| Agent | Indications | Dose |
| Adenosine* | - Supraventricular tachycardia (SVT)
| - Initial dose 0.1 mg/kg (children >50 kg receive 6 mg) given as rapid IV or IO push closest to central circulation; follow immediately with 5 mL saline flush (10 to 20 mL saline flush for larger child or adolescent)
- If not responsive in 2 minutes, give second dose of 0.2 mg/kg (children >50 kg receive 12 mg) follow immediately with 5 mL saline flush; if not responsive after additional 2 minutes, give third dose of 0.3 mg/kg (maximum 12 mg) follow immediately with 5 mL saline flush
|
| Amiodarone¶ | - Pulseless ventricular arrhythmias not responsive to CPR, defibrillation, and epinephrine
- Stable ventricular tachycardia
- SVT refractory to adenosine
| - Cardiac arrest: 5 mg/kg rapid IV or IO bolus (maximum dose 300 mg); may repeat 5 mg/kg dose two times up to a maximum of 15 mg/kg
- Perfusing patient: 5 mg/kg IV or IO (maximum dose 300 mg) dilute to 2 mg/mL or less and infuse over 20 to 60 minutes; may repeat 5 mg/kg dose two times up to a maximum of 15 mg/kg during acute treatment
|
| Atropine | - Vagally mediated bradycardia
- Primary atrioventricular block
- Bradycardia not responsive to oxygen, airway support, and epinephrine administration
- Prevention of bradycardia during endotracheal intubation for children <1 year of age, children 1-5 years of age receiving succinylcholine, and children over 5 years of age receiving a second dose of succinylcholine
| - 0.02 mg/kg IV or IO (minimum 0.1 mgΔ, maximum single dose 0.5 mg for child or 1 mg for adolescent); may repeat once in 3 to 5 minutes
- Maximum total dose 1 mg (child) or 2 mg (adolescent)◊
- Only if IV and IO not available, may give via endotracheal tube (ET) 0.04 to 0.06 mg/kg diluted with 3 to 5 mL saline; repeat once if needed (IV or IO are preferred)
|
| Calcium chloride§ | - Hypocalcemia
- Hypermagnesemia
- Hyperkalemia
- Calcium channel blocker (CCB) overdose
| - Cardiac arrest: 20 mg/kg given as 0.2 mL/kg of 10% calcium chloride solution, maximum 2 g (20 mL, 14 mmol) per dose; dilute in an equal amount of D5W or NS and give slow IV or IO push; repeat in 10 minutes if needed
- Perfusing patient: 10 to 20 mg/kg given as 0.1 to 0.2 mL/kg of 10% calcium chloride solution, maximum 2 g (20 mL, 14 mmol) per dose; dilute in an equal amount of D5W or NS and give IV or IO over 5 to 10 minutes (for initial stabilization in CCB overdose or severe symptomatic hyperkalemia); or dilute in 10 to 50 mL D5W or NS and give IV or IO over 10 to 20 minutes in perfusing patient with severe symptomatic hypocalcemia (eg, tetany, carpopedal spasm, or seizure); may repeat in 10 minutes if needed
- Conversions: 10% calcium chloride = 100 mg/mL calcium chloride = 27.3 mg/mL elemental calcium = 0.68 mmol/mL calcium
- Peripheral administration of calcium chloride is not recommended§
- Forms precipitate with sodium bicarbonate, do not co-infuse
|
| Calcium gluconate | - Hypocalcemia
- Hypermagnesemia
- Hyperkalemia
- Calcium channel blocker (CCB) overdose
- (Alternate to calcium chloride for perfusing patient; provides slower correction of ionized calcium concentration but less likely to cause tissue injury when given by peripheral IV)
| - Cardiac arrest: 60 mg/kg given as 0.6 mL/kg of 10% calcium gluconate solution, maximum 3 g (30 mL, 7 mmol) per dose; dilute in an equal amount of D5W or NS and give slow IV or IO push; repeat in 10 minutes if needed. Calcium chloride preferred if available and patient has central venous access.
- Perfusing patient: 60 mg/kg given as 0.6 mL/kg of 10% calcium gluconate solution, maximum 2 g (20 mL, 4.5 mmol) per dose; dilute in an equal amount of D5W or NS and give IV or IO over 5 to 10 minutes for initial stabilization in CCB overdose or severe symptomatic hyperkalemia, may repeat if needed or follow by continuous infusion (CCB overdose); or dilute in 10 to 50 mL D5W or NS and give IV or IO over 10 to 20 minutes in perfusing patient with severe symptomatic hypocalcemia (eg, tetany, carpopedal spasm, or seizures); may repeat in 10 minutes if needed
- Conversions: 10% calcium gluconate = 100 mg/mL calcium gluconate = 9.3 mg/mL elemental calcium = 0.23 mmol/mL calcium
- Forms precipitate with sodium bicarbonate, do not co-infuse
|
| Epinephrine¥ | - Asystole
- Pulseless electrical activity
- Pulseless ventricular arrhythmias not responsive to initial defibrillation
- Bradycardia not responsive to oxygen and support of airway and breathing
| - 0.01 mg/kg IV or IO given as 0.1 mL/kg using the 0.1 mg/mL solution up to 1 mg per dose
- Repeat every 3 to 5 minutes as needed; not compatible with sodium bicarbonate
- Only if IV and IO are not available, may give endotracheal (ET) 0.1 mg/kg as 0.1 mL/kg using the 1 mg/mL solution up to 2.5 mg per dose diluted to 3 to 5 mL with saline; repeat every 3 to 5 minutes as needed (IV or IO are preferred)
- Examples of epinephrine infusion for refractory anaphylaxis (perfusing patient) are provided as separate tables in UpToDate
|
| Glucose (dextrose) | - Documented blood glucose ≤60 mg/dL (3.3 mmol/L)‡
| - 0.5 to 1 g/kg, IV or IO, as follows:
- Infants and children <5 years: 5 to 10 mL/kg of 10% dextrose solution
- Children ≥5 years: 2 to 4 mL/kg of 25% dextrose solution (preferred) or 1 to 2 mL/kg of 50% dextrose solution
|
| Lidocaine | - Pulseless ventricular arrhythmias not responsive to CPR, defibrillation, and epinephrine
| - 1 mg/kg rapid IV or IO bolus
- Follow the bolus with an infusion of 20 to 50 mcg/kg/minute. If the start of the infusion will be delayed longer than 15 minutes, then a second IV or IO bolus dose of 1 mg/kg is suggested.
- Only if IV and IO not available, may give via endotracheal tube (ET) 2 to 3 mg/kg, flush with 5 mL NS and follow with 5 assisted manual ventilations (IV and IO are preferred)
|
| Magnesium sulfate | - Polymorphic ventricular tachycardia (torsades de pointes)
- Documented hypomagnesemia
| - Cardiac arrest (pulseless torsades): 25 to 50 mg/kg; given as 0.05 to 0.1 mL/kg of 50% magnesium sulfate solution up to maximum 2 g (4 mL) per dose; dilute in 10 mL D5W, give IV or IO over 1 to 2 minutes
- Perfusing patient (torsades, hypomagnesemia, status asthmaticus)†: Same dose as for cardiac arrest, except dilute dose in 10 to 50 mL D5W or NS and infuse over 15 minutes (maximum 150 mg per minute)
- Conversions: 50% magnesium sulfate = 500 mg/mL magnesium sulfate = 2 mmol/mL magnesium
|
| Oxygen | - All infants and children outside of the neonatal period
| - 100% initial dose via nonrebreathing face mask or bag-mask ventilation, wean as clinically indicated
|
| Procainamide** | - Stable ventricular tachycardia
- SVT in patients with Wolff-Parkinson-White syndrome or refractory to adenosine
| - Loading dose (pediatric cardiology consultation advised):
- Neonates: 7 to 10 mg/kg IV or IO
- Older infants and children ≥1 year: 15 mg/kg IV or IO
- Maximum: 1 g
- To avoid transient hypotension caused by rapid administration, give the loading dose slowly over 30 to 60 minutes. During loading, ensure frequent BP measurements and continuous ECG monitoring.
- For stable patients in normal sinus rhythm who are receiving procainamide, stop administration if the QRS interval increases >50% from baseline or an arrhythmia develops
- After the loading dose, start a continuous IV infusion at 20 mcg/kg per minute and titrate up to a maximum dose of 80 mcg/kg per minute, as needed, for rhythm control (maximum daily dose, 2 g over 24 hours)
- Measure plasma levels (procainamide and N-acetyl procainamide) four hours after completion of the loading dose
|
| Sodium bicarbonate¶¶ | - Hyperkalemia
- Poisoning by sodium channel blocking agents (eg, cyclic antidepressants, type Ia antiarrhythmic agents) with prolongation of QRS interval (>0.1 msec)
- Prolonged cardiac arrest with documented severe metabolic acidosis (routine use in resuscitation is NOT recommended)
- Shock with documented metabolic acidosis
| - Infants <6 months: 1 mEq/kg IV or IO given as 2 mL/kg of 4.2% solution
- Infants ≥6 months and children: 1 mEq/kg IV or IO given as 1 mL/kg of 8.4% solution
- Maximum single dose 50 mEq (child) to 100 mEq (adolescent)
- 0.5 mEq/kg subsequent doses after 10 minutes given as:
- Child: 0.5 mL/kg of 8.4% solution
- Infants under 6 months: 1 mL/kg of 4.2% solution
- Forms precipitate with calcium and can inactivate epinephrine, do not co-infuse
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