1 Moran

D5 1 2 Normal Saline Classification Essay

 

 

Roughly Isotonic- contains multiple Electrolytes (does not contain Mg2 or PO)

                       Tx for: Hypovalemia

                                       Burns

                                       Fluid loss as bile/diarrhea

                                       Metabolic Acidosis

The drug information in this statement assists health care providers and facilities in preparing for a crisis. This document is not designed for use during an actual emergency. It is useful to precalculate and distribute volumetric doses (eg, mL/kg) using the specific drug concentrations that are available in a particular institution. Precalculated drug cards or length-based resuscitation tapes are useful in the preparation process. This document does not provide comprehensive drug information. Descriptions of drug indications and side effects have been purposely limited.

Drug dosages are generally presented as milligram per kilogram (mg/kg). An exception is made for high-potency drugs (vasoactive amines and nitroprusside). For these drugs, dosage is given in microgram per kilogram (μg/kg) in Table 1.

In general, drug doses (including “bolus” doses) should be administered over several minutes to avoid transiently excessive blood levels of the drug. Exceptions to this rule include: adenosine, epinephrine, atropine, and muscle relaxants. Infusion devices (intravenous [IV] infusion pumps) should be used for all vasoactive drugs administered as a continuous infusion, such as dopamine or nitroprusside.

Unless otherwise indicated, the IV route is preferred. In an emergency, intraosseous administration is an acceptable alternative when IV access cannot be obtained within 90 seconds or after three attempts to establish IV access. For some drugs, such as epinephrine, atropine, naloxone, and lidocaine, endotracheal administration is appropriate. A recommended method of endotracheal delivery is to administer thedrug with or dilute in 1 to 5 mL of isotonic saline through a catheter inserted to the tip of the endotracheal tube. This method may enhance absorption from the lung.

The dosages provided are recommendations based upon expert consensus. The Committee on Drugs recognizes that pediatric labeling and dosage information do not exist for many of these drugs. Dosage should be individualized, taking into account the patient's age, weight, underlying illness, concurrently administered drugs, and known hypersensitivity.

A physician who administers drugs that depress the respiratory or central nervous system must have the skills necessary to manage the potential complications. It is important to implement the guidelines for monitoring published by the American Academy of Pediatrics.4A practitioner who uses a neuromuscular blocking agent (“muscle relaxant”) must be qualified to maintain the patient's airway through bag and mask ventilation and endotracheal intubation. Once the patient has received the muscle relaxant, there is no longer any respiratory effort.

SOME CONSIDERATIONS FOR THE USE OF DRUGS FOR ENDOTRACHEAL INTUBATION

The choice of drugs for control of the airway should address two concerns: adequate sedation/analgesia for laryngoscopy and appropriate selection of a muscle relaxant, if indicated. A patient who is in full cardiac arrest does not require sedatives or muscle relaxants to safely gain control of the airway. When cardiac arrest has not occurred, endotracheal intubation of the patient who is ill or who has been injured—especially if there is associated head injury—may be facilitated by administration of a sedative (benzodiazepine), IV local anesthetic (lidocaine), opioid (fentanyl), and a neuromuscular blocking drug. The choice of drugs depends on the physiologic status of the patient. A patient who is hypovolemic would be placed at risk with the rapid IV administration of barbiturates (such as methohexital or thiopental) because of the cardiac depressant and vasodilator effects of barbiturates. Ketamine would be a better choice in this circumstance. Conversely, a patient with a closed head injury would benefit from the use of barbiturates and/or lidocaine and fentanyl because this would reduce cerebral blood flow and cerebral oxygen consumption and therefore intracranial pressure. Following head injury, ketamine therapy increases cerebral blood flow and intracranial pressure.

Combining drugs with different modes of action may be advantageous. For example, adding a benzodiazepine or narcotic to the regimen may prolong the effect and/or enable a reduction in the dose of ketamine or barbiturate required to sedate.

Airway equipment appropriate for the patient's size and age must be immediately available before a neuromuscular blocking agent is administered. This equipment includes an appropriate-sized face mask, a bag-mask-valve device for positive pressure ventilation, endotracheal tubes, oral airways, functioning laryngoscope blades, functioning handles, suction catheters, and suction apparatus to clear the airway if the patient vomits. The patient should be fully monitored with a cardiac monitor, blood pressure readings, and pulse oximetry. Nasogastric (orogastric) suction catheters are helpful in evacuating and decompressing the patient's stomach if gastric distention occurs. A stethoscope should be available to check breath sounds.

The choice of muscle relaxant depends on the circumstances. Succinylcholine remains the muscle relaxant of choice for the emergency control of the airway and is generally the muscle relaxant of choice for patients with a “full stomach.” It has the most rapid onset and shortest duration of the relaxants that are currently available and has the longest “track record” for overall safety.

Administration of succinylcholine should be preceded by atropine to prevent significant bradycardia. In children over 5 years of age, a defasciculating dose of a nondepolarizing relaxant (10% of an intubating dose) 2 to 3 minutes before succinylcholine may prevent muscle fasciculations. Cricoid pressure is applied (firm pressure on the cricoid cartilage) to prevent passive regurgitation during laryngoscopy and intubation.

If succinylcholine therapy is contraindicated (history of malignant hyperthermia, muscular dystrophy, neuromuscular disease, neurologic denervation injury or crush injury), a nondepolarizing muscle relaxant is indicated. With nondepolarizing agents, the onset of neuromuscular blockade may be somewhat delayed compared with succinylcholine. Also, the duration of paralysis is markedly prolonged compared with succinylcholine. The peak effect of pancuronium, for example, generally occurs 2 to 3 minutes after administration. The effects of the most recently approved relaxant (rocuronium) occur within 45 seconds to 1 minute. This time is dose-dependent and in higher doses (0.8 to 1.2 mg/kg) is similar to that of succinylcholine. Rocuronium may be a reasonable alternative to succinylcholine when succinylcholine is contraindicated.

Recent concerns about the elective use of succinylcholine in pediatric patients have focused on the occasional reports of hyperkalemic cardiac arrest, particularly in children with undiagnosed Duchenne muscular dystrophy. The incidence of Duchenne muscular dystrophy is only 1 in 3000 to 8000 male children. The revised labeling continues to permit the use of succinylcholine for emergency control of the airway and treatment of laryngospasm. Succinylcholine is the only neuromuscular blocking agent currently available that has been demonstrated to be effective after intramuscular (IM) administration when emergency control of the airway is required and there is no IV access. In this circumstance, the dosage must be increased to 4 to 5 mg/kg IM. Atropine is administered simultaneously. Following IM succinylcholine, onset of neuromuscular blockade takes approximately 2 to 5 minutes; the response in patients who are hypotensive or hypovolemic is unpredictable. Standard textbooks of advanced life support, eg, Pediatric Advanced Life Support orAdvanced Pediatric Life Support (PALS, APLS), should be consulted for more detail.1

Adenosine

  Indication: Supraventricular tachycardia

  Dosage:  Initial dose: 0.05 mg/kg as rapidly as possible followed by flush of the IV catheter.

Subsequent doses: If atrioventricular (AV) block occurs or if there is no response within 30 seconds, increase by 0.05 mg/kg (eg, 0.1 mg/kg followed by flush of the IV catheter; if no response, increase to 0.15 mg/kg and flush IV catheter).

Maximum single dose, 12 mg.

WARNING: Contraindicated in heart transplant patients.

  Note: Higher doses of adenosine may be needed when a patient is taking methylxanthine preparations.

 Note:  The antidote for profound bradycardia is aminophylline, 5 to 6 mg/kg over 5 minutes.Atropine is contraindicated. A defibrillator must be immediately available.

Albuterol

  Indication: Status asthmaticus, bronchospasm

  Dosage: 0.1 to 0.15 mg/kg by nebulization. Repeat as needed.

  Note:  0.02 to 0.03 mL/kg of 5 mg/mL solution with normal saline to make 3 mL total in nebulizer; maximum single dose, 2.5 mg.

  Note:  Administration can be repeated and dose adjusted until desired clinical effect or symptomatic tachycardia.

  Note:  Oxygen is the preferred gas source for nebulization. Supplemental oxygen should be considered when compressed air driven nebulizers are used or when oxygen flow rate dictated by nebulizer is inadequate. Blended oxygen may be required for premature newborns who are still at risk for retinopathy of prematurity.

Atropine Sulfate

  Indication: 1) Symptomatic bradycardia

  Dosage:  Intramuscular (IM): 0.02 to 0.04 mg/kg

Intratracheal: 0.02 to 0.04 mg/kg

IV: 0.02 mg/kg.

Minimum single dose, 0.1 mg

Maximum single dose, 0.5 mg for child, 1.0 mg for adolescent. This dose may be repeated once.

  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.

  Note:  If administered through an endotracheal tube, follow the dose with or dilute in saline flush (1 to 5 mL) based on patient size.

 Indication: 2) Anticholinesterase poisoning.

  Dosage:  IV: 0.05 mg/kg

Repeat as needed for clinical effect.

  Note: Anticholinesterase poisonings may require large doses of atropine or the addition of pralidoxime.

 Indication: 3) To prevent succinylcholine-induced bradycardia.

  Dosage: 0.02 mg/kg IV or 0.02 to 0.04 mg/kg IM just before or simultaneously with succinylcholine

Bicarbonate, Sodium

  Indication:  1) Metabolic acidosis

2) Tricyclic antidepressant overdose.

  Dosage: IV: 1 to 2 mEq/kg

WARNING:  Only 0.5 mEq/mL concentration should be used for newborns; dilution of available stock solutions may be necessary. Administer slowly because bicarbonate solution is hyperosmotic.

 Note:  Routine initial use of sodium bicarbonate in cardiac arrest is not recommended. However, sodium bicarbonate may be used in cases with documented metabolic acidosisafter effective ventilation has been established.

Calcium Chloride

  Indication:  1) Ionized hypocalcemia

2) Hyperkalemia

3) Hypermagnesemia

4) Calcium channel blocker toxicity

  Dosage:  IV: 20 mg/kg (if using 10% CaCl2, dose is 0.2 mL/kg). Inject slowly. Repeat dose as necessary for desired clinical effect.

WARNING:  Stop injection if symptomatic bradycardia occurs. Extravascular administration can result in severe skin injuries.  

Note:  Calcium is recommended for cardiac resuscitation only in cases of documented hyperkalemia, hypocalcemia, or calcium channel blocker toxicity.

Calcium Gluconate

  Indication:  1) Ionized hypocalcemia

2) Hyperkalemia

3) Hypermagnesemia

4) Calcium channel blocker toxicity

Ionizes as rapidly as calcium chloride and may be substituted using three times the dose of calcium chloride (mg/kg).

  Dosage:  IV: 60 mg/kg (if using 10% gluconate, dose is 0.6 mL/kg). Inject slowly. Repeat dose as necessary for desired clinical effect.

WARNING:  Stop injection if symptomatic bradycardia occurs. Extravascular administration can result in severe skin injuries.

  Note:  Calcium is recommended for cardiac resuscitation only in cases of documented hyperkalemia, hypocalcemia, or calcium channel blocker toxicity.

Charcoal, Activated

 Indication:  Acute ingestion of selected toxic substances

  Dosage:  1 to 2 g/kg

  Note:  Administer as a slurry or down a nasogastric tube. Note that iron, lithium, alcohols, ethylene glycol, alkalies, fluoride, mineral acids, and potassium do not bond to activated charcoal.

 WARNING:  Commercially available preparations of activated charcoal often contain a cathartic, such as sorbitol. Fatal hypernatremic dehydration has been reported after repeated doses of charcoal with sorbitol. Nonsorbitol-containing products should be used if repeated doses are necessary.

Dexamethasone

 Indication:  1) Emergency treatment of elevated intracranial pressure due to brain tumor

  Dosage:  IV: 1 to 2 mg/kg as a loading dose

Maintenance dose, 1 mg/kg/24 h

 Indication: 2) Croup

  Dosage:  IV, IM, or PO: 0.6 mg/kg dexamethasone, 1 dose/d, or 2 mg/kg/24 h of prednisone. Further dosing and route of administration determined by clinical course.

Diazepam

 Indication:  Status epilepticus

  Dosage:  IV: 0.1 mg/kg every 2 minutes. Maximum dose, 0.3 mg/kg (maximum 10 mg/dose).

  Dosage:  Rectal: 0.5 mg/kg up to 20 mg

  Note:  Do not give as IM injection.

 WARNING:  There is an increased incidence of apnea when combined with other sedative agents or when given rapidly. One must be prepared to provide respiratory support. Monitor oxygen saturation.

Diazoxide

 Indication:  Hypertensive crisis

  Dosage:  IV: 1 to 3 mg/kg rapid IV push.

  Note:  Alternative regimen: 3 to 5 mg/kg IV over 30 minutes. This is reported to result in fewer problems with hypotension or hyperglycemia.

Digoxin Immune FAB (Digibind)

 Indication:  Digoxin or digitoxin toxicity

  Dosage:  1) Administer digoxin immune FAB intravenously in an amount equimolar to the total body load of digoxin or digitoxin.

2) 38 mg digoxin immune FAB binds 0.5 mg digoxin or digitoxin

 Dosing methods:

 A: Based on amount ingested:

  1)  For digoxin tablets, oral solution, IM injection

Dose in mg =

  2)  For digitoxin tablets, digoxin capsules, IV digoxin or IV digitoxin

Dose in mg =

 B: Based on serum digoxin or digitoxin concentration (SDC)

  1)  Digoxin

Dose in mg =

  2)  Digitoxin

Dose in mg =

 C:  If neither amount ingested nor serum concentration is known, 760 mg of digoxin immune FAB should be administered.

Diphenhydramine

 Indication:  1) Acute hypersensitivity reactions

2) Dystonic reactions

  Dosage:  V or IM: 1 to 2 mg/kg.

Maximum dosage, 50 mg.

  Note:  May cause sedation, especially if other sedative agents are being used.

May cause hypotension.

Dopamine

 Indication:  Continued shock after volume resuscitation

  Dosage:  IV infusion: 2 to 20 μg/kg/min.

A widely recommended starting dosage is 10 μg/kg/min. Titrate to desired clinical effect.

  Note:  Preparation of infusion solution: 6 mg × body weight (kg) diluted to 100 mL. Infuse at 10 mL/h = 10 μg/kg/min using a constant infusion pump.

 WARNING:  Extravascular administration can result in severe skin injuries.

Dobutamine

 Indication:  Impaired cardiac contractility

  Dosage:  IV infusion: 5 to 25 μg/kg/min.

A widely recommended starting dosage is 10 μg/kg/min. Titrate for desired clinical effect.

  Note:  Preparation of infusion solution: 6 mg × body weight (kg) diluted to 100 mL. Infuse at 10 mL/h = 10 μg/kg/min using a constant infusion pump.

Epinephrine

 Indication: 1)  Cardiac arrest or profound bradycardia, asystole, ventricular fibrillation, or pulseless electrical activity

  Initial Dose:  IV: 10 μg/kg (0.01 mg/kg)

Intraosseous: 10 μg/kg (0.01 mg/kg)

Endotracheal: 100 μg/kg (0.10 mg/kg)

  Note:  10 μg/kg = 0.1 mL/kg of 1:10 000 dilution

100 μg/kg = 0.1 mL/kg of 1:1000 dilution

  Note:  If administered through an endotracheal tube, follow the dose with saline flush or dilute in isotonic saline flush (1 to 5 mL) based on patient size.

  Subsequent doses: given every 3 to 5 minutes

  IV: 100 μg/kg (0.1 mg/kg)

  Intraosseous: 100 μg/kg (0.1 mg/kg)

  Endotracheal: 100 μg/kg (0.1 mg/kg)

  Note:  For subsequent doses of epinephrine, a dosage up to 200 μg/kg (0.2 mg/kg) may be given.

 Indication:  2) Anaphylaxis

  Dosage:  Subcutaneous (SC): 10 μg/kg per dose (maximum 3 doses)

IV: 10 μg/kg per dose:

10 μg/kg = 0.01 mL/kg of 1:1000 dilution or 0.1 mL/kg of a 1:10 000 dilution

  Note:  Repeat the SC dose every 20 minutes while attempting IV access. Some anaphylactic reactions, eg, latex allergy, require large doses of epinephrine. A continuous infusion of epinephrine may be necessary.

 Indication:  3) Continued shock after volume resuscitation

  Dosage:  IV infusion: 0.1 to 3.0 μg/kg/min.

Start at lowest dose and titrate for desired clinical effect.

  Note:  Preparation of infusion solution: 0.6 mg × body weight (kg) diluted to 100 mL. Infuse at 1 mL/h = 0.1 μg/kg/min using a constant infusion pump.

  Note:  Extravasation can result in tissue necrosis injuries.

 Indication:  4) Status asthmaticus, bronchospasm

  Dosage:  SC: 10 μg/kg per dose

10 μg/kg = 0.01 mL/kg of 1:1000 dilution

Maximum single dose, 300 μg (0.3 mL of 1:1000 dilution).

  Note:  Albuterol administered by inhalation is now considered the agent of choice for treatment of acute exacerbations of asthma.

  Note:  Repeat SC dose every 20 minutes if needed for clinical effect. Total of 3 doses.

 Indication:  5) Laryngotracheobronchitis:

  Dosage:  Racemic epinephrine, 2.25% inhalation solution

0–20 kg: 0.25 mL in 2 mL with normal saline administered by nebulizer

20–40 kg: 0.50 mL in 2 mL with normal saline administered by nebulizer

>40 kg: 0.75 mL in 2 mL with normal saline administered by nebulizer

  Note:  L-Epinephrine: An equal volume of 1% L-epinephrine (1:100) is approximately equivalent in biologic activity to 2.25% racemic epinephrine; one can be substituted for the other in equal volumes for inhalation.

Alternatively, 5 mL of 1:1,000 L-epinephrine is equivalent to 0.5 mL of 1:100.

Fentanyl

 Indication:  Pain

  Dosage:  IV: 0.5 μg to 2.0 μg/kg. Repeat dose as necessary for clinical effect.

  Note:  Higher doses may be necessary if the patient is tolerant.

  Note:  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 in slowly over several minutes.

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

Flumazenil

 Indication:  Benzodiazepine intoxication

  Dosage:  IV: 5 to 10 μg/kg (up to 100 μg/kg has been used)

Maximum dose, 1 mg

  Note:  Useful only for benzodiazepine intoxication.

 WARNING:  Duration of action is shorter than most clinically important benzodiazepines. Resedation may occur. May precipitate acute withdrawal in dependent patients; use drug with caution as its use may be associated with seizures. Patients who receive flumazenil should be continuously observed for resedation for at least 2 hours after the last dose of flumazenil.

Fosphenytoin

 Indication:  Status epilepticus (same as phenytoin)

  Dosage:  ALWAYS IN PHENYTOIN EQUIVALENTS (PE)

10 to 20 mg PE/kg (same as phenytoin)

  Route of administration:  IM or IV: 1 to 3 mg PE/kg/min; maximum rate 150 mg PE/min

  Note:  Data are currently being collected on children less than 6 years of age.

Itching is a common and controllable by reducing flow rate.

 WARNING:  Rate of infusion should not exceed 3 mg PE/kg/min. Heart rate should be monitored and the rate of infusion reduced if the heart rate decreases by 10 beats/minute (same as phenytoin).

Furosemide

 Indication:  1) Fluid overload

2) Congestive heart failure

  Dosage: IV, IM: 1 mg/kg

Glucagon

 Indication:  1) Hypoglycemia due to insulin excess

  Dosage:  Adult and adolescent: 0.5 to 1.0 mg SC, IM, IV; repeat every 20 minutes

Pediatric: 0.025 mg/kg up to 1.0 mg SC, IM, IV; repeat the dose every 20 minutes if needed for clinical effect. Total of 3 doses.

  Note:  An attempt should be made to provide a simultaneous IV glucose infusion.

 Indication:  2) Beta-blocker or calcium channel blocker overdose

   Dosage:  Adolescent

IV: 2 to 3 mg followed by a 5 mg/h infusion.

   Pediatric

IV: 0.025 to 0.05 mg/kg followed by 0.07 mg/kg/h infusion.

Glucose

 Indication:  Hypoglycemia

  Initial Dose:  IV: 250 to 500 mg/kg

  Maintenance

  Dose:  Constant infusion of 10% dextrose in water at a rate of 100 mL/kg/24 h (7 mg/kg/min). Older children may require a substantially lower dose. The rate should be titrated to appropriate glucose values.

  Note:  250 to 500 mg/kg = 2.5 to 5.0 mL/kg of D10%

250 to 500 mg/kg = 1.0 to 2.0 mL/kg of D25%

250 to 500 mg/kg = 0.5 to 1.0 mL/kg of D50%

  Note:  Neonates should receive 10% to 12.5% glucose administered slowly.

  Note:  Glucose levels should be determined before and during administration. If large volumes of dextrose are administered, include electrolytes to prevent hyponatremia and hypokalemia.

Haloperidol

 Indication:  Psychosis with agitation

  Dosage:  IM, IV: 0.1 mg/kg, may repeat hourly as necessary. Maximum single dose, 5 mg.

  Note:  Hypotension and dystonic reactions may occur.

Insulin, Regular

 Indication:  1) Diabetic ketoacidosis

  Dosage:  SC: 0.25 to 0.5 unit/kg per dose

IV infusion dose: 0.05 to 0.1 unit/kg/h

Neonatal dose: 0.05 unit/kg/h

  Note:  Blood glucose levels should be closely monitored. Appropriate fluid and electrolyte therapy are also required in treating diabetic ketoacidosis.

 Indication:  2) Hyperkalemia

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

  Note:  Potassium levels in blood or serum should be monitored.

Ipecac Syrup

 Indication:  Acute ingestion of selected toxic substances

  Dosage:  Oral (PO): 6-month-old to 1-year-old = 10 mL

>1 year old = 15 mL

Adolescent/young adult = 30 mL

 WARNING:  Do not use when patient is suffering from central nervous system depression or if having seizures. Contraindicated in caustic and hydrocarbon ingestion. Patients who ingest pesticides or other chemicals that may have a hydrocarbon base may need to have emesis induced. Consult your regional poison control center.

 Note:  Administer with 120 to 180 mL of fluid; 90% effective in inducing vomiting within 25 minutes of first dose. May repeat once.

 Note:  Activated charcoal is now considered the first line therapy for most oral ingestions treated in the hospital setting.

Kayexalate (Sodium Polystyrene Sulfonate)

 Indication:  Treatment of hyperkalemia

  Dosage:  Adults and adolescents

PO: 15 g (60 mL) 1 to 4 times/day

Rectal: 30 to 50 g every 6 hours

Children

PO: 1.0 g/kg every 6 hours

Rectal: 1.0 g/kg/dose every 2 to 6 hours (for small children and infants use lower doses by using the practical exchange ratio of 1 mEq K+/g of resin).

 WARNING:  Avoid using the commercially available liquid preparation in neonates due to the hyperosmolar preservative (Sorbitol) content. Extremely premature newborns may develop intestinal hemorrhage (hematochezia) from rectal Kayexalate.

Ketamine

 Indication: 1) Sedation/analgesia

  Dosage:  IM: 1 to 2 mg/kg

IV: 0.5 to 1 mg/kg

 Indication: 2) Adjunct to intubation

  Dosage:  IV: 1 to 2 mg/kg

  Note:  Laryngospasm associated with ketamine is usually reversed with oxygen administration and positive pressure ventilation.

  Note:  Atropine or other antisialogogue should be used to prevent increased salivation.

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

Lidocaine

 Indication:  1) Ventricular arrhythmia

  Dosage:  IV: 1 mg/kg as a single dose slowly, repeat every 5 to 10 minutes to desired effect or until maximum dose of 3 mg/kg is given

IV infusion: 20 to 50 μg/kg/min

Endotracheal: 1 mg/kg

  Note:  If administered through an endotracheal tube, follow the dose with saline flush or dilute in isotonic saline flush (1 to 5 mL) based on patient size.

  Note:  Preparation of infusion solution: add 120 mg (6 mL of a 2.0% concentration) to 100 mL of 5% glucose in water. Infusion of 1.0 to 2.5 mL/kg/h will deliver 20 to 50 μg/kg/min.

  Note:  A reduced infusion rate should be used in patients with a low cardiac output.

 WARNING:  Contraindicated in complete heart block and wide complex tachycardia due to accessory conduction pathways.

 Note:  Excessive dosage may result in myocardial depression, hypotension, central excitation, and seizures.

 Indication:  2) To attenuate airway reflexes before endotracheal intubation or airway manipulation in patients with elevated intracranial pressure

  Dosage:  1 mg/kg IV as a single dose 30 seconds before airway instrumentation.

Lorazepam

 Indication:  1) Status epilepticus

2) Adjunct for intubation

  Dosage:  IM or IV: 0.05 to 0.1 mg/kg

Repeat doses every 10 to 15 minutes for clinical effect.

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

Mannitol

 Indication:  Increased intracranial pressure

  Dosage:  IV: 0.25 g/kg given over a 15-minute infusion.

  Note:  A larger dose (0.5 g/kg given over 15 minutes) may be appropriate in an acute intracranial hypertensive crisis. In conjunction with mannitol, other measures to control intracranial pressure such as hyperventilation, barbiturates, and muscle relaxation (using a neuromuscular blocking agent) should be considered.

 WARNING:  Rapid administration may cause hypotension, hyperosmolality, and elevated intracranial pressure.

Meperidine

 Indication:  Pain

  Dosage:  IV or IM: 1 to 2 mg/kg

Repeat dose is necessary for clinical effect.

  Note:  Higher doses may be necessary if patient is tolerant.

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

Methylprednisolone

 Indication:  1) Asthma/allergic reaction

  Dosage:  IV: 1 to 2 mg/kg every 6 hours

 Indication:  2) Spinal cord injury

  Dosage:  IV: 30 mg/kg over 15 minutes. In 45 minutes begin a continuous infusion of 5 to 6 mg/kg/h for 23 hours.

 Indication:  3) Croup

  Dosage:  IV: 1 to 2 mg/kg of methylprednisolone, then 0.5 mg/kg every 6 to 8 hours.

Midazolam

 Indication:  Adjunct for endotracheal intubation or for sedation/anxiolysis

  Dosage:  IV: 0.05 to 0.2 mg/kg given over several minutes.

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

Morphine Sulfate

 Indication:  Pain, infundibular spasm (“Tet Spell”)

  Dosage:  IV (slowly) or IM: 0.05 to 0.1 mg/kg.

Repeat dose as necessary for clinical effect.

  Note:  Higher doses may be necessary if patient is tolerant.

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

Naloxone

 Indication:  Respiratory depression induced by opioid

  Dosage:  IV, IM: 0.1 mg/kg from birth (including premature infants) until age 5 years or 20 kg of weight. Thereafter, the minimum dose is 2.0 mg. Doses may be repeated as needed to maintain opiate reversal. IM absorption may be erratic.

  Note:  This dosage is indicated for acute opiate intoxication. Titration to effect with lower initial doses (0.01 mg/kg or 10 μg/kg) should be considered for other clinical situations, eg, respiratory depression during pain management.

 WARNING:  May induce acute withdrawal in opioid dependency. Patients who receive naloxone should be continuously observed for renarcotization for at least 2 hours after the last dose of naloxone.

Nitroprusside

 Indication:  Hypertensive crisis

  Dosage:  IV: 0.5 to 10 μg/kg/min.

Start at the lowest dosage and titrate for the desired clinical effect. Administer through low dead space system or as close to IV catheter as possible to prevent accidental bolus injection.

  Note:  Preparation of infusion solution: 6 mg × body weight (kg) diluted to 100 mL D5W. Infuse at 1 mL/h = 1 μg/kg/min using a constant infusion pump.

  Note:  Bottle, burette, or syringe pump but not the IV tubing should be covered with protective foil to avoid breakdown by light.

 WARNING:  Administration may result in profound hypotension. Patients should be closely monitored. Blood pressure should be continuously monitored with an arterial line.

 WARNING:  Cyanide toxicity can result from large doses and/or prolonged infusions. Patients should be closely monitored for the development of metabolic acidosis. Patients with decreased renal function may be at increased risk.

Oxygen

 Indication:  1) Hypoxemia and/or respiratory distress

2) Carbon monoxide poisoning

3) Shock

  Dosage:  100% by nonrebreather mask initially or endotracheal tube; wean as tolerated.

  Note:  The administration of supplemental oxygen should be considered during EVERYpediatric emergency.

Pancuronium

 Indication:  1) Neuromuscular blockade to facilitate mechanical ventilation

2) Emergency intubation

  Dosage:  IV: 0.1 mg/kg

  Note:  This drug does not alter the level of consciousness or provide analgesia or amnesia.

  Note:  This agent can be used when succinylcholine is contraindicated. Pancuronium is a long-acting neuromuscular blocker that requires ventilatory assistance for at least 1 hour. Satisfactory conditions for endotracheal intubation will generally occur 2 to 3 minutes after administration.

 WARNING:  Ventilatory support will be necessary. Personnel with skills in advanced 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.

Phenobarbital

 Indication:  Status epilepticus

  Dosage:  IV: 20 mg/kg. Maximum dose, 1000 mg.

Repeat dose once if necessary for clinical effect after 15 minutes.

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

Phenylephrine

 Indication:  Infundibular spasm (“Tet Spell”)

  Dosage:  5 to 20 μg/kg push then followed by infusion at 0.1 to 5.0 μg/kg/min.

 WARNING:  Blood pressure must be carefully followed and dose titrated to effect.

Phenytoin

 Indication:  Status epilepticus

  Dosage:  IV: 10 to 20 mg/kg initial dose.

Maximum initial dose, 1000 mg.

Maximum rate of administration, 50 mg/min or 1 mg/kg/min, whichever is less.

  Note:  The lower dose is indicated in neonates because of increased risk of toxicity due to decreased protein binding. Should be diluted in normal saline to avoid precipitation.

 WARNING:  Rate of infusion should not exceed 0.1 mL of undiluted preparation per kg/min. Heart rate should be monitored and the rate of infusion reduced if the heart rate decreases by 10 beats/minute.

Procainamide

 Indication:  Wide complex tachycardia

  Dosage:  IV: Start at 3 to 6 mg/kg/dose over 5 minutes not to exceed 100 mg to a titrated maximum of 15 mg/kg/loading dose.

Maintenance dose, 20 to 80 μg/kg/min (0.02 to 0.08 mg/kg/min); maximum, 2 g/24 h.

 WARNING:  If 50% QRS widening or hypotension occurs during loading dose, the remainder of the loading dose is held, and the maintenance dose is delayed until these signs have resolved.

Propranolol

 Indication:  Infundibular spasm (“Tet Spell”)

  Dosage:  IV: 0.01 to 0.02 mg/kg per dose infused over 10 min in 5% dextrose in water.

Maximum initial dose, 1.0 mg

  Note:  Oxygen should be administered first. Morphine is also an effective treatment for infundibular spasms. Phenylephrine is another adjunct for reversal of infundibular spasm. Use is contraindicated in congestive heart failure. Avoid in patients with a history of bronchospasm.

Prostaglandin E1

 Indication:  Possible ductal-dependent cardiac malformation in the neonatal period

  Dosage:  0.05 to 0.10 μg/kg/min as an infusion in 5% dextrose in water.

  Note:  Preparation of infusion solution: 250 μg in 80 mL of D5W infuse at 1 mL/kg/h = 0.05 μg/kg/min.

 WARNING:  Apnea, hyperthermia, and seizures may occur. Be prepared to provide respiratory support. Monitor oxygen saturation.

Rocuronium

 Indication:  1) Neuromuscular blockade to facilitate mechanical ventilation

2) Emergency intubation

  Dosage:  IV: 0.8 to 1.2 mg/kg

  Note:  This drug does not alter the level of consciousness or provide analgesia or amnesia.

  Note:  Alternative to succinylcholine for rapid intubation when succinylcholine is contraindicated. Duration of block is generally 30 to 45 minutes and is dose-dependent. Satisfactory conditions for endotracheal intubation will generally occur 45 to 60 seconds after administration.

 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.

Succinylcholine

 Indication:  Neuromuscular blockade for emergency intubation or treatment of laryngospasm

  Dosage:  1 to 2 mg/kg IV

4 to 5 mg/kg IM

 WARNING:  Contraindicated with previous history of malignant hyperthermia, severe burns, spinal cord injury, neuromuscular disease, or myopathies. When these contraindications exist use a nondepolarizing muscle relaxant such as rocuronium. Despite reports of acute rhabdomyolysis, hyperkalemia, and cardiac arrest with succinylcholine, this agent remains the drug of choice when immediate securing of an airway is indicated.

 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.

  Note:  Atropine, 0.02 mg/kg (minimum dose, 0.1 mg), should be combined with or precede succinylcholine to prevent bradycardia or asystole. Satisfactory conditions for endotracheal intubation generally occur 30 to 45 seconds after IV administration and 3 to 5 minutes after IM administration.

  Note:  If cardiac arrest occurs immediately after administration of succinylcholine, hyperkalemia must be suspected and treatment for this condition initiated. Hyperkalemia is especially likely to be responsible for cardiac arrest occurring in male children 8 years of age or younger.

Thiopental

 Indication:  1) Adjunct to intubation

  Dosage:  IV: 4 to 6 mg/kg

  Note:  A lower dose may be used if other sedatives/narcotics have been administered.

 WARNING:  IM administration leads to tissue necrosis.

 WARNING:  Be prepared to provide respiratory support. Monitor oxygen saturation. High doses are associated with hypotension and apnea. Use with caution in patients with cardiac compromise or hypovolemia.

 Indication:  2) Control of intracranial hypertension

  Dosage:  1 to 2 mg/kg, repeated as necessary

Vecuronium

 Indication:  1) Neuromuscular blockade to facilitate mechanical ventilation

2) Emergency intubation

  Dosage:  IV: 0.1 mg/kg

  Note:  This drug does not alter the level of consciousness or provide analgesia or amnesia.

  Note:  This agent may be used for emergency intubation when succinylcholine is contraindicated. Satisfactory conditions for endotracheal intubation generally occur 1.5 to 2.0 minutes after administration.

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.

Committee on Drugs, 1996 to 1997

Cheston M. Berlin, Jr, MD, Chair

D. Gail McCarver, MD

Daniel A. Notterman, MD

Robert M. Ward, MD

Douglas N. Weismann, MD

Geraldine S. Wilson, MD

John T. Wilson, MD

Liaison Representatives

Donald R. Bennett, MD, PhD

American Medical Association/United States Pharmacopeia

Joseph Mulinare, MD, MSPH

Centers for Disease Control and Prevention

Iffath Abbasi Hoskins, MD

American College of Obstetricians and Gynecologists

Paul Kaufman, MD

Pharmaceutical Research and Manufacturers of America

Siddika Mithani, MD

Health Protection Branch, Canada

Gloria Troendle, MD

Food and Drug Administration

Sumner J. Yaffe, MD

National Institutes of Health

AAP Section Liaisons

Section on Anesthesiology

Charles J. Coté, MD

Section on Allergy and Immunology

Stanley J. Szefler, MD

REFERENCES

  • Copyright © 1998 American Academy of Pediatrics

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