Two tools, two ways of working
The question "emergency medicine pocket handbook or app?" is often framed as either-or. For emergency physicians and anaesthesia teams, the two media are complementary rather than competing. An emergency pocket handbook provides a fixed structure that can be read at a glance. An emergency medicine app, by contrast, can perform individual calculations and update content centrally.
What matters is less the medium itself than how well it fits the situation: How time-critical is the decision? Is the dose fixed or weight-based? Does an infusion rate in ml/h need to be determined? The following examples are taken from the compendium "Notfall & Narkose", which is available as a printed A6 pocket handbook and as a web app.
Where paper is faster
Resuscitation: fixed doses, clear timing
In cardiac arrest, many drug doses for adults are not weight-based but tied to specific steps in the algorithm. One example is lidocaine as an alternative to amiodarone in VF/pVT according to ERC 2025:
- 100 mg i.v./i.o. after the 3rd shock (with 2 % solution = 5 ml)
- 50 mg i.v./i.o. after the 5th shock (= 2.5 ml)
Lidocaine is used only if amiodarone is not available or if lidocaine has been specified locally. The two drugs are not combined.
Information of this kind requires no calculation. An open page shows dose, volume and timing at a glance. There is no device to unlock and no navigation.
The same applies to magnesium sulfate in torsade de pointes. According to ERC 2025, 2 g i.v. is given over 10 min and may be repeated once if required. In cardiac arrest, 2 g i.v. over 1–2 min is recommended. With a 50 % solution, each corresponds to 4 ml.
Conditions on scene
Irrespective of content, several practical factors favour paper:
- No technical dependency: no battery, no start-up, no login, no reliance on network coverage or a device.
- Gloves and environment: a touchscreen is often difficult to operate with contaminated or wet gloves. A book can also be held by a second person.
- Overview: a double page shows dosage, contraindications and notes simultaneously. This makes it easier to read aloud within the team (closed-loop communication).
- Familiar locations: anyone who works regularly with the same book soon finds frequently used pages "blind".
Where the app calculates with the exact weight
Weight-based dosing between table rows
Printed dosing tables necessarily work with weight bands. For lorazepam in paediatric status epilepticus (first stage), the dose is 0.1 mg/kg i.v. slowly, maximum 4 mg, repeated once if necessary (Glauser et al. 2016). The compendium's table includes, among others, these bands:
- 10 kg → 1 mg (0.5 ml of the 2 mg/ml solution)
- 15 kg → 1.5 mg (0.75 ml)
- 20 kg → 2 mg (1 ml)
If the estimated weight lies between two rows, the user of the book has to interpolate or calculate mentally. Under time pressure, this is a recognised source of error. The app calculates with the weight entered and displays dose and volume directly.
Note also that lorazepam is supplied as 2 mg/ml and is diluted 1:1 before i.v. administration. The volume of the final solution changes accordingly.
Making maximum doses visible
In adults, the first-stage dose of lorazepam is likewise 0.1 mg/kg i.v., maximum 4 mg (S2k guideline on status epilepticus). In the compendium's table, the maximum dose of 4 mg (2 ml) is reached consistently from 50 kg upwards. Whether book or app: what matters is that the limit is stated explicitly and cannot be exceeded by calculation.
The guideline also points out that underdosing is a common error. The maximum dose is therefore no reason to dose too cautiously.
Syringe driver infusion rates
The benefit of calculation becomes particularly clear with continuous infusions. According to the summary of product characteristics, dexmedetomidine for sedation of intensive care patients (target RASS 0 to −3) is started at 0.7 µg/kg/h and titrated to 0.2–1.4 µg/kg/h. A dilution of 4 µg/ml is used; the concentrate (100 µg/ml) is never given undiluted.
For 80 kg, the table gives a range of 16–112 µg/h, corresponding to 4–28 ml/h. For other weights and each titration step, the rate has to be recalculated. Here, an app reduces mental arithmetic and conversion errors between µg/kg/h, µg/h and ml/h.
Further points to note:
- According to the summary of product characteristics, no loading dose in this indication, owing to bradycardia and hypotension or hypertension.
- Regulatory warning from the EMA (2022) on increased mortality in intensive care patients ≤ 65 years in the SPICE III trial. Benefit and risk must be weighed individually.
What neither medium takes over
Neither an emergency pocket handbook nor an app replaces the following steps:
- Check the concentration on the label. Lidocaine is marketed as 1 % and 2 % solutions. Depending on product and country, magnesium sulfate is available as 10 %, 20 % or 50 % and is labelled partly in g of salt, partly in mmol. A correctly calculated dose results in the wrong volume if the wrong ampoule is used.
- Estimate weight realistically. The precision of an app calculation is only as good as the weight entered. A rate accurate to the decimal place suggests a precision that an estimate in the field does not have.
- Titrate to effect. For fentanyl for analgesia in spontaneously breathing patients, the summary of product characteristics states 50–200 µg i.v. initially. In emergencies, start low (e.g. 50 µg) and titrate to effect. Reduce the dose in older patients, in hypovolaemia and in combination with sedatives. Monitoring (SpO₂, ideally etCO₂) and the means to ventilate are mandatory. Here, the clinical response matters more than any table.
- Read contraindications and warnings. Examples include AV block, myasthenia gravis or hepatic impairment, depending on the drug.
Currency and guideline status
A structural argument for the app is central updating. Guidelines change, and corrections after publication also occur: the ERC 2025 guideline on Adult Advanced Life Support was supplemented by a corrigendum in 2026.
For other sources, the status is explicitly in flux. According to the AWMF register, the S2k guideline on status epilepticus in adults is under revision (no new version as of 10/2026).
A printed book reflects the status at the editorial deadline. Users should therefore be aware of the edition and the guideline status. Conversely, the same applies to digital content: a revision date and a reference for each dose make it transparent what a recommendation is based on.
Practical combination in the field
From these differences, a pragmatic division of labour can be derived:
- Book for time-critical fixed doses and algorithms: resuscitation, torsade, initial measures where there is no time to spare for operating a device.
- App for weight-based doses and infusion rates: paediatric emergencies between weight bands, syringe driver settings, dose adjustment during titration.
- Book as a fallback: in case of a flat battery, no network or device problems.
- App for preparation and debriefing: reviewing notes, contraindications and sources outside the acute situation.
- Four-eyes principle: one person reads from the book or app, a second draws up the drug and checks the label. Dose and volume are communicated aloud.
Conclusion
The printed pocket handbook has the edge where information must be visible immediately without calculation and where technical dependencies are a hindrance. The emergency medicine app plays to its strengths when calculations are needed for an individual body weight, an infusion rate has to be determined or an updated guideline status needs to be reflected.
Robust comparative studies on the error rates of the two media in prehospital use are limited. The combination is therefore primarily a pragmatic judgement. In both cases, label checks, realistic weight estimation and clinical titration remain the physician's responsibility.
References
- Kurzfassung der Leitlinien des European Resuscitation Council 2025. Notfall Rettungsmed 2025.
- Soar J, Böttiger BW et al. European Resuscitation Council Guidelines 2025 Adult Advanced Life Support. Resuscitation 2025;215 Suppl 1:110769 (Korrigendum 2026).
- Lott C et al. European Resuscitation Council Guidelines 2025: Special Circumstances in Resuscitation. Resuscitation 2025;215 Suppl 1:110753.
- Rosenow F, Weber J et al. S2k-Leitlinie Status epilepticus im Erwachsenenalter. Deutsche Gesellschaft für Neurologie gemeinsam mit der Österreichischen Gesellschaft für Neurologie (ÖGN), 2020; AWMF-Register 030-079, korrigierte Registerfassung 03/2022, gültig bis 29.06.2025 – laut AWMF-Register in Überarbeitung (Stand 10/2026 keine Neufassung). Publikation: Nervenarzt 2021.
- Glauser T, Shinnar S, Gloss D et al. Evidence-based guideline: Treatment of convulsive status epilepticus in children and adults. Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr 2016;16:48–61.
- Fachinformation (EPAR) Dexmedetomidin 100 Mikrogramm/ml Konzentrat zur Herstellung einer Infusionslösung, EMA – aktuelle Fassung.
- Fachinformation Fentanyl 0,05 mg/ml Injektionslösung (Fentanylcitrat) – aktuelle Fassung.
This article does not replace clinical judgement in the individual case or the current summary of product characteristics and guidelines.
