 1 mg total
Route: IV · Onset: 1–2 minutes · Duration: 30–60 minutes (often shorter than benzodiazepine — re-sedation likely)
Clinical pearls: CAUTION: Use is highly restricted in EMS. Risk of precipitating seizures in dependent patients or mixed overdose (especially TCA). Supportive care (airway, ventilation) is the safer first-line approach for benzo overdose. Monitor for re-sedation — flumazenil is short-acting. Many systems do not carry it.
Furosemide (Lasix)
Loop Diuretic · ALS · cardiac
Inhibits Na-K-2Cl cotransporter in the loop of Henle — promotes diuresis and reduces preload. Rapid venodilation occurs before diuresis.
Indications
Acute pulmonary edema (fluid overload)
Congestive heart failure exacerbation
Hypertensive emergency with pulmonary edema
Contraindications
Hypovolemia / dehydration
Anuria / renal failure (relative)
Hypersensitivity to sulfonamides (cross-reaction, relative)
Pre-eclampsia (relative)
Dosing and administration
Adult: 0.5–1 mg/kg IV (typical 40–80 mg). May repeat per protocol. Pediatric: 1 mg/kg IV (max 6 mg/kg/day)
Route: IV, IM · Onset: IV: 5 min (venodilation); diuresis 30–60 min · Duration: 2–6 hours
Clinical pearls: CPAP/BiPAP and nitroglycerin are now first-line for acute pulmonary edema — furosemide is an adjunct. Ensure adequate BP before administering. Monitor for hypokalemia with repeated dosing. Foley may be needed.
Adult: Agitation: 5–10 mg IM. Severe: up to 10 mg IM. Antiemetic: 0.5–2 mg IV/IM. Pediatric: 0.05–0.15 mg/kg IM (max 5 mg)
Route: IM (preferred), IV (use with caution — risk of torsades) · Onset: IM: 10–20 min; IV: 5–10 min · Duration: 12–24 hours
Clinical pearls: Commonly combined with midazolam (5+5 or 5+10) for excited delirium — provides faster sedation. Risk of QT prolongation — avoid with other QT-prolonging drugs. Watch for extrapyramidal symptoms (EPS) / dystonic reactions — treat with diphenhydramine. Droperidol is an alternative.
Heparin
Anticoagulant (Indirect Thrombin Inhibitor) · ALS · cardiac
Binds to antithrombin III, accelerating its inactivation of thrombin (factor IIa) and factor Xa — prevents fibrin clot formation and propagation.
Indications
Acute coronary syndrome / STEMI (adjunct to PCI or fibrinolytics)
Unstable angina
Pulmonary embolism
Acute ischemic stroke (rare — per protocol)
DVT
IFT maintenance of existing infusions
Contraindications
Active bleeding / hemorrhage
Recent intracranial hemorrhage or surgery
Severe thrombocytopenia / HIT (heparin-induced thrombocytopenia)
Severe uncontrolled hypertension
Bleeding diathesis
Dosing and administration
Adult: ACS/STEMI bolus: 60 units/kg IV (max 4,000 units), then infusion 12 units/kg/hr (max 1,000 units/hr). Maintain existing infusions during IFT per orders. Pediatric: 75 units/kg IV bolus, then 20 units/kg/hr infusion (per protocol)
Route: IV bolus, IV infusion, SC · Onset: IV: Immediate · Duration: 1–2 hours (IV)
Clinical pearls: Most commonly encountered as an existing IFT infusion. Reversal: protamine sulfate (1 mg per 100 units heparin given in last 4 hr, max 50 mg). Monitor for bleeding (IV sites, mucosa, neuro changes). aPTT goal 1.5–2.5x baseline. Distinct from low molecular weight heparin (enoxaparin/Lovenox) — not interchangeable.
Hydromorphone (Dilaudid)
Opioid Analgesic · ALS · analgesic
Potent mu-opioid receptor agonist — analgesia roughly 5–7× more potent than morphine on a milligram basis with similar duration and a slightly faster onset.
Pain refractory to morphine or fentanyl per protocol
IFT pain control of patients already on hydromorphone PCA
Contraindications
Respiratory depression / hypoventilation
Known hypersensitivity to opioids
Hemodynamic instability (relative)
Concurrent CNS depressants (use cautiously)
Dosing and administration
Adult: 0.5–1 mg IV/IM/SC q2–4h. Titrate to effect. Pediatric: 0.015 mg/kg IV q3–4h (max 0.5 mg/dose) — per medical control
Route: IV, IM, SC, IN (less common) · Onset: IV: 5 min; IM: 15 min · Duration: 3–4 hours
Clinical pearls: Dose conservatively — milligram-for-milligram far more potent than morphine. Reverse with naloxone if needed. Often encountered on IFT as patient-controlled analgesia (PCA) — confirm pump settings and lockout intervals before transport.
Hydroxocobalamin (Cyanokit)
Cyanide Antidote / Vitamin B12 Precursor · ALS · toxicology
Binds cyanide ions to form cyanocobalamin (non-toxic), which is then renally excreted.
Indications
Cyanide poisoning (confirmed or suspected)
Smoke inhalation with suspected cyanide toxicity (house fires, industrial exposure)
Unexplained refractory metabolic acidosis with altered LOC
Contraindications
Hypersensitivity (rare)
Dosing and administration
Adult: 5 g IV over 15 minutes. May repeat 5 g x2 (total 15 g) for severe cases. Pediatric: 70 mg/kg IV over 15 minutes (max 5 g)
Route: IV infusion (large bore — solution is very viscous) · Onset: Minutes · Duration: Variable
Clinical pearls: Turns patient skin, urine, and mucous membranes bright red-pink for up to 5 days (expected — document to ED). Interference with co-oximetry and lab tests. Do NOT use with sodium thiosulfate in same line. First-line for smoke inhalation cyanide — safer than older nitrite kits in hypoxic patients. Indicated for ANY significant smoke inhalation patient who is hemodynamically unstable.
Insulin (Regular)
Pancreatic Hormone (Short-Acting) · ALS · metabolic
Drives potassium intracellularly via Na/K-ATPase activation (used in hyperkalemia) and lowers serum glucose by promoting cellular glucose uptake.
Indications
Hyperkalemia with ECG changes (paired with dextrose)
Severe DKA / HHS (IFT, with established orders)
Maintenance of existing insulin infusions during transfer
Contraindications
Hypoglycemia
Hypokalemia (without potassium replacement)
Known hypersensitivity
Dosing and administration
Adult: Hyperkalemia: 10 units regular insulin IV WITH 25 g dextrose (D50) IV. DKA infusion: 0.1 unit/kg/hr per orders. Pediatric: Hyperkalemia: 0.1 unit/kg IV with 0.5 g/kg dextrose. DKA: 0.05–0.1 unit/kg/hr per orders.
Route: IV bolus, IV infusion, SC (rare in EMS) · Onset: IV: 10–30 min for K+ shift · Duration: 4–6 hours (potassium effect 2–6 hr)
Clinical pearls: Always co-administer dextrose for hyperkalemia to prevent iatrogenic hypoglycemia — recheck BGL within 30 min and again at 1 hr. Insulin only shifts potassium intracellularly; total body potassium is unchanged — definitive treatment is renal/dialysis. For IFT infusions, verify pump settings, drip concentration, and most recent BGL/K+ at handoff.
Ipratropium (Atrovent)
Anticholinergic Bronchodilator · ALS · respiratory
Blocks muscarinic receptors in bronchial smooth muscle, bronchodilates.
Indications
COPD exacerbation
Acute asthma (adjunct to albuterol)
Contraindications
Hypersensitivity to atropine or ipratropium
Dosing and administration
Adult: 0.5 mg (2.5 mL unit dose) via nebulizer with albuterol Pediatric: 0.25–0.5 mg via nebulizer
Clinical pearls: Always combine with albuterol (DuoNeb). Avoid eye contact — can worsen glaucoma.
Ketamine
Dissociative Anesthetic / Analgesic · ALS · analgesic
NMDA receptor antagonist — produces dissociative anesthesia, analgesia, and bronchodilation while preserving airway reflexes and hemodynamic stability.
Indications
RSI induction (hemodynamically unstable patients)
Sedation for painful procedures
Refractory bronchospasm / severe asthma
Pain management (sub-dissociative dose)
Excited delirium / chemical restraint
Contraindications
Increased intracranial pressure (relative — historical concern, now disputed)
Active psychosis (relative)
Laryngospasm history (relative)
Aortic dissection / hypertensive emergency
Dosing and administration
Adult: RSI induction: 1–2 mg/kg IV or 4 mg/kg IM. Sub-dissociative analgesia: 0.1–0.3 mg/kg IV slow push. Severe asthma: 1–2 mg/kg IV Pediatric: RSI induction: 1–2 mg/kg IV; 4–5 mg/kg IM. Procedural sedation: 1–1.5 mg/kg IV; 4–5 mg/kg IM
Route: IV, IM · Onset: IV: 30–60 sec; IM: 3–5 min · Duration: IV: 10–15 min; IM: 15–30 min
Clinical pearls: Preferred RSI induction agent in hypotensive/shocked patients — maintains BP and HR. Increases secretions (consider glycopyrrolate). May cause emergence reactions (dysphoria) — benzodiazepine co-administration reduces risk. Excellent bronchodilator for refractory asthma. Does NOT reliably suppress laryngeal reflexes — be prepared for active airway management.
Ketorolac (Toradol)
NSAID / Non-Opioid Analgesic · ALS · analgesic
Inhibits COX-1 and COX-2, reducing prostaglandin synthesis — anti-inflammatory and analgesic without opioid effects.
Pain management where opioids are undesirable or contraindicated
Adjunct to opioid analgesics (opioid-sparing)
Contraindications
Active GI ulcer or bleeding
Renal impairment (NSAIDs worsen renal function)
Coagulopathy / anticoagulant therapy
Aspirin or NSAID allergy
Pregnancy (especially 3rd trimester)
Dosing and administration
Adult: 15–30 mg IV (over 15 sec), or 30–60 mg IM. Peds-adapted: 0.5 mg/kg IV (max 15 mg IV, 30 mg IM). Pediatric: 0.5 mg/kg IV/IM (max 15 mg IV, 30 mg IM) — use with caution in children
Route: IV, IM · Onset: IV: 5–10 min; IM: 30–60 min · Duration: 4–6 hours
Clinical pearls: NSAID with potent analgesic effect — effective for renal colic, often comparable to opioids. Do NOT give for > 5 days. Parenteral dose limit is lower than IM dose — lower IV dose (15 mg) is standard to minimize GI/renal risk. Excellent choice for pain management in patients with opioid sensitivity or protocol-restricted opioid use.
Labetalol
Mixed Alpha / Beta Blocker · ALS · cardiac
Non-selective beta-blocker with selective alpha-1 blockade (beta:alpha ratio ~7:1 IV) — lowers BP via reduced SVR without reflex tachycardia.
Severe bradycardia / heart block (2nd or 3rd degree)
Cardiogenic shock
Severe asthma / COPD with bronchospasm
Acute decompensated heart failure
Cocaine-induced hypertension (relative — risk of unopposed alpha)
Dosing and administration
Adult: 10–20 mg IV slow push over 2 min; may double dose q10 min (max 300 mg total). Infusion: 0.5–2 mg/min titrated to BP. Pediatric: 0.2–1 mg/kg IV (max 40 mg per dose); per protocol
Route: IV slow push, IV infusion · Onset: IV: 2–5 minutes · Duration: 2–4 hours
Clinical pearls: Excellent first-line for hypertensive emergency in stroke and aortic dissection — does not increase HR. Position patient supine — postural hypotension possible. Monitor BP and HR every 5 min. Frequently encountered as IFT infusion. Nicardipine is an alternative for stroke BP management.
Levetiracetam (Keppra)
Antiepileptic · ALS · neurological
Binds synaptic vesicle protein SV2A, modulating neurotransmitter release — broad-spectrum seizure suppression with minimal hemodynamic or sedative effect.
Indications
Status epilepticus (second-line after benzodiazepines)
Active seizures refractory to lorazepam/midazolam
Seizure prophylaxis after head injury / stroke (per protocol)
Contraindications
Known hypersensitivity
Caution in severe renal impairment (dose adjustment)
Dosing and administration
Adult: 60 mg/kg IV (max 4.5 g) over 10 min. Maintenance: 1000–1500 mg IV q12h. Pediatric: 60 mg/kg IV (max 4.5 g) over 5–10 min
Route: IV infusion (dilute in 100 mL NS or D5W) · Onset: Minutes · Duration: 6–8 hours (single dose)
Clinical pearls: Per the 2019 ESETT trial, levetiracetam, fosphenytoin, and valproate are equally effective second-line agents for benzodiazepine-refractory status epilepticus — choose based on availability and patient profile. Far less sedating and hemodynamically safer than phenytoin. Becoming a common EMS drip for refractory seizures; verify dilution and infusion time before push.
Lidocaine
Antiarrhythmic (Class Ib) / Local Anesthetic · ALS · cardiac
Route: IV, IM · Onset: IV: 2–5 min; IM: 10–20 min · Duration: 6–8 hours (longer than midazolam)
Clinical pearls: Longer duration than midazolam — good for prolonged seizure control but requires more respiratory monitoring. Monitor airway and O2 sat closely. Reversal agent: flumazenil (use with caution — may precipitate withdrawal seizures in dependent patients). Preferred by many systems for status epilepticus due to longer duration.
Adult: Torsades: 1–2 g IV over 15 min. Eclampsia: 4–6 g IV over 15–20 min Pediatric: 25–50 mg/kg IV (max 2 g)
Route: IV — must be diluted and given slowly · Onset: Minutes · Duration: 30–60 minutes
Clinical pearls: Monitor for respiratory depression, hypotension. Calcium gluconate reverses toxicity. Have calcium available.
Mannitol
Osmotic Diuretic · ALS · neurological
Increases plasma osmolality, drawing water from cerebral and ocular tissues into the vascular space, then promoting osmotic diuresis. Reduces intracranial pressure within minutes.
Indications
Increased intracranial pressure (severe TBI with herniation signs)
Cerebral edema (mass lesion, stroke)
Acute angle-closure glaucoma
Rhabdomyolysis (forced diuresis — rare in EMS)
Contraindications
Anuria / established renal failure
Severe dehydration / hypovolemia
Active intracranial bleeding (relative — may worsen)
Severe pulmonary edema / heart failure
Dosing and administration
Adult: 0.25–1 g/kg IV over 15–30 min (typical 50–100 g). May repeat per protocol. Pediatric: 0.25–1 g/kg IV over 15–30 min
Route: IV infusion — use 0.22 micron in-line filter (crystallizes) · Onset: 5–15 minutes (ICP reduction) · Duration: 1.5–6 hours
Clinical pearls: Predominantly an IFT / critical-care transport drug. Always use an in-line filter — solution may crystallize at lower temperatures (warm bag if needed). Monitor BP, urine output, and serum osmolality goals per orders. Hypertonic saline (3%) is a common alternative for ICP control.
Methylprednisolone (Solu-Medrol)
Corticosteroid · ALS · respiratory
Potent anti-inflammatory — reduces airway edema and inflammation; stabilizes mast cells. Delayed onset (1–4 hrs) but prolongs bronchodilator effect.
Indications
Severe asthma / status asthmaticus (adjunct to bronchodilators)
COPD exacerbation (adjunct)
Anaphylaxis (adjunct after epinephrine)
Spinal cord injury (controversial — per protocol)
Contraindications
Active systemic fungal infection
Hypersensitivity
Dosing and administration
Adult: Asthma/COPD: 125 mg IV/IM. Anaphylaxis: 125–250 mg IV. Spinal cord injury: 30 mg/kg IV over 15 min (if within 8 hrs, per protocol). Pediatric: 1–2 mg/kg IV/IM (max 125 mg). Asthma: 1 mg/kg IV/IM.
Route: IV, IM · Onset: 30 min–4 hours (not a rescue drug — effects are delayed) · Duration: 4–6 hours
Clinical pearls: NOT a rescue medication — give early to shorten overall course. Epinephrine and bronchodilators are first-line for acute asthma/anaphylaxis. Spinal cord injury indication is controversial — follow local protocol. Single prehospital dose has minimal side effects.
Adult: 0.4–2 mg IV/IM/IN q2–3 min (titrate to respirations, not full reversal). IN: 4 mg per nostril Pediatric: 0.01 mg/kg IV/IO/IM (max 2 mg per dose)
Route: IV, IM, IN, ETT · Onset: IV: 1–2 min; IM: 5 min; IN: 2–5 min · Duration: 30–90 minutes (shorter than most opioids — may need redosing)
Clinical pearls: Titrate to respiratory effort — avoid full reversal (precipitates acute withdrawal/agitation). Half-life shorter than most opioids.
Nicardipine (Cardene)
Calcium Channel Blocker (Dihydropyridine) · ALS · cardiac
Selective L-type calcium channel blocker with predominantly arterial vasodilation — lowers SVR and BP with minimal cardiac effect (no significant negative inotropy at therapeutic doses).
Adult: Infusion: Start 5 mg/hr IV; titrate by 2.5 mg/hr q5–15 min (max 15 mg/hr). Once at goal BP, decrease to 3 mg/hr maintenance. Pediatric: 1–3 mcg/kg/min IV infusion (per protocol)
Route: IV infusion (dedicated line — change site q12 hr if peripheral due to phlebitis) · Onset: 5–15 minutes · Duration: 30–60 minutes after infusion stopped
Clinical pearls: Highly titratable — preferred for stroke BP management because of smooth, predictable response without affecting HR. Often used in combination with labetalol. Causes peripheral phlebitis — rotate IV site. Frequently encountered as an IFT infusion. Reflex tachycardia possible but minimal compared to nifedipine.
NMDA receptor antagonism and endogenous opioid release produce analgesia, mild sedation, and amnesia at sub-anesthetic concentrations. Self-administered as a 50/50 nitrous oxide / oxygen mixture.
Adult: Patient self-administers via demand-valve mask until pain relieved or patient drops mask Pediatric: Same demand-valve technique — child must be cooperative and able to hold mask
Clinical pearls: Patient self-administration is the safety mechanism — they drop the mask before becoming over-sedated. Vent the ambulance / scavenge to protect the crew (chronic exposure linked to neuropathy and reproductive risk). Not carried by every system; common in ski / wilderness / OB transport programs. Where carried, often part of BLS scope under medical direction.
Norepinephrine (Levophed)
Catecholamine / Vasopressor · ALS · cardiac
Potent alpha-1 and alpha-2 agonist (vasoconstriction) with moderate beta-1 activity (mild inotropy) — raises MAP primarily through SVR.
Indications
Septic shock (first-line vasopressor per Surviving Sepsis Campaign)
Distributive shock
Neurogenic shock
Refractory hypotension after fluid resuscitation
Contraindications
Hypovolemia not corrected (relative — address volume first)
Mesenteric / peripheral vascular thrombosis
Dosing and administration
Adult: 0.01–3 mcg/kg/min IV infusion — titrate to MAP > 65 mmHg. Start at 0.1–0.2 mcg/kg/min. Pediatric: 0.05–2 mcg/kg/min IV infusion — titrate to effect
Route: IV infusion — central line preferred; large-bore peripheral acceptable short-term · Onset: 1–2 minutes · Duration: Minutes after stopping infusion
Clinical pearls: Now preferred over dopamine as first-line vasopressor for septic shock (lower arrhythmia rate). Vesicant — extravasation causes severe tissue necrosis; monitor IV site closely. Requires infusion pump. Peripheral extravasation: treat with phentolamine 5–10 mg injected around site.
Olanzapine (Zyprexa)
Atypical Antipsychotic · ALS · neurological
Antagonizes dopamine D2 and serotonin 5-HT2A receptors — sedation, antipsychotic effect, and antiemesis with a lower extrapyramidal-symptom and QT-prolongation profile than haloperidol or droperidol.
Behavioral emergency in known psychiatric patients
Severe nausea/vomiting (off-label, refractory)
Contraindications
Known hypersensitivity
Dementia-related psychosis (FDA boxed warning — increased mortality in elderly)
Concurrent IM benzodiazepine within ~1 hour (risk of severe hypotension and respiratory depression — separate by ≥ 60 min)
Dosing and administration
Adult: Agitation: 5–10 mg IM. Orally disintegrating tablet (Zydis): 5–10 mg PO if cooperative. Pediatric: Adolescent (≥ 13 yr): 2.5–5 mg IM/PO — per medical control
Route: IM, PO (orally disintegrating tablet) · Onset: IM: 15–45 min; PO: 30–60 min · Duration: 12–24 hours
Clinical pearls: Lower QT and EPS risk than haloperidol/droperidol — useful when QT status is unknown. Critical safety point: avoid stacking with parenteral benzodiazepines — synergistic respiratory depression and hypotension have caused deaths. Orally disintegrating tablet is useful for cooperative patients refusing injection.
Ondansetron (Zofran)
Antiemetic (5-HT3 antagonist) · ALS · gastrointestinal
Blocks serotonin 5-HT3 receptors in chemoreceptor trigger zone.
Route: IV, IM, ODT · Onset: IV: 30 min; ODT: 30–60 min · Duration: 4–8 hours
Clinical pearls: Preferred over promethazine for peds (less sedation). Safe in pregnancy. Dissolving tablet works without IV access.
Oral Glucose (Glutose / Instaglucose)
Carbohydrate / Glucose · BLS · metabolic
Absorbed through oral mucosa and GI tract — rapidly raises blood glucose in conscious hypoglycemic patients.
Indications
Symptomatic hypoglycemia with intact airway/gag reflex
Altered mental status from suspected hypoglycemia (patient can swallow)
Contraindications
Altered mental status / inability to protect airway (aspiration risk)
Unconscious patient
Confirmed hyperglycemia
Dosing and administration
Adult: 15–25 g PO (1 tube of glucose gel = 15 g). May repeat in 15 min if still symptomatic. Pediatric: 0.5–1 g/kg PO; typical 1 tube (15 g) for children
Route: PO — place between cheek and gum, ensure swallowing · Onset: 10–20 minutes · Duration: Variable — supplement with food/complex carbs after
Clinical pearls: BLS-level intervention — does not require IV access. ONLY use in alert patients who can protect their airway. Confirm hypoglycemia with glucometer first if time permits. Patient should eat a snack after recovery to prevent rebound hypoglycemia.
Oxygen
Gas / Respiratory · BLS · respiratory
Increases FiO2, corrects hypoxemia.
Indications
Hypoxia (SpO2 < 94%)
Respiratory distress
Shock
CO poisoning
Chest pain
Contraindications
COPD with known CO2 retention: titrate to SpO2 88–92%
Clinical pearls: Target SpO2 94–99% for most adults. COPD: 88–92%. High-flow NRB for CO poisoning regardless of SpO2.
Phenylephrine
Selective Alpha-1 Agonist / Vasopressor · ALS · cardiac
Pure alpha-1 adrenergic agonist — produces peripheral vasoconstriction and increased SVR with no direct beta effect. Reflex bradycardia is common.
Indications
Hypotension with tachycardia (where beta agonism is undesirable)
Hypotension during anesthesia / sedation
Septic shock (alternative to norepinephrine in select patients)
Bridging agent during IFT — push-dose or infusion
Contraindications
Severe hypertension
Ventricular tachycardia
Narrow-angle glaucoma (relative)
MAOI use within 14 days
Dosing and administration
Adult: Push-dose: 50–200 mcg IV q1–5 min. Infusion: 0.1–1.5 mcg/kg/min (typical 40–180 mcg/min). Pediatric: 5–20 mcg/kg IV bolus; 0.1–0.5 mcg/kg/min infusion (per orders)
Route: IV push, IV infusion (dedicated line preferred) · Onset: IV: 1–2 minutes · Duration: 10–20 minutes (push); titratable infusion
Clinical pearls: Useful when tachycardia limits use of norepinephrine or epinephrine (e.g., post-arrest with rapid AF). Reflex bradycardia is expected and usually does not require treatment. Vesicant — use largest available vein and monitor IV site closely. Push-dose: dilute 10 mg vial in 100 mL NS for 100 mcg/mL.
Pralidoxime (2-PAM)
Cholinesterase Reactivator / Organophosphate Antidote · ALS · toxicology
Reactivates acetylcholinesterase inhibited by organophosphates (pesticides, nerve agents) by binding to the organophosphate-enzyme complex, restoring normal enzyme activity.
Carbamate poisoning (limited benefit but may be given)
Contraindications
Carbamate toxicity (some evidence of harm — per medical control)
Hypersensitivity
Dosing and administration
Adult: 1–2 g IV over 15–30 min. May repeat 1 g in 1 hour if weakness persists. IM auto-injector (DuoDote): 600 mg IM. Pediatric: 25–50 mg/kg IV over 15–30 min (max 1 g initial dose)
Route: IV infusion, IM (auto-injector in mass casualty / nerve agent settings) · Onset: IV: Minutes · Duration: Variable
Clinical pearls: ALWAYS give with atropine first — atropine addresses muscarinic effects (secretions, bronchospasm), 2-PAM addresses nicotinic effects (muscle weakness, paralysis). Effectiveness decreases rapidly after exposure — give as soon as possible. In nerve agent mass casualty, use DuoDote auto-injector. SLUDGE: Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis.
Procainamide
Antiarrhythmic (Class Ia) · ALS · cardiac
Blocks sodium channels — slows conduction velocity and increases refractory period. Effective for both atrial and ventricular arrhythmias.
Indications
Stable wide-complex tachycardia (suspected VT)
WPW with atrial fibrillation (preferred over adenosine/diltiazem)
Stable SVT refractory to other agents
Contraindications
QT prolongation (risk of Torsades)
Complete heart block
Torsades de Pointes
SBP < 90 mmHg
Myasthenia gravis
Dosing and administration
Adult: 20–50 mg/min IV infusion until arrhythmia suppressed, QRS widens > 50%, max 17 mg/kg total. Maintenance: 1–4 mg/min. Pediatric: 15 mg/kg IV over 30–60 min (per protocol)
Route: IV infusion — must be given slowly · Onset: Minutes (infusion-rate dependent) · Duration: 3–6 hours
Clinical pearls: STOP infusion if: BP drops > 15 mmHg, QRS widens > 50%, arrhythmia terminates. Can cause significant hypotension with rapid administration. Alternative to amiodarone for stable VT. Preferred agent for WPW with A-fib (diltiazem/adenosine/digoxin can accelerate accessory pathway — dangerous).
Promethazine (Phenergan)
Phenothiazine Antiemetic / Antihistamine · ALS · gastrointestinal
Blocks H1 histamine, dopamine D2, and muscarinic receptors — antiemetic, sedative, and antihistamine effect.
Indications
Nausea / vomiting
Motion sickness
Allergic reactions (adjunct)
Sedation / sleep aid (off-label)
Contraindications
Children < 2 years (FDA black box — fatal respiratory depression)
Comatose / severely depressed patients
Bone marrow suppression
IV use via small / hand veins (extravasation causes severe tissue necrosis / gangrene — IM or large-vein deep IV only)
Concurrent CNS depressants (caution)
Dosing and administration
Adult: 12.5–25 mg IM, PO, or PR. IV (with extreme caution): 6.25–12.5 mg diluted, slow push into running large-vein line. Pediatric: Age ≥ 2 yr: 0.25–1 mg/kg IM/PO/PR (max 25 mg). NEVER use < 2 yr.
Route: IM (preferred), PO, PR; IV only with strict precautions · Onset: IM: 20 min; IV: 5 min · Duration: 4–6 hours
Clinical pearls: FDA black box warning for IV use — severe extravasation injury (gangrene, amputation) reported. Many systems restrict to IM or have removed IV use entirely. Always dilute IV doses, use the largest available vein, and stop immediately for any pain / burning at the IV site. Strongly sedating — monitor airway. Safer alternatives (ondansetron, droperidol) are first-line in modern EMS.
Propofol (Diprivan)
Sedative-Hypnotic (Phenol Derivative) · ALS · airway
Potentiates GABA-A inhibition in the CNS — produces rapid sedation, hypnosis, and amnesia. Brief duration of action (5–10 min) allows fine titration. Causes vasodilation and direct myocardial depression.
Indications
Maintenance of sedation in intubated patients (IFT / critical-care transport)
Procedural sedation (per protocol)
Refractory status epilepticus (per protocol)
RSI induction in hemodynamically stable patients (alternative to etomidate)
Contraindications
Hypotension / hemodynamic instability
Egg, soy, or sulfite allergy (relative)
Pediatric ICU sedation infusions (FDA caution)
Hypersensitivity
Dosing and administration
Adult: Induction: 1.5–2.5 mg/kg IV. Maintenance infusion: 5–50 mcg/kg/min titrated. Pediatric: Induction: 2.5–3.5 mg/kg IV (≥ 3 yr). Maintenance: avoid prolonged infusion in peds.
Route: IV bolus, IV infusion (dedicated line — emulsion supports microbial growth, change tubing q12h) · Onset: 30–60 seconds · Duration: 5–10 minutes (single bolus)
Clinical pearls: Causes significant hypotension — bolus cautiously and have a fluid bolus and pressors ready. Watch for propofol infusion syndrome with prolonged high-dose infusions (metabolic acidosis, rhabdomyolysis, cardiac collapse). Most commonly encountered as an IFT sedation drip — verify rate, concentration (10 mg/mL), and most recent vitals at handoff. The white emulsion contains lipid calories — relevant for prolonged infusions.
Push-Dose Epinephrine
Sympathomimetic / Vasopressor (Diluted Bolus) · ALS · cardiac
Same as standard epinephrine — alpha-mediated vasoconstriction and beta-1 inotropy/chronotropy. Diluted concentration (10 mcg/mL) allows small IV boluses for transient pressure support.
Anaphylaxis with hypotension where IM epi insufficient
Bradycardia with hypotension (refractory to atropine)
Contraindications
No absolute contraindications in shock states
Caution in ischemic heart disease and tachyarrhythmias
Dosing and administration
Adult: 10–20 mcg (1–2 mL of push-dose mixture) IV q2–5 min titrated to MAP > 65. Mixture: 1 mL of 1:10,000 epinephrine (100 mcg) + 9 mL NS in 10 mL syringe = 10 mcg/mL. Pediatric: 1 mcg/kg IV (per protocol — rarely used)
Clinical pearls: LABEL THE SYRINGE CLEARLY — confusion with cardiac arrest dose (1 mg) is a high-risk medication error. Bridge to a continuous infusion (norepinephrine) — push-dose is short-acting. Useful peri-intubation when sedation/paralysis cause hypotension. Always document concentration and dose volume. Monitor HR closely — tachyarrhythmias possible.
Rocuronium
Non-Depolarizing Neuromuscular Blocking Agent · ALS · airway
Competitively blocks acetylcholine at the neuromuscular junction — produces flaccid paralysis without fasciculations.
Indications
RSI (Rapid Sequence Intubation) — paralytic agent
Facilitated intubation
Alternative to succinylcholine when succinylcholine is contraindicated
Contraindications
No access to sugammadex (when used for RSI — inability to reverse)
Hypersensitivity to rocuronium
Dosing and administration
Adult: RSI: 1.2 mg/kg IV/IO (high-dose for RSI-equivalent onset). Routine intubation: 0.6 mg/kg IV. Pediatric: RSI: 1.2 mg/kg IV/IO. Routine: 0.6 mg/kg IV
Route: IV, IO · Onset: RSI dose (1.2 mg/kg): 60–90 seconds. Routine dose (0.6 mg/kg): 2–3 min · Duration: 30–60 minutes (significantly longer than succinylcholine)
Clinical pearls: CRITICAL advantage: Reversible with sugammadex (16 mg/kg IV) — immediate reversal within 3 min even at deep block. MUST have sugammadex available if using as primary RSI paralytic. High-dose (1.2 mg/kg) required to match succinylcholine's 60-sec onset. Duration is much longer than succinylcholine — cannot wake patient up if intubation fails without sugammadex. Preferred when succinylcholine is contraindicated.
Sodium Bicarbonate
Alkalinizing Agent · ALS · metabolic
Buffers metabolic acidosis; widens sodium channel in TCA/Na-channel blocker overdose.
Clinical pearls: Flush line before and after — incompatible with many drugs (especially calcium). Generates CO2 — ensure adequate ventilation.
Succinylcholine
Depolarizing Neuromuscular Blocking Agent · ALS · airway
Mimics acetylcholine at the neuromuscular junction, causing persistent depolarization and transient fasciculations followed by flaccid paralysis.
Indications
RSI (Rapid Sequence Intubation) — paralytic agent
Facilitated intubation
Laryngospasm (small dose)
Contraindications
Hyperkalemia or risk of dangerous K⁺ rise (crush injuries > 72 hrs, burns > 72 hrs, denervation injuries, prolonged immobility)
Malignant hyperthermia history / family history
Pseudocholinesterase deficiency (relative)
Penetrating eye injury (relative)
Myopathies / muscular dystrophy
Dosing and administration
Adult: RSI: 1–1.5 mg/kg IV/IO (typical 100 mg for 70 kg adult). Laryngospasm: 0.1–0.5 mg/kg IV Pediatric: RSI: 1–2 mg/kg IV/IO (higher dose needed due to larger Vd). IM: 3–4 mg/kg if no IV access (max 150 mg)
Route: IV, IO, IM (if no IV access) · Onset: IV: 30–60 sec · Duration: 6–10 minutes (short-acting — ideal for difficult airway backup)
Clinical pearls: CRITICAL: Always have a backup plan if intubation fails — paralysis is not reversible and patient will be apneic. Pretreat with atropine in pediatric patients (< 5 yrs) to prevent bradycardia. Causes fasciculations before paralysis. Hyperkalemia risk increases significantly after 72 hours in crush injury, burns, or denervation. Rocuronium (1.2 mg/kg) is an alternative if contraindicated — reversed with sugammadex.
Tenecteplase (TNKase)
Fibrinolytic / Modified Tissue Plasminogen Activator · ALS · cardiac
Genetically modified tPA with greater fibrin specificity and longer half-life — converts plasminogen to plasmin to lyse fibrin clots. Single weight-based bolus rather than infusion.
Indications
STEMI within 12 hr of symptom onset when timely PCI is not available (rural / wilderness EMS)
Acute ischemic stroke within window (off-label, increasingly used per recent trials and protocols)
Massive PE (per protocol)
Contraindications
Active internal bleeding
Recent intracranial / spinal surgery or trauma (< 3 mo)
History of intracranial hemorrhage
SBP > 180 / DBP > 110 (uncontrolled)
Recent major surgery (< 14 days)
Bleeding diathesis / INR > 1.7
Suspected aortic dissection
Dosing and administration
Adult: Single IV bolus over 5 sec — weight-based: < 60 kg: 30 mg; 60–69: 35 mg; 70–79: 40 mg; 80–89: 45 mg; ≥ 90 kg: 50 mg. Stroke (per protocol): 0.25 mg/kg (max 25 mg) IV bolus. Pediatric: Not routinely indicated in prehospital pediatrics
Route: IV bolus over 5 seconds — dedicated line · Onset: Minutes (clot lysis) · Duration: Fibrinolytic effect persists for hours
Clinical pearls: Single-bolus dosing makes TNK far more practical for EMS than alteplase infusion. Always paired with antiplatelet (ASA + P2Y12 inhibitor) and anticoagulant (heparin / enoxaparin) per STEMI protocol. Maintain SBP < 180 / DBP < 105 during and 24 hr after administration. Monitor for bleeding (gums, IV sites, neuro changes). Avoid IM injections, arterial sticks, and NG tubes.
Thiamine (Vitamin B1)
Vitamin / Cofactor · ALS · metabolic
Essential cofactor for glucose metabolism (pyruvate dehydrogenase, alpha-ketoglutarate dehydrogenase). Deficiency causes inability to metabolize glucose in the brain, leading to Wernicke encephalopathy.
Alcoholism / chronic malnutrition before dextrose administration
Altered mental status in malnourished patients
Suspected nutritional deficiency
Contraindications
Hypersensitivity (rare — anaphylaxis reported with rapid IV infusion)
Dosing and administration
Adult: 100 mg IV/IM before or with dextrose. Wernicke's: 500 mg IV over 30 min. Pediatric: 10–25 mg IV/IM (per protocol)
Route: IV (slow push or infusion), IM · Onset: IV: Minutes · Duration: Hours (requires ongoing adequate nutrition)
Clinical pearls: Give BEFORE dextrose in alcoholic or malnourished patients — administering glucose without thiamine can precipitate Wernicke encephalopathy (a neurological emergency). Classic triad: confusion, ataxia, ophthalmoplegia. Often underdosed — 100 mg is minimum; 500 mg preferred for suspected Wernicke's. Safe drug with minimal side effects.
Tranexamic Acid (TXA)
Antifibrinolytic · ALS · toxicology
Synthetic lysine analog — binds plasminogen and plasmin, blocking their interaction with fibrin and preventing clot breakdown. Stabilizes existing clots.
Indications
Major trauma with significant hemorrhage (within 3 hr of injury — CRASH-2 criteria)
Suspected internal bleeding with hemodynamic instability
Postpartum hemorrhage
GI bleed (per protocol)
Epistaxis (topical)
Traumatic brain injury with suspected intracranial hemorrhage (per protocol)
Contraindications
Active intravascular thrombosis (DVT, PE, stroke)
History of seizure (relative — high doses lower threshold)
Subarachnoid hemorrhage (relative)
Hypersensitivity
Dosing and administration
Adult: 1 g IV over 10 min (loading dose); followed by 1 g IV over 8 hr (maintenance — usually at receiving facility). Must be given within 3 hr of injury for maximum benefit. Pediatric: 15 mg/kg IV over 10 min (max 1 g)
Route: IV slow push / short infusion (rapid push causes hypotension) · Onset: Minutes · Duration: 3–8 hours
Clinical pearls: CRASH-2 trial: significant mortality reduction in trauma when given within 3 hr; possible HARM if given after 3 hr — verify time of injury before administration. Slow administration (over 10 min) prevents hypotension. Compatible with most fluids and blood products. Becoming standard in trauma protocols. Document exact time of injury and infusion start.
Vasopressin
Antidiuretic Hormone (ADH) / Vasopressor · ALS · cardiac
V1 receptor agonist — direct vasoconstriction independent of adrenergic pathways. Effective in acidotic/hypoxic states where catecholamines lose efficacy.
Indications
Cardiac arrest (VF, PVT, asystole, PEA) — alternative/adjunct to epinephrine
Refractory vasodilatory shock (adjunct to norepinephrine)
Septic shock (vasopressin deficiency state)
Contraindications
Responsive patients with coronary artery disease (may cause angina)
Chronic nephritis
Dosing and administration
Adult: Cardiac arrest: 40 units IV/IO (one-time dose — may replace 1st or 2nd epinephrine dose per protocol). Vasodilatory shock: 0.03–0.04 units/min IV infusion. Pediatric: 0.4–1 unit/kg IV/IO (max 40 units) — per protocol
Route: IV, IO · Onset: Minutes · Duration: 10–20 minutes
Clinical pearls: 2015 AHA guidelines removed vasopressin as a separate recommendation (no advantage over epinephrine alone in arrest), but many systems still carry it. May be beneficial in prolonged arrest where epinephrine becomes less effective. Does NOT cause tachycardia. In septic shock, used as a norepinephrine-sparing agent at fixed low dose (0.03 units/min) — NOT titrated.
Vecuronium
Non-Depolarizing Neuromuscular Blocker (Aminosteroid) · ALS · airway
Competitively blocks acetylcholine at the neuromuscular junction — produces flaccid paralysis without depolarization. Intermediate duration of action.
Indications
Maintenance paralysis after RSI (continued ventilation, transport)
RSI when succinylcholine is contraindicated (alternative to rocuronium)
Facilitation of mechanical ventilation
Contraindications
No definitive secured airway plan (paralyzed patient cannot breathe — common pitfall)
Inability to ventilate / intubate
Known hypersensitivity
Dosing and administration
Adult: RSI: 0.1 mg/kg IV. Maintenance: 0.01–0.015 mg/kg IV q20–40 min or infusion 0.8–1.2 mcg/kg/min. Pediatric: 0.1 mg/kg IV (intubation); maintenance 0.01 mg/kg q20–40 min
Route: IV bolus, IV infusion · Onset: 2–4 minutes · Duration: 30–40 minutes
Clinical pearls: Ensure adequate sedation and analgesia — paralysis WITHOUT sedation is one of the worst things you can do to a patient. Slower onset than rocuronium, so rocuronium is generally preferred for RSI when succinylcholine is unavailable. Reversal: sugammadex (preferred where carried) or neostigmine + glycopyrrolate. Confirm tube placement immediately after paralysis.
Ziprasidone (Geodon)
Atypical Antipsychotic · ALS · neurological
Antagonizes dopamine D2 and serotonin 5-HT2A receptors — antipsychotic and sedating effect. Modest QT prolongation, less than haloperidol/droperidol but more than olanzapine.
Indications
Acute agitation in known psychiatric patients
Behavioral emergency / chemical restraint when olanzapine/droperidol unavailable
Contraindications
Known QT prolongation
Recent MI / uncompensated heart failure
Concurrent QT-prolonging drugs
Hypersensitivity
Dosing and administration
Adult: 10–20 mg IM. Max 40 mg/24 hr. May repeat 10 mg q2h or 20 mg q4h. Pediatric: Not routinely used in prehospital pediatrics
Route: IM only (do not give IV in EMS) · Onset: IM: 15–30 min · Duration: 2–4 hours
Clinical pearls: Useful alternative when olanzapine or droperidol are unavailable; less sedating than olanzapine and shorter-acting than haloperidol. Obtain a baseline ECG when feasible — QT prolongation is dose-dependent. Reconstitute powder with provided diluent immediately before use.