PEDIATRIC SURGE POCKET GUIDE. Clinical checklists, guides, and just-in-time references to manage a surge of pediatric patients.

Transcription

1 PEDIATRIC SURGE POCKET GUIDE Clinical checklists, guides, and just-in-time references to manage a surge of pediatric patients. Sections Normal Values Triage and Assessment Treatment and Medications Equipment Decontamination Mental Health Pediatric Safe Areas

2 PEDIATRIC SURGE POCKET GUIDE This Pocket Guide was a collaborative effort by: Los Angeles County Department of Public Health Los Angeles County Emergency Medical Services Agency Childrens Hospital Los Angeles Pediatric Liaison Nurses of Los Angeles County Pediatric Disaster Resource Center Long Beach Department of Health and Human Services Pasadena Public Health Department This publication was supported by Grant Cooperative Agreement number 5U90TP from the U.S. Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC. June 2009

3 PEDIATRIC SURGE POCKET GUIDE: CONTENTS Overview: Pediatric Risks During Disasters...1 Section 1: Normal Values...2 Using Kilograms...3 Normal Pediatric Vital Signs...4 Normal Development...5 Daily Maintenance Fluid and Electrolyte Requirements...6 Normal Blood Volume...7 IV Administration Tips...8 Appropriate Infant Nutritional Components... 9 Section 2: Triage and Assessment...10 Pediatric Assessment Triangle...11 JumpSTART Field Pediatric Multicasualty Triage System...12 Treatment Prioritization...13 Clinical Features of Dehydration...14 Wong-Baker FACES Pain Rating Scale...15

4 FLACC Post-Operative Pain Scale...16 Glasgow Coma Scale...17 Burn Assessment: Pediatric Rule of Nines...18 Section 3: Treatment and Medications...19 Fluid Resuscitation...24 Hypovolemic Shock...25 Analgesics Acetaminophen, Ibuprofen, Morphine...26 Fentanyl...28 Dilaudid...30 Lortab...32 Antibiotics Doxycycline, Doxycycline for Anthrax...34 Clindamycin...36 Vancomycin...38 Metronidazole...39 Amoxicillin...40 Cefazolin...42

5 Ceftriaxone...44 Ciprofloxacin, Ciprofloxacin for Anthrax...46 Cefotaxime...48 Antipyretics Acetaminophen, Ibuprofen...50 Antivirals Seasonal Flu...51 H1N1 Influenza...52 Asthma Medications Albuterol...54 Methylprednisolone, Prednisone...56 Racemic Epinephrine...58 Atrovent...60 Xopenex (levalbuterol)...62 Cardiac Medications Adenosine, Furosemide, Labetalol, Nifedipine...64

6 Infusion Formulas Dopamine/Dobutamine, Epinephrine/Norepinephrine, Amiodarone, Lidocaine, Milrinone, Nitroprusside/Nicardipine, Terbutaline...66 Neurology Medications Lorazepam, Diazepam Rectal, Fosphenytoin, Phenobarbital, Mannitol 20%...67 Paralyzing Agents Rocuronium, Succinylcholine, Vecuronium...69 Resuscitation Medications Atropine, Amiodarone, Calcium Chloride 10%, Epinephrine 1:10,000, Epinephrine 1: Glucose (D25W), Glucose (D10W), Lidocaine, Sodium bicarb 4.2%, Sodium bicarb 8.4 %...72 Reversal Agents Flumazenil, Naloxone...74 Sedation Medications Etomidate, Fentanyl, Ketamine, Midazolam, Thiopental...75

7 Other Medications Diphtheria Tetanus...77 Color Code Drug Doses by Weight 3 kg, Color Code: Grey kg, Color Code: Grey kg, Color Code: Grey kg, Color Code: Pink kg, Color Code: Red kg, Color Code: Purple kg, Color Code: Yellow kg, Color Code: White kg, Color Code: Blue kg, Color Code: Orange kg, Color Code: Green...88 Nerve Agent & Cyanide Treatment Overview months, Color Code: Grey - Avg Wt: 4 kg months, Color Code: Pink - Avg Wt: 6.5 kg mos, Color Code: Red - Avg Wt: 8.5 kg mos, Color Code: Purple - Avg Wt: 10.5 kg...93

8 1.5-3 yrs, Color Code: Yellow - Avg Wt: 13 kg Years, Color Code: White - Avg Wt: 16.5 kg Years, Color Code: Blue - Avg Wt: 20.5 kg Years, Color Code: Orange - Avg Wt: 26 kg yrs, Color Code: Green - Avg Wt: 33 kg...98 Burn Treatment: Fluid Resuscitation...99 Section 4: Equipment Equipment Estimations Equipment Sizes C-Collar Size Information Section 5: Decontamination Decontamination Considerations Ambulatory Decon: Infants and Toddlers: Less than 2 years old Ambulatory Decon: Pre-School: 2-8 years old Ambulatory Decon: School Age: 8-18 years old Non-Ambulatory Decon: All Ages...110

9 Section 6: Mental Health Psychological First Aid: Objectives Psychological First Aid: Steps Psychological First Aid: Steps Mental Health Considerations Section 7: Pediatric Safe Areas Security Considerations Pediatric Safe Area Considerations: Location Pediatric Safe Area Considerations: Equipment and Supplies Pediatric Identification Considerations for Accompanied Children Resource Contacts References Notes Pages...124

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11 OVERVIEW: PEDIATRIC RISKS DURING DISASTERS Characteristic Respiratory Gastrointestinal Skin Endocrine Thermoregulation Developmental Psychological Risk Higher breaths/minute increases exposure to inhaled agents Nuclear fallout and heavier gases settle lower to the ground and may affect children more severely. May be more at risk for dehydration from vomiting and diarrhea after exposure to contamination. Higher body surface area increases risk of skin exposure. Skin is thinner and more susceptible to injury from burns, chemicals and absorbable toxins. Increased risk of thyroid cancer from radiation exposure. Less able to cope with temperature problems with higher risk of hypothermia. Less capability to escape environmental dangers or anticipate hazards. Prolonged stress from critical incidents. Susceptible to separation anxiety. 1

12 SECTION 1: NORMAL VALUES Contents Using Kilograms...3 Normal Pediatric Vital Signs...4 Normal Development...5 Daily Maintenance Fluid and Electrolyte Requirements...6 Normal Blood Volume...7 IV Administration Tips...8 Appropriate Infant Nutritional Components...9 2

13 USING KILOGRAMS Weigh all children in kilograms. 1kg = 2.2 lbs Example: 20 lb child 20 lb divided by 2.2 = 9 kg Method to estimate weight: Newborn (term): usually 3 kg 1-10 yrs: age multiplied by (kg) >10 yrs: age multiplied by (kg) If available, a Broselow Tape may be used for weight estimation. 3

14 NORMAL PEDIATRIC VITAL SIGNS HR beats/min RR breaths/min BP (sys) mm/hg BP (dias) mm/hg Newborn 0-1 month Infant 1-12 months Toddler 1-3 years Pre-School Age 3-5 years School Age 5-11 years Adolescent years Adult 18+ years

15 NORMAL DEVELOPMENT Age Gross Motor Skills Fine Motor Skills 2 months Flexed position when prone Inhibited grasp reflex 4 months Rolls from front to back, back to side Carries object to mouth 6 months Rolls from back to abdomen Holds bottle 9 months Sits steady, creeps or crawls Holds objects in both hands and bangs together 12 months Cruises well Bangs 2 blocks together mos Pushes and pulls toys Uses cup well, some spoon agility 2 years Runs well with wide stance Turns doorknob and unscrews lids 3 years Climbs stairs alternating feet Copies circles and cross 4 years Hops, jumps, and skips on one foot Draws person with greater than 3 body parts 5 years Skips alternating feet Prints some letters 5

16 DAILY MAINTENANCE FLUID AND ELECTROLYTE REQUIREMENTS Calculation Fluids Per Hour Fluids Per 24 Hour Period Maintenance Electrolyte Calculations for IV Fluid 4mL/kg/hr for first 10kg of weight 2mL/kg/hr for next 10 kg of weight 1mL/kg/hr for each kg over 20kg 100mL/kg for the first 10kg body weight 1000mL+ 50mL/kg for the next 10kg body weight 1500mL+ 20mL for each kg of body weight over 20kg Sodium: 3-4 meq/kg/day or meq/m2/day Potassium: 2-3 meq/kg/day or meq/m2/day 6

17 Total blood volume varies by weight. Approximate volume is 80mL/kg. NORMAL BLOOD VOLUME Examples: Newborn = ~3 kg x 80mL = 240 ml 5 year old = ~25 kg x 80mL = 2000 ml (2L) 13 year old = ~50 kg x 80mL = 4000 ml (4L) PRBC/Platelet/Albumin 5%/FFP = 10mL/kg 7

18 IV ADMINISTRATION TIPS For IV infusions in children, an over the-needle 22 to 24 gauge catheter may be used It may be possible to place a larger gauge catheter in older children Catheter should be secured with a transparent dressing and tape Use of a padded armboard may be helpful to secure IV in young children It is important to secure IV tubing to prevent infants and children from becoming entangled or from accidently pulling catheter or needle out If possible, amount of fluid hung that can be infused to patient should be limited to 2 of fluid with the use of buretrol or IV pump 8

19 APPROPRIATE INFANT NUTRITIONAL COMPONENTS Age Birth - 1 month 2-3 ounces (6-90 ml) per feeding breast or bottle every months 3-4 ounces ( ml) per feeding every months 6-8 months 8-10 months months Formulas 4-5 ounces ( ml) per feeding, four or more time daily Begins baby food, usually rice cereal 6-8 ounces ( ml) per feeding, four times daily Eats baby food such as rice cereal, fruits and vegetables 6 ounces (180 ml) per feeding, four times a day Soft finger foods 6-8 ounces ( mL) per feeding, four times a day Soft table foods, uses spoon and cup with lid Milk Based: Enfamil, Enfacare & Similac Soy Based: Prosobee & Isomil 9

20 SECTION 2: TRIAGE AND ASSESSMENT TOOLS Contents Pediatric Assessment Triangle...11 JumpSTART Field Pediatric Multicasualty Triage System...12 Treatment Prioritization...13 Clinical Features of Dehydration...14 Wong-Baker FACES Pain Rating Scale...15 FLACC Post-Operative Pain Scale...16 Glasgow Coma Scale...17 Burn Assessment: Pediatric Rule of Nines

21 PEDIATRIC ASSESSMENT TRIANGLE APPEARANCE Mental status Muscle tone Body position CIRCULATION Color Component Appearance Breathing Circulation Signs Focus on the child s mental status and muscle tone Direct attention to respiratory rate and respiratory effort Use skin signs, color and capillary refill as indicators of the patient s circulatory status 11

22 JUMPSTART FIELD PEDIATRIC MULTICASUALTY TRIAGE SYSTEM MINOR IMMEDIATE DECEASED IMMEDIATE IMMEDIATE IMMEDIATE DECEASED IMMEDIATE DELAYED 12

23 TREATMENT PRIORITIZATION Triage Category RED Immediate YELLOW Delayed GREEN Minimal BLACK Expectant or Dead Description Patients who do not obey commands, or do not have a peripheral pulse, or are in respiratory distress, or have uncontrolled major hemorrhage Remaining patients who do not fit the Red/Immediate or Green/Minimal categories Patients with mild injuries that are self-limited and can tolerate a delay in care without increasing mortality risk Expectant: Patients who have injuries incompatible with life given the currently available resources Dead: Patients who are not breathing after life-saving interventions 13

24 CLINICAL FEATURES OF DEHYDRATION Feature Mild (<5%) Moderate (5% to 10%) Severe (<10%) Heart rate Normal Slightly increased Rapid, weak Systolic BP Normal Normal to orthostatic, >10 mmhg change Hypotension Urine output Decreased Moderately decreased Marked decrease, anuria Mucous membranes Anterior fontanel Slightly dry Very dry Parched Normal Normal to sunken Sunken Tears Present Decreased, eyes sunken Absent, eyes sunken Skin Normal turgor Decreased turgor Tenting Skin perfusion Normal capillary refill (<2 seconds) Capillary refill slowed (2-4 seconds); skin cool to touch Capillary refill markedly delayed (>4 seconds); skin cool, mottled, gray 14

25 WONG-BAKER FACES PAIN RATING SCALE Instructions: 1. Point to each face using the words to describe the pain intensity. 2. Ask the child to choose face that best describes own pain and record the appropriate number. Rating scale is recommended for persons age 3 years and older. 15

26 FLACC POST-OPERATIVE PAIN SCALE Category Face No particular expression or smile Occasional grimace or frown, withdrawn, disinterested Frequent to constant frown, clenched jaws, quivering chin Legs Normal position or relaxed Uneasy, restless, tense Kicking or legs drawn up Activity Lying quietly, normal position, moves easily Squirming, shifting back and forth, tense Arched, rigid, or jerking Cry No cry (awake or asleep) Moans, whimpers, occasional complaint Crying steadily, screams or sobs, frequent complaints Consolability Content, relaxed Reassured by occasional touching, hugging or being talked to, distractible Difficult to console or comfort Five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; and (C) Consolability; is scored from 0-2, which results in a total score between zero and ten. 16

27 GLASGOW COMA SCALE Category For Patients <2 Years Old For Patients >2 Years Old Eye Opening (E) Verbal Response (V) (4) Spontaneous (3) To speech (2) To pain (1) None (5) Coos, babbles (4) Irritable, cries (3) Cries to pain (2) Moans to pain (1) None (4) Spontaneous (3) To speech (2) To pain (1) None (5) Oriented (4) Confused (3) Inappropriate words (2) Incomprehensible (1) None Motor Response (M) (6) Normal spontaneous movements (5) Withdraws from touch (4) Withdraws from pain (3) Abnormal flexion (2) Abnormal extension (1) None The lowest possible score is 3 (deep coma or death). The highest is 15 (fully awake and aware) (6) Obeys commands (5) Localizes to pain (4) Withdrawal to pain (3) Flexion to pain (2) Extension to pain (1) None 17

28 BURN ASSESSMENT: PEDIATRIC RULE OF NINES The Rule of Nines is a convenient, quick method to determine burn size. Only second and third degree burn injury are used to calculate the extent of burn that is applied to burn formula calculations. Alternate Method: The size of the patient s hand, including the fingers, represents approximately 1% of their body surface. This is useful to for mapping irregular areas of burns. Pediatric Considerations Increased fluid requirements relative to adults Increased surface area : mass ratio Hypoglycemia may occur in infants (<30 kg) due to limited glycogen reserves 18

29 SECTION 3: TREATMENT AND MEDICATIONS Contents Fluid Resuscitation...24 Hypovolemic Shock...25 Analgesics Part 1: Newborn - 6 Years: Acetaminophen, Ibuprofen, Morphine...26 Part 1: 7 Years and Older: Acetaminophen, Ibuprofen, Morphine...27 Part 2: Newborn - 6 Years: Fentanyl...28 Part 2: 7 Years and Older: Fentanyl...29 Part 3: Newborn - 6 Years: Dilaudid (Oral, IV, IM, SubQ)...30 Part 3: 7 Years and Older: Dilaudid (Oral, IV, IM, SubQ)...31 Part 4: Newborn - 6 Years: Lortab...32 Part 4: 7 Years and Older: Lortab...33 Antibiotics Part 1: Newborn - 6 Years: Doxycycline, Doxycycline for Anthrax...34 Part 1: 7 Years and Older: Doxycycline, Doxycycline for Anthrax...35 Part 2: Newborn - 6 Years: Clindamycin...36 Part 2: 7 Years and Older: Clindamycin...37 Part 3: Vancomycin...38 Part 4: Metronidazole...39 Part 5: Newborn - 6 Years: Amoxicillin

30 Part 5: 7 Years and Older: Amoxicillin...41 Part 6: Newborn - 6 Years: Cefazolin...42 Part 6: 7 Years and Older: Cefazolin...43 Part 7: Newborn - 6 Years: Ceftriaxone...44 Part 7: 7 Years and Older: Ceftriaxone...45 Part 8: Newborn - 6 Years: Ciprofloxacin, Ciprofloxacin for Anthrax...46 Part 8: 7 Years and Older: Ciprofloxacin, Ciprofloxacin for Anthrax...47 Part 9: Newborn - 6 Years: Cefotaxime...48 Part 9: 7 Years and Older: Cefotaxime...49 Antipyretics: Acetaminophen, Ibuprofen...50 Antivirals Seasonal Flu...51 H1N1 Influenza: Less than 1 Year: Oseltamivir...52 H1N1 Influenza: 1 Year and Older: Oseltamivir...53 Asthma Medications Part 1: Newborn - 6 Years: Albuterol...54 Part 1: 7 Years and Older: Albuterol...55 Part 2: Newborn - 6 Years: Methylprednisolone, Prednisone...56 Part 2: 7 Years and Older: Methylprednisolone, Prednisone...57 Part 3: Newborn - 6 Years: Racemic Epinephrine...58 Part 3: 7 Years and Older: Racemic Epinephrine...59 Part 4: Newborn - 6 Years: Atrovent

31 Part 4: 7 Years and Older: Atrovent...61 Part 5: Newborn - 6 Years: Xopenex (levalbuterol)...62 Part 5: 7 Years and Older: Xopenex (levalbuterol)...63 Cardiac Medications Newborn to 6 Years Old: Adenosine, Furosemide, Labetalol, Nifedipine Years and Older: Adenosine, Furosemide, Labetalol, Nifedipine...65 Infusion Formulas: Dopamine/Dobutamine, Epinephrine/Norepinephrine, Amiodarone, Lidocaine, Milrinone, Nitroprusside/Nicardipine, Terbutaline...66 Neurology Medications Newborn to 6 Years: Lorezepam, Diazepam Rectal, Fosphenytoin, Phenobarbital, Mannitol 20% Years and Older: Lorezepam, Diazepam Rectal, Fosphenytoin, Phenobarbital, Mannitol 20%...68 Paralyzing Agents: Rocuronium, Succinylcholine, Vecuronium...69 Resuscitation Medications Part 1: Newborn to 6 Yrs: Atropine, Amiodarone, Calcium Chloride 10%, Epinephrine 1:10,000, Epinephrine 1: Part 1: 7 Years and Older: Atropine, Amiodarone, Calcium Chloride 10%, Epinephrine 1:10,000, Epinephrine 1: Part 2: Newborn -6 Yrs: Glucose (D25W), Glucose (D10W), Lidocaine, Sodium bicarb 21

32 4.2%, Sodium bicarb 8.4 %...72 Part 2: 7 Years and Older: Glucose (D25W), Glucose (D10W), Lidocaine, Sodium bicarb 4.2%, Sodium bicarb 8.4 %...73 Reversal Agents: Flumazenil, Naloxone...74 Sedation Medications Newborn to 6 Years Old: Etomidate, Fentanyl, Ketamine, Midazolam, Thiopental Years and Older: Etomidate, Fentanyl, Ketamine, Midazolam, Thiopental...76 Other Medications: Diphtheria Tetanus...77 Color Code Drug Doses by Weight 3 kg, Color Code: Grey kg, Color Code: Grey kg, Color Code: Grey kg, Color Code: Pink kg, Color Code: Red kg, Color Code: Purple kg, Color Code: Yellow kg, Color Code: White kg, Color Code: Blue kg, Color Code: Orange kg, Color Code: Green

33 Nerve Agent & Cyanide Treatment Overview months, Color Code: Grey - Avg Wt: 4 kg months, Color Code: Pink - Avg Wt: 6.5 kg mos, Color Code: Red - Avg Wt: 8.5 kg mos, Color Code: Purple - Avg Wt: 10.5 kg yrs, Color Code: Yellow - Avg Wt: 13 kg Years, Color Code: White - Avg Wt: 16.5 kg Years, Color Code: Blue - Avg Wt: 20.5 kg Years, Color Code: Orange - Avg Wt: 26 kg yrs, Color Code: Green - Avg Wt: 33 kg...98 Burn Treatment: Fluid Resuscitation

34 FLUID RESUSCITATION 1. Administer 20 ml/kg of isotonic or crystalloid solution (NS or LR) 2. Monitor Peripheral perfusion Urine output Vital signs LOC 3. Repeat bolus if no improvement 4. Reassess status Consider blood products in traumatic injuries requiring >40-60 ml/kg of fluid PRBC/Platelet/Albumin 10mL/kg See next page on Hypovolemic Shock. 24

35 HYPOVOLEMIC SHOCK Hypovolemic shock is the most common type of shock in children. Blood is the ideal fluid replacement for volume losses caused by trauma in children who do not respond to ml/kg of NS/LR. Children increase their cardiac output by tachycardia, therefore: Bradycardia is an ominous sign! Things to look for: Slow or irregular breathing Grunting Bradycardia Cyanosis Hypotension Decreased LOC 25

36 ANALGESICS, PART 1: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Acetaminophen /kg/ every 4-6 Oral Ibuprofen 5-10 /kg every 6-8 Max 40 / kg/day Oral X Morphine /kg every 2-4, as needed Max 15/ dose IV/IM/ SubQ q 4-8 hrs

37 ANALGESICS, PART 1: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Acetaminophen /kg/ q 4-6 Max 4 g/day Oral Ibuprofen 5-10 /kg q 6-8 Max 40 / kg/day or 1.2 g/day Oral Morphine /kg every 2-4, as needed Max 15 / dose IV/IM/ SubQ

38 ANALGESICS, PART 2: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Neonates: Slow IV push: 1-4 μg/kg/dose; May repeat every 2-4. Fentanyl Children, 1-12 years: Sedation for minor procedures/ analgesia Children, 1-3 years: 1-3 μg/kg/dose 3 min. before procedure, may repeat after minutes. Children: 3-12 years: 1-2 μg/kg/dose 3 min. before procedure; may repeat after 3-60 minutes. Neonates: Slow IV push Children: IM/ slow IV push 3-12 μg 5-20 μg μg μg μg 28

39 ANALGESICS, PART 2: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Fentanyl Children, 1-12 years: Sedation for minor procedures/analgesia Children, 3-12 years: 1-2 μg /kg/dose 3 min. before procedure; may repeat after 3-60 minutes. IM/ slow IV push μg μg μg μg 29

40 ANALGESICS, PART 3: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Dilaudid Young children <11 years: /kg/ dose every 4-6 as needed Max dose 5/dose. Oral Dilaudid Young children <11 years: /kg/dose every 3-6 as needed. Children <11 years: IV

41 ANALGESICS, PART 3: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Dilaudid Young children <11 years: /kg/dose every 4-6 as needed; Max dose 5/dose. Older children >12 years: 1-2 /dose every 3-4 as needed Oral Dilaudid Young children <11 years: /kg/dose every 3-6 as needed. Older children >12 years: /dose every 3-4 as needed Children <11 yrs: IV Children >12 yrs: IM/IV/ SubQ

42 ANALGESICS, PART 4: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Lortab For moderate to severe pain Children and adults <50 kg: Usual initial dose: 0.2 /kg every 3-4 as the hydrocodone component. Oral X X

43 ANALGESICS, PART 4: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Lortab For moderate to severe pain Children and adults <50 kg: Usual initial dose: 0.2 /kg every 3-4 Children and adults 50 kg: Usual initial dose: 10 every 3-4 as the hydrocodone component. Oral

44 ANTIBIOTICS, PART 1: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Doxycycline None for ages Newborn to 6 years n/a None Doxycycline for Anthrax None for ages Newborn to 6 years n/a None 34

45 ANTIBIOTICS, PART 1: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Doxycycline Children 8 yrs: 1-2 /kg every12 Not to exceed 200 /day. Adolescents and adults: /day in 1-2 divided doses Oral/IV Doxycycline for Anthrax Children 8 yrs: 2.5 /kg every 12 for 60 days Adolescents and adults: 100 every 12 for 60 days. Oral/IV

46 ANTIBIOTICS, PART 2: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Clindamycin Neonates >2000 g: /kg/day divided every 6-8 Infants and children: /kg/day divided every 6-8 Max dose: 4.8 g/day Neonates: IM/IV Infants, children: Oral/IM/IV per day divided every per day divided every per day divided every per day divided every per day divided every

47 ANTIBIOTICS, PART 2: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Clindamycin Infants and children: /kg/day divided every 6-8 Max dose: 4.8 g/day. Adolescents and adults: g/day in divided doses Max dose: 4.8 g/day Oral/IM/IV per day divided every per day divided every g per day divided every

48 ANTIBIOTICS, PART 3 Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Vancomycin Neonates > 2000g: 45 /kg/day divided every 8 hrs Infants >1 month and children: 40 /kg/day in divided doses every 6 hrs IV 45 every 8 50 every every every every 8 Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Vancomycin 40 /kg/day in divided doses every 6 hrs IV 250 every every every every 8 38

49 ANTIBIOTICS, PART 4 Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Metronidazole Neonates >2000 g: 30 /kg/day divided every12 hrs Infants and children: 30/kg/day divided every 6-8 Max dose: 4 g/ day Oral/IV 45 every per day divided every per day divided every per day divided every per day divided every 6-8 Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Metronidazole 30/kg/day divided every 6-8 hrs Max dose: 4 g/day Oral/IV 750 per day divided q per day divided q per day divided q per day divided q

50 ANTIBIOTICS, PART 5: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Amoxicillin Neonates and infants <3 mos: /kg/day in divided doses every 12 Infants >3 months and children: /kg/day in divided doses every 12 Oral per day divided every per day divided every per day divided every per day divided every per day divided every 12 40

51 ANTIBIOTICS, PART 5: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Amoxicillin Children: /kg/day in divided doses every 12 Adults: every 8 Max dose 2-3 g/day Oral per day divided every per day divided every per day divided every 12 Adults per day divided every 8 41

52 ANTIBIOTICS, PART 6: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Cefazolin Neonates >2000g: 60 /kg/day divided every 8. Infants and children: /kg/day in divided doses every 8 Max dose 6g/day Oral 180 per day divided every per day divided every per day divided every per day divided every per day divided every 8 42

53 ANTIBIOTICS, PART 6: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Cefazolin Children: /kg/day in divided doses every 8 Max dose 6g/day Adults: g every 6-8. Oral per day divided every per day divided every per day divided every g every

54 ANTIBIOTICS, PART 7: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Ceftriaxone Neonates >2000g: /kg/day given every 24 Infants and children: /kg/day divided every Neonates Oral Infants and children: Oral/IM every per day divided every per day divided every per day divided every per day divided every

55 ANTIBIOTICS, PART 7: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Ceftriaxone Children: /kg/day divided every Adults: 1-2 g every Max dose: 4 g/day Children: Oral/IM Adults: Oral per day divided every per day divided every per day divided every g per dose 45

56 ANTIBIOTICS, PART 8: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Ciprofloxacin Neonates: 7-40 /kg/day divided q 12 hrs Children: IV /kg/day divided q 12 hrs Max dose: 800 /day Neonate s: IV Children: Oral/IV per day divided every per day divided every per day divided every per day divided every per day divided every 12 Ciprofloxacin for Anthrax Children: /kg/day divided every 12 hrs for 60 days Max dose: 800 /day Oral: 30 /kg/day divided q 12 IV: 20 /kg/day divided q per day divided every per day divided every per day divided every per day divided every per day divided every 12 46

57 ANTIBIOTICS, PART 8: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Ciprofloxacin Children: IV /kg/day divided q 12 Max dose: 800 /day Adults: every 12 Children: Oral/IV Adults: Oral/IV per day divided every per day divided every per day divided every per day divided every 12 Ciprofloxacin for Anthrax Children: /kg/day divided q 12 hrs for 60 days Max dose: 800 /day Adults: Oral: 500 q 12 for 60 days IV: 400 q 12 hrs for 60 days Oral: 30 /kg/day divided q 12 IV: 20 /kg/day divided q per day divided every per day divided every per day divided every per day divided every 12 47

58 ANTIBIOTICS, PART 9: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Cefotaxime Neonates >2000g: /kg/day divided every 6-8 Infants and children, 1-12 years: <50 kg: /kg/day divided every 6-8 Max: 2g/dose IV per day divided every per day divided every per day divided every per day divided every 6-8 Max 2 g/ dose per day divided every 6-8 Max 2 g/ dose 48

59 ANTIBIOTICS, PART 9: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Cefotaxime Children, 1-12 years: <50 kg: /kg/day divided every 6-8 Max: 2 g/dose IV 2500 per day divided every g per day divided every g per dose every g per dose every kg: 1-2 g every 6-8 hrs Max: 12 g/day Max 2 g/ dose Max 2 g/ dose Max 2 g/ dose Max 12 g/ day 49

60 ANTIPYRETICS Drug Dose Route 0-3 mos (3 kg) 4-11 mos (6 kg) 1-2 years (9 kg) 2-3 yrs (12 kg) Acetaminophen /kg every 4-6 Oral Ibuprofen 5-10 /kg Oral X 5-10 /kg every 6-8 Max 40 /kg/day Drug Dose Route 4-5 yrs (18 kg) 6-8 yrs (24 kg) 9-10 yrs (30 kg) 11 yrs (36 kg) Acetaminophen /kg every 4-6 Oral Ibuprofen 5-10 /kg Oral 5-10 /kg every 6-8 Max 40 /kg/day 50

61 ANTIVIRALS: SEASONAL FLU Recommendations for the treatment and chemoprophylaxis of influenza change frequently, in particular because of changes in circulating strains and their antiviral resistance. It is important to check the CDC website for the latest recommendations. CDC antiviral recommendations can be found here: 51

62 ANTIVIRALS: H1N1 INFLUENZA: LESS THAN 1 YEAR Recommendations for the treatment and chemoprophylaxis of H1N1 influenza change frequently, in particular because of ongoing antiviral resistance. Check the CDC website for the latest recommendations: Age Oseltamivir: Recommended treatment dose for 5 days <3 months 12 twice daily 3-5 months 20 twice daily 6-11 months 25 twice daily Age Oseltamivir: Recommended prophylaxis dose for 10 days <3 months Not recommended unless situation judged critical due to limited data on use in this age group 3-5 months 20 once daily 6-11 months 25 once daily Pregnant women are known to be at higher risk for complications from infection with seasonal influenza viruses, and severe disease among pregnant women was reported during past pandemics. For further information about influenza antiviral medications, including contraindications and adverse effects, refer to the CDC website. 52

63 ANTIVIRALS: H1N1 INFLUENZA: 1 YEAR AND OLDER Recommendations for the treatment and chemoprophylaxis of H1N1 influenza change frequently, in particular because of ongoing antiviral resistance. It is important to check the CDC website for the latest recommendations. Information contained in the tables below can be found here: Agent, group Treatment Chemoprophylaxis Oseltamivir Children 12 months 15 kg or less 60 per day divided into 2 doses 30 once per day kg 90 per day divided into 2 doses 45 once per day kg 120 per day divided into 2 doses 60 once per day >40 kg 150 per day divided into 2 doses 75 once per day Zanamivir Children Two 5- inhalations (10 total) twice per day (age, 7 years or older) Two 5- inhalations (10 total) once per day (age, 5 years or older) 53

64 ASTHMA MEDICATIONS, PART 1: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Albuterol <12 years: 1-2 inhalation 4 times/day using a tube spacer >12 years and greater 1-2 inhalations every 4-6 Inhalation MDI: 90 µg/ spray <12 years: 1-2 inhalation 4 times/day using a tube spacer ml/kg of 0.5% solution every 4-6 Albuterol Range: every 2-6 hrs Max dose: 5 = 1 ml Min dose: 1.25 Inhalation solution (for nebulization) ml ml ml ml ml Dilute dosage in 1-2 ml NS 54

65 ASTHMA MEDICATIONS, PART 1: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Albuterol <12 years: 1-2 inhalation 4 times/day using a tube spacer > 12 years: 1-2 inhalations every 4-6 Inhalation MDI: 90 µg/ spray <12 years: 1-2 inhalation 4 times/day using a tube spacer 12 years and greater 1-2 inhalations every ml/kg of 0.5% solution every 4-6 Albuterol Range: every 2-6 hrs Max dose: 5 = 1 ml Min dose 1.25 Inhalation solution (for nebulization) ml ml ml ml Dilute dosage in 1-2 ml NS 55

66 ASTHMA MEDICATIONS, PART 2: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Methylprednisolone 1 /kg/dose every 6 IV X X Prednisone 1-2 /kg/day in divided doses 1-2 times/day for 3-5 days Oral X

67 ASTHMA MEDICATIONS, PART 2: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Methylprednisolone 1 /kg/dose every 6 IV Prednisone 1-2 /kg/day in divided doses 1-2 times/day for 3-5 days Oral per day divided doses, 1-2 times/day per day divided doses, 1-2 times/day per day divided doses, 1-2 times/day Max: 60 /day per day divided doses, 1-2 times/day Max: 60 /day 57

68 ASTHMA MEDICATIONS, PART 3: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Racemic Epinephrine µg (1 inhalation of a commercially available aerosol preparation) Repeated once, if necessary, after at least 1 minute Subsequent doses should not be administered for at least 3. Inhalation: MDI X X X X 1 inhalation Racemic Epinephrine, 2.25% solution 1 3 deep inhalations Do not repeat more often than every 3 Discontinue if symptoms not relieved within 20 minutes or if symptoms become worse Inhalation: Hand bulb nebulizer X X X X 1-3 deep inhalations 58

69 ASTHMA MEDICATIONS, PART 3: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) µg (1 inhalation of a commercially available aerosol preparation) Racemic Epinephrine Repeated once, if necessary, after at least 1 minute Subsequent doses should not be administered for at least 3. Inhalation: MDI 1 inhalation Racemic Epinephrine, 2.25% solution 1 3 deep inhalations Do not repeat more often than every 3 Discontinue if symptoms not relieved within 20 minutes or if symptoms become worse Inhalation: Hand bulb nebulizer 1 3 deep inhalations 59

70 ASTHMA MEDICATIONS, PART 4: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Atrovent (Oral, MDI) Children: 1-2 inhalations every 6-8 ; up to 6 inhalations in 24 Oral inhalation (MDI) X 1-2 inhalations every 6-8 ; up to 6 inhalations in 24 Atrovent (Inhalation, Nebulizer) Neonates: 25 µg/kg/dose 3 times/day Children: µg every 6-8 Inhalation solution (for nebulization) 75 µg µg every

71 ASTHMA MEDICATIONS, PART 4: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Atrovent (Oral, MDI) Children: 1-2 inhalations every 6-8 ; up to 6 inhalations in 24 Adolescents and adults: 2-3 inhalations 4 times/day; up to 12 inhalations in 24 Oral inhalation (MDI) 1-2 inhalations every 6-8 ; up to 6 inhalations in inhalations 4 times/day; up to 12 inhalations in 24 Atrovent (Inhalation, Nebulizer) Children: µg every 6-8 Inhalation solution (for nebulization) µg every

72 ASTHMA MEDICATIONS, PART 5: NEWBORN - 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Xopenex (levalbuterol) Acute asthma exacerbation (NAEPP, 2007) Children: /kg (minimum dose: 1.25 ) every 20 minutes for 3 doses then /kg (not to exceed 5 ) every 1-4 as needed Nebulizer X X Xopenex (levalbuterol) Acute asthma exacerbation (NAEPP, 2007) Children: 4-8 puffs every 20 minutes for 3 doses then every 1-4 Inhalation, MDI: 45 µg/spray X 4-8 puffs every 20 minutes for 3 doses then every

73 ASTHMA MEDICATIONS, PART 5: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Xopenex (levalbuterol) Acute asthma exacerbation (NAEPP, 2007) Children: /kg (minimum dose: 1.25 ) every 20 minutes for 3 doses then /kg (not to exceed 5 ) every 1-4 as needed Nebulizer Xopenex (levalbuterol) Acute asthma exacerbation (NAEPP, 2007) Children: 4-8 puffs every 20 minutes for 3 doses then every 1-4 Adults: 4-8 puffs every 20 minutes for up to 4 then every 1-4 as needed Inhalation, MDI: 45 µg/spray 4-8 puffs every 20 minutes for 3 doses then every

74 CARDIAC MEDICATIONS: NEWBORN TO 6 YEARS OLD Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Adenosine /kg IV rapid Furosemide 1 /kg IV Labetalol /kg IV X Nifedipine /kg PO X

75 CARDIAC MEDICATIONS: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Adenosine /kg IV rapid max 6-12 Furosemide 1 /kg IV Labetalol /kg IV max Nifedipine /kg PO max 10 65

76 INFUSION FORMULAS Drug Dose in μg/kg/min Preparation Dopamine/ Dobutamine Dopamine: 2-20 Dobutamine: [6 x (wt in kg)] = to add to 100mL D5W/IV rate of 1mL/hr = 1 μg/kg/min Epinephrine/ Norepinephrine Epi: Norepi: [0.6 x (wt in kg)] = to add to 100mL D5W/IV rate of 1mL/hr = 0.1 μg/kg/min Amiodarone 5-10 (load 5 /kg) [6 x (wt in kg)] = to add to 100mL D5W/IV rate of 1mL/hr = 1 μg/kg/min Lidocaine [120 x (wt in kg)] = to add to 100mL D5W/IV rate of 1mL/hr = 20 μg/kg/min Milrinone Nitroprusside/ Nicardipine (load μg/kg) Nitro: Nicard: [0.6 x (wt in kg)] = to add to 100mL D5W/IV rate of 1mL/hr = 0.1 μg/kg/min [6 x (wt in kg)] = to add to 100mL D5W/IV rate of 1mL/hr = 1 μg/kg/min Terbutaline 0.4 [0.6 x (wt in kg)] = to add to 100mL D5W/IV rate of 1mL/hr = 0.1 μg/kg/min 66

77 NEUROLOGY MEDICATIONS: NEWBORN TO 6 YEARS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Lorazepam /kg IV slow Diazepam Rectal /kg Rectal X X Fosphenytoin Load PE = /kg IV 30 min X Phenobarbital Load /kg IV infusn Mannitol 20% g/kg IV slow g g 5-10 g g g 67

78 NEUROLOGY MEDICATIONS: 7 YRS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Lorazepam /kg IV slow max 4 Diazepam Rectal /kg Rectal Fosphenytoin Load PE = /kg IV 30 min g Phenobarbital Load /kg IV infusn g Mannitol 20% g/kg IV slow g g g max 50 g 68

79 PARALYZING AGENTS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Rocuronium /kg IV Succinylcholine Vecuronium 1-2 /kg 0.1 /kg IV IV Drug Dose Ro ute 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Rocuronium /kg IV Succinylcholine 1-2 /kg IV Vecuronium 0.1 /kg IV (max 150) 5 (max 10) 69

80 RESUSCITATION MEDS, PART 1: NEWBORN - 6 YRS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Atropine 0.02 /kg IV/ETT Amiodarone Calcium Chloride 10% Epinephrine 1:10,000 Epinephrine 1: /kg x 3 max 20 /kg = 0.2 ml/kg 0.01 /kg = 0.1 ml/kg 0.1 /kg = 0.1 ml/kg IV IV slow IV/IO 0.3 ml 0.5 ml 1 ml 1.5 ml 2 ml IV/ETT/IO X 0.5 ml 1 ml 1.5 ml 2 ml 70

81 RESUSCITATION MEDS, PART 1: 7 YRS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Atropine 0.02 /kg IV/ETT max 1 Amiodarone 5 /kg x 3 max IV Calcium Chloride 10% 20 /kg = 0.2 ml/kg IV slow max 500 Epinephrine 1:10, /kg = 0.1 ml/kg IV/IO 2.5 ml 3 ml 4 ml max 10 ml Epinephrine 1: /kg = 0.1 ml/kg IV/ETT/IO 2.5 ml 3 ml 4 ml max 10 ml 71

82 RESUSCITATION MEDS, PART 2: NEWBORN - 6 YRS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Glucose (D25W) Glucose (D10W) 0.5 g/kg = 2mL/kg 0.5 g/kg = 5mL/kg IV X 10 ml 20 ml 30 ml 40 ml IV 15 ml 25 ml X X X Lidocaine 1 /kg IV/IO Sodium bicarb 4.2% Sodium bicarb 8.4 % 1 meq/kg = 2 ml/kg 1 meq/kg = 1 ml/kg IV 6 ml 10 ml X X X IV X X 10 ml 15 ml 20 ml 72

83 RESUSCITATION MEDS, PART 2: 7 YRS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Glucose (D25W) Glucose (D10W) 0.5 g/kg = 2mL/kg 0.5 g/kg = 5mL/kg IV 50 ml 60 ml 80 ml 100 ml IV X X X X Lidocaine 1 /kg IV/ETT max 100 Sodium bicarb 4.2% Sodium bicarb 8.4 % 1 meq/kg = 2 ml/kg 1 meq/kg = 1 ml/kg IV X X X X IV 25 ml 30 ml 40 ml 50 ml 73

84 REVERSAL AGENTS Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) Flumazenil 0.01 /kg IV Naloxone 0.1 /kg IV/ETT Drug Dose Route 4-6 yrs (20 kg) 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Flumazenil 0.01 /kg IV (1 max) Naloxone 0.1 /kg IV

85 SEDATION MEDICATIONS: NEWBORN TO 6 YEARS OLD Drug Dose Route Newborn (3 kg) 3-6 mos (5 kg) 1 year (10 kg) 2-3 yrs (15 kg) 4-6 yrs (20 kg) Etomidate 0.3 /kg IV Fentanyl analgesic <36 mos: 1-3μg/kg >36 mos: 1-2μg/kg IV slow 2-12 μg 5-20 μg μg μg μg Ketamine 1-2 /kg IV Midazolam /kg IV Thiopental 4-6/kg ETT

86 SEDATION MEDICATIONS: 7 YEARS AND OLDER Drug Dose Route 7-9 yrs (25 kg) yrs (30 kg) yrs (40 kg) >15 yrs (>50 kg) Etomidate 0.3 /kg IV Fentanyl 1-4μg/kg IV slow μg μg μg Ketamine 1-2 /kg IV μg (max 400) Midazolam /kg IV max max 5 Thiopental 4-6/kg ETT

87 OTHER MEDICATIONS Drug Dose Route DT (Diphtheria Tetanus) 0.5 ml IM DO NOT give SubQ 77

88 G R E Y COLOR CODE DRUG DOSES BY WEIGHT: 3 KG COLOR CODE: GREY NORMAL VITAL SIGNS Heart Rate: Respirations: B/P Systolic: >60 DEFIBRILLATION Cardioversion 3 Joules 6 Joules 6 Joules Defibrillation 6 Joules 12 Joules 12 Joules ACLS DRUGS-- INITIAL DOSE Adenosine: 0.3 Calcium Chloride: 60 Epinephrine 1:10,000: 0.03 Amiodarone: 15 Sodium Bicarbonate: 3 meq DOPAMINE (400 / 5mL) Add 18 (0.2 ml) to 100 ml bag of NS Start at 10 mcgtt/ minute Titrate to signs of adequate perfusion or maximum of 20 mcgtt/minute MEDICATIONS Albuterol HHN: 2.5 Dextrose 25% slow IV: 6 ml Midazolam IV/IM/IN: 0.3 Diphenhydramine*: 3 Epinephrine 1:1,000 IM: 0.03 Glucagon IM: 1 Morphine Sulfate*: 0.3 Naloxone IV/IM/IN: 0.3 Normal Saline IV Bolus: 60 ml * IV or IM G R E Y 78

89 G R E Y COLOR CODE DRUG DOSES BY WEIGHT: 4 KG COLOR CODE: GREY NORMAL VITAL SIGNS Heart Rate: Respirations: B/P Systolic: >60 DEFIBRILLATION Cardioversion 4 Joules 8 Joules 8 Joules Defibrillation 8 Joules 16 Joules 16 Joules ACLS DRUGS-- INITIAL DOSE Adenosine: 0.4 Calcium Chloride: 80 Epinephrine 1:10,000: 0.04 Amiodarone: 20 Sodium Bicarbonate: 4 meq DOPAMINE (400 / 5 ml) Add 24 (0.3 ml) to 100 ml bag of NS Start at 10 mcgtt/ minute Titrate to signs of adequate perfusion or maximum of 20 mcgtt/minute MEDICATIONS Albuterol HHN: 2.5 Dextrose 25% slow IV: 8 ml Midazolam IV/IM/IN: 0.4 Diphenhydramine*: 4 Epinephrine 1:1,000 IM: 0.04 Glucagon IM: 1 Morphine Sulfate*: 0.4 Naloxone IV/IM/IN: 0.4 Normal Saline IV Bolus: 80 ml * IV or IM G R E Y 79

90 G R E Y COLOR CODE DRUG DOSES BY WEIGHT: 5 KG COLOR CODE: GREY NORMAL VITAL SIGNS Heart Rate: Respirations: B/P Systolic: >60 DEFIBRILLATION Cardioversion 5 Joules 10 Joules 10 Joules Defibrillation 10 Joules 20 Joules 20 Joules ACLS DRUGS-- INITIAL DOSE Adenosine: 0.5 Calcium Chloride: 100 Epinephrine 1:10,000: 0.05 Amiodarone: 25 Sodium Bicarbonate: 5 meq DOPAMINE (400 / 5 ml) Add 30 (0.4 ml) to 100 ml bag of NS Start at 10 mcgtt/ minute Titrate to signs of adequate perfusion or maximum of 20 mcgtt/minute MEDICATIONS Albuterol HHN: 2.5 Dextrose 25% slow IV: 10 ml Midazolam IV/IM/IN: 0.5 Diphenhydramine*: 5 Epinephrine 1:1,000 IM: 0.05 Glucagon IM: 1 Morphine Sulfate*: 0.5 Naloxone IV/IM/IN: 0.5 Normal Saline IV Bolus: 100 ml * IV or IM G R E Y 80

91 P I N K COLOR CODE DRUG DOSES BY WEIGHT: 6-7 KG COLOR CODE: PINK: 3-6 MONTHS; LENGTH: CM NORMAL VITAL SIGNS Heart Rate: Respirations: B/P Systolic: >70 DEFIBRILLATION Cardioversion 7 Joules 14 Joules 14 Joules Defibrillation 13 Joules 26 Joules 26 Joules ACLS DRUGS-- INITIAL DOSE Adenosine: 0.65 Calcium Chloride: 130 Epinephrine 1:10,000: Amiodarone: 32 Sodium Bicarbonate: 6 meq DOPAMINE (400 / 5 ml) Add 40 (0.5 ml) to 100 ml bag of NS Start at 10 mcgtt/ minute Titrate to signs of adequate perfusion or maximum of 20 mcgtt/minute MEDICATIONS Albuterol HHN: 2.5 Atropine IV: 0.13 Dextrose 25% slow IV: 13 ml Midazolam IV/IM/IN: 0.6 Diphenhydramine*: 6 Epinephrine 1:1,000 IM: Glucagon IM: 1 Morphine Sulfate*: 0.6 Naloxone IV/IM/IN: 0.6 Normal Saline IV Bolus: 130 ml * IV or IM P I N K 81

92 R E D COLOR CODE DRUG DOSES BY WEIGHT: 8-9 KG COLOR CODE: RED: 7-10 MONTHS; LENGTH: CM NORMAL VITAL SIGNS Heart Rate: Respirations: B/P Systolic: >70 DEFIBRILLATION Cardioversion 9 Joules 17 Joules 17 Joules Defibrillation 17 Joules 34 Joules 34 Joules ACLS DRUGS-- INITIAL DOSE Adenosine: 0.85 Calcium Chloride: 170 Epinephrine 1:10,000: Amiodarone: 42 Sodium Bicarbonate: 8 meq DOPAMINE (400 / 5 ml) Add 50 (0.6 ml) to 100 ml bag of NS Start at 10 mcgtt/ minute Titrate to signs of adequate perfusion or maximum of 20 mcgtt/minute MEDICATIONS Albuterol HHN: 2.5 Atropine IV: 0.17 Dextrose 25% slow IV: 17 ml Midazolam IV/IM/IN: 0.8 Diphenhydramine*: 8 Epinephrine 1:1,000 IM: Glucagon IM: 1 Morphine Sulfate*: 0.8 Naloxone IV/IM/IN: 0.8 Normal Saline IV Bolus: 170 ml * IV or IM R E D 82

93 P U R P L E COLOR CODE DRUG DOSES BY WEIGHT: KG COLOR CODE: PURPLE: MONTHS; LENGTH: CM NORMAL VITAL SIGNS Heart Rate: Respirations: B/P Systolic: >70 DEFIBRILLATION Cardioversion 10 Joules 20 Joules 20 Joules Defibrillation 20 Joules 40 Joules 40 Joules ACLS DRUGS-- INITIAL DOSE Adenosine: 1 Calcium Chloride: 210 Epinephrine 1:10,000: 0.1 Amiodarone: 52 Sodium Bicarbonate: 10.5 meq DOPAMINE (400 / 5 ml) Add 60 (0.8 ml) to 100 ml bag of NS Start at 10 mcgtt/ minute Titrate to signs of adequate perfusion or maximum of 20 mcgtt/minute MEDICATIONS Albuterol HHN: 5 Atropine IV: 0.21 Dextrose 25% slow IV: 20 ml Midazolam IV/IM/IN: 1 Diphenhydramine*: 10 Epinephrine 1:1,000 IM: 0.1 Glucagon IM: 1 Morphine Sulfate*: 1 Naloxone IV/IM/IN: 1 Normal Saline IV Bolus: 200 ml * IV or IM P U R P L E 83

94 COLOR CODE DRUG DOSES BY WEIGHT: KG COLOR CODE: YELLOW: MONTHS; LENGTH: CM Y E L L O W NORMAL VITAL SIGNS Heart Rate: Respirations: B/P Systolic: >70 DEFIBRILLATION Cardioversion 13 Joules 26 Joules 26 Joules Defibrillation 26 Joules 52 Joules 52 Joules ACLS DRUGS-- INITIAL DOSE Adenosine: 1.3 Calcium Chloride: 260 Epinephrine 1:10,000: 0.13 Amiodarone: 65 Sodium Bicarbonate: 13 meq DOPAMINE (400 / 5mL) Add 80 (1 ml) to a 100 ml bag of NS Start at 10 mcgtt/ minute Titrate to signs of adequate perfusion or maximum of 20 mcgtt/minute MEDICATIONS Albuterol HHN: 5 Atropine IV: 0.26 Dextrose 25% slow IV**: 25 ml Dextrose 50% slow IV**: 13 ml Midazolam IV/IM/IN: 1.3 Diphenhydramine*: 13 Epinephrine 1:1,000 IM: 0.13 Glucagon IM: 1 Morphine Sulfate*: 1.3 Naloxone IV/IM/IN: 1.3 Normal Saline IV Bolus: 250 ml * IV or IM ** D years, D 50 > 2 years Y E L L O W 84

95 W H I T E COLOR CODE DRUG DOSES BY WEIGHT: KG COLOR CODE: WHITE: 3-4 YEARS; LENGTH: CM NORMAL VITAL SIGNS Heart Rate: Respirations: B/P Systolic: >75 DEFIBRILLATION Cardioversion 17 Joules 33 Joules 33 Joules Defibrillation 33 Joules 66 Joules 66 Joules ACLS DRUGS-- INITIAL DOSE Adenosine: 1.7 Calcium Chloride: 330 Epinephrine 1:10,000: 0.17 Amiodarone: 80 Sodium Bicarbonate: 16.5 meq DOPAMINE (400 / 5 ml) Add 100 (1.2mL) to 100 ml bag of NS Start at 10 mcgtt/ minute Titrate to signs of adequate perfusion or maximum of 20 mcgtt/minute MEDICATIONS Albuterol HHN: 5 Atropine IV: 0.33 Dextrose 50% slow IV: 16 ml Midazolam IV/IM/IN: 1.6 Diphenhydramine*: 16 Epinephrine 1:1,000 IM: 0.17 Glucagon IM: 1 Morphine Sulfate*: 1.6 Naloxone IV/IM/IN: 1.6 Normal Saline IV Bolus: 300 ml * IV or IM W H I T E 85