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.

Subjects:
CME
Topics:
pediatric emergency medicine, resuscitation, phenytoin, pediatric advanced life support, rapid sequence induction and intubation, select the dosage, dosage form or route of administration, ventricular fibrillation

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.

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

Brian Bates, MD

David J. Burchfield, MD

Richard L. Gorman, MD

Richard P. Walls, MD

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

Raymond J. Koteras, MHA

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 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. 
            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. 
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.

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TABLE 2

Potentially Useful Rescue, Reversal, and/or Antidotal Agents

Agent/ConditionRescue, 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/ConditionRescue, 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.

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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.

1
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
2
American Heart Association, Subcommittee on Pediatric Resuscitation.
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Copyright © 2008 by the American Academy of Pediatrics
2008