TABLE 1

Potentially Useful Drugs in Pediatric Emergencies

AdenosineDiphenhydramineGlucagonLorazepamPhenytoin
AlbuterolDobutamineGlucoseMagnesium sulfatePrednisone/Prednisolone
Alprostadil (see Prostaglandin E1)DopamineHaloperidolMannitolProcainamide
EpinephrineHydrocortisoneMethylprednisolonePropranolol
AmiodaroneEpinephrine, racemicInsulinMidazolamProstaglandin E1
AtropineEtomidateIpratropiumMilrinoneRocuronium
Bicarbonate, sodiumFentanylKayexalate™ (see sodium polystyrene sulfonate)MorphineSodium polystyrene sulfonate
Calcium chlorideFlumazenilNalmefene
Charcoal, activatedFosphenytoinNaloxoneSuccinlycholine
DexamethasoneFurosemideKetamineNitroprussideThiopental
DiazepamLevalbuterol (see albuterol)NorepinephrineVecuronium
Phenobarbital
Lidocaine
Adenosine
    IndicationSupraventricular tachycardia
        DosageInitial 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 dosesIf 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.
    NoteContinuous electrocardiographic monitoring should be employed during use. A defibrillator must be immediately available.
    WarningContraindicated 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
    IndicationAsthma exacerbation, bronchospasm
        DosageIntermittent 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.
    NotesOxygen 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
    IndicationPulseless ventricular fibrillation (VT)
        DosageIV/IO: 5 mg/kg rapid bolus (maximum: 300 mg); may be repeated up to a total daily dose of 15 mg/kg.
    IndicationVT/supraventricular tachycardia with a pulse.
        DosageIV/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.
    NoteAmiodarone 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.
    WarningMay 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
    IndicationSymptomatic vagally mediated bradycardia or AV block
Symptomatic bradycardia unresponsive to oxygenation, ventilation, and epinephrine
        DosageIV/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.
    NoteOxygenation 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.
    IndicationAnticholinesterase poisoning
        DosageIV: 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.
    IndicationPrevention of bradycardia associated with RSI
        DosageIV/IO: 0.01–0.02 mg/kg (minimum dose: 0.1 mg; maximum dose: 1 mg) before administration of sedative/anesthetic and paralytic agents.
    WarningAtropine sulfate comes in different concentrations; calculate dosage accordingly.
Bicarbonate, sodium
    IndicationMetabolic acidosis
Hyperkalemia
Sodium channel blocker (eg, tricyclic antidepressant) overdose
        DosageIV/IO: 1–2 mEq/kg given slowly; do not give by ET route.
    NotesOnly 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
    IndicationsHypocalcemia
Hyperkalemia
Hypermagnesemia
Calcium channel blocker toxicity
        DosageIV/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.
    NotesCalcium 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.
    WarningStop 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
    IndicationAcute ingestion of selected toxic substances
        Dosage1–2 g/kg PO or nasogastrically; adolescent/adult dose: 50–100 g.
    NoteConsultation 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.
    WarningsIf 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
    IndicationEmergency treatment of elevated ICP caused by brain tumor
        DosageIV/IO: 1–2 mg/kg.
    IndicationLaryngotracheobronchitis (croup)
Asthma exacerbation
        DosageIV, IM, or PO: 0.6 mg/kg (maximum: 16 mg).
    NoteFurther dosing and route of administration determined by clinical course.
Diazepam
    IndicationStatus epilepticus
        DosageIV: 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).
    NoteIM 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.
    WarningThere 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
    IndicationsAcute hypersensitivity reactions
Dystonic reactions
        DosageIV/IM: 1–2 mg/kg (maximum initial dosage: 50 mg).
    NoteMay 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
    IndicationCardiogenic shock, congestive heart failure
        DosageIV infusion: 2–20 μg/kg per min, titrated to desired clinical effect.
    WarningMay 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
    IndicationCardiogenic/distributive shock
        DosageIV infusion: 2–20 μg/kg per min, titrated to desired clinical effect.
    NoteEffects 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.
    WarningMay 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/formulationEpinephrine 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.
    IndicationCardiopulmonary resuscitation
        Dosage
            IV/IONewborn 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.
            ETNewborn 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.
    NoteIV 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.
    IndicationAnaphylaxis
        DosageIM/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.
    IndicationContinued shock after volume resuscitation
        DosageIV 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.
    WarningIV 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.
    IndicationSevere asthma exacerbation
        DosageSC: 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.
    IndicationLaryngotracheobronchitis (croup)
        Dosage0.5 mL/kg of 1:1000 solution (maximum: 5 mL = 5 mg) administered by nebulizer.
Epinephrine, racemic
    IndicationLaryngotracheobronchitis (croup)
Acute airway edema
        Dosage2.25% inhalation solution: 0.05 mL/kg (maximum: 0.5 mL) in 2 mL of normal saline administered by nebulizer.
    NoteMany 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
    IndicationSedation for RSI
        DosageIV/IO: 0.2–0.4 mg/kg (maximum: 20 mg).
Etomidate
    IndicationSedation for RSI
        DosageIV/IO: 0.2–0.4 mg/kg (maximum: 20 mg).
    NotesWill 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
    IndicationsPain
Adjunct to intubation
        DosageIV: 1–2 μg/kg. Repeat dose as necessary to desired clinical effect.
    NotesRapid 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.
    WarningThere 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
    IndicationsBenzodiazepine overdose
Required or desired reversal of therapeutic benzodiazepine effect
        DosageIV: 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.
    NoteMost 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.
    WarningMay 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
    IndicationStatus epilepticus
        DosageGiven 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.
    NotesWhen given IV, itching is common and controllable by reducing the flow rate.
Lower risk of hypotension or cardiac effects than phenytoin.
    WarningRate 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
    IndicationsFluid overload
Congestive heart failure/pulmonary edema
        DosageIV/IM: 1–2 mg/kg (usual maximum dose: 20 mg for patients not chronically on loop diuretics).
    NoteMay cause significant hypokalemia.
Glucagon
    IndicationHypoglycemia caused by insulin excess (as adjunct to glucose).
        DosageIV/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.
    Indicationβ-adrenergic blocker or calcium channel blocker overdose.
        DosageIV: 0.03–0.15 mg/kg, followed by an infusion of 0.07 mg/kg per h (maximum: 5 mg/h).
        Adolescent dosage5–10 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.
    NoteMay cause nausea/vomiting because of delayed gastric emptying.
Glucose
    IndicationsHypoglycemia
Hyperkalemia
        Initial Dose
            ChildrenIV/IO: 0.5–1.0 g/kg.
            NeonatesIV: 200 mg/kg as D10W only.
        Maintenance doseConstant 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.
    NotesFor 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
    IndicationPsychosis with agitation
        DosageIM/IV: 0.05–0.15 mg/kg; may repeat hourly as necessary. Maximum single dose: 5 mg.
    NotesHypotension and dystonic reactions may occur.
Repeated doses can prolong QT interval and precipitate torsades de pointes.
Hydrocortisone
    IndicationAdrenal insufficiency
        DosageIV/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.
    NoteDo not underdose. Strongly consider concomitant fluid bolus of 20 mL/kg of D5NS or D10NS during the first hour of treatment.
Insulin, regular
    IndicationDKA
        DosageIV 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.
    NoteIV 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.
    IndicationHyperkalemia (although glucose alone is effective).
        DosageIV: 0.1 unit/kg with 400 mg/kg glucose. Ratio is 1 unit of insulin for every 4 g of glucose.
Ipratropium
    IndicationAdjunct to β-agonists for status asthmaticus/bronchospasm
    PreparationNebulized solution (0.25 mg/mL).
        DosageChildren <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.
    NotesMay be mixed with albuterol for nebulization.
Should not be used as first-line therapy.
Kayexalate (Sanofi-Aventis, Bridgewater, NJ)—see sodium polystyrene sulfonate
Ketamine
    IndicationsSedation/analgesia
Adjunct to intubation
Infundibular spasm (hypercyanotic spell with tetralogy of Fallot)
        DosageIV: 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.
    NotesDoses 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.
    WarningBe prepared to provide respiratory support. Monitor oxygen saturation. Avoid use in patients with increased ICP or increased intraocular pressure.
Levalbuterol—see albuterol
Lidocaine
    IndicationVentricular arrhythmias, wide complex tachycardia
        DosageIV/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.
    NoteRecent data suggest that lidocaine is less effective than amiodarone but may be used if amiodarone is not available.
    WarningHigh concentrations may cause myocardial depression, hypotension, and seizures. Contraindicated in complete heart block and wide complex tachycardia attributable to accessory conduction pathways.
    IndicationICP protection before ET intubation or airway manipulation.
        Dosage1–2 mg/kg IV as a single dose 30 s to 5 min before airway instrumentation.
    NoteConsidered 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
    IndicationStatus epilepticus
        DosageIV/IM: 0.05–0.10 mg/kg (maximum: 4 mg per dose).
May repeat dose every 10–15 min if needed for continued seizures.
    WarningThere 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
    IndicationsHypomagnesemia
Torsades de pointes VT
Refractory status asthmaticus
        DosageIV/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.
    WarningRapid infusion may cause hypotension and bradycardia. Have calcium chloride available if needed to reverse magnesium toxicity.
Mannitol
    IndicationIncreased ICP
        DosageIV: .25–1 g/kg given over 20–30 min.
    NoteLarger 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.
    NoteAdminister through a filter; do not use solutions that contain crystals.
Methylprednisolone
    IndicationsAsthma/allergic reaction
Laryngotracheobronchitis (croup)
        DosageIV/IM: 1–2 mg/kg initial dose (must use acetate salt for IM route).
    IndicationSpinal cord injury
        DosageIV: 30 mg/kg over 15 min, followed in 45 min by a continuous infusion of 5.4 mg/kg per h for 23 h.
    NoteAdministration within 8 h of injury is optimal.
Midazolam
    IndicationSedation/anxiolysis
        DosageIV: 0.05–0.10 mg/kg given over 2–3 min (maximum single dose: 5 mg).
    NotePeak 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.
        DosagePO: 0.25–0.50 mg/kg (maximum: 20 mg). Children <6 y old may require up to 1 mg/kg.
    IndicationAdjunct for ET intubation
        DosageIV: 0.2 mg/kg.
    NoteLower 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.
    IndicationSeizures
        DosageIM: 0.2 mg/kg (maximum: 6 mg per dose); may repeat every 10–15 min.
    NoteOther benzodiazepines (eg, lorazepam) are typically used for initial IV treatment of status epilepticus.
    IndicationRefractory status epilepticus, not controlled by standard therapies.
        DosageIV: 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.
    WarningThere 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
    IndicationMyocardial dysfunction and increased SVR/PVR (eg, after cardiac surgery, normotensive septic shock).
        DosageIV/IO: loading dose of 50–75 μg/kg over 10–60 min.
Infusion: 0.50–0.75 μg/kg per min.
    WarningMay 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
    IndicationsPain
Infundibular spasm (hypercyanotic spell with tetralogy of Fallot)
        DosageIV (slowly)/IM: 0.1 mg/kg.
    NotesRepeat 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.
    WarningThere 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
    IndicationApnea/respiratory depression caused by opioid overdose
        DosageIV/IM: 0.25–0.50 μg/kg every 2 min.
    NotesDuration 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.
    WarningMay 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
    IndicationApnea/respiratory depression caused by opioid overdose
        Dosage
            Newborn infantsIV/IM: 0.1 mg/kg (ET route not recommended for newborn infants).
            Older infants/childrenIV/IO/IM/SC: <5 y old or <20 kg: 0.1 mg/kg; ≥5 y old or ≥20 kg: 2 mg.
    NotesUse 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.
    WarningMay 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
    IndicationsHypertensive crisis
Cardiogenic shock (associated with high SVR)
        DosageIV: 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.
    NoteBottle, burette, or syringe pump should be covered with protective foil to avoid breakdown by light. IV tubing does not need protective foil.
    WarningAdministration 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
    IndicationHypotensive (usually distributive) shock, with low SVR and unresponsive to fluid resuscitation (eg, hypotensive septic shock, neurogenic shock).
        DosageIV/IO: 0.1–2.0 μg/kg per min, titrated to desired effect.
    WarningMay 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
    IndicationStatus epilepticus
        DosageIV: 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).
    WarningThere is an increased incidence of apnea when combined with other sedative agents. Be prepared to provide respiratory support. Monitor oxygen saturation.
Phenytoin
    IndicationStatus epilepticus
        DosageNeonates IV: 10 mg/kg.
Children IV: 20 mg/kg.
    NotesMaximum 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.
    WarningMay 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
    IndicationAsthma, acute exacerbation
        DosageInitial 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).
        NotesNo 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
    IndicationsWide complex tachycardia with a pulse, atrial flutter/fibrillation, supraventricular tachycardia resistant to other drugs
        DosageIV/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).
    WarningMay 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
    IndicationInfundibular spasm (hypercyanotic spell with tetralogy of Fallot)
        DosageIV: 0.15–0.25 mg/kg per dose infused over 10 min in D5W.
Maximum initial dose: 1 mg. May repeat dose once.
    NoteOxygen 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)
    IndicationSuspected or proven ductal-dependent cardiac malformation in the neonatal period
        DosageIV/IO: 0.05–0.10 μg/kg per min infusion in D5W (maximum dose: 0.2 μg/kg per min).
    WarningApnea, hyperthermia, and seizures may occur; however, none are reasons to stop infusion. Be prepared to provide respiratory support.
Rocuronium
    IndicationsParalysis to facilitate mechanical ventilation
Emergency intubation
        DosageIV: 1 mg/kg.
    NotesThis 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.
    WarningVentilatory 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)
    IndicationHyperkalemia
        DosagePO: 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.
    WarningAvoid 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
    IndicationsEmergency intubation
Laryngospasm
        DosageIV: 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).
    NotesThis 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.
    WarningCauses 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).
    WarningVentilatory 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
    IndicationSedation/anesthesia for RSI
        DosageIV: 2–6 mg/kg.
    NoteMay 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.
    WarningsIM 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
    IndicationsParalysis to facilitate mechanical ventilation
Emergency intubation
        DosageIV: 0.1 mg/kg for routine paralysis; 0.2 mg/kg for intubation.
    NotesThis 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.
    WarningVentilatory 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.