Pediatric Emergency Resuscitation Medications

Medication Action Indication Does/Route Notes
Adenosine Slows conduction of impulses through the AV node.
  • SVT with adequate perfusion.
  • SVT with inadequate perfusion if cardioversion is being prepared or delayed.
  • May be considered in regular monomorphic wide-complex tachycardias with adequate perfusion (possible SVT with aberrancy).
  • 0.1 mg/kg (max 6 mg) rapid IV/IO push, followed by rapid 5–10 mL NS flush.
  • If not effective: 0.2 mg/kg (max 12 mg) rapid IV/IO push, followed by rapid 5–10 mL NS flush.
  • Patient should be on a monitor and have a rhythm strip run during administration.
  • Therapeutic effects can be blocked by caffeine or theophylline.
  • Can temporarily cause very slow ventricular rate or transient asystole; resolves as drug is eliminated.
Albuterol Selective, short-acting inhaled β2-adrenergic agonist; bronchodilator.
  • Asthma exacerbations.
  • Bronchospasm due to anaphylaxis or viral respiratory tract infections.
  • Hyperkalemia.
  • MDI (90 mcg/actuation): 4–8 inhalations every 20 min as needed for 3 doses, then every 1–4 h as indicated.
  • Neb (intermittent) < 20 kg: 2.5 mg/dose every 20 min as needed.
  • Neb (intermittent) > 20 kg: 5 mg/dose every 20 min as needed.
  • Neb (continuous): 0.5 mg/kg/hr, titrate as needed (max 20 mg/hr).
  • May cause cardiac arrhythmias, ↑ or ↓ blood pressure.
  • May cause transient hypokalemia, which can exacerbate arrhythmias.
  • Use with caution in patients with arrhythmias or hypertension.
Amiodarone Class III antiarrhythmic; delays repolarization and prolongs QT interval.
  • Shock-refractory VF/pVT.
  • Supraventricular tachycardia (SVT).
  • VT with pulse.
  • VF/pVT: 5 mg/kg (max 300 mg) IV/IO; may repeat 2 more times (daily max 15 mg/kg, adolescent max 2.2 g).
  • SVT/VT with pulse: 5 mg/kg (max 300 mg) IV/IO over 20–60 min; may repeat to daily max 15 mg/kg (adolescent max 2.2 g).
  • Do not use with other QT-prolonging drugs (e.g., procainamide).
  • May cause hypotension; infuse slowly and monitor BP.
  • May cause bradycardia or AV block; slow or discontinue if bradycardia occurs; ensure pacing availability in high-risk patients.
  • Cardiology consultation strongly recommended.
Atropine Blocks acetylcholine at muscarinic receptors; increases SA node firing and AV conduction.
  • Bradycardia with inadequate perfusion due to increased vagal tone or AV block.
  • Known or suspected organophosphate poisoning.
  • Bradycardia: 0.02 mg/kg IV/IO (min 0.1 mg, max 0.5 mg); may repeat once after 3–5 min (max total 1 mg in children, 3 mg in adolescents).
  • ETT: 0.04–0.06 mg/kg.
  • Organophosphate poisoning < 12 y: 0.05 mg/kg IV/IO, repeat q5 min doubling dose until symptoms resolve.
  • Organophosphate poisoning ≥ 12 y: 1 mg IV/IO, repeat q5 min doubling dose until symptoms resolve.
  • Higher doses may be required for organophosphate poisoning.
Calcium chloride Parenteral calcium; preferred in critically ill children; rapidly raises ionized calcium.
  • Hypocalcemia.
  • Hyperkalemia with widened QRS (to prevent VF).
  • Hypermagnesemia.
  • Calcium channel blocker toxicity.
  • 20 mg/kg (0.2 mL/kg of 10% solution) IV/IO slow push.
  • Repeat as needed to achieve desired effect.
  • Use only for resuscitation in documented hypocalcemia, hyperkalemia, hypermagnesemia, or CCB toxicity.
  • Monitor for symptomatic bradycardia; discontinue if occurs.
  • Central line preferred; peripheral extravasation may cause severe tissue injury.
  • Use with caution in patients receiving digitalis.
Calcium gluconate Parenteral calcium solution; alternative to calcium chloride.
  • Same indications as calcium chloride.
  • 60 mg/kg (0.6 mL/kg of 10% solution) IV/IO slow push.
  • Repeat as needed to achieve desired effect.
  • Use only if calcium chloride unavailable.
  • Contraindicated in neonates receiving ceftriaxone (risk of intravascular precipitates and organ damage).
  • In children > 28 days on ceftriaxone, do not administer simultaneously through same line; flush thoroughly if sequential.
  • Rapid administration may cause hypotension, bradycardia, arrhythmias, syncope, or cardiac arrest.
  • Central line preferred; peripheral extravasation may cause severe tissue injury.
  • Avoid in patients receiving cardiac glycosides (arrhythmia risk).
Dexamethasone Synthetic glucocorticoid with anti-inflammatory activity.
  • Upper airway edema in croup.
  • Acute asthma exacerbation.
  • 0.6 mg/kg (max 16 mg) PO/IV/IM; single dose for croup; every 24 h for asthma exacerbation.
  • May cause hyperglycemia/reduced glucose tolerance, especially in predisposed patients.
Diphenhydramine First-generation (sedating) H1 antihistamine.
  • Anaphylaxis.
  • Anaphylactic shock.
  • 1–2 mg/kg (max 50 mg) IM/IV/PO.
  • May cause sedation and respiratory depression, especially with other sedatives.
  • May cause hypotension.
  • Rapid IV infusion may precipitate seizures.
  • May cause paradoxical agitation.
Dobutamine Synthetic adrenergic agent (β1/β2); primarily inotropic.
  • Certain forms of shock requiring inotropic support.
  • Conditions affecting heart contractility and/or rate.
  • 2–20 mcg/kg/min IV/IO infusion, titrated to effect.
  • May decrease blood pressure via β2 effects; may require concurrent α-adrenergic agent (e.g., dopamine).
  • May increase myocardial oxygen demand and cause tachyarrhythmias.
Dopamine Precursor of norepinephrine; dose-dependent chronotropic, inotropic, and vasopressor effects.
  • Fluid-refractory shock.
  • Cardiogenic shock.
  • 2–20 mcg/kg/min IV/IO infusion, titrated to clinical effect.
  • Doses > 20 mcg/kg/min may cause tachyarrhythmias; consider alternative agent if higher doses required.
Epinephrine / Racemic epinephrine Acts on α- and β-adrenergic receptors; increases SVR, contractility, and heart rate.
  • Cardiac arrest (VF, pVT, PEA, asystole).
  • Bradycardia with inadequate perfusion.
  • Certain forms of fluid-refractory shock needing vasopressor/inotropic support.
  • Anaphylaxis.
  • Acute severe asthma exacerbation.
  • Upper airway edema in croup.
  • Bronchospasm due to bronchiolitis.
  • Arrest/bradycardia: 0.01 mg/kg IV/IO q3–5 min (max single dose 1 mg); ETT: 0.1 mg/kg if no IV/IO.
  • PEA/asystole: same dosing as above.
  • Shock: 0.1–1 mcg/kg/min IV/IO infusion, titrate to effect.
  • Anaphylaxis airway edema/angioedema: 0.01 mg/kg IM (max 0.3 mg) of 1 mg/mL, q10–15 min as needed.
  • Severe asthma: 0.01 mg/kg (max 0.3–0.5 mg) SC of 1 mg/mL, q20 min ×3, then as indicated.
  • Croup/bronchiolitis (epinephrine): 3 mg (3 mL of 1 mg/mL) in 3 mL NS via neb.
  • Croup/bronchiolitis (racemic): 0.25–0.5 mL of 2.25% solution in 3 mL NS via neb.
  • May increase BP, HR, and myocardial oxygen demand.
  • IV infiltration may cause severe local injury; phentolamine may be injected intradermally to counteract.
  • Verify correct concentration (0.1 mg/mL vs 1 mg/mL) to avoid critical dosing errors.
Flumazenil Benzodiazepine antagonist/reversal agent.
  • Benzodiazepine reversal.
  • Initial: 0.01 mg/kg (max 0.2 mg) IV over 15 s.
  • Repeat: 0.01 mg/kg (max 0.2 mg) IV at 1-min intervals, up to 4 doses (max total 0.05 mg/kg or 1 mg, whichever is lower).
  • Duration shorter than most benzodiazepines; repeat dosing may be required.
  • Provide supportive care and airway management throughout.
  • May precipitate seizures in patients on benzodiazepines for seizure disorders.
  • May provoke acute withdrawal in benzodiazepine-dependent patients.
Furosemide Loop diuretic.
  • Fluid overload.
  • Congestive heart failure/pulmonary edema.
  • 1 mg/kg IV/IM initial dose.
  • May increase dose by up to 1 mg/kg ≥ 2 h after previous dose, repeating until desired response (max 6 mg/kg).
  • May cause severe hypokalemia.
  • Excessive diuresis can cause intravascular volume depletion and circulatory collapse.
Glucose (Dextrose) Glucose replacement solution.
  • Hypoglycemia.
  • 0.5–1 g/kg IV/IO.
  • Newborns/infants/children: 5–10 mL/kg of 10% dextrose in water.
  • Infants/children: 2–4 mL/kg of 25% dextrose in water.
  • Hyperglycemia is potentially detrimental in critical illness and should be avoided when possible.
Heparin (unfractionated / low–molecular weight) Inhibits reactions involved in blood clotting.
  • Pulmonary embolism.
  • Unfractionated: 75 U/kg IV over 10 min, then 20 U/kg/hr (children/adolescents) or 28 U/kg/hr (infants).
  • LMWH: 1 mg/kg SC q12h (age > 2 months to 18 years); 1.5 mg/kg q12h (infants < 2 months).
  • Use UFH in unstable or high-bleeding-risk patients (shorter half-life, easier reversal).
  • Monitor coagulation labs frequently with UFH.
  • Both UFH and LMWH may cause bleeding or thrombocytopenia.
  • Difficult to achieve therapeutic levels with LMWH in infants.
Hydrocortisone Corticosteroid used to replace endogenous steroids.
  • Fluid-refractory, catecholamine-resistant shock with confirmed or at-risk adrenal insufficiency (e.g., purpura fulminans, prior steroid therapy, adrenal/pituitary abnormality).
  • 2 mg/kg IV/IO (max 100 mg).
  • Obtain pretreatment cortisol level if possible.
  • May cause fluid retention and hyperglycemia/glucose intolerance.
Insulin, regular Short-acting insulin; lowers blood glucose and shifts potassium into cells.
  • Diabetic ketoacidosis (DKA).
  • Persistent post–cardiac arrest hyperglycemia.
  • Hyperkalemia (with glucose).
  • DKA/hyperglycemia: 0.05–0.1 U/kg/hr IV infusion; continue until ketoacidosis resolves (follow facility protocol).
  • Hyperkalemia: 0.1 U/kg IV with 400 mg/kg glucose IV (1 U insulin per 4 g glucose).
  • Monitor glucose and potassium at least hourly to avoid hypoglycemia and hypokalemia.
  • Gradually reduce glucose by 50–100 mg/dL per hour in DKA/hyperglycemia.
  • Ensure appropriate fluid and electrolyte replacement in DKA.
Ipratropium bromide Quaternary ammonium derivative of atropine; anticholinergic bronchodilator.
  • Often used with albuterol for acute bronchospasm (asthma and other conditions).
  • 0.5 mg via neb every 20 min for up to 3 doses.
  • Or combined ipratropium/albuterol (3 mL = 0.5 mg ipratropium + 2.5 mg albuterol) via neb every 20 min ×3.
  • Not first-line therapy.
  • May cause dry mouth and GI upset.
  • Eye exposure may cause pupillary dilation and ↑ intraocular pressure.
Ketamine Dissociative anesthetic with bronchodilator activity.
  • Sedation for endotracheal intubation (preferred in status asthmaticus).
  • Refractory bronchospasm (status asthmaticus).
  • Preintubation: 1–2 mg/kg IV.
  • Continuous infusion (≥ 5 months): 0.5–2 mg/kg IV load, then 5–20 mcg/kg/min IV infusion, titrated to effect.
  • Optimal dose for refractory bronchospasm not established.
  • May cause hypersalivation; consider drying agents (e.g., atropine, scopolamine).
  • May cause laryngospasm; prior airway instability or tracheal surgery/stenosis are relative contraindications.
  • May increase intracranial and intraocular pressure.
Levalbuterol Selective, short-acting inhaled β2-agonist; active isomer of albuterol.
  • Asthma exacerbation.
  • Bronchospasm from other causes.
  • MDI: 4–8 inhalations every 20 min for 3 doses, then every 1–4 h as indicated.
  • Neb < 20 kg: 1.25 mg/dose every 20 min as needed.
  • Neb > 20 kg: 2.5 mg/dose every 20 min as needed.
  • May cause arrhythmias and BP changes.
  • May cause transient hypokalemia, increasing arrhythmia risk.
  • Use with caution in patients with arrhythmias or hypertension.
Lidocaine Class Ib antiarrhythmic (Na+ channel blocker); slightly prolongs QT.
  • Shock-refractory VF/pVT.
  • 1 mg/kg IV/IO loading dose.
  • Maintenance: 20–50 mcg/kg/min infusion (repeat bolus if infusion started > 15 min after initial bolus).
  • Excess levels may cause circulatory depression, hypotension, and seizures.
  • Contraindicated in complete heart block and wide-complex tachycardia due to accessory pathways.
  • Do not alternate between amiodarone and lidocaine.
Magnesium sulfate Cofactor in Na+, Ca2+, and K+ transport across cell membranes.
  • Torsades de pointes.
  • Severe asthma (status asthmaticus) not responding to first-line measures.
  • Hypomagnesemia.
  • Pulseless torsades: 25–50 mg/kg IV/IO bolus (max 2 g).
  • Status asthmaticus: 25–50 mg/kg IV/IO over 15–30 min (max 2 g).
  • Hypomagnesemia: 25–50 mg/kg IV/IO over 10–20 min (max 2 g).
  • Rapid infusion may cause hypotension or bradycardia.
  • Have calcium chloride available to reverse magnesium toxicity.
Mannitol Osmotic diuretic; shifts intracellular water to extracellular/vascular space, reducing intracranial edema and pressure.
  • Increased intracranial pressure.
  • 0.25–1 g/kg IV/IO over 20–30 min.
  • Repeat as needed to maintain serum osmolality < 320 mOsm/kg.
  • Use with other ICP-lowering measures (e.g., head elevation, sedation).
  • Monitor BP and avoid hypotension.
  • Insert urinary catheter; monitor for hyperosmolality and volume depletion.
Methylprednisolone sodium succinate Synthetic glucocorticoid with anti-inflammatory activity.
  • Anaphylaxis.
  • Upper airway edema due to other conditions (e.g., croup, alternative to dexamethasone).
  • Acute asthma exacerbation.
  • Initial: 2 mg/kg IV/IO/IM.
  • Maintenance: 1–2 mg/kg/day divided q6–12h (max daily dose 120 mg).
  • Monitor for hyperglycemia/glucose intolerance and hypokalemia.
  • May cause hypertension and fluid retention.
Milrinone Phosphodiesterase-3 inhibitor with inotropic, lusitropic, and vasodilatory properties.
  • Certain forms of shock requiring inotropic support and/or afterload reduction.
  • Conditions affecting the heart muscle.
  • Loading dose: 50 mcg/kg IV/IO over 10–60 min.
  • Infusion: 0.25–0.75 mcg/kg/min.
  • May cause hypotension and ventricular arrhythmias.
  • Monitor BP and ECG continuously; ensure adequate intravascular volume.
  • Loading dose may be omitted in shock with hypotension.
Naloxone Competitively binds to μ-opioid receptors; opioid antagonist.
  • Apnea or respiratory depression due to opioid overdose.
  • Complete reversal: 0.1 mg/kg (max 2 mg) IV/IO/IM/SC q2–3 min as needed.
  • Partial reversal: 1–5 mcg/kg IV/IO/IM/SC, titrated to effect.
  • Infusion: 0.002–0.16 mg/kg/hr IV/IO.
  • Public access: 0.4 mg IM or 2 mg IN, repeat q2–3 min as needed.
  • May precipitate acute withdrawal in opioid-dependent patients.
  • In neonates, opioid withdrawal may be life-threatening if not recognized and treated.
  • Use lower doses (1–15 mcg/kg) to reverse respiratory depression while preserving analgesia.
Nitroglycerin Vasodilator (venous > arterial).
  • Acute heart failure/cardiogenic shock.
  • Hypertensive crisis.
  • Myocardial ischemia.
  • Infants/children: 0.25–0.5 mcg/kg/min IV/IO infusion; increase by 1 mcg/kg/min q15–20 min as tolerated to effect.
  • Adolescents: 5–10 mcg/min IV/IO infusion; increase to max 200 mcg/min as tolerated.
  • May cause severe hypotension and paradoxical bradycardia.
  • Use with caution in pre-existing hypotension or volume depletion.
Nitroprusside Nitric oxide donor; induces vasodilation via smooth muscle relaxation.
  • Low–cardiac output, high-SVR shock.
  • 0.3–1 mcg/kg/min IV/IO, starting at lowest dose and titrating to effect (max 8 mcg/kg/min).
  • May induce profound hypotension; continuous monitoring with arterial line recommended.
  • Avoid accidental flushing/bolus of line.
  • Protect from light (cover bottle/syringe).
  • Risk of cyanide/thiocyanate toxicity, especially with high doses, prolonged use, or hepatic/renal insufficiency; monitor for metabolic acidosis and thiocyanate levels if > 3 mcg/kg/min.
Norepinephrine Acts on α- and β-adrenergic receptors; increases HR, contractility, and vasoconstriction.
  • Certain types of fluid-refractory shock requiring vasopressor support.
  • 0.05–2 mcg/kg/min IV/IO infusion, titrated upward to desired effect.
  • May cause tachycardia, reflex bradycardia, arrhythmias, and hypertension.
  • Potent vasoconstrictor; extravasation can cause necrosis. Phentolamine may be injected intradermally to counteract.
Phenylephrine Pure α-adrenergic agonist; increases blood pressure via vasoconstriction. Shock with isolated peripheral vasodilation and normal/increased cardiac output (e.g., neurogenic shock, anaphylactic shock refractory to epinephrine). 0.1–0.5 mcg/kg/min IV/IO infusion, titrated to effect. May cause hypertension or reduced cardiac output.
May induce reflex bradycardia.
Severe peripheral vasoconstriction may cause tissue necrosis if extravasation occurs.
Monitor kidney function due to risk of visceral vasoconstriction.
Potassium chloride Potassium supplement. Symptomatic hypokalemia (K+ < 3.5 mEq/L).
Hypokalemia-associated arrhythmias (torsades, VF, pVT, asystole). 		0.5–1 mEq/kg (max 40 mEq) IV at ≤0.5 mEq/kg/hr.
Recheck potassium 1–2 hours after infusion; repeat as needed. 		Must accompany appropriate arrhythmia management.
Continuous cardiac monitoring required.
Treat concurrent hypomagnesemia to improve potassium reabsorption.
Prednisone / Prednisolone Synthetic glucocorticoid with anti-inflammatory activity. Mild, moderate, or severe asthma exacerbation.
Upper airway edema in croup. 		1–2 mg/kg/day PO in 1–2 doses for 3–10 days (max 60 mg/day).
Taper if used >10 days. 		Oral route preferred if GI absorption intact.
Monitor for hyperglycemia, hypokalemia, hypertension, fluid retention.
Risk of adrenal suppression with prolonged supraphysiologic dosing.
Procainamide Class Ia antiarrhythmic; sodium channel blocker; prolongs QT. VT with pulse (second line after cardioversion if unstable).
Supraventricular tachycardia (SVT). 		15 mg/kg IV/IO over 30–60 minutes. Do not use with amiodarone or other QT-prolonging drugs.
May cause hypotension, decreased cardiac function, prolonged QT, torsades, heart block, or arrest.
Stop infusion if QRS widens ≥50% or hypotension develops.
Cardiology consultation strongly recommended.
Prostaglandin E1 (PGE1) Vasodilator that maintains ductus arteriosus patency. Suspected or confirmed ductal-dependent congenital heart disease. Initial: 0.05–0.1 mcg/kg/min IV/IO, titrate up to 0.1 mcg/kg/min.
Maintenance: 0.01–0.05 mcg/kg/min. 		May cause apnea, hyperthermia, or seizures—do NOT discontinue infusion; provide respiratory support as needed.
May cause hypotension; ensure adequate intravascular volume.
Sodium bicarbonate Alkalinizing agent. Hyperkalemia with widened QRS.
Severe metabolic acidosis (pH < 7.15) unresponsive to ventilation/oxygenation.
Sodium channel blocker toxicity (e.g., TCA overdose). 		1 mEq/kg IV/IO slow push.
For sodium channel blocker toxicity: titrate to serum pH 7.45–7.55; follow with 150 mEq/L infusion. 		Routine use in cardiac arrest not recommended.
Ensure adequate ventilation to eliminate CO₂ load.
Do NOT administer via ETT.
Use 4.2% (0.5 mEq/mL) only in infants <1 month.
Terbutaline Systemic short-acting selective β₂-agonist; bronchodilator. Acute severe asthma exacerbation. Subcutaneous: 0.01 mg/kg (max 0.4 mg), repeat q20 min.
IV/IO infusion: start 0.4 mcg/kg/min, titrate 0.1–10 mcg/kg/min. 		May cause BP and HR changes, arrhythmias, hypertension.
May cause transient hypokalemia, increasing arrhythmia risk.
Tranexamic Acid (TXA) Antifibrinolytic; prevents clot breakdown. Hemorrhage due to trauma. Loading: 15 mg/kg (max 1 g) IV over 10 min.
Maintenance: 2 mg/kg/hr IV for ≥8 hours or until bleeding stops. 		Risk of thrombosis; caution in thromboembolic disease.
May cause ureteral obstruction in upper urinary tract bleeding.
Contraindicated in subarachnoid hemorrhage.
Contraindicated in patients with color vision defects.
Vasopressin V1 receptor agonist; potent vasoconstrictor. Catecholamine-resistant shock requiring vasopressor support. 0.0002–0.002 units/kg/min (0.2–2 milliunits/kg/min) IV/IO infusion. May cause water intoxication and hyponatremia.
Use with caution in renal dysfunction or pre-existing hyponatremia.