SEMP Quick Tips

Emergency Medicine Pharmacotherapy Reference

Clinical Disclaimer: This reference tool is for educational purposes only. Always verify dosing with institutional protocols and current literature. Individual patient factors may require dose adjustments.

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🎯RSI Induction Agents ▼

Always administer induction agents before paralytics to ensure unconsciousness prior to paralysis

Fixed dosing often more practical in emergency situations when weight unknown. Weight-based dosing preferred for precision in ICU settings.

Etomidate

0.3 mg/kg IV (usual max 30 mg)

First-line for hemodynamically unstable patients

Hemodynamically neutral, may decrease ICP, rapid onset (15-45 seconds), short duration

No analgesia, myoclonus, single-dose adrenal suppression (10-24 hours)

Ketamine

1-2 mg/kg IV (usual max 200 mg)

Preferred for hypotensive patients, bronchospasm, pediatrics

Dissociative anesthesia with analgesia, bronchodilation, maintains respiratory drive, sympathomimetic effects

May increase BP/HR, emergence reactions, increased secretions, avoid in severe HTN

Midazolam

0.1-0.3 mg/kg IV

Alternative agent, especially in elderly or when antiepileptic properties desired

Antiepileptic, amnestic, reversible with flumazenil, familiar to most providers

Possible hypotension, slower onset, respiratory depression, longer duration than preferred

💪Neuromuscular Blocking Agents ▼

Rocuronium

1.2 mg/kg IBW IV (usual max 100 mg)

First-line paralytic agent - safest profile

No contraindications, reversible with sugammadex, predictable onset and duration

Slower onset (60-90 seconds), longer duration (45-60 minutes)

Succinylcholine

1-2 mg/kg IV (usual max 200 mg)

When rapid paralysis essential and no contraindications exist

Fastest onset (30-45 seconds), shortest duration (5-10 minutes), rapid recovery if intubation fails

CONTRAINDICATIONS: Hyperkalemia, burns >24-48h, denervating diseases, muscular dystrophy, rhabdomyolysis, prolonged immobilization, spinal cord injury >24-48h

🧘Post-Intubation Analgosedation ▼

Analgesia should precede sedation. Avoid prolonged paralysis when possible.

Fentanyl

Bolus: 25-100 mcg IV q15min PRN
Infusion: 50-300 mcg/hr (0.7-4 mcg/kg/hr)

Primary analgesic for procedural and ongoing pain management

Potent analgesia, minimal hemodynamic effects, rapid onset/offset, familiar to providers

Respiratory depression, potential chest wall rigidity (high doses), short half-life requires frequent dosing

Propofol

5-50 mcg/kg/min infusion (start low, titrate up)

Primary sedative agent for mechanically ventilated patients

Rapid on/off kinetics, titratable, antiemetic properties, may decrease ICP

Hypotension (dose-dependent), no analgesia, propofol infusion syndrome (rare, high doses), requires lipid monitoring

Midazolam

Bolus: 1-5 mg IV q15min PRN
Infusion: 0.02-0.1 mg/kg/hr

Alternative sedative, especially beneficial for seizure activity

Anxiolytic, anticonvulsant, amnestic, reversible with flumazenil

Accumulation with prolonged use, delirium risk, no analgesia, variable metabolism

🫀Vasopressors & Inotropes ▼

Norepinephrine

Weight-based: 0.02-0.5 mcg/kg/min IV
Fixed dose: 2-40 mcg/min IV (start 5-10 mcg/min)

First-line for distributive shock (sepsis), cardiogenic shock

Standard concentration: 4 mg in 250 mL (16 mcg/mL). At 15 mL/hr = 4 mcg/min

Potent vasoconstrictor, minimal chronotropic effects, evidence-based for sepsis

Peripheral ischemia risk, requires central access for prolonged use, minimal inotropic effect

Epinephrine

Weight-based: 0.01-0.5 mcg/kg/min IV
Fixed dose: 1-40 mcg/min IV (start 2-5 mcg/min)

Cardiac arrest, anaphylaxis, refractory shock, severe asthma

Standard concentration: 2 mg in 250 mL (8 mcg/mL). At 15 mL/hr = 2 mcg/min

Combined inotropic and vasopressor effects, bronchodilation, first-line for anaphylaxis

Arrhythmogenic, increased myocardial oxygen demand, may worsen lactate levels

Vasopressin

Fixed dose: 0.01-0.04 units/min IV (do not titrate above 0.04)
Typical start: 0.02-0.03 units/min IV

Adjunct to norepinephrine, GI bleeding, cardiac arrest

Standard concentration: 20 units in 250 mL (0.08 units/mL). At 15 mL/hr = 0.02 units/min

Effective in acidotic conditions, antidiuretic effects, may allow norepinephrine sparing

Coronary and mesenteric vasoconstriction, digital ischemia, do not exceed 0.04 units/min

Phenylephrine

Weight-based: 0.5-2 mcg/kg/min IV
Fixed dose: 40-200 mcg/min IV (start 40-80 mcg/min)

Neurogenic shock, when tachycardia is undesirable

Standard concentration: 20 mg in 250 mL (80 mcg/mL). At 30 mL/hr = 40 mcg/min

Pure alpha-1 agonist, no beta effects, can use peripherally short-term

Reflex bradycardia, decreased cardiac output, less potent than norepinephrine

⚡Push Dose Pressors ▼

For immediate hemodynamic support while establishing continuous infusions. Use with extreme caution.

Push Dose Epinephrine

10-20 mcg IV push q2-5min PRN

Severe hypotension, cardiac arrest, anaphylaxis

1mg/10mL prefilled syringe → withdraw 1mL → dilute in 9mL NS = 100mcg/10mL final concentration

Extremely potent - can cause severe hypertension, arrhythmias, coronary ischemia

Push Dose Phenylephrine

50-200 mcg IV push q2-5min PRN

Hypotension without tachycardia, neurogenic shock

10mg/1mL vial → draw 1mL → dilute in 99mL NS = 100mcg/mL final concentration

May cause significant reflex bradycardia and decreased cardiac output

Push Dose Vasopressin

1-2 units IV push

Refractory distributive shock, cardiac arrest

Use 20 units/mL vial as supplied. Draw 0.05-0.1mL (1-2 units) for administration

Potent vasoconstrictor - risk of coronary and peripheral ischemia

🩸Antihypertensive Agents ▼

Avoid precipitous BP reduction. Target 10-20% reduction in first hour for most hypertensive emergencies.

Nicardipine

5-15 mg/hr IV infusion (start 5 mg/hr, titrate by 2.5 mg/hr q5-15min)

First-line for most hypertensive emergencies

Titratable, cerebral and coronary vasodilation, renal protective, predictable onset/offset

Expensive, requires mixing, may cause reflex tachycardia, negative inotropic effects

Clevidipine

1-2 mg/hr IV infusion (titrate by 1-2 mg/hr q2-5min, max 32 mg/hr)

Perioperative HTN, when precise BP control needed

Ultra-short half-life (1 minute), precise titration, arterial selectivity, preserves coronary perfusion

Very expensive, lipid emulsion (avoid in egg/soy allergy), requires frequent monitoring

Labetalol

Bolus: 20 mg IV, then 40-80 mg q10min (max 300 mg)
Infusion: 0.5-2 mg/min IV

Hypertensive emergency, especially with tachycardia or aortic dissection

Combined alpha/beta blockade, reduces HR and BP, safe in pregnancy, familiar to providers

Contraindicated in heart failure, asthma, bradycardia, cocaine intoxication, may mask hypoglycemia

Esmolol

Loading: 500 mcg/kg IV over 1 min
Infusion: 50-300 mcg/kg/min IV

Perioperative HTN, aortic dissection, when reversible beta-blockade desired

Ultra-short half-life (9 minutes), titratable, rapidly reversible

Same contraindications as labetalol, requires continuous infusion, less BP reduction than other agents

Metoprolol

5-15 mg IV q6h PRN or 25-100 mg PO BID

Post-MI, heart failure with preserved EF, rate control

Cardioselective, evidence-based for post-MI, familiar to providers, inexpensive

Less titratable than infusions, contraindicated in acute heart failure, bradycardia

Hydralazine

10-20 mg IV q4-6h PRN (onset 10-30 min, duration 2-6 hrs)

Preeclampsia/eclampsia, heart failure with reduced EF

Safe in pregnancy, afterload reduction beneficial in heart failure, inexpensive

Unpredictable response, may cause precipitous hypotension, reflex tachycardia, avoid in CAD/stroke

Nitroglycerin

10-200 mcg/min IV infusion (start 10-20 mcg/min, titrate by 10 mcg/min q5min)

Acute coronary syndrome, flash pulmonary edema, hypertensive emergency with chest pain

Coronary vasodilation, preload reduction, antiplatelet effects, rapid onset

Tolerance with prolonged use, headache, hypotension, contraindicated with PDE-5 inhibitors

⚡ Emergency Dosing Quick Reference

Etomidate: 0.3 mg/kg IV

Ketamine: 1-2 mg/kg IV

Rocuronium: 1.2 mg/kg IBW IV

Succinylcholine: 1-2 mg/kg IV

Fentanyl: 25-100 mcg IV bolus

Propofol: 5-50 mcg/kg/min

Norepinephrine: Start 5-10 mcg/min

Epinephrine: Start 2-5 mcg/min

Vasopressin: 0.02-0.03 units/min

Phenylephrine: Start 40-80 mcg/min

Push Epi: 10-20 mcg IV push

Push Phenylephrine: 50-200 mcg IV

Nicardipine: Start 5 mg/hr IV

Labetalol: 20 mg IV bolus