In this VETgirl online veterinary continuing education blog, Dr. Garret Pachtinger, VMD, DACVECC addresses his “must-have” drugs to use in the veterinary ER crash cart or toolbox. These are common medications that are necessary in an emergency situation or in a critically ill veterinary patient.

A common question I get asked as a veterinary emergency and critical care specialist, “What 5 drugs can I not live without?”

My initial 5 include:

  • Epinephrine
  • Atropine
  • Dextrose
  • Diazepam
  • Dexamethasone sodium phosphate (DexSP)

Today, I am going to dive a little bit deeper into the pool.  Let’s chat about the 2nd set of 5 drugs I can not live without in clinical practice.

Drug 6: Levetiracetam (Keppra) – While the first line of defense for a seizure patient is often diazepam (valium), and phenobarbital is a mainstay therapy for neurologists… Levetiracetam (Keppra) has become an anticonvulsant favorite in the toolbox of many neurologists.  Aside from being effective, as a single agent it is relatively non-sedating.  This is a very helpful drug trait as performing a neurologic examination in a sedated patient is understandably challenging!  It is also a maintenance drug, unlike diazepam.  As compared to Phenobarbital, Levetiracetam is not metabolized by the liver and is excreted by the kidneys and there is no current concern for liver value elevations (or azotemia).  The dose is 10–20 mg/kg PO TID.  Extended release (BID) formulations are also available.

Drug 7: Furosemide (Lasix): Furosemide is most frequently used diuretic, period.  It can be administered by a wide variety of routes (PO, IM, SQ, IV) although in the acute heart failure patient, the intravenous route is recommended (if possible!).  Furosemide can also be administered as a constant rate infusion.  2mg/kg as a bolus is a common starting dose in small animal medicine for the CHF patient, although higher doses (e.g. 4mg/kg) can also be considered.

Drug 8: Lidocaine: In my opinion, ventricular arrhythmias are the most common arrythmias seen in small animal emergency medicine.  While isolated ventricular beats are not considered life threatening, sustained ventricular tachycardia is associated with an increased morbidity and mortality and thus requires therapy.  Common dosing includes a bolus(es) at 2–4 mg/kg IV slowly, followed by a constant rate infusion (30–80 µg/kg/minute).

Lidocaine is one of the top 5 drugs we use in the veterinary ER
Drug 9: Calcium Gluconate: While other benefits exist, this is a fan favorite for hyperkalemic patients, notably the urethral obstruction or acute renal injury hyperkalemic patient.  While calcium gluconate does not alter the serum potassium concentration, it is cardioprotective, altering the membrane potential of cardiac muscles.  The dose range is 50-150mg/kg IV.  With that said, who doesn’t love an easy to remember shortcut?  For a standard hyperkalemic blocked cat, the dose is 3ml/cat (using the 10% formulation).

Drug 10: Crystalloid fluids: Are you surprised to see fluids on a drug list?  I’m not.  Many of us forget that fluids are a drug.  Unlike the dose of Amoxicillin, standard dosing is more anecdotal than evidence when speaking about fluid therapy.  What is the calculation for a fluid rate in a 10-year-old dog, with a 3/6 heart murmur that also has concurrent diabetes?  Is that different than a 12-year-old cat with a 2/6 murmur without diabetes?  Side effects of fluid therapy such as fluid overload or electrolyte derangements should not be overlooked.  Like any medication, fluid therapy dosing must be formulated based upon each individual patient’s condition with the goal of both patient improvement and to avoid potentially life threatening complications of therapy.

Did I miss anything?  Comment below – we would love to hear what emergency medications YOU can’t live without!

Dr. Garret Pachtinger, DACVECC

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