Critical Care and Emergency Medicine
Resuscitation pharmacology
Epinephrine for cardiac arrest: 0.01 mg/kg IV/IO of the 1:10,000 concentration (0.1 mL/kg, max 1 mg), repeated every 3–5 minutes; the endotracheal dose is 0.1 mg/kg of 1:1000. Defibrillation begins at 2 J/kg and escalates to 4 J/kg and then at least 4 J/kg (not exceeding 10 J/kg or the adult dose). Begin CPR for bradycardia with a heart rate below 60 beats per minute and poor perfusion despite adequate oxygenation and ventilation. Fluid resuscitation is 20 mL/kg isotonic crystalloid boluses, reassessing after each.
Anaphylaxis and shock
Epinephrine IM 0.01 mg/kg of 1:1000 (max 0.3 mg for children under 30 kg, 0.5 mg above), repeated every 5–15 minutes, with adjunctive fluids, H1 and H2 blockers, and corticosteroids. Septic shock requires broad-spectrum antibiotics within 1 hour, fluid boluses, and early vasoactive support; epinephrine is often first-line in cold shock and norepinephrine in warm shock.
Status asthmaticus and sedation
Continuous albuterol at 0.5 mg/kg/hour, ipratropium, systemic corticosteroids, and intravenous magnesium sulfate 25–50 mg/kg (max 2 g) for severe exacerbations. For sedation, watch for propofol infusion syndrome (metabolic acidosis, rhabdomyolysis, arrhythmia) during prolonged high-dose infusions; dexmedetomidine causes bradycardia and hypotension.
Worked example
A 15 kg child in cardiac arrest: epinephrine 0.01 mg/kg = 0.15 mg, which is 1.5 mL of the 1:10,000 (0.1 mg/mL) concentration. A common error is to draw 0.15 mL of 1:1000, delivering one-tenth the intended dose.