The harriet lane handbook a manual for peadiatric house officers 20th, 2015

GLASGOW COMA SCALE
Activity
Eye opening

Verbal

Motor

Score
4
3
2
1
5
4
3
2
1
6
5
4
3
2
1

Child/Adult
Spontaneous
To speech
To pain
None

Oriented
Confused
Inappropriate
Incomprehensible
None
Obeys commands
Localizes to pain
Withdraws to pain
Abnormal flexion
Abnormal extension
None

Score
4
3
2
1
5
4
3
2
1
6
5
4
3
2
1

Adapted from Hunt B, Nelson K. The Johns Hopkins Children’s Center Kids Kard, 2014.

Infant
Spontaneous
To speech/sound
To pain
None
Coos/babbles
Irritable cry
Cries to pain
Moans to pain
None
Normal spontaneous
Withdraws to touch
Withdraws to pain
Abnormal flexion (decorticate)
Abnormal extension (decerebrate)
None


IV INFUSIONS*

 

Medication

Dose (mcg/kg/min)

Dilution in 100 mL D5W

IV Infusion Rate

Alprostadil ­(prostaglandin E1)
Amiodarone
DOPamine
DOBUTamine
EPINEPHrine
Lidocaine
Phenylephrine
Terbutaline
Vasopressin (pressor)

0.05–0.1
5–15
2–20
2–20
0.1–1
20–50
0.05–2
0.1–10
0.5–2 milliunits/kg/min

0.3 mg/kg
6 mg/kg
6 mg/kg
6 mg/kg
0.6 mg/kg
6 mg/kg
0.3 mg/kg
0.6 mg/kg
6 milliunits/kg

1 mL/hr = 0.05 mcg/kg/min
1 mL/hr = 1 mcg/kg/min
1 mL/hr = 1 mcg/kg/min
1 mL/hr = 1 mcg/kg/min
1 mL/hr = 0.1 mcg/kg/min
1 mL/hr = 1 mcg/kg/min
1 mL/hr = 0.05 mcg/kg/min
1 mL/hr = 0.1 mcg/kg/min
1 mL/hr = 1 milliunit/kg/min

* Standardized concentrations are recommended when available.

RESUSCITATION MEDICATIONS
Adenosine
Supraventricular tachycardia
Amiodarone
Ventricular tachycardia
Ventricular fibrillation
Atropine
Bradycardia (increased vagal tone)
Primary AV block
Calcium chloride (10%)
Hypocalcemia
Dextrose
Epinephrine
Pulseless arrest
Bradycardia (symptomatic)
Anaphylaxis

Insulin (Regular or Aspart)
Hyperkalemia
Magnesium sulfate
Torsades de pointes
Hypomagnesemia
Naloxone
Opioid overdose
Coma
Sodium Bicarbonate (8.4%)
Metabolic acidosis
Hyperkalemia
Tricyclic antidepressant overdose
Vasopressin

0.1 mg/kg IV/IO RAPID BOLUS (over 1-2 sec), Flush with 10 mL normal
saline
May repeat at 0.2 mg/kg IV/IO after 2 min
Max first dose 6 mg, max subsequent dose 12 mg
5 mg/kg IV/IO
No Pulse: Push Undiluted
Pulse: Dilute and give over 30 minutes
Max first dose 300 mg, max subsequent dose 150 mg
Monitor for hypotension
0.02 mg/kg IV/IO, 0.04–0.06 mg/kg ETT
Max single dose 0.5 mg
Repeat once if needed
20 mg/kg IV/IO
Max dose 1 g
<5 kg: 10% dextrose 10 mL/kg
5-44 kg: 25% dextrose 4 mL/kg

≥45 kg: 50% dextrose 2 mL/kg, max single dose 50 g = 100 mL
0.01 mg/kg (0.1 mL/kg) 1:10,000 IV/IO every 3–5 min (max single dose
1 mg)
0.1 mg/kg (0.1 mL/kg) 1:1000 ETT every 3–5 min (max single dose 2.5 mg)
Anaphylaxis: 0.01 mg/kg (0.01 mL/kg) of 1:1000 IM (max 0.5 mg)
in thigh every 15 min PRN
Standardized/Autoinjector:
<10 kg: 0.01 mg/kg (0.01 mL/kg) of 1:1000 IM
10-30 kg: 0.15 mg IM
>30 kg: 0.3 mg IM
0.1 units/kg IV/IO with 1 g/kg of dextrose
Max single dose 10 units
50 mg/kg IV/IO
No Pulse: Push
Pulse: Give over 15-20 minutes
Max single dose 2 g
Monitor for hypotension/bradycardia
Respiratory Depression: 0.001-0.005 mg/kg/dose IV/IO/IM/SubQ (max
0.08 mg first dose, may titrate to effect)
Full Reversal/Arrest Dose: 0.1 mg/kg IV/IO/IM/SubQ (max dose 2 mg)
ETT dose 2–3 times IV dose. May give every 2 min PRN
1 mEq/kg IV/IO
Dilute 1:1 with sterile water for <10 kg
Hyperkalemia: Max single dose 50 mEq
0.5 units/kg/dose IV/IO
Max single dose 40 units

ETT Meds (NAVEL: naloxone, atropine, vasopressin, epinephrine, lidocaine)—dilute meds to 5 mL with NS, follow with positive-pressure ventilation.
Special thanks to LeAnn McNamara and Angela Helder, Clinical Pharmacy Specialists, for their expert guidance with IV infusion and resuscitation
medications guidelines.

Adapted from Hunt B, Nelson K. The Johns Hopkins Children’s Center Kids Kard, 2014, and the American Heart Association, PALS Pocket Card,
2010.


TWENTIETH
EDITION

THE
HARRIET LANE
HANDBOOK
A Manual for Pediatric House Officers

The Harriet Lane Service at
The Charlotte R. Bloomberg Children’s Center of
The Johns Hopkins Hospital

EDITORS
Branden Engorn, MD
Jamie Flerlage, MD


1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
THE HARRIET LANE HANDBOOK, TWENTIETH EDITION
Copyright © 2015 by Saunders, an imprint of Elsevier Inc.

ISBN: 978-0-323-09644-7
International Edition: 978-0-323-1124-4

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This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or
medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein.
In using such information or methods they should be mindful of their own safety and the safety
of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised
to check the most current information provided (i) on procedures featured or (ii) by the
manufacturer of each product to be administered, to verify the recommended dose or formula,
the method and duration of administration, and contraindications. It is the responsibility
of practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to
take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or
editors assume any liability for any injury and/or damage to persons or property as a matter
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Previous editions copyrighted 2012, 2009, 2005, 2002, 2000, 1996, 1993, 1991, 1987, 1984,
1981, 1978, 1975, 1972, 1969 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
Library of Congress Cataloging-in-Publication Data
Harriet Lane Service (Johns Hopkins Hospital), author.
The Harriet Lane handbook : a manual for pediatric house officers / the Harriet Lane Service,

Children’s Medical and Surgical Center of the Johns Hopkins Hospital ; editors, Jamie Flerlage,
Branden Engorn. -- Twentieth edition.
  p. ; cm.
Preceded by the Harriet Lane handbook / editors, Megan M. Tschudy, Kristin M. Arcara. 19th ed.
c2012.
Includes bibliographical references and index.
ISBN 978-0-323-09644-7 (pbk. : alk. paper)
I. Flerlage, Jamie, editor of compilation. II. Engorn, Branden, editor of compilation. III. Title.
[DNLM: 1. Pediatrics--Handbooks. WS 29]
RJ48
618.92--dc232014003506
Publishing Services Manager: Anne Altepeter
Senior Content Strategist: Jim Merritt
Project Manager: Cindy Thoms
Content Development Manager: Lucia Gunzel
Senior Content Development Specialist: Andrea Vosburgh Manager, Art and Design: Steven Stave
Printed in the United States of America
Last digit is the print number: 9 8 7 6 5 4 3 2 1


To all who use this book
May the work you do better the lives
of children everywhere.
To our patients
May we serve you well and learn
from you each day.
To our families
To Anne and Bob Laubisch and my
entire family, thank you for your endless
­encouragement in my life that has allowed

me to follow my dreams.
To Jayne and Steven Engorn and my
entire family, thank you for teaching me
to work hard and never give up, and that
family gets us through both the good times
and the bad times.
To our spouses
To Tim Flerlage, my amazing husband
and best friend, thank you for your daily
­support that allows me to do what I love,
and for that I am forever grateful.
To Kristin Moosmann Engorn, my
­wonderful wife and best friend,
coming home to you is the perfect
ending to every day.
To our mentors
To Julia McMillan, may you know that
your mentorship has shaped our lives
and that you are the physician
we will always strive to be.
To George Dover, The Johns Hopkins
Children’s Center will forever be indebted
to you for all the love, compassion,
dedication, and time that you have given
to enhance the lives of countless children
and families.


Preface
“Why this child? Why this disease? Why now?”

—Barton Childs, MD
The Harriet Lane Handbook was first developed in 1953 after Harrison
Spencer (chief resident in 1950–1951) suggested that residents should write
a pocket-sized “pearl book.” As recounted by Henry Seidel, the first editor
of The Harriet Lane Handbook, “Six of us began without funds and without
[the] supervision of our elders, meeting sporadically around a table in the
library of the Harriet Lane Home.” The product of their efforts was a concise
yet comprehensive handbook that became an indispensable tool for the residents of the Harriet Lane Home. Ultimately, Robert Cooke (department chief,
1956–1974) realized the potential of the handbook, and, with his backing,
the fifth edition was published for widespread distribution by Year Book. Since
that time, the handbook has been regularly updated and rigorously revised to
reflect the most up-to-date information and clinical guidelines available. It has
grown from a humble Hopkins resident “pearl book” to become a nationally
and internationally respected clinical resource. Now translated into many
languages, the handbook is still intended as an easy-to-use manual to help
pediatricians provide current and comprehensive pediatric care.
Today, The Harriet Lane Handbook continues to be updated and revised
by house officers for house officers. Recognizing the limit to what can be
included in a pocket guide, additional information has been placed online
and for use via mobile applications.
This symbol
throughout the chapters denotes online content in Expert
Consult.The online-only content includes expanded text, tables, additional
images, and other references.
In this edition, the following are just a few examples of the changes
made to enhance the usefulness of the book, decrease the weight of
white coat pockets everywhere, and reflect changes made in guidelines
and management since the ninetheenth edition of the The Harriet Lane
Handbook:
• Most notable, the cover has been changed from its traditional picture

of the Johns Hopkins Dome to a photo of our new home, The Charlotte
R. Bloomberg Children’s Center. The change for this edition commemorates 100 years since the opening of the Harriet Lane Home, 20 editions
of The Harriet Lane Handbook, and the beginning of the next century of
pediatric care at Johns Hopkins Hospital.
• In the Development, Behavior, and Mental Health chapter, the content
has been updated to reflect the changes in the new Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition, most notably the
diagnostic criteria for intellectual disability.
• In the Procedures chapter, links to the New England Journal of Medicine
“Videos in Clinical Medicine” were added to the online content. Images
for various procedures were updated.
ix


x 

  Preface

• In the Trauma, Burns, and Common Critical Care Emergencies chapter,

new additions include practice parameters for pediatric and neonatal
septic shock as well as guidelines for the acute management of severe
traumatic brain injury.
• The Genetics chapter has been divided for usability into two sections,
metabolism and dysmorphology, and a table of collection information for
common genetic tests was added.
• The photo atlas in the Radiology chapter has been expanded and improved.
• The majority of the Formulary Adjunct chapter content was moved to the
relevant chapters.
The Harriet Lane Handbook, designed for pediatric house staff, was

made possible by the extraordinary efforts of this year’s senior resident
class, the members of which balanced their busy schedules with authoring
the chapters that follow. We are grateful to each of these residents along
with their faculty advisors, who selflessly dedicated their time to improve
the quality and content of this publication.The spirit of this handbook is our
residents, who are the heart and soul of our department.
Chapter Title
1. Emergency Management
2. Poisonings
3. Procedures
4. Trauma, Burns, and Common
Critical Care Emergencies
5. Adolescent Medicine
6. Analgesia and Procedural
Sedation
7. Cardiology

8. Dermatology
9. Development, Behavior, and
Mental Health
10. Endocrinology
11. Fluids and Electrolytes
12. Gastroenterology
13. Genetics: Metabolism and
Dysmorphology
14. Hematology

15. Immunology and Allergy
16. Immunoprophylaxis
17. Microbiology and Infectious

Disease
18. Neonatology
19. Nephrology

Resident

Faculty Advisor

Stephanie Chin-Sang, MD
Zachary Nayak, MD
Jocelyn Ronda, MD
Bradley D. McCammack, MD
Emily Krennerich, MD

Jennifer Anders, MD
Mitchell Goldstein, MD
Suzanne Doyon, MD
Jason Custer, MD
Melissa J. Sacco, MD
Dylan Stewart, MD
Arik Marcell, MD, MPH
Myron Yaster, MD

Natalie Spicyn, MD, MHS
Sean Barnes, MD, MBA
Catherine B. Gretchen, MD
Arpana S. Rayannavar, MD
Jing Fang, MD
Melissa Kwan, MD
Teresa Mark, MD

Emily Young Thomas, MD
Tina Navidi, MD
Jessica Duis, MD
Radha Gajjar, MD
Elizabeth Jalazo, MD
Emily Braun, MD
Jennifer Albon, MD
Edith Dietz, MD
Courtney Mangus, MD
Lauren Beard, MD
Katie Shaw, MD

Jane Crosson, MD
William Ravekes, MD
W. Reid Thompson, MD
Bernard Cohen, MD
Mary Leppert, MB, BCh, BAO
Emily Frosch, MD
David Cooke, MD
Michael Barone, MD
Darla Shores, MD
Ronald Cohn, MD
Ada Hamosh, MD
James Casella, MD
Clifford Takemoto, MD
Jeffrey Keffer, MD
Robert Wood, MD
Ravit Boger, MD
Pranita Tamma, MD
Sue Aucott, MD

Jeffrey Fadrowski, MD


Preface  xi
Chapter Title
20. Neurology

Resident
Lisa Sun, MD

21. Nutrition and Growth

Michael Koldobskiy, MD
Jenifer Thompson, MS, RD, CSP
M. Eric Kohler, MD, PhD
Jessica Knight-Perry, MD
Margaret Grala, MD
Jessica Knight-Perry, MD
Steven C. Marek, MD

22. Oncology
23. Palliative Care
24. Pulmonology
25. Radiology
26. Rheumatology
27. Blood Chemistries and Body
Fluids
28. Biostatistics and EvidenceBased Medicine
29. Drug Dosages

30. Formulary Adjunct
31. Drugs in Renal Failure

   

Branden Engorn, MD
Jamie Flerlage, MD
Kari Bjornard, MD, MPH
Carlton K.K. Lee, PharmD,
MPH
Branden Engorn, MD
Jamie Flerlage, MD
Sara Mixter, MD, MPH
J. Deanna Wilson, MD
Monica C. Mix, MD
Branden Engorn, MD

Faculty Advisor
Thomas Crawford, MD
Christopher Oakley, MD
Eric Kossoff, MD
Sybil Klaus, MD
Patrick Brown, MD
Nancy Hutton, MD
Laura Sterni, MD
Jane Benson, MD
Sangeeta Sule, MD, PhD
Edward Sills, MD
Lori Sokoll, PhD
Janet Serwint, MD, MPH

Carlton K.K. Lee, PharmD,
MPH
Carlton K.K. Lee, PharmD,
MPH
Angela Helder, PharmD

The Formulary, which is undoubtedly the most used handbook section,
is complete, concise, and up to date thanks to the efforts of Carlton K.K.
Lee, PharmD, MPH. With each edition, he carefully updates, revises, and
improves the section. His herculean efforts make the Formulary one of the
most useful and cited pediatric drug reference texts available.
We truly are humbled to have the opportunity to build on the great work
of the preceding editors: Drs. Henry Seidel, Harrison Spencer, William
Friedman, Robert Haslam, Jerry Winkelstein, Herbert Swick, Dennis
Headings, Kenneth Schuberth, Basil Zitelli, Jeffery Biller, Andrew Yeager,
Cynthia Cole, Peter Rowe, Mary Greene, Kevin Johnson, Michael Barone,
George Siberry, Robert Iannone, Veronica Gunn, Christian Nechyba, Jason
Robertson, Nicole Shilkofski, Jason Custer, Rachel Rau, Megan Tschudy,
and Kristin Arcara. Many of these previous editors continue to contribute
to the learning and maturation of the Harriet Lane house staff. They all are
true examples of outstanding clinicians, educators, and mentors.
An undertaking of this magnitude could not have been accomplished
without the support and dedication of some extraordinary people. First, a
thanks to Kathy Miller, who has been an unwavering constant in the face of
change, an advocate for residents, and a huge help with The Harriet Lane
Handbook. We offer our deepest gratitude to our chairman, George Dover,
whose compassion for children, dedication to improvement, and endless
hours of service continue to enhance the Johns Hopkins Children’s Center

xii 

  Preface

and pediatric resident education. He has taught years of chief residents
that "perfect is the evil of the good." Our special thanks go to our friends
and mentors, Jeffrey Fadrowski and Barry Solomon, who have taught us
that enthusiasm is a vector for change. Thank you to our program director,
Janet Serwint, whose leadership continues to deeply enrich our lives. She
is the example of excellence in patient care, scholarship, and education.
Thank you for teaching us that "data is power." Finally, none of this would
have been possible without Julia McMillan. She is a true academic pediatrician in every sense of the word. She is the consummate diagnostician who
has shaped the careers of countless pediatricians. She will forever be the
pediatrician we strive to emulate.
Residents
Ibukun Akinboyo
Martha Amoako
Julia Aziz
Nikita Barai
Benjamin Barnes
Carolyn Bramante
May Chen
Natalia Diaz-Rodriguez
Grace Milad Felix
Timothy Flerlage
Ashley Foster
Wendy Goldstein
Helen Hughes
Fatima Ismail

Allison Kaeding
Lauren Kahl
Jennifer Kamens
Jillian Kaskavage
Kathryn Lemberg
Iris Leviner
Sarah Mahoney
Marisa Matthys
Zwena McLeod
Melanie McNally
Steven Miller
Kathryn Neubauer
Benjamin Oldfield
Danna Qunibi
Jacqueline Salas
Laura Scott
Miranda Simon

Interns
Annika Barnett
Devika Bhushan
Danielle Bliss
Madeline Cayton
Sally Cohen-Cutler
Matthew Elrick
Caitlin Engelhard
Amy Franciscovich
Michelle Gontasz
Taryn Hill
Daniel Hindman

Jennifer Hoffmann
Geoffrey Kelly
Christopher Knoll
Jennifer Miller
Idoreyin Montague
Candice Nalley
Angela-Tu Nguyen
Olamide Olambiwonnu
Christina Peroutka
Kristal Prather
Kristina Pyclik
Anirudh Ramesh
Naomi Rios
Camille Robinson
Suzanne Rossi
Jessica Rubens
Philip Sacks
Shivang Shah
Amena Smith
Heather Wasik
Olivia Widger

Branden Engorn
Jamie Flerlage


Emergency Management
Stephanie Chin-Sang, MD
When approaching a patient in cardiopulmonary arrest, one must first
and foremost focus on the A, B, C, D, and Es. The history, physical exam,

and laboratory studies should closely follow a rapid primary assessment.
NOTE: The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care updates the 2005
guidelines by recommending that immediate chest compressions should
be the first step in reviving victims of sudden cardiac arrest, so the new
acronym C-A-B has come into use and is presented in this section. The
original A-B-C pathway remains the accepted method for rapid assessment
and management of any critically ill patient.1
See the 2010 AHA CPR guidelines.
I.  INITIAL ASSESSMENT: C-A-B
A.Assess pulse: If infant/child is unresponsive and not breathing
(gasps do not count as breathing), health care providers may take
up to 10 seconds to feel for pulse (brachial in infant, carotid/femoral in child).2
1.If pulseless, immediately begin chest compressions (see Circulation, B.1).
2.If pulse, begin A-B-C pathway of evaluation.
II. AIRWAY3-6
A.Assessment
1.Assess airway patency; think about obstruction: Head tilt/chin lift (or jaw
thrust if injury suspected) to open airway.
2.Assess for spontaneous respiration: If no spontaneous respirations, begin
ventilating via rescue breaths, bag-mask, or endotracheal tube.
3.Assess adequacy of respirations:
a.Look for chest rise.
b.Recognize signs of distress (stridor, tachypnea, flaring, retractions,
­accessory muscle use, wheezes).
B.Management3-12
1.Equipment
a.Bag-mask ventilation with cricoid pressure may be used indefinitely if
ventilating effectively (look at chest rise).
b.Use oral or nasopharyngeal airway in patients with obstruction:
(1)Oral: Unconscious patients—measure from corner of mouth to

mandibular angle.
(2)Nasal: Conscious patients—measure tip of nose to tragus of ear.
3

1

Chapter 1


4 

 

Part I  Pediatric Acute Care

c.Laryngeal mask airway (LMA): Simple way to secure an airway (no laryngoscopy needed), especially in difficult airways; does not prevent aspiration.
2.Intubation: Indicated for (impending) respiratory failure, obstruction, airway protection, pharmacotherapy, or need for likely prolonged support
a.Equipment (see page i): SOAP (Suction, Oxygen, Airway Supplies, Pharmacology)
(1)Laryngoscope blade:

(a)Miller (straight blade):

(i)#00-1 for premature to 2 months

(ii)#1 for 3 months to 3 years

(iii)#2 for > 3 years

(b)Macintosh (curved blade):

(i)#2 for > 2 years

(ii)#3 for > 8 years
(2)Endotracheal tube (ETT):

(a)Size determination: Internal diameter of ETT (mm) = (Age/4) +
4, or use length-based resuscitation tape to estimate.

(b)Approximate depth of insertion in cm = ETT size × 3.

(c)Uncuffed ETT for patients <8 years of age (note: cuffed tube
can be used in children <8 y/o—see AHA guidelines for sizing
recommendations).

(d)Stylet should not extend beyond the distal end of the ETT.

(e)Attach end-tidal CO2 monitor as confirmation of placement and
effectiveness of chest compressions if applicable.
(3)Nasogastric tube (NGT): To decompress the stomach; measure
from nose to angle of jaw to xiphoid for depth of insertion.
b.Rapid sequence intubation (RSI) recommended for aspiration risk:
(1)Preoxygenate with non-rebreather at 100% O2 for minimum of 3
minutes:

(a)Do not use positive-pressure ventilation (PPV) unless patient
effort is inadequate.

(b)Children have less oxygen/respiratory reserve than adults, owing to
higher oxygen consumption and lower functional residual capacity.
(2)See Fig. 1-1 and Table 1-1 for drugs used for RSI (adjunct, sedative, paralytic). Important considerations in choosing appropriate

agents include clinical scenario, allergies, presence of neuromuscular disease, anatomic abnormalities, or hemodynamic status.
(3)For patients who are difficult to mask ventilate or have difficult
airways, may consider sedation without paralysis and the assistance
of subspecialists (anesthesiology and otolaryngology).
c.Procedure (attempts should not exceed 30 seconds):
(1)Preoxygenate with 100% O2.
(2)Administer intubation medications (see Fig. 1-1 and Table 1-1).
(3)Apply cricoid pressure to prevent aspiration (Sellick maneuver) during bag-valve-mask ventilation and intubation. (Note: Use of cricoid
pressure is optional; no benefit has been demonstrated.)


Chapter 1 Emergency Management  5

1

Preparation
Preoxygenation with 100% O2
Atropine 0.01 mg/kg (adult dose: 0.5-1 mg; maximum dose: 3 mg)
Cricoid pressure
Sedative (see B)
Paralytic

A

Thiopental 3–5 mg/kg or
Etomidate 0.2–0.3 mg/kg

Normotensive

Mild

Thiopental 1–2 mg/kg or
Ketamine 1–2 mg/kg or
Midazolam 0.1 mg/kg or
Etomidate 0.2–0.3 mg/kg

Severe

None or
Lidocaine 1 mg/kg and/or
Fentanyl 2 mcg/kg or
Etomidate 0.2–0.3 mg/kg

Normotensive

Thiopental 3–5 mg/kg
Lidocaine 1 mg/kg

Hypotensive

Lidocaine 1 mg/kg
Fentanyl 2–5 mcg/kg
Thiopental 1–2 mg/kg

Shock

Head injury

B

Status
asthmaticus

Lidocaine 1 mg/kg
Ketamine 1–2 mg/kg

FIGURE 1-1
A, Treatment algorithm for intubation. B, Sedation options. (Modified from Nichols DG,
Yaster M, Lappe DG, et al [eds]. Golden Hour: The Handbook of Advanced Pediatric Life
Support. St Louis: Mosby; 1996:29.)


6 

 

Part I  Pediatric Acute Care

TABLE 1-1
RAPID-SEQUENCE INTUBATION MEDICATIONS
Drug

Dose

Comments

0.01–0.02 mg/kg
IV/IO
Adult dose: 0.5-1.0
mg; max: 3 mg

+ Vagolytic; prevents bradycardia, especially with
succinylcholine, and reduces oral secretions
− Tachycardia, pupil dilation eliminates ability to
examine pupillary reflexes
Less than 0.1 mg may case paradoxical
bradycardia
Indication: Can be used as premedication in all
circumstances
+ Blunts ICP spike, decreased gag/cough;
controls ventricular arrhythmias
Indication: Good premedication for shock,
arrhythmia, elevated ICP, and status asthmaticus

ADJUNCTS (FIRST)
Atropine (vagolytic)

Lidocaine
1 mg/kg IV/IO;
(optional anesthetic) max 100 mg/dose

SEDATIVE-HYPNOTIC (SECOND)
Thiopental
3–5 mg/kg IV/IO if
(barbiturate)
normotensive
1–2 mg/kg IV/IO if
hypotensive

Ketamine (NMDA

receptor antagonist)

Midazolam
(benzodiazepine)

Fentanyl (opiate)

Etomidate
(imidazole/hypnotic)

Propofol
(sedative-hypnotic)

+ Decreases O2 consumption and cerebral blood
flow
− Vasodilation and myocardial depression; may
increase oral secretions, cause bronchospasm/
laryngospasm (not to be used in asthma)
Indication: Drug of choice for increased ICP
1–2 mg/kg IV/IO or
+ Bronchodilation; catecholamine release may
4–10 mg/kg IM
benefit hemodynamically unstable patients
− May increase BP, HR, and oral secretions; may
cause laryngospasm; contraindicated in eye
injuries; likely insignificant rise in ICP
Indication: Drug of choice for asthma
0.05–0.1 mg/kg IV/IO + Amnestic and anticonvulsant properties
Max total dose of
− Respiratory depression/apnea, hypotension,

10 mg
and myocardial depression
Indication: Mild shock
1–5 mcg/kg IV/IO
+ Fewest hemodynamic effects of all opiates
NOTE: Fentanyl is
− Chest wall rigidity with high dose or rapid
dosed in mcg/kg, not administration; cannot use with MAOIs
mg/kg.
Indication: Shock
0.3 mg/kg IV/IO
+ Cardiovascular neutral; decreases ICP
− Exacerbates adrenal insufficiency (inhibits
11-beta hydroxylase)
Indication: Patients with severe shock, especially
cardiac patients
2 mg/kg IV/IO
+ Extremely quick onset and short duration; blood
pressure lowering; good antiemetic
− Hypotension and profound myocardial depression; contraindicated in patients with egg allergy
Indication: Induction agent for general
anesthesia


Chapter 1 Emergency Management  7

Drug

Dose

Comments

PARALYTICS (NEUROMUSCULAR BLOCKERS) (THIRD)
Succinylcholine
(depolarizing)

1–2 mg/kg IV/IO
2–4 mg/kg IM

Vecuronium (nondepolarizing)

0.1 mg/kg IV/IO

Rocuronium (nondepolarizing)

0.6–1.2 mg/kg IV/IO
1.8 mg/kg IM

+ Quick onset (30–60 sec), short duration (3–6
min) make it an ideal paralytic
− Irreversible; bradycardia in <5 years old or
with rapid doses; increased risk of malignant
hyperthermia; contraindicated in burns, massive
trauma/muscle injury, neuromuscular disease,
myopathies, eye injuries, renal insufficiency
+ Onset 70–120 sec; cardiovascular neutral
− Duration 30–90 min; must wait 30–45 min to
reverse with glycopyrrolate and neostigmine
Indication: When succinylcholine contraindicated
or when longer-term paralysis desired

+ Quicker onset (30–60 sec), shorter acting than
vecuronium; cardiovascular neutral
− Duration 30–60 min; may reverse in 30 min
with gylcopyrrolate and neostigmine

+, Potential advantages; −, potential disadvantages or cautions; BP, blood pressure; HR, heart rate; ICP, intracranial
pressure; MAOI, monoamine oxidase inhibitor.












(4)Use scissoring technique to open mouth.
(5)Hold laryngoscope blade in left hand. Insert blade into right side of
mouth, sweeping tongue to the left out of line of vision.
(6)Advance blade to epiglottis. With straight blade, lift up, directly
lifting the epiglottis to view cords. With curved blade, place tip in
vallecula, elevate the epiglottis to visualize the vocal cords.
(7)If possible, have another person hand over the tube, maintaining
direct visualization, and pass through cords until black marker
reaches the level of the cords.
(8)Hold endotracheal tube firmly against the lip until tube is securely
taped.

(9)Verify ETT placement: observe chest wall movement, auscultation
in both axillae and epigastrium, end-tidal CO2 detection (there
will be a false-negative response if there is no effective pulmonary
circulation), improvement in oxygen saturation, chest radiograph,
repeat direct laryngoscopy to visualize ETT.
(10)If available, in-line continuous CO2 detection should be used.
III. BREATHING3,4,13,14

A.Assessment
Once airway is secured, continually reevaluate ETT positioning (listen for
breath sounds). Acute respiratory failure may signify Displacement of the
ETT, Obstruction, Pneumothorax, or Equipment failure (DOPE).

1

TABLE 1-1
RAPID-SEQUENCE INTUBATION MEDICATIONS (Continued)


8 

 

Part I  Pediatric Acute Care

B.Management
1.Mouth-to-mouth or mouth-to-nose breathing: provide two slow breaths
(1 sec/breath) initially. For newborns, apply one breath for every three
chest compressions. In infants and children, apply two breaths after
30 compressions (one rescuer) or two breaths after 15 compressions

(two rescuers). Breaths should have adequate volume to cause
chest rise.
2.Bag-mask ventilation is used at a rate of 20 breaths/min (30 breaths/min
in infants) using the E-C technique:
a.Use non-dominant hand to create a C with thumb and index finger
over top of mask. Ensure a good seal, but do not push down on mask.
Hook remaining fingers around the mandible (not the soft tissues of
the neck!), with the fifth finger on the angle creating an E, and lift the
mandible up toward the mask.
b.Assess chest expansion and breath sounds.
c.Decompress stomach with orogastric or nasogastric tube with prolonged
bag-mask ventilation.
3.Endotracheal intubation: See prior section.
IV. CIRCULATION3-5,13
A.Assessment
1.Rate/rhythm: Assess for bradycardia, tachycardia, abnormal rhythm, or
asystole. Generally, bradycardia requiring chest compressions is <60
beats/min; tachycardia of >220 beats/min suggests tachyarrhythmia
rather than sinus tachycardia.
2.Perfusion:
a.Assess pulses, capillary refill (<2 sec = normal, 2 to 5 sec = delayed,
>5 sec suggests shock), mentation, and urine output (if Foley in place).
b.If one cannot identify a pulse within 10 seconds, initiate cardiopulmonary resuscitation (CPR).
3.Blood pressure (BP): Hypotension is a late manifestation of circulatory
compromise. Can be calculated in children >1 year with
formula: Hypotension = Systolic BP< [70 + (2 × Age in years)]

B.Management (Table 1-2)15
1.Chest compressions
a.Press hard (1⁄3 to ½ anteroposterior [AP] diameter of chest) and fast

(100-120 per minute) on backboard base with full recoil and minimal
interruption.
b.Use end-tidal CO2 to estimate effectiveness (<20 mmHg indicates inadequate compressions).
c.Use two-finger technique for infant if single rescuer available; otherwise,
two thumbs with hands encircling chest is preferable.
2.Use of automated external defibrillator (AED): To determine whether
rhythm is shockable, use an AED/defibrillator.


Chapter 1 Emergency Management  9

Infants
Pre-pubertal children
Adolescents/adults

Location*

Rate (per min)

Compressions: Ventilation

1 fingerbreadth below
intermammary line
2 fingerbreadths below
intermammary line

>100

15:2 (2 rescuers)
30:2 (1 rescuer)

15:2 (2 rescuers)
30:2 (1 rescuer)

Lower half of sternum

≥100
100

30:2 (1 or 2 rescuers)

*Depth of compressions should be one third to one half anteroposterior diameter of the chest.

3.Resuscitation with poor perfusion and shock:
a.Optimize oxygen delivery with supplemental O2.
b.Support respirations to reduce work of patient.
c.Place intraosseous (IO) access immediately if in arrest and/or if intravenous (IV) access not obtained within 90 seconds.
d.Resuscitation fluids are lactated Ringer’s or normal saline.
(1)Give up to three 20-mL/kg boluses each within 5 minutes for a total
of 60 mL/kg in the first 15 minutes after presentation, checking for
hepatomegaly after each bolus.
(2)5- to 10-mL/kg bolus in patient with cardiac insufficiency.
(3)Consider colloid such as albumin, plasma, packed red blood cells
(PRBCs) if poor response to crystalloids.
e.Identify type of shock: Hypovolemia, cardiogenic (congenital heart
disease, myocarditis, cardiomyopathy, arrhythmia), distributive (sepsis,
anaphylaxis, neurogenic), obstructive (pulmonary embolus [PE], cardiac
tamponade, tension pneumothorax).
f.Pharmacotherapy (See inside front cover and consider stress-dose
corticosteroids and/or antibiotics if applicable.)
V.  ALLERGIC EMERGENCIES (ANAPHYLAXIS)16,17

A.Definition
1. A rapid-onset immunoglobulin (Ig) E–mediated systemic allergic reaction
involving multiple organ systems, including two or more of the following:
a.Cutaneous/mucosal (flushing, urticaria, pruritus, angioedema); seen
in 90%
b.Respiratory (laryngeal edema, bronchospasm, dyspnea, wheezing,
stridor, hypoxemia); seen in ≈70%
c.Gastrointestinal (GI) (vomiting, diarrhea, nausea, crampy abdominal
pain); seen in ≈ -40% to 50%
d.Circulatory (tachycardia, hypotension, syncope); seen in ≈ -30% to 40%
2.Initial reaction may be delayed for several hours AND symptoms may
recur up to 72 hours after initial recovery. Patients should therefore be
observed for a minimum of 6 to 24 hours for late-phase symptoms.
B.Initial Management
1.Remove/stop exposure to precipitating antigen.

1

TABLE 1-2
MANAGEMENT OF CIRCULATION


10 

 

Part I  Pediatric Acute Care

2.Epinephrine = mainstay of therapy. While performing ABCs, immediately give intramuscular (IM) epinephrine, 0.01 mg/kg (0.01 mL/kg) of
1:1000 subcutaneously (SQ) or IM (maximum dose 0.5 mg). Repeat

every 5 minutes as needed. Site of choice is lateral aspect of the thigh,
owing to its vascularity.
3.Establish airway and give O2 and PPV as needed.
4.Obtain IV access, Trendelenburg position with head 30 degrees below
feet, administer fluid boluses followed by pressors as needed.
5.Histamine-1 receptor antagonist such as diphenhydramine, 1 to 2 mg/kg
via IM, IV, or oral (PO) route (maximum dose, 50 mg). Also consider a
histamine-2 receptor antagonist (e.g., ranitidine).
6.Corticosteroids help prevent the late phase of the allergic response. Administer methylprednisolone in a 2-mg/kg IV bolus, followed by 2 mg/kg/
day IV or IM, divided every 6 hours, or prednisone, 2 mg/kg PO once daily.
7.Albuterol 2.5 mg for <30 kg, 5 mg for >30 kg, for bronchospasm or
wheezing. Repeat every 15 minutes as needed.
8.Racemic epinephrine 0.5 mL of 2.25% solution inhaled for signs of upper airway obstruction
9.Patient should be discharged with an Epi-Pen (>30 kg), Epi-Pen Junior
(<30 kg), or comparable injectable epinephrine product with specific
instructions on appropriate use, as well as an anaphylaxis action plan.
VI.  RESPIRATORY EMERGENCIES18
The hallmark of upper airway obstruction is stridor, whereas lower airway
obstruction is characterized by cough, wheeze, and a prolonged expiratory
phase.
  
A.Asthma19,20
Lower airway obstruction resulting from triad of inflammation, bronchospasm, and increased secretions:
1.Assessment: Respiratory rate (RR), work of breathing, O2 saturation,
heart rate (HR), peak expiratory flow, alertness, color
2.Initial management:
a.Give O2 to keep saturation >95%.
b.Administer inhaled β-agonists: Nebulized albuterol as often as
needed.
c.Ipratropium bromide

d.Steroids: Methylprednisolone, 2 mg/kg IV/IM bolus, then 2 mg/kg/day
divided every 6 hours; or prednisone/prednisolone, 2 mg/kg PO every
24 hours; requires minimum of 3 to 4 hours to take effect.
e.If air movement is still poor despite maximizing above therapy:
(1)Epinephrine: 0.01 mg/kg (0.01 mL/kg) of 1:1000 subcutaneously
(SQ) or IM (maximum dose 0.5 mg)

(a)Bronchodilator, vasopressor, and inotropic effects

(b)Short-acting (~15 min) and should be used as temporizing
rather than definitive therapy


Chapter 1 Emergency Management  11
(2)Magnesium sulfate: 25 to 75 mg/kg/dose IV or IM (maximum 2 g)
­infused over 20 minutes.

(a)Smooth muscle relaxant; relieves bronchospasm.

(b)Many clinicians advise giving a saline bolus prior to administration, because hypotension may result.

(c)Contraindicated if patient already has significant hypotension or
renal insufficiency.
(3)Terbutaline: 0.01 mg/kg SQ (maximum dose 0.4 mg) every 15
minutes up to three doses.

(a)Systemic β2-agonist limited by cardiac intolerance.

(b)Monitor continuous 12-lead electrocardiogram (ECG), cardiac
enzymes, urinalysis (UA), and electrolytes.

3.Further management: If incomplete or poor response, consider obtaining
an arterial blood gas value.
 NOTE: A normalizing Pco2 is often a sign of impending respiratory failure.
a.Maximize and continue initial treatments.
b.Terbutaline 2 to 10 mcg/kg IV load, followed by continuous infusion of
0.1 to 4 mcg/kg/min titrated to effect in increments of 0.1 to 0.2 mcg/kg/
min every 30 minutes depending on clinical response. Infusion should
be started with lowest possible dose; doses as high as 10 mcg/kg/min
have been used. Use appropriate cardiac monitoring in intensive care
unit (ICU), as above.
c.A helium (≥70%) and oxygen mixture may be of some benefit in the
critically ill patient but is more useful in upper airway edema. Avoid use
in the hypoxic patient.
d.Methylxanthines (e.g., aminophylline) may be considered in the ICU setting but have significant side effects and have not been shown to affect
intubation rates or length of hospital stay.
e.Noninvasive positive-pressure ventilation (e.g., BiPAP) may be used
in patients with impending respiratory failure, both as a temporizing
measure and to avoid intubation, but requires a cooperative patient with
spontaneous respirations.
4.Intubation of those with acute asthma is dangerous and should be
reserved for impending respiratory arrest.
a.Indications for endotracheal intubation include deteriorating mental
status, severe hypoxemia, and respiratory or cardiac arrest.
b.Use lidocaine as adjunct and ketamine for sedative (see Fig. 1-1 and
Table 1-1).
c.Consider using an inhaled anesthetic such as isoflurane.
5.Hypotension: Result of air trapping, hyperinflation, and therefore
decreased pulmonary venous return. See Section IV.B.3 for
management. Definitive treatment is reducing lower airway obstruction.
B.Upper Airway Obstruction21-24

Upper airway obstruction is most commonly caused by foreign-body aspiration or infection.

1




12 

 

Part I  Pediatric Acute Care

1.Epiglottitis: Most often affects children between 2 and 7 years, but may
occur at any age. This is a true emergency involving cellulitis and edema
of the epiglottis, aryepiglottic folds, and hypopharynx.
a.Patient is usually febrile, anxious, and toxic appearing, with sore
throat, drooling, respiratory distress, stridor, tachypnea, and ­tripod
­positioning (sitting forward supported by both arms, with neck extended and chin thrust out). Any agitation of the child may cause complete
obstruction, so avoid invasive procedures/evaluation until airway is
secured.
b.Unobtrusively give O2 (blow-by). Nothing by mouth, monitor with pulse
oximetry, allow parent to hold patient.
c.Summon epiglottitis team (most senior pediatrician, anesthesiologist,
intensive care physician, and otolaryngologist in hospital).
d.Management options:
(1)If unstable (unresponsive, cyanotic, bradycardic) → emergently
intubate.
(2)If stable with high suspicion → take patient to operating room for
laryngoscopy and intubation under general anesthesia.

(3)If stable with moderate or low suspicion → obtain lateral neck radiographs to confirm.
e.After airway is secure, obtain cultures of blood and epiglottic surface.
Begin antibiotics to cover Haemophilus influenzae type B, Streptococcus
pneumoniae, group A streptococci, Staphylococcus aureus.
f.Epiglottitis may also be caused by thermal injury, caustic ingestion, or
foreign body.
2.Croup (laryngotracheobronchitis): Most common in infants 6 to 36
months. Croup is a common syndrome involving inflammation of the
subglottic area; presents with fever, barking cough, and stridor. Patients
rarely appear toxic, as in epiglottitis.
a.Mild (no stridor at rest): Treat with minimal disturbance, cool mist,
hydration, antipyretics, and consider steroids.
b.Moderate to severe:
(1)The efficacy of mist therapy is not established.
(2)Racemic epinephrine. After administering, observe for a minimum
of 2 to 4 hours, owing to potential for rebound obstruction. Hospitalize if more than one nebulization required.
(3)Dexamethasone, 0.3 to 0.6 mg/kg IV, IM, or PO once. Effect lasts
2 to 3 days. Alternatively, nebulized budesonide (2 mg) may be
used, though little data exist to support its use, and some studies
find it inferior to dexamethasone.
(4)A helium-oxygen mixture may decrease resistance to turbulent gas
flow through a narrowed airway.
c.If a child fails to respond as expected to therapy, consider other etiologies (e.g., retropharyngeal abscess, bacterial tracheitis, subglottic stenosis, epiglottitis, foreign body). Obtain airway radiography, computed
tomography (CT), and evaluation by otolaryngology or anesthesiology.


3.Foreign-body aspiration: Occurs most often in children 6 months to
3 years old. It frequently involves hot dogs, candy, peanuts, grapes,
or balloons. Most events unwitnessed, so suspect this in children with
sudden-onset choking, stridor, or wheezing.

a.If the patient is stable (i.e., forcefully coughing, well oxygenated),
removal of the foreign body by bronchoscopy or laryngoscopy should be
attempted in a controlled environment.
b.If the patient is unable to speak, moves air poorly, or is cyanotic:
(1)Infant: Place infant over arm or rest on lap. Give five back blows
between the scapulae. If unsuccessful, turn infant over and give five
chest thrusts (not abdominal thrusts).
(2)Child: Perform five abdominal thrusts (Heimlich maneuver) from
behind a sitting or standing child.
(3)After back, chest, and/or abdominal thrusts, open mouth using tonguejaw lift and remove foreign body if visualized. Do not attempt blind
finger sweeps. Magill forceps may be used to retrieve objects in the
posterior pharynx. Ventilate if unconscious, and repeat sequence as
needed.
(4)If there is complete airway obstruction and the patient cannot
be ventilated by bag-valve mask or ETT, consider percutaneous
(needle) cricothyrotomy (Fig. 1-2).4
VII.  NEUROLOGIC EMERGENCIES
.Altered States of Consciousness25
A
1.Assessment: Range of mental status includes alert, confused, disoriented, delirious, lethargic, stuporous, and comatose.
a.History: Consider structural versus medical causes (Box 1-1). Obtain
history of trauma, ingestion, infection, fasting, drug use, diabetes, seizure, or other neurologic disorder.
b.Examination: Assess HR, BP, respiratory pattern, Glasgow Coma
Scale (Table 1-3), temperature, pupillary response, funduscopy (a
late finding, absence of papilledema does not rule out increased
intracranial pressure [ICP]), rash, abnormal posturing, and focal
neurologic signs.
2.Acute traumatic head injury:26
a.Assess pupillary response:
(1)Blown pupil: Elevate head of bed, hyperventilate, maintain blood

pressure, administer hypertonic saline and/or mannitol.
3.Management of coma:
a.Airway (with cervical spine immobilization), Breathing, Circulation, Dstick, Oxygen, Naloxone, Thiamine (ABC DON'T)
(1)Naloxone, 0.1 mg/kg IV, IM, SQ, or ETT (maximum dose, 2 mg). Repeat as necessary, given short half-life (in case of opiate intoxication).
(2)Thiamine, 100 mg IV (before starting glucose in adolescents, in
case of alcoholism or eating disorder).
(3)D25W, 2 to 4 mL/kg IV bolus if hypoglycemia is present.

1

Chapter 1 Emergency Management  13


14 

 

Part I  Pediatric Acute Care

Cricothyroid membrane

FIGURE 1-2
Percutaneous (needle) cricothyrotomy. Extend neck, attach a 3-mL syringe to a 14- to
18-gauge intravenous catheter, and introduce catheter through cricothyroid membrane
(inferior to thyroid cartilage, superior tocricoid cartilage). Aspirate air to confirm position. Remove syringe and needle, attach catheter to an adaptor from a 3.0-mm endotracheal tube, which can then be used for positive-pressure oxygenation. (Modified from
Dieckmann RA, Fiser DH, Selbst SM. Illustrated Textbook of Pediatric Emergency and
Critical Care Procedures. St Louis: Mosby, 1997:118.)
BOX 1-1
DIFFERENTIAL DIAGNOSIS OF ALTERED LEVEL OF CONSCIOUSNESS
I.  Structural Causes

Vascular—e.g., cerebrovascular accident, cerebral vein thrombosis
Increased intracranial pressure—e.g., hydrocephalus, tumor, abscess, cyst,
subdural empyema, pseudotumor cerebri
Trauma (intracranial hemorrhage, diffuse cerebral swelling, shaken baby syndrome)
II.  Medical Causes
Anoxia
Hypothermia/hyperthermia
Metabolic—e.g., inborn errors of metabolism, diabetic ketoacidosis, hyperammonemia, uremia, hypoglycemia, electrolyte abnormality
Infection—e.g., sepsis, meningitis, encephalitis, subdural empyema
Seizure/postictal state
Toxins/ingestions
Psychiatric/psychogenic
Modified from Avner J. Altered states of consciousness. Pediatr Rev. 2006;27:331-337.


Chapter 1 Emergency Management  15

Glasgow Coma Scale
Activity

Best Response

Modified Coma Scale for Infants
Activity

Best Response

EYE OPENING
Spontaneous
To speech

To pain
None
VERBAL
Oriented
Confused
Inappropriate words
Nonspecific sounds
None
MOTOR
Follows commands
Localizes pain
Withdraws to pain
Abnormal flexion
Abnormal extension
None

4
3
2
1

Spontaneous
To speech
To pain
None

4
3
2
1

5
4
3
2
1

Coo/babbles
Irritable
Cries to pain
Moans to pain
None

5
4
3
2
1

6

6

5
4
3
2

Normal spontaneous
movements

Withdraws to touch
Withdraws to pain
Abnormal flexion
Abnormal extension

5
4
3
2

1

None

1

Data from Jennet B, Teasdale G. Aspects of coma after severe head injury. Lancet. 1977;1:878; and James HE. Neurologic
evaluation and support in the child with an acute brain insult. Pediatr Ann. 1986;15:16.

b.Laboratory tests: Consider complete blood cell count (CBC), electrolytes,
liver function tests, NH3, lactate, toxicology screen (serum and urine;
always include salicylate and acetaminophen levels), blood gas, serum
osmolality, prothrombin time (PT)/partial thromboplastin time (PTT), and
blood/urine culture. If patient is an infant or toddler, consider assessment of plasma amino acids, urine organic acids, and other appropriate
metabolic workup.
c.If meningitis or encephalitis is suspected, consider lumbar puncture
(LP) and start antibiotics and acyclovir.
d.Request emergency head CT after ABCs are stabilized; consider neurosurgical consultation and electroencephalogram (EEG) if indicated.
e.If ingestion is suspected, airway must be protected before GI decontamination (see Chapter 2).
f.Monitor Glasgow Coma Scale and reassess frequently (see Table 1-3).

B.Status Epilepticus27,28
 See Chapter 20 for non-acute evaluation and management of seizures.
1.Assessment: Common causes of childhood seizures include electrolyte
abnormalities, hypoglycemia, fever, subtherapeutic anticonvulsant
levels, central nervous system (CNS) infections, trauma, toxic ingestion,
and metabolic abnormalities. Consider specific patient history, such as

1

TABLE 1-3
COMA SCALES


16 

 

Part I  Pediatric Acute Care

shunt malfunction in patient with ventriculoperitoneal shunt. Less common causes include vascular, neoplastic, and endocrine diseases.
2.Acute management of seizures (Table 1-4): If CNS infection is suspected,
give antibiotics and/or acyclovir early.
3.Diagnostic workup: When stable, workup may include CT or magnetic
resonance imaging, EEG, and LP.

TABLE 1-4
ACUTE MANAGEMENT OF SEIZURES
Time (min)

Intervention

0–5

Stabilize patient.
Assess airway, breathing, circulation, and vital signs.
Administer oxygen.
Obtain IV or IO access.
Consider hypoglycemia, thiamine deficiency, intoxication (dextrose, thiamine,
naloxone may be given immediately if suspected).
Obtain laboratory studies: consider glucose, electrolytes, calcium, magnesium, blood
gas, CBC, BUN, creatinine, LFTs, toxicology screen, anticonvulsant levels, blood
culture (if infection is suspected).
Initial screening history and physical examination
Begin pharmacotherapy:
Lorazepam (Ativan), 0.05–0.1 mg/kg IV/IM, max dose 2 mg
Or
Diazepam (Valium), 0.2–0.5 mg/kg IV (0.5 mg/kg rectally); max dose <5 y/o: 5 mg,
>5 y/o: 10 mg
May repeat lorazepam or diazepam 5–10 min after initial dose
If seizure persists, load with one of the following:
1.Fosphenytoin* 15–20 mg PE/kg IV/IM at 3 mg PE/kg/min via peripheral IV line
(maximum 150 mg PE/min). If given IM, may require mulitple dosing sites.
2.Phenytoin† 15–20 mg/kg IV at rate not to exceed 1 mg/kg/min via central line
3.Phenobarbital 15–20 mg/kg IV at rate not to exceed 1 mg/kg/min
If seizure persists:
Levetiracetam 20–30 mg/kg IV at 5 mg/kg/min; or valproate 20 mg/kg IV
at 5 mg/kg/min
May give phenobarbital at this time if still seizing at 5 minutes and (fos) phenytoin
previously used
Additional phenytoin or fosphenytoin 5 mg/kg over 12 hr for goal serum level of 10 mg/L

Additional phenobarbital 5 mg/kg/dose every 15–30 min (maximum total dose of
30 mg/kg; be prepared to support respirations)

5–15

15–25

25–40

40–60

If seizure persists,‡ consider pentobarbital, midazolam, or general anesthesia in
intensive care unit. Avoid paralytics.

*Fosphenytoin dosed as phenytoin equivalent (PE).
†Phenytoin may be contraindicated for seizures secondary to alcohol withdrawal or most ingestions (see Chapter 2).
‡Pyridoxine 100 mg IV in infant with persistent initial seizure.
BUN, Blood urea nitrogen; CBC, complete blood cell count; CT, computed tomography; EEG, electroencephalogram; LFTs,
liver function tests; IM, intramuscular; IO, intraosseus; IV, intravenous.
Modified from Abend, NS, Dlugos, DJ. Treatment of refractory status epilepticus: literature review and a proposed protocol.
Pediatr Neurol. 2008;38:377.


Chapter 1 Emergency Management  17

1

REFERENCES
1.Field JM, Hazinski MF, Sayre MR, et al. 2010 American Heart Association
guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.

Circulation. 2010:Nov 2;122(18 Suppl 3):S640-656.
2.Berg MD, Schexnayder SM, Chameides L, et al. Part 13: pediatric basic life
support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl
3):S862-S875.
3.American Heart Association. Pediatric advanced life support. Pediatrics.
2006;117:e1005-e1028.
4.Nichols DG, Yaster M, Lappe DG, et al, eds. Golden Hour: The Handbook of
Advanced Pediatric Life Support. St Louis: Mosby, 1996.
5.Ralston M, Hazinski MF, Zaritsky AL, et al, eds. Pediatric Advanced Life Support
Provider Manual. Dallas: American Heart Association, Subcommittee on Pediatric
Resuscitation, 2006.
6.Sagarin MJ, Barton ED, Chng YM, et al. Airway management by US and Canadian
emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Ann Emerg Med. 2005;46:328-336.
7.American Heart Association. Pharmacology. In: Pediatric Advanced Life Support
Provider Manual. Dallas: American Heart Association, Subcommittee on Pediatric
Resuscitation; 2006:228.
8.Sagarin MJ, Chiang V, Sakles JC, et al. Rapid sequence intubation for pediatric
emergency airway management. Pediatr Emerg Care. 2002;18:417.
9.Zelicof-Paul A, Smith-Lockridge A, Schnadower D, et al. Controversies in rapid
sequence intubation in children. Curr Opin Pediatr. 2005;17:355.
10.Sivilotti ML, Filbin MR, Murray HE, et al. Does the sedative agent facilitate emergency rapid sequence intubation? Acad Emerg Med. 2003;10:612.
11.Perry J, Lee J, Wells G. Rocuronium versus succinylcholine for rapid sequence
induction intubation. Cochrane Database Syst Rev. 2003:CD002788.
12.Trethewy CE, Burrows JM, Clausen D, Doherty SR. Effectiveness of cricoid
pressure in preventing gastric aspiration during rapid sequence intubation in the
emergency department: study protocol for a randomised controlled trial Trials.
Epub 2012 Feb 16;13:17.
13.Pediatric basic life support. Circulation. 2005;112:IV156.
14.Berg RA, Sanders AB, Kern KB, et al. Adverse hemodynamic effects of interrupting chest compressions for rescue breathing during cardiopulmonary resuscitation for ventricular fibrillation cardiac arrest. Circulation. 2001;104:2465.
15.Stevenson AG, McGowan J, Evans AL, et al. CPR for children: one hand or two?

Resuscitation. 2005;64:205.
16.Sampson HA, Munoz-Furlong A. Second symposium on the definition and management of anaphylaxis: summary report—Second National Institute of Allergy
and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J
Allergy Clin Immunol. 2006;117:391-397.
17.Lee JM, Greenes DS. Biphasic anaphylactic reactions in pediatrics. Pediatrics.
2000;106:762.
18.Luten RC, Kissoon N. The difficult pediatric airway. In: Walls RM, ed. Manual of
Emergency Management. 2nd ed. Philadelphia: Williams & Wilkins, 2004:236.
19.National Asthma Education and Prevention Program. Expert Panel Report
III: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD:
National Heart, Lung and Blood Institute; National Heart, Lung, and Blood
Institute, 2007.