Preparing for Pediatric Emergencies: Drugs to Consider

INTRODUCTION

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

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

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

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

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

Committee on Drugs, 2005–2006

Wayne Snodgrass, MD, Chairperson

Daniel Frattarelli, MD

Mary A. Hegenbarth, MD

Mark L. Hudak, MD

Matthew Knight, MD

Lynne Maxwell, MD

Robert E. Shaddy, MD

Past Committee Members

Brian Bates, MD

David J. Burchfield, MD

Richard L. Gorman, MD

Richard P. Walls, MD

Liaisons

John J. Alexander, MD

Food and Drug Administration

Donald R. Bennett, MD

American Medical Association

George P. Giacoia, MD

National Institutes of Health

Doreen M. Matsui, MD

Canadian Paediatric Society

Joseph Mulinare, MD

Centers for Disease Control and Prevention

Adelaide Robb, MD

American Academy of Child and Adolescent Psychiatry

Hari C. Sachs, MD

Food and Drug Administration

Staff

Raymond J. Koteras, MHA