Commonly Used Medications in PALS

Adenosine

Antiarrhythmic

SVT

1st dose = 0.1 mg/kg rapid IV push to max of 6 mg
2nd dose = 0.2 mg/kg rapid IV push to max of 12 mg

Dizziness, headache, metallic taste, shortness of breath, hypotension, slow or fast heart rate, nausea, flushing, sweating

Cardiac monitoring during administration; administer through central line if available; flush with saline following administration

Amiodarone

Antiarrhythmic

SVT, VT with pulses, VF, VT without pulse

SVT or VT with pulse:
5mg/kg load over 20-60 minutes to 300 mg max

VF or VT without pulse: 5mg/kg rapid bolus to
300 mg max

Headache, dizziness, tremors, syncope, hypotension, bradycardia, CHF, nausea, vomiting, diarrhea, rash, skin discoloration, hair loss, flushing, coagulation problems

Monitor ECG and BP; use with caution in patients with a perfusing rhythm, hepatic failure; contraindicated for 2nd or 3rd degree heart block

Atropine

Anticholinergic

Symptomatic bradycardia, toxins and overdoses

Bradycardia: 0.02 mg/kg IV with 0.5 mg max dose may repeat one time
By ETT: 0.04-0.06 mg/kg

Toxins/overdose:
0.02-0.05 mg/kg repeated every 20-30 minutes until symptoms reverse

Headache, dizziness, confusion, anxiety, flushing, visual difficulties, pupil dilation, dry mouth, tachycardia, high or low blood pressure, nausea, vomiting, constipation, urinary retention, painful urination, rash, dry skin

Monitor ECG, oxygen, and BP; administer before intubation if bradycardic; contraindicated in glaucoma and tachyarrhythmias

Epinephrine

Catecholamine vasopressor, Inotrope

Anaphylaxis, asthma, symptomatic bradycardia, croup, shock, cardiac arrest, toxins or overdose

Anaphylaxis: 0.01 mg/kg every 15 minutes to max of 0.3 mg

Asthma: (1:1000) 0.01 mg/kg subcutaneous every 15 minutes to max 0.3 mg

Symptomatic bradycardia: 0.01 mg/kg IV every 3-5 minutes to max dose of 1 mg

Croup: 0.25 ml Racemic epi solution via nebulizer

Cardiac arrest: 0.01 mg/kg (1:10000) IV or 0.1 mg/kg (1:1000) per ET tube every 3-5 minutes

Shock: 0.1-1 mcg/kg/ minute IV infusion

Toxins/ODs: 0.01 mg/kg (1:10000) IV to max dose of 1 mg

Tremors, anxiety, headaches, dizziness, confusion, hallucinations, dyspnea, SVT, VT, palpitations, hypertension, nausea, vomiting, hyperglycemia, hypokalemia, vasoconstriction

Available in 1:1000 and 1:10000 concentrations so the team must be aware of which concentration is being used; monitor BP, oxygen, and ECG; give via central line if possible; do not give in cocaine induced VT

Oxygen

Elemental gas

Hypoxia, respiratory distress or failure, shock, trauma, cardiac arrest

In resuscitation, administer at 100% via high flow system and titrate to response to maintain oxygen saturation >94%

Headache, dry nose/ mouth, airway obstruction if secretions become dry

Monitor oxygen saturation; insufficient flow rates may cause carbon dioxide retention

Albumin

Plasma volume expander

Shock, trauma, burns

0.5-1 g/kg by rapid infusion

Fluid overload, increased respiratory rate, flushing, rash, hypocalcemia

Use within 4 hours of opening vial

Albuterol

Bronchodilator

Asthma, bronchospasm, hyperkalemia

2.5 mg if weight <20 kg

5 mg if weight >20 kg

Tremors, anxiety, headaches, bad taste, dry nose/throat, dyspnea, wheezing, tachycardia, hypotension, nausea, vomiting, flushing

Should not be used with tachyarrhythmias

Alprostadil

Prostaglandin vasodilator

Maintain patency of ductus arteriosus in congenital heart disease

Initial:
0.05-0.1 mcg/kg/minute

Maintenance:
0.01-0.05 mcg/kg/minute

Apnea, bradycardia, vasodilation, hypotension, cardiac arrest, diarrhea, renal failure, flushing, fever, hypoglycemia, DIC, hypocalcemia, seizures

May cause tissue sloughing, must not be bolused or stopped suddenly, should be refrigerated until administered

Calcium chloride/gluconate

Electrolyte

Hypocalcemia, hyperkalemia; consider for calcium channel blocker overdose

In cardiac arrest: 20 mg/kg IV bolus into central line

In non-arrest: infuse over 30-60 minutes

Hypotension, cardiac arrhythmias, cardiac arrest, burn or sclerosis of peripheral veins, hypercalcemia

Monitor ECG and BP; contraindicated in digtoxicity or hypercalcemia; flush IV tubing before and after administration; do not administer with phosphorus-containing solutions

Dexamethasone

Corticosteroid

Croup, asthma

0.6 mg/kg for one dose (max dose 16 mg)

Headache, insomnia, seizures, psychosis, visual difficulties, hypertension, edema, tachycardia, osteoporosis, diarrhea, nausea, GI bleeding, flushing, sweating, poor wound healing, hyperglycemia, sodium and fluid retention, hemorrhage, hypokalemia

Can be given PO, IM or IV

Dextrose

Carbohydrate

Hypoglycemia

0.5-1 g/kg

Sclerosis of veins, hyperglycemia

Do not administer during resuscitation unless hypoglycemia is documented; use point of care glucose monitoring

Diphenhydramine

Antihistamine

Anaphylaxis after epinephrine

1-2 mg/kg every 4 to 6 hours to a max dose of 50 mg

Dizziness, drowsiness, CNS symptoms, blurred vision, pupil dilation, dry nose/mouth/throat, hypotension, tachycardia, nausea, vomiting, urinary retention or frequency photosensitivity

Monitor oxygen saturations and BP; use with caution in presence of glaucoma, ulcer, hyperthyroidism

Dobutamine

Beta-adrenergic

Ventricular dysfunction

2-20 mcg/kg/minute infusion

Headache, dizziness, hypotension, palpitations, angina, nausea, vomiting thrombocytopenia

Monitor ECG and BP; do not mix with sodium bicarbonate or alkaline solutions

Dopamine

Catecholamine vasopressor, inotrope

Ventricular dysfunction, cardiogenic or distributive shock

2-20 mcg/kg/minute infusion titrated to response

Headache, dyspnea, palpitations, PVCs, SVT, VT, nausea, vomiting, acute renal failure

Monitor ECG and BP; avoid high infusion rates; do not mix in alkaline solutions or with sodium bicarbonate

Etomidate

Short acting sedative with no analgesic properties

Sedation for intubation or for patients with hypotension or multiple trauma

0.2-0.4 mg/kg IV over 30 to 60 seconds with max dose of 20 mg

Fast or slow respiratory rate, high or low blood pressure, tachycardia nausea, vomiting, cough

Sedation will last
10-15 minutes; monitor oxygen, BP and respiratory function; avoid use in septic shock

Furosemide

Loop diuretic

Pulmonary edema,
fluid overload

1 mg/kg IV or IM to max dose of 20 mg

Headache, weakness, vertigo, hearing and vision problems, dry mouth, ECG changes, nausea, vomiting, diarrhea, abdominal cramping, polyuria, glycosuria, muscle cramps, sweating, hives, hyperglycemia, anemia, hypokalemia, hyponatremia, metabolic alkalosis

Monitor BP, BUN, serum creatinine and electrolytes (especially potassium)

Hydrocortisone

Corticosteroid

Adrenal insufficiency associated with septic shock

2 mg/kg IV bolus to max dose of 100 mg

Psychological signs, infections, blurred vision, hypertension, diarrhea, nausea, vomiting, osteoporosis, flushing, sweating, slow wound healing, hyperglycemia

Watch for signs of infection

Inamrinone

Inotrope

Myocardial dysfunction, cardiogenic shock, CHF

Loading dose 0.75-1 mg/kg bolus over 5-10 minutes may repeat twice to max dose of 3mg/kg

Infusion at 5-10 mcg/kg/minute

Hypoxemia, hypotension, angina, arrhythmias nausea, vomiting, abdominal pain, jaundice, allergic reactions, thrombocytopenia

Monitor ECG, oxygen, and BP

Ipratropium

Anticholinergic bronchodilator

Asthma

250-500 mcg every 20 minutes via nebulizer for 3 doses

Anxiety, dizziness, headache, dry mouth, blurred vision, cough, bronchospasm, palpitations, nausea, vomiting, rash

Monitor oxygen; if medication gets in eyes, will cause pupil dilation

Lidocaine

Antiarrhythmic

VF, pulseless VT, wide complex tachycardia,

RSI

Tachyarrhythmias and VF: 1 mg/kg IV bolus followed by infusion of
20-50 mcg/kg/minute infusion

RSI: 1-2 mg/kg IV

CNS symptoms, tinnitus, blurred vision, hypotension, heart block, bradycardia, cardiac arrest, dyspnea, respiratory depression, nausea, vomiting, rash

Monitor ECG and BP;

May cause seizures; contraindicated for wide complex bradycardia

Magnesium sulfate

Electrolyte, bronchodilator

Asthma; torsades de pointes; hypo-magnesemia

Asthma: 25-50 mg/kg over 15-30 minutes IV

Pulseless torsades:
25-50 mg/kg bolus

VT with pulses and torsades: 25-50 mg/kg over 10-20 minutes

Confusion, sedation, weakness, respiratory depression, hypotension, heart block, bradycardia, cardiac arrest, nausea, vomiting, muscle cramps, flushing, sweating

Monitor ECG, oxygen and BP; rapid bolus may cause hypotension and bradycardia; calcium chloride can be used if needed to reverse hypermagnesemia

Methylprednisolone

Corticosteroid

Asthma, anaphylactic shock

2 mg/kg to max of 60 mg IV as loading dose;
0.5 mg/kg every 6 hours as maintenance dose

Depression, headache, weakness, hypertension, diarrhea, nausea, pancreatitis, ulcer, osteoporosis, hyperglycemia

Watch for rare anaphylaxis

Milrinone

Inotrope, vasodilator

Cardiogenic shock or post-surgery CHF

50 mcg/kg IV over 10-60 minutes as loading dose
0.25-0.75 mcg/kg/minute IV infusion as maintenance dose

Headache, tremor, hypotension, ventricular arrhythmias, angina, nausea, vomiting, jaundice, hypokalemia

Monitor ECG, BP and platelet count; hypovolemia may make hypotension worse; use longer infusion time

Naloxone

Opioid antagonist

Narcotic reversal

For total reversal:
0.1 mg/kg IV bolus every 2 minutes to max dose of 2 mg
Total reversal not needed: 1-5 mcg/kg IV (titrate to response required)

Seizures, drowsiness, rapid respiratory rate, pulmonary edema, VF, VT, tachycardia, asystole, hypertension nausea, vomiting

Monitor ECG, oxygen and BP; repeat doses often needed; establish assisted ventilation before administration; monitor newborn of addicted mother

Nitroglycerine

Vasodilator, antihypertensive

CHF,

cardiogenic shock

Begin infusion at 0.25-0.5 mcg/kg/minute and titrate every 15-20 minutes to max dose of 10 mcg/kg/minute

Headache, dizziness, hypoxemia, hypotension, cardiac arrest, tachycardia, flushing, pallor

Monitor ECG and BP; watch for hypotension in hypovolemic children

Nitroprusside

Vasodilator antihypertensive

Cardiogenic shock

Hypertension

0.3-1 mcg/kg/minute for initial dose then titrate to max 8 mcg/kg/minute

Seizures, dizziness, headache, agitation, hypotension, slow or fast heart rate, nausea, vomiting

Monitor ECG and BP; if used for prolonged times; thiocyanate and cyanide levels should be monitored

Norepinephrine

Inotrope vasopressor

Hypotensive shock

0.1-2 mcg/kg/minute titrated to desired BP

Headache respiratory distress hypertension arrhythmias renal failure

Monitor ECG and BP; IV infiltration may lead to tissue necrosis; should be administered via central line; do not mix in alkaline solution

Procainamide

Antiarrhythmic

SVT, atrial flutter, VT with pulse

15 mg/kg as loading dose over 30-60 minutes

Headache, dizziness, confusion, weakness, hypotension, prolonged QT interval, heart blocks and cardiac arrest, nausea, vomiting, diarrhea, rash, edema, anemia, neutropenia

Monitor ECG (particularly QT interval) and BP; expert consultation should be called before administration

Sodium bicarbonate

Electrolyte to produce alkalinity

Severe metabolic acidosis,

hyperkalemia,

tricyclic overdose

1 mEq/kg slow IV bolus to max of 50 mEq

For overdose 1-2 mEq/kg bolus repeating until pH >7.45 follow with infusion of sodium bicarb solution to maintain alkalosis

CNS symptoms, arrhythmia, hypotension, cardiac arrest, renal calculi, cyanosis, edema, metabolic alkalosis and other derangements, water retention

Monitor ECG, oxygen and ABGs; ensure adequate ventilatory support to reduce the chance of carbon dioxide accumulation; not recommended in cardiac arrest

Terbutaline

Bronchodilator, beta adrenergic agonist

Asthma,

hyperkalemia

0.1-10 mcg/kg/ minute IV Infusion

10 mcg/kg SQ every 10-15 minutes until IV is established

CNS symptoms, palpitations, tachycardia, nausea, vomiting, arrhythmias, hypotension

Monitor ECG, oxygen and BP; use cautiously in children with hypokalemia

Vasopressin

Antidiuretic hormone analogue

Cardiac arrest,

septic shock

0.4-1 unit/kg bolus to max of 40 units

Fever, vertigo, dysrhythmias, hypertension, nausea, vomiting, abdominal cramps, urticaria

Monitor BP and distal pulses; watch for signs of water intoxication; tissue necrosis may develop from IV extravasation