Paediatric Emergency Medicines

Emergency medicines in children are given by weight in mg/kg or mL/kg, with the dose confirmed by a second person. Preparing doses in advance by weight band or length tape lowers errors. Every dose gives the generic name, route, dose and maximum for the commonest emergencies.

Preparation. Confirm weight, allergy and concentration before drawing up. Flush intravenous or intraosseous lines with 0.9% sodium chloride after each drug.

• Anaphylaxis: adrenaline 10 mcg/kg intramuscularly (0.01 mL/kg of 1 mg/mL), maximum 500 mcg, into the anterolateral thigh. Age-banded alternative: under 6 months 100 to 150 mcg, 6 months to 6 years 150 mcg, 6 to 12 years 300 mcg, over 12 years 500 mcg. Repeat after 5 minutes if no improvement. Give 10 mL/kg 0.9% sodium chloride for hypotension.
• Croup: dexamethasone 0.15 to 0.6 mg/kg orally once (maximum 10 mg). Severe croup: nebulised adrenaline 400 mcg/kg (0.4 mL/kg of 1 mg/mL, maximum 5 mL).
• Acute severe asthma: salbutamol 2 to 10 puffs by spacer or 2.5 to 5 mg nebulised, ipratropium, prednisolone 1 to 2 mg/kg (maximum 40 mg) and magnesium sulphate 40 to 50 mg/kg (maximum 2 g).
• Hypoglycaemia: 10% glucose 2 mL/kg intravenously, repeated after 10 minutes if glucose remains low; glucagon 0.5 mg (under 25 kg) or 1 mg (25 kg and over) intramuscularly if no access.
• Seizure over 5 minutes: midazolam 0.2 mg/kg intramuscularly (maximum 10 mg) or lorazepam 0.1 mg/kg intravenously (maximum 4 mg).
• Shock: 10 to 20 mL/kg isotonic crystalloid, reassessing after each bolus, plus ceftriaxone 80 mg/kg intravenously (maximum 4 g) within the first hour for suspected sepsis.
• Severe malaria: artesunate 2.4 mg/kg intravenously (3 mg/kg if under 20 kg) at 0, 12 and 24 hours, then once daily until oral therapy is possible.
• Raised intracranial pressure: 3% sodium chloride 2 to 5 mL/kg over 10 to 20 minutes, or mannitol 0.25 to 0.5 g/kg over 20 minutes.
• Hyperkalaemia with ECG change: calcium gluconate 10%, 0.5 mL/kg intravenously over 5 to 10 minutes (maximum 20 mL), then salbutamol nebulised and glucose with insulin as directed by a specialist.
• Opioid toxicity with respiratory depression: naloxone 4 to 10 mcg/kg intravenously, titrated; 100 mcg/kg (maximum 2 mg) for arrest.
• Paracetamol poisoning: acetylcysteine 150 mg/kg intravenously over 1 hour, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours, started after level assessment and under toxicology advice.

Neonates. Doses differ; adrenaline for anaphylaxis and benzodiazepines need neonatal verification, and phenobarbital is used for seizures.

Kidney and liver impairment. Emergency doses are not reduced for the first dose, but repeat doses of magnesium, phenobarbital and benzodiazepines are lowered.

Obesity. Use the dose for ideal weight with a cap at the adult dose.

Special groups. Adolescents who are pregnant need modified drug selection. In East Africa, malaria, severe malnutrition, sickle cell crisis and acute gastroenteritis alter fluid choice and volumes, and stock-outs of intravenous artesunate mean rectal artesunate 10 mg/kg is given before referral.

Monitoring. Continuous cardiac monitoring and SpO2, blood glucose every 30 to 60 minutes after hypoglycaemia, and capillary refill and blood pressure after fluids.

Referral and escalation. Escalate all children needing more than one dose of adrenaline, more than 40 mL/kg of fluid, a second benzodiazepine dose, or any intravenous infusion of a vasoactive or sedative drug.

Stopping. Stop each emergency drug once the target is met, and plan observation for at least 4 to 6 hours after anaphylaxis, with a second dose of adrenaline available.