Bedside Snapshot
- Use It When
- Calculating any pediatric emergency drug, fluid, blood product or shock energy dose, or checking a dose against the measured weight and maximum.
- Key Numbers
- Arrest epinephrine: 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL), max 1 mg
- Defibrillation: 2, then 4 J/kg (max 10 J/kg)
- Amiodarone: 5 mg/kg (max 300 mg; 150 mg later)
- Adenosine: 0.1, then 0.2 mg/kg (max 6, then 12 mg)
- Formulas
- Volume: mg dose ÷ mg/mL = mL
- Maintenance: 4 mL/kg/hr (first 10 kg), + 2 (next 10 kg), + 1 mL/kg/hr (each kg over 20)
- Weight, age 1–5 years: (2 × age) + 8 kg
- Action Thresholds
- Hypoglycemia (under 70 mg/dL): D10 5 mL/kg; neonates 2 mL/kg
- Shock bolus: 10–20 mL/kg, then reassess
- Stop boluses for crackles or an enlarged liver
- Watch Out
- Epinephrine 1 mg/mL IV is a 10-fold overdose. Check kg not lbs, mcg not mg, and the vial concentration before drawing up.
Overview & Pediatric Differences
Pediatric dosing goes wrong easily. Every step involves a weight, a unit and a concentration, often under time pressure. Almost every pediatric emergency drug is weight-based, so each dose has two steps. First, the mg/kg calculation. Then the volume calculation at the concentration on the vial. Both steps must be checked. The result must stay within the stated maximum.
This is a dosing reference for the drugs, fluids and antidotes you reach for most often in pediatric emergencies. Every dose is per kilogram of confirmed weight. Where a dose depends on protocol or on the product, the page says so.
Why Kids Are Different
- Dose scales with weight: a 2 kg infant and a 40 kg adolescent differ 20-fold in every mg/kg dose. One wrong weight multiplies every drug.
- Small volumes: a 10 kg child needs 0.1 mg of epinephrine. That is 1 mL of 0.1 mg/mL. Miss a decimal or misread the concentration, and the dose moves 10-fold.
- Different drug handling: neonates and young infants have larger volumes of distribution and slower clearance for many drugs. Per-kg doses can differ from older children. See Special Populations.
- Narrow reserve: children hold on with tachycardia and vasoconstriction, then decompensate abruptly. Hypotension is a late sign.
Scope: this page covers single-dose and bolus drugs, shock energy and fluid boluses. It does not dose continuous sedation, analgesia or vasoactive infusions. Midazolam IV sedation and morphine are not included either. For those, follow the local infusion protocol and pump-programming rules. Maintenance fluid rates use the Holliday-Segar formula (see the reference list).
Pediatric dosing source: doses come from AHA/AAP 2025 when it states a dose. If it does not, they come from the NASEMSO National Model EMS Clinical Guidelines v3.0 (2022), then the US label. If no source gives a dose, the page shows none. A pediatric maximum never exceeds the adult maximum dose (NASEMSO Universal Care Guideline, p. 13). Doses are off-label unless marked labeled.
How to Use
- Get the weight: use a measured weight when possible. Otherwise use a confident recent caregiver weight, or the length-based tape (see Limitations & Alternatives). Record the weight in kg and its source.
- Convert units: pounds ÷ 2.2 = kg. Confirm the weight is in kilograms before any calculation.
- Calculate the mg dose: weight (kg) × mg/kg. Compare it with the stated maximum and use the lower figure.
- Convert mg to mL: mg ÷ concentration (mg/mL) = mL. Read the concentration on the vial, not on the shelf label.
- Verify aloud: state the drug, the weight, the mg dose and the mL volume. A second clinician checks every high-alert drug.
Worked example (14 kg child in arrest): Start with 0.01 mg/kg × 14 kg, which gives 0.14 mg. Divide by the 0.1 mg/mL on the vial: 0.14 mg ÷ 0.1 mg/mL = 1.4 mL. You never reach the 1 mg maximum. Draw 1.4 mL from a 1 mg/mL vial by mistake and you deliver 1.4 mg. That is 10 times the intended dose.
Interpretation & Action Thresholds
| Finding or Threshold | Meaning | Action |
|---|---|---|
| Glucose under 70 mg/dL | Hypoglycemia (ADA Level 1; under 54 mg/dL is Level 2) | D10 5 mL/kg (2 mL/kg in neonates), recheck glucose, then infusion |
| Potassium high with peaked T waves or wide QRS | Hyperkalemia with ECG changes | Calcium chloride 20 mg/kg (max 1 g); insulin with dextrose at the arrest dose in the dosing table (no non-arrest pediatric insulin dose is set on this page); avoid succinylcholine |
| Systolic BP below the age floor | Hypotension (age floor on the vital-signs page) | Isotonic bolus 10–20 mL/kg, reassess after each, then vasoactive per protocol |
| Crackles, enlarged liver or rising work of breathing during a bolus | Fluid overload | Stop the bolus; reassess; diuresis or positive pressure per protocol |
| Seizure lasting 5 minutes or longer | Status epilepticus | Benzodiazepine now: IV lorazepam or diazepam, or IM or IN midazolam without access |
Use these thresholds to act at the bedside, not to dose. Doses and rates are in the Medications & Dosing sections below.
Treat hypoglycemia when glucose is below 70 mg/dL (ADA Level 1; Level 2 is below 54 mg/dL; Level 3 is altered mental or physical status needing assistance at any glucose; ADA Standards of Care 2026, Section 6). The NASEMSO model guideline differs. It treats symptomatic patients at 60 mg/dL or less (NASEMSO v3.0, p. 84).
Limitations & Alternatives
- Weight estimates are only approximations. Work down this order: measured weight, then a confident recent caregiver weight, then the length-based tape, then an age formula.
- Length-based and age-based weights are less reliable in children with obesity. Get a measured weight whenever you can.
- Age formulas (APLS): 0–12 months: (age in months × 0.5) + 4 kg. 1–5 years: (2 × age) + 8 kg. 6–12 years: (3 × age) + 7 kg.
| Method | How | Strengths | Weaknesses |
|---|---|---|---|
| Measured weight | Bed scale or scale | Most accurate | Takes time; may not be possible in an emergency |
| Caregiver report | Recent weight from home, chart or record | Fast and often close | Can be outdated or guessed |
| Length-based tape | Measure head to heel on the tape | Quick; gives color zones and doses | Less reliable in obesity; measure to the heel, not the toes |
| Age formula | APLS formula above | No equipment needed | Least accurate; unreliable at the extremes of growth |
Medications & Dosing: Resuscitation & Cardiac
Every dose below follows the source order in the Overview. Local protocol applies only where a row says so. Do the arrest math before the resuscitation starts, from the measured or confirmed weight. The algorithm is on the Pediatric Cardiac Arrest page.
| Drug | Dose & Route | Max | Notes |
|---|---|---|---|
| Epinephrine 0.1 mg/mL (IV/IO) High-alert | Arrest, or bradycardia with poor perfusion that persists after oxygenation, ventilation and correction of other causes: 0.01 mg/kg IV/IO = 0.1 mL/kg of 0.1 mg/mL | 1 mg per dose | Every 3–5 min until ROSC (2025 AHA Part 8, rec 3, COR 2b, LOE C-LD; PALS cardiac arrest algorithm: 0.01 mg/kg, max 1 mg). Bradycardia with poor perfusion (heart rate under 60 despite oxygen and ventilation): start CPR, and give epinephrine if the bradycardia persists after other causes are corrected (2025 AHA Part 8, bradycardia recs 2–3, COR 1, LOE C-EO). Neonates: 0.01–0.03 mg/kg IV/IO (2025 AHA Part 5, rec 1, COR 1, LOE B-NR), repeated every 3–5 min while heart rate is under 60/min (Part 5, rec 4, COR 2b, LOE C-LD). If no access, endotracheal 0.05–0.1 mg/kg only while access is placed (Part 5, rec 3, COR 2a, LOE C-LD). |
| Defibrillation (energy) | First shock 2 J/kg (2–4 J/kg acceptable) Later shocks 4 J/kg (higher may be considered) | 10 J/kg or adult dose | VF or pulseless VT (2025 AHA Part 8, recs 1–2: initial 2–4 J/kg, COR 2a, LOE C-LD; later shocks 4 J/kg, up to 10 J/kg or the adult dose, COR 2b, LOE C-LD). Shock, then CPR per the cardiac arrest algorithm. |
| Synchronized cardioversion (energy) | 0.5–1 J/kg, then 2 J/kg | Adult dose (cap per NASEMSO p. 13) | Unstable tachycardia with a pulse (2025 AHA Part 8: SVT rec 4, COR 2a, LOE C-LD; wide-complex rec 3, COR 2a, LOE C-EO). Use synchronized mode; sedate if the child is awake (per protocol). |
| Amiodarone High-alert | 5 mg/kg IV/IO rapid bolus (shock-refractory VF/pVT) = 0.1 mL/kg of 50 mg/mL | 300 mg first dose; later doses 150 mg; up to 3 doses | Not for torsades (give magnesium). Perfusing VT or SVT: 5 mg/kg over 20–60 min with expert input (off-label; prior PALS 2020 algorithm dose, not stated in the 2025 PALS sidebars). A rapid push can drop blood pressure. Do not give IV amiodarone for pre-excited AF or flutter (2025 AHA Part 9, rec 3, COR 3: Harm, LOE C-LD; adult recommendation). |
| Lidocaine High-alert | 1 mg/kg IV/IO bolus (VF/pVT; alternative to amiodarone) = 0.05 mL/kg of 20 mg/mL | 100 mg per bolus | Infusion 20–50 mcg/kg/min (max 50); use the lower end in shock, heart failure or after arrest, per protocol. Use a pump; write the rate in mcg/kg/min. |
| Adenosine, first dose High-alert | 0.1 mg/kg rapid IV/IO push, then NS flush = 0.033 mL/kg of 3 mg/mL | 6 mg | Stable regular narrow-complex SVT. Run a rhythm strip during the push. Vagal maneuvers first if the child is stable (per protocol). |
| Adenosine, second dose | 0.2 mg/kg rapid IV/IO push, then NS flush = 0.067 mL/kg of 3 mg/mL | 12 mg | If no conversion. Transient asystole is expected. |
| Atropine | 0.02 mg/kg IV/IO (minimum 0.1 mg) = 0.2 mL/kg of 0.1 mg/mL | 0.5 mg per dose | Bradycardia from increased vagal tone or AV block, after oxygenation and ventilation (2025 AHA Part 8, bradycardia rec 1, COR 1, LOE C-LD; PALS bradycardia algorithm: minimum 0.1 mg, maximum single dose 0.5 mg, may repeat once). For bradycardia with poor perfusion, epinephrine is first-line. Over 40 kg or over 14 years: adult dose, 1 mg IV every 3–5 min, maximum total 3 mg (NASEMSO v3.0 pp. 13, 36). |
| Calcium chloride 10% | 20 mg/kg IV/IO slowly (over 5 min for hyperkalemia; over 10 min for CCB toxicity) = 0.2 mL/kg of 10% (100 mg/mL) Hypocalcemia (label): 2.7–5 mg/kg IV slowly, no faster than 1 mL/min | 1 g per dose | Routine calcium in pediatric cardiac arrest is not recommended: COR 3: No Benefit, LOE B-NR (2025 AHA Part 8, rec 6), except hypocalcemia, calcium-channel blocker overdose or hyperkalemia. In hyperkalemic arrest, effectiveness is not well established (2025 AHA Part 10, COR 2b, LOE C-LD). Use for documented hypocalcemia, hyperkalemia with ECG changes, or calcium-channel blocker toxicity. Calcium gluconate 60 mg/kg IV over 10 min, max 3 g (adult dose), is the preferred peripheral option because chloride carries more tissue-injury risk (NASEMSO v3.0 p. 296). Differs from FDA label: the label is for hypocalcemia only; the 20 mg/kg dose here is off-label for hyperkalemia and calcium-channel blocker toxicity. Calcium-channel blocker toxicity: calcium is reasonable (2025 AHA Part 10, rec 5, COR 2a, LOE C-EO). Differs from AHA 2023 Table 2 (prior guidance; its 2025 calcium figures are not verified here), which allows a child bolus up to the adult 2 g and an infusion of 20–40 mg/kg/hr; this page caps the bolus at 1 g. Central line or IO preferred for chloride; extravasation injures tissue. |
| Sodium bicarbonate Hyperkalemia | 1 mEq/kg IV/IO, slowly = 1 mL/kg of 8.4% (1 mEq/mL), or 2 mL/kg of 4.2% (0.5 mEq/mL) under about 3 months | 50 mEq per dose | Hyperkalemia, including cardiac arrest: effectiveness is not well established (2025 AHA Part 10, COR 2b, LOE C-EO). Routine use in pediatric cardiac arrest is not recommended (2025 AHA Part 8, rec 5, COR 3: No Benefit, LOE B-NR). Infants under about 3 months: 4.2% (0.5 mEq/mL) per the AHA 2025 Part 10 Table 4 footnote (children 0.5 mEq/mL). Not for routine newborn resuscitation. |
| Sodium bicarbonate Sodium-channel blocker toxicity | 1–3 mEq/kg IV/IO, slowly = 1–3 mL/kg of 8.4% (1 mEq/mL) Under about 3 months: 2–6 mL/kg of 4.2% (0.5 mEq/mL) | Not above the adult dose (50–150 mEq) | Tricyclic or other sodium-channel blocker toxicity: life-threatening cardiotoxicity (2025 AHA Part 10: TCA in children COR 2a, LOE C-LD; other sodium-channel blockers COR 2a, LOE C-EO). Infants under about 3 months: 4.2% (0.5 mEq/mL) per the AHA 2025 Part 10 Table 4 footnote (children 0.5 mEq/mL). Not for routine newborn resuscitation. |
Medications & Dosing: Sedation, Analgesia & RSI
Within a minute, an induction drug can stop breathing or take away airway tone. Have suction, bag-mask ventilation and a rescue plan ready. Draw up post-intubation sedation and analgesia before the induction drug. Analgesia and sedation are two separate decisions. Pick each one by indication and protocol.
| Drug | Dose & Route | Max | Notes |
|---|---|---|---|
| Etomidate High-alert | 0.3 mg/kg IV over 30–60 s = 0.15 mL/kg of 2 mg/mL | 0.6 mg/kg; single dose | FDA label: age 10 years and older. Under 10 is off-label and per protocol. Avoid in children with sepsis or septic shock (SSC Children 2026, conditional recommendation, low certainty). No analgesia. |
| Ketamine (RSI or induction) High-alert | 1–2 mg/kg IV/IO over 30–60 s = 0.1–0.2 mL/kg of 10 mg/mL | 2 mg/kg per induction | Keeps airway reflexes. Blood pressure and heart rate usually rise (transient). Start post-intubation analgesia. Use the 10 mg/mL vial for IV boluses. |
| Ketamine (IM sedation) | 4–5 mg/kg IM = 0.08–0.1 mL/kg of 50 mg/mL | Per protocol; no fixed max | Procedural sedation range in common practice. The IM label dose is for anesthesia (6.5–13 mg/kg). Use the 50 or 100 mg/mL vial for IM; the 10 mg/mL vial is too dilute for IM use. |
| Succinylcholine High-alert | Infants and small children: 2 mg/kg IV rapid push = 0.1 mL/kg of 20 mg/mL Older children and adolescents: 1 mg/kg IV = 0.05 mL/kg | Single dose; no IV maximum in label | Emergency intubation only. Bradycardia is common after a first dose in children; have atropine ready. Contraindicated in myopathies and in suspected malignant hyperthermia. See Special Populations for hyperkalemia risks. |
| Succinylcholine (IM, no IV access) | Up to 3–4 mg/kg IM = 0.15–0.2 mL/kg of 20 mg/mL | 150 mg total | Onset about 2–3 min. Plan oxygenation and bag-mask ventilation for the slower onset. |
| Rocuronium High-alert | 1 mg/kg IV/IO (off-label; source: Bisesi 2024 pediatric RSI practice study) = 0.1 mL/kg of 10 mg/mL | Single dose; max 1.2 mg/kg (not above the adult dose) | Non-depolarizing alternative when succinylcholine is contraindicated. Differs from FDA label: label does not recommend rocuronium for pediatric RSI; labeled intubating dose 0.6 mg/kg. Onset is slower and paralysis lasts longer. |
| Fentanyl (IV/IO) High-alert | 1 mcg/kg IV/IO, slowly over 1–2 min = 0.02 mL/kg of 50 mcg/mL | 100 mcg maximum initial dose; repeat after 5 min if indicated | Analgesia (NASEMSO v3.0 p. 94). Dosed in micrograms: write out “micrograms”. Watch breathing after each dose. |
| Fentanyl (intranasal) High-alert | 1 mcg/kg IN, split between the nares = 0.02 mL/kg of 50 mcg/mL | 100 mcg maximum initial dose | Neonates: specialist use only. Repeat after 5 min if indicated. 1 mcg/kg, max initial dose 100 mcg (NASEMSO v3.0 p. 94). Differs: RCH Melbourne (2025) gives 1.5 mcg/kg IN, capped at 75 mcg at 50 mcg/mL (volume limit). |
| Naloxone | Titrate to breathing. Label first dose: 0.01 mg/kg IV (0.01 mL/kg of 1 mg/mL). Full reversal: 0.1 mg/kg IV/IO/IM/IN (0.1 mL/kg of 1 mg/mL) | 2 mg per dose; repeat every 2–3 min | Opioid toxicity with respiratory depression: ventilate first, then titrate (0.01 mg/kg, then up to 0.1 mg/kg) to adequate breathing. Use the full 0.1 mg/kg for arrest or life-threatening toxicity. In opioid-dependent or chronic-opioid children, use the lowest effective dose; full reversal can precipitate withdrawal and agitation. Intranasal dose depends on the device and protocol. Monitor for re-sedation. |
Medications & Dosing: Seizure, Respiratory & Allergy
Once a seizure has lasted 5 minutes, a benzodiazepine is first-line (AES guideline). With IV access, lorazepam or diazepam is the preferred choice. No IV access? Intramuscular or intranasal midazolam is the usual choice. Fosphenytoin is preferred over phenytoin when both are available.
| Drug | Dose & Route | Max | Notes |
|---|---|---|---|
| Midazolam (IM or IN) | 0.2 mg/kg IM or IN = 0.04 mL/kg of 5 mg/mL | 10 mg per dose | IM is preferred. With IV/IO access, midazolam 0.1 mg/kg IV, max 4 mg (NASEMSO v3.0 p. 102). Status epilepticus with no IV access: AES trials used 5 mg IM for children 13–40 kg. Use preservative-free product in neonates. |
| Lorazepam (IV/IO) High-alert | 0.1 mg/kg slow IV/IO = 0.05 mL/kg of 2 mg/mL | 4 mg per dose; may repeat once | First-line with IV access (AES guideline, Level A). Give slowly. Respiratory depression is common; have airway equipment ready. |
| Diazepam (IV/IO) High-alert | 0.2 mg/kg slow IV/IO = 0.04 mL/kg of 5 mg/mL | 8 mg per dose; may repeat once at full dose | Alternative with IV access. AES 2016 rates IV lorazepam and IV diazepam as established (Level A) in children. The 0.2 mg/kg dose with an 8 mg maximum is the dose used in the AES-cited PECARN trial. For rectal gel, see the next row. |
| Diazepam rectal gel (when no IV or IM route is possible) | Age 2–5 years: 0.5 mg/kg Age 6–11 years: 0.3 mg/kg Age 12 years and older: 0.2 mg/kg Round up to the next unit dose (2.5 mg steps) | 20 mg per dose | Age bands are from the label (DailyMed). The label indication starts at age 2 years; for younger children, follow the protocol. Volume depends on the device. |
| Fosphenytoin | 20 mg PE/kg IV/IO at no more than 2 mg PE/kg/min or 150 mg PE/min, whichever is slower | Adult dose: 1,500 mg PE | Preferred over phenytoin when both are available (AES guideline). Cardiac monitoring during the infusion. |
| Levetiracetam | 60 mg/kg IV over 10 min (children 2 years and older) | 4,500 mg | Second-line agent per protocol. The 60 mg/kg regimen is the ESETT regimen (see References). AES 2016 lists fosphenytoin, valproic acid and levetiracetam as second-therapy options, with no clear evidence that one is better. Valproate dosing is not given on this page. |
| Albuterol (nebulized) | Age 2 years and older: 2.5 mg nebulized for mild wheeze without distress; 5 mg nebulized (or 6 puffs MDI) for respiratory distress with bronchospasm | 5 mg per dose (adult dose) | Asthma or bronchospasm: repeat at the same dose for ongoing distress. Under 2 years: not covered by NASEMSO; do not give in bronchiolitis (AAP). Differs: EPR-3 0.15 mg/kg (min 2.5 mg, max 5 mg) every 20 min up to 3 doses, and 4–8 puffs; GINA 2026 is more conservative. |
| Ipratropium (nebulized) | 0.5 mg nebulized (age 2 years and older), added to albuterol | 0.5 mg per dose | Added to albuterol in moderate to severe asthma, up to 3 doses. Under 2 years and in bronchiolitis: do not give. Differs: GINA 2026 gives 0.25 mg (4 puffs) at age 5 years and under, up to 3 doses. Differs from FDA label: not established in children under 12 years (nebulizer solution). |
| Magnesium sulfate (IV/IO) High-alert | Asthma, age 2 years and older: 40 mg/kg IV over 10–15 min Dilute 50% (500 mg/mL) to 20% (200 mg/mL) first, then give 0.2 mL/kg of 20% | 2 g per dose | Never push undiluted 50%: the label requires dilution to 20% or less before IV use (for example 1 mL of 50% in 1.5 mL diluent). Check reflexes and respirations; hold further doses for absent knee jerk or respiratory depression (label). Severe asthma not responding to first-line treatment (Cochrane review). Differs from GINA 2026, which gives 40–50 mg/kg over 20–60 min (NASEMSO v3.0 p. 192). Torsades: 25–50 mg/kg IV/IO (adult 2 g over 1–2 min); max 2 g. Not amiodarone. |
| Dexamethasone | Croup: 0.6 mg/kg PO, IM or IV once = 0.15 mL/kg of 4 mg/mL (IV or IM) | 16 mg per dose | Croup: single dose (NASEMSO v3.0 p. 156). Asthma, age 2 years and older: 0.6 mg/kg PO (solution), or IV/IM if critically ill, once; max 16 mg. Differs from GINA 2026: 0.3–0.6 mg/kg, max 12 mg; some trials give 0.6 mg/kg daily for 2 days. |
| Epinephrine 1 mg/mL (IM), anaphylaxis | 0.01 mg/kg IM, outer thigh = 0.01 mL/kg of 1 mg/mL | 0.3 mg (child); 0.5 mg (adolescent) | Repeat every 5–15 min if needed. IV epinephrine is for arrest or refractory shock only, not for anaphylaxis alone. |
Medications & Dosing: Fluids, Dextrose & Antidotes
Boluses are dosed in mL/kg of isotonic fluid, and you reassess after each one. Dextrose is measured in grams, so the volume depends on the concentration. High-alert concentrated products are listed separately.
| Drug | Dose & Route | Max | Notes |
|---|---|---|---|
| Normal saline or lactated Ringer’s | 10–20 mL/kg IV/IO over 5–20 min, repeat after reassessment | Reassess after each bolus; no fixed first-hour limit on this page | Balanced crystalloid is the default for children with septic shock (SSC Children 2026, conditional). PRoMPT BOLUS (Balamuth et al., NEJM 2026; 9,041 children, 47 emergency departments) found no kidney-outcome difference: major adverse kidney event at 30 days 3.4% with balanced fluid vs 3.0% with 0.9% saline (risk ratio 1.10, 95% CI 0.88 to 1.40); hyperchloremia 31.4% vs 49.0%. Use 0.9% saline when raised ICP (for example CNS infection) is a concern. AHA 2025 Part 8, rec 2 (COR 2a, LOE B-R): isotonic crystalloids or colloids can be effective as the initial fluid. AHA 2025 Part 8, rec 3 (COR 2a, LOE B-NR): either balanced or unbalanced solutions can be effective. Stop for crackles, an enlarged liver or rising work of breathing. DKA: bolus only for shock, and avoid rapid large volumes (cerebral edema risk). Heart failure or cardiogenic shock: smaller aliquots with close reassessment. Trauma: early blood per the hemorrhagic-shock protocol. One pediatric study linked over 60 mL/kg of crystalloid with lower survival. Push-pull technique: see the shock page. |
| Newborn volume expansion | 10–20 mL/kg normal saline or blood (hypovolemia or blood loss) | Reassess after each bolus | Newborns still bradycardic (under 60/min) after ventilation, compressions and epinephrine, with evidence of hypovolemia (2025 AHA Part 5, recs 1–2; COR 2b, LOE C-EO). Normal saline is the crystalloid of choice in newborn blood loss. |
| Packed red blood cells | 10–20 mL/kg IV/IO; faster in hemorrhage | Per transfusion protocol | Hemorrhagic shock: give early, after at most one 20 mL/kg crystalloid bolus. O-negative if type is unknown (per protocol). |
| Dextrose 10% (D10) | 5–10 mL/kg IV/IO (0.5–1 g/kg) = 5–10 mL/kg of 10% (0.1 g/mL) | 25 g per dose | Hypoglycemia (glucose under 70 mg/dL; ADA Level 1). Recheck glucose; follow with a dextrose infusion or dextrose-containing maintenance fluid. |
| Dextrose 10%, neonates | 2 mL/kg IV/IO (0.2 g/kg) = 2 mL/kg of 10% (0.1 g/mL) | None established; titrate to glucose | Avoid D25 and D50 in neonates and small infants (venous injury, rebound hypoglycemia). Follow with an infusion. |
| Dextrose 25% (D25), older children only High-alert | 2–4 mL/kg IV/IO (0.5–1 g/kg) = 2–4 mL/kg of 25% (0.25 g/mL) | 25 g per dose | Not for neonates or small infants. D50 is reserved for adolescents and adults. |
| Hypertonic saline 3% High-alert | 2–5 mL/kg IV over 10–20 min Hyponatremic seizure: 2 mL/kg over 10 min | 100 mL per dose (hyponatremic seizure) | Symptomatic hyponatremia or raised intracranial pressure. Monitor sodium and neurologic status per protocol. |
| Insulin (DKA infusion) High-alert | 0.05–0.1 units/kg/hr IV infusion, no bolus; start 1 hr after fluids | Titrate per protocol; no fixed max | Check potassium before starting. If K+ is below 3.5 mmol/L, start potassium replacement (at 10 mmol/h) and delay insulin until K+ is above 3.5 mmol/L (adult consensus threshold; confirm the protocol value). Recheck potassium 2 h after starting, then every 4 h. Add dextrose per protocol as glucose falls. Do not give an IV bolus in children with DKA (ISPAD guidance). |
| Insulin (hyperkalemia) High-alert | 0.1 units/kg IV over 15–30 min, with dextrose 0.5 g/kg (D10 5 mL/kg) | 10 units | Cardiac arrest from suspected hyperkalemia (2025 AHA Part 10, Table 3, children). Insulin and glucose: effectiveness not well established (COR 2b, LOE C-EO). Non-arrest hyperkalemia: no pediatric dose is established on this page. Monitor glucose for hypoglycemia after the dose. |
| Activated charcoal | 1 g/kg PO or by NG tube, single dose | Adult dose (up to 50 g) | Recent potentially toxic ingestion with a protected airway, after poison-center advice (1-800-222-1222). Not for caustics. |
| Atropine (organophosphate poisoning) | Mild exposure, initial IM dose by age and weight: infant 0–2 yr 0.05 mg/kg; 3–7 yr (13–25 kg) 1 mg; 8–14 yr (26–50 kg) 2 mg Severe exposure: infant 0.1 mg/kg; 3–7 yr 2 mg; 8–14 yr 4 mg; 14 yr and older 6 mg | Titrate to effect; no fixed max | Give immediately (2025 AHA Part 10, organophosphate rec 1, COR 1, LOE A). Repeat and double the dose every 5 min until secretions dry and the chest is clear (full atropinization endpoints per 2025 AHA Part 10, rec 1 text: clear chest on auscultation, heart rate above 80/min, systolic BP above 80 mm Hg). Doses: NASEMSO v3.0 pp. 264–265. Pair with pralidoxime per poison-center protocol. Watch secretions, pupils and breathing. |
| Hydroxocobalamin (cyanide) | 70 mg/kg IV over 15 min = 2.8 mL/kg of 25 mg/mL | 5 g per dose (adult dose) | Pediatric: 70 mg/kg IV/IO, not above the adult dose (2025 AHA Part 10, COR 1, LOE C-EO, children). Differs from FDA label: pediatric safety and effectiveness not established; 70 mg/kg is used outside the US. Call poison control. Give through a separate IV line: it is physically and chemically incompatible with several drugs (including sodium thiosulfate, sodium nitrite and ascorbic acid), and blood products should not share its line. It turns skin and urine red and interferes with colorimetric lab tests, so draw baseline labs before infusion if possible. |
Many drugs on this page are high-alert: Get a second clinician to check every pediatric dose in mg, mL and mg/kg. Read the concentration on the vial before you draw anything up.
Pitfalls & Safety Checks
| Pitfall | Consequence | Prevention |
|---|---|---|
| Pounds used as kilograms | 22 lb entered as 22 kg: a 2.2-fold overdose | Confirm kg on the scale, or divide lb by 2.2 before any calculation |
| 1 mg/mL epinephrine drawn for an IV arrest dose (formerly 1:1,000) | 10-fold overdose | Read the vial. IV/IO arrest uses 0.1 mg/mL (formerly 1:10,000); 1 mg/mL is for IM use |
| mcg written as mg (fentanyl) | 1,000-fold overdose | Write “micrograms” in full; never abbreviate as μg |
| Adult maximum exceeded | A 70 kg adolescent: atropine 0.02 mg/kg = 1.4 mg, above the 0.5 mg pediatric maximum | Compare every result with the maximum; use the adult protocol for adolescents |
| Amiodarone for torsades | Can worsen QT prolongation; magnesium is first-line | Match the drug to the rhythm. For torsades, give magnesium |
| Infusion units mixed (mg/min vs mcg/kg/min) | Pump rate errors for lidocaine and other infusions | Program the pump in mcg/kg/min with the weight entered; second-person check |
| Length tape measured to the toes | Wrong length zone, so wrong color and wrong doses | Measure head to heel and confirm the zone with the caregiver if possible |
| Drug given outside its label age (etomidate under 10 years) | The label gives inadequate data; dosing is not established | Use the protocol for the age group; consult medical direction |
The 10-fold epinephrine error: A 1 mg/mL syringe pushed IV is a 10-fold overdose, and it is the arrest-strength one (formerly 1:1,000). Say the concentration out loud. Say the dose in mg and mL. A second person checks it before every IV push.
Special Populations
Neonates and Young Infants
- Epinephrine: IV/IO 0.01–0.03 mg/kg. Use endotracheal 0.05–0.1 mg/kg only while vascular access is still being obtained (2025 AHA Part 5, rec 3, COR 2a, LOE C-LD).
- Succinylcholine: per-kg needs run higher in infants. The label sets the adult figure at 0.6 mg/kg, against 2–3 mg/kg in neonates and infants up to 6 months, and 1–2 mg/kg in infants up to 2 years. Follow the neonatal protocol.
- Dextrose: use D10 at 2 mL/kg. Avoid D25 and D50. They are hyperosmolar, and they cause venous injury and rebound hypoglycemia.
- Other: use preservative-free midazolam, because some vials contain benzyl alcohol. No neonatal sodium bicarbonate dose is established on this page. Sodium bicarbonate is not for routine newborn resuscitation or routine pediatric arrest (2025 AHA Part 8, rec 5, COR 3: No Benefit). For neonatal hyperkalemia or sodium-channel toxicity, use the neonatal protocol.
Infants and Young Children
- Etomidate: the FDA label has inadequate data for induction under age 10, so use it only per protocol. Avoid it in children with sepsis or septic shock (SSC Children 2026).
- Anesthetic and sedative exposure before age 3: repeated or prolonged exposure carries an FDA developing-brain warning for ketamine and etomidate. That warning is no reason to withhold a necessary procedure.
- Lidocaine: infants under 6 months are more prone to methemoglobinemia. Keep an eye on SpO₂ and color.
Adolescents
- Switch to adult doses for a child over 40 kg or over 14 years, whichever comes first (NASEMSO v3.0 p. 13). That is the only switch rule on this page.
- Adult maximums then apply. Amiodarone is 300 mg for the first dose, then 150 mg. Epinephrine IM is 0.5 mg for an adolescent.
Children with Special Health Care Needs
- Muscular dystrophy (Duchenne or Becker): succinylcholine is contraindicated. The risk is hyperkalemic rhabdomyolysis and arrest. Use rocuronium.
- Major burns, multiple trauma, extensive denervation or upper motor neuron injury (including spinal cord injury): After the acute phase of injury, the label contraindicates succinylcholine because of severe hyperkalemia and cardiac arrest. The risk rises over time. It usually peaks 7–10 days after injury, and its onset and duration are not defined. Use rocuronium.
- Ask caregivers for the Emergency Information Form, medication list and device details (tracheostomy, shunt, feeding tube, home ventilator).
Children with Obesity
- Length-based and age-based weights are unreliable here. Get a measured weight, then apply the dosing-weight rule in the drug's protocol.
Prehospital & Transport Considerations
| Level | Typical Role in Weight-Based Dosing |
|---|---|
| EMT | Weight and length measurement, bag-mask ventilation, glucose check, and any drug the local protocol allows (commonly epinephrine auto-injector or naloxone) |
| AEMT | Dextrose, naloxone, albuterol and IM epinephrine, per local protocol |
| Paramedic | Arrest drugs, IO access, RSI, sedation and seizure drugs, per local protocol; pre-calculated doses |
| RN (ED/ICU) | Pump-based weight-based infusions; double-check of every high-alert dose |
| Critical Care Transport | Infusions, sedation and paralysis with a ventilator; concentration and pump settings per agency |
- Preparation: pre-drawn or color-coded syringes. Label each one with drug, mg, mL and concentration. Prepare them before the call where protocol allows.
- Destination: a pediatric-ready ED or PICU. For injury, a pediatric trauma center.
- Restraint: secure the child in a child restraint on the stretcher. Never let a caregiver hold the child on their lap.
- Infants: keep them warm. Dry, cover and warm the infant before and during transport.
- Handoff: give a structured report, such as IMIST-AMBO or MIST. Include the weight in kg, and each drug with its time, dose and route.
Clinical Pearls
Calculate before the arrest: the moment you have a weight, work out and write down the epinephrine, atropine and dextrose volumes. Many teams carry pre-calculated cards from a length-based system. Don't start the math mid-arrest.
A measured weight beats every estimate: if the bed or stretcher has an integrated scale, use it. A real weight takes one source of error out of every calculation for the rest of the resuscitation.
Ketamine keeps breathing effort and blood pressure: it keeps airway reflexes. In trials it transiently raised heart rate and blood pressure. That makes it a common choice for a child who is hemodynamically fragile. It still needs airway readiness and post-intubation analgesia.
Match the drug to the rhythm: amiodarone and lidocaine treat shock-refractory VF or pulseless VT. Torsades gets magnesium first. Get the rhythm right before anything gets drawn up.
References
- American Heart Association. 2025 AHA Guidelines for CPR and ECC, Parts 5, 8, 9 and 10 (Part 8 with the American Academy of Pediatrics). Circulation. 2025. Part 5: https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/neonatal-resuscitation; Part 8: https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/pediatric-advanced-life-support (doi: https://doi.org/10.1161/cir.0000000000001368); Part 9: https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-advanced-life-support; Part 10: https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-and-pediatric-special-circumstances-of-resuscitation
- National Association of State EMS Officials (NASEMSO). National Model EMS Clinical Guidelines, version 3.0. March 2022. https://hhs.iowa.gov/media/198/download
- Global Initiative for Asthma (GINA). 2026 GINA Strategy Report. 2026. https://ginasthma.org/2026-gina-strategy-report/; National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. NHLBI, 2007. https://www.nhlbi.nih.gov/sites/default/files/media/docs/EPR-3_Asthma_Full_Report_2007.pdf
- Glauser T, et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults. Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48-61. https://pmc.ncbi.nlm.nih.gov/articles/PMC4749120/; Kapur J, et al. Randomized trial of three anticonvulsant medications for status epilepticus. N Engl J Med. 2019;381:2103-2113. https://doi.org/10.1056/NEJMoa1905795
- International Society for Pediatric and Adolescent Diabetes. ISPAD clinical practice consensus guidelines 2022: diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2022. https://doi.org/10.1111/pedi.13406; Hyperglycaemic crises in adults with diabetes: a consensus report. Diabetologia. 2024. https://doi.org/10.1007/s00125-024-06183-8
- Kew KM, et al. Intravenous magnesium sulfate for treating children with acute asthma in the emergency department. Cochrane Database Syst Rev. 2016. https://doi.org/10.1002/14651858.CD011050.pub2
- Holliday MA, Segar WE. The maintenance need for water in parenteral fluid therapy. Pediatrics. 1957;19(5):823. https://doi.org/10.1542/peds.19.5.823
- Prescribing information on DailyMed (accessed 2026-10-14): CYANOKIT (hydroxocobalamin) for injection, BTG International, set ID d56fcc8d-bd64-46ab-b0c0-2124bd745a6b https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=d56fcc8d-bd64-46ab-b0c0-2124bd745a6b; AMIDATE (etomidate) injection, Hospira, set ID b7ed5bf8-ba75-44dc-8f81-96b4ad5766be https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b7ed5bf8-ba75-44dc-8f81-96b4ad5766be; naloxone hydrochloride injection, Dr. Reddy's, set ID b1303f15-c48b-a44d-b28a-72f370094e02 https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b1303f15-c48b-a44d-b28a-72f370094e02; magnesium sulfate injection (50%), Fresenius Kabi, set ID 77f70e00-3934-4fd9-a581-4cf3df8c42d2 https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=77f70e00-3934-4fd9-a581-4cf3df8c42d2; ANECTINE (succinylcholine chloride) injection, Sandoz, set ID 04a4e6f5-6fa1-42e1-a3f9-21fca7786b15 https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=04a4e6f5-6fa1-42e1-a3f9-21fca7786b15; diazepam rectal gel, Navinta, set ID b5b17a28-2cab-4c0d-8f9d-7b224e4d0989 https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b5b17a28-2cab-4c0d-8f9d-7b224e4d0989.
- Balamuth F, Weiss SL, Long E, Thompson GC, et al. Balanced fluid or 0.9% saline in children treated for septic shock. N Engl J Med. 2026;395(9):870-881. https://doi.org/10.1056/NEJMoa2601969; Weiss SL, et al. Surviving Sepsis Campaign international guidelines for the management of sepsis and septic shock in children 2026. Pediatr Crit Care Med. 2026;27(4):379-434. https://doi.org/10.1097/PCC.0000000000003927
- American Diabetes Association Professional Practice Committee. 6. Glycemic goals, hypoglycemia, and hyperglycemic crises: Standards of Care in Diabetes—2026. Diabetes Care. 2026;49(suppl 1):S132-S149. https://doi.org/10.2337/dc26-S006
- Bisesi SA, Stauber SD, Hutchinson DJ, Acquisto NM. Current practices and safety of medication use during pediatric rapid sequence intubation. J Pediatr Pharmacol Ther. 2024;29(1):66-75. https://doi.org/10.5863/1551-6776-29.1.66
- Royal Children's Hospital Melbourne. Clinical practice guideline: intranasal fentanyl (last updated October 2025). https://www.rch.org.au/clinicalguide/guideline_index/intranasal_fentanyl/
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.
AI Assistance Notice
AI was used to assist in organizing, paraphrasing, and formatting this information.