Drugs for Pediatric Emergencies Committee on Drugs ABSTRACT. This statement provides current recom- obtained within 90 seconds or after three attempts to mendations about the use of emergency drugs for acute establish IV access. For some drugs, such as epineph- pediatric problems that require pharmacologic interven- rine, atropine, naloxone, and lidocaine, endotracheal tion. At each clinical setting, physicians and other pro- administration is appropriate. A recommended viders should evaluate drug, equipment, and training method of endotracheal delivery is to administer the needs. The information provided here is not all-inclusive drug with or dilute in 1 to 5 mL of isotonic saline and is not intended to be appropriate to every health care setting. When possible, dosage recommendations are through a catheter inserted to the tip of the endotra- consistent with those in standard references, such as the cheal tube. This method may enhance absorption Advanced Pediatric Life Support (APLS) and Pediatric from the lung. Advanced Life Support (PALS) textbooks.1–3 Additional The dosages provided are recommendations based guidance is available in the manual Emergency Medical upon expert consensus. The Committee on Drugs Services for Children: The Role of the Primary Care Pro- recognizes that pediatric labeling and dosage infor- vider, published by the American Academy of Pediatrics, mation do not exist for many of these drugs. Dosage as well as in the PALS and APLS textbooks. should be individualized, taking into account the patient’s age, weight, underlying illness, concur- ABBREVIATIONS. APLS, Advanced Pediatric Life Support (text- rently administered drugs, and known hypersensi- book); PALS, Pediatric Advanced Life Support (textbook); IV, intra- tivity. venous; IM, intramuscular; PO, oral. A physician who administers drugs that depress the respiratory or central nervous system must have he drug information in this statement assists the skills necessary to manage the potential compli- health care providers and facilities in prepar- cations. It is important to implement the guidelines ing for a crisis. This document is not designed for monitoring published by the American Academy T of Pediatrics.4 A practitioner who uses a neuromus- for use during an actual emergency. It is useful to precalculate and distribute volumetric doses (eg, cular blocking agent (“muscle relaxant”) must be mL/kg) using the specific drug concentrations that qualified to maintain the patient’s airway through are available in a particular institution. Precalculated bag and mask ventilation and endotracheal intuba- drug cards or length-based resuscitation tapes are tion. Once the patient has received the muscle re- useful in the preparation process. This document laxant, there is no longer any respiratory effort. does not provide comprehensive drug information. Descriptions of drug indications and side effects SOME CONSIDERATIONS FOR THE USE OF have been purposely limited. DRUGS FOR ENDOTRACHEAL INTUBATION Drug dosages are generally presented as milligram The choice of drugs for control of the airway per kilogram (mg/kg). An exception is made for should address two concerns: adequate sedation/ high-potency drugs (vasoactive amines and nitro- analgesia for laryngoscopy and appropriate selection prusside). For these drugs, dosage is given in micro- of a muscle relaxant, if indicated. A patient who is in gram per kilogram (mg/kg) in Table 1. full cardiac arrest does not require sedatives or mus- In general, drug doses (including “bolus” doses) cle relaxants to safely gain control of the airway. should be administered over several minutes to When cardiac arrest has not occurred, endotracheal avoid transiently excessive blood levels of the drug. intubation of the patient who is ill or who has been Exceptions to this rule include: adenosine, epineph- injured—especially if there is associated head inju- rine, atropine, and muscle relaxants. Infusion devices ry—may be facilitated by administration of a seda- (intravenous [IV] infusion pumps) should be used tive (benzodiazepine), IV local anesthetic (lidocaine), for all vasoactive drugs administered as a continuous opioid (fentanyl), and a neuromuscular blocking infusion, such as dopamine or nitroprusside. drug. The choice of drugs depends on the physio- Unless otherwise indicated, the IV route is pre- logic status of the patient. A patient who is hypov- ferred. In an emergency, intraosseous administration olemic would be placed at risk with the rapid IV is an acceptable alternative when IV access cannot be administration of barbiturates (such as methohexital or thiopental) because of the cardiac depressant and vasodilator effects of barbiturates. Ketamine would The recommendations in this statement do not indicate an exclusive course be a better choice in this circumstance. Conversely, a of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. patient with a closed head injury would benefit from PEDIATRICS (ISSN 0031 4005). Copyright © 1998 by the American Acad- the use of barbiturates and/or lidocaine and fentanyl emy of Pediatrics. because this would reduce cerebral blood flow and http://www.pediatrics.org/cgi/content/full/101/1/Downloaded from www.aappublications.org/newse13 by PEDIATRICSguest on September Vol. 26, 101 2021 No. 1 January 1998 1of11 cerebral oxygen consumption and therefore intracra- If succinylcholine therapy is contraindicated (his- nial pressure. Following head injury, ketamine ther- tory of malignant hyperthermia, muscular dystro- apy increases cerebral blood flow and intracranial phy, neuromuscular disease, neurologic denervation pressure. injury or crush injury), a nondepolarizing muscle Combining drugs with different modes of action relaxant is indicated. With nondepolarizing agents, may be advantageous. For example, adding a benzo- the onset of neuromuscular blockade may be some- diazepine or narcotic to the regimen may prolong the what delayed compared with succinylcholine. Also, effect and/or enable a reduction in the dose of ket- the duration of paralysis is markedly prolonged amine or barbiturate required to sedate. compared with succinylcholine. The peak effect of Airway equipment appropriate for the patient’s pancuronium, for example, generally occurs 2 to 3 size and age must be immediately available before a minutes after administration. The effects of the most neuromuscular blocking agent is administered. This recently approved relaxant (rocuronium) occur equipment includes an appropriate-sized face mask, a bag-mask-valve device for positive pressure venti- within 45 seconds to 1 minute. This time is dose- lation, endotracheal tubes, oral airways, functioning dependent and in higher doses (0.8 to 1.2 mg/kg) is laryngoscope blades, functioning handles, suction similar to that of succinylcholine. Rocuronium may catheters, and suction apparatus to clear the airway if be a reasonable alternative to succinylcholine when the patient vomits. The patient should be fully mon- succinylcholine is contraindicated. itored with a cardiac monitor, blood pressure read- Recent concerns about the elective use of succinyl- ings, and pulse oximetry. Nasogastric (orogastric) choline in pediatric patients have focused on the suction catheters are helpful in evacuating and de- occasional reports of hyperkalemic cardiac arrest, compressing the patient’s stomach if gastric disten- particularly in children with undiagnosed Duchenne tion occurs. A stethoscope should be available to muscular dystrophy. The incidence of Duchenne check breath sounds. muscular dystrophy is only 1 in 3000 to 8000 male The choice of muscle relaxant depends on the cir- children. The revised labeling continues to permit cumstances. Succinylcholine remains the muscle re- the use of succinylcholine for emergency control of laxant of choice for the emergency control of the the airway and treatment of laryngospasm. Succinyl- airway and is generally the muscle relaxant of choice choline is the only neuromuscular blocking agent cur- for patients with a “full stomach.” It has the most rently available that has been demonstrated to be effective rapid onset and shortest duration of the relaxants after intramuscular (IM) administration when emergency that are currently available and has the longest control of the airway is required and there is no IV access. “track record” for overall safety. In this circumstance, the dosage must be increased to Administration of succinylcholine should be pre- 4 to 5 mg/kg IM. Atropine is administered simulta- ceded by atropine to prevent significant bradycardia. neously. Following IM succinylcholine, onset of neu- In children over 5 years of age, a defasciculating dose romuscular blockade takes approximately 2 to 5 min- of a nondepolarizing relaxant (10% of an intubating utes; the response in patients who are hypotensive or dose) 2 to 3 minutes before succinylcholine may pre- vent muscle fasciculations. Cricoid pressure is ap- hypovolemic is unpredictable. Standard textbooks of plied (firm pressure on the cricoid cartilage) to pre- advanced life support, eg, Pediatric Advanced Life Sup- vent passive regurgitation during laryngoscopy and port or Advanced Pediatric Life Support (PALS, APLS), 1–4 intubation. should be consulted for more detail. TABLE 1. Frequently Used Emergency Drugs Adenosine Diazoxide Glucose Meperidine Phenylephrine Albuterol Digibind Haloperidol Methylprednisolone Phenytoin Atropine Diphenhydramine Insulin Midazolam