Pulseless Arrest Tachycardia with Pulse Bradycardia with Pulse

2nd Ed. June 2021

Modified Glasgow Coma Score APGAR
Stanford Peds Eye 4
Infant
Spontaneous
Child/Adult
Spontaneous
0 1 2
CPR and Poor Perfusion and Poor Perfusion
Housestaff Card
3 Only to speech Only to speech Appearance Start CPR Rate: 100-120/min
2 Only to pain Only to pain (color) Blue or Pale Acrocyanotic Completely pink
Depth: Infant 1.5 in
1 No response No response Give Oxygen
Attach defibrillator, monitors
Child 2-4 in ▷ Identify and treat underlying cause ▷ Identify and treat underlying cause
Verbal* 5 Coos and babbles Oriented, appropriate Pulse Absent <100 bpm >100 bpm Compressions:breath
▷Maintain
▷Oxygen
▷IV/IO access
4 Irritable, cries Confused
▷Maintain
▷Oxygen
▷IV/IO access
Infant/child 15:2
J. Bradley Segal, MD, MBE; Jeff Moss, PharmD; Kevin Kuo, MD, MHPE 3 Cries to pain Inappropriate words patent airway;
▷Monitors
▷12-lead EKG (if
Grimace Cry or Active Adolescent 30:2 patent airway;
▷Monitors
▷12-lead EKG (if
Note: This card contains guidelines and recommendations
2 Moans to pain Incomprehensible No response Grimace assist breathing (Cardiac, BP, available; don’t
(reflex irritability) withdrawal Advanced airway assist breathing (Cardiac, BP, available; don’t
based on published information. Specific medications, doses,
and techniques may be adjusted based on patient condition and Motor
1
6
No response
Moves spontaneously
No response
Follows commands
Rhythm 10 breaths per minute as necessary pulse Ox) delay therapy)
as necessary pulse Ox) delay therapy)
clinician judgement. This card is to be used only by clini- 5 Withdraws to touch Localizes to pain Activity
(motor tone) Limp Some flexion Active motion Yes shockable? No
sites.google.com/view/peds
cians with appropriate experience, training, and supervision. 4 Withdraws to pain Withdraws to pain Narrow QRS Wide QRS
This card is not meant to be a comprehensive guide to therapy. Decorticate posturing Decorticate posturing
PDF, feedback, links 3 (≤ 90ms) (> 90ms)
(flexion)
Neonatal Resuscitation Algorithm—2015
Decerebrate posturing
(flexion)
Update
Respiration
Decerebrate posturing Absent
Weak cry;
Good, crying VFib or Pulseless VTach Asystole or PEA Evaluate QRS duration
Operator (650) 497-8000
2
1
(extension)
No response
(extension)
No response
hypoventilation
Cardiopulmonary compromise?
Directory x288 Antenatal counseling
Hypotension, acutely AMS, signs of shock
Code/Rapid x211 * If patient intubated, score Verbal section 1T, e.g. E4 V1T M6, or 11T Team briefing and equipment check Defibrilation*
Shock Evaluate rhythm with Possible
Labs, Rads, Rx Support 1 shock: 2 J/kg
st
C
- Radiology x1-2267 - Child Life x7-8336 Intubation Sequences Neonatal Resuscitation Algorithm 2nd shock: 4 J/kg 12-lead EKG or monitor Ventricular Yes No
- Main lab x7-8613 - Phone interpreter x4-8222 Pre-intubation Birth [≤10 J/kg or adult dose] Tachycardia
- Inpt Pharmacy x7-8287 - IT support x8-7500 Monitors, 100% FiO2 for >2-3min, PIV, suction, ETCO2, oral airway, Neonatal Resuscitation Algorithm—2015 Update CPR 2 min Adult: 120J→150J→200J
- Outpt Pharmacy x4-5124 - Infection Control p28199 alternative ETT and blades. Have NS bolus available if Pt has ↓ BP with PPV. IV/IO access Start CPR if
▷Support ABCs
Infant stays with mother for routine
- Blood Bank x3-6444 - Pt experience x4-4847 Standard Sequences Antenatal
Team briefing care:
counseling
and equipment Probable Sinus Probable SVT HR < 60 bpm
▷Give Oxygen
warm check
and maintain normal
- Micro x4-8632 - RT x1-9613 - Consider premedication for children <5yo (2-5 min before laryngoscopy) Term gestation? Yes CPR 2 min
▷ Atropine 0.02 mg/kg IV [≤0.5mg] Good tone? temperature, position airway, clear Tachycardia ▷ Compatible Hx with poor perfusion
▷Observe
Patient flow - Security x3-7222
- Nursing Sup x7-8430 - SW x7-8303 or Glycopyrrolate 4-10 mcg/kg [≤100-200mcg] Breathing or crying? secretions if needed, dry.
Birth Rhythm shockable? No IV/IO access
▷ Compatible Hx (nonspecific, Cardiopulmonary
despite oxygenation
▷Consider expert
- Sedation:
Ongoing evaluation Epinephrine 0.01 mg/kg vague); history of compromise?
- Transfer Center x3-7342 Procedures ▷ Known cause
and ventilation consultation
- Peds ED x3-4422 - Vascular Access p47422 ▷ Option 1: Fentanyl 1-2 mcg/kg IV [≤100mcg]
No
Infant stays with mother for routine A Yes [≤ 1 mg] IV/IO
▷ P waves present and abrupt Δ HR Hypotension,
and Midazolam 0.1-0.2 mg/kg IV [≤5mg] care: warm and maintain normal - Repeat every 3-5min
- Anesthesia
Term gestation?
Hospitalists/Residents x1-9705 Yes
temperature, position airway, clear normal ▷ P waves absent/ acutely AMS,
▷ Option 2: Ketamine 1-2 mg/kg IV Warm and maintain normal temperature, Good tone?
Consider advanced CPR
- Blue Hospitalist x1-9849 - ECHO x7-8683 secretions if needed, dry.
Shock ▷ Variable RR; abnormal signs of shock

1 minute
Breathing or crying?
▷ Option 3: Propofol 1-2 mg/kg IV position airway, clear secretions if Ongoing evaluation airway
- Silver Hospitalist x1-1148 - ECG x7-8685 - Neuromuscular Blockade: needed, dry, stimulate No constant PR ▷ HR not variable Rate: 100-120/min
- BMT Hospitalist x1-9579 - Massive Trnsfsn. x3-6445 ▷ Rocuronium 0.6-1.2 mg/kg ▷ Infant: <220 bpm ▷ Infant: ≥ 220 bpm Yes No Depth: Infant 1.5 in
- NF Sup x1-9639 - Phlebotomy x7-5619 Warm and maintain normal temperature, Child 2-4 in
Resume CPR (2 min) and ▷ Child:<180 bpm ▷ Child: ≥180 bpm
Persistent

1 minute
Special Cases position airway, clear secretions if
- Chief 's Office x7-8919 - EEG (8a-430p) x7-8685 Compressions:breath
- Head injury: Consider lidocaine premedication 1-1.5 mg/kg IV, then
Etomidate 0.3 mg/kg IV or propofol 1-2 mg/kg IV Apnea or gasping?
No
needed, dry, stimulate

Labored breathing or
Epinephrine 0.01 mg/kg Rhythm shockable? Infant/child 15:2 bradycardia? No
Vitals, Measures, Equipment by Age - Asthma: Ketamine 1-2 mg/kg IV HR below 100/min? persistent cyanosis? [1mg if ≥50kg/≥18yo] IV/IO Synchronized Adolescent 30:2
- Hemodynamic instability: Ketamine 1-2 mg/kg IV or Etomidate 0.3 mg/kg IV
No
Labored breathing or - Repeat every 3-5 min No Yes Cardioversion Advanced airway
Yes
Apnea or gasping?
Identify and Consider vagal
Term* 1-6mo 6-12mo 2y 4y 6y 10y 14y 18y Yes
HR below 100/min?
Yes
persistent cyanosis?
Consider advanced airway ▷ Turn selector switch to 10 breaths per minute
treat cause maneuvers*
95– 120– 110– 90– 80– 70– 65– 60– 55– Sedation, Analgesia, Amnesia Yes Yes D "DEFIB" Consider possible
HR 160 170 150 150 130 115 110 100 100
PPV Position and clear airway
Position and clear airway
▷ Using ENERGY SELECT, enter causes (H’s/T’s):
Dose (IV) Kinetics Dose (other) Notes Spo2 monitor
PPV
Spo2 monitor Spo2 monitor Rhythm 0.5-1 J/kg [adult 100J]
RR 40–60 25–40 25–40 20–30 20-25 15-25 15-25 10-20 10-20
Opioids
Spo2 monitor
Supplementary O2 as needed
Supplementary O2 as needed No ▷Epinephrine
0.01 mg/kg ▷ Hypoxia
0.05-0.2 mg/kg Pro: Experienced use, Consider ECG monitor Consider ECG monitor
Consider CPAP shockable? ▷Cardiology
consult advised ▷ Press "SYNC ON/OFF" button
SBP Φ 80– 85– 85– 85– 90– 90– 95– 100– 110–
Morphine
[≤4 mg] Peak 20 min including EOL care Consider CPAP CPR 2 min Verify that white down arrows IV/IO [≤1mg] ▷ Hypothermia
95 105 100 105 105 110 115 120 120 IV present, bolus Adenosine
▷If
UOP
gtt: 0.025-0.2 mg/kg/hr Duration 4 hr
[≤2-20 mg/hr]
Con: Histamine release
(vasodilation and pruritis) B Yes Treat reversible present above each R wave, ▷ Repeat every 3-5 min ▷ Hypervagotonia
≥2-3 ≥2 ≥1.5 ≥1 ≥0.5
No Postresuscitation care ▷ 1st dose: 0.1 mg/kg [≤6mg]
(mL/kg/hr) Initial PCA settings: HR below 100/min? causes "SYNC" message on display ▷Atropine
0.02 mg/kg IV/
Bladder Hydromorphone
0.003-0.015 mg/kg
[≤0.4-1mg] Peak 10-20 min
Demand 2-4 mcg/kg
[≤200mcg]
Pro: Longer acting than
fentanyl
No Postresuscitation care
Team debriefing
▷ 2nd dose: 0.2 mg/kg [≤12mg] ▷ Hypovolemia
30– 46– 71– 105– 139– 164– 201– <650 <700 HR below 100/min? Yes
Shock ▷If ▷ Stand clear, remove O2. Press
Capacity 84 131 203 301 397 467 573 (Dilaudid) gtt: 10-50 mcg/kg/hr Duration 4 hr Lockout 8 minutes Con: Slower onset than Team debriefing no access, or Adenosine ineffective IO [min 0.1mg; max ▷ Head injury/↑ICP
(mL) Δ [≤0.5-3 mg/hr] Basal rate 1 mcg/kg/hr
[≤50 mcg/hr]
fentanyl
Check chest movement synchronized cardioversion and hold "SHOCK" button
* 0–7 days of life
0.5-2 mcg/kg Pro: Fast. Minimal ICP, CV Yes Ventilation corrective steps if needed ▷ If not effective, increase to 0.5mg] for increased vagal ▷ Hypoglycemia
Φ Adjust for height/gender/age. Ben Solomon's BP calculator: http://bit.ly/Pedi_BP Targeted Preductal Spo2
changes. No histamine release
 SBP 65 + (2 x Age[yrs]) MAP 40 + (1.5 x Age[yrs]) 5th percentile
≥ ≥ Fentanyl
[≤50-100mcg] Peak 5 min Intransal:
Con: Chest wall rigidity (give
ETT or laryngeal mask if needed
After Birth Rhythm 2 J/kg. NOTE: You must press tone or primary AV block ▷ Hypo-/
PMID: 17273118
gtt: 1-5 mcg/kg/hr Duration 1-2 hrs 1.5-2 mcg/kg
IV pushes slowly). Distributes Check chest movement Resume CPR (2 min) and "SYNC ON/OFF" again
[50-200 mcg/hr]
Ventilation corrective steps if needed No
to tissue. Avoid in ECMO
1 min 60%-65%
Amiodarone 5 mg/kg IV/IO*
shockable? ▷ May repeat x1 Hyperkalemia
Δ Bladder Capacity (oz.) = 4.5 x [Age (yrs)0.40 ] (PMID 9366371, not validated ≥14yo). 1oz = 29.6mL Benzos IM: 0.05 mg/kg ETT or laryngeal mask if needed
HR below 60/min? Targeted Preductal 2Sp o
min 2 65%-70% Yes *Vagal maneuvers: Place cold
Term* 1-6mo 6-12mo 2y 4y 6y 10y 14y 18y 0.05-0.1 mg/kg Peak 15 min [≤4mg] Pro: Anti-Sz After Birth - May repeat up to x2, or If rhythm regular and QRS ▷Consider
transthoracic/ ▷ [H]+ ions (acidosis)
Lorazepam [≤2-4mg] Duration 6 hr PO: 0.05-0.1 mg/kg Con: ↓ airway tone Yes 3 min 70%-75% No plastic bag on face for 15-30 sec, or
[≤2mg] Lidocaine 1 mg/kg IV/IO^ stimulate rectum with thermometer. monomorphic, consider Adenosine transvenous pacing
Wt (kg) 3.5 7 10 12 16 22 35 50+ 50+ 0.1 mg/kg Intubate if not already done 1 min 60%-65%
4 min 75%-80%
- then 20-50 mcg/kg/min gtt
▷ Heart transplant
IM: 0.1-0.15 mg/kg No
Pro: Minimal ICP changes. In older children, encourage ▷ 1st dose: 0.1 mg/kg [≤6mg] ▷Treat
underlying causes
ETT size
uncuffed 3-3.5§ 3.5-4§ 4-4.5§ 4-4.5§ 5-5.5§ 5-5.5§ 6-6.5§ 7§ 7-8§ Midazolam
[≤2-5mg] Peak 5 min
gtt: 0.025-0.3 mg/kg/hr Duration 60 min
Intransal: 0.2 mg/kg
PO: 0.5 mg/kg
Anti-Sz
Con: ↓BP. ↓ airway tone
HR below 60/min?
Chest compressions
Coordinate with PPV 2 min 65%-70%
5 min 80%-85%
Treat reversible causes
Go to bearing down (Valsalva) for 15-20 sec. ▷ 2nd dose: 0.2 mg/kg [≤12mg] ▷ Toxins
ETT to
A or B
[≤2-4 mg/hr] 100% O2 10 min 85%-95%
gum (cm) 9 11 12 13 15 16 18 21 20–22 ECG monitor Carotid massage and orbital pressure ▷ Tamponade
Yes 3 min 70%-75% * In ACLS ≤300mg (1st dose), ≤150mg (2nd dose)
Pro: No ↓RR Consider emergency UVC
Dexmedetomidine gtt: 0.2-1.5 mcg/kg/hr Peak 5-10 min Intransal: ^ In ACLS 1-1.5 mg/kg, then 0.5-0.75 mg/kg should not be performed in children.
Type Miller Miller or Macintosh Usually Mac (with loading dose) Con: ↓HR, ↓BP at high Cardiology ▷ Tension PTX
Blade

(Precedex) Duration 1-2 hrs 0.5-2 mcg/kg doses. Avoid in heart block Intubate 4 min 75%-80%
if not already done C/S advised
*Defibrilation Asystole/PEA: go to C or D ▷ Thrombosis
Size 1 1 1–1.5 1–2 1.5–2 2 2–3 3 3–4 Chest compressions HR below 60/min?
5 min 80%-85% If pulseless arrest develops,
0.5-1 mg/kg IM: 3-7 mg/kg Pro: No ↓RR Coordinate with PPV ▷ Turn selector switch Organized rhythm: check pulse
LMA 1 1 1-2 1.5–2 2 2.5 3 4 5 Ketamine gtt: 0-1 mg/kg/hr
Peak 5 min
Intransal: 1.5 mg/kg Bronchodilator Yes Consider possible causes (H’s/T’s): proceed to PALS algorithm (coronary/pulmonary)
5–20 mcg/kg/min
Duration 1-2 hrs
Con: ↑ secretions
100% O2 10 min 85%-95% to "DEFIB" Pulse present (ROSC): post-cardiac arrest care
[≤100 mg]
ECG monitor ▷Hypovolemia
▷Hypo-/
▷Tamponade
(start CPR) ▷ Trauma
NG (Fr) 8 8 8–10 10 10-12 12 14 16 18 IV epinephrine ▷ Using ENERGY SELECT,
Pro: Fast. Anti-Sz. Amnesia Consider emergency UVC If HR persistently below 60/min enter energy level (Joules) Targeted Temperature LPCH Pathway
▷Hypoxia
Hyperkalemia ▷Tension
PTX
Suction 8 8 8 8 10 10 12 12 12–14 Con: ↓BP. Rare but fatal Consider hypovolemia Management (TTM)
cath (Fr) Propofol
1-4 mg/kg Peak 1 min
Propofol Infusion Syndrome. Consider pneumothorax © 2015 American Heart Association
▷ Stand clear, remove O2. ▷Hypothermia
▷Hypoglycemia
▷Thrombosis

gtt: 20-200 mcg/kg/min Duration 10 min Cardiac arrest, no response to
Foley (Fr) 5 6 8 8 10 10 12 12 12 No analgesia. Avoid if soy/ Press and hold "SHOCK" ▷[H]
+ ions (acidosis) ▷Toxins
▷Trauma

egg allergy or ketogenic diet verbal commands after ROSC
§ 1/2 size down for cuffed tube HR below 60/min?
 #4312
NEURO CV Anaphylaxis Dehydration/AKI
ANC =
Prerenal Intrinsic Postrenal
ANC < 500/mm and
WBC x (% Neuts + % IG) DKA
Status Epilepticus = ≥3 consecutive ventricular beats (wide Febrile Neutropenia
3
e.g. AKI ATN Obstruction
Nonsustained VTach (NSVT) QRS), lasting ≤30 sec, with HR >100 Biphasic reaction Management:
FENa <1% >1% >4% Temp ≥38.3 C or ≥38.0 C x2 in 24h
IM Epinephrine 0.01 mg/kg [≤0.3mg; ≤0.3mL] IV bolus 20 ml/kg NS or LR, repeat PRN ABCs, monitors, 2 PIVs. Labs Definition:
- Often ASx, self-resolving, incidentally 15% of Pts, usually in ≤12h Start empiric Abx in <30 min 1. Serum glucose > 200 mg/dL
ABCs. Start stopwatch, 100% FiO2, IV, monitors, BG Special cases Management: Identify and Tx if reversible causes ▷ Repeat q5-15min x1-3
(reported up to 72h) - Consider 5–10 ml/kg if cardiac Hx or Hgb < 7 FEUrea ≤35% >50% N/a W/up: CBCd stat, CRP, BCx (central line (1) Bolus 10-20 ml/kg NS or LR (over 1 hour) then
IV/IO established: <1mo: If seizure ≥10-15min, use ▷ DDx: Electrolyte imbalance, malpositioned line, noted on cardiac telemetry Attach monitors, FiO2 100%, place recumbent, elevate BLEs - Avoid bolusing IV dextrose -Standard:
Cefepime + peripheral), UA/UCx (bag or clean catch (2A) Start insulin gtt: 2. Metabolic acidosis (venous
Phenobarbital 20 mg/kg. If Sz ≥15- ↓BP, hypoxia, anemia, adverse drug effect, MI, HF - Consider Chem 10, CBC, EKG, CXR Labs: (optional) draw serum Consider 20 ml/kg Pedialyte NG/GT if available
Chem 7, urine Na + urine urea (w/ Cr) -Line
infection/cellulitis: Cefepime + Vancomycin only) +/- CXR, RVP - Consider 0.05 units/kg/hr for <5yo pH<7.3 or HCO3<15) and
▷ Lorazepam 0.1 mg/kg [≤4mg] IV over 2min ▷ If shock (poor perfusion, ↓BP): bolus 20 ml/kg NS/LR - Target further w/up based on HPI, 3. Ketosis (≥2+ ketonuria
20m give adtnl 10 mg/kg. See NICU Cardiology C/S, especially if structural heart defect, multiple episodes, symptomatic, p/w syncope, or strong FH tryptase 15m–3h and/or -Abd
infection: Pip/Tazo or Cefepime + flagyl - Consider 0.1 units/kg/hr for ≥5yo and
- Repeat prn, monitor UOP histamine 15m–25m after Sx: ↓[Phos], ↓[K], peripheral edema, -Unstable, ill-appearing (toxic, ↓BP): Meropenem or ß-hydroxybutyrate ≥3)
No IV access: protocol.
<6mo: Consider PT/PTT, LDH, ▷ If bronchospasm: Albuterol Neb 2.5-5 mg, repeat PRN Refeeding Syndrome ↓[Mg], ↑ [glucose], CHF, Sz, rhabdo
physical exam (including oral, perianal) (2B) Start 1.5xMF using 2-bag system:
▷ Midazolam 0.2 mg/kg [≤10mg] IM/buccal/nasal Life/organ threatening HTN (e.g. AMS, HF) onset of Sx + Vancomycin (see Sepsis) ▷ Bag 1: NS + 20 KCl + 20 KPhos Severity: by venous pH
AAs, lactate, pyruvate, urine studies Hypertensive Emergency Typically SBP ≥30 + upper limit wnl ▷ If refractory anaphylaxis: Epinephrine gtt 0.1-1 mcg/kg/min
Avoid catheterization, rectal temp, PR meds
- Mild < 7.3 - 7.2
▷ Diazepam 0.3-0.5 mg/kg [≤20mg] PR Management: ▷ Bag 2: D10 NS + 20 KCl + 20 KPhos
(UA, reducing substances, OAs, AAs). Drips Non drips: ▷ Can also consider: IV Methylpred 1 mg/kg [≤125mg],
There is no contraindication
to epinephrine in the setting of - Continuous tele, Chem 10, CBC, CK, EKG - At risk: Anorexia nervosa, FTT, ↓↓/no nutrition ID - Only start Bag 2 when: glucose <300 - Moderate < 7.2 - 7.1
Sz persists 6-10 min <1yo: Consider Pyridoxine 100mg IV Benadryl 1 mg/kg [≤50mg], IV famotidine 0.5 mg/kg [≤20 mg] anaphylaxis - D/c feeds. Replete electrolytes. Monitor for for ≥5-10 days or glucose dropping >100 mg/dL/hr - Severe < 7.1
▷ Repeat Lorazepam x1 IV if Sz ≥15min.
▷ Nitroprusside 0.5-10 mcg/kg/min gtt
- Usual max = 3. Cyanide and thiocyanate
▷ Hydralazine 0.1-0.2 mg/kg IV/IM [≤20mg] q4-6h
▷ Labetalol 0.25-1 mg/kg IV [≤20mg] q4-6h HF, arrhythmia - Highest mortality from cardiac complications Sepsis / Septic Shock - Potassium: If initial [K] >5.5, and non-hemolyzed, Labs: glucose POC q1, VBG q4,
▷ and Call for 2nd-line AED Fever: Antipyretics. Add BCx, UCx. toxicity risk. Send thiocyanate level if - Avoid in asthma, BPD, pheochromocytoma Bronchiolitis Notes - Before starting dextrose-containing fluids, (resting HR >70 can be abnml in severe anorexia)
Shock hold K in fluids until serum [K] <5.5 Chem 10 q4, UA, ß-hydroxybu-
If c/f meningitis, add Abx, Acyclovir. - Consider NPO if RR >70 give IV thiamine 100mg - Consider Wernicke's if AMS/ataxia/ocular dysfxn Suspected Sepsis: Initial management Total time: <60 min (3) After 4-6h on 2-bag system:
Sz persists 10-20 min >4 mcg/kg/min or on drip ≥3-5days. (Current SBP - 95th %tile)
- RVP and CXR are not - Establish IV. FiO2 100%. DO2 < VO2 tyrate, HbA1c, CBCd, CRP
Initial goal: ↓ SBP by ≤ Desats/Increased WOB: - If ↑[Na], can change to ½ NS
▷ Fosphenytoin 20 mg/kg [≤1.5g] IV/IM over 10m
Consider LP.
Hypoglycemia: Slow IV bolus D10
Avoid in renal/hepatic dysfunction 4 - Consider congestion/nasal obstruction, mucus plugging. routinely recommended GI ▷ In <5 min: 1st 20 ml/kg NS bolus . Vitals q5m. Call rapid. inadequate oxygen
- If ↑[Cl], can change to acetate-containing fluids or ½ NS
Alternate VBG/Chem 10 q2h
▷ Esmolol 500 mcg/kg over 1 min, then - Labs: BG, CMP, CBCd, CRP, BCx, VBG, lactic acid, UA, T&S, coags
delivery (DO2) for
- SE: ↓BP 2.5 mL/kg. First give Thiamine 100mg W/up: Chem 7, CBC, UA, cycle BP q2min. 1st line: reposition, suction q2-4h + PRN - If improving → worsening: can W/up: Chem 7 (↑BUN), LFTs, Corrected Sodium:
▷ and Contact Neurology IM/IV if adult or Hx malnutrition.
50-200 mcg/kg/min gtt
Consider CXR, EKG, Echo, Kidney US, Tox, head CT - Stepwise escalation: blowby O2 PRN → 0.25-4 L NC → evaluate for AOM, consider Upper GI Bleed coags +/- lipase, H pylori, KUB, Target additionasl w/up to identify source of sepsis.
cellular demands (VO2)
Cerebral edema: #1 cause of mortality. Monitor and Tx = [Na] +(2 x
Glucose - 100
)
- Avoid in asthma, BPD, pheo - Start appropriate Abx in <60 min Oxygen delivery promptly if Sx of ↑ ICP. At ↑ risk: initial ↓PaCO2 or ↑BUN. 100
Hyponatremia: 3% NaCl 3-5 ml/kg. 0.5-2 L/kg HFNC → CPAP → BiPAP → intubation/IPPV CRP, CBCd, CXR, UA Abd US, endoscopy
Sz persists 20-40 min ▷ Clevidipine 0.5-1 mcg/kg/min gtt, Hypertensive Urgency ASx, no organ damage ABCs, 2 large IVs, CBC, T&S, NG lavage, NPO ▷ 3% NaCl 3-5 cc/kg IV (PIV ok). Can also give Mannitol If corrected Na <140: increase
Head trauma: Early stat head CT. ▷ Hydralazine 0.25 mg/kg PO [≤25mg] q6-12h prn Dehydration - Routine albuterol not a/w ↓BP or ↑HR and ↑RR DO2 = CaO2 x CO
▷ Levetiracetam 40–60 mg/kg [≤4.5g] IV over 5-15m Ketogenic diet: No Propofol. ↑ by 0.5-1 every 2-10 min [max ≤10] ▷ Start PPI: DDx: 0.5-1 g/kg IV over 20-30 min, may repeat in 30 min prn frequency of sodium monitoring
▷ Isradipine (Dynacirc) 0.05-0.1 mg/kg PO q6-8h - Monitor UOP (see vitals table for wnl by age), trend Wt QD shorter hospitalization. Can
- IV Pantoprazole 1 mg/kg [≤80mg] x1 Esophageal varices, esophagitis, ▷ 2nd 20 ml/kg NS bolus, re-evaluate Arterial oxygen content
▷ Phenobarbital 20 mg/kg IV over 15m Toxin induced: Avoid Fosphenytoin, - Adults: initial dose 1-2 mg/hr, typical ▷ NSG c/s. Consider CT head
4-6 mg/hr [max ≤21 mg/hr] [≤10mg]. Effect in 2-3 hrs - If dry, bolus 20cc/kg. If no PO, D5 NS/LR at 1xMF` trial ACT if severe.
then 0.1-0.2 mg/kg/hr [≤8mg/hr] gtt
gastritis, ulcer, idiopathic, foreign If persistent: CaO2= Hgb(Sat)(1.34) ▷ R/o ↓[glucose] and ↓[Na] Repletion of Mg, HCO3 not routine
- SE: ↓RR after benzos use Phenobarbital instead. body, Mallory Weiss, Dieulafoy's, ▷ 3rd 20 ml/kg NS bolus + (PaO2)(0.003)
- or IV Pantoprazole 1 mg/kg [≤40mg] BID AVM, IBD, vasculitis (HSP),
▷ Valproic acid 20–40 mg/kg [≤3g] IV over 10m W/up: BG, CBCd, Chem 10, Use Westley Score to determine
- or PO Omeprazole 1 mg/kg [≤20mg] BID ▷ Verify appropriate Abx started. Correct if ↓glucose, ↓Ca2+
QT Croup / Post-Extubation Stridor pancreatitis. other sources of Hypoglycemia For BG <45, draw critical labs before Tx if possible:
- Caution in <2yo, liver/metabolic dz
LFTs, NH3, VBG, b-HCG, Tox Acquired Long QT & Torsades QTC ≥ 500 ms QTC =
√RR
croup severity
▷ Transfuse as needed blood (e.g. hemoptysis, swallowed If persistent:
Cardiac Output
screen, AED levels, EEG, MRI Moderate if: ▷ Start peripheral epinephrine (0.05 - 0.3 mcg/kg/min) CO = SV x HR PO: Carb (e.g. fruit juice) x1-2, recheck BG in 15-30min - Labs (on ice): CMP, insulin, β-hydroxy,
Definitive: Dexamethasone IV/IM/PO x1 Temporizing: Rac Epi 0.05 ml/kg [≤5ml] ▷ Consider endoscopic repair, IR embolization maternal blood)
▷ Consider RSI. Order EEG ABCs. Cardiac tele, PIV, Chem 10, EKG. Cards c/s IV: (1) Slow bolus 2.5 mL/kg D10 (preferred) cortisol, GH, C-peptide, FFAs, lactate,
vs CT. Neurology C/s advised. ♀>460 ms ♂>450 ms Mild Croup: 0.15-0.6 mg/kg [≤16mg] x1 (2.25%), repeat PRN ▷ Obtain central access. Consider RSI (consider ketamine, rocuronium)
▷ Review meds Varices: if present, can add Octreotide. Load 1-2 mcg/kg [≤100mcg] IV, then SIRS if ≥2
Refractory Status: RSI, IPPV. Titrate drips to burst suppression on EEG and maintain for 24-48h. Most common ↑QTc causes: Mod/Severe Croup: 0.6 mg/kg [≤16mg] x1 - Labs: Consider cortisol, central venous blood gas, lactate or 1 mL/kg D25 acylcarnitine, NH4, urine OAs
▷ Replete lytes: K > 4, Mg > 2, iCal > 1.2 1-2 mcg/kg/hr gtt [≤50]. Monitor for ↓HR, ↓glucose. Taper over 24 hrs. - Temp >38.5 C or
Consider central access, inotropes for ↓BP (pentobarb, propofol). - Meds, ↓K, ↓Mg Post-Extubation: 0.25-0.5 mg/kg [≤10mg] q6h Tip: For better dexamethasone taste, If persistent: then (2) Infuse 3-5 ml/kg/hr D10. Check BG - Note: If PIV extravasates,
<36 C ↑[glucose] → ↑ tissue injury
- Midazolam: 0.2 mg/kg load, then 0.05-2 mg/kg/hr gtt. Bolus Torsades de pointes: assess hemodynamics, Tx promptly Less common: Consider: Heliox 80/20 (↓ to 70/30 - 60/40 for ↑FiO2) request IV formulation for PO use ▷ For cold shock: titrate epinephrine
- Tachycardia or q30-60m until stable (70-120)
0.2 mg/kg prn breakthrough Sz. Titrate gtt ↑ by 0.05-0.1 q3-4h Stable: Bolus IV magnesium sulfate 25-50 mg/kg
- ↓Ca, Tox, congenital CPAP Acute Pancreatitis W/up: CBCd, Chem 10, lipase, amylase, LFTs, CRP,
triglyceride, b-HCG. Consider KUB, RUQ US, EtOH
▷ For warm shock: start central norepinephrine (0.05-0.3 mcg/kg/min). Echo Bradycardia
- Pentobarbital: 5-10 mg/kg load, then 1-5 mg/kg/hr gtt LPCH [≤2g] over 15 min or faster as needed. Monitor BP
EKG warning signs of Torsades FEN Initial management: Notes
▷ Consider further imaging for source, consider other causes of shock - Tachypnea TOX Poison Control:
- Propofol: 1-2 mg/kg load, then 100-350 mcg/kg/min gtt Pathways - Ventricular ectopy If persistent: - Abnml WBC for 1(800) 222-1222
Unstable ( ↓BP, AMS, chest pain, HF): Immediate - T wave alternans Hyperkalemia - NPO. Bolus 20 ml/kg NS or LR
- Start 1.5-2xMF, titrate to UOP
- Sensitivity lipase > amylase. Usually ↑ ≥3x wnl
- In adults, ↑ BUN trend over initial 24h a/w
▷ Consider 10 ml/kg pRBC transfusion if Hgb <10 age or >10% IG
Acetaminophen toxicity
cardioversion / defibrillation. Can bolus IV Mag. - AV block
Increased ICP If patient becomes pulseless → PALS algorithm (start CPR) - or QRS widening Discontinue all K-containing IVF (including TPN) Indictations for emergent Tx: - Replete calcium. Goal [glucose] < 200 ↑ risk mortality
▷ Consider stress dose steroids (see A
' drenal Crisis')
If persistent: Catecholamine Resistant Shock. Assure euvolemia.
Sepsis if
- SIRS and N-Acetylcysteine (NAC):
Consider stopping NAC when:
(1) Pt ASx (2) APAP <10/undetectable
ABCs, IV, O2, monitors CPP = Emergent Tx: – EKG changes - Manage pain. Consider PCA - Post-pyloric (NJ) feeds preferred to TPN. Dc ▷ If warm shock and on norepi: consider epinephrine vs vasopressin - Suspected infection - IV 150 mg/kg [≤15g] over 1hr, then 50 mg/kg and (3) ALT < 50% peak
Early NSG involvement MAP – ICP If impending herniation RESP If no IV: Albuterol Neb 2.5-10mg then
– Muscle weakness/paralysis
– [K] > 7 - If appetite, no ileus, no N/V: can trial low enteral nutrition if not tolerated (↑ abd pain, ▷ If cold shock, ScvO2 <70%, Hgb >10, and on epi: add norepinephrine Septic Shock if [≤5g] over 4hr, then 100 mg/kg [≤10g] over 16hr Add Activated Charcoal 1 g/kg [≤50g]
Sx: ↑BP with ↑/↓ HR, anisoco- - Note: if cold shock, wnl BP, Scv <70%, Hgb >10, on epi: add milrinone if < 4h ingestion of > 150 mg/kg
Status Asthmaticus
when possible. wnl ICP < 20 mmHg ▷ Calcium Gluconate 60 mg/kg [≤3g] IV over 5min or – [K] > 6 and continued risk of ↑ fat, soft diet in first 24h, slowly ADAT vomiting, bloating, diarrhea). Use low-fat high - Sepsis and then repeat as needed or
ria, severe HA, coma, abnml resp Calcium Chloride 20 mg/kg [≤1g] IV over 20min* and (e.g. tumor lysis syndrome) - Workup cause protein formula - CV dysfunction - PO/NG 140 mg/kg x1, then 70 mg/kg q4h x17 (unless GI obstruction or aspiration risk)
Stabilization and management
pattern, hemiplegia, or flexor/ ABCs, monitors, SpO2 >92, PIV ▷ Regular insulin 0.1 units/kg [≤ 10 units]
▷ RSI if refractory hypoxia, hypoventilation, Initial Tx: LPCH with W/up: VBG w/ lytes, CBC,
HEME/ONC Vasoactives Sx (isolated BZD OD): ↓CNS, wnl vitals
GCS ≤8 or <12 and rapidly declining,
extensor posturing
▷ Albuterol 10-20mg/hr continuous Pathway IV Dextrose central over 30m. Check BG after 1h
<5yo: 5 mL/kg D10
Chem 10, cardiac tele, can trend
EKG
Benzodiazepine overdose
▷ Bolus 3% NaCl 5 mL/kg [≤500mL] ↑uric acid, ↑K, ↑Phos, Dose Receptor DDx:
loss of airway reflexes
or 23.4% NaCl 0.5 mL/kg [≤30mL]
`or 8 puffs MDI q1h x1-3 ≥5yo: 2 mL/kg D25 [≤100mL] and Common causes: hemolyzed Tumor Lysis Syndrome ↓Ca, ↑LDH, uremia (mcg/kg/min) (agonism) Notes Caution: risks of reversal often outweigh benefits. Co-ingestant (esp if ↓RR), hypoglycemia,
▷ HOB 30 degrees, head midline or 2.5–5 mg Neb q20min x1-3 sample, exogenous (IVF, TPN), Reversal can provoke seizures, particularly if Hx BZD CO poisoning, stroke, meningitis, head
▷ Start non-emergent Tx (reduce total K) and
▷ Rapidly correct if: and/or IV Mannitol 0.25 - 1 g/kg ▷ Ipratropium neb 0.5–0.75 mg ▷ Start D5 NS/LR at 1.5-2x MF, maintain urine 1-5 D ↑ renal blood flow exposure or ↓ Sz threshold. Apply clinical judgement trauma, encephalitis
▷ Consider Sodium Bicarb 1 mEq/kg [≤ 50 mEq] renal failure, cell death (rhabdo, At ↑ risk: high grade NH lymphoma (Burkitt’s),
▷ ↓BP Goal CPP > 40 infant, ▷ Hyperventilate to clinical improvement ▷ Dexamethasone 0.6 mg/kg [≤16mg] IV/PO SG ≤ 1.010 6 - 10 β1
or Methylpred 2 mg/kg [≤125mg] IV
tumor lysis, crush injury, burn), ALL with WBC >100K, AML w/ WBC >50K, Dopamine Ionotrope (↑ SV) Flumazenil 0.01 mg/kg IV [≤0.2 mg] over 15 sec - Peak effect: 6-10 min
>50 child, >60 adolescent as brief temporizing measure If failed response: metabolic acidosis, drug effect ▷ Chem 10 + uric acid q4-6h, LDH q24h. Space
11 - 20 α1 ↑ SVR, ↑ afterload - May repeat 0.005-0.01 mg/kg [≤0.2 mg] x4 [max ≤1mg]
▷ ↓O2 Goal SpO2 ≥ 93 If poor response: ▷ Repeat emergent Tx. Consider HD/CRRT labs as able. Manage electrolyte abnormalities significant tumor burden, highly sensitive to chemo - Duration: 45-75 min
▷ RSI with Etomidate + Rocuronium For extremis, can add Epinephrine (spironolactone, ACE-I), CAH,
▷ ↑CO2 Goal PaCO2 35 – 40 ▷ Magnesium sulfate 25–50 mg/kg IV [≤2g] over 20 min 0.01 mg/kg [≤0.5mg] IM/SC q20m x3 ▷ Allopurinol: start 24-48hrs before Chemo ≤0.05 β1 + β2 Chronotrope, ionotrope, ↓ SVR
- Consider Lidocaine 1 - 1.5 mg/kg adrenal insufficiency, hematoma Complications: acute renal failure, electrolyte Epinephrine
▷ Identify, Tx: If poor response: Non-emergent Tx: ▷ Rasburicase: 0.1-0.2 mg/kg [≤6mg] IV abnormalities (hyperkalemia) 0.06 - 2 α1 ↑ SVR Narcotic overdose Sx: ↓RR, ↓Temp, ↓HR, ↓BP, pinpoint pupils
- Fever [≤100mg] as premed to blunt ICP spike ▷ HFNC 0.5–2 lpm/kg [≤20-30] or CPAP 5 cm H20 once if uric acid ≥8-10 mg/dL. Trend
- Hgb ≤7 ▷ Correct reversible causes
EKG changes: Peaked T-wave
Potent vasoconstrictor (↑↑SVR),
- Make NPO, start D5 NS or LR at 1xMF. VBG, trend TCOM/EtCO2 → PR and QRS prolongation Consider furosemide for fluid overload,↑K, ↑Phos Norepi 0.01 - 1 α1 >> β1 Naloxone IV/IM
- Glucose <60 - Uncontrolled pain uric acid q6-12h until resolution of TLS chronotrope, ionotrope
- Naloxone half-life: 60-90 min
Special cases ▷ BiPAP 10/5 → 14/6 → 16/8 → 20/10 cm H20 ▷ Furosemide 1-2 mg/kg IV/PO [≤40mg] q6-12h → loss of P-wave → Sine wave Milrinone 0.25 - 0.75 PDE3 (inhibitor) Ionotrope, lusitropy (↑ diastolic ▷ Partial reversal: 1-5 mcg/kg
- Repeat dose q30-60 min PRN
fxn), ↓ afterload
If ICP remains >20 mmHg - If not tolerating NPPV, consider Precedex or Ketamine for anxiolysis ▷ Sodium polystyrene sulfonate 1 g/kg PO/PR [≤30g] q6h ▷ Full reversal: 0.1 mg/kg [≤2mg/dose]
Seizure: Lorazepam 0.1 mg/kg IV [≤4mg]. ▷ Terbutaline: load 10 mcg/kg IV over 10 min, then 0.4 mcg/kg/min gtt
*Preferred in setting of cardiac arrest Transfusion pRBCs
↑↑ SVR , reflex ↓ HR (avoid in
▷ Bolus 3% NaCl 5 mL/kg [≤500ml] over Avoid if bowel obstruction, post-operative, on opioids, or impending arrest. May be infused - 10 cc/kg over 2-4h Phenylephrine 0.1 - 0.5 α1
Tx promptly. Start or ↑ AED. - Can ↑ by 0.25–0.5 mcg/kg/min [≤3] prn q30min
cardiogenic shock)
Sx: Tremor, MS Δ’s, ↑DTRs, ↑HR, ↑BP,
10-30 min (central preferred, PIV okay)
High risk for Sz (e.g. severe TBI, depressed Fx, - Cardiac tele. Trend EKG, troponin q12h. SE: May develop ↑K, ↓BP
ileus, preterm neonate. Check for drug-drug interactions more rapidly depending on scenario. Fresh frozen plasma (FFP) - May ↑ Hgb 2-3 gm/dL Shock 0.3 - 2 V1 Isolated ↑↑ SVR Serotonin Syndrome ↑Temp, ↑diaphoresis, clonus
or 23.4% NaCl 0.5 mL/kg [≤30mL] - 10-20 cc/kg may ↑ Coags to >30% wnl - Use 5 ml/kg over 4h if initial Hgb <5 (mU/kg/min) [Max ≤40 mU/min]
parenchymal abnormality): consider AED PPx - Caution β-agonists ≥20 mg/hr → ↑ risk arrhythmia. Consider bolusing Vasopressin Initial management - W/up: CBC, Chem 7, LFTs, coags,
over 20 min (central line only) - Minimal effect if INR <1.7 DI 0.5 - 10 ↑ aquaporin translocation in
or Mannitol 0.25-1 g/kg over 20-30m Intubated: Avoid high PIP/PEEP if possible. NS/LR to ↓ HR Hyponatremia Rate of correction varies by
duration of hyponatremia - Give if transfusing ≥ ~105-120 cc/kg pRBC
Platelets
- 1 unit/10 kg [≤6 units] over 30-60m
(mU/kg/hr)
V2
kidney tubule; central DI only - Monitors, PIV, d/c serotonergics creatinine phosphokinase, BCx, UA,
Consider lidocaine 1–1.5 mg/kg IV or ▷ Aminophylline: load 6 mg/kg IV, then 0.5–1 mg/kg/hr gtt - Sedate: Lorazepam 0.02-0.04 mg/kg IV [≤2mg] CXR, CT head, LP
- May ↑ Plt by 30-50K
▷ Temporarily hyperventilate to PaCO2 30-35
2 mg/kg ETT 3–5 min before suctioning.
- Check drug level in 6-12h, titrate gtt to goal level 10-15 mcg/mL Chronic and/or Asymptomatic
- ↑ [Na] by 4–6 mEq/L over initial 24h
Labs: Initially check [Na] q4-6 hours until Cryoprecipitate
- 1 unit/10 kg [≤12 units] over 30min - Use 10 cc/kg if patient Wt <10 kg
ENDO ▷ Repeat q10min PRN - Common causes: MAOI, SSRI, meperidine,
▷ Neuroimaging per NSG ▷ Heliox: mixture 80/20 He:O2 trajectory established - SpO2 ≥94, IVF, cardiac tele dextromethorphan (DayQuil), MDMA
- If obstructive hydrocephalus present, Trauma: Maintain C-collar during - ↓ He:O2 to 70/30 or 60/40 for ↑FiO2 requirement - Can generally correct using isotonic fluids - May ↑ fibrinogen 60-100 mg/dL - Give if Plt <10 and either active Sx: ↓BP, shock, ↓[Na], ↑[K] +/- vomiting,
Slow correction: - Commonly given for fibrinogen <150 + active Adrenal Crisis diarrhea, abd pain, fever, AMS, ↓[glucose]
- Then if persistent Sx, consider Cyproheptadine - Avoid Acetaminophen
discuss emergent EVD RSI. Confirm C-collar not too tight. Severe Symptoms (Sz, AMS, ↓RR) - ↑ [Na] by 6–8 mEq/L per day
bleeding or Onc Pt
If refractory Unknown etiology: early stat head CT.
If refractory
▷ DDx: consider foreign body, vocal cord paralysis, congenital (rings, slings, laryngomalacia), mediastinal mass ▷ 3% NaCl 3–5 mL/kg over 10-15m (central
- If high risk, ↑ [Na] by 4–6 mEq/L/day
bleeding or for fibrinogen <100 mg/dL
Hydrocortisone (Solu-Cortef ) IV/IM
ETHICS
- Labs: BG, chem 7. Consider cortisol,
▷ 3% NaCl 0.1-1 mL/kg/hr, goal [Na] > 155 Vasogenic edema (e.g. brain tumor, abscess, ▷ Intubation: consider Ketamine +/- Atropine +/- Rocuronium (see RSI) preferred, PIV okay) Massive Transfusion 1:1:1 of pRBC, Plt, FFP. Activate massive transfusion protocol Informed Consent I. Disclose relevant information
(1) 50 mg/m2 or 1-2 mg/kg [≤100 mg] x1 then ACTH before Tx (1º vs 2º adrenal insuf ). - Clinical issue
▷ D/w NSG (decompressive craniectomy, EVD) meningitis): Load Dexamethasone 1-2 mg/kg ▷ IPPV: Sedation with ketamine +/- midazolam. Avoid prolonged paralytics. Potential settings: – May ↑ serum [Na] by 2.5-4 mEq/L Rapid correction: - C/b coagulopathy, dilutional ↓ Plt, hypothermia, citrate toxicity (→ ↓[Ca]2+), ↑ [K] (2) 12.5-25 mg/m2 or 1 mg/kg [≤50 mg] q6h II. Recommend a plan
- Risks
volume control 8 cc/kg, max PIP 45cm, low RR, long E time (I:E ≥4). Allow permissive hypercapnia, Adtnl w/up for CAH
▷ Pentobarbital coma: load 5-10 mg/kg IV, IV [≤10mg], then give 0.5 mg/kg q6h. Persistent Sx: Repeat 3% NaCl bolus x1-2 - ↑ [Na] by 5 mEq/L over initial 3-4h, and - Consider Tranexamic Acid (vs Amicar) III. Assess for understanding of I and II
- Alternatives
PEEP set at 1-2 cmH20 below auto-PEEP. Anticipate air leak, PTX. Ketamine 1 mg/kg IV q1h In emergency, may use initial dosing: - Correct electrolytes, volume depletion,
then 1-3 mg/kg/hr gtt. Order vasoactives Note: does not help cytogenetic edema (e.g. If central access: Infuse 3% NaCl at 1-2 mL/kg/hr ↑ by ≤8 mEq/L over initial 24h ▷ If trauma: TXA 15 mg/kg [≤1g] load, then 2 mg/kg/hr [≤125 mg/hr] gtt for 8hr
0-3yo = 25mg 3-12y = 50mg ≥12yo = 100mg IV. Elicit decision
- Consequences
PRN suctioning and/or Lidocaine 1 mg/kg ETT q4h PRN suctioning to ↓ bronchospasm. - If severe/refractory bleeding, may consider recombinant factor VIIa 30-90 mcg/kg
hypoglycemia
V Document consent (if applicable)
to bedside for ↓ BP stroke) or widespread trauma (e.g. TBI) ▷ Consider isoflurane. Consider VV ECMO. until transition to isotonic fluids (NS, LR) - Then ↑ by 6–8 mEq/L per day