Pediatric 20 Minute Card
This information is to be used only as a guide, and is not a substitute for independent medical judgment.Actual doses may vary, depending on clinical conditions.  All information is subject to regular revision.  
Airway Breathing and Circulation 
Drug of First Choice - 100% 0xygen!
 
Resuscitation Drug Doses

Quick Reference Resuscitation By Age
Intraosseous Infusion
Hypoglycemia
Decompensated
Shock Blood Pressures
Narcan
If Repeated Doses of Epinephrine Are Needed
Airway Emergencies
Asthma
Croup
Rapid Sequence Intubation
Initial Ventilator Settings
Cardiac
Hypertensive Emergencies
Anxiolysis/Analgesia/Conscious Sedation
Sedation Complications and Management
Seizures/Increased Intracranial Pressure
Diabetes
Intravenous Fluids
Sepsis/Meningitis/Septic Shock
Blood Products
Hyperkalemia
Miscellaneous Ingestions and Anaphylaxis

Resuscitation Drug Doses

Epinephrine 1:10,000
conc: 0.1 mg/cc   
dose: 0.1 cc/kg q5min Repeat dose Use 10XConcentration (1:1,000) the initial IV dose
IV IM ET or IO 

Atropine 
conc: 0.1 mg/cc 
dose: 0.1-0.3 cc/kg q 5-10 min IV IM ET or IO 

Sodium Bicarbonate**    Use only with prolonged cardiac arrest (>10 min) or with documented metabolic acidosis  
conc: 1 meq/cc (adult)    0.5 meq/cc (infant)  
dose: 1-2 meq/kg     Max 0.5 mg  q 5 min  IV only

Intraosseous Infusion
(fluids, blood products, catecholamines, glucose) when peripheral IV or cut down not successful:
#18 or 20 gauge spinal, bone marrow or Intraosseous needle with stylet into medial tibia 2-3 cm below anterior tibial tubercle  

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Quick Reference
When all that is known is the approximate age of the victim the following information provides a preparation point for resuscitation on arrival

Newborn 3 kg   ET  (mm) 3.0 Epi 0.5 cc Atropine 1.0 cc Bicarb 6-12 cc (infant)
Infant 5 kg   ET  (mm) 3.5-4.0 Epi 0.5 cc Atropine 1.0 cc Bicarb 10-20 cc (infant)
Toddler 110 kg   ET  (mm) 4.5-5.0 Epi 1 cc Atropine 1.0 cc Bicarb 10 cc adult
6 yo 20 kg   ET  (mm) 5.0-5.5 Epi 2 cc Atropine 2 cc Bicarb 20 cc adult
9 yo 30 kg   ET  (mm) 6-6.5 Epi 3 cc Atropine 3 cc Bicarb 30 cc adult
Adolesc 50 kg   ET (mm) 7-7.5 Epi 5 cc Atropine 5 cc Bicarb 1 amp
Adult 70 kg   ET  (mm) 8.0 Epi 10 cc Atropine 5 cc Bicarb 1 amp
*    Use uncuffed ETT if child < 7-8 years old  unless difficulty maintaining pressure

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Hypoglycemia

Hypogycemia In ER (after drawing 3 cc in purple top on ice) 
         
Dextrose: (D25) 2-3 cc/kg IV or (D10) 5-10 cc/kg IV 
          
Glucagon: 0.1 mg/kg IM, IV or SC (max 1.0 mg)
Hypoglycemia in Hospital (IODM, poor feeding, insulin excess)

Neonates D10W 2 cc/kg bolus    
O
lder children D25W 2 cc/kg bolus   
Then continuous infusion of D10W with electrolytes           
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Shock 
Lower limits of systolic B.P.: 0-1 month: > 60 ;1 month to 1 year: > 70  > 1 year: > 70+(2x age in yrs)           

If repeated doses of epinephrine are needed, think epinephrine infusion
(0.1-1.0 mcg/kg/min).   If fluid loaded and normal heart rate, but shock think dopamine infusion (3-20 mcg/kg/min).   If primary cardiac, think  dobutamine (3-20 mcg/kg/min)
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Airway Emergencies  Dr. Landon 652-6075
Asthma
Albuterol
:   0.15 mg/kg in 1.5 cc.  NS q 20min.x2-3. 
Continuous albuterol via Heart nebulizer in ICU only; start at 0.3mg/kg/h and increase by 0.1 as needed to max 1.2 mg/kg/h.  Watch the K+ q 6h  

Epinephrine
:  (1:1000) 0.01 cc/kg sc q 20 min x3 (max 0.3 cc/dose) if poor inspiration
Susphrine
:  0.005 cc/kg 0.15 cc max  
Aminophylline
:  Load 5-7 mg/kg over 20 min IV 1 mg/Kg will increase serum level by 2 mcg/ml. 
  
Therapeutic levels are 8-12 for infant<6mo. 5-15 for child 
   Maintenance drip:>1 year  0.9-1.1 mg/kg/hr >9 years    0.6-0.7 mg/kg/hr  

Methylprednisolone
:  (solumedrol) 2mg/kg then 1mg/kg/dose q6H 
Croup
Decadron: 0.6 mg/kg IM/PO x 1 
Racemic Epinephrine: 0.25-0.50 cc in 2.5-4.0 c NS Aerosol for stridor  
Budesonide (Pulmicort) 500mg via PariJet LC nebulizer ikf possible   
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Rapid Sequence Intubation
Intubation ETT size
= (age +16)/4 in mm (after 12-18 mos) 
Pavulon: 0.01 mg/kg (Defasciculating dose) (for >  4 yr old) 
Atropine: 0.01 - 0.02 mg/kg IV (Min 0.1 mg, Max 0.5 mg) (for < 10 yr old) 
Valium: 0.1 mg/kg or Thiopental/Surital 2-4 mg/kg IV 
 
Lidocaine: 1 mg/kg IV; infusion 20-50 mcg/kg/min (for elevated ICP) 
 
Succinylcholine: 1.0-2.0 mg/kg IV (Max 100 mg) or
Pancuronium (Pavulon)/Vecuronium 0.1 mg/kg
 Neonates: 0.06-0.1 mg/kg/dose IV q 1-2 h    Older children 0.1 mg/kg/dose IV q 1-2 h  
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Initial Ventilator Setting Consider transfer if >60% Oxygen or >10PEEP
Be guided by manometer on bag valve mask ventilation and by clinical response: 

     
In > 2 y.o. 10 ml/kg tidal volume rate 20  
     
In < 2 y.o. use pressure ventilator PIP 20/PEEP 4 Rate 20.   
AVOID ZEEP (Zero End Expiratory Pressure) except in status asthmaticus.  Increase PEEP to 10-15 in ARDS. 
Sedate and paralyze as required (with adequate hydration)  

      
Fentanyl - 1-3 mcg/kg  q 1-2 hour  
     
Midazolam - 0.05-0.2 mg/kg q 1-2 hour  
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Cardiac (GIVE OXYGEN!!) Dr. Leong 497-7214
Atropine
: 0.02 mg/kg IV or ETT x2 only (Min 0.1 mg, Max 0.5 mg)
Epinephrine: 0.1 cc/kg of 1:10,000 if IV, or 1:1,000 if ETT.  Repeat IV with 1:1000 or give ETT 0.1-0.2 cc/kg
Digoxin: digitalize or LOAD with with 25-50 micrograms/kg (1/2 initially, q 8 h x2) then of loading dose daily divided into two daily doses
Defibrillation: 2 watt secs/kg then double to repeat x 2 only
Cardioversion: 0.5-1.0 watt sec/kg synchronized
Lidocaine:1 mg/kg IV; infusion 20-50 mcg/kg/min
Bretylium:5 mg/kg slow IV (may increase to 10 mg/kg if defibrillation unsuccessful)
Adenosine:0.05 mg/kg push.  May double and repeat times 2
Propranolol: 0.01-0.1mg/kg IV (max 10 mg dose) q 6-8 hr.
Verapamil: 0.1-0.3 mg/kg IV dose over 2 min, may repeat q 30 min (avoid if <3y.o./concurrent use of beta blockers)
Lasix:1 mg/kg IV or 2 mg/kg p.o.
Sodium bicarbonate: 1-2 meq/kg IV q 5 min, for documented acidosis, (pH<7.20 or cardiac arrest for > 5 min)
Prostaglandin E: Start 0.05 mcg/kg/min, then titrate (duct dependant cyanotic heart disease)  
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 Hypertensive Emergency (Check BP yourself x2 with proper cuff) Dr. Yadin 1-310-825-6301-1 and page
 Nifedipine: 0.25 mg - 0.50 mg/kg po or sublingual
Hydralazine: 0.2-0.6 mg/kg IM Iv q 30-60 mi
 Nitroprusside: 0.5-8.0 mcg/kg/min
Labetalol: 20 mg or 1-2 mg/kg, whichever is lower, IVP over 2 min.; may give 40-80 mg q 10 min, up to total of 300 mg. IV infusion: start at 2 mg/min.
Diazoxide: 5 mg/kg Rapid IV push, may repeat q 30 min x 2  
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Analgesia/Anxiolysis/Conscious Sedation (see Complications)
Narcan0.03-0.1 mg/kg/dose q 2-3 min IV, IM, ET  Adult/teenage dose = 3 amps    
Morphine 0.1 mg/kg/dose IM/IV q 2-4 h 
Morphine drip 0.01-0.04 mg/kg/h, monitor oximetry, RR, apnea] 
Chloral Hydrate 50 mg/kg po or pr. May repeat x 2 or oral Versed 0.2-0.4                  mg/kg (maximum 15 mg)
Acetaminophen 5-15 mg/kg up to 5 doses per day q 4 -6 hours 
EMLA cream apply 1 hour prior to blood draw or LP 
Midazolam - 0. 3-0.75 mg/kg PO/PR (max 15 mg)  
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Seizures/Increased Intracranial Pressure 
 
(Prepare to intubate and/or treat respiratory depression)  
Seizures: 
Step 1
. Lorazepam: (Ativan) 0.1 mg/kg IV. PR or IM, may repeat in 5 minutes maximum dose 4 mg.May substitute Valium but Lorazepam will last longer in the CNS.  Rectal route preferable to IM if unable to start IV.  If unresponsive to Lorazepam x 2, use Dilantin next
Step2.
Dilantin: 20 mg/kg slow IV load with EKG monitor (in NS), then if needed, phenobarbital, as below (Watch for hypotension.  Dilantin for stabilization only if a neonate)
Step
3. Phenobarbital: 10-20 mg/kg IV load (give only if Lorazepam + Dilantin have been given) (PREPARE TO INTUBATE)
Increased ICP: Maintain CPP > 50mm Hg., CPP = MAP-ICP, whichever is higher
Mannitol 0.25-1.0 Grams/kg IV q 2 h
Decadron 0.5-1.0 mg/kg IV load, follow with .025 mg/kg IV q 6 h             HYPERVENTILATE ACUTELY but maintain brain perfusion with pCO2>25
Lasix first 24 hours after trauma  
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  Diabetes (DKA) 
Watch the K+ - When urine established replace as KCL and KPO4
Maintain BP first and then rehydrate cautiously over 36-48 hrs.
Insulin (regular) 0.1 units/kg initially; then 0.05-0.3 units/kg/hr IV drip
Blood sugar to fall 75 mg/dl/hour - If faster will cause increased ICP   
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Intravenous Fluids 
Shock NS or LR 20 cc/kg and reassess.  Be guided by heart rate and                  peripheral perfusion not blood pressure
Maintenance: "D5 Electrolyte 48" (D5 0.2 NSw/20 meq KCl/liter)  
      
1st 10 kg at 100 cc/kg/24 h;  
      
2nd 10 kg 50 cc/kg/24 h; > 20 kg 20 cc/kg/24 h  
     
(Do not use for bolus) 
Hypotonic: Dehydration meq NaCl required = 0.6x body weight in kg x                desired increase in Na+. 
Isotonic: Dehydration Treat shock first, then calculate half the deficit plus                maintenance over the first 8 hours 

Burns maintenance + LR 4 ml x wt in kg x % BSA over 24 hours half infused over first 8 hours.  Do not add potassium.  Minor < 15 % BSA/Moderate 15-25 % BSA.  Consider burn unit if >15% BSA.  
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Sepsis/Meningitis/Septic Shock
(Use Amp/Cefotaxime if < 2 months and meningitis
Ampicillin: 100 mg/kg IV load then 100-200 mg/kg/24 h + q 4-6 h
Gentamicin: 2.5 mg/kg/dose IV (q 12 h  < 7 days q 8h > 7 days)
Ceftazidime: 50 mg/kg/dose IV/IM q 8 h (use Ceftaz + Gent for fever +
neutropenia w/o central line)
Cefotaxime: 50 mg/kg/dose q6 h, IV or IM (E. Coli meningitis)
Vancomycin: 30-45 mg/kg/day, IV q 8 h (for documented Staph epi central line sepsis)
Cefuroxime: 25 mg/kg/ IV q 8 h May load 50 mg/kg (Pneumonia ENT)
Nafcillin: 40-50 mg/kg/dose IV q 6 h (use Naf + Ceftaz for fever + neutropenia + central line)
Ceftriaxone: 50 mg/kg/dose IV/IM q 12 h
Decadron: 0.15 mg/kg q 6 h x 4 days if bacterial meningitis and > 2 mo. old
Amphotericin: per protocol if fever > 5 days in febrile neutropenic pt.  
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Blood products
Use irradiated leucopore filtered blood products in oncology patients
10 cc/kg PRBC's will raise Hct 5%
0.1 unit/kg platelets will raise platelets count 25,000/mm3
10 units/kg of Factor VIII will raise level 20 %    
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 Hyperkalemia (K+ > 7 or EKG changes) 
Ca gluconate: 10% 0.5 cc/kg IV over 3 min (max 10cc)(for severe cases i.e.                  absent P waves, wide QRS, arrythmias)
NaHCO3: 1 cc/kg IV (add in moderate cases i.e. peaked T waves)

"GIK" 
 
8 cc D50W+1 unit regular insulin IV to be give at 1 cc/kg 

Kayexalate
: 1-2 gm/kg/day p.o., pr divided q 6 h (use alone in mild cases                 with no EKG changes)  
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Miscellaneous/Ingestion and Anaphylaxis
Epinephrine
: (1:1000) 0.01 ml/kg/dose; Benadryl IV 1-2 mg/kg:  Fluids. NS 20 cc/kg - Prepare for intubation Diphenhydramine: (Benadryl) As for anaphylaxis or phenothiazine overdose, 1-2 mg/kg IV (max 300 mg/day)
Ipecac < 1 yr. 10 ml; 1-12 yrs 15 ml; > 12 yrs 30 ml repeat x 1 after 20 min
Charcoal: 1 gm/kg
N-acetylcysteine: 20% for acetaminophen OD 140 mg/kg (200 mg/kg if charcoal  Per NG or dilute to  5% po then 70 mg/kg q4h      
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Sedation Complications and Management   
Narcan 0.03-0.1 mg/kg/dose q 2-3 min IV, IM, ET  Adult/teenage dose = 3 amps   
Complication Vomiting
Possible Cause Crying Full stomach (air or food) pain Most common with narcotics and chloral hydrate
Supportive Measures position patient to lateral decubitus assure patient airway suction antiemetic if applicable

Complication
Untoward Reactions Agitation Dysphoria Hallucination
Possible Cause Deep sedation Minimal stimulation Hypoglycemia Hypothermia Most common with narcotics,midazolam, and chloral hydrate
Supportive Measures Assure patient airway Supplemental oxygen Restraints Drug Treatment when applicable

Complication
Hypoventilation Apnea Respiratory Depression 
Possible Cause Airway Obstruction/Chest mass Most common with narcotics, especially when combined with a benzodiazepine
Supportive Measures Assure patient airway Position Supplemental oxygen Nasal/Oral airway
Bag-Valve-Mask Ventilation Reversal Agents prn Intubation prn

Complication
Hypotension
Possible Cause Bleeding Hypoxia Myocardial depression Allergic reaction Most common with IV morphine
Supportive Measures Position IV Fluids Vasopressors Reversal agent Inotropes

Complication
Cardiac Dysrhythmias (brady or tachy) Cardiac Arrest
Possible Cause Hypoxia Vagal Pain Hypovolemia Fever Medications
Supportive Measures Assure patent airway Supplemental oxygen Bag Valve Mask ventilation Drug treatment when applicable BLA/ACLS prn IV fluids Analgesics/antipyretic

Complication
Hypothermia
Possible Cause Exposure Low Birth Weight Stress
Supportive Measures Apply warming techniques Supplemental oxygen

Complication
Seizures
Possible Cause Hypoxia Hypoglycemia Underlying medical condition Fever Local anesthetic toxicity
Supportive Measures Assure patent airway Supplemental oxygen Bag Valve Mask ventilation BLS/ACLS prn Accu-check of blood sugar antipyretics anticonvulsants

Complication Anaphylaxis
Possible Cause Drug/latex sensitivity Sensitivity to medications used
Supportive Measures Assure patent airway Epinephrine 1:1000 Supplemental oxygen IV Fluids BLS/ACLS prn IV steroids Benadryl/Zantac
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