Compare gauges, choose an access site, calculate a drip, and check why a bag is draining slowly or delivering less fluid than expected.
Critical casualty: make early IO part of the access plan. For most critical patients in ACM Extended, treat IO as a routine priority so urgent medication has a route while your best IV sites remain available for blood and fluids. Repeated IV attempts consume time and can leave holes that compromise later sites.
Plan one running bag or Y set per access site. The prepared set menu refuses another running line on an occupied IV or IO. A blood Y set includes its clamped saline reserve, but still occupies one access site. More independent infusions require more usable sites.
Use the available IO procedure to obtain a medication route. Keep the best peripheral IV sites for blood or another infusion that needs its own line.
Why: a difficult peripheral vein should not hold up the whole access plan. IO avoids the peripheral IV leakage model.
Match the site to the medication, required flow and vein you can actually palpate. Check previous attempts before inserting.
Why: a functioning smaller catheter is more useful than a larger catheter that misses or leaks.
Then assign a purpose to each access site.
In a critical patient, IO provides a medication path while preserving IV sites for fluids. If using an IV, choose intact anatomy and reassess that exact site for leakage, bruising and pain.
Why: leaked medication can cause local injury and reduce the dose reaching circulation. Moving to an upper IV or an EJ does not make it immune.
Use a suitable IV for the planned fluid or medication. A lower risk medication can still be lost through a compromised site.
Why: absence of a vesicant label does not prove that the displayed syringe dose reached the patient.
For peripheral IV access, check the limb before choosing a gauge.
On a limb, placing below a missed or removed site can send fluid toward the old hole and cause leakage. An intact IV above every compromised site avoids that particular downstream hole rule.
Why: the game tracks the upper, middle and lower tiers and the actual height of the puncture within them. Choosing the same tier alone is not enough.
Low pressure narrows the peripheral placement target and weakens the palpation cue. Larger, shallower, less mobile veins are more forgiving.
Why: a larger catheter reduces the placement margin further. IO or EJ may be useful when the peripheral target is poor.
Lower gauge numbers mean larger catheters. Flow is only one part of the choice: placement accuracy, vein caliber and an intact delivery path determine whether that capacity is useful.
Choose when: rapid fluid delivery needs the capacity and a large, usable vein supports it.
Tradeoff: tightest placement margin. An oversized attempt adds a further penalty; forearm placement is especially unforgiving.
375 mL/min base0.65× target
Choose when: you need substantial fluid capacity and have a suitable peripheral target.
Tradeoff: still needs a vein large enough for the catheter. It is oversized for the modeled popliteal target.
250 mL/min base0.85× target
Choose when: the vein or placement conditions favor a smaller catheter and its available flow is sufficient.
Tradeoff: half the configured 16G flow. Improve the access plan if resuscitation needs more independent capacity.
125 mL/min base1.15× target
Choose when: a small or difficult target makes successful placement the priority.
Tradeoff: lowest IV capacity. Do not let repeated small IV attempts delay IO in a critical patient.
87.5 mL/min base1.35× target
Base flow is before the clamp, fluid and pressure modifiers. Target multipliers apply before vein anatomy and perfusion. These numbers describe the game configuration.
| Access location | Why consider it? | What changes the decision? |
|---|---|---|
Upper arm: Basilic | Largest modeled limb vein caliber, shallow and relatively stable; supports the normal 14G threshold. | Preserve it when you need fluid capacity. A proximal peripheral IV can still leak and develop vesicant injury. An occupied upper arm cuff or AED position can block insertion. |
Middle arm: AC fossa | Moderately large, shallow target with a normal 16G threshold. | Less forgiving than the upper arm model. Check whether a missed or removed site lies above it. |
Lower arm: Cephalic | An additional forearm option that preserves upper sites for later use. | Small caliber and high vein mobility make placement harder. A 14G must be extremely central; favor a more forgiving gauge if flow needs allow. |
Upper leg: Great Saphenous | Large target once located; normal 16G threshold. | Greater modeled depth makes palpation harder. Limb pressure still changes the placement margin. |
Middle leg: Popliteal | Another access option when other sites are occupied or damaged. | Smaller and deeper target with a normal 18G threshold. A larger catheter incurs an oversize penalty. |
Lower leg: Dorsal Arch | Relatively generous, stable target in this game's catalog; normal 16G threshold. | Check every compromised site above it. The name alone does not imply a tiny target in this implementation. |
External jugular: EJ | Its minigame does not use the peripheral systolic pressure penalty; gauge still changes accuracy. | It remains peripheral for vesicant injury. The downstream hole direction reverses: a neck puncture toward the clavicle can compromise a new stick above it on the same side. |
IO: FAST1 or EZ IO | Early medication access for critical casualties; independent of a damaged peripheral IV's leakage state. | Use the supported IO site and procedure. Base capacities are about 162.5 and 137.5 mL/min respectively, so IO is not automatically the fastest fluid route. |
The early IO recommendation is a gameplay priority for critical casualties. The game does not require every critical patient to receive one before other treatment.
The current delivery path applies vesicant injury to medication that actually leaks at the selected peripheral IV, including upper sites and EJ. IO leakage is not modeled by that path. This does not make IO immune to medication overdose, systemic adverse effects or other access problems.
Calcium chloride, epinephrine, norepinephrine, HTS and mannitol are examples in the vesicant table. Amiodarone, magnesium and esmolol use irritant entries. Calcium gluconate also has a higher threshold entry. Check each medication card and the access site instead of assuming that a medication or proximal site is harmless.
Verified against ACM Extended revision 21f8694:
| Access | Flow factor | Peripheral target multiplier |
|---|---|---|
14G | 1.50 | 0.65 |
16G | 1.00 | 0.85 |
18G | 0.50 | 1.15 |
20G | 0.35 | 1.35 |
FAST1 IO | 0.65 | Separate IO procedure |
EZ IO | 0.55 | Separate IO procedure |
What makes placement easier
A larger target multiplier makes the peripheral IV minigame more forgiving. A lower gauge number means a larger bore. Vein caliber, depth, movement and gauge suitability modify the target further. A catheter larger than the vein’s configured limit adds a placement penalty.
In gameGame default: 18G flow
18G uses the initialized 0.50 flow factor. The flow function contains a 0.55 fallback for an absent setting; that fallback is not the normal initialized value.
Establish a peripheral IV
Open the medical menu, select an arm or leg, then choose Establish IV. Apply the band, palpate the target with an empty hand, scrub the site, and select a catheter gauge from the tray. The images below are the mod’s actual 18G catheter frames. Other gauges use the same advance, thread and retract sequence.
Default mouse controls: LMB = left mouse button; MMB = middle mouse button (press the wheel); RMB = right mouse button. SCROLL UP / SCROLL DOWN mean rotate the wheel.
Stages advance every 7 seconds while on screen. The thin line below shows time until the next stage. Use the arrows or stage selector at any time. Slideshow keyboard: LEFT ARROW / RIGHT ARROW, HOME / END. Pause to read or inspect a frame.
FRAME 00 / 14
LMB Select the catheter
Press LMB on the 18G tray slot to pick it up. Move the mouse to position the needle tip over the vein you palpated.
Aim using the visible tip. The tip can lag behind the cursor; arm position also changes the approach angle.
CONTINUOUS INSERTION · FRAMES 01–06
Hold LMB + move the mouse toward the needle tip
Press and hold LMB at the puncture point. Keep holding it while moving the mouse forward along the catheter’s axis. Release LMB to pause; hold it again to continue. Once fully inserted, use SCROLL UP to thread.
These six frames play as one continuous motion. The flashback artwork can also appear on a missed puncture; assess the finished access rather than relying on the artwork alone.
CONTINUOUS THREADING · FRAMES 07–11
SCROLL UP Thread · SCROLL DOWN Reverse
After full insertion, use SCROLL UP to advance the catheter off the seated needle in 20% steps. Reach 100% threading before retracting the needle. SCROLL DOWN reverses one step.
At 100%, press MMB or SPACE to retract the needle. RMB away from the band also works. RMB on the band removes the band instead. SPACE is the default withdrawal key and can be changed by mission configuration.
FRAME 12 / 14
MMB or SPACE Start needle retraction
Once the catheter is fully threaded, press MMB or SPACE once. RMB away from the band is another option. This starts the automatic safety sequence.
After that press, the game advances the safety frames automatically. No additional drag or scrolling is needed.
FRAME 13 / 14
Automatic after MMB, SPACE or RMB
No further input is needed. Let the needle capture and withdrawal finish.
The procedure commits the catheter outcome after needle withdrawal. A missed puncture can leave a compromised site.
FRAME 14 / 14
RMB Remove band · LMB Done
Press RMB on the applied band to remove it. Press LMB on Done to return to the medical menu, then select the intended access for fluid or medication delivery.
Reassess the site for swelling, confirm actual bag drainage and check the patient’s response. A seated hub alone does not prove successful delivery.
The artwork alone does not establish a successful IV. A missed puncture can still reach the hubbed frame and leave a compromised site. Remove the band and reassess for swelling or poor delivery. Compare actual fluid delivery with the site rules below.
| Action | Key or mouse input | What to check |
|---|---|---|
Open the procedure | Medical menu > select an arm or leg > Establish IV | The action opens the placement screen. Picking up a catheter requires that gauge in your inventory. |
Apply a constricting band | LMB on BAND, move it to the limb, then LMB at the snapped position | Requires a NAR BOA constricting band in your kit. This is separate from catheter placement. |
Palpate | Hold LMB and move the mouse over the limb with no tool held | With the band applied, the fingertip indicator changes as you approach the vein. Position and perfusion affect the feedback. |
Scrub | LMB on the alcohol pad slot; hold LMB and move the mouse across the site | Actual coverage performs the scrub. Press LMB on the pad slot again to put it down. |
Pick up or put down a catheter | LMB on a gauge slot | The available gauges are 14G, 16G, 18G and 20G. Put a held catheter down before choosing another gauge. |
Insert and advance | Hold LMB at the entry point and move the mouse toward the tip along the needle axis | Release LMB to pause. Hold LMB again to continue. Sideways mouse movement does not advance it. |
Thread | SCROLL UP to thread; SCROLL DOWN to reverse | Available after full insertion. Each wheel step changes threading by 20%. Reach 100% before withdrawal. |
Needle safety and withdrawal | MMB or SPACE; alternatively RMB away from the band | Available only after full threading. SPACE is the default mission configurable withdrawal key. |
Remove band | RMB on the applied band | A constricting band on the IV limb blocks IV flow until removed. |
Change limb view | LMB on Flip (Front/Back) | Use the other face to reach the corresponding veins. |
Pan the view | UP ARROW / DOWN ARROW | Moves the view without using the wheel needed for threading. |
Remove a placed catheter | Put tools down; hold LMB on the hub and move the mouse backward along its axis | This removes the catheter. It is different from retracting the insertion needle. |
Leave the screen | LMB on Done or ESC | Returns to the medical menu. Closing the screen does not establish an unfinished catheter. |
Select the head and choose Establish EJ IV. The action is available when the patient is unconscious, prone or dead. EJ placement uses the neck view and does not require a constricting band. Use the same insertion, threading and safety controls. The image sequence above illustrates the catheter; the neck has its own orientation and target geometry.
Controls and artwork checked at revision abf6253. See insertion and flash artwork behavior, mouse controls and keyboard controls.
| Site | Low end of peripheral patency | Full patency |
|---|---|---|
Arm | Systolic pressure 70 or below | Systolic pressure 90 or above |
Leg | Systolic pressure 60 or below | Systolic pressure 80 or above |
External jugular | Does not use the peripheral pressure window | Patency is set to 1; gauge still changes target size |
Peripheral IV patency
Between the endpoints, patency increases linearly. Low patency reduces the feel radius, hit radius and maximum palpation indicator intensity. It does not reduce the minigame hit radius to zero. The vein’s own geometry still matters at full patency.
External jugular target size
At the default EJ settings, target radius grows from 0.0045 at 14G to 0.0075 at 20G, expressed as a fraction of the body image width. These are minigame geometry values.
The roller clamp maps position to drops per minute. The drop set converts drops into milliliters. Results below show the requested flow before catheter limits, pressure cuffs, complications and fluid specific rules.
| Calculation | Formula |
|---|---|
Clamp to drip rate | 5 × round(maximum drops × (position / 100)curve / 5). Positions at or below 1% return zero. |
Volume rate | mL/min = gtt/min ÷ gtt/mL |
Medication rate | mg/min = concentration in mg/mL × mL/min |
Bag duration | Minutes = remaining mL ÷ mL/min; a closed clamp has no completion time |
In gameDefault clamp and drop set
Default maximum: 120 gtt/min. Default exponent: 2. Default drop set: 20 gtt/mL. The supported sets are 10, 15, 20 and 60 gtt/mL.
| Drip rate | 10 gtt/mL | 15 gtt/mL | 20 gtt/mL | 60 gtt/mL |
|---|---|---|---|---|
20 gtt/min | 2 mL/min | 1.33 mL/min | 1 mL/min | 0.33 mL/min |
60 gtt/min | 6 mL/min | 4 mL/min | 3 mL/min | 1 mL/min |
120 gtt/min | 12 mL/min | 8 mL/min | 6 mL/min | 2 mL/min |
| Factor | Game behavior |
|---|---|
No access or an invalid site | No flow |
Constricting band on the IV body part | Blocks IV flow until removed; this check does not block IO |
AAJT occlusion | Blocks affected access |
Tracked medication bag | Uses that bag’s requested clamp rate, capped by access capacity before the cuff multiplier |
Untracked fluid bag | Also uses the ACE flow setting, native IV/IO multipliers and fluid type multiplier |
Bag held up | Raises access capacity; a requested rate already below that capacity stays the same |
Pressure infuser cuff | Multiplies delivered flow after the clamp/capacity comparison. Default full boost is 2.5×, decaying with a 150-second half-life until the remaining pressure falls below 0.08 |
Blood warmer path | Uses the configured warmed blood rate, default 100 mL/min |
Cold blood | Default initial flow factor 0.65, easing toward 1 as the unit warms |
Native IV complication stages | Drainage factors are 1.00, 0.90 and 0.85 for stages 0, 1 and 2 |
Several native bag types at one site | Native sharing rules can divide the available flow; a Y line saline reserve is excluded from blood’s sharing divisor |
Confirm actual delivery
Track the bag’s actual remaining volume and the patient’s response. The clamp display alone cannot include every modifier in the final fluid calculation.
| Site condition | Fraction of drained fluid admitted to circulation |
|---|---|
Intact site | 100% |
Native stage-2 infiltration | 80% |
Compromised catheter flag | 20% |
Stage-2 infiltration and compromised flag together | 16% |
IO | This IV leakage calculation returns 100% |
In gameWhat reaches circulation
Fractions multiply. A bag can lose 100 mL while only 16 mL reaches circulation in the combined case. Infused medication uses the same split: the systemic dose follows admitted volume, and the remainder is recorded as local leakage. See fluid compartments and conversion for what happens after fluid enters circulation.
| Calculation | Formula |
|---|---|
Final volume for a fresh prepared bag | Carrier volume + every injected solution volume |
Bag concentration | Medication amount remaining ÷ total solution volume remaining |
Delivered dose per minute | Bag concentration × mL/min actually admitted to circulation |
Dose per hour | Bag concentration × mL/h actually admitted |
Drops per minute | mL/min × set factor in gtt/mL |
50 mg ketamine added to 100 mL saline, delivered at 60 mL/h. This is a game arithmetic example.
Check the delivered rate
Use the drip calculator with the final bag concentration, then confirm actual drainage and clinical effect. With a 20 gtt/mL set, 60 mL/h requires 20 gtt/min before flow limits and complications. An intact bag draining at that rate takes 101 minutes to empty in the example.
CautionClamp increments and shared bags
The default clamp changes in 5 gtt/min increments. A requested dose rate may therefore fall between available settings. Site leakage also reduces the systemic dose. When multiple medications share a bag, one clamp changes every component’s rate together; it cannot independently titrate each medication. Do not assume that menu acceptance establishes chemical compatibility.
CautionReassess during delivery
Pressors, sedatives and opioids still have adverse effects and interactions when infused. Delivery stopping does not instantly remove drug already received. Keep a working airway plan, reassess sedation and ventilation, and check the infusion site during PFC and transport.
Supported bags
Prepared medication bags accept the listed injectable medications in normal saline. Premixed bags have their own route and dose records.
| Preparation rule | Current value |
|---|---|
Allowed medication additions | Amiodarone, epinephrine, norepinephrine, lidocaine, ketamine, TXA, fentanyl, morphine, midazolam, ondansetron, calcium chloride, calcium gluconate, ceftriaxone and propofol |
Allowed bag type for adding medication | Saline |
Carrier matching | Saline and PlasmaLyte identities are recognized by the carrier matching logic; this does not widen the medication addition allowlist |
Flush required IV/IO pushes, when enabled | Adenosine, amiodarone, calcium gluconate, calcium chloride and epinephrine |
Flush required effect | The pushed dose waits in the line until Flush IV Line (Saline) delivers it |
Y line flush cadence | After 2 units or 1,000 mL of blood; uses 50 mL saline over 5 seconds |
Small vial remnant | Residual volume at or below 0.0105 mL can be discarded |
CautionCheck the administration route
Prepared syringe route handling differs from native medication actions. Review the route notes on the medication cards before assuming that a legacy class or a drawable vial has a native action for every route.
With [HARDCORE] Medications enabled, IV and IO pushes deliver continuously. Choose a duration, watch the remaining volume and use Stop Push when you want administration to stop.
Check the amount as well as the time. The default times below are game presets, not guaranteed safe limits. A larger or more concentrated syringe delivers more medication per second at the same selected duration. Most drugs benefit from avoiding an abrupt peak; adenosine is the deliberate rapid-push exception.
IV / IO medication enters in measured portions. Push becomes a red Stop Push button. Closing or reopening either medical menu keeps the same push running at its original rate.
Drug-specific defaults and rapid manual-push consequences apply. IM uses its original administration path.
The normal administration path commits the medication at completion. Closing the dialog before completion cancels that uncommitted administration. The optional IV / IO duration field remains, normally blank with a 3-second default.
Normal dose effects, interactions, overdose and actual infusion-rate hazards remain active.
After 15 seconds of uninterrupted delivery, about 2.50 mL has been pushed and 2.50 mL remains. Drug mass per second also depends on concentration. This volume example does not select a medication dose.
Compounded syringes use the longest component default. Ketofol uses 30 seconds because both ketamine and propofol default to 30 seconds. Other unlisted drugs use the 3-second fallback. The preset does not replace checking the syringe's total medication content.
| Medication | Default time | Why duration matters |
|---|---|---|
3 s | Keep this one rapid. Slow delivery weakens its brief SVT conversion effect. With Hardcore offThe manual bolus speed penalty is absent with Hardcore off. Adenosine infusion still has a weak conversion multiplier. | |
30 s | Rapid IV / IO delivery can add a temporary loss of respiratory drive on top of the dose effect. With Hardcore offThe added rapid-ketamine load is absent with Hardcore off; dose, sedation and combination effects remain. | |
300 s (5 min) | Check elemental calcium delivery rate and accumulated excess. Excessive delivery can cause severe cardiovascular toxicity. With Hardcore offNormal mode spreads manual toxicity input over a reference window. Calcium replacement and excessive accumulated calcium still matter. | |
120 s (2 min) | At the full 3 g replacement reference, 120 seconds delivers 139.5 mg/min elemental calcium, above the 100 mg/min fast-rate onset. A 300-second delivery gives 55.8 mg/min; earlier doses still matter. With Hardcore offNormal mode spreads manual toxicity input over a reference window. This salt remains distinct from calcium chloride. | |
300 s (5 min) | Fast delivery can lower vascular resistance and pressure. Follow rhythm, pressure and cumulative dose. With Hardcore offNormal mode spreads the custom bolus drive over at least 600 seconds. This is an internal physiology window, not the visible push timer. | |
60 s (1 min) | The actual push rate feeds existing pressor support. Follow pressure, perfusion and rhythm; no separate rapid-norepinephrine syndrome is added. With Hardcore offNormal mode spreads the custom bolus drive over at least 60 seconds. Infusions continue to use actual delivered flow. | |
60 s (1 min) | Delivery builds the concentration that controls heavy blockade, bradycardia and hypotension. With Hardcore offNormal mode spreads custom bolus input over at least 60 seconds. Concentration-dependent toxicity remains active. | |
60 s (1 min) | Follow accumulated concentration as well as push speed. Seizures and cardiac toxicity remain possible as exposure rises. With Hardcore offNormal mode spreads custom bolus input over at least 120 seconds. Existing concentration toxicity and clearance modifiers remain. | |
300 s (5 min) | Fast delivery can cause bradycardia and hypotension. Check the delivered mass per minute. With Hardcore offNormal mode spreads custom bolus input over at least 300 seconds. Actual infusion-rate hazards remain active. | |
30 s | Rapid delivery can add a sharper temporary fall in respiratory drive, vascular resistance and pressure. With Hardcore offThe added rapid-propofol load is absent with Hardcore off. Normal hypnosis, pressure effects and interactions remain. | |
60 s (1 min) | Rapid delivery can add temporary respiratory and hemodynamic depression, especially with other sedatives. With Hardcore offThe added rapid-midazolam load is absent with Hardcore off. Normal sedation and combination effects remain. | |
30 s | Rapid delivery can add temporary opioid respiratory and cardiovascular depression. Include other sedatives in the assessment. With Hardcore offThe added rapid-opioid load is absent with Hardcore off. Opioid effects, overdose and interactions remain. | |
60 s (1 min) | Rapid delivery can add temporary opioid respiratory and cardiovascular depression. Allow for effects already on board. With Hardcore offThe added rapid-opioid load is absent with Hardcore off. Opioid effects, overdose and interactions remain. | |
30 s | Rapid delivery can modestly accelerate establishment of blockade. Dose remains dominant; paralysis supplies no sedation. With Hardcore offThe rapid-delivery multiplier is absent with Hardcore off. Native dose-dependent paralysis remains. |
150 mg amiodarone over 300 seconds = 30 mg/min. That is above the model's 25 mg/min onset for its fast-rate pressure penalty. The 300-second preset does not bypass that threshold. Total dose, elapsed time and response must be considered together.
Adding saline while keeping the same medication mass and total push time does not reduce the average medication mass per minute. Stopping early reduces the total amount delivered, but does not change the rate that was running before the stop.
Adenosine uses a different rule: with Hardcore on, the speed multiplier is strongest through 5 seconds per 6 mg equivalent and weakens as delivery slows. The default is 3 seconds. See its card for supported rhythms and flushing.
The card effect curves describe native timing after a reference dose reaches the patient. An incremental push spreads that dose across time; do not read the curve's peak as a countdown from pressing Push.
The running push continues. When the Narc Box is closed, the syringe appears in the lower right corner with its actual artwork, moving plunger, remaining mL and mL/s.
Return to the same patient, Body Map, IV / IO site and syringe. The red Stop Push button is available. Opening the menu preserves the current timer and rate.
The remaining contents return to the same carousel syringe, tracked to 0.01 mL. Medication already admitted stays delivered. Drug and saline components are removed in their mixture proportions.
Select the remaining syringe and check the duration again. A new run divides its remaining target volume by that duration. It can therefore have a different mL/s from the previous run.
Stay within the configured AED distance limit. Both people must be outside vehicles or in the same vehicle. The fallback distance is 5 m; use your mission's actual setting.
Leaving that range or vehicle context stops administration. The push also stops if the selected vascular access is removed or replaced, or the provider becomes incapable of continuing.
With Require saline flush after push enabled, applicable doses still wait for the required flush. A long incremental push is kept as one logical load per medication, catheter and uninterrupted push session, retaining accumulated dose and elapsed push time.
Flushing therefore does not turn its many delivery portions into separate simultaneous rapid pushes. Prepared measured epinephrine follows its dedicated delivery path.
A stopped push can briefly show Stopping... while network acknowledgements settle. Rejected portions are restored to the same syringe; delayed requests are retried. Closing a menu is not a stop command while the Hardcore push is active.
For infusion concentrations and risk ranges, use the infusion reference. For preparation, see Ketofol and pressor mixtures. For every Hardcore switch, use the Hardcore settings comparison.
Push behavior reviewed against ACM Extended dev bc90fc7: Suggested times · Normal and incremental administration · Push start and target volume · Continuous flow and leash · Stop and remaining contents · Corner syringe · Reopen the same treatment · Rapid medication effects · Manual and infusion rate handling · Flush consolidation.
Choose a recipe to walk through the in-game controls and watch the syringe fill. The examples use the mod's stock concentrations and preparation rules. Each component keeps its own dose and effects after it reaches the patient.
With Hardcore Medications on, compound syringes use the longest component push time. Ketofol defaults to 30 seconds for the current target volume. Read how to set the push rate, stop a partial syringe and continue with menus closed.
10 mL compound syringe · ketamine + propofol
The named game recipe combines equal liquid volumes of two different stock concentrations. Its mass ratio is 5:1 ketamine to propofol.
Open the syringe draw view in the Narc Box and select a 10 mL empty syringe. Compounding is already the default; there is no separate Mix mode.
Select ketamine 50 mg/mL, pull the plunger to 5 mL, then press Draw. This locks in 250 mg and leaves room for the second component.
Select propofol 10 mg/mL. Pull from the existing 5 mL level to 10 mL total, then press Draw again. The added 5 mL supplies 50 mg propofol.
Use Select Syringe Tag to record both concentrations, then press Save. The recognized label reads Ketamine 250 mg + propofol 50 mg (10 mL; 5:1 mg ratio). Confirm the selected syringe before administering a measured volume.
10 mL contains 250 mg ketamine + 50 mg propofol. Each 1 mL contains 25 mg + 5 mg.
Enter a number within the shown range.
Each 1 mL contains 25 mg ketamine + 5 mg propofol.
The preview shows the contents of the selected volume. It does not predict serum concentration or the patient's response.
Keep in view: This describes the full prepared container. It does not make 10 mL a single dose. Ketamine and propofol both contribute to the active hypnotic load; titrate to the game patient's response, ventilation and perfusion.
10 mL dilution · cardiac-strength source
The recognized dilution uses the 0.1 mg/mL cardiac vial and a prefilled saline flush. The finished syringe contains 10 mcg/mL.
Select the prefilled 10 mL saline flush in the syringe draw view. The flush supplies its own syringe.
Use the flush waste workflow to reduce the saline to 9 mL. This creates exactly 1 mL of room for the cardiac-strength source.
Choose epinephrine 0.1 mg/mL and draw 1 mL into the retained saline. Complete the flush preparation. The exact recipe is 9 mL saline + 1 mL cardiac-strength epinephrine.
Check the prepared syringe label 10 mcg/mL. Its stored administration options include 1 mL, 2 mL and the full remaining volume. Keep the container total distinct from the selected push volume.
10 mL contains 100 mcg. Each 1 mL contains 10 mcg; 2 mL contains 20 mcg.
Enter a number within the shown range.
Each 1 mL contains 10 mcg epinephrine.
The preview shows the contents of the selected volume. It does not predict serum concentration or the patient's response.
Keep in view: The 1 mg/mL epinephrine stock is ten times stronger and is not the source for this named dilution. A full 10 mL syringe contains 100 mcg; it is not one 10 mcg push.
4 mg added to 250 mL normal saline
A simple game preparation example for tracking one pressor at a time. Injected medication solution adds to the carrier volume.
Choose the prepared/spiked 250 mL normal saline set, then select Prep Infusion. This opens the draw view in bag preparation mode.
Choose norepinephrine 1 mg/mL and measure 4 mL. The syringe contains 4 mg before transfer.
Press Inject Into Bag. The selected set now contains 4 mg in 254 mL. Use the bag's generated label to verify the medication total and final volume.
Attach through a functioning access site, set the roller clamp and confirm actual drainage. Check pressure, perfusion, rhythm and the site. The flow preview below calculates solution content per minute.
250 mL saline + 4 mL medication = 254 mL. Concentration: 4,000 mcg ÷ 254 mL ≈ 15.748 mcg/mL.
Enter a number within the shown range.
At 60 mL/h: Norepinephrine ≈ 15.748 mcg/min.
Arithmetic assumes this much solution reaches the circulation. A closed clamp, blocked site or leakage changes actual delivery. The two-pressor example shares one flow setting.
Keep in view: The bag total is a preparation example, not a target dose or serum level. Poor volume, acidosis, cold and low calcium can reduce pressor benefit. Check the vesicant guidance when selecting and monitoring the site.
1 mg added to 100 mL normal saline
This bag example uses the 1 mg/mL epinephrine stock. Its source and final concentration differ from the cardiac-vial flush recipe above.
Choose the prepared/spiked 100 mL normal saline set, then select Prep Infusion.
Choose the 1 mg/mL stock and draw 1 mL. If using the 0.1 mg/mL cardiac vial instead, the same 1 mg requires 10 mL and creates a different final concentration.
Press Inject Into Bag. This stock creates 1 mg in 101 mL. Recheck the prepared set's label before attaching it.
Open the clamp to the intended setting and confirm actual drainage. Track rate, rhythm and perfusion along with pressure; follow the access site for leakage or irritation.
100 mL saline + 1 mL medication = 101 mL. Concentration: 1,000 mcg ÷ 101 mL ≈ 9.901 mcg/mL.
Enter a number within the shown range.
At 60 mL/h: Epinephrine ≈ 9.901 mcg/min.
Arithmetic assumes this much solution reaches the circulation. A closed clamp, blocked site or leakage changes actual delivery. The two-pressor example shares one flow setting.
Keep in view: Epinephrine has its own cardiac drive and rhythm risks. Neither a target MAP nor a healthy-looking serum display alone establishes that escalation is beneficial.
Norepinephrine + epinephrine · shared flow demonstration
The preparation code can retain multiple components in the same saline set. This is a demonstration of that game mechanic, with one flow setting controlling both drugs.
Open Prep Infusion on the selected normal saline set. Keep this same set selected for both additions.
Draw 4 mL norepinephrine 1 mg/mL, then press Inject Into Bag. The set now contains 4 mg in 254 mL.
Reopen Prep Infusion for that same set. Draw 1 mL epinephrine 1 mg/mL and press Inject Into Bag. Verify both components on the resulting 255 mL bag label.
The single clamp now changes both rates in a fixed 4:1 mass ratio. Use separately controlled bags and access paths when the game situation requires independent adjustment.
250 + 4 + 1 = 255 mL. Norepinephrine ≈ 15.686 mcg/mL; epinephrine ≈ 3.922 mcg/mL.
Enter a number within the shown range.
At 60 mL/h: Norepinephrine ≈ 15.686 mcg/min; Epinephrine ≈ 3.922 mcg/min.
Arithmetic assumes this much solution reaches the circulation. A closed clamp, blocked site or leakage changes actual delivery. The two-pressor example shares one flow setting.
Keep in view: There is no special named combination bonus for this bag. Each component retains its own effects and risks. Menu support does not establish real-world chemical compatibility, and this example is not a preferred treatment recipe.
Their induction-normalized active loads add to hypnosis. Ketamine can support heart rate and vascular resistance when reserve is intact. Severe hypovolemia and acidosis reduce that support; propofol's depressant effect can then dominate.
Watch: response, ventilation, pressure and perfusion. Equal milliliters do not mean equal milligrams or guaranteed pressure stability.
Fentanyl or morphine can amplify a hypnotic's effect. Opioids alone do not supply the model's stand-alone hypnosis. Opioid combinations also add respiratory and cardiovascular depression.
Watch: respiratory drive and accumulating sedation. Effects interact whether drugs share a syringe or arrive separately.
The model adds a bounded hypnosis synergy while both drugs remain active. It also models extra respiratory and pressure burden. The extra hypnosis fades as either component wears off.
Watch: the combined active load, not just the most recently administered drug.
Norepinephrine's support enters peripheral resistance; epinephrine retains its own cardiac drive. Both contributions still depend on the patient's condition. Combining them does not bypass volume, calcium, temperature or acidosis effects.
Watch: pressure, flow and rhythm. With a shared bag, increasing the clamp increases both component rates together.
For the relevant game thresholds and serum display limits, use the infusion dose and risk guide. For ketamine sedation assessment, see Ventilator Settings & Tips.
Game preparation and interaction review 98d18bb: Named syringe recipes · Draw and Save · Cardiac-vial dilution · Prepared syringe pushes · Bag components and final volume · Combined hypnotic load · Sedation and reserve · Drug interactions · Pressor pathways. The syringe images are original mod artwork.
Prolonged field care
Continuous medication drips are intended to be used more often during prolonged field care (PFC). Sustained analgesia, sedation and pressure support require repeated monitoring, reliable access and time to manage the bag and clamp.
Tactical field care
During tactical field care (TFC), prioritize immediate bleeding control, airway and breathing support, indicated medications, resuscitation and evacuation. A drip should have a clear purpose that justifies the setup and attention it needs. This is a gameplay emphasis, not a ban: blood resuscitation and indicated finite infusions may still be needed during TFC.
Finite and continuous delivery
“Infusion” includes a finite dose delivered over time. “Continuous drip” describes ongoing delivery adjusted to a sustained treatment goal. Starting an infusion does not guarantee a stable patient or remove the need to reassess. The Joint Trauma System guidelines include separate TCCC and prolonged care references.
Choose a medication to explore delivery over time, or open its quick reference to compare dose ranges and hazards. Use the mixture workbench for syringe preparation and pressor bags.
Game reference, default settings. There is no single safe dose for every patient. These ranges separate actual rate hazards, current drug effect and accumulated exposure. Where the mod has no defined toxicity cutoff, the guide says so. A reference range is not a guarantee of safety, and a high cutoff is not a target.
Weight examples use 83 kg. Values in mg/min, mcg/min, mg/kg and total mg are different quantities. Any concentration called a proxy is an internal game estimate, not a measured laboratory result.
The recipe is what you prepare. A 4 mg norepinephrine bag or a 2.5 g esmolol bag does not mean the patient should receive that amount at once.
Concentration × admitted flow determines the dose per minute. Leakage, a closed clamp or a blocked route can make the actual dose lower than requested. Use the drip calculator with the final mixture concentration.
Earlier pushes and drips continue to act. Active-equivalent dose means the amount represented by the current onset and washout weighted drug effect, not simply the total emptied from the bag.
Choose a medication, change its actual delivered rate and inspect how its game value accumulates or clears.
Actual infusion flow, concentration accumulation and existing dose or combination effects remain active with Hardcore Medications off. The setting changes manual bolus rate handling and adds rapid push consequences; it does not disable these infusion models. Manual push guidance >
There is no universal ideal serum level. Most bands here are configured debug references. Sedation, pressor response and overdose may read different variables. Lidocaine, esmolol and calcium have explicit concentration or excess thresholds; those boundaries are not a guarantee of safety below them.
The curve starts at zero, holds actual admitted delivery constant and uses the default configuration. It estimates the source's accumulation in one second steps, including calcium and amiodarone input easing. A prior bolus, changing perfusion, lost IV fluid, addon settings or another drug can change the live result. Calcium is an excess accumulator shared by both salts, not a laboratory calcium measurement. Magnesium's debug band does not align with its raw proxy scale at native treatment rates.
IV and IO: the same amount admitted to circulation feeds this estimate. Check the site's actual delivery; a leaking IV can drain a bag without admitting that entire dose.
Concentration and mixture review: ACM Extended dev 98d18bb. Manual push comparison: bc90fc7. Individual source links accompany each medication below.
No matching infusions. Try another medication or clear the search.
Below 25 mg/min: below the specific fast infusion penalty. The source example is 150 mg over 10 minutes = 15 mg/min. The native effect reference is 150 mg.
Above 25 to 90 mg/min: the modeled resistance drop increases, making hypotension more likely. Existing low pressure and esmolol make the overall response less forgiving.
90 mg/min or more: the fast infusion penalty is fully expressed once its rate smoothing catches up. 2,200 mg accumulated also enters the separate torsades risk gate; that is not a daily allowance. Active amiodarone burden above 2,310 mg equivalent can trigger the family overdose syndrome.
Reassess: Follow blood pressure, pulse and rhythm. Amiodarone does not treat torsades. Lowering the clamp does not immediately erase drug effect or cumulative exposure.
Allow for timing: 10 s native peak; rate hazard builds over about 15 s and eases over about 35 s after reduction.
Hardcore Medications uses the selected manual push time for the custom rate drive. With it off, that drive is spread over at least 600 s. Physical infusion rates and cumulative overdose remain active in either mode. The 300 s syringe default is not a guarantee of staying below the rate threshold. Hardcore push comparison >
Source review 98d18bb: Drug thresholds · Circulation effects · Active overdose burden.
0–0.5 mcg/min: below the added epinephrine heart rate drive onset. 0.5–15 mcg/min: that drive rises toward its full +50 BPM target adjustment. These are effect bands, not a universally safe titration range.
15 mcg/min or more: the added rate drive has reached its cap, while arrhythmia burden can continue rising. The 1 mg native reference and 1 mg preparation example are not routine doses for a perfusing patient.
At default settings, infusion alone reaches the atrial tachycardia score at about 20 mcg/min and the SVT score at about 38.9 mcg/min. These are eased rates; pulse state, rhythm, heart rate and sustained exposure gates must also qualify. Prior bolus support can reach the score sooner.
Reassess: Track pulse, rhythm, pressure, perfusion and the exact access site. The 1 mg/mL and 0.1 mg/mL stocks deliver the same drug; confirm which vial is selected before drawing.
Allow for timing: 5 s native peak; pressor delivery response ramps over about 45 s and fades over about 120 s.
The displayed rates describe an infusion in either mode. Manual epinephrine uses a separate bolus support path, so its syringe push cannot be read directly from this concentration plot. Hardcore push comparison >
Source review 98d18bb: Drug thresholds · Circulation effects · Rhythm gates · Addon Options defaults.
0.05–0.1 mcg/kg/min is the source’s starting titration band: 4.15–8.3 mcg/min at 83 kg. The native effect reference is only 80 mcg; 4 mg is an amount used to prepare a bag.
Below that band: less support may be sufficient, or pressure may remain inadequate. Above it: you are beyond the starting band, not automatically overdosed. Titrate to the patient’s response and restore missing volume.
No universal toxic mcg/min cutoff is implemented. Pressure overshoot, worsening perfusion and extravasation remain reasons to reassess or reduce delivery. The default added MAP support cap is 25 mmHg before physiological gates; more drug does not guarantee more useful support. The configured 1 mg maxDose field is not a working norepinephrine overdose syndrome.
Reassess: Reassess pressure, perfusion, volume, calcium, temperature and acidosis. A distal site does not turn norepinephrine into epinephrine; actual leakage still causes local injury.
Allow for timing: 30 s native peak; pressor response ramps over about 45 s and fades over about 120 s.
Hardcore Medications uses the selected manual push time. With it off, the custom bolus drive is spread over at least 60 s. Physical infusion delivery and its perfusion gates remain active in either mode. Hardcore push comparison >
Source review 98d18bb: Drug thresholds · Circulation effects · Addon Options defaults · Supported overdose handlers.
83 mg at 83 kg is one native IV effect reference, equivalent to 1 mg/kg. The preparation recipe uses 100 mg. A partial reference is a smaller current antiarrhythmic effect, not proof of a safe infusion rate.
At 5 mcg/mL: the debug label changes to early CNS. This is a display caution; the separate seizure trigger begins at 12 mcg/mL. The eventual steady level is admitted mg/min divided by clearance. Shock and an esmolol proxy above 0.1 mcg/mL reduce clearance, so an unchanged rate can accumulate further.
12 mcg/mL: seizure trigger unless suppressed; 15 mcg/mL: cardiac toxicity begins; 25 mcg/mL: bradyasystolic arrest threshold. With normal 0.40 L/min clearance, the corresponding steady rates are 4.8, 6 and 10 mg/min. With both shock and esmolol, they fall to about 2.02, 2.52 and 4.2 mg/min. These are eventual plateaus, not instant rate triggers or recommended doses.
Reassess: Watch rhythm, pressure, breathing and seizure activity. Prior boluses change the starting level. Controlling a seizure does not remove lidocaine or prevent cardiac toxicity.
Allow for timing: 5 s native peak. The separate concentration proxy uses 0.7 L/kg distribution and 0.40 L/min normal clearance: about a 101 min half-life at 83 kg. The older 330 s setting does not drive this accumulator.
The serum accumulator and its seizure or cardiac toxicity remain active in either mode. Hardcore Medications uses the selected manual push time; with it off, the custom bolus input is spread over at least 120 s. Infusions retain their actual delivery rate. Hardcore push comparison >
Source review 98d18bb: Drug thresholds · Circulation effects · Lidocaine toxicity.
0.1–0.2 mg/kg IV/IO spans the native analgesic anchors: 8.3–16.6 mg at 83 kg. At full effect, ketamine alone reaches the default induction level near 1.75 mg/kg, or 145.25 mg at 83 kg.
Between analgesia and induction: analgesia and hypnosis change separately. Repeated doses and an infusion add to the same current exposure. A 50 mg bag recipe is neither an induction requirement nor a maximum.
Extra respiratory depression begins above 1.6 induction equivalents, about 2.8 mg/kg IV at full effect, and increases toward 3.2 equivalents. The family overdose evaluator can trigger above 262.5 mg of active IV-equivalent ketamine alone; IM ketamine and esketamine also contribute through their own thresholds. Shock, rapid IV pushes and combinations can cause problems below that total.
Reassess: Reassess breathing, pressure and actual sedation. See Ventilator Settings & Tips for the nystagmus finding. Rocuronium contributes no sedation.
Allow for timing: 5 s IV/IO native peak. Sedation depends on current combined effect, not merely time since the syringe was pushed.
Hardcore Medications adds the rapid manual push consequence; dose-dependent sedation, shock sensitivity and combined drug effects remain with it off. The 30 s syringe default is separate from the native 5 s effect peak and this display-only infusion proxy. Hardcore push comparison >
Source review 98d18bb: Extended medication data · Active overdose burden · Sedation physiology · Combined sedation.
0–1 g delivered: builds toward one native medication reference as the dose takes effect. 1 g is the preparation example and effect reference; it describes a finite hemorrhage adjunct.
Beyond 1 g: more delivered drug and carrier do not replace pressure, packing, blood replacement or other bleeding control. Account for earlier TXA doses before adding another bag.
No dedicated high-dose toxicity threshold or safe maintenance rate is implemented in the reviewed TXA path. Do not read that absence as an unlimited safe range. This wiki does not assign an invented red cutoff or a continuous treatment schedule.
Reassess: Track total delivered amount, remaining bleeding and the need for further treatment. Close the clamp when the intended finite amount has been delivered.
Allow for timing: 15 s native peak for an admitted reference amount.
Source review 98d18bb: Native medication data · Preparation amounts · Admitted medication.
0.5–1 mcg/kg IV/IO spans the native analgesic anchors: 41.5–83 mcg at 83 kg. The 100 mcg recipe amount is the bag’s content example, not a guaranteed safe exposure.
Above 110 mcg of active IV-equivalent exposure can satisfy the native instability check when heart rate is below 50. Respiratory depression and loss of CO₂ response can matter before an overdose syndrome appears.
Fentanyl alone can trigger the opioid overdose evaluator above 157.5 mcg of active IV-equivalent exposure. Morphine, IM fentanyl and the lozenge add to the same normalized family burden; do not add their raw mg together. Sedatives increase respiratory risk below this threshold.
Reassess: Follow ventilation and consciousness as well as pain. Opioids are analgesic adjuncts; they do not provide reliable hypnosis by themselves. Naloxone reverses opioid effects, but reassessment remains necessary.
Allow for timing: 10 s IV/IO native peak; effect can persist after the line stops.
Hardcore Medications adds a short-lived rapid manual push penalty to breathing and vascular resistance. It excludes true infusion delivery from this added penalty. Native opioid depression, interactions and overdose remain in either mode; the 30 s syringe default is not a dose limit. Hardcore push comparison >
Source review 98d18bb: Native medication data · Active overdose burden · Conditional instability · Drug interactions.
0.05–0.1 mg/kg IV/IO spans the native analgesic anchors: 4.15–8.3 mg at 83 kg. The preparation example contains 10 mg.
Above 10 mg of active IV-equivalent exposure can satisfy the native instability check when heart rate is below 50. Pressure and respiratory response still need reassessment below that amount.
Morphine alone can trigger the opioid overdose evaluator above 12.6 mg of active IV-equivalent exposure. Fentanyl and other opioid routes reduce the remaining family margin. Propofol or midazolam add respiratory and pressure depression.
Reassess: Follow pain, pressure, breathing and current opioid exposure. A partly empty bag does not show how much active medication remains in the patient.
Allow for timing: 25 s IV/IO native peak; 1,300 s native duration.
Hardcore Medications adds a short-lived rapid manual push penalty to breathing and vascular resistance. It excludes true infusion delivery from this added penalty. Native opioid depression, interactions and overdose remain in either mode; the 60 s syringe default is not a dose limit. Hardcore push comparison >
Source review 98d18bb: Native medication data · Active overdose burden · Conditional instability · Drug interactions.
0–5 mg current IV equivalent: builds toward one native reference. 5 mg contributes about half an induction equivalent; 10 mg alone reaches one equivalent at full effect with default tuning.
Above 5–10 mg, or when combined with another sedative: hypnosis, respiratory depression and pressure effects accumulate. Propofol and opioids amplify the combined response. Allow for its slower peak before repeating.
No universal mg/min danger threshold is wired for midazolam. Its 20 mg unstableDose and 30 mg maxDose config fields do not establish a functioning, separate IV overdose gate in the reviewed handlers. Loss of breathing or deteriorating pressure is dangerous at any dose.
Reassess: Check ventilator delivery, CO₂, spontaneous effort, sedation and pressure. Muscle paralysis can hide movement without treating awareness.
Allow for timing: 240 s IV native peak; a long effect tail follows delivery.
Hardcore Medications adds a short-lived rapid manual push penalty to breathing and vascular resistance. It excludes true infusion delivery from this added penalty. Sedation and drug interactions remain with it off; the 60 s syringe default does not replace the slower native effect peak. Hardcore push comparison >
Source review 98d18bb: Extended medication data · Combined sedation · Sedation physiology · Supported overdose handlers · Conditional instability.
0–4 mg current IV equivalent: builds toward one native nausea-treatment reference. The preparation example contains 4 mg.
4–8 mg: greater exposure is not automatically greater symptom relief. It does not reverse opioid respiratory depression or replace reassessment of the cause of vomiting.
Above 8 mg of active IV-equivalent exposure with HR below 50 can satisfy the native instability check. There is no separate ondansetron overdose syndrome in the supported overdose handler and no validated safe continuous rate in this model.
Reassess: Reassess nausea, vomiting, pulse and other medications. Treat it as an indicated finite administration rather than a routine indefinite drip.
Allow for timing: 15 s IV/IO native peak.
Source review 98d18bb: Native medication data · Conditional instability · Supported overdose handlers.
1 g is the native replacement reference. One slow arithmetic example is 1 g over 10 min = 100 mg/min of calcium chloride, or 27.3 mg/min elemental calcium. The model’s elemental fraction is 0.273.
Sustained delivery above about 219.8 mg/min of the salt can eventually exceed the modeled excess-calcium threshold, even before a fast-rate penalty appears. This derives from 60 mg/min elemental calcium and assumes no previous excess. Stop when the intended replacement is delivered.
Fast-rate toxicity begins above about 366.3 mg/min of salt and reaches full depth near 1,025.6 mg/min. Independently, the excess-calcium proxy enters toxicity above 1 mg/dL and reaches full depth at 4 mg/dL. The worse of the rate and accumulation effects applies; severe bradycardia and arrest are possible.
Reassess: Track cumulative calcium, transfusion context, pressure, rhythm and IV site integrity. Calcium gluconate adds to the same elemental calcium burden. This is not the patient’s measured total serum calcium. For transfusion replacement, see first/fourth-unit timing and the 1 g over 5 min example.
Allow for timing: 300 s native effect peak; toxicity has its own rate and accumulation timing.
The shared excess-calcium accumulator and physical infusion rate penalty remain active in either mode. Hardcore Medications uses the selected manual push time; with it off, the custom bolus drive is spread over at least 300 s. Replacement credit remains dose-dependent. Hardcore push comparison >
Source review 98d18bb: Drug thresholds · Circulation effects · Extended medication data · Calcium replacement credit.
3 g gives about 1 g of CaCl₂-equivalent replacement credit. Over 10 min, that is 300 mg/min of gluconate, or 27.9 mg/min elemental calcium. The elemental fraction is 0.093.
Sustained delivery above about 645.2 mg/min of the salt can eventually exceed the modeled excess-calcium threshold from a zero starting excess. The gentler salt does not remove the shared accumulation risk.
Fast-rate toxicity begins above about 1,075.3 mg/min of salt and reaches full depth near 3,010.8 mg/min. The same excess-calcium thresholds apply: above 1 mg/dL enters toxicity, and 4 mg/dL reaches full depth. Previous calcium chloride or gluconate reduces the remaining margin.
Reassess: Use the correct salt concentration and count both salts. Reassess rhythm, pressure and site leakage; replacement credit and elemental toxicity use different conversions. 3 g over the 120 s Hardcore default delivers 139.5 mg/min elemental calcium, above the 100 mg/min fast-rate onset. See the 3 g over 5 min example and transfusion timing.
Allow for timing: 420 s native effect peak; toxicity uses a separate accumulator.
The shared excess-calcium accumulator and physical infusion rate penalty remain active in either mode. Hardcore Medications uses the selected manual push time; with it off, the custom bolus drive is spread over at least 180 s. Its 120 s syringe default is not a guarantee of staying below the rate threshold. Hardcore push comparison >
Source review 98d18bb: Drug thresholds · Circulation effects · Extended medication data · Calcium replacement credit.
0–1 g delivered: builds toward the 1 g game reference as effect develops. The preparation example uses 10 mL from the 100 mg/mL stock.
Beyond the intended finite amount: additional bag content is not evidence that more antibiotic is required. The game retains ceftriaxone’s identity while using the shared antibiotic-care abstraction.
No dedicated ceftriaxone overdose cutoff or safe ongoing infusion rate is implemented in the reviewed path. The generalized debug concentration band is display-only and must not be presented as a toxicity boundary.
Reassess: Track the amount actually delivered and the treatment indication. Continue the underlying trauma and evacuation plan.
Allow for timing: 5 s native IV/IO reference peak; not a prediction of real antibiotic response time.
Source review 98d18bb: Extended medication data · Native medication data · Preparation amounts · Admitted medication · Circulation effects.
0–100 mg at 83 kg spans zero to one native effect equivalent. At full effect, 100 mg alone gives one induction equivalent; the reference scales with body weight.
More than one reference, or mixed sedatives: hypnosis and respiratory depression increase. Opioids and midazolam can achieve a given hypnotic effect with less propofol while adding respiratory and pressure risk.
No universal safe mg/min limit or separate propofol overdose trigger is defined here. The 200 mg unstableDose and 400 mg maxDose fields are not functioning standalone propofol gates in the reviewed handlers. Hypovolemia and acidosis worsen the pressure response; apnea or hypotension can occur below those numbers.
Reassess: Follow delivered ventilation, CO₂, pressure and sedation. Supply analgesia separately when required. Avoid treating a motionless, paralyzed patient as proof of adequate hypnosis.
Allow for timing: 90 s IV/IO native peak; 480 s native duration.
Hardcore Medications adds a short-lived rapid manual push penalty to breathing and vascular resistance. It excludes true infusion delivery from this added penalty. Native hypnosis, pressure effects and drug interactions remain with it off; the 30 s syringe default is not a dose limit. Hardcore push comparison >
Source review 98d18bb: Extended medication data · Combined sedation · Sedation physiology · Supported overdose handlers · Conditional instability.
The modeled display band is 0.5–2 mcg/mL. At default clearance, its steady input equivalent is 1.75–7 mg/min, or 10.5–42 mL/h of the 10 mg/mL premix. This is a game reference band, not proof of safe perfusion.
Above 7 to 17.5 mg/min, a constant infusion can eventually settle in the 2–5 mcg/mL toxicity band. A previous bolus changes the starting level. Native rate control and this accumulation model are separate.
Above 2 mcg/mL: increasing bradycardia and hypotension. 5 mcg/mL or higher: full modeled overdose depth. A steady 17.5 mg/min reaches that plateau, but not immediately. The full 2.5 g bag is inventory content, not an administration target.
Reassess: Follow pulse, pressure and rhythm. Amiodarone adds nodal and pressure depression; esmolol also reduces lidocaine clearance.
Allow for timing: 20 s native peak. The concentration proxy uses 0.5 L/kg distribution and 3.5 L/min clearance: about an 8.2 min half-life at 83 kg. Boluses and infusions both contribute; lowering the rate does not immediately reset the level.
The serum accumulator, native rate control and overdose effects remain active in either mode. Hardcore Medications uses the selected manual push time; with it off, the custom bolus input is spread over at least 60 s. Infusions retain their actual delivery rate. Hardcore push comparison >
Source review 98d18bb: Drug thresholds · Circulation effects · Drug interactions.
The native reference is 2 g. The source’s example range is 200–400 mg/min, equivalent to a 2 g dose over 10–5 min. At 40 mg/mL, this is 300–600 mL/h for a finite bag.
Above 800 to 2,500 mg/min: the fast infusion penalty rises, suppressing heart rate and reducing resistance. Below 800 mg/min only means this particular fast-rate penalty has not started.
2,500 mg/min or more: full fast-rate penalty after smoothing. Excessively fast delivery can worsen bradycardia and pressure. The generic 2–4 mg/dL debug band is display-only. Its numerical scale does not track the native finite-dose example, and it does not trigger these effects. Use delivered amount, native effect and the separate fast-rate penalty when interpreting the response.
Reassess: For torsades, enough native effect must develop before a termination attempt. Continue arrest care and correct causes; a bag being attached is not proof that a therapeutic amount reached the patient.
Allow for timing: 90 s native peak; fast-rate penalty builds over about 15 s.
The fast infusion penalty remains active in either mode. Hardcore Medications uses the selected manual push time; with it off, the custom bolus drive is spread over at least 300 s. Dose-dependent rhythm treatment and native medication timing remain separate. Hardcore push comparison >
Source review 98d18bb: Drug thresholds · Circulation effects · Extended medication data.
0–250 mL spans zero to the osmotherapy reference volume, containing up to 7.5 g NaCl. At default settings, 250 mL can lower the ICP proxy by up to 8 mmHg and add 3 mEq/L to the sodium proxy, subject to its floors and ceiling.
Repeated volumes: add sodium and consume the remaining sodium margin. The full bag is a calibration amount, not an instruction to empty it. Benefits depend on the current ICP and retained TBI state.
Sodium at or above 160 mEq/L by default: further osmotherapy stops lowering ICP. The setting can be changed. The reviewed path does not define a separate universal dangerous mL/min or total-volume cutoff; the ceiling is a loss-of-benefit boundary, not a promise that lower values are safe.
Reassess: Follow neurological findings, perfusion, delivered volume and the exact site. HTS extravasation is a local tissue hazard. It is not routine volume-resuscitation crystalloid.
Allow for timing: Osmotherapy follows actual admitted volume, not a native medication peak curve.
Source review 98d18bb: Drug thresholds · Osmotherapy · Addon Options defaults · Preparation amounts.
0–500 mL spans zero to the default osmotherapy reference, or 0–100 g at 200 mg/mL. The full reference can lower the ICP proxy by up to 8 mmHg while the model permits benefit.
Repeated volumes: cannot drive ICP below its treatment floor. Mannitol’s configured sodium increment is zero, unlike HTS, but an already reached sodium ceiling still blocks this osmotherapy path.
No standalone safe-to-dangerous dose or rate boundary is implemented for mannitol in this path. Do not turn the 100 g bag total into a routine dose or an unlimited repeat allowance. Reassess low pressure, volume state and leakage instead of chasing the ICP number with another bag.
Reassess: Track perfusion, volume, neurological findings and site integrity. Keep the ongoing injury and its recovery requirements in view after a temporary ICP improvement.
Allow for timing: Effect follows admitted volume through the separate osmotherapy model.
Source review 98d18bb: Drug thresholds · Osmotherapy · Preparation amounts.
Opioids share an overdose burden. Each active exposure is divided by that route’s own overdose limit. The family syndrome can trigger when the sum is greater than 1.05. For example, 100 mcg of active IV fentanyl plus 5 mg of active IV morphine gives:
This exceeds the shared trigger even though each drug alone is below its own trigger. Sedatives can also impair breathing below that threshold. The arithmetic describes current effect at those exposures, not an immediate prediction after injection.
Display bands do not always control toxicity. The generalized debug bands for epinephrine, norepinephrine, ketamine, opioids, midazolam, ondansetron, TXA, ceftriaxone and magnesium are display-only. Their actual effects use other code paths. In contrast, lidocaine, esmolol and calcium have concentration proxies that do drive specific hazards. Do not treat every green debug band as a safe-dose certificate.
Rate reductions take time. Fast infusion penalties use an onset and offset, and drugs already received continue through their own effect curves. Stop escalating simply because the last adjustment has not yet reached its peak.
Dose and risk review: ACM Extended revision 98d18bb. Each medication includes its exact source links. Prepared saline support and premixes follow the medication registry.
Preparation menu coverage
The current preparation menu supports 14 medications added to normal saline and four premixed medication bags. All other medication/product cards are accounted for below. The mixture workbench shows how the game stores and delivers several components in one syringe or saline set. Each component keeps its own dose; one bag clamp changes all of its component rates together.
Read the concentration examples
| Medication | Stock concentration | Amount in this recipe | Draw for this example | Final volume with 100 mL saline | Example bag concentration | Purpose and reassessment |
|---|---|---|---|---|---|---|
50 mg/mL | 150 mg | 3 mL | 103 mL | ≈ 1.46 mg/mL | Rhythm treatment; follow rhythm and pressure | |
1 mg/mL | 1 mg | 1 mL | 101 mL | ≈ 9.91 mcg/mL | Pressor support; follow rate, rhythm and perfusion | |
0.1 mg/mL | 1 mg | 10 mL | 110 mL | ≈ 9.10 mcg/mL | Same medication as epinephrine; different vial concentration and injected volume | |
1 mg/mL | 4 mg | 4 mL | 104 mL | ≈ 38.47 mcg/mL | Pressor support; follow pressure and the access site | |
20 mg/mL | 100 mg | 5 mL | 105 mL | ≈ 0.96 mg/mL | Ventricular rhythm treatment; monitor rhythm and cumulative exposure | |
50 mg/mL | 50 mg | 1 mL | 101 mL | ≈ 0.50 mg/mL | Analgesia or sedation; follow response and breathing | |
100 mg/mL | 1 g | 10 mL | 110 mL | ≈ 9.10 mg/mL | Finite hemorrhage adjunct; continue direct bleeding control | |
50 mcg/mL | 100 mcg | 2 mL | 102 mL | ≈ 0.99 mcg/mL | Analgesia; follow respiratory drive and sedation | |
5 mg/mL | 10 mg | 2 mL | 102 mL | ≈ 98.04 mcg/mL | Analgesia; follow respiratory drive and pressure | |
1 mg/mL | 5 mg | 5 mL | 105 mL | ≈ 47.62 mcg/mL | Sedation; follow ventilation and cumulative sedation | |
2 mg/mL | 4 mg | 2 mL | 102 mL | ≈ 39.22 mcg/mL | Nausea treatment; reassess the symptom | |
100 mg/mL | 1 g | 10 mL | 110 mL | ≈ 9.10 mg/mL | Calcium replacement; track cumulative dose and site integrity | |
100 mg/mL | 3 g | 30 mL | 130 mL | ≈ 23.08 mg/mL | Calcium replacement; 3 g gives about 1 g CaCl₂-equivalent game credit | |
100 mg/mL | 1 g | 10 mL | 110 mL | ≈ 9.10 mg/mL | Antibiotic administration; finite course and evacuation context | |
10 mg/mL | 100 mg | 10 mL | 110 mL | ≈ 0.91 mg/mL | Sustained sedation; follow ventilation and blood pressure |
In gameEpinephrine stock volumes
Epinephrine has two stocks: the 1 mg/mL vial requires 1 mL for this example, making 101 mL at about 0.0099 mg/mL. The cardiac vial contains 0.1 mg/mL and requires 10 mL, making 110 mL at about 0.0091 mg/mL. Both deliver the same medication; their source volumes differ.
CautionCarrier and access requirements
Carrier rules: only a bag whose preparation menu permits normal saline medication addition can be used for these recipes. Do not infer eligibility from PlasmaLyte carrier recognition or from a fluid’s ability to run through the same access. Prepared medication reaches the patient through the selected functioning IV or IO site.
| Medication | Full bag content | Bag volume | Concentration | Use |
|---|---|---|---|---|
2.5 g | 250 mL | 10 mg/mL | Rate control; assess pressure and rhythm. The vial is a separate presentation. | |
7.5 g | 250 mL | 30 mg/mL | Osmotherapy; delivered volume drives the effect. | |
2 g | 50 mL | 40 mg/mL | Torsades treatment; effect develops as medication is delivered. | |
100 g | 500 mL | 200 mg/mL | Osmotherapy; delivered volume drives the effect. |
Using a premixed bag
These bags already contain their medication and are selected from the add bag menu. A newly attached premix starts with its clamp closed until it is set. A partly used bag keeps the corresponding fraction of its original drug content. HTS 3% is 30 mg/mL sodium chloride; mannitol is 200 mg/mL. Their full bag totals are product contents, not instructions to administer the entire bag.
| Medication or product | Current support |
|---|---|
Rapid IV/IO push with the applicable flush; no prepared saline infusion | |
Inhaled product; no infusion | |
Native medication action or supported syringe route; no prepared saline infusion | |
NOT IN GAME. Unavailable; retained only as a legacy reference. No prepared infusion or current treatment dose. | |
Native antibiotic presentation; no prepared saline infusion | |
Native product; separate from ketamine infusion support | |
Oral transmucosal product; injectable fentanyl is listed above | |
Local rescue medication; no prepared saline infusion | |
Native nasal product; no prepared saline infusion | |
Native product; no prepared saline infusion | |
Inhaled product; no infusion | |
Local rescue medication; no prepared saline infusion | |
Supported syringe administration; no prepared saline infusion | |
Supported syringe administration; no prepared saline infusion |
In gameVial and premix support
The injectable esmolol presentation does not appear in the saline addition list; its premixed bag is the supported infusion. The same distinction applies to other osmotherapy presentations. See each medication card for route, dose, onset, peak effect, contraindications, side effects and interactions.
Game behavior checked against ACM Extended on 13 September 2026. Physiological explanations and illustrative examples are labeled separately from game calculations.
The original access capacity and fluid flow reference was checked at the preceding revision on 13 September 2026:
