Preparing for Pediatric Emergencies: Drugs to Consider

Hegenbarth, Mary A.; and the Committee on Drugs

doi:10.1542/peds.2007-3284

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From the American Academy of Pediatrics| February 01 2008

Preparing for Pediatric Emergencies: Drugs to Consider

Mary A. Hegenbarth, MD;

Mary A. Hegenbarth, MD

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and the Committee on Drugs

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Pediatrics (2008) 121 (2): 433–443.

https://doi.org/10.1542/peds.2007-3284

This clinical report provides current recommendations regarding the selection and use of drugs in preparation for pediatric emergencies. It is not intended to be a comprehensive list of all medications that may be used in all emergencies. When possible, dosage recommendations are consistent with those used in current emergency references such as the Advanced Pediatric Life Support and Pediatric Advanced Life Support textbooks and the recently revised American Heart Association resuscitation guidelines.

INTRODUCTION

The purpose of this document is to assist health care professionals and facilities in their preparation for pediatric emergencies. This clinical report enables the practitioner to review current recommendations for the use of emergency medications in acutely ill children who require pharmacologic intervention. New agents and changing patterns of practice make it necessary to revise and update this clinical report.

This document is not intended to be an all-inclusive list of drugs used in pediatric emergencies, and it does not provide detailed drug information. Antimicrobial agents are not included in this document. Descriptions of medication indications and adverse effects are limited. Although not all-inclusive, the drug information listed in Table 1 should be helpful to practitioners and institutions when selecting which pharmacologic agents to have readily available for use in pediatric emergencies. The selection of which drugs to have available will depend on the setting; although emergency departments and hospitals will likely need the majority of the agents listed, a much more limited selection would likely be needed in a practitioner's office. This information should also be helpful for creating or editing preprinted drug-dosage charts. Table 2 contains a list of rescue, reversal, and antidote medications that may be useful in specific settings; it lists only the agents and indications and is not augmented with textual descriptions.

Dosages are generally given as milligrams per kilogram. The format for presented dosages is consistent with American Academy of Pediatrics recommendations for reducing medication errors.¹ For high-potency drugs such as prostaglandins, vasoactive amines, nitroprusside, and fentanyl, dosages are given as micrograms per kilograms. Historically, the weight-based “rule of 6” was recommended for preparation of vasoactive drip medications.² However, the Joint Commission and other organizations have recommended that standardized drip concentrations should replace rule-of-6 calculations to reduce the possibility of medication errors.³ The selection of drugs for use in pediatric emergencies is only one part in a large system or program that needs to be designed effectively to manage pediatric patients in an emergency situation. It is the creation, monitoring, and evaluation of these systems that will result in an improved outcome for pediatric patients.⁴

Rates and routes of administration are drug specific, and proper infusion systems should be used. Both adverse events and therapeutic effectiveness are dose and rate dependent, especially when highly potent vasoactive medications are administered. In general, most drugs should be administered over several minutes to avoid transient excessive blood concentrations. However, exceptions exist. One example is adenosine, for which rapid infusion is needed for efficacy. Another example of the importance of administration rate is phenytoin/fosphenytoin, for which slow infusion is necessary to minimize adverse events. Please refer to the text below. Unless otherwise indicated, the intravenous (IV) route is preferred. In an emergency, intraosseous (IO) administration is an acceptable alternative when IV access cannot be promptly obtained. Although certain drugs (lidocaine, epinephrine, atropine, naloxone [memory aid: LEAN]) can be administered endotracheally if no vascular access has been obtained, any vascular access (IV or IO) is preferred, because tracheal drug administration results in lower, less predictable drug concentrations than intravascular administration.⁵ If the endotracheal (ET) route is used, administer the drug with or diluted in 1 to 5 mL of isotonic saline solution followed by manual ventilations. ET administration of naloxone is no longer recommended for neonates.⁶

Most of the medications listed in this clinical report are used for airway management, resuscitation, sedation, analgesia, status epilepticus, or asthma. The Committee on Drugs recognizes that gaps exist in pediatric labeling and dosage information for many of these drugs. Despite these gaps, the package inserts, labels, and available medical literature should be consulted for additional information. The continued lack of clinical testing in pediatric populations before Food and Drug Administration approval of therapeutic agents makes it impossible to have the clinical data to support all pediatric dosing recommendations. Although local practice patterns and individual preferences exist for the use and dosage of many of these medications, the information provided in this document includes recommendations that are based on consensus opinion and literature review. References for individual drug indications and dosing are not provided in this report. Dosages should be individualized, taking into account the patient's age, weight, underlying illness, concurrently administered drugs, and known hypersensitivity. This committee recommends use of the current Advanced Pediatric Life Support⁷ and Pediatric Advanced Life Support⁸ textbooks, updated American Heart Association guidelines,⁵ and additional references for more detailed information on pediatric resuscitation algorithms, rapid-sequence intubation (RSI), procedural sedation, and treatment of asthma.^9,10 For newborn infants, practitioners can consult the Textbook of Neonatal Resuscitation¹¹ and updated American Heart Association guidelines⁶ for detailed information concerning management of neonatal emergencies and appropriate drugs, dosages, and routes of administration. In addition, preprinted medication cards and/or length-based resuscitation tapes (eg, Broselow tape) should be readily available at all sites that provide medical care for children.

Committee on Drugs, 2005–2006

Wayne Snodgrass, MD, Chairperson

Daniel Frattarelli, MD

Mary A. Hegenbarth, MD

Mark L. Hudak, MD

Matthew Knight, MD

Lynne Maxwell, MD

Robert E. Shaddy, MD

Past Committee Members

Brian Bates, MD

David J. Burchfield, MD

Richard L. Gorman, MD

Richard P. Walls, MD

Liaisons

John J. Alexander, MD

Food and Drug Administration

Donald R. Bennett, MD

American Medical Association

George P. Giacoia, MD

National Institutes of Health

Doreen M. Matsui, MD

Canadian Paediatric Society

Joseph Mulinare, MD

Centers for Disease Control and Prevention

Adelaide Robb, MD

American Academy of Child and Adolescent Psychiatry

Hari C. Sachs, MD

Food and Drug Administration

Staff

Raymond J. Koteras, MHA

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

REFERENCES

American Academy of Pediatrics, Committee on Drugs and Committee on Hospital Care. Prevention of medication errors in the pediatric inpatient setting.

Pediatrics.

2003

;

112

(2):

431

–436

American Heart Association, Subcommittee on Pediatric Resuscitation.

PALS (Pediatric Advanced Life Support) Provider Manual

. Dallas, TX: American Heart Association;

2002

Joint Commission on Accreditation of Healthcare Organizations.

Comprehensive Accreditation Manual for Hospitals: The Official Handbook

. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations;

2006

American Academy of Pediatrics, National Initiative for Children's Health Care Quality Project Advisory Committee. Principles of patient safety in pediatrics.

Pediatrics.

2001

;

107

(6):

1473

–1475

American Heart Association. Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, part 12: pediatric advanced life support.

Circulation.

2005

;

112

(24 suppl):

IV167

–IV187

American Heart Association. Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care, part 13: neonatal resuscitation guidelines.

Circulation.

2005

;

112

(24 suppl):

IV188

–IV195

American Academy of Pediatrics and American College of Emergency Physicians, APLS Steering Committee and Editorial Board.

APLS: The Pediatric Emergency Medicine Resource

. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics;

2004

American Heart Association, PALS Subcommittee 2006–2007.

PALS (Pediatric Advanced Life Support) Provider Manual

. American Heart Association: Dallas, TX;

2006

American Academy of Pediatrics and American Academy of Pediatric Dentistry; Coté CJ, Wilson S; Work Group on Sedation. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update.

Pediatrics.

2006

;

118

(6):

2587

–2602

National Asthma Education and Prevention Program.

Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma—Update on Selected Topics 2002

. Bethesda, MD: National Institutes of Health;

2003

. Publication 02-5074

American Heart Association and American Academy of Pediatrics.

Textbook of Neonatal Resuscitation

. 5th ed. Dallas, TX: American Heart Association;

2006

2008

TABLE 1

Potentially Useful Drugs in Pediatric Emergencies

Adenosine

Diphenhydramine

Glucagon

Lorazepam

Phenytoin

Albuterol

Dobutamine

Glucose

Magnesium sulfate

Prednisone/Prednisolone

Alprostadil (see Prostaglandin E₁)

Dopamine

Haloperidol

Mannitol

Procainamide

Epinephrine

Hydrocortisone

Methylprednisolone

Propranolol

Amiodarone

Epinephrine, racemic

Insulin

Midazolam

Prostaglandin E₁

Atropine

Etomidate

Ipratropium

Milrinone

Rocuronium

Bicarbonate, sodium

Fentanyl

Kayexalate™ (see sodium polystyrene sulfonate)

Morphine

Sodium polystyrene sulfonate

Calcium chloride

Flumazenil

Nalmefene

Charcoal, activated

Fosphenytoin

Naloxone

Succinlycholine

Dexamethasone

Furosemide

Ketamine

Nitroprusside

Thiopental

Diazepam

Levalbuterol (see albuterol)

Norepinephrine

Vecuronium

Phenobarbital

Lidocaine

Adenosine

Indication

Supraventricular tachycardia

Dosage

Initial dose: 0.1 mg/kg IV (maximum: 6 mg for first dose) as rapidly as possible, followed by immediate rapid flush of the IV catheter with 5–10 mL of normal saline. A 2-syringe technique is preferred; a larger flush of up to 20 mL may be helpful in older children. The most proximal IV site possible should be used. Adenosine may be given intraosseously if IV access has not been achieved.

Subsequent doses

If no AV block occurs and there is no response within 30 s, give double the initial dose (0.2 mg/kg, up to 12 mg maximum for second/subsequent doses) followed by immediate rapid saline flush as described above.

Note

Continuous electrocardiographic monitoring should be employed during use. A defibrillator must be immediately available.

Warning

Contraindicated in patients who have had a heart transplant; contraindicated in second- and third-degree AV block or sick-sinus syndrome unless a pacemaker has been placed.

Albuterol

Indication

Asthma exacerbation, bronchospasm

Dosage

Intermittent treatment with 0.5% nebulizer solution (5 mg/mL): minimum dose 2.5 mg (0.5 mL) every 20 min for 3 doses, then 0.15–0.30 mg/kg up to 10 mg every 1–4 h as needed. Dilute in a minimum of 2–3 mL of saline solution for adequate nebulization.

Continuous/prolonged nebulization: 0.5 mg/kg per h up to 10–15 mg/h diluted in a larger amount of saline by prolonged nebulization (total amount of fluid is determined by particular type of nebulizer delivery device, usually 25–30 mL for 1 h of nebulization).

Metered-dose inhaler: 4–8 puffs (90 μg per puff) every 15–20 min for 3 doses. Repeat every 1–4 h as needed. A spacer/holding chamber must be used when administering metered-dose inhaler treatments.

Administration can be repeated and dose can be adjusted until desired clinical effect unless patient develops symptomatic tachycardia.

Notes

Oxygen is the preferred gas source for nebulization. Supplemental oxygen may be needed when compressed air–driven nebulizers are used or when the oxygen flow rate dictated by the nebulizer device is inadequate to maintain adequate oxygen saturation.

Levalbuterol may also be used; the dose is half of the (racemic) albuterol dose listed above.

Alprostadil—see prostaglandin E₁

Amiodarone

Indication

Pulseless ventricular fibrillation (VT)

Dosage

IV/IO: 5 mg/kg rapid bolus (maximum: 300 mg); may be repeated up to a total daily dose of 15 mg/kg.

Indication

VT/supraventricular tachycardia with a pulse.

Dosage

IV/IO: 5 mg/kg (maximum: 300 mg) over 20–60 min. Adjust administration rate to urgency. May be followed by infusion of 5 μg/kg per min, increased to maximum of 10 μg/kg per min. Concentration of continuous infusion should not exceed 2 mg/mL and should be diluted with D5W.

Note

Amiodarone is only appropriate in pulseless ventricular arrhythmias after defibrillation and epinephrine have been initiated. Because of its long half-life and potential drug interactions, cardiologist consultation is recommended when considering amiodarone treatment outside of the cardiac arrest setting.

Warning

May cause hypotension, bradycardia, heart block, prolonged QT interval, and torsades de pointes VT. Should not be used in combination with procainamide or other drugs that cause QT prolongation without expert consultation. Contraindicated in severe sinus node dysfunction, marked sinus bradycardia, and second- and third-degree AV block.

Do not confuse name with amrinone; potential fatal complications if drugs or dosages are interchanged.

Atropine

Indication

Symptomatic vagally mediated bradycardia or AV block

Symptomatic bradycardia unresponsive to oxygenation, ventilation, and epinephrine

Dosage

IV/IO: 0.02 mg/kg.

Minimum single dose: 0.1 mg.

Maximum single dose: 0.5 mg for a child, 1.0 mg for an adolescent.

May repeat dose every 5 min to maximum total dose of 1 mg for a child and 2 mg for an adolescent or adult.

IM: 0.02–0.04 mg/kg.

ET: Neonates: 0.01–0.03 mg/kg.

Children and adolescents: 0.03–0.06 mg/kg.

Follow with or dilute in saline flush (1–5 mL) based on patient size.

Note

Oxygenation and ventilation are essential first maneuvers in the treatment of symptomatic bradycardia. Epinephrine is the drug of choice if oxygen and adequate ventilation are not effective in the treatment of hypoxia-induced bradycardia.

Indication

Anticholinesterase poisoning

Dosage

IV: for children, 0.05 mg/kg (up to initial adult dose: 2–5 mg).

Repeat/adjust dose as needed for clinical effect. If response to initial dose is inadequate, may double the dose and repeat every 10–20 min as needed to dry pulmonary secretions and achieve anticholinergic effect (atropinization). Anticholinesterase or nerve gas poisonings may require large doses of atropine and the addition of pralidoxime.

Indication

Prevention of bradycardia associated with RSI

Dosage

IV/IO: 0.01–0.02 mg/kg (minimum dose: 0.1 mg; maximum dose: 1 mg) before administration of sedative/anesthetic and paralytic agents.

Warning

Atropine sulfate comes in different concentrations; calculate dosage accordingly.

Bicarbonate, sodium

Indication

Metabolic acidosis

Hyperkalemia

Sodium channel blocker (eg, tricyclic antidepressant) overdose

Dosage

IV/IO: 1–2 mEq/kg given slowly; do not give by ET route.

Notes

Only the 0.5 mEq/mL concentration should be used for newborn infants; dilution of available stock solutions may be necessary. Do not mix sodium bicarbonate with vasoactive amines or calcium.

Routine initial use of sodium bicarbonate to treat cardiac arrest is not recommended. However, sodium bicarbonate may be used in patients with documented metabolic acidosis after effective ventilation has been established (effective ventilation is needed to allow elimination of excess CO₂ produced by bicarbonate).

For sodium channel blocker overdose, titrate bicarbonate to maintain a serum pH of 7.45–7.55, followed by infusion of 150 mEq NaHCO₃/L solution to maintain alkalosis.

Calcium chloride

Indications

Hypocalcemia

Hyperkalemia

Hypermagnesemia

Calcium channel blocker toxicity

Dosage

IV/IO: 20 mg/kg (0.2 mL/kg for 10% CaCl₂). Give by slow push for cardiac arrest; infuse over 30–60 min for other indications. Monitor heart rate; repeat dose as necessary for desired clinical effect.

Notes

Calcium chloride administration results in a more rapid increase in ionized calcium concentration than calcium gluconate and is preferred for the critically ill child. Calcium gluconate (dose: 60 mg/kg) may be substituted if calcium chloride is not available.

Recommended for cardiac resuscitation only in cases of documented hyperkalemia, hypocalcemia, hypermagnesemia, or calcium channel blocker toxicity.

Warning

Stop injection if symptomatic bradycardia occurs. Administration through a central venous catheter is preferred; extravasation through a peripheral IV line may cause severe skin and soft tissue injury.

Charcoal, activated

Indication

Acute ingestion of selected toxic substances

Dosage

1–2 g/kg PO or nasogastrically; adolescent/adult dose: 50–100 g.

Note

Consultation with poison center/clinical toxicologist is strongly encouraged before use (national Poison Control Center telephone number: 800-222-1222). Iron, lithium, alcohols, ethylene glycol, alkalis, fluoride, mineral acids, and potassium are not bound by activated charcoal.

Warnings

If airway protective reflexes are impaired, the risk of administering activated charcoal may outweigh the benefits.

Commercially available preparations of activated charcoal often contain sorbitol as a cathartic. Fatal hypernatremic dehydration has been reported after repeated doses of charcoal with sorbitol. Non–sorbitol-containing products should be used for children <1 y old and if repeated doses of charcoal are necessary.

Dexamethasone

Indication

Emergency treatment of elevated ICP caused by brain tumor

Dosage

IV/IO: 1–2 mg/kg.

Indication

Laryngotracheobronchitis (croup)

Asthma exacerbation

Dosage

IV, IM, or PO: 0.6 mg/kg (maximum: 16 mg).

Note

Further dosing and route of administration determined by clinical course.

Diazepam

Indication

Status epilepticus

Dosage

IV: 0.1–0.3 mg/kg every 5–10 min (maximum: 10 mg per dose). Administer over ∼2 min to avoid pain at IV site.

Rectal: 0.5 mg/kg up to 20 mg (this route may be useful when IV access is unavailable, but absorption may be erratic).

Note

IM route is not recommended because of tissue necrosis (other benzodiazepines, such as lorazepam and midazolam, may be given IM). Diazepam should be followed immediately by a long-acting anticonvulsant, such as phenytoin/fosphenytoin, because it is rapidly redistributed and seizures often recur within 15–20 min. Lorazepam may be preferred, because it has a prolonged duration of anticonvulsant activity.

Warning

There is an increased incidence of apnea when diazepam is given rapidly IV or when it is used in combination with other sedative agents. Monitor oxygen saturation and respiratory effort. Be prepared to support ventilation. Flumazenil may be administered to reverse life-threatening respiratory depression caused by diazepam or other benzodiazepines; however, it also counteracts the anticonvulsant effects and may precipitate seizures.

Diphenhydramine

Indications

Acute hypersensitivity reactions

Dystonic reactions

Dosage

IV/IM: 1–2 mg/kg (maximum initial dosage: 50 mg).

Note

May cause sedation and respiratory suppression, especially if using other sedative agents. May cause hypotension. Rapid IV administration may precipitate seizures. All doses may cause paradoxical excitement or agitation.

Dobutamine

Indication

Cardiogenic shock, congestive heart failure

Dosage

IV infusion: 2–20 μg/kg per min, titrated to desired clinical effect.

Warning

May cause tachyarrhythmias/ectopic beats, hypotension, and hypertension. Extravascular administration can result in severe skin injury. Phentolamine (dose: 0.1–0.2 mg/kg up to 10 mg diluted in 10 mL of 0.9% sodium chloride) injected intradermally at extravasation site may be helpful for counteracting dermal vasoconstriction.

Dopamine

Indication

Cardiogenic/distributive shock

Dosage

IV infusion: 2–20 μg/kg per min, titrated to desired clinical effect.

Note

Effects are dose dependent; low-dose (1–5 μg/kg per min) infusions usually stimulate dopaminergic and β-adrenergic receptors; α-adrenergic effects predominate at higher doses.

Warning

May cause arrhythmias and hypertension. Infusion rates of >20 μg/kg per min may cause peripheral, renal, and splanchnic vasoconstriction and ischemia. Extravascular administration can result in severe skin injury. Phentolamine (dose: 0.1–0.2 mg/kg up to 10 mg diluted in 10 mL of 0.9% sodium chloride) injected intradermally at extravasation site may be helpful for counteracting dermal vasoconstriction.

Epinephrine

Dosage/formulation

Epinephrine is available in 2 concentrations: 1:1000 (1 mg/mL) and 1:10 000 (0.1 mg/mL). Use caution to ensure selection of the appropriate concentration for the route of administration and patient age/condition. To convert mg/kg dosage to mL/kg: 0.01 mg/kg = 0.1 mL/kg of 1:10 000 solution and 0.1 mg/kg = 0.1 mL/kg of 1:1000 solution.

Indication

Cardiopulmonary resuscitation

Dosage

IV/IO

Newborn infants: 0.01–0.03 mg/kg of 1:10 000 solution.

Older infants/children: 0.01 mg/kg of 1:10 000 solution (maximum: 1 mg), repeated every 3–5 min.

Newborn infants: 0.03–0.10 mg/kg of 1:10 000 solution.

Older infants/children: 0.1 mg/kg of 1:1000 solution (maximum: 10 mg).

Follow ET administration with saline flush or dilute in isotonic saline (1–5 mL) based on patient size.

Note

IV high-dose epinephrine (0.1 mg/kg) is no longer recommended for routine use in resuscitation. It may be considered in exceptional circumstances such as β-blocker poisoning.

Indication

Anaphylaxis

Dosage

IM/SC: 0.01 mg/kg of 1:1000 solution (maximum: 0.3–0.5 mg), repeated every 5–20 min. The IM route is preferred for anaphylaxis. Severe reactions (eg, latex allergy) may require IV epinephrine (see above); a continuous infusion of epinephrine may be necessary.

Indication

Continued shock after volume resuscitation

Dosage

IV infusion: 0.1–1.0 μg/kg per min. Start at lowest dose and titrate to desired clinical effect. Doses as high as 5 μg/kg per min are sometimes necessary.

Warning

IV infiltration can result in severe skin injury. Phentolamine (dose: 0.1–0.2 mg/kg up to 10 mg diluted in 10 mL of 0.9% sodium chloride) injected intradermally at extravasation site may be helpful for counteracting dermal vasoconstriction.

Indication

Severe asthma exacerbation

Dosage

SC: 0.01 mg/kg of 1:1000 solution (maximum: 0.3–0.5 mg); may repeat every 20 min up to 3 doses. Begin simultaneous treatment with inhaled β-agonist (albuterol) and corticosteroids.

Indication

Laryngotracheobronchitis (croup)

Dosage

0.5 mL/kg of 1:1000 solution (maximum: 5 mL = 5 mg) administered by nebulizer.

Epinephrine, racemic

Indication

Laryngotracheobronchitis (croup)

Acute airway edema

Dosage

2.25% inhalation solution: 0.05 mL/kg (maximum: 0.5 mL) in 2 mL of normal saline administered by nebulizer.

Note

Many institutions use a standard 0.5-mL dose of racemic epinephrine for all patients. If racemic epinephrine is not available, single-isomer l-epinephrine (1:1000) can be substituted in a dosage of 0.5 mL/kg up to 5 mL.

Etomidate

Indication

Sedation for RSI

Dosage

IV/IO: 0.2–0.4 mg/kg (maximum: 20 mg).

Etomidate

Indication

Sedation for RSI

Dosage

IV/IO: 0.2–0.4 mg/kg (maximum: 20 mg).

Notes

Will lower ICP and does not usually lower blood pressure. Desirable agent for patients with head injury, multisystem trauma, or hypotension. Rapid onset: duration ∼ 10–15 min. This agent does not have analgesic properties.

May cause brief myoclonic activity (hiccups, cough, twitching) and may exacerbate focal seizure disorders. Causes transient adrenal suppression that is not clinically significant.

Fentanyl

Indications

Pain

Adjunct to intubation

Dosage

IV: 1–2 μg/kg. Repeat dose as necessary to desired clinical effect.

Notes

Rapid administration of fentanyl has been associated with both glottic and chest wall rigidity, even with dosages as low as 1 μg/kg. Therefore, fentanyl should be titrated slowly over several minutes when used for treatment of pain. More rapid administration is allowable before intubation, particularly if a muscle relaxant is also being administered.

Higher doses (1–5 μg/kg) are often recommended for intubation.

Warning

There is an increased incidence of apnea when combined with other sedative agents, particularly benzodiazepines. Be prepared to administer naloxone or nalmefene and provide respiratory support. May cause chest wall and glottic rigidity, which may be reversed with naloxone/nalmefene or a muscle relaxant. Be prepared for the loss of the desired clinical effect (analgesia) if a reversal agent is given.

Flumazenil

Indications

Benzodiazepine overdose

Required or desired reversal of therapeutic benzodiazepine effect

Dosage

IV: 0.01–0.02 mg/kg (maximum: 0.2 mg); repeat at 1-min intervals to a maximum cumulative dose of 0.05 mg/kg or 1 mg, whichever is lower. When IV access is unavailable, may be given IM.

Note

Most patients with oversedation attributable to benzodiazepines may be managed with supportive care alone. The duration of action of flumazenil is shorter than for most benzodiazepines; repeat dosage may be necessary. Patients should be observed continuously for at least 2 h after the last dose of flumazenil.

Warning

May precipitate acute withdrawal in benzodiazepine-dependent patients. Use with extreme caution in children with underlying seizure disorders who are being treated with benzodiazepines; flumazenil reverses the anticonvulsant effects and may precipitate seizures. Contraindicated in tricyclic antidepressant overdose; may induce seizures or arrhythmias.

Fosphenytoin

Indication

Status epilepticus

Dosage

Given in phenytoin equivalents (PE).

IV: 15–20 PE/kg, infused at a rate of 1–3 PE/kg per min (maximum rate: 150 PE per min).

IM: 15–20 PE/kg.

Notes

When given IV, itching is common and controllable by reducing the flow rate.

Lower risk of hypotension or cardiac effects than phenytoin.

Warning

Rate of infusion should not exceed 3 PE/kg per min. Monitor heart rate via ECG, and reduce the rate of infusion if heart rate decreases by 10 beats per min.

Furosemide

Indications

Fluid overload

Congestive heart failure/pulmonary edema

Dosage

IV/IM: 1–2 mg/kg (usual maximum dose: 20 mg for patients not chronically on loop diuretics).

Note

May cause significant hypokalemia.

Glucagon

Indication

Hypoglycemia caused by insulin excess (as adjunct to glucose).

Dosage

IV/IM/SC: 0.03 mg/kg up to maximum of 1 mg; repeat every 15 min up to a total of 3 doses if needed for clinical effect.

Indication

β-adrenergic blocker or calcium channel blocker overdose.

Dosage

IV: 0.03–0.15 mg/kg, followed by an infusion of 0.07 mg/kg per h (maximum: 5 mg/h).

Adolescent dosage

5–10 mg over several min, followed by infusion of 1–5 mg/h. Reconstitute doses of >2 mg in sterile water rather than the diluent supplied by the manufacturer.

Note

May cause nausea/vomiting because of delayed gastric emptying.

Glucose

Indications

Hypoglycemia

Hyperkalemia

Initial Dose

Children

IV/IO: 0.5–1.0 g/kg.

Neonates

IV: 200 mg/kg as D10W only.

Maintenance dose

Constant infusion of D10W-containing IV fluids with appropriate maintenance electrolytes at a rate of 100 mL/kg per 24 h (7 mg/kg per min). Older children may require a substantially lower dose. The rate should be titrated to achieve normoglycemia, because hyperglycemia has its own adverse central nervous system effects.

Notes

For D10W: 200 mg/kg = 2 mL/kg; 0.5–1.0 g/kg = 5–10 mL/kg.

For D25W: 0.5–1.0 g/kg = 2–4 mL/kg.

For D50W: 0.5–1.0 g/kg = 1–2 mL/kg.

D50W is irritating to veins; dilution to 25% dextrose is desirable.

Glucose, sodium, and potassium levels should be monitored carefully. Depending on etiology, hypoglycemia may recur.

Haloperidol

Indication

Psychosis with agitation

Dosage

IM/IV: 0.05–0.15 mg/kg; may repeat hourly as necessary. Maximum single dose: 5 mg.

Notes

Hypotension and dystonic reactions may occur.

Repeated doses can prolong QT interval and precipitate torsades de pointes.

Hydrocortisone

Indication

Adrenal insufficiency

Dosage

IV/IO: 2–3 mg/kg (maximum: 100 mg) over 3–5 min, followed by 1–5 mg/kg every 6 h for infants or 12.5 mg/m² every 6 h for older children.

Note

Do not underdose. Strongly consider concomitant fluid bolus of 20 mL/kg of D5NS or D10NS during the first hour of treatment.

Insulin, regular

Indication

DKA

Dosage

IV infusion: 0.05–0.10 unit/kg per h.

Neonatal IV: 0.05 unit/kg per h.

SC: 0.25–0.50 unit/kg per dose.

Note

IV bolus insulin is not generally recommended for children with DKA. Monitor blood glucose and potassium concentrations hourly or more closely as needed, with the goal of gradually reducing the blood glucose level by 50–100 mg/dL per h. Appropriate fluid and electrolyte therapy is also essential when treating DKA.

Indication

Hyperkalemia (although glucose alone is effective).

Dosage

IV: 0.1 unit/kg with 400 mg/kg glucose. Ratio is 1 unit of insulin for every 4 g of glucose.

Ipratropium

Indication

Adjunct to β-agonists for status asthmaticus/bronchospasm

Preparation

Nebulized solution (0.25 mg/mL).

Dosage

Children <12 y old: 0.25 mg nebulized every 20 min for up to 3 doses.

Children ≥12 y old: 0.5 mg nebulized every 20 min for up to 3 doses.

Notes

May be mixed with albuterol for nebulization.

Should not be used as first-line therapy.

Kayexalate (Sanofi-Aventis, Bridgewater, NJ)—see sodium polystyrene sulfonate

Ketamine

Indications

Sedation/analgesia

Adjunct to intubation

Infundibular spasm (hypercyanotic spell with tetralogy of Fallot)

Dosage

IV: 1–2 mg/kg, titrate repeat doses to desired effect.

IM: 4–5 mg/kg (onset of action within ∼ 5 min); may repeat half the initial dose if patient is not fully dissociated.

Notes

Doses listed above are recommended to achieve dissociative sedation/anesthesia. Lower doses may be used to provide analgesia without full dissociation.

Laryngospasm may occur, most often associated with rapid infusion or concomitant upper respiratory infection. It is usually reversible with oxygen administration, repositioning of the airway, and brief positive-pressure ventilation. Rarely, treatment with a muscle relaxant may be required.

Atropine or glycopyrrolate may be used to prevent increased salivation.

Warning

Be prepared to provide respiratory support. Monitor oxygen saturation. Avoid use in patients with increased ICP or increased intraocular pressure.

Levalbuterol—see albuterol

Lidocaine

Indication

Ventricular arrhythmias, wide complex tachycardia

Dosage

IV/IO: 1 mg/kg (maximum: 100 mg), repeat every 5–10 min to desired effect or until maximum dose of 3 mg/kg is given.

IV infusion: 20–50 μg/kg per min.

ET: 2–3 mg/kg, followed by or diluted in isotonic saline (1–5 mL) based on patient size.

Note

Recent data suggest that lidocaine is less effective than amiodarone but may be used if amiodarone is not available.

Warning

High concentrations may cause myocardial depression, hypotension, and seizures. Contraindicated in complete heart block and wide complex tachycardia attributable to accessory conduction pathways.

Indication

ICP protection before ET intubation or airway manipulation.

Dosage

1–2 mg/kg IV as a single dose 30 s to 5 min before airway instrumentation.

Note

Considered optional adjunct for RSI in patients with head injury/increased ICP. When a neuroprotective agent that reduces ICP (eg, etomidate, thiopental) is used, lidocaine is less likely to provide additional benefit.

Lorazepam

Indication

Status epilepticus

Dosage

IV/IM: 0.05–0.10 mg/kg (maximum: 4 mg per dose).

May repeat dose every 10–15 min if needed for continued seizures.

Warning

There is an increased incidence of apnea when combined with other sedative agents. Monitor oxygen saturation and be prepared to provide respiratory support. Flumazenil may be administered to reverse life-threatening respiratory depression caused by lorazepam; however, it will also counteract the anticonvulsant effects and may precipitate recurrence of seizures.

Magnesium sulfate

Indications

Hypomagnesemia

Torsades de pointes VT

Refractory status asthmaticus

Dosage

IV/IO: 25–50 mg/kg (maximum: 2 g).

Given by bolus for pulseless torsades, over 10–20 min for hypomagnesemia/torsades with pulses, and over 15–30 min for status asthmaticus.

Warning

Rapid infusion may cause hypotension and bradycardia. Have calcium chloride available if needed to reverse magnesium toxicity.

Mannitol

Indication

Increased ICP

Dosage

IV: .25–1 g/kg given over 20–30 min.

Note

Larger doses (≥0.5 g/kg given over 15 min) may be appropriate in an acute intracranial hypertensive crisis. In conjunction with mannitol, other measures to control ICP such as hyperventilation, sedation/analgesia, head-of-bed elevation, cerebrospinal fluid drainage, barbiturates, and muscle relaxation (using a neuromuscular blocking agent) should be considered. A urine-collecting catheter should be placed when using mannitol. Monitor for hyperosmolality.

Note

Administer through a filter; do not use solutions that contain crystals.

Methylprednisolone

Indications

Asthma/allergic reaction

Laryngotracheobronchitis (croup)

Dosage

IV/IM: 1–2 mg/kg initial dose (must use acetate salt for IM route).

Indication

Spinal cord injury

Dosage

IV: 30 mg/kg over 15 min, followed in 45 min by a continuous infusion of 5.4 mg/kg per h for 23 h.

Note

Administration within 8 h of injury is optimal.

Midazolam

Indication

Sedation/anxiolysis

Dosage

IV: 0.05–0.10 mg/kg given over 2–3 min (maximum single dose: 5 mg).

Note

Peak effect occurs at 3–5 min. Dose/observe and redose/observe every 3–5 min to avoid oversedation. Paradoxical agitation may occur, especially in younger children.

Dosage

PO: 0.25–0.50 mg/kg (maximum: 20 mg). Children <6 y old may require up to 1 mg/kg.

Indication

Adjunct for ET intubation

Dosage

IV: 0.2 mg/kg.

Note

Lower doses of midazolam are ineffective for RSI. After preoxygenation, allow sufficient time (2–3 min) for midazolam to take effect before administration of muscle relaxant.

Indication

Seizures

Dosage

IM: 0.2 mg/kg (maximum: 6 mg per dose); may repeat every 10–15 min.

Note

Other benzodiazepines (eg, lorazepam) are typically used for initial IV treatment of status epilepticus.

Indication

Refractory status epilepticus, not controlled by standard therapies.

Dosage

IV: Loading dose 0.15–0.20 mg/kg, followed by continuous infusion of 1 μg/kg per min, increasing by increments of 1 μg/kg per min (maximum: 5 μg/kg per min) every 15 min until seizures stop.

Warning

There is an increased incidence of apnea when combined with other sedative agents. Be prepared to provide respiratory support regardless of route of administration. Monitor oxygen saturation. Flumazenil may be administered to reverse life-threatening respiratory depression caused by benzodiazepines such as midazolam; however, it will also reverse the anticonvulsant effects and may precipitate seizures.

Milrinone

Indication

Myocardial dysfunction and increased SVR/PVR (eg, after cardiac surgery, normotensive septic shock).

Dosage

IV/IO: loading dose of 50–75 μg/kg over 10–60 min.

Infusion: 0.50–0.75 μg/kg per min.

Warning

May cause hypotension, ventricular arrhythmias, and angina. Monitor blood pressure and ECG continuously. Intravascular volume must be maintained. Longer infusion times reduce the risk of hypotension.

Morphine

Indications

Pain

Infundibular spasm (hypercyanotic spell with tetralogy of Fallot)

Dosage

IV (slowly)/IM: 0.1 mg/kg.

Notes

Repeat dose as necessary for clinical effect. Burn pain often requires larger or more frequent doses.

Higher doses may be necessary if patient is tolerant. Histamine release with flushing, itching, and hives is common. Histamine release may also cause hypotension, particularly in unstable cardiac/trauma patients; fentanyl may be preferred in these situations.

Warning

There is an increased incidence of apnea when combined with other sedative agents, particularly benzodiazepines. Be prepared to administer naloxone/nalmefene. Monitor the patient's vital signs and oxygen saturation. Be prepared to provide respiratory support.

Nalmefene

Indication

Apnea/respiratory depression caused by opioid overdose

Dosage

IV/IM: 0.25–0.50 μg/kg every 2 min.

Notes

Duration of action is 4–8 h (vs <1 h for naloxone).

For reversal of respiratory depression in sedation/analgesia or patients with pain, lower doses are indicated to avoid complete reversal of analgesia.

Do not administer nalmefene to a newborn infant whose mother is suspected of long-term opioid use because of the risk of acute withdrawal.

Warning

May induce acute withdrawal in opioid-dependent patients. Patients should be observed continuously for recurrence of respiratory depression and other narcotic effects for at least 4 h after the last dose of nalmefene. Not recommended for empiric use in coma of unknown etiology.

Naloxone

Indication

Apnea/respiratory depression caused by opioid overdose

Dosage

Newborn infants

IV/IM: 0.1 mg/kg (ET route not recommended for newborn infants).

Older infants/children

IV/IO/IM/SC: <5 y old or <20 kg: 0.1 mg/kg; ≥5 y old or ≥20 kg: 2 mg.

Notes

Use lower doses (1–15 μg/kg) to reverse respiratory depression associated with therapeutic opioid use.

Doses may be repeated as needed to maintain opiate reversal.

Do not administer naloxone to a newborn infant whose mother is suspected of long-term opioid use because of the risk of seizures/acute withdrawal.

Warning

Nitroprusside

Indications

Hypertensive crisis

Cardiogenic shock (associated with high SVR)

Dosage

IV: starting dose 0.3–0.5 μg/kg per min (maximum dose: 10 μg/kg per min). Start at the lowest dosage and titrate for the desired clinical effect.

Note

Bottle, burette, or syringe pump should be covered with protective foil to avoid breakdown by light. IV tubing does not need protective foil.

Warning

Administration may result in profound hypotension. Blood pressure should be monitored continuously with an arterial line. Extreme caution should be used to avoid accidental flushing/bolus injection of the IV line. May cause cyanide/thiocyanate toxicity and metabolic acidosis, especially in patients with hepatic or renal insufficiency.

Norepinephrine

Indication

Hypotensive (usually distributive) shock, with low SVR and unresponsive to fluid resuscitation (eg, hypotensive septic shock, neurogenic shock).

Dosage

IV/IO: 0.1–2.0 μg/kg per min, titrated to desired effect.

Warning

May cause tachycardia, bradycardia, arrhythmias, and hypertension. Extravascular administration can result in severe skin injury. Phentolamine (dose: 0.1–0.2 mg/kg up to 10 mg diluted in 10 mL of 0.9% sodium chloride) injected intradermally at extravasation site may be helpful for counteracting dermal vasoconstriction.

Phenobarbital

Indication

Status epilepticus

Dosage

IV: 20 mg/kg (maximum dose: 1000 mg), infused over 10 min. Repeat dose once if necessary after 15 min (maximum total dose: 40 mg/kg).

Warning

There is an increased incidence of apnea when combined with other sedative agents. Be prepared to provide respiratory support. Monitor oxygen saturation.

Phenytoin

Indication

Status epilepticus

Dosage

Neonates IV: 10 mg/kg.

Children IV: 20 mg/kg.

Notes

Maximum initial dose: 1000 mg. Recommended infusion time is 10–20 min; drug-delivery rate not to exceed 1 mg/kg per min.

Neonates have an increased risk of toxicity because of decreased protein binding; phenobarbital is preferred.

Phenytoin should be diluted in normal saline to avoid precipitation. Incompatible with glucose-containing solutions.

Warning

May cause hypotension and arrhythmias, especially with rapid infusion. Heart rate should be monitored, and the rate of infusion should be reduced if the heart rate decreases by 10 beats per min. If available, fosphenytoin is preferred, because it has a lower risk of adverse cardiac effects.

Prednisone/prednisolone

Indication

Asthma, acute exacerbation

Dosage

Initial dose: 1–2 mg/kg PO (maximum: 60 mg); subsequent dose: 1–2 mg/kg per d divided in 1–2 doses per d for 3–10 d (maximum: 60 mg per d).

Notes

No advantage of IV or IM preparations over the PO route if gastrointestinal absorption is not impaired.

No need to taper steroid dose if used for <10 d.

Procainamide

Indications

Wide complex tachycardia with a pulse, atrial flutter/fibrillation, supraventricular tachycardia resistant to other drugs

Dosage

IV/IO loading dose: 15 mg/kg over 30–60 min.

Adult dose: 20 mg/min IV infusion up to total maximum dose of 17 mg/kg (maximum loading dose: 1.0–1.5 g).

Warning

May cause hypotension, negative inotropic effect, prolonged QT interval, torsades de pointes, heart block, and cardiac arrest. If ≥50% QRS widening or hypotension occurs during administration of the drug, the remainder of the dose should be held. Cardiologist consultation is strongly recommended when considering the use of this medication. Should not be used with amiodarone or other drugs that prolong QT interval without expert consultation.

Propranolol

Indication

Infundibular spasm (hypercyanotic spell with tetralogy of Fallot)

Dosage

IV: 0.15–0.25 mg/kg per dose infused over 10 min in D5W.

Maximum initial dose: 1 mg. May repeat dose once.

Note

Oxygen should be administered first. Morphine is considered the first-line drug for the treatment of infundibular spasm. Use with caution in congestive heart failure.

Prostaglandin E₁ (alprostadil)

Indication

Suspected or proven ductal-dependent cardiac malformation in the neonatal period

Dosage

IV/IO: 0.05–0.10 μg/kg per min infusion in D5W (maximum dose: 0.2 μg/kg per min).

Warning

Apnea, hyperthermia, and seizures may occur; however, none are reasons to stop infusion. Be prepared to provide respiratory support.

Rocuronium

Indications

Paralysis to facilitate mechanical ventilation

Emergency intubation

Dosage

IV: 1 mg/kg.

Notes

This drug does not provide sedation, analgesia, or amnesia.

Satisfactory conditions for ET intubation (adequate relaxation) will generally occur in 60–90 s. Duration of action is ∼30–45 min and is dose dependent.

Warning

Ventilatory support is necessary. Personnel with skills in airway management must be present and prepared to respond when this agent is administered. Age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation should be immediately available.

Sodium polystyrene sulfonate (Kayexalate)

Indication

Hyperkalemia

Dosage

PO: 1 g/kg up to 15 g (60 mL) every 6 h as needed.

Rectal: 1 g/kg up to 50 g every 6 h as needed.

Warning

Avoid using the commercially available liquid preparation in neonates because of the hyperosmolar preservative (sorbitol) content. Hospital pharmacies can prepare sorbitol-free preparations. Extremely preterm neonates may develop intestinal hemorrhage (hematochezia) from rectal Kayexalate.

Succinylcholine

Indications

Emergency intubation

Laryngospasm

Dosage

IV: 1–2 mg/kg (2 mg/kg for infants <6 mo of age).

IM: 4 mg/kg IM (5 mg/kg for infants <6 mo of age).

Notes

This drug does not provide sedation, analgesia, or amnesia.

Atropine 0.02 mg/kg (minimum dose: 0.1 mg; maximum dose: 1 mg) is typically administered before succinylcholine to prevent bradycardia or asystole. If being used for patients with increased ICP, a defasciculation dose of a nondepolarizing agent (eg, 0.01 mg/kg of vecuronium) may be considered.

Satisfactory conditions (adequate relaxation) for ET intubation generally occur 30–45 s after IV administration and 3–5 min after IM administration. Duration of action is ∼5–10 min.

Warning

Causes increased serum potassium levels, which may be life-threatening in patients with a previous history of malignant hyperthermia, severe burns/crush injury, spinal cord injury, neuromuscular disease, or myopathy. When these contraindications exist, use a nondepolarizing muscle relaxant such as rocuronium. If cardiac arrest occurs immediately after administration of succinylcholine, suspect hyperkalemia (particularly in boys <9 y old).

Warning

Thiopental

Indication

Sedation/anesthesia for RSI

Dosage

IV: 2–6 mg/kg.

Note

May need to use lower dose if other sedatives/narcotics have been administered. Flush with saline before administration of rocuronium or vecuronium to avoid precipitation and obstruction of IV tubing.

Warnings

IM administration leads to tissue necrosis.

Be prepared to provide respiratory support. Monitor oxygen saturation. Causes vasodilation and decreased cardiac output; higher doses are associated with hypotension and apnea. If patient has cardiovascular dysfunction or volume depletion, consider etomidate as alternative.

Vecuronium

Indications

Paralysis to facilitate mechanical ventilation

Emergency intubation

Dosage

IV: 0.1 mg/kg for routine paralysis; 0.2 mg/kg for intubation.

Notes

This drug does not provide sedation, analgesia, or amnesia.

Satisfactory conditions (adequate relaxation) for ET intubation generally do not occur until 2 min after administration. Duration of action is ∼45–90 min (dose dependent). Rocuronium or succinylcholine is preferred for facilitating rapid intubation in emergency situations.

Warning

Adenosine
Indication	Supraventricular tachycardia
Dosage	Initial dose: 0.1 mg/kg IV (maximum: 6 mg for first dose) as rapidly as possible, followed by immediate rapid flush of the IV catheter with 5–10 mL of normal saline. A 2-syringe technique is preferred; a larger flush of up to 20 mL may be helpful in older children. The most proximal IV site possible should be used. Adenosine may be given intraosseously if IV access has not been achieved.
Subsequent doses	If no AV block occurs and there is no response within 30 s, give double the initial dose (0.2 mg/kg, up to 12 mg maximum for second/subsequent doses) followed by immediate rapid saline flush as described above.
Note	Continuous electrocardiographic monitoring should be employed during use. A defibrillator must be immediately available.
Warning	Contraindicated in patients who have had a heart transplant; contraindicated in second- and third-degree AV block or sick-sinus syndrome unless a pacemaker has been placed.
Albuterol
Indication	Asthma exacerbation, bronchospasm
Dosage	Intermittent treatment with 0.5% nebulizer solution (5 mg/mL): minimum dose 2.5 mg (0.5 mL) every 20 min for 3 doses, then 0.15–0.30 mg/kg up to 10 mg every 1–4 h as needed. Dilute in a minimum of 2–3 mL of saline solution for adequate nebulization.
	Continuous/prolonged nebulization: 0.5 mg/kg per h up to 10–15 mg/h diluted in a larger amount of saline by prolonged nebulization (total amount of fluid is determined by particular type of nebulizer delivery device, usually 25–30 mL for 1 h of nebulization).
	Metered-dose inhaler: 4–8 puffs (90 μg per puff) every 15–20 min for 3 doses. Repeat every 1–4 h as needed. A spacer/holding chamber must be used when administering metered-dose inhaler treatments.
	Administration can be repeated and dose can be adjusted until desired clinical effect unless patient develops symptomatic tachycardia.
Notes	Oxygen is the preferred gas source for nebulization. Supplemental oxygen may be needed when compressed air–driven nebulizers are used or when the oxygen flow rate dictated by the nebulizer device is inadequate to maintain adequate oxygen saturation.
	Levalbuterol may also be used; the dose is half of the (racemic) albuterol dose listed above.
Alprostadil—see prostaglandin E₁
Amiodarone
Indication	Pulseless ventricular fibrillation (VT)
Dosage	IV/IO: 5 mg/kg rapid bolus (maximum: 300 mg); may be repeated up to a total daily dose of 15 mg/kg.
Indication	VT/supraventricular tachycardia with a pulse.
Dosage	IV/IO: 5 mg/kg (maximum: 300 mg) over 20–60 min. Adjust administration rate to urgency. May be followed by infusion of 5 μg/kg per min, increased to maximum of 10 μg/kg per min. Concentration of continuous infusion should not exceed 2 mg/mL and should be diluted with D5W.
Note	Amiodarone is only appropriate in pulseless ventricular arrhythmias after defibrillation and epinephrine have been initiated. Because of its long half-life and potential drug interactions, cardiologist consultation is recommended when considering amiodarone treatment outside of the cardiac arrest setting.
Warning	May cause hypotension, bradycardia, heart block, prolonged QT interval, and torsades de pointes VT. Should not be used in combination with procainamide or other drugs that cause QT prolongation without expert consultation. Contraindicated in severe sinus node dysfunction, marked sinus bradycardia, and second- and third-degree AV block.
	Do not confuse name with amrinone; potential fatal complications if drugs or dosages are interchanged.
Atropine
Indication	Symptomatic vagally mediated bradycardia or AV block
	Symptomatic bradycardia unresponsive to oxygenation, ventilation, and epinephrine
Dosage	IV/IO: 0.02 mg/kg.
	Minimum single dose: 0.1 mg.
	Maximum single dose: 0.5 mg for a child, 1.0 mg for an adolescent.
	May repeat dose every 5 min to maximum total dose of 1 mg for a child and 2 mg for an adolescent or adult.
	IM: 0.02–0.04 mg/kg.
	ET: Neonates: 0.01–0.03 mg/kg.
	Children and adolescents: 0.03–0.06 mg/kg.
	Follow with or dilute in saline flush (1–5 mL) based on patient size.
Note	Oxygenation and ventilation are essential first maneuvers in the treatment of symptomatic bradycardia. Epinephrine is the drug of choice if oxygen and adequate ventilation are not effective in the treatment of hypoxia-induced bradycardia.
Indication	Anticholinesterase poisoning
Dosage	IV: for children, 0.05 mg/kg (up to initial adult dose: 2–5 mg).
	Repeat/adjust dose as needed for clinical effect. If response to initial dose is inadequate, may double the dose and repeat every 10–20 min as needed to dry pulmonary secretions and achieve anticholinergic effect (atropinization). Anticholinesterase or nerve gas poisonings may require large doses of atropine and the addition of pralidoxime.
Indication	Prevention of bradycardia associated with RSI
Dosage	IV/IO: 0.01–0.02 mg/kg (minimum dose: 0.1 mg; maximum dose: 1 mg) before administration of sedative/anesthetic and paralytic agents.
Warning	Atropine sulfate comes in different concentrations; calculate dosage accordingly.
Bicarbonate, sodium
Indication	Metabolic acidosis
	Hyperkalemia
	Sodium channel blocker (eg, tricyclic antidepressant) overdose
Dosage	IV/IO: 1–2 mEq/kg given slowly; do not give by ET route.
Notes	Only the 0.5 mEq/mL concentration should be used for newborn infants; dilution of available stock solutions may be necessary. Do not mix sodium bicarbonate with vasoactive amines or calcium.
	Routine initial use of sodium bicarbonate to treat cardiac arrest is not recommended. However, sodium bicarbonate may be used in patients with documented metabolic acidosis after effective ventilation has been established (effective ventilation is needed to allow elimination of excess CO₂ produced by bicarbonate).
	For sodium channel blocker overdose, titrate bicarbonate to maintain a serum pH of 7.45–7.55, followed by infusion of 150 mEq NaHCO₃/L solution to maintain alkalosis.
Calcium chloride
Indications	Hypocalcemia
	Hyperkalemia
	Hypermagnesemia
	Calcium channel blocker toxicity
Dosage	IV/IO: 20 mg/kg (0.2 mL/kg for 10% CaCl₂). Give by slow push for cardiac arrest; infuse over 30–60 min for other indications. Monitor heart rate; repeat dose as necessary for desired clinical effect.
Notes	Calcium chloride administration results in a more rapid increase in ionized calcium concentration than calcium gluconate and is preferred for the critically ill child. Calcium gluconate (dose: 60 mg/kg) may be substituted if calcium chloride is not available.
	Recommended for cardiac resuscitation only in cases of documented hyperkalemia, hypocalcemia, hypermagnesemia, or calcium channel blocker toxicity.
Warning	Stop injection if symptomatic bradycardia occurs. Administration through a central venous catheter is preferred; extravasation through a peripheral IV line may cause severe skin and soft tissue injury.
Charcoal, activated
Indication	Acute ingestion of selected toxic substances
Dosage	1–2 g/kg PO or nasogastrically; adolescent/adult dose: 50–100 g.
Note	Consultation with poison center/clinical toxicologist is strongly encouraged before use (national Poison Control Center telephone number: 800-222-1222). Iron, lithium, alcohols, ethylene glycol, alkalis, fluoride, mineral acids, and potassium are not bound by activated charcoal.
Warnings	If airway protective reflexes are impaired, the risk of administering activated charcoal may outweigh the benefits.
	Commercially available preparations of activated charcoal often contain sorbitol as a cathartic. Fatal hypernatremic dehydration has been reported after repeated doses of charcoal with sorbitol. Non–sorbitol-containing products should be used for children <1 y old and if repeated doses of charcoal are necessary.
Dexamethasone
Indication	Emergency treatment of elevated ICP caused by brain tumor
Dosage	IV/IO: 1–2 mg/kg.
Indication	Laryngotracheobronchitis (croup)
	Asthma exacerbation
Dosage	IV, IM, or PO: 0.6 mg/kg (maximum: 16 mg).
Note	Further dosing and route of administration determined by clinical course.
Diazepam
Indication	Status epilepticus
Dosage	IV: 0.1–0.3 mg/kg every 5–10 min (maximum: 10 mg per dose). Administer over ∼2 min to avoid pain at IV site.
	Rectal: 0.5 mg/kg up to 20 mg (this route may be useful when IV access is unavailable, but absorption may be erratic).
Note	IM route is not recommended because of tissue necrosis (other benzodiazepines, such as lorazepam and midazolam, may be given IM). Diazepam should be followed immediately by a long-acting anticonvulsant, such as phenytoin/fosphenytoin, because it is rapidly redistributed and seizures often recur within 15–20 min. Lorazepam may be preferred, because it has a prolonged duration of anticonvulsant activity.
Warning	There is an increased incidence of apnea when diazepam is given rapidly IV or when it is used in combination with other sedative agents. Monitor oxygen saturation and respiratory effort. Be prepared to support ventilation. Flumazenil may be administered to reverse life-threatening respiratory depression caused by diazepam or other benzodiazepines; however, it also counteracts the anticonvulsant effects and may precipitate seizures.
Diphenhydramine
Indications	Acute hypersensitivity reactions
	Dystonic reactions
Dosage	IV/IM: 1–2 mg/kg (maximum initial dosage: 50 mg).
Note	May cause sedation and respiratory suppression, especially if using other sedative agents. May cause hypotension. Rapid IV administration may precipitate seizures. All doses may cause paradoxical excitement or agitation.
Dobutamine
Indication	Cardiogenic shock, congestive heart failure
Dosage	IV infusion: 2–20 μg/kg per min, titrated to desired clinical effect.
Warning	May cause tachyarrhythmias/ectopic beats, hypotension, and hypertension. Extravascular administration can result in severe skin injury. Phentolamine (dose: 0.1–0.2 mg/kg up to 10 mg diluted in 10 mL of 0.9% sodium chloride) injected intradermally at extravasation site may be helpful for counteracting dermal vasoconstriction.
Dopamine
Indication	Cardiogenic/distributive shock
Dosage	IV infusion: 2–20 μg/kg per min, titrated to desired clinical effect.
Note	Effects are dose dependent; low-dose (1–5 μg/kg per min) infusions usually stimulate dopaminergic and β-adrenergic receptors; α-adrenergic effects predominate at higher doses.
Warning	May cause arrhythmias and hypertension. Infusion rates of >20 μg/kg per min may cause peripheral, renal, and splanchnic vasoconstriction and ischemia. Extravascular administration can result in severe skin injury. Phentolamine (dose: 0.1–0.2 mg/kg up to 10 mg diluted in 10 mL of 0.9% sodium chloride) injected intradermally at extravasation site may be helpful for counteracting dermal vasoconstriction.
Epinephrine
Dosage/formulation	Epinephrine is available in 2 concentrations: 1:1000 (1 mg/mL) and 1:10 000 (0.1 mg/mL). Use caution to ensure selection of the appropriate concentration for the route of administration and patient age/condition. To convert mg/kg dosage to mL/kg: 0.01 mg/kg = 0.1 mL/kg of 1:10 000 solution and 0.1 mg/kg = 0.1 mL/kg of 1:1000 solution.
Indication	Cardiopulmonary resuscitation
Dosage
IV/IO	Newborn infants: 0.01–0.03 mg/kg of 1:10 000 solution.
	Older infants/children: 0.01 mg/kg of 1:10 000 solution (maximum: 1 mg), repeated every 3–5 min.
ET	Newborn infants: 0.03–0.10 mg/kg of 1:10 000 solution.
	Older infants/children: 0.1 mg/kg of 1:1000 solution (maximum: 10 mg).
	Follow ET administration with saline flush or dilute in isotonic saline (1–5 mL) based on patient size.
Note	IV high-dose epinephrine (0.1 mg/kg) is no longer recommended for routine use in resuscitation. It may be considered in exceptional circumstances such as β-blocker poisoning.
Indication	Anaphylaxis
Dosage	IM/SC: 0.01 mg/kg of 1:1000 solution (maximum: 0.3–0.5 mg), repeated every 5–20 min. The IM route is preferred for anaphylaxis. Severe reactions (eg, latex allergy) may require IV epinephrine (see above); a continuous infusion of epinephrine may be necessary.
Indication	Continued shock after volume resuscitation
Dosage	IV infusion: 0.1–1.0 μg/kg per min. Start at lowest dose and titrate to desired clinical effect. Doses as high as 5 μg/kg per min are sometimes necessary.
Warning	IV infiltration can result in severe skin injury. Phentolamine (dose: 0.1–0.2 mg/kg up to 10 mg diluted in 10 mL of 0.9% sodium chloride) injected intradermally at extravasation site may be helpful for counteracting dermal vasoconstriction.
Indication	Severe asthma exacerbation
Dosage	SC: 0.01 mg/kg of 1:1000 solution (maximum: 0.3–0.5 mg); may repeat every 20 min up to 3 doses. Begin simultaneous treatment with inhaled β-agonist (albuterol) and corticosteroids.
Indication	Laryngotracheobronchitis (croup)
Dosage	0.5 mL/kg of 1:1000 solution (maximum: 5 mL = 5 mg) administered by nebulizer.
Epinephrine, racemic
Indication	Laryngotracheobronchitis (croup)
	Acute airway edema
Dosage	2.25% inhalation solution: 0.05 mL/kg (maximum: 0.5 mL) in 2 mL of normal saline administered by nebulizer.
Note	Many institutions use a standard 0.5-mL dose of racemic epinephrine for all patients. If racemic epinephrine is not available, single-isomer l-epinephrine (1:1000) can be substituted in a dosage of 0.5 mL/kg up to 5 mL.
Etomidate
Indication	Sedation for RSI
Dosage	IV/IO: 0.2–0.4 mg/kg (maximum: 20 mg).
Etomidate
Indication	Sedation for RSI
Dosage	IV/IO: 0.2–0.4 mg/kg (maximum: 20 mg).
Notes	Will lower ICP and does not usually lower blood pressure. Desirable agent for patients with head injury, multisystem trauma, or hypotension. Rapid onset: duration ∼ 10–15 min. This agent does not have analgesic properties.
	May cause brief myoclonic activity (hiccups, cough, twitching) and may exacerbate focal seizure disorders. Causes transient adrenal suppression that is not clinically significant.
Fentanyl
Indications	Pain
	Adjunct to intubation
Dosage	IV: 1–2 μg/kg. Repeat dose as necessary to desired clinical effect.
Notes	Rapid administration of fentanyl has been associated with both glottic and chest wall rigidity, even with dosages as low as 1 μg/kg. Therefore, fentanyl should be titrated slowly over several minutes when used for treatment of pain. More rapid administration is allowable before intubation, particularly if a muscle relaxant is also being administered.
	Higher doses (1–5 μg/kg) are often recommended for intubation.
Warning	There is an increased incidence of apnea when combined with other sedative agents, particularly benzodiazepines. Be prepared to administer naloxone or nalmefene and provide respiratory support. May cause chest wall and glottic rigidity, which may be reversed with naloxone/nalmefene or a muscle relaxant. Be prepared for the loss of the desired clinical effect (analgesia) if a reversal agent is given.
Flumazenil
Indications	Benzodiazepine overdose
	Required or desired reversal of therapeutic benzodiazepine effect
Dosage	IV: 0.01–0.02 mg/kg (maximum: 0.2 mg); repeat at 1-min intervals to a maximum cumulative dose of 0.05 mg/kg or 1 mg, whichever is lower. When IV access is unavailable, may be given IM.
Note	Most patients with oversedation attributable to benzodiazepines may be managed with supportive care alone. The duration of action of flumazenil is shorter than for most benzodiazepines; repeat dosage may be necessary. Patients should be observed continuously for at least 2 h after the last dose of flumazenil.
Warning	May precipitate acute withdrawal in benzodiazepine-dependent patients. Use with extreme caution in children with underlying seizure disorders who are being treated with benzodiazepines; flumazenil reverses the anticonvulsant effects and may precipitate seizures. Contraindicated in tricyclic antidepressant overdose; may induce seizures or arrhythmias.
Fosphenytoin
Indication	Status epilepticus
Dosage	Given in phenytoin equivalents (PE).
	IV: 15–20 PE/kg, infused at a rate of 1–3 PE/kg per min (maximum rate: 150 PE per min).
	IM: 15–20 PE/kg.
Notes	When given IV, itching is common and controllable by reducing the flow rate.
	Lower risk of hypotension or cardiac effects than phenytoin.
Warning	Rate of infusion should not exceed 3 PE/kg per min. Monitor heart rate via ECG, and reduce the rate of infusion if heart rate decreases by 10 beats per min.
Furosemide
Indications	Fluid overload
	Congestive heart failure/pulmonary edema
Dosage	IV/IM: 1–2 mg/kg (usual maximum dose: 20 mg for patients not chronically on loop diuretics).
Note	May cause significant hypokalemia.
Glucagon
Indication	Hypoglycemia caused by insulin excess (as adjunct to glucose).
Dosage	IV/IM/SC: 0.03 mg/kg up to maximum of 1 mg; repeat every 15 min up to a total of 3 doses if needed for clinical effect.
Indication	β-adrenergic blocker or calcium channel blocker overdose.
Dosage	IV: 0.03–0.15 mg/kg, followed by an infusion of 0.07 mg/kg per h (maximum: 5 mg/h).
Adolescent dosage	5–10 mg over several min, followed by infusion of 1–5 mg/h. Reconstitute doses of >2 mg in sterile water rather than the diluent supplied by the manufacturer.
Note	May cause nausea/vomiting because of delayed gastric emptying.
Glucose
Indications	Hypoglycemia
	Hyperkalemia
Initial Dose
Children	IV/IO: 0.5–1.0 g/kg.
Neonates	IV: 200 mg/kg as D10W only.
Maintenance dose	Constant infusion of D10W-containing IV fluids with appropriate maintenance electrolytes at a rate of 100 mL/kg per 24 h (7 mg/kg per min). Older children may require a substantially lower dose. The rate should be titrated to achieve normoglycemia, because hyperglycemia has its own adverse central nervous system effects.
Notes	For D10W: 200 mg/kg = 2 mL/kg; 0.5–1.0 g/kg = 5–10 mL/kg.
	For D25W: 0.5–1.0 g/kg = 2–4 mL/kg.
	For D50W: 0.5–1.0 g/kg = 1–2 mL/kg.
	D50W is irritating to veins; dilution to 25% dextrose is desirable.
	Glucose, sodium, and potassium levels should be monitored carefully. Depending on etiology, hypoglycemia may recur.
Haloperidol
Indication	Psychosis with agitation
Dosage	IM/IV: 0.05–0.15 mg/kg; may repeat hourly as necessary. Maximum single dose: 5 mg.
Notes	Hypotension and dystonic reactions may occur.
	Repeated doses can prolong QT interval and precipitate torsades de pointes.
Hydrocortisone
Indication	Adrenal insufficiency
Dosage	IV/IO: 2–3 mg/kg (maximum: 100 mg) over 3–5 min, followed by 1–5 mg/kg every 6 h for infants or 12.5 mg/m² every 6 h for older children.
Note	Do not underdose. Strongly consider concomitant fluid bolus of 20 mL/kg of D5NS or D10NS during the first hour of treatment.
Insulin, regular
Indication	DKA
Dosage	IV infusion: 0.05–0.10 unit/kg per h.
	Neonatal IV: 0.05 unit/kg per h.
	SC: 0.25–0.50 unit/kg per dose.
Note	IV bolus insulin is not generally recommended for children with DKA. Monitor blood glucose and potassium concentrations hourly or more closely as needed, with the goal of gradually reducing the blood glucose level by 50–100 mg/dL per h. Appropriate fluid and electrolyte therapy is also essential when treating DKA.
Indication	Hyperkalemia (although glucose alone is effective).
Dosage	IV: 0.1 unit/kg with 400 mg/kg glucose. Ratio is 1 unit of insulin for every 4 g of glucose.
Ipratropium
Indication	Adjunct to β-agonists for status asthmaticus/bronchospasm
Preparation	Nebulized solution (0.25 mg/mL).
Dosage	Children <12 y old: 0.25 mg nebulized every 20 min for up to 3 doses.
	Children ≥12 y old: 0.5 mg nebulized every 20 min for up to 3 doses.
Notes	May be mixed with albuterol for nebulization.
	Should not be used as first-line therapy.
Kayexalate (Sanofi-Aventis, Bridgewater, NJ)—see sodium polystyrene sulfonate
Ketamine
Indications	Sedation/analgesia
	Adjunct to intubation
	Infundibular spasm (hypercyanotic spell with tetralogy of Fallot)
Dosage	IV: 1–2 mg/kg, titrate repeat doses to desired effect.
	IM: 4–5 mg/kg (onset of action within ∼ 5 min); may repeat half the initial dose if patient is not fully dissociated.
Notes	Doses listed above are recommended to achieve dissociative sedation/anesthesia. Lower doses may be used to provide analgesia without full dissociation.
	Laryngospasm may occur, most often associated with rapid infusion or concomitant upper respiratory infection. It is usually reversible with oxygen administration, repositioning of the airway, and brief positive-pressure ventilation. Rarely, treatment with a muscle relaxant may be required.
	Atropine or glycopyrrolate may be used to prevent increased salivation.
Warning	Be prepared to provide respiratory support. Monitor oxygen saturation. Avoid use in patients with increased ICP or increased intraocular pressure.
Levalbuterol—see albuterol
Lidocaine
Indication	Ventricular arrhythmias, wide complex tachycardia
Dosage	IV/IO: 1 mg/kg (maximum: 100 mg), repeat every 5–10 min to desired effect or until maximum dose of 3 mg/kg is given.
	IV infusion: 20–50 μg/kg per min.
	ET: 2–3 mg/kg, followed by or diluted in isotonic saline (1–5 mL) based on patient size.
Note	Recent data suggest that lidocaine is less effective than amiodarone but may be used if amiodarone is not available.
Warning	High concentrations may cause myocardial depression, hypotension, and seizures. Contraindicated in complete heart block and wide complex tachycardia attributable to accessory conduction pathways.
Indication	ICP protection before ET intubation or airway manipulation.
Dosage	1–2 mg/kg IV as a single dose 30 s to 5 min before airway instrumentation.
Note	Considered optional adjunct for RSI in patients with head injury/increased ICP. When a neuroprotective agent that reduces ICP (eg, etomidate, thiopental) is used, lidocaine is less likely to provide additional benefit.
Lorazepam
Indication	Status epilepticus
Dosage	IV/IM: 0.05–0.10 mg/kg (maximum: 4 mg per dose).
	May repeat dose every 10–15 min if needed for continued seizures.
Warning	There is an increased incidence of apnea when combined with other sedative agents. Monitor oxygen saturation and be prepared to provide respiratory support. Flumazenil may be administered to reverse life-threatening respiratory depression caused by lorazepam; however, it will also counteract the anticonvulsant effects and may precipitate recurrence of seizures.
Magnesium sulfate
Indications	Hypomagnesemia
	Torsades de pointes VT
	Refractory status asthmaticus
Dosage	IV/IO: 25–50 mg/kg (maximum: 2 g).
	Given by bolus for pulseless torsades, over 10–20 min for hypomagnesemia/torsades with pulses, and over 15–30 min for status asthmaticus.
Warning	Rapid infusion may cause hypotension and bradycardia. Have calcium chloride available if needed to reverse magnesium toxicity.
Mannitol
Indication	Increased ICP
Dosage	IV: .25–1 g/kg given over 20–30 min.
Note	Larger doses (≥0.5 g/kg given over 15 min) may be appropriate in an acute intracranial hypertensive crisis. In conjunction with mannitol, other measures to control ICP such as hyperventilation, sedation/analgesia, head-of-bed elevation, cerebrospinal fluid drainage, barbiturates, and muscle relaxation (using a neuromuscular blocking agent) should be considered. A urine-collecting catheter should be placed when using mannitol. Monitor for hyperosmolality.
Note	Administer through a filter; do not use solutions that contain crystals.
Methylprednisolone
Indications	Asthma/allergic reaction
	Laryngotracheobronchitis (croup)
Dosage	IV/IM: 1–2 mg/kg initial dose (must use acetate salt for IM route).
Indication	Spinal cord injury
Dosage	IV: 30 mg/kg over 15 min, followed in 45 min by a continuous infusion of 5.4 mg/kg per h for 23 h.
Note	Administration within 8 h of injury is optimal.
Midazolam
Indication	Sedation/anxiolysis
Dosage	IV: 0.05–0.10 mg/kg given over 2–3 min (maximum single dose: 5 mg).
Note	Peak effect occurs at 3–5 min. Dose/observe and redose/observe every 3–5 min to avoid oversedation. Paradoxical agitation may occur, especially in younger children.
Dosage	PO: 0.25–0.50 mg/kg (maximum: 20 mg). Children <6 y old may require up to 1 mg/kg.
Indication	Adjunct for ET intubation
Dosage	IV: 0.2 mg/kg.
Note	Lower doses of midazolam are ineffective for RSI. After preoxygenation, allow sufficient time (2–3 min) for midazolam to take effect before administration of muscle relaxant.
Indication	Seizures
Dosage	IM: 0.2 mg/kg (maximum: 6 mg per dose); may repeat every 10–15 min.
Note	Other benzodiazepines (eg, lorazepam) are typically used for initial IV treatment of status epilepticus.
Indication	Refractory status epilepticus, not controlled by standard therapies.
Dosage	IV: Loading dose 0.15–0.20 mg/kg, followed by continuous infusion of 1 μg/kg per min, increasing by increments of 1 μg/kg per min (maximum: 5 μg/kg per min) every 15 min until seizures stop.
Warning	There is an increased incidence of apnea when combined with other sedative agents. Be prepared to provide respiratory support regardless of route of administration. Monitor oxygen saturation. Flumazenil may be administered to reverse life-threatening respiratory depression caused by benzodiazepines such as midazolam; however, it will also reverse the anticonvulsant effects and may precipitate seizures.
Milrinone
Indication	Myocardial dysfunction and increased SVR/PVR (eg, after cardiac surgery, normotensive septic shock).
Dosage	IV/IO: loading dose of 50–75 μg/kg over 10–60 min.
	Infusion: 0.50–0.75 μg/kg per min.
Warning	May cause hypotension, ventricular arrhythmias, and angina. Monitor blood pressure and ECG continuously. Intravascular volume must be maintained. Longer infusion times reduce the risk of hypotension.
Morphine
Indications	Pain
	Infundibular spasm (hypercyanotic spell with tetralogy of Fallot)
Dosage	IV (slowly)/IM: 0.1 mg/kg.
Notes	Repeat dose as necessary for clinical effect. Burn pain often requires larger or more frequent doses.
	Higher doses may be necessary if patient is tolerant. Histamine release with flushing, itching, and hives is common. Histamine release may also cause hypotension, particularly in unstable cardiac/trauma patients; fentanyl may be preferred in these situations.
Warning	There is an increased incidence of apnea when combined with other sedative agents, particularly benzodiazepines. Be prepared to administer naloxone/nalmefene. Monitor the patient's vital signs and oxygen saturation. Be prepared to provide respiratory support.
Nalmefene
Indication	Apnea/respiratory depression caused by opioid overdose
Dosage	IV/IM: 0.25–0.50 μg/kg every 2 min.
Notes	Duration of action is 4–8 h (vs <1 h for naloxone).
	For reversal of respiratory depression in sedation/analgesia or patients with pain, lower doses are indicated to avoid complete reversal of analgesia.
	Do not administer nalmefene to a newborn infant whose mother is suspected of long-term opioid use because of the risk of acute withdrawal.
Warning	May induce acute withdrawal in opioid-dependent patients. Patients should be observed continuously for recurrence of respiratory depression and other narcotic effects for at least 4 h after the last dose of nalmefene. Not recommended for empiric use in coma of unknown etiology.
Naloxone
Indication	Apnea/respiratory depression caused by opioid overdose
Dosage
Newborn infants	IV/IM: 0.1 mg/kg (ET route not recommended for newborn infants).
Older infants/children	IV/IO/IM/SC: <5 y old or <20 kg: 0.1 mg/kg; ≥5 y old or ≥20 kg: 2 mg.
Notes	Use lower doses (1–15 μg/kg) to reverse respiratory depression associated with therapeutic opioid use.
	Doses may be repeated as needed to maintain opiate reversal.
	Do not administer naloxone to a newborn infant whose mother is suspected of long-term opioid use because of the risk of seizures/acute withdrawal.
Warning	May induce acute withdrawal in opioid-dependent patients. Patients should be observed continuously for recurrence of respiratory depression and other narcotic effects for at least 2 h after the last dose of naloxone.
Nitroprusside
Indications	Hypertensive crisis
	Cardiogenic shock (associated with high SVR)
Dosage	IV: starting dose 0.3–0.5 μg/kg per min (maximum dose: 10 μg/kg per min). Start at the lowest dosage and titrate for the desired clinical effect.
Note	Bottle, burette, or syringe pump should be covered with protective foil to avoid breakdown by light. IV tubing does not need protective foil.
Warning	Administration may result in profound hypotension. Blood pressure should be monitored continuously with an arterial line. Extreme caution should be used to avoid accidental flushing/bolus injection of the IV line. May cause cyanide/thiocyanate toxicity and metabolic acidosis, especially in patients with hepatic or renal insufficiency.
Norepinephrine
Indication	Hypotensive (usually distributive) shock, with low SVR and unresponsive to fluid resuscitation (eg, hypotensive septic shock, neurogenic shock).
Dosage	IV/IO: 0.1–2.0 μg/kg per min, titrated to desired effect.
Warning	May cause tachycardia, bradycardia, arrhythmias, and hypertension. Extravascular administration can result in severe skin injury. Phentolamine (dose: 0.1–0.2 mg/kg up to 10 mg diluted in 10 mL of 0.9% sodium chloride) injected intradermally at extravasation site may be helpful for counteracting dermal vasoconstriction.
Phenobarbital
Indication	Status epilepticus
Dosage	IV: 20 mg/kg (maximum dose: 1000 mg), infused over 10 min. Repeat dose once if necessary after 15 min (maximum total dose: 40 mg/kg).
Warning	There is an increased incidence of apnea when combined with other sedative agents. Be prepared to provide respiratory support. Monitor oxygen saturation.
Phenytoin
Indication	Status epilepticus
Dosage	Neonates IV: 10 mg/kg.
	Children IV: 20 mg/kg.
Notes	Maximum initial dose: 1000 mg. Recommended infusion time is 10–20 min; drug-delivery rate not to exceed 1 mg/kg per min.
	Neonates have an increased risk of toxicity because of decreased protein binding; phenobarbital is preferred.
	Phenytoin should be diluted in normal saline to avoid precipitation. Incompatible with glucose-containing solutions.
Warning	May cause hypotension and arrhythmias, especially with rapid infusion. Heart rate should be monitored, and the rate of infusion should be reduced if the heart rate decreases by 10 beats per min. If available, fosphenytoin is preferred, because it has a lower risk of adverse cardiac effects.
Prednisone/prednisolone
Indication	Asthma, acute exacerbation
Dosage	Initial dose: 1–2 mg/kg PO (maximum: 60 mg); subsequent dose: 1–2 mg/kg per d divided in 1–2 doses per d for 3–10 d (maximum: 60 mg per d).
Notes	No advantage of IV or IM preparations over the PO route if gastrointestinal absorption is not impaired.
	No need to taper steroid dose if used for <10 d.
Procainamide
Indications	Wide complex tachycardia with a pulse, atrial flutter/fibrillation, supraventricular tachycardia resistant to other drugs
Dosage	IV/IO loading dose: 15 mg/kg over 30–60 min.
	Adult dose: 20 mg/min IV infusion up to total maximum dose of 17 mg/kg (maximum loading dose: 1.0–1.5 g).
Warning	May cause hypotension, negative inotropic effect, prolonged QT interval, torsades de pointes, heart block, and cardiac arrest. If ≥50% QRS widening or hypotension occurs during administration of the drug, the remainder of the dose should be held. Cardiologist consultation is strongly recommended when considering the use of this medication. Should not be used with amiodarone or other drugs that prolong QT interval without expert consultation.
Propranolol
Indication	Infundibular spasm (hypercyanotic spell with tetralogy of Fallot)
Dosage	IV: 0.15–0.25 mg/kg per dose infused over 10 min in D5W.
	Maximum initial dose: 1 mg. May repeat dose once.
Note	Oxygen should be administered first. Morphine is considered the first-line drug for the treatment of infundibular spasm. Use with caution in congestive heart failure.
Prostaglandin E₁ (alprostadil)
Indication	Suspected or proven ductal-dependent cardiac malformation in the neonatal period
Dosage	IV/IO: 0.05–0.10 μg/kg per min infusion in D5W (maximum dose: 0.2 μg/kg per min).
Warning	Apnea, hyperthermia, and seizures may occur; however, none are reasons to stop infusion. Be prepared to provide respiratory support.
Rocuronium
Indications	Paralysis to facilitate mechanical ventilation
	Emergency intubation
Dosage	IV: 1 mg/kg.
Notes	This drug does not provide sedation, analgesia, or amnesia.
	Satisfactory conditions for ET intubation (adequate relaxation) will generally occur in 60–90 s. Duration of action is ∼30–45 min and is dose dependent.
Warning	Ventilatory support is necessary. Personnel with skills in airway management must be present and prepared to respond when this agent is administered. Age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation should be immediately available.
Sodium polystyrene sulfonate (Kayexalate)
Indication	Hyperkalemia
Dosage	PO: 1 g/kg up to 15 g (60 mL) every 6 h as needed.
	Rectal: 1 g/kg up to 50 g every 6 h as needed.
Warning	Avoid using the commercially available liquid preparation in neonates because of the hyperosmolar preservative (sorbitol) content. Hospital pharmacies can prepare sorbitol-free preparations. Extremely preterm neonates may develop intestinal hemorrhage (hematochezia) from rectal Kayexalate.
Succinylcholine
Indications	Emergency intubation
	Laryngospasm
Dosage	IV: 1–2 mg/kg (2 mg/kg for infants <6 mo of age).
	IM: 4 mg/kg IM (5 mg/kg for infants <6 mo of age).
Notes	This drug does not provide sedation, analgesia, or amnesia.
	Atropine 0.02 mg/kg (minimum dose: 0.1 mg; maximum dose: 1 mg) is typically administered before succinylcholine to prevent bradycardia or asystole. If being used for patients with increased ICP, a defasciculation dose of a nondepolarizing agent (eg, 0.01 mg/kg of vecuronium) may be considered.
	Satisfactory conditions (adequate relaxation) for ET intubation generally occur 30–45 s after IV administration and 3–5 min after IM administration. Duration of action is ∼5–10 min.
Warning	Causes increased serum potassium levels, which may be life-threatening in patients with a previous history of malignant hyperthermia, severe burns/crush injury, spinal cord injury, neuromuscular disease, or myopathy. When these contraindications exist, use a nondepolarizing muscle relaxant such as rocuronium. If cardiac arrest occurs immediately after administration of succinylcholine, suspect hyperkalemia (particularly in boys <9 y old).
Warning	Ventilatory support is necessary. Personnel with skills in airway management must be present and prepared to respond when this agent is administered. Age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation should be immediately available.
Thiopental
Indication	Sedation/anesthesia for RSI
Dosage	IV: 2–6 mg/kg.
Note	May need to use lower dose if other sedatives/narcotics have been administered. Flush with saline before administration of rocuronium or vecuronium to avoid precipitation and obstruction of IV tubing.
Warnings	IM administration leads to tissue necrosis.
	Be prepared to provide respiratory support. Monitor oxygen saturation. Causes vasodilation and decreased cardiac output; higher doses are associated with hypotension and apnea. If patient has cardiovascular dysfunction or volume depletion, consider etomidate as alternative.
Vecuronium
Indications	Paralysis to facilitate mechanical ventilation
	Emergency intubation
Dosage	IV: 0.1 mg/kg for routine paralysis; 0.2 mg/kg for intubation.
Notes	This drug does not provide sedation, analgesia, or amnesia.
	Satisfactory conditions (adequate relaxation) for ET intubation generally do not occur until 2 min after administration. Duration of action is ∼45–90 min (dose dependent). Rocuronium or succinylcholine is preferred for facilitating rapid intubation in emergency situations.
Warning	Ventilatory support is necessary. Personnel with skills in airway management must be present and prepared to respond when this agent is administered. Age-appropriate equipment for suctioning, oxygenation, intubation, and ventilation should be immediately available.

AV indicates atrioventricular; VT, ventricular tachycardia; DnW, n% dextrose in water; IM, intramuscular; PO, per os (oral); DKA, diabetic ketoacidosis; ICP, intracranial pressure; SC, subcutaneous; PE, phenytoin equivalents; ECG, electrocardiogram; DnNS, n% dextrose in normal saline; SVR, systemic vascular resistance; PVR, pulmonary vascular resistance.

TABLE 2

Potentially Useful Rescue, Reversal, and/or Antidotal Agents

Agent/Condition	Rescue, Reversal, and/or Antidote
Chemical intoxications
Alcohol, toxic (eg, methanol)	Ethanol, thiamine, fomepizole (4 methyl-1H-pyrazole)
Iron	Deferoxamine
Carbon monoxide	Oxygen
Cyanide	Hydroxocobalamin (Cyanokit; Dey, LP, Napa, CA) is preferred antidote; cyanide kit (amyl nitrate, sodium nitrate, sodium thiosulfate) may be used if hydroxocobalamin unavailable
Lead	Dimercaprol (British anti-Lewisite [BAL]); edetate calcium disodium (Ca- EDTA); DMSA (succimer [Chemet])
Drug intoxications
Acetaminophen	N-acetylcysteine
Benzodiazepines	Flumazenil
β-adrenergic blockers	Glucagon
Digoxin	Digoxin immune Fab (Digibind; GlaxoSmithKline, Research Triangle Park, NC)
Heparin	Protamine sulfate
Isoniazid	Pyridoxine
Opiates	Naloxone, nalmefene
Envenomations
Snake bites	Snake-specific antivenoms (eg, CroFab [Protherics, Yorkshire, United Kingdom] for Crotalidae [rattlesnakes]; coral snake antivenom, etc)
Black widow spider bites	Latrodectus antivenom
Metabolic crises
Methemoglobinemia	Methylene blue
Hyperkalemia	Bicarbonate, glucose and insulin, calcium, sodium polystyrene resin (Kayexalate)
Miscellaneous
Nondepolarizing muscle relaxants	Neostigmine, pyridostigmine, edrophonium
Cholinergics (organophosphates, carbamates)	Atropine, pralidoxime
Radionuclides
Iodine	Potassium iodide
Plutonium	Pentetate calcium disodium (Ca-DTPA) within 24 h followed by pentetate zinc trisodium (Zn-DTPA)
Americium	Zn-DTPA or Ca-DTPA
Uranium	Sodium bicarbonate and tubular diuretics
Cesium	Prussian blue
Tritium	Water
Phosphorus	Individualize treatment; consult Poison Control Center

Agent/Condition	Rescue, Reversal, and/or Antidote
Chemical intoxications
Alcohol, toxic (eg, methanol)	Ethanol, thiamine, fomepizole (4 methyl-1H-pyrazole)
Iron	Deferoxamine
Carbon monoxide	Oxygen
Cyanide	Hydroxocobalamin (Cyanokit; Dey, LP, Napa, CA) is preferred antidote; cyanide kit (amyl nitrate, sodium nitrate, sodium thiosulfate) may be used if hydroxocobalamin unavailable
Lead	Dimercaprol (British anti-Lewisite [BAL]); edetate calcium disodium (Ca- EDTA); DMSA (succimer [Chemet])
Drug intoxications
Acetaminophen	N-acetylcysteine
Benzodiazepines	Flumazenil
β-adrenergic blockers	Glucagon
Digoxin	Digoxin immune Fab (Digibind; GlaxoSmithKline, Research Triangle Park, NC)
Heparin	Protamine sulfate
Isoniazid	Pyridoxine
Opiates	Naloxone, nalmefene
Envenomations
Snake bites	Snake-specific antivenoms (eg, CroFab [Protherics, Yorkshire, United Kingdom] for Crotalidae [rattlesnakes]; coral snake antivenom, etc)
Black widow spider bites	Latrodectus antivenom
Metabolic crises
Methemoglobinemia	Methylene blue
Hyperkalemia	Bicarbonate, glucose and insulin, calcium, sodium polystyrene resin (Kayexalate)
Miscellaneous
Nondepolarizing muscle relaxants	Neostigmine, pyridostigmine, edrophonium
Cholinergics (organophosphates, carbamates)	Atropine, pralidoxime
Radionuclides
Iodine	Potassium iodide
Plutonium	Pentetate calcium disodium (Ca-DTPA) within 24 h followed by pentetate zinc trisodium (Zn-DTPA)
Americium	Zn-DTPA or Ca-DTPA
Uranium	Sodium bicarbonate and tubular diuretics
Cesium	Prussian blue
Tritium	Water
Phosphorus	Individualize treatment; consult Poison Control Center

Consultation with a toxicologist or the Poison Control Center (national telephone number: 800-222-1222) strongly advised if considering antidote administration.

American Academy of Pediatrics, Committee on Drugs and Committee on Hospital Care. Prevention of medication errors in the pediatric inpatient setting.

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Preparing for Pediatric Emergencies: Drugs to Consider

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Preparing for Pediatric Emergencies: Drugs to Consider

INTRODUCTION

Committee on Drugs, 2005–2006

Past Committee Members

Liaisons

Staff

REFERENCES

Contents

Data & Figures

Supplements

References

Related

Citing articles via

Email alerts

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