Rapid Guide to Bolus Drugs and Infusions in EMS / Critical Care Transport

 

ENGLISH — AUDITED VERSION 2026

Rapid Guide to Bolus Drugs and Infusions in EMS / Critical Care Transport

Scientific, pharmacological and operational audit for EMS Solutions International

By DrRamonReyesMD ⚕️ | Updated 2026

The original chart is operationally useful, but pharmacologically incomplete and partially outdated for 2026. Its core value is valid: it reduces cognitive load during emergencies by converting high-risk drug calculations into rapid visual references. However, any bolus/infusion guide used in ALS, mobile ICU, critical care transport or tactical medicine must now be redesigned around medication safety, standardised concentrations, double-check systems, modern shock physiology, smart-pump compatibility and current resuscitation doctrine.

The most important finding is that the chart reflects an older prehospital pharmacology model: strong presence of dopamine and vecuronium, limited norepinephrine development, insufficient modern trauma resuscitation content, and absence or under-representation of ketamine, tranexamic acid, calcium, rocuronium and vasopressin.

Modern 2026 practice must give norepinephrine a central role. The Surviving Sepsis Campaign recommends norepinephrine as the first-line vasopressor for adults with septic shock, over dopamine and other vasopressors, because dopamine carries a higher arrhythmogenic burden and is now reserved for selected situations rather than routine shock management. DOI: 10.1007/s00134-021-06506-y.

Dopamine should be downgraded. It may remain as a backup option in specific bradycardic shock phenotypes, but it should not occupy a dominant visual position in a modern EMS critical-care card. In most contemporary systems, the practical vasopressor hierarchy is norepinephrine first, vasopressin as adjunct in selected refractory vasodilatory shock, and epinephrine as an additional agent in specific scenarios.

Epinephrine remains essential, but must be framed correctly: cardiac arrest, anaphylaxis, peri-arrest shock, severe bronchospasm/anaphylactic physiology, and selected refractory shock states. The 2025 AHA Adult Advanced Life Support guideline remains the key reference for cardiac arrest drug strategy. DOI: 10.1161/CIR.0000000000001376.

Amiodarone remains valid in shockable cardiac arrest algorithms and selected malignant ventricular arrhythmias, but the chart should avoid creating the impression that antiarrhythmics replace high-quality CPR, early defibrillation, correction of reversible causes, and post-ROSC critical care. ERC 2025 also reinforces that advanced life support is a system, not a drug-centred ritual.

Tranexamic acid must be added. Its absence is a major doctrinal gap. In trauma with significant haemorrhage or risk of major bleeding, TXA is time-dependent and should be given as early as possible, ideally within 3 hours of injury. CRASH-2 showed mortality benefit in bleeding trauma patients. DOI: 10.1016/S0140-6736(10)60835-5. The timing analysis showed that delayed administration loses benefit and may be harmful when given late. DOI: 10.1016/S0140-6736(11)60278-X.

Calcium must be added to any serious 2026 trauma/DCR card. Modern damage-control resuscitation recognises hypocalcaemia as a lethal contributor during massive transfusion, citrate load, shock physiology and coagulopathy. The JTS Damage Control Resuscitation guideline includes calcium updates and integrates TXA, blood-first resuscitation and low-titre group O whole blood strategies.

Ketamine must be present. It is no longer optional in a modern EMS/tactical/critical transport drug card. It belongs in analgesia, dissociative sedation, RSI induction, severe agitation, trauma pain, burns, extrication medicine and bronchospasm. TCCC guidance specifically includes ketamine administration considerations and emphasises close monitoring of airway, breathing and circulation when potent analgesics are used.

Midazolam should remain, but with warnings. Benzodiazepines are useful for seizures, procedural sedation and selected agitation, but they can cause respiratory depression, hypotension, delirium, prolonged sedation and dangerous synergy with opioids. ICU sedation guidance has moved toward lighter, protocolised, analgesia-first and non-benzodiazepine strategies when appropriate. PADIS 2018 DOI: 10.1097/CCM.0000000000003299; SCCM issued a focused update in 2025.

Fentanyl and morphine remain useful but should be embedded in a respiratory-safety framework. A modern chart must force the operator to think: oxygenation, ventilation, capnography where available, hypotension, elderly patient, shock state, opioid-benzodiazepine combination and need for airway readiness.

Vecuronium should not be the primary RSI paralytic in a modern card. Rocuronium and succinylcholine should be included, with local protocol governance. Neuromuscular blockers must never be administered to conscious patients without adequate induction, sedation and analgesia. ERC 2025 explicitly warns that paralytics alone should not be given to conscious patients.

The paediatric section must be redesigned. Paediatric drug errors are among the highest-risk errors in emergency pharmacology. A 2026 card should use weight bands, maximum doses, concentration standardisation, colour zones, double-check prompts and QR-linked calculators. It must not depend on mental arithmetic under stress.

The visual design must be simplified. The current style is information-rich but cognitively overloaded. A safer 2026 version should use fewer colours, larger fonts, clearer adult/paediatric separation, one drug per module, final concentration highlighted, warning icons for high-alert medications, and an explicit “verify dose–drug–route–concentration–pump rate” line.

Final professional judgement

The original chart has historical and operational value, but it is not sufficiently modern for 2026 without revision. It should not be discarded; it should be rebuilt.

A 2026 EMS Solutions International version should be structured around:

Resuscitation: epinephrine, amiodarone/lidocaine, magnesium, calcium, bicarbonate only when indicated.
Shock: norepinephrine first-line, vasopressin adjunct, epinephrine selected use, dopamine downgraded.
Trauma / DCR: TXA, calcium, blood-first strategy, restricted crystalloids, hypothermia prevention.
RSI: ketamine, etomidate, rocuronium, succinylcholine, fentanyl as selected adjunct.
Analgesia / Sedation: ketamine, fentanyl, morphine, midazolam, propofol/dexmedetomidine where system capability allows.
Safety layer: paediatric bands, double-checks, final concentrations, smart pump rates, contraindication alerts and version control.

This is the correct direction for EMS, mobile ICU, tactical medicine, offshore medicine, remote medicine and critical care transport in 2026.

By DrRamonReyesMD ⚕️
EMS Solutions International | 2026