PEDIATRIC ADVANCED LIFE SUPPORT (PALS) MEDICATIONS
Medications play a critical role in pediatric resuscitation by treating cardiac arrest, arrhythmias, hypotension, and underlying causes of deterioration. Accurate, weight-based dosing is essential to ensure safe and effective administration.
Key Goals of PALS Medications:
Support circulation and oxygen delivery. Correct life-threatening arrhythmias. Restore hemodynamic stability. Treat the underlying cause of deterioration.
CARDIAC ARREST MEDICATIONS
1. Epinephrine (First-Line for Cardiac Arrest & Bradycardia)
Indications:
- Cardiac arrest (asystole, PEA, VF, pVT)
- Symptomatic bradycardia unresponsive to oxygenation and ventilation
Dose:
- IV/IO: 0.01 mg/kg (1:10,000 solution) every 3-5 minutes (max single dose: 1 mg).
- ETT (if no IV/IO access): 0.1 mg/kg (1:1,000 solution), diluted in 3-5 mL NS.
Epinephrine is the most important drug in cardiac arrest—administer as soon as IV/IO access is available!
2. Amiodarone (Antiarrhythmic for VF/pVT)
Indications:
- Shockable rhythms (VF, pulseless VT) unresponsive to CPR, shocks, and epinephrine.
Dose:
- 5 mg/kg IV/IO bolus over 3-5 minutes (max single dose: 300 mg).
- May repeat up to 2 more times for refractory VF/pVT (max total dose: 15 mg/kg).
Alternative: Lidocaine (1 mg/kg IV/IO bolus), max 100 mg per dose.
BRADYCARDIA MEDICATIONS
3. Atropine (For Bradycardia Due to Vagal Stimulation or AV Block)
Indications:
- Symptomatic bradycardia caused by increased vagal tone or primary AV block.
- Not first-line—Epinephrine is preferred in most cases!
Dose:
- IV/IO: 0.02 mg/kg (min dose: 0.1 mg, max single dose: 0.5 mg).
- May repeat once after 5 minutes.
Avoid in hypoxic bradycardia—oxygenation and epinephrine should be prioritized.
TACHYCARDIA MEDICATIONS
4. Adenosine (First-Line for Supraventricular Tachycardia – SVT)
Indications:
- Narrow complex SVT (HR >220 bpm in infants, >180 bpm in children).
- Only use if rhythm is regular and monomorphic.
Dose:
- IV/IO Rapid Push (followed by immediate saline flush):
- First dose: 0.1 mg/kg (max 6 mg).
- Second dose (if no effect): 0.2 mg/kg (max 12 mg).
Adenosine must be given as a rapid bolus, followed by an immediate flush!
5. Amiodarone or Procainamide (For Wide Complex Tachycardia – VT)
Indications:
- Monomorphic VT (with a pulse) that is stable.
Amiodarone Dose:
- 5 mg/kg IV over 20-60 minutes (max single dose: 300 mg).
Procainamide Dose:
- 15 mg/kg IV over 30-60 minutes.
Do NOT give Amiodarone and Procainamide together due to risk of QT prolongation!
SHOCK & HYPOTENSION MEDICATIONS
6. Vasoactive Medications (For Shock & Hypotension Unresponsive to Fluids)
| Condition | First-Line Drug | Dose |
|---|---|---|
| Hypotensive Shock | Epinephrine or Dopamine | Epinephrine: 0.1-0.3 mcg/kg/min IV Dopamine: 5-10 mcg/kg/min IV |
| Cardiogenic Shock | Dobutamine or Epinephrine | Dobutamine: 5-20 mcg/kg/min IV Epinephrine: 0.1-0.3 mcg/kg/min IV |
| Septic Shock (Cold Shock) | Epinephrine | 0.1-0.3 mcg/kg/min IV |
| Septic Shock (Warm Shock) | Norepinephrine | 0.05-0.1 mcg/kg/min IV |
Start vasoactive drugs early if fluid resuscitation fails to restore perfusion!
FLUID RESUSCITATION
7. Isotonic Fluids for Shock
Indications:
- Hypovolemic, distributive, or septic shock.
Dose:
- 20 mL/kg IV bolus of normal saline (NS) or lactated Ringer’s (LR) over 5-10 minutes.
- Repeat up to 60 mL/kg, reassessing after each bolus.
Use smaller fluid boluses (5-10 mL/kg) in cardiogenic shock to avoid pulmonary edema!
ELECTROLYTE & METABOLIC MEDICATIONS
8. Dextrose (For Hypoglycemia – Glucose <70 mg/dL)
Dose:
- Neonates: D10W 5 mL/kg IV.
- Infants & Children: D25W 2 mL/kg IV.
- Adolescents: D50W 1 mL/kg IV.
Always check glucose in an unresponsive child!
9. Calcium Gluconate (For Hypocalcemia or Hyperkalemia)
Dose:
- Calcium Gluconate 60 mg/kg IV (max 2 g).
- Calcium Chloride (more potent): 20 mg/kg IV (max 1 g).
Do NOT mix calcium with bicarbonate in the same line—will cause precipitation!
10. Sodium Bicarbonate (For Severe Acidosis or Hyperkalemia)
Dose:
- 1 mEq/kg IV slow push.
Only use in prolonged cardiac arrest or severe metabolic acidosis (pH <7.1).
SUMMARY: PALS MEDICATIONS QUICK REFERENCE
| Drug | Indication | Dose |
|---|---|---|
| Epinephrine | Cardiac arrest, bradycardia, shock | 0.01 mg/kg IV q3-5 min (max 1 mg/dose) |
| Atropine | Bradycardia (vagal, AV block) | 0.02 mg/kg IV (min 0.1 mg, max 0.5 mg/dose) |
| Adenosine | SVT | 0.1 mg/kg IV push, repeat 0.2 mg/kg (max 6 mg, 12 mg) |
| Amiodarone | VF, pVT, VT | 5 mg/kg IV (max 300 mg/dose) |
| Lidocaine | VF, pVT | 1 mg/kg IV bolus (max 100 mg/dose) |
| Fluids (NS/LR) | Shock | 20 mL/kg IV over 5-10 min |
| Dextrose | Hypoglycemia | D10 (5 mL/kg), D25 (2 mL/kg), D50 (1 mL/kg) |
FINAL TAKEAWAYS
Epinephrine is the most critical drug for cardiac arrest and shock. Adenosine is the first-line treatment for SVT, but must be given rapidly. Use fluids cautiously in cardiogenic shock—consider inotropes instead. Electrolyte imbalances (hypoglycemia, hyperkalemia) must be corrected early.
Takeaway: Mastering PALS medications ensures timely, accurate, and effective resuscitation in pediatric emergencies!