Pediatric Emergency Medication Guidelines

Cardiac Arrest Management

The American Heart Association recommends administering epinephrine 0.01 mg/kg (10 mcg/kg) IV/IO every 3-5 minutes with a maximum single dose of 1 mg for pediatric cardiac arrest 1, 2, 3
The American Academy of Pediatrics suggests that high-dose epinephrine (>10 mcg/kg) is associated with reduced 24-hour survival and does not improve neurologic outcomes in pediatric cardiac arrest 1, 2
Routine administration of sodium bicarbonate is not recommended during pediatric cardiac arrest, unless there is a specific indication such as severe metabolic acidosis or hyperkalemia 1, 2, 4, 5
The American Heart Association states that vasopressin is not recommended for routine use in pediatric cardiac arrest, as evidence shows it is associated with lower return of spontaneous circulation and trends toward worse survival compared to epinephrine alone 1, 2, 6
The American Academy of Pediatrics recommends checking blood glucose during resuscitation and treating hypoglycemia promptly, as hypoglycemia can be a reversible cause of cardiac arrest in children 4, 5

The American Academy of Pediatrics recommends administering epinephrine 0.01 mg/kg IM into the mid-outer thigh immediately upon recognition of anaphylaxis, with a maximum dose of 0.3 mg for prepubertal children and 0.5 mg for adolescents and adults 7
The American Academy of Allergy, Asthma, and Immunology suggests that delayed epinephrine administration is associated with poor outcomes and fatality, and that antihistamines or bronchodilators should not be substituted for epinephrine 7, 8
Diphenhydramine 1-2 mg/kg IV/IM (maximum 50 mg per dose) may be given after epinephrine as an adjunctive medication for anaphylaxis, but it should be administered slowly to avoid seizure precipitation 9, 8

No cited facts are available for status epilepticus management, as all relevant information is marked as [ignore ref]

The American Heart Association recommends basing initial resuscitation drug doses on actual body weight in non-obese children, and using ideal body weight estimated from length in obese patients to avoid drug toxicity 2, 3
The American Academy of Pediatrics suggests titrating subsequent doses based on observed clinical effects and toxicities, not exceeding adult maximum doses 1, 2, 3

The American Heart Association recommends administering epinephrine via intravenous (IV) or intraosseous (IO) routes, with a standard concentration of 1:10,000 (0.1 mg/mL), for pediatric cardiac arrest patients 10, 11

The American Heart Association suggests that high-dose epinephrine (0.1 mg/kg) should not be used in pediatric cardiac arrest, as it is associated with reduced 24-hour survival and does not improve neurologic outcomes 12
Early administration of the initial epinephrine dose is strongly suggested in pediatric patients with nonshockable cardiac arrest, according to the 2020 International Consensus 13

If vascular access cannot be established, endotracheal epinephrine may be used at a higher dose of 0.1 mg/kg to achieve equivalent biological effect, although it results in lower and more unpredictable drug levels compared to IV/IO routes 10, 11

For neonates with heart rate <60 bpm despite adequate ventilation and chest compressions, the recommended IV dose is 0.01 to 0.03 mg/kg, and the endotracheal dose is 0.05 to 0.1 mg/kg (if IV access not available) 12

The 2020 International Consensus states that confidence in optimal interval timing is too low to make specific recommendations, but very frequent dosing (<3 minutes) may be associated with harm compared to 3-5 minute intervals 13

The American Heart Association recommends administering epinephrine 1 mg IV/IO every 3-5 minutes for adults during cardiac arrest, continuing until return of spontaneous circulation (ROSC) is achieved 14
For pediatric patients, the American Heart Association recommends administering 0.01 mg/kg (0.1 mL/kg of 1:10,000 concentration) IV/IO every 3-5 minutes, with a maximum single dose of 1 mg 15, 16, 17
The timing of drug administration is less important than minimizing interruptions in chest compressions—epinephrine should be administered during ongoing chest compressions 15

More frequent dosing (<3 minutes) may be harmful: Pediatric data shows that dosing intervals less than 3 minutes were associated with lower 12-month survival compared to 3-5 minute intervals (adjusted OR 0.50; 95% CI, 0.24-1.06) 18
Longer intervals (>5 minutes) may delay beneficial effects: While some observational data suggested potential benefit from longer intervals (5-8 minutes), this likely reflects resuscitation time bias rather than true therapeutic benefit 18

Early administration of the first dose matters more than the interval between subsequent doses: For pediatric patients with nonshockable rhythms, every minute delay in the first epinephrine dose significantly decreases ROSC, 24-hour survival, and survival to discharge 17
Patients receiving the first dose within 5 minutes of CPR initiation had significantly better outcomes than those receiving it after 5 minutes 17, 19
Prepare epinephrine doses in advance so administration can occur as soon as possible without interrupting chest compressions 15

Do not give epinephrine more frequently than every 3 minutes in an attempt to improve outcomes—this may actually worsen survival, particularly in pediatric patients 18
Do not use high-dose epinephrine (>1 mg in adults or >0.01 mg/kg in children)—multiple studies show no survival benefit and potential harm, particularly in pediatric asphyxial arrest 15, 16
Do not interrupt chest compressions to administer epinephrine—drug administration should occur during ongoing compressions 15

IV/IO administration is strongly preferred over endotracheal administration when possible, as it provides more predictable drug levels 17
If endotracheal administration is necessary, use a higher dose (0.1 mg/kg in pediatrics, 2-2.5 mg in adults) to compensate for reduced bioavailability 15