Paramedics carry a broad pharmacy of medications covering cardiac arrest, pain, seizures, breathing emergencies, overdoses, low blood sugar, and more. The exact list varies by state and local protocol, but most systems in the United States draw from a common set of drugs outlined in the National Model EMS Clinical Guidelines. What follows is a practical breakdown of the major categories and the specific medications paramedics use in each.
Cardiac Arrest and Heart Rhythm Drugs
The largest group of medications paramedics carry targets the heart. During cardiac arrest, epinephrine is the cornerstone drug, used in cases of ventricular fibrillation, pulseless ventricular tachycardia, asystole (flatline), and pulseless electrical activity. If a patient’s heart is in a shockable rhythm that doesn’t respond to defibrillation, paramedics can add amiodarone or lidocaine. The American Heart Association recommends an initial 300 mg dose of amiodarone, with a second 150 mg dose if needed. For lidocaine, the first dose is weight-based at 1.0 to 1.5 mg/kg.
Beyond cardiac arrest, paramedics manage abnormal heart rhythms with several other drugs. Adenosine is used to break a dangerously fast heart rhythm called supraventricular tachycardia, essentially resetting the heart’s electrical signal. Diltiazem helps control the heart rate in atrial fibrillation that isn’t responding to other interventions. Atropine speeds up a heart that’s beating too slowly, particularly when the slow rate is causing low blood pressure or other symptoms. Dopamine can be given as a continuous drip to support blood pressure in cardiogenic shock. Vasopressin serves as an alternative to epinephrine during cardiac arrest in some protocols.
Sodium bicarbonate rounds out the cardiac toolkit. Paramedics give it for severe metabolic acidosis, certain drug overdoses, and dangerously high potassium levels, all of which can compromise the heart. Magnesium sulfate treats a specific type of cardiac arrest rhythm called torsades de pointes and is also used for seizures related to pregnancy complications.
Pain Management
Paramedics have several options for treating pain in the field, and protocols vary significantly across the country. A 2024 review of U.S. prehospital protocols found that fentanyl is the most widely authorized pain medication, appearing in 98 protocols studied. Morphine was included in 73, ketamine in 64, and ketorolac (a non-opioid anti-inflammatory) in 42.
Fentanyl is favored for its fast onset and flexibility. Every protocol that includes it allows intravenous delivery, while about 77% also permit intranasal administration, a nasal spray that works well when starting an IV would be difficult or time-consuming. Roughly 70% of protocols allow intramuscular injection as well. Most systems use weight-based dosing for fentanyl, morphine, and ketamine, meaning the amount given is calculated from the patient’s body weight. Ketorolac, by contrast, is almost always given as a fixed dose regardless of weight.
Ketamine deserves a special note because it serves double duty. At lower, sub-anesthetic doses it provides strong pain relief, while at higher doses it’s used for sedation. About a third of protocols that include ketamine allow it to be given intranasally. Some systems also authorize oral acetaminophen and ibuprofen for milder pain, and nitrous oxide (an inhaled gas the patient breathes through a mask) for moderate pain during transport.
Seizure Medications
Active seizures are one of the most time-sensitive emergencies paramedics treat, and benzodiazepines are the primary tool. The three most common options are midazolam, diazepam, and lorazepam. All three work by calming excessive electrical activity in the brain, but practical considerations determine which one gets used in the field.
Midazolam has become the preferred choice for many EMS systems because it can be given as an intramuscular injection or sprayed into the nose, avoiding the need to start an IV on a seizing patient. A landmark trial published in the New England Journal of Medicine found that intramuscular midazolam was at least as safe and effective as intravenous lorazepam for stopping prolonged seizures before hospital arrival. Adults in the study received 10 mg of intramuscular midazolam, while children between roughly 30 and 90 pounds received 5 mg. Lorazepam, although slightly more effective in hospital settings, has a short shelf life without refrigeration, which makes it less practical for an ambulance. Diazepam remains available in many systems and can also be given rectally for pediatric seizures when IV access isn’t possible.
Breathing Emergencies
For asthma attacks, COPD flare-ups, and other causes of airway constriction, paramedics administer bronchodilators through a nebulizer, a device that turns liquid medication into a fine mist the patient inhales. Albuterol is the first-line bronchodilator, relaxing the muscles around the airways to open them up. Ipratropium is often combined with albuterol for a stronger effect, particularly in severe COPD exacerbations. Epinephrine also plays a role here. In anaphylaxis, where the airway can swell shut, intramuscular epinephrine is the most critical intervention. It’s also used for severe croup in children.
For patients who need a breathing tube placed, paramedics in many systems are authorized to perform rapid sequence intubation, which requires its own set of medications (covered below).
Airway Management and Sedation
When a patient can’t protect their own airway, paramedics may need to place a breathing tube through a procedure called rapid sequence intubation. This involves giving two types of medications simultaneously: a sedative to render the patient unconscious and a paralytic to relax the muscles of the jaw and vocal cords.
The most commonly used sedative for this purpose is etomidate, given at 0.15 to 0.3 mg/kg intravenously. It works quickly and has minimal effect on blood pressure, which matters in critically ill patients. Ketamine (at a higher dose of 2 mg/kg) is the main alternative, especially when low blood pressure is a concern. Propofol is a third option but tends to drop blood pressure, so it’s reserved for patients who are hemodynamically stable.
On the paralytic side, succinylcholine is the most widely used agent. It acts within about a minute and wears off in 5 to 10 minutes, giving a short window of muscle relaxation. Rocuronium is the alternative, particularly for patients who have conditions that make succinylcholine risky. It takes slightly longer to kick in (1 to 2 minutes) but lasts much longer, around 45 to 70 minutes.
Opioid Overdose Reversal
Naloxone is the standard reversal agent for opioid overdoses and one of the most frequently administered prehospital medications. Paramedics can give it intravenously, intramuscularly, or intranasally. The typical initial adult dose ranges from 0.4 to 2 mg when given by IV or IM, or up to 4 mg intranasally. For children, the dose is weight-based at 0.1 mg/kg, with a maximum of 2 mg by IV/IM or 4 mg intranasally.
The key principle with naloxone is titration. Paramedics aim to restore adequate breathing rather than fully reversing all opioid effects, because giving too much too fast can throw a patient into acute withdrawal, causing vomiting, agitation, and a dangerous spike in heart rate. Doses can be repeated every 2 to 5 minutes until breathing improves. Intranasal and IV routes allow the most precise titration.
Low Blood Sugar Treatment
Hypoglycemia (low blood sugar) is a common EMS call, and paramedics carry two main treatments. If they can establish IV access, they give dextrose, a concentrated sugar solution pushed directly into a vein. Many systems have shifted from 50% dextrose (D50) to 10% dextrose (D10), which is less irritating to veins. A randomized trial comparing the two concentrations found no difference in recovery time, with both achieving a median recovery of about 8 minutes.
When IV access isn’t available, glucagon is the backup. It works by signaling the liver to release stored sugar into the bloodstream. The standard adult dose is 1 mg given by intramuscular injection. Children under about 55 pounds receive 0.5 mg. If there’s no response after 15 minutes, a second dose can be given. Glucagon is also available as a nasal spray in some systems.
Nausea and Vomiting
Ondansetron is the go-to anti-nausea medication in most EMS systems. It’s effective, has relatively few side effects, and can be given intravenously, intramuscularly, or as a tablet that dissolves on the tongue, making it versatile for field use. The typical adult dose is 4 mg intravenously. Pediatric dosing is weight-based at 0.15 mg/kg, with a maximum of 16 mg per dose. Some older protocols still include promethazine, though it has largely fallen out of favor due to its sedating effects and risk of tissue damage if it leaks out of a vein.
How These Medications Are Given
Paramedics deliver drugs through several routes depending on the situation. Intravenous (IV) lines are the most common and allow precise dosing with the fastest onset. When veins are collapsed or inaccessible, as often happens in cardiac arrest or severe dehydration, paramedics can drill an intraosseous (IO) line directly into bone (usually the shin or upper arm), which delivers medication to the bloodstream almost as quickly as an IV. Current resuscitation guidelines support IV as the primary route for cardiac arrest drugs, with IO reserved for patients where IV access can’t be established.
Intramuscular (IM) injections are used when speed matters but IV access would cause delay, as with epinephrine in anaphylaxis or midazolam for seizures. Intranasal (IN) delivery, where medication is sprayed into the nose and absorbed through the mucous membranes, has become increasingly popular for naloxone, fentanyl, and midazolam. It’s painless, requires no needles, and can be given to uncooperative or seizing patients. Nebulized medications are inhaled for respiratory emergencies, and some drugs like nitroglycerin are given under the tongue.
Why Protocols Vary
There is no single national list of medications that every paramedic carries. Each state has its own scope of practice, and within states, individual EMS agencies operate under the medical direction of a physician who approves their specific drug formulary. The National Model EMS Clinical Guidelines (currently Version 3.0, revised March 2022) serve as a template, but local medical directors can add or remove medications based on their system’s needs, training, and transport times. A paramedic working in a rural area with 45-minute transport times may carry a broader formulary than one in an urban system where the hospital is minutes away. Similarly, some states authorize paramedics to perform rapid sequence intubation while others do not. The common thread is that paramedics function as extensions of a physician’s license, and every medication they give is governed by protocols that physician has approved.