Conceptual Overview
Medication errors in pediatrics occur at 3× the rate of adult errors, and the majority involve dosing calculations. Unlike adult medicine where most drugs have standard flat doses ("give 2 mg of Ativan"), nearly every pediatric medication requires a weight-based calculation followed by a concentration-based volume calculation. This two-step math under pressure is where errors happen.
This page provides a rapid reference for the emergency medications you're most likely to need during a pediatric resuscitation or critical encounter. Every dose listed includes the concentration and has the math framework you need to get from "mg/kg" to "mL to draw up."
The 10-fold error: The single most dangerous medication error in pediatrics is the 10-fold dosing error - giving 10× the intended dose due to a decimal point error or concentration confusion. This is especially common with epinephrine (1:1,000 vs 1:10,000), opioids (mg vs mcg), and insulin. Always double-check your math. Always have a second person verify high-risk medication doses. Write it down, calculate it twice.
Cardiac Arrest Medications
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| Medication | Dose | Concentration | Volume Calculation | Max |
|---|---|---|---|---|
| Epinephrine (cardiac arrest) | 0.01 mg/kg IV/IO | 1:10,000 (0.1 mg/mL) | 0.1 mL/kg | 1 mg (10 mL) |
| Epinephrine (anaphylaxis) | 0.01 mg/kg IM | 1:1,000 (1 mg/mL) | 0.01 mL/kg | 0.3 mg (child), 0.5 mg (adolescent) |
| Amiodarone | 5 mg/kg IV/IO bolus | 50 mg/mL | 0.1 mL/kg | 300 mg (1st dose) |
| Lidocaine | 1 mg/kg IV/IO | 20 mg/mL (2%) | 0.05 mL/kg | 100 mg |
| Atropine | 0.02 mg/kg IV/IO | 0.1 mg/mL | 0.2 mL/kg | 0.5 mg; min 0.1 mg |
| Adenosine (1st dose) | 0.1 mg/kg rapid IV push | 3 mg/mL | 0.033 mL/kg | 6 mg |
| Adenosine (2nd dose) | 0.2 mg/kg rapid IV push | 3 mg/mL | 0.067 mL/kg | 12 mg |
The epinephrine concentration trap: There are TWO concentrations of epinephrine you need to know: 1:10,000 (0.1 mg/mL) for IV/IO cardiac arrest dosing and 1:1,000 (1 mg/mL) for IM anaphylaxis dosing. Giving 1:1,000 IV is a 10-fold overdose. Many institutions now use mg/mL labeling instead of ratio notation to reduce confusion. Know both systems.
RSI / Sedation Medications
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| Medication | Dose | Route | Onset | Notes |
|---|---|---|---|---|
| Etomidate | 0.3 mg/kg IV | IV | 30-60 sec | Hemodynamically neutral; avoid in septic shock (adrenal suppression) |
| Ketamine | 1-2 mg/kg IV; 3-4 mg/kg IM | IV/IM | IV: 1 min; IM: 3-5 min | Maintains airway reflexes; hemodynamically supportive; good for shock/asthma |
| Midazolam | 0.1-0.2 mg/kg IV; 0.2 mg/kg IN | IV/IN/IM | IV: 2-3 min; IN: 5 min | Anxiolysis/sedation; causes hypotension; IN for seizures |
| Succinylcholine | 1-2 mg/kg IV; 4 mg/kg IM | IV/IM | IV: 30-60 sec | Depolarizing paralytic; contraindicated in hyperK, burns >24h, crush, neuromuscular disease |
| Rocuronium | 1 mg/kg IV | IV | 60-90 sec | Non-depolarizing; preferred over sux in many centers; sugammadex reversal available |
| Fentanyl | 1-2 mcg/kg IV | IV | 2-3 min | Analgesic; minimal hemodynamic effect; note mcg (not mg) |
| Morphine | 0.1 mg/kg IV | IV | 5-10 min | Histamine release → hypotension; caution in hypovolemia |
Fentanyl is dosed in micrograms, not milligrams: Fentanyl is 100× more potent than morphine. The dose is 1-2 mcg/kg, not mg/kg. A 10 kg infant gets 10-20 mcg (0.2-0.4 mL of 50 mcg/mL concentration). Confusing mcg with mg results in a 1000-fold overdose. This is one of the most common fatal medication errors in pediatrics. Check, double check, and have someone verify.
Ketamine is the "desert island" pediatric sedative: If you could only take one sedation drug into a pediatric emergency, it would be ketamine. It provides sedation AND analgesia, is hemodynamically supportive (increases HR and BP), maintains airway reflexes and respiratory drive (at appropriate doses), is bronchodilatory (great for asthma), and can be given IV or IM. It's versatile, safe, and well-established in pediatric emergency medicine.
Fluid & Blood Products
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| Product | Dose | Rate | Notes |
|---|---|---|---|
| NS or LR bolus | 20 mL/kg | Over 5-20 min, repeat × 3 PRN | Standard resuscitation fluid; push via syringe for speed |
| pRBCs | 10-20 mL/kg | Over 30-60 min (emergent: as fast as possible) | After 40-60 mL/kg crystalloid with ongoing shock; use O-neg if type unknown |
| D10W (dextrose) | 5 mL/kg IV/IO | Bolus | For hypoglycemia (<60 mg/dL); follow with D10W infusion or dextrose-containing maintenance IVF |
| 3% Hypertonic saline | 2-5 mL/kg IV | Over 10-20 min | For symptomatic hyponatremia or refractory increased ICP; central line preferred |
Maintenance fluid calculation (Holliday-Segar):
- First 10 kg: 4 mL/kg/hr
- Next 10 kg (11-20): 2 mL/kg/hr
- Each kg >20: 1 mL/kg/hr
Common Dosing Errors & Safety Checks
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| Error Type | Example | Prevention |
|---|---|---|
| 10-fold error | Calculating 10 mg instead of 1 mg (decimal shift) | Always double-check decimal placement; have second person verify |
| Weight in lbs vs kg | Using 22 lbs instead of 10 kg → 2.2× overdose | Always confirm weight is in kg; divide lbs by 2.2 |
| Concentration confusion | Epi 1:1,000 IV instead of 1:10,000 → 10× overdose | Label syringes; verify concentration on vial before drawing |
| mcg vs mg confusion | Fentanyl 1 mg/kg instead of 1 mcg/kg → 1000× overdose | Spell out "micrograms"; avoid abbreviating mcg as μg |
| Wrong concentration in syringe | Different concentration on shelf than expected | Read the vial, not the shelf label; verify with pharmacist |
| Exceeding adult max dose | 70 kg adolescent: epi dose calculates to 0.7 mg (correct) but atropine calculates to 1.4 mg (exceeds 0.5 mg max) | Always check max dose against the weight-based calculation |
The "5 Rights" still apply under pressure: Right patient, right drug, right dose, right route, right time. In a chaotic resuscitation, it's tempting to skip verification steps. Don't. Read the vial label out loud before drawing. State the dose and the patient's weight out loud before pushing. Have the recorder verify the math. These seconds of verification prevent catastrophic errors.
Quick Reference
Critical Emergency Doses (memorize these)
- Epinephrine (arrest): 0.01 mg/kg = 0.1 mL/kg of 1:10,000
- Epinephrine (anaphylaxis): 0.01 mg/kg = 0.01 mL/kg of 1:1,000 IM
- Amiodarone: 5 mg/kg IV (max 300 mg)
- Atropine: 0.02 mg/kg IV (min 0.1, max 0.5 mg)
- Adenosine: 0.1 → 0.2 mg/kg rapid push (max 6 → 12 mg)
- Dextrose: D10W 5 mL/kg
- NS bolus: 20 mL/kg (push it fast)
- Defibrillation: 2 → 4 J/kg (max 10 J/kg)
- Cardioversion: 0.5-1 → 2 J/kg
Safety Checks
- Confirm weight in kg (not lbs)
- Check concentration on the vial, not the shelf
- Verify dose does not exceed max adult dose
- Have second person verify high-risk medications
- Use Broselow tape when weight unknown
Maintenance IVF (Holliday-Segar)
- 0-10 kg: 4 mL/kg/hr
- 11-20 kg: + 2 mL/kg/hr
- >20 kg: + 1 mL/kg/hr
Clinical Pearls
Pre-calculate your drugs: The best time to calculate pediatric drug doses is before you need them. In clinical practice, many resuscitation teams use weight-based dose cards (printed from Broselow/Handtevy systems) that are pre-calculated. If you don't have a pre-calculated card, the first thing to do when you get a patient weight is to calculate and write down epinephrine, atropine, and dextrose doses immediately. Don't wait for the arrest to start doing math.
The syringe push-pull technique: When giving a 20 mL/kg fluid bolus to a 5 kg baby (100 mL), connecting a 1L bag and running it wide open is too slow. Use a 60 mL syringe with a stopcock: draw from the bag, push into the patient, repeat. You can deliver 20 mL/kg in under 5 minutes this way. This is the standard technique for rapid pediatric fluid resuscitation.
Always weigh the child if possible: Even in an emergency, if the child is on a stretcher or bed with integrated scales, get an actual weight. Estimated weights (by formula, Broselow, or caregiver report) are approximations. An actual measured weight eliminates one entire source of error from every medication calculation for the duration of the resuscitation.
D25 and D50 are NOT for neonates and small infants: High-concentration dextrose (D25W, D50W) is hyperosmolar and can cause venous sclerosis, tissue necrosis if extravasated, and rebound hypoglycemia. Use D10W at 5 mL/kg for neonates and infants. For older children, D25W at 2 mL/kg is acceptable. Reserve D50W for adolescents and adults only.
References
- Ralston M, Hazinski MF, et al. Pediatric Advanced Life Support (PALS) Provider Manual. American Heart Association; 2020.
- Kaushal R, Bates DW, Landrigan C, et al. Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285(16):2114-2120.
- Taketomo CK, Hodding JH, Kraus DM. Pediatric & Neonatal Dosage Handbook. 28th ed. Lexicomp; 2021.
- Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957;19(5):823-832.
- Broselow JB, Luten RC. The Broselow Pediatric Emergency Tape. Vital Signs Inc; Updated 2019.
Medical Disclaimer
- For Educational Purposes Only: This content is intended for educational reference and should not be used for clinical decision-making.
- Not a Substitute for Professional Judgment: Always consult your local protocols, institutional guidelines, and supervising physicians.
- Verify Before Acting: Users are responsible for verifying information through authoritative sources before any clinical application.
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