Medications/Drugs used in PALS course

There are many areas you need to be familiar with in order to pass your Pediatric Advanced Life Support (PALS) exam, but perhaps none require more studying than the medications. This requires knowing more than the names of the drugs that will show up on your exam. You need to know their primary uses, which drug to administer in certain situations and the dosages of that particular drug. Additionally, there is other information about each drug you need to be familiar with in order to adequately prepare yourself for a given situation. Here is a quick reference sheet that shows you everything you need to know about the medications that will appear on your PALS exam.

Energy Levels

Synchronized Cardioversion (Used for SVT)
1st Attempt 0.5-1J/kg
2nd Attempt 2 J/kg
Defibrillation Energy (Used for pVT, VF)1st Attempt 2-4 J/kg
2nd Attempt 4 J/kg or higher max 10 J/kg

Drugs Used in PALS

AdenosineSVT 0.1 mg/kg IV/IO rapid push (max 6 mg), second dose 0.2 mg/kg IV/IO rapid push (max 12 mg)
AlbuterolAsthma, anaphylaxis (bronchospasm), hyperkalemia MDI: 4 to 8 puffs via inhalation q 20 minutes PRN with spacer (or ET if intubated)Nebulizer: 2.5 mg/dose (wt <20 kg) or 5 mg/dose (wt >20 kg) via inhalation q 20 minutes PRNContinuous nebulizer: 0.5 mg/kg per hour via inhalation (max 20 mg/h)
AmiodaroneSVT, VT (with pulses) 5 mg/kg IV/IO load over 20 to 60 minutes (max 300 mg), repeat to daily max 15 mg/kg (2.2 g in adolescents)
Pulseless arrest (ie, VF/pulseless VT) 5 mg/kg IV/IO bolus (max 300 mg), repeat to daily max 15 mg/kg (2.2 g in adolescents)
Atropine sulfateBradycardia (symptomatic)0.02 mg/kg IV/IO (max single dose 0.5 mg), may repeat dose once in 3 to 5 minutes, max total dose child 1 mg, max total dose adolescent 3 mg0.04 to 0.06 mg/kg ET
Toxins/overdose (eg, organophosphate, carbamate)<12 years: 0.05 mg/kg IV/IO initially; then repeated and doubling the dose every 5 minutes until muscarinic symptoms reverse≥12 years: 1 mg IV/IO initially; then repeated and doubling the dose every 5 minutes until muscarinic symptoms reverse
Calcium chloride 10%Hypocalcemia, hyperkalemia, hypermagnesemia, calcium channel blocker overdose 20 mg/kg (0.2 mL/kg) IV/IO slow push during arrest, repeat PRN
Calcium gluconateHypocalcemia, hyperkalemia, hypermagnesemia, calcium channel blocker overdose 60 mg/kg (0.6 mL/kg) IV/IO slow push during arrest; repeat PRN
DexamethasoneCroup0.6 mg/kg PO/IM/IV (max 16 mg)
Asthma0.6 mg/kg PO/IM/IV every 24 hours (max 16 mg)
Dextrose (glucose)Hypoglycemia0.5 to 1 g/kg IV/IO (D25W 2 to 4 mL/kg; D10W 5 to 10 mL/kg)
EpinephrinePulseless arrest, bradycardia (symptomatic) 0.01 mg/kg (0.1 mL/kg of the 0.1 mg/mL concentration) IV/IO q 3 to 5 minutes (max single dose 1 mg)0.1 mg/kg (0.1 mL/kg of the 1 mg/mL concentration) ET q 3 to 5 minutes
Hypotensive shock 0.1 to 1 mcg/kg per minute IV/IO infusion (consider higher doses if needed)
Anaphylaxis IM autoinjector 0.3 mg (for patient weighing ≥30 kg) or IM junior autoinjector 0.15 mg (for patient weighing 10 to 30 kg)0.01 mg/kg (0.01 mL/kg of the 1 mg/mL concentration) IM q 15 minutes PRN (max single dose 0.3 mg)0.01 mg/kg (0.1 mL/kg of the 0.1 mg/mL concentration) IV/IO q 3 to 5 minutes (max single dose 1 mg) if hypotensive0.1 to 1 mcg/kg per minute IV/IO infusion if hypotension persists despite fluids and IM injection
Asthma 0.01 mg/kg (0.01 mL/kg of the 1 mg/mL concentration) subcutaneously q 15 minutes (max 0.3 mg or 0.3 mL)
Croup 0.25 to 0.5 mL racemic solution (2.25%) mixed in 3 mL NS via inhalation3 mg (3 mL of the 1 mg/mL concentration) epinephrine mixed with 3 mL NS (which yields 0.25 mL racemic epinephrine solution) via inhalation
EtomidateRSI 0.2 to 0.4 mg/kg IV/IO infused over 30 to 60 seconds (max 20 mg) will produce rapid sedation that lasts for 10 to 15 minutes
HydrocortisoneAdrenal insufficiency 2 mg/kg IV bolus (max 100 mg)
Ipratropium bromideAsthma 250 to 500 mcg via inhalation q 20 minutes PRN × 3 doses
LidocaineVF/pulseless VT, wide-complex tachycardia (with pulses)1 mg/kg IV/IO bolusMaintenance: 20 to 50 mcg/kg per minute IV/IO infusion (repeat bolus dose if infusion initiated >15 minutes after initial bolus)2 to 3 mg/kg ET
Magnesium sulfateAsthma (refractory status asthmaticus), torsades de pointes, hypomagnesemia 25 to 50 mg/kg IV/IO bolus (max 2 g) (pulseless VT) or over 10 to 20 minutes (VT with pulses) or slow infusion over 15 to 30 minutes (status asthmaticus)
MethylprednisoloneAsthma (status asthmaticus), anaphylactic shock Load: 2 mg/kg IV/IO/IM (max 60 mg); only use acetate salt IMMaintenance: 0.5 mg/kg IV/IO q 6 hours (max 120 mg/d)
MilrinoneMyocardial dysfunction and increased SVR/PVR Loading dose: 50 mcg/kg IV/IO over 10 to 60 minutes followed by 0.25 to 0.75 mcg/kg per minute IV/IO infusion
NaloxoneNarcotic (opiate) reversal Total reversal required (for narcotic toxicity secondary to overdose): 0.1 mg/kg IV/IO/IM/subcutaneous bolus q 2 minutes PRN (max 2 mg)Total reversal not required (eg, for respiratory depression associated with therapeutic narcotic use): 1 to 5 mcg/kg IV/IO/IM/subcutaneously; titrate to desired effectMaintain reversal: 0.002 to 0.16 mg/kg per hour IV/IO infusion
NitroglycerinHeart failure, cardiogenic shock Initiate at 0.25 to 0.5 mcg/kg per minute IV/IO infusion; titrate by 1 mcg/kg per minute q 15 to 20 minutes as tolerated. Typical dose range 1 to 5 mcg/kg per minute (max 10 mcg/kg per minute)In adolescents, start with 5 to 10 mcg per minute (not per kilogram per minute) and increase to max 200 mcg per minute
NitroprussideCardiogenic shock (ie, associated with high SVR), severe hypertension 0.3 to 1 mcg/kg per minute initial dose; then titrate up to 8 mcg/kg per minute PRN
NorepinephrineHypotensive (usually distributive) shock (ie, low SVR and fluid refractory) 0.05 to 2 mcg/kg per minute IV/IO infusion; titrate to desired effect
ProstaglandinE1 (PGE1)Ductal-dependent congenital heart disease (all forms) 0.05 to 0.1 mcg/kg per minute IV/IO infusion initially; then 0.01 to 0.05 mcg/kg per minute IV/IO
Sodium bicarbonateMetabolic acidosis (severe), hyperkalemia 1 mEq/kg IV/IO slow bolus
Sodium channel blocker overdose (eg, tricyclic antidepressant) 1 to 2 mEq/kg IV/IO bolus until serum pH is >7.45 (7.50 to 7.55 for severe poisoning) followed by IV/IO infusion of 150 mEq NaHCO3/L solution titrated to maintain alkalosis
VasopressinCatecholamine-resistant hypotension 0.0002 to 0.002 unit/kg per minute (0.2 to 2 milliunits/kg per minute) continuous infusion

Pediatric Assessment Triangle

Initial Assessment
Identify life-threatening condition-What does the child look like from the doorway/across the room?
Does this child need BLS?
Activate the emergency response system
Check pulse/breathing simultaneously

Appearance-Assess the level of consciousness are they able to respond, crying if infant, and muscle tone?
Work of breathing-increased work of breathing, sitting position (tripod/sniffing), retractions, stridor/wheezing/grunting breath sounds?
Circulation-pink, pale, mottled, cyanosis?
Primary Assessment
-Determine if patent, listen and look for air movement/breath sounds,
-Upper airway obstruction-look for increased inspiratory effort with retractions, snoring or high pitched stridor, no breath sounds indicate complete obstruction
-Interventions-position of comfort elevate the head of the bed, head tilt chin lift/jaw thrust, suctioning, airway adjuncts (oral/nasal airway, LMA, ETT), foreign body removal

-Respiratory rate and pattern, effort, breath sounds, oxygen saturation

-Capillary refill time normal is 2 seconds or less (increases as skin perfusion decreases causes dehydration, shock, hypothermia)
-Skin color-Pallor (poor perfusion, decreased blood supply related to hypovolemic/cardiogenic shock, hypothermia) Mottling (vasoconstriction due to shock, hypoxia, hypovolemia) Cyanosis (shock, respiratory distress, CHF etc)

-Level of consciousness-Hypoxia, shock, seizures, drugs, poor cerebral perfusion can cause irritability, lethargy, and decreased LOC.
-Pupil reaction
-Blood glucose test on everyone

-Look for trauma, bleeding, burns, petechiae, purpura
Secondary AssessmentSAMPLE pneumonic
Signs and symptoms-onset of illness
Past Medical History
Last Meal
Events-leading up to the current illness or injury

Focused physical examination

Reversible causes for PEA/Asystole H’s & T’s
Hydrogen Ions (acidosis)
Tension pneumothorax
Tamponade (cardiac)
Thrombosis (cardiac/pulmonary)
Diagnostic TestingABG
Chest Xray
Blood Glucose

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