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Doses of Emergency Drugs

Pediatrics by Medscape, Micromedex, & BNF

Ameer Saadallah M.B.Ch.B.

3rd edition

31-3-2019

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Table of Contents Table of Contents ......................................................................................................... 1

General dosing info ....................................................................................................... 3

Analgesics: ................................................................................................................... 4

Acetaminophen:. ...................................................................................................... 4

Ibuprofen: ............................................................................................................... 4

Diclofenac: ............................................................................................................... 4

Tramadol:................................................................................................................. 5

Pethidine:................................................................................................................. 5

Morphine: ................................................................................................................ 5

Antiemetic & Spasmolytic: ............................................................................................. 7

Ondansetron (Devomit): ............................................................................................ 7

Metoclopramide (Plasil): ............................................................................................ 7

Hyoscine butylbromide (Buscopan): ............................................................................ 7

Antimicrobials: ............................................................................................................. 8

Amoxicillin: ............................................................................................................... 8

Ceftriaxon: ............................................................................................................... 8

Cefotaxime (Claforan): ............................................................................................... 8

Ceftazidime: ............................................................................................................. 8

Vancomycin: ............................................................................................................. 8

Meropenem: ............................................................................................................ 9

Trimethoprim/Sulfamethoxazole ................................................................................ 9

Azithromycin: .......................................................................................................... 9

Gentamicin: .............................................................................................................. 9

Amikacin: ................................................................................................................. 9

Acyclovir (Zovirax): .................................................................................................. 10

Metronidazole (Flagyl): ............................................................................................ 11

Diloxanide furoate, or paromomycin ......................................................................... 11

Steroids: .................................................................................................................... 12

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Hydrocortisone: ...................................................................................................... 12

Prednisone: ............................................................................................................ 12

Methylprednisolone: ............................................................................................... 12

Dexamethasone: ..................................................................................................... 12

Nebulized drugs: ......................................................................................................... 13

Epinephrine (solution): ............................................................................................ 13

Salbutamol (Ventoline): ........................................................................................... 13

Ipratropium bromide (Atrovent): (Nebulized) ............................................................. 14

Budesonide (Pulmicort) Nebulized: ........................................................................... 14

Manage like an expert: ................................................................................................ 15

Anaphylactic shock (Adults and Pediatrics): ............................................................... 15

Status Asthmaticus (Adults and Pediatrics): ................................................................ 18

Status Epilepticus (Adults and Pediatrics): .................................................................. 21

Pediatric Febrile Seizures: ........................................................................................ 23

Pediatric DKA: ......................................................................................................... 24

Pediatric Advanced Life Support (PALS): ..................................................................... 27

Pediatric Urinary Tract Infection: .............................................................................. 29

Pediatric Pyelonephritis: .......................................................................................... 30

Croup:.................................................................................................................... 31

Epiglottitis: ............................................................................................................. 32

Bronchiolitis: .......................................................................................................... 33

Pediatric Pneumonia: .............................................................................................. 34

Tonsillitis and Pharyngitis Empiric Therapy: ................................................................ 35

Acute Bronchitis: ..................................................................................................... 36

Pediatric Gastroenteritis: ......................................................................................... 37

Bacterial Meningitis (adults and pediatrics): ............................................................... 40

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General dosing info BNF Dose calculation:

Many children’s doses are standardised by weight; occasionally, the doses have been

standardised by body surface area (in m2).

For most drugs, the adult maximum dose should not be exceeded.

Calculation by body-weight in the overweight child may result in much higher doses being

administered than necessary; in such cases, dose should be calculated from an ideal

weight, related to height and age.

Dose frequency:

Antibacterials are generally given at regular intervals throughout the day. Some flexibility

should be allowed in children to avoid waking them during the night. For example, the

night-time dose may be given at the child’s bedtime.

Where new or potentially toxic drugs are used, the manufacturers’ recommended doses

should be carefully followed.

Rote:

Whenever possible, intramuscular injections should be avoided in children because they

are painful.

When a prescription for a liquid oral preparation is written and the dose ordered is smaller

than 5mL an oral syringe will be supplied.

Parents should be advised not to add any medicines to the infant’s feed, since the drug

may interact with the milk or other liquid in it; moreover the ingested dosage may be

reduced if the child does not drink all the contents.

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Analgesics: Acetaminophen: Syrup, solution, or suspension, tablet, suppository.

General dosing: 10-15 mg/kg X 4-6 Neonates: 12.5 mg/kg IV X 4 1 month-2 years: 12.5 mg/kg IV X 4 2-12 years: 10-15 mg/kg X 4-6 60 Kg > like adults.

Dose adjustment in severe RF Dose adjustment in any liver disease Contraindicated in active liver disease & severe LF.

Onset: 60 minutes in oral route.

Note: Once IV container is penetrated, use within 6 hours. Do not administer simultaneously with diazepam (physically incompatible). Insert suppository well into rectum.

Ibuprofen: tablet, oral suspension Fever & Pain, 6 months to 12 years:

5-10 mg/kg X 3-4; not to exceed 40 mg/kg/day

Onset: 30-60 minutes

Severe RF: dose should be adjusted. Severe LF: contraindicated.

Diclofenac: Diclofenac sodium: Child 6 months–17 years: -Postoperative pain: < 12 kg: 12.5 mg X 2 by rectum for maximum 4 days > 12 kg and above: 1 mg/kg X 3 (max. per dose 50 mg) for maximum 4 days

-Inflammation | Mild to moderate pain:

0.3–1 mg/kg X 3 (max. per dose 50 mg) oral or by rectum.

Diclofenac potassium: Postoperative pain:

Child 9–13 years (> 35 kg): Up to 2 mg/kg ÷ 3 orally; maximum 100 mg per day

Child 14–17 years: 70-100 mg daily ÷ 2–3 orally

Fever in ear, nose, or throat infection Child 9–17 years (> 35 kg): Up to 2 mg/kg daily ÷ 3; maximum 100 mg per day

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Tramadol: Moderate to severe pain: 50–100 mg IV, IM X4-6, intravenous injection to be given over 2–3 minutes

Postoperative pain IV: Initially 100 mg, then 50 mg every 10–20 minutes if required up to

total maximum 250mg (including initial dose) in first hour, then 50–100 mg X 4-6,

intravenous injection to be given over 2–3 minutes; maximum 600 mg per day

Use is contraindicated for children less than 12 years.

Avoid use in 12-18 years who have other risk factors for respiratory depression.

Used with caution in patients with history of epilepsy (contraindicated in uncontrolled

epilepsy)

Use the lowest effective dose for the shortest duration.

Pethidine: PO/IM/SC 1-1.8 mg/kg every 3-4 hours as needed, individual dose not to exceed 100 mg

In general, it is not recommended as a first choice, if no other options, limit use in acute

pain to ≤48hr; doses should not exceed 600 mg/24hr

Oral route is not recommended for treatment of acute or chronic pain

Renal impairment: Contraindicated.

Hepatic impairment: Consider lower initial dose initially.

Onset: rapid

Contraindicated in:

Significant respiratory depression.

Acute or severe bronchial asthma in an unmonitored setting or in absence of

resuscitative equipment.

Known or suspected gastrointestinal obstruction, including paralytic ileus.

Within 2 weeks of monoamine oxidase inhibitor (MAOI) therapy

Morphine: IV, IM, SC, PO, suppository Analgesia/Cyanotic Tetralogy of Fallot:

Neonates (<30 days): 0.3-1.2 mg/kg ÷ 6 IM/SC

Infants and children (PO solution): 0.2-0.5 mg/kg PO every 4-6 hours as needed

Infants and children (IM/SC): 0.05-0.2 mg/kg every 2-4 hours as needed, not to exceed

15 mg/dose

Pain:

Continuous infusion: 0.025-2.6 mg/kg/hr IV; average, 0.06 mg/kg/hr

Neonates (<30 days): 0.01-0.02 mg/kg/hr by IV infusion

Postoperative pain: 0.01-0.04 mg/kg/hr by IV infusion

Sickle-cell disease, cancer: 0.04-0.07 mg/kg/hr by IV infusion

Onset: oral 15-30 min; IV <5 min

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Contraindications:

GI obstruction including paralytic ileus

Respiratory depression, acute or severe bronchial asthma, upper airway obstruction.

Within 2 weeks of monoamine oxidase inhibitor (MAOI) therapy

Injectable formulation: Heart failure due to chronic lung disease, head injuries, brain

tumors, deliriums tremens, seizure disorders, during labor when premature birth

anticipated

Immediate release tablets/solution: Hypercarbia (In patients who may be susceptible to

intracranial effects of CO2 retention ‘’e.g., those with evidence of increased intracranial

pressure or brain tumors’’, therapy may reduce respiratory drive, and resultant CO2

retention can further increase intracranial pressure)

Epidural/intrathecal: Upper airway obstruction

Suppository formulcation: Cardiac arrhythmia, increased intracranial or cerebrospinal

pressure, acute alcoholism, use after biliary tract surgery, surgical anastomosis.

Notes:

Consider lowest end of dosing range and monitor for side effects in elderly patients and

those with renal or hepatic impairment.

May cause constipation; consider preventive measures (eg, stool softener, increased

fiber) to reduce potential for constipation, especially in patients with unstable angina

and patients with myocardial infarction

Use with caution in patients with biliary tract dysfunction, including acute pancreatitis; use

may cause constriction of sphincter of Oddi diminishing biliary and pancreatic secretion

Therapy may cause severe hypotension including orthostatic hypotension and syncope

in ambulatory patients

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Antiemetic & Spasmolytic:

Ondansetron (Devomit): oral, IV, IM IV: 0.1 mg/kg to be given over at least 30 seconds, max per dose 4 mg, max per day 32 mg.

Gastroenteritis (orally):

8-15 kg: 2 mg dissolved orally as a single dose.

15-30 kg: 4 mg dissolved orally as a single dose.

More than 30 kg: 8 mg dissolved orally as a single dose.

Severe hepatic impairment: not to exceed 8 mg/day

Metoclopramide (Plasil): oral, IV, IM

Dose: 0.1-0.15 mg/kg X3 IV over 3 minutes

Risk of neurological effects such as extrapyramidal disorders and tardive dyskinesia outweigh the benefits in long-term or high-dose treatment. To help minimise the risk of potentially serious neurological adverse effects, the following restrictions to indications, dose and duration of use have been made:

In children aged 1–18 years, metoclopramide should only be used as a second-line optionfor prevention of delayed chemotherapy-induced nausea and vomiting and for treatmentof established postoperative nausea and vomiting.

Use of metoclopramide is contra-indicated in children aged under 1 year.

Metoclopramide should only be prescribed for short term use (up to 5 days).

Contraindications:

When stimulation of gastrointestinal motility might be dangerous (e.g., in the presence ofgastrointestinal hemorrhage, mechanical obstruction, or perforation)

History of epilepsy

Other drugs causing extrapyramidal symptoms (eg, phenothiazines, butyrophenones)

Hyoscine butylbromide (Buscopan): Oral, IV, IM Smooth muscle spasm of gastro-intestinal or genito-urinary system (oral):

Child 6–11 years: 10 mg X 3

Child 12–17 years: 20 mg X 4

Bowel colic (in palliative care): Oral IV, IM:

Child 1 month–4 years: 0.3-0.5 mg/kg X 3–4 (max. per dose 5 mg)

Child 5–11 years: 5–10 mg X 3-4

Child 12–17 years: 10–20 mg X 3-4

Contraindication: tachycardia

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Antimicrobials: Amoxicillin: IV: Neonate: 30-60 mg/kg X 2 Child: 20-60 mg/kg X 3 maximum dose 1 g X 3

Oral: Neonate: 30 mg/kg X 3 (max. per dose 125 mg). 1–11 months: 125 mg 3 X 3; up to 30 mg/kg X 3 Child 1–4 years: 250 mg X 3; up to 30 mg/kg X 3 5–11 years: 500 mg X 3; up to 30 mg/kg X 3 (max. per dose 1 g)

Dose adjustment is severe RF.

Note: For suspension, shake well before use. Discard after 14 days. If taste is unacceptable, mixed with milk, fruit juice & other drinks. After mixing administer immediately & completely. Amoxiclav should not be taken on empty stomach (reduced absorption).

Ceftriaxon: IV, IM 50-100 mg/kg ÷ 1-2 (Maximum 2g/day)

Cefotaxime (Claforan): IV, IM 50-200 mg/kg/day IV/IM ÷ 3-4 doses

Ceftazidime: IV, IM <1 month: Safety and efficacy not established 1 month-12 years: 90-150 mg/kg IV ÷ 3 doses, maximum dose 2g X 3

Vancomycin: IV 15 mg/kg X 3, maximum 2 g per day

Preparation: Initially add 10 mL of distilled water to 500-mg vial and 20 mL of distilled water to 1-g vial to yield 50 mg/mL solution. The dose to be infused should be further diluted in a solution and given over at least 1 hr. Adjust dose in RF

Notes:

Avoid rapid infusion because of risk of red man syndrome (flushing, pruritus,

hypotension, erythema, and urticaria).

Avoid extravasation; necrosis may occur.

Oral preparations are only indicated for treatment of pseudomembranous colitis; not

effective for systemic infections.

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Meropenem: IV Neonate 1-7 days: 20 mg/kg X 2, increased to 40 mg/kg X 2 in severe infections

Neonate 7- 28 days: 20 mg/kg X 3, increased to 40 mg/kg X 3 in severe infections

Child 1m–11 y (body-weight up to 50 kg): 10–20 mg/kg X 3

Preparation: Initially add 10 mL of distilled water to 500-mg vial and 20 mL of distilled water to 1-g vial to yield 50 mg/mL solution. The dose to be infused should be further diluted in a solution and given over at least 30 minutes. Adjust dose in RF

Trimethoprim/Sulfamethoxazole TMP/SMX: parenteral, oral suspension, tablet

<2 months: Contraindicated

Mild to Moderate Infections:

8mg TMP/kg/day PO ÷ 4 dosesSerious Infections:

15-20 mg TMP/kg/day PO ÷ 4 doses

8-12 mg TMP/kg/day IV ÷ 2-4 doses.

Contraindicated in:

Severe RF

Severe LF

Megalobalstic anemia or folate deficiency.

Azithromycin: Oral solution, tablet <6 months: Safety and efficacy not established -10 mg/kg once daily for 3 days (max. per dose 500 mg). - Or: 10 mg/kg once on day 1 followed by 5 mg/kg on days 2-5. Renal impairment: Use with caution

Gentamicin: IV, IM Infants: 2.5 mg/kg X 3 Children and adolescents: 2-2.5 mg/kg X 3

Renal impairment: Dose adjusted

Amikacin: IV, IM 5-7.5 mg/kg X 3 Infused over 1-2 hours in infants.

Renal impairment: Dose adjusted Notes about aminoglycosides (Gentamicin and Amikacin): Narrow therapeutic index (not intended for long-term therapy)

Patients treated with aminoglycosides should be under close clinical observation; high

risk of toxicity associated with their use

Avoid potent diuretics (eg, ethacrynic acid, furosemide) because they increase risk of

ototoxicity.

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Risk of ototoxicity; tinnitus or vertigo may be indications of vestibular injury and

impending bilateral irreversible damage; discontinue therapy if signs of ototoxicity occur

Risk of nephrotoxicity; other factors that increase patient risk of ototoxicity include

advanced age and dehydration

Use caution in patients with hearing and renal impairment.

Neuromuscular blockade and respiratory paralysis have been reported, especially when

given soon after anesthesia or muscle relaxants; if blockage occurs, calcium salts may

reverse these phenomena, but mechanical respiratory assistance may be necessary

Acyclovir (Zovirax): oral suspension, tablet, capsule, IV Neonatal Herpes Simplex Virus Infection:

30 mg/kg/day IV into 3 doses IV for 14-21 days;

Alternatively, 20 mg/kg X 3 IV for 14-21 days

In obese patients, use ideal body weight

Herpes Simplex Virus Encephalitis

3 months-12 years: 20 mg/kg X 3 IV for 10 days; up to 14-21 days reported

In obese patients, use ideal body weight

>12 years: 10-15 mg/kg X 3 IV for 14-21 days

Mucocutaneous Herpes Simplex Virus Infection

Treatment in immunocompromised patients: <12 years: 10 mg/kg X 3 IV for 7 days

In obese patients, use IBW

>12 years: 5-10 mg/kg/day IV ÷ 3 for 5-7 days; up to 14 days reported

Herpes Zoster (Shingles)

<12 years (immunocompromised): 20 mg/kg X 3 IV for 7 days

In obese patients, use IBW

>12 years (immunocompetent): 800 mg X 5 PO while awake for 7-10 days

>12 years (immunocompromised): 10 mg/kg X 3 IV for 7-10 days

Varicella Zoster (Chickenpox)

≥2 years and <40 kg: 20 mg/kg X 4 PO for 5 days; not to exceed 800 mg/dose

In obese patients, use IBW

>40 kg: 800 mg X 4 PO for 5 days

Immunocompromised patients

o <12 years: 20 mg/kg X 3 IV for 7 days

o >12 years: 10 mg/kg X 3 IV for 7 days

Adjust dose in RF

Notes:

Maintain adequate hydration during PO or IV therapy

Avoid rapid infusion because of risk of renal damage

Use with caution in patients receiving nephrotoxic drugs

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Metronidazole (Flagyl): Oral, IV Anaerobic Infection: 1-2 months: Loading dose 15 mg/kg, followed by 7.5 mg/kg X 3 (after 8 hours), for a total duration of 7 days. 2 months–17 years: 7.5 mg/kg X 3 (max. per dose 500 mg) usually treated for 7 days.

Amebiasis & amebic liver abscess: 11-17 mg/kg X 3 for 10 days.

Giardiasis: 5 mg/kg X 3 for 7-10 days.

Severe RF: No dose adjustment (although metabolites may accumulate, monitor for SE). Severe LF: Reduce dose.

Diloxanide furoate, or paromomycin: tablet Amebiasis: 500 mg X 3 for 10 days after treatment by metronidazole.

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Steroids: Hydrocortisone: PO, IV, IM Inflammation:

Oral: 2.5-10 mg/kg ÷ 3-4.

IV: 1-5 mg/kg ÷ 1-2

Status Asthmaticus

Loading: 4-8 mg/kg IV ÷ 4 for 24 hr; not to exceed 250 mg, then:

IV Maintenance: 2 mg/kg/day IV ÷ 4

PO Maintenance: 0.5-1 mg/kg IV X 4

Prednisone: oral solution, tablet Inflammation: 0.5-2 mg/kg PO ÷ 1-2 for 3-10 days; not to exceed 80 mg/day

Acute Asthma: <12 years: 1-2 mg/kg PO ÷ 1-2 for 3-10 days; not to exceed 80 mg/day ≥12 years: 40-60 mg PO once daily for 3-10 days

Methylprednisolone: Oral, IV, IM Inflammation: 0.5-1.7 mg/kg ÷ 2

Status Asthmaticus: <12 years: 1-2 mg/kg IV/IM ÷ 2 until peak expiratory flow is 70% of predicted or personal best; not to exceed 60 mg/day >12 years: 40-80 mg IM ÷ 1-2 until peak expiratory flow is 70% of predicted or personal best; not to exceed 60 mg/day

Dexamethasone: PO, IV, IM Airway Edema: 0.5-2 mg/kg ÷ 4, starting 24 hours before extubation and continued for 4-6

doses afterward

Croup: 0.6 mg/kg one dose only; not to exceed 16 mg

Inflammation: 0.08-0.3 mg/kg ÷ 2-4

Meningitis: >6 weeks: 0.6 mg/kg/day ÷ 4 for first 2-4 days of antibiotic therapy, starting 10-

20 minutes before or simultaneously with first antibiotic dose

Cerebral Edema Associated With Brain Tumor: 1-2 mg/kg once; maintenance: 1-1.5 mg/kg ÷

4-6; not to exceed 16 mg/day

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Nebulized drugs: Epinephrine (solution): > 1 month of age: 0.4 mg/kg (max. per dose 5 mg) of 1:1000 epinephrine solution. Dose to be repeated after 30 minutes if necessary. Note: it is used when patient is not effectively controlled with corticosteroid treatment

The effects of nebulised adrenaline for the treatment of croup lasts for 2–3 hours.

Salbutamol (Ventoline): Severe bronchospasm: 1-Nebulizer:

Child 1 month–4 years: 2.5 mg

Child 5–11 years: 2.5–5 mg

Adults: 5 mg

Repeat every 20–30 minutes or when required, give via oxygen driven nebuliser if

available (all ages)

Calmly breathe through your mouth until no more mist is formed (~5-15 minutes).

Preparations are either 2.5 mg/2.5 ml (used without dilution), or 0.5 ml of 0.5% solution diluted

with NS to a total of 2.5 ml)

It can also be given continuously (10-15 mg/h)

2-Metered-dose inhaler with spacer chamber:

All ages 2-4 puffs, repeated at 15- to 30-minute intervals as needed.

Each puff is to be inhaled separately, give via large volume spacer (and a close-fitting face

mask in children under 3 years).

Administration: 1-Aerosol metered-dose inhaler:

Prime inhaler (before first-time use or when inhaler has not been used for >2

weeks): Release 4 test sprays into the air, away from the face

Shake well before each use

Breathe out fully through the mouth; place mouthpiece fully into mouth, holding

inhaler in its upright position and close lips around it

While breathing in deeply and slowly through the mouth, fully depress the top of the

metal canister with your index finger

Hold your breath for ≤10 sec; before breathing out

For additional puffs, wait 1 minute, shake inhaler again, and repeat steps listed

above; replace cap after use

2-Powder metered-dose inhaler:

Does NOT require priming

Do not use with a spacer or volume holding chamber

Note:

Salbutamol and ipratropium bromide solutions are compatible and can be mixed for nebulisation.

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Ipratropium bromide (Atrovent): (Nebulized) Child 1 month–11 years: 0.25 mg

Child 12–17 years: 0.5 mg

Adults: 0.5 mg

* Dose can be repeated every 20 min for 3 doses, then it can be given X 4-6.

Budesonide (Pulmicort) Nebulized: Prophylaxis of asthma:

Child 6 months–11 years: 125–500 micrograms twice daily, adjusted according to response;

maximum 2 mg per day

Child 12–17 years: Initially 0.25–1 mg twice daily, adjusted according to response, doses

higher than recommended max. may be used in severe disease; maximum 2 mg per day

Croup

Child: 2 mg for 1 dose, alternatively 1 mg for 2 doses separated by a 30 minute interval, dose

may be repeated every 12 hours until clinical improvement

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Manage like an expert: Medscape

Anaphylactic shock (Adults and Pediatrics): Medscape & BNF

Summary:

- Oxygen

- Leg elevation

- Adrenaline 1:1000 IM in anterolateral thigh, repeated every 10 minutes:

Pediatrics: 0.01 mL/kg. max. per dose (0.5 ml)

Adults: 0.3-0.5 mL

-Allermine (Chlorphenamine): IM/slow IV injection

Child 1–5 months: 0.25 mg/kg (max. per dose 2.5 mg)

Child 6 months–5 years: 2.5 mg

Child 6–11 years: 5 mg

Adults: 10 mg

-Zantac (Ranitidine): IM/IV

Pediatrics: 1 mg/kg X 4

Adults: 50 mg X 3-4

-Hydrocortisone: IM/IV in pediatrics, IV in adults

Child 1–5 months: 25 mg X 3

Child 6 months–5 years: 50 mg X 3

Child 6–11 years: Initially 100 mg X 3

Child 12–17 years: Initially 200 mg X 3

Adults IV: 100–300 mg

-If chest examination reveals wheeze or stridor: nebulized salbutamol

Child 1 month–4 years: 2.5 mg

Child 5–11 years: 2.5–5 mg

Adults: 5 mg

*Calmly breathe through your mouth until no more mist is formed (~5-15 minutes).

*Repeat every 20–30 minutes or when required, give via oxygen driven nebuliser if

available (all ages)

- If hypotension or tachycardia: administer a fluid bolus of 20 mg/kg for children and 1 L for

adults. It can be repeated to reach to total of 80 ml/kg in pediatrics or 5 L in adults.

- Monitor for 6-24 hours depending on severity

- On discharge: Loratidine + Prednisolone for 2-3 days

Details:

Note: Intramuscular route is important because of peripheral vasoconstriction.

Prevent further contact with allergen

Place the patient in the supine position with legs elevated.

Oxygen & Ensure airway patency

Adrenaline (epinephrine): 1:1000 solution SC/IM in anterolateral aspect of the thigh

(vastus lateralis) until adequate response:

Pediatrics: 0.01 mg/kg (0.01 mL/kg) max. per dose (0.5 mg)

Adults: 0.3-0.5 mg (0.3-0.5 mL), not to exceed 0.5 mg (0.5 mL) per injection

*Adrenaline can be repeated every 5-10 minutes as necessary (all ages).

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H1 + H2 blockers: Allermine (Chlorphenamine): IM/slow IV injection

Child 1–5 months: 0.25 mg/kg (max. per dose 2.5 mg)

Child 6 months–5 years: 2.5 mg

Child 6–11 years: 5 mg

Child 12–17 years: 10 mg

Adult: 10 mg

* Allermine can be repeated if necessary; maximum 4 doses per day (all ages).

Zantac (Ranitidine): IM/IV

Pediatrics: 1 mg/kg X 4

Adults: 50 mg X 3-4

* Zantac can be repeated if necessary; maximum 4 doses per day (all ages).

Hydrocortisone: IM/IV in pediatrics, IV in adults Child 1–5 months: Initially 25 mg 3 times a day

Child 6 months–5 years: Initially 50 mg 3 times a day

Child 6–11 years: Initially 100 mg 3 times a day

Child 12–17 years: Initially 200 mg 3 times a day

*Dose can be adjusted according to response (pediatrics)

Adults IV: 100–300 mg, to be administered as sodium succinate

*Administer corticosteriods early to prevent a potential late-phase reaction (biphasic anaphylaxis)

Inhaled Salbutamol (Ventolin): for wheeze and stridor 1-Nebulizer:

Child 1 month–4 years: 2.5 mg

Child 5–11 years: 2.5–5 mg

Child >12 years: 5 mg

Adults: 5 mg

Repeat every 20–30 minutes or when required, give via oxygen driven nebuliser if

available (all ages)

Calmly breathe through your mouth until no more mist is formed (~5-15 minutes).

Preparations are either 2.5 mg/2.5 ml (used without dilution), or 0.5 ml of 0.5% solution diluted

with NS to a total of 2.5 ml)

It can also be given continuously (10-15 mg/h)

2-Metered-dose inhaler with spacer chamber:

All ages 2-4 puffs, repeated at 15- to 30-minute intervals as needed.

Each puff is to be inhaled separately, give via large volume spacer (and a close-fitting face

mask in children under 3 years).

Blood Pressure Management:

IV fluids: If hypotension or tachycardia is present, administer a fluid bolus of 20 mg/kg for

children and 1 L for adults.

Depending on response, fluid boluses may be repeated up to a total of 80 m/kg in

pediatrics, and 5 L or more in adults.

Vasopressors: It is indicated for patients unresponsive to fluid resuscitation:

17

Epinephrine (0.1-1 mcg/kg/min IV) should be considered as the initial vasopressor in

children.

Dopamine (2-20 mcg/kg/min IV) may be used in addition to epinephrine.

Norepinephrine (0.1-2 mcg/kg/min IV) is a potent vasopressor. It is usually considered

in children unresponsive to epinephrine.

Glucagon IV: It may help with refractory symptoms in patients who are taking a beta-blocker.

Children:

o Loading: 20-30 mcg/kg (not to exceed a cumulative dose of 1 mg) over 5 minutes

o Maintenance: 5-15 mcg/min.

Adults:

o Loading: 50-150 mcg/kg IV over 1 minute

o Maintenance: 3-5 mg/hr or 50-100 mcg/kg/hr IV

Monitoring:

Patients with non–life-threatening symptoms may be observed for 4-6 hours after

successful treatment and then discharged.

Some investigators recommend 24 hours.

Outpatient medications (for 2-3 days):

The oral forms of antihistamines and corticosteroids that should be continued for a short

time (2-3 days) following an episode:

Steroids (e.g. Prednisone):

Children, a dose of 0.5-1 mg/kg/day in divided doses

Adults, a dose of 1 mg/kg/day in divided doses

H1 -blocker antihistamine (e.g. loratadine):

Children: 5 mg once daily

Adults: 10 mg once daily

H2 -blocker antihistamine (e.g. Ranitidine)

Children: Not recommended

Adullts: 150 mg X 2

18

Status Asthmaticus (Adults and Pediatrics): Summary:

Supplemental oxygen; in severe cases mechanical ventilation.

Inhaled Salbutamol ± Ipratropium bromide:

A-Nebulized salbutamol (Ventolin):

o Child 1 month–4 years: 2.5 mg

o Child 5–11 years: 2.5–5 mg

o Adults: 5 mg

*Calmly breathe through your mouth until no more mist is formed (~5-15 minutes).

*Repeat every 20–30 minutes or when required, give via oxygen driven nebuliser if

available (all ages)

B- Nebulized Ipratropium bromide (Atrovent):

o Child 1 month–11 years: 0.25 mg

o Adults: 0.5 mg

* Dose can be repeated every 20 min for 3 doses, then it can be given X 4-6.

Note: Salbutamol and ipratropium bromide solutions are compatible and can be mixed for

nebulisation.

Hydrocortisone:

Pediatrics: 4-8 mg/kg ÷ 4 until conversion to oral prednisolone.

Adults: 100 mg X 4 until conversion to oral prednisolone.

On discharge: Reduce recurrence by a short course of systemic corticosteroids.

Details:

Inhaled Salbutamol (Ventolin):

Nebulizer: o Child 1 month–4 years: 2.5 mg

o Child 5–11 years: 2.5–5 mg

o Child >12 years: 5 mg

o Adults: 5 mg

Repeat every 20–30 minutes or when required, give via oxygen driven nebuliser if available (all ages)

Calmly breathe through your mouth until no more mist is formed (~5-15 minutes).

Preparations are either 2.5 mg/2.5 ml (used without dilution), or 0.5 ml of 0.5% solution diluted

with NS to a total of 2.5 ml)

It can also be given continuously (10-15 mg/h)

Metered-dose inhaler with spacer chamber: o All ages 2-4 puffs, repeated at 15- to 30-minute intervals as needed.

Each puff is to be inhaled separately, give via large volume spacer (and a close-fitting face

mask in children under 3 years).

IV: Some patients with severe, refractory status asthmaticus may benefit from the addition of beta-agonists delivered intravenously.

Note: Most patients respond within 1 hour of treatment.

19

Ipratropium bromide (Atrovent): (Nebulized) o Child 1 month–11 years: 0.25 mg

o Child 12–17 years: 0.5 mg

o Adults: 0.5 mg

* Dose can be repeated every 20 min for 3 doses, then it can be given X 4-6.

The maximal effect of inhaled ipratropium occurs 30–60 minutes after use; its duration of

action is 3 to 6 hours and bronchodilation can usually be maintained with treatment 3

times a day.

It can be synergistic with albuterol or other beta2-agonists when treating severe acute

asthma exacerbations.

Ipratropium may also be used as an alternative bronchodilator in patients who are unable

to tolerate inhaled beta2-agonists. Because children appear to have more cholinergic

receptors, they are more responsive to parasympathetic stimulation than adults.

Epinephrine:

Patients whose bronchoconstriction is resistant to continuous nebulizer treatments with

beta2-agonists may be candidates for nonselective beta2-agonists (epinephrine 0.3-0.5 mg

administered subcutaneously). However, systemic therapy has no proven advantage over

aerosol therapy with selective beta2 agents.

Caution in patients with other complicating factors (eg, congestive heart failure (CHF),

history of cardiac arrhythmia).

Note: Endotracheal adrenaline in patients who are intubated has been associated with variable success in different studies. However, based on the current literature, no specific advantage can be gained at this point by using endotracheal adrenaline.[22]

Steroids:

Hydrocortisone: Pediatrics: 4-8 mg/kg ÷ 4 (max. per dose 100 mg) until conversion to oral prednisolone. Adults: 100 mg X 4 until conversion to oral prednisolone.

Prednisone: for 3-10 days Pediatrics: 1-2 mg/kg ÷ 2 Adults: 40-60 mg ÷ 1-2

Methylprednisolone 1 mg/kg X 4

Corticosteroid treatment for acute asthma is necessary but has potential adverse effects like hyperglycemia and hypokalemia. Thus, monitoring of glucose & potassium is essential.

Corticosteroid onset of action usually requires at least 4-6 hours. Theophylline or aminophylline: -Aminophylline: The loading dose is usually 5-6 mg/kg, followed by a continuous infusion of 0.5-0.9 mg/kg/h. -Theophylline: loading dose is 6mg/kg infused over 20-30 minutes, followed by maintenance:

o 1.5-6 months: 0.5 mg/kg/hr IV or 10 mg/kg/day PO in divided doses

o 6-12 months: 0.6-0.7 mg/kg/hr IV or 12-18 mg/kg/day PO in divided doses

o 1-9 years: 1 mg/kg/hr IV or 8 mg/kg X 3 PO (extended release)

o 9-12 years: 0.8-0.9 mg/kg/hr IV or 6.4 mg/kg X 3 PO (extended release)

o 12-16 years: 0.7 mg/kg/hr IV or 5.6 mg/kg X 3 PO (extended release)

o Adults: 1mg/kg/h IV in the emergent setting.

20

Starting intravenous aminophylline may be reasonable in patients who do not respond to medical treatment with bronchodilators, oxygen, corticosteroids, and intravenous fluids within 24 hours. Data suggest that aminophylline may have an anti-inflammatory effect in addition to its bronchodilator properties. Magnesium sulfate Adults: 1-2.5 g over 20 minutes. Pediatrics: 25-50 mg/kg IV over 10-20 minutes Intravenous magnesium sulfate infusion has been advocated in the past for the treatment of acute asthma. Magnesium can relax smooth muscle and hence may cause bronchodilation by competing with calcium at calcium-mediated smooth muscle ̶ binding sites.

Sedatives Patients may benefit from sedatives in very small doses and under controlled, monitored settings. Sedatives should be used judiciously, if at all. For example, lorazepam (0.5 or 1 mg intravenously) could be used for patients who are very anxious and are undergoing appropriate and aggressive bronchodilator therapy.

21

Status Epilepticus (Adults and Pediatrics):

Summary for pediatrics:

Step 1 (5 min):

IV access & withdraw blood for analysis: glucose, electrolyes, CBC, LFT, & RFT.

D5NS 20 mL/kg/h over 20 minutes

Glucose: Pediatrics 2 mL/kg of 25%. Adults 50 mL of 50%, along with 100 mg of thiamine

Naloxone - 0.1 mg/kg/dose

Pyridoxine - 50-100 mg

Antibiotics

Step 2 (5-15 min):

Diazepam: 1 m – 5 y: 0.1-0.3 mg/kg; may be repeated every 5 minutes up to a MAX of 5 mg. 5 y – 18 y: 0.1-0.3 mg/kg; may be repeated every 5 minutes, up to a MAX of 10 mg.

Adult: 5-10 mg IV slowly; may be repeated every 10 minutes, up to a MAX of 20-30 mg. Both oral and IV preparations may be administered in 0.3-0.5 mg/kg/dose rectally if required. sahealth

Rectal diazepam at 0.5 mg/kg (not to exceed 10 mg).

Step 3 (after 15 min) Phenobarbital 10-20 mg/kg IV over 10-15 minutes (not to exceed 700 mg IV; be prepared to intubate patient; closely monitor hemodynamics and support blood pressure as indicated. Note: IV administration may require 15 minutes or longer to reach peak concentration in the brain.

Step 4: General anesthesia (patient already intubated)

Supportive care:

Place patients in the lateral decubitus position to avoid aspiration of emesis and toprevent epiglottis closure over the glottis.

Administer supplemental 100% oxygen by facemask

Assist ventilation and use artificial airways (eg, endotracheal intubation) as needed

Suction secretions and decompress the stomach with a nasogastric tube.

Details for both adults and pediatrics:

Step 1: First 5 minutes of seizure activity (if witnessed):

Establish intravenous access and to obtain samples for laboratory tests and for seizuremedication levels.

Infuse D5NS 20 mL/kg/h

If serum glucose is low or cannot be measured give:o Pediatrics 2 mL/kg of 25% glucose.o Adults 50 mL of 50% glucose, along with 100 mg of thiamine to avoid Wernicke-

Korsakoff syndrome.

Selected agents and indications are as follows:

Naloxone - 0.1 mg/kg/dose intravenously preferably (if needed may administerintramuscularly/subcutaneously) for narcotic overdose

Pyridoxine - 50-100 mg intravenously/intramuscularly for possible dependency, deficiency,or isoniazid toxicity

22

Antibiotics - If meningitis is strongly suspected, initiate treatment with antibiotics prior to cerebrospinal fluid (CSF) analysis or CNS imaging

Most seizures stop without anticonvulsant medications. Monitoring:

Vital signs

Carefully monitor the patient's temperature because hyperthermia may worsen brain damage caused by seizures.

Step 2 (6-15 min):

Diazepam: 1 m – 5 y: 0.1-0.3 mg/kg; may be repeated every 5 minutes up to a MAX of 5 mg. 5 y – 18 y: 0.1-0.3 mg/kg; may be repeated every 5 minutes, up to a MAX of 10 mg.

Adult: 5-10 mg IV slowly; may be repeated every 10 minutes, up to a MAX of 20-30 mg. Both oral and IV preparations may be administered in 0.3-0.5 mg/kg/dose rectally if required. sahealth

Lorazepam: 0.05-0.1 mg/kg; not to exceed infusion rate of 0.05 mg/kg over 2-5 min Alternative: If IV line is unavailable, use rectally administered (PR) diazepam at 0.5 mg/kg (not to exceed 10 mg) or midazolam at 0.2 mg/kg intramuscularly (IM), IV, or intranasally.

Step 3 (16-35 min)

Phenytoin (20 mg/kg) IV or fosphenytoin (20 mg phenytoin-equivalent/kg) IV over 20 min; not to exceed infusion rate of 1 mg/kg/min or 50 mg/min in adults; do not dilute in 5% dextrose in water (D5W).

If seizures persist, administer 5 mg/kg for additional 2 doses (if blood pressure is within the reference range and no history of cardiac disease is present).

Alternative: Phenobarbital 10-20 mg/kg IV over 10-15 minutes (not to exceed 700 mg IV; be prepared to intubate patient; closely monitor hemodynamics and support blood pressure as indicated. Note: IV administration may require 15 minutes or longer to reach peak concentration in the brain.

Step 4 (45-60 min)‡: Pentobarbital anesthesia (patient already intubated)

Loading dose: 5-7 mg/kg IV; may repeat 1-mg/kg to 5-mg/kg boluses until EEG exhibits burst suppression; closely monitor hemodynamics and support blood pressure as indicated

Maintenance dose: 0.5-3 mg/kg/h IV; monitor EEG to keep burst suppression pattern at 2-8 bursts/min

With phenobarbital-induced anesthesia, repeated boluses of 10 mg/kg are administered until cessation of ictal activity or appearance of hypotension; closely monitor hemodynamics and support blood pressure as indicated.

Alternative: -Midazolam anesthesia: 0.1-0.3 mg/kg followed by infusion at a rate of 0.1-0.3 mg/kg/h. closely monitor hemodynamics and support blood pressure as indicated; when seizures stop, continue same dose for 48 h then wean by decrements of 1-2 mcg/kg/min every 15 min. -Propofol anesthesia : initial bolus 2 mg/kg IV; repeat if seizures continue and follow by IV infusion of 5-10 mg/kg/h, if necessary, guided by EEG monitoring; taper dose 12 h after seizure activity stops; closely monitor hemodynamics and support blood pressure as indicated.

Notes to step 4:

Thiopental (thiopentone) is often used rather than pentobarbital in the UK.

High-dose phenobarbital has also been used.

23

Notes:

If the seizures cease, no further drugs are immediately necessary.

In many pediatric institutions, phenobarbital is the second-line choice, rather than fosphenytoin or phenytoin, especially for febrile and neonatal siezures.

Phenobarbital's major disadvantages are that it significantly depresses mental status and causes respiratory difficulty.

Midazolam is the only benzodiazepine that can be administered safely intramuscularly while providing rapid onset equivalent to that of intravenous agents and a moderate duration of action.

Intranasal midazolam may also be an option in children with prolonged seizure without an IV access.

Fosphenytoin is preferable, as it provides the advantage of a potentially rapid rate of administration with less risk of venous irritation (eg, to avoid the risk of purple-glove syndrome with phenytoin).

Reports have shown the efficacy of levetiracetam as an add-on therapy in adults with refractory SE, with reported loading doses of 500-3000 mg/day and a maintenance dose of 2000-3000 mg/d. In children, the reported loading dose is 30-40 mg/kg.

Further Inpatient Care Any child with persistent altered mental status (despite cessation of seizure activity) or with prolonged status epilepticus should be admitted to a pediatric critical care unit. Treat the underlying cause.

Pediatric Febrile Seizures: Summary: - Diazepam 0.3 mg/kg X 3 orally throughout the febrile illness until the child was afebrile for 24 hours - Rectal acetaminophen 10 mg/kg X 4 Detalis: Antiepileptics:

On the basis of risk/benefit analysis, neither long-term nor intermittent anticonvulsant therapy is indicated for children who have experienced 1 or more simple febrile seizures.

Continuous therapy with phenobarbital or valproate decreases the occurrence of subsequent febrile seizures, but it is not recommended.

Oral diazepam can reduce the risk of subsequent febrile seizures. Because it is intermittent, this therapy probably has the fewest adverse effects. If preventing subsequent febrile seizures is essential, this would be the treatment of choice. [4]

Diazepam 0.3 mg/kg X 3 oral throughout the febrile illness until the child was afebrile for 24 hours (A study reported in New England Journal of Medicine). However, this dosage was frequently associated with side effects such as imbalance, lethargy, and irritability.

Antipyretics:

Rectal acetaminophen 10 mg/kg given every 6 hours may prevent febrile seizure recurrence within the same febrile episode, suggested by a randomized controlled trial published in 2018

Although it has been felt that antipyretic therapy cannot prevent simple febrile seizures, it is desirable for other reasons, for instance comfort.

24

Pediatric DKA: Summary: -Fluids: Resuscitation: NS 10-20 mL/kg over 20-60 minutes. Calculate fluid deficit (maximum 8% of body weight). Slowly correct the fluid deficit over

48 hours. Provide normal maintenance fluids together with the calculated deficit. Administer NS until blood glucose levels have fallen to 250-300 mg/dL, at which time

change to D5NS or D5 ½ NS until the child is eating and drinking normally. -Insulin Replacement: Time to start insulin is one hour after starting fluid resuscitation especially in the newly

diagnosed child. Continuous IV insulin infusion at a rate of 0.1 U/kg/h. Blood glucose levels should not fall faster than 90 mg/dl (5 mmol/L) per hour. The infusion

rate of insulin can be reduced as blood glucose levels fall but should not drop below 0.05 U/kg/h.

Do not discontinue infusion until subcutaneous insulin has been given when the child has recovered.

-Potassium: After initial resuscitation and if a good renal output has been maintained add potassium to

all replacement fluids.

Serum/Plasma K+ (mEq/L) Potassium Chloride (KCL) Dose in Infusion Fluids

< 2.5 mEq/L Carefully monitored administration of 1 mEq/kg body weight by separate infusion over 1 h

2.5-3.5 mEq/L 40 mEq/L

3.5-5 mEq/L 20 mEq/L

5-6 mEq/L 10 mEq/L (optional)

Over 6 mEq/L Stop K+ and repeat level in 2 h

-Monitoring: Specifically designed recording charts make the process of care much easier. These usually include: Insulin infusion, deficit fluid, maintenance fluid, blood glucose,

vitals, & electrolytes. Frequent neurologic examination hourly during the first 12 hours (or any time a change in

the level of consciousness is suspected). Details: Fluid Replacement:

Resuscitate with 10-20 mL/kg of NS over 30 minutes. After resuscitation, calculate fluid deficit by clinical assessment to a maximum 8% of

body weight, then slowly correct the fluid deficit over 48 hours by providing normal maintenance fluids together with the calculated deficit. Remember to subtract any initial resuscitation fluid boluses given from the total calculated deficit

Administer isotonic sodium chloride solution until blood glucose levels have fallen to 250-300 mg/dL, at which time change to D5NS or D5 ½ NS until the child is eating and drinking normally.

25

Notes: If cerebral edema develops, restrict fluid replacement to two thirds of normal maintenance and replace the deficit over a period of 48 hours or longer Although strict assessment of fluid balance is important, replacement of ongoing losses is not normally required. Insulin Replacement:

Continous IV insulin infusion at a rate of 0.1 U/kg/h is given. Blood glucose levels not fall faster than 90 mg/dl (5 mmol/L) per hour. The infusion

rate of insulin can be reduced as blood glucose levels fall but should not drop below 0.05 U/kg/h.

If blood glucose falls below 120 mg% (ie, 7 mmol/L), increase the concentration of infused glucose to prevent hypoglycemia.

Do not discontinue infusion until subcutaneous insulin has been given when the child has recovered.

Note: Time to start insulin is one hour after starting fluid resuscitation especially in the newly diagnosed child. The results of a prospective national study of diabetic ketoacidosis in the United Kingdom suggested a greater risk of cerebral edema in patients who received insulin within the first hour of treatment.

Potassium:

After initial resuscitation and if a good renal output has been maintained add potassium to all replacement fluids.

Potassium chloride most commonly is administered. This theoretically could make the acidosis worse, but no evidence indicates that administration of other potassium salts, such as phosphate or acetate, is more effective.

Serum/Plasma K+ (mEq/L) Potassium Chloride (KCL) Dose in Infusion Fluids

< 2.5 mEq/L Carefully monitored administration of 1 mEq/kg body weight by separate infusion over 1 h

2.5-3.5 mEq/L 40 mEq/L

3.5-5 mEq/L 20 mEq/L

5-6 mEq/L 10 mEq/L (optional)

Over 6 mEq/L Stop K+ and repeat level in 2 h

Monitoring: Specifically designed recording charts make the process of care much easier. These usually include: Insulin infusion, deficit fluid, maintenance fluid, blood glucose,

vitals, & electrolytes. Frequent review of neurologic status at least hourly (or any time a change in the level of

consciousness is suspected)—is essential during the first 12 hours of diabetic ketoacidosis treatment. Promptly treat any suspected cerebral edema.

26

Treatment of Cerebral Edema: Only half of children who develop cerebral edema have obvious signs of deterioration; children may present with respiratory arrest. If cerebral edema is suspected and hypoglycemia is excluded, prompt treatment with an osmotic diuretic is indicated, followed by a CT scan and referral to a neurosurgeon.

Mannitol: is 0.5-1 g/kg infused over 30 minutes, which can be repeated after 1 hour. Hypertonic saline (3%): 5-10 mL/kg, infused over 30 minutes, which can be repeated

after 1 hour.

27

Pediatric Advanced Life Support (PALS): Algorithm by Davidson’s, Details by Medscape

Maintain airway: put a towel under the shoulders to render the neck in the neutral

position (hyperextension in pediatrics obstructs the airway), jaw thrust, oropharyngeal

airway, nasopharygeal airway, laryngeal mask, or endotracheal tube.

Oxygen & suction of the oropharynx

Compression-to-ventilation ratio is 15:2 for multiple rescuers: give 15 compression, then

give 2 breaths (don’t ventilate and compress simultaneously)

Adrenaline (epinephrine):

1:10,000 solution (0.1 mg/mL) IO/IV : 0.01 mg/kg; not to exceed 1 mg; repeat every

3-5min until return of spontaneous circulation

1:1000 solution (1 mg/mL) endotracheal tube: 0.1 mg/kg (0.1 mL/kg); not to exceed

2.5 mg q3-5min until IO/IVP access established or spontaneous circulation achieved.

Flush with 5 mL of normal saline immediately after administration.

Atropine: 0.01-0.03 mg/kg IV, IM, SC, endotracheal tube.

Amiodarone (after 3 DC shocks):

5 mg/kg IV bolus, may be repeated for a total 2-3 doses.

Shock Energy

2 J/kg first shock

4 J/kg second shocks

≥4 J/kg subsequent shocks, maximum 10 J/kg or adult dose

Most DC shock devices have the adult paddle placed over the pediatric

one, which can be removed easily by a button on side of the paddle.

When delivering the shock through the apico-sternal method (one

paddle at the apex of the heart & the other on the sternum), if the two paddles

28

come into contact with each other on the anterior chest wall, you should use the

anteriopeosterior method (one pad is placed anteriorly over the sternum, the other

is placed posteriorly between the scapulae).

Lidocaine 1 mg/kg IV/IO loading dose, 20-50 mcg/kg/min maintenance infusion

Flush medications with fluid after and elevate extremity for 10-20 seconds.

Combining medications is not recommended and may cause harm.

Routine use of sodium bicarbonate is not recommended and may cause harm.

Endotracheal tube or laryngeal mask:

Ventilate every 6 seconds without interruption of chest compression (compress

chest 100 times /min).

In neonatal resuscitation only, even in the presence of ETT, interrupt chest

compression (3 compressions: 1 breath).

Stop CPR for no longer than 10 seconds for the placement of an advanced airway.

Notes:

For septic shock, the initial fluid bolus is 20 mL/kg.

Amiodarone or lidocaine is equally acceptable for the treatment of shock-refractory

VT/VF in children.

There is no evidence to support the routine use of atropine as a premedication to

prevent bradycardia in emergency pediatric (age >1 year) intubations.

For children who are comatose in the first several days after cardiac arrest, fever should

be treated aggressively.

For comatose children resuscitated from out-of-hospital cardiac arrest (OHCA), maintain

either 5 days of normothermia or 2 days of initial continuous hypothermia (32˚C-34˚C)

followed by 3 days of normothermia.

Avoid vigorous compression of the ambu bag to prevent pneumothorax.

If the chest is not raising during giving breaths, you are not doing it the right way.

29

Pediatric Urinary Tract Infection: Summary:

IV fluids: 1-1.5 times the usual maintenance rate.

Antibiotics for 7-14 days.

Ceftriaxone: 75 mg/kg/day IV/IM ÷ 1-2

When feasible, change to oral Trimethoprim (TMP)/Sulfamethoxazol (SMX) 6-12 mg/kg of

TMP ÷ 2

Dysurea:

Increasing fluid intake to enhance urine dilution

Use of acetaminophen and NSAIDs.

Add phenazopyridine hydrochloride (Pyridium) If voiding symptoms are severe and

persistent. Do not administer phenazopyridine for longer than 48 hours, because of the

risk of methemoglobinemia, hemolytic anemia, and other adverse reactions.

Sitting in a tub of warm water for 20-30 minutes 3-4 times daily also often affords symptomatic relief.

Details:

Antibiotics: Antibiotics can be given for 7 or 14 days.

A 4-day course of an oral antibiotic agent is recommended for the treatment of cystitis.

Initial treatment:

Single dose of ceftriaxone (75 mg/kg IV/IM q12-24h).

Or gentamicin (2.5 mg/kg IV/IM as a single dose) If the patient has cephalosporin

allergy.

Patients who demonstrate a satisfactory response can be switched to an oral antibacterial

agent at therapeutic doses within the next 12-18 hours.

Parenteral Treatment:

Ceftriaxone:

50-75 mg/kg/day IV/IM as a single dose or ÷ 2

Do not use in infants < 6 wk of age; parenteral antibiotic with long half-life; may displace

bilirubin from albumin.

Cefotaxime:

150 mg/kg/day ÷ 3-4 IV/IM.

Safe to use in infants < 6 wk of age; used with ampicillin in infants aged 2-8 wk

Ampicillin:

100 mg/kg/day IV/IM ÷ 3

Used with gentamicin in neonates < 2 wk of age; for enterococci and patients allergic to

cephalosporins

Gentamicin:

Term neonates < 7 days: 3.5-5 mg/kg/dose IV q24h

Infants and children < 5 years: 2.5 mg/kg/dose IV q8h

or single daily dosing of 5-7.5 mg/kg/dose IV with normal renal function

Children ≥5 y: 2-2.5 mg/kg/dose IV q8h

or single daily dosing of 5-7.5 mg/kg/dose IV q24h with normal renal function

*Monitor blood levels and kidney function if therapy

30

Empiric oral treatment:

Trimethoprim/Sulfamethoxazole (TMP/SMZ): 30-60 mg/kg SMZ, 6-12 mg/kg TMP ÷ 2

Amoxicillin/clavulanic acid: 20-40 mg/kg ÷ 3

Cephalexin: 50-100 mg/kg ÷ 4

Cefixime: 8 mg/kg q24h

Cefpodoxime: 10 mg/kg ÷ 2

Nitrofurantoin: 5-7 mg/kg ÷ 4

Nitrofurantoin may be used to treat cystitis. It is not suitable for the treatment of

pyelonephritis, because of its limited tissue penetration.

Pediatric Pyelonephritis: Antibiotic Therapy Initial therapy with IV antibiotics for 3-4 days followed by oral therapy to complete a 10-14 day course is equivalent to 10-14 days of IV therapy. Initial oral therapy with cefixime or amoxicillin-clavulanate is equivalent to IV ceftriaxone for 3 days followed by oral therapy. IV gentamicin may be dosed daily, rather than 3 times a day, for children who require IV treatment or who are infected with multiresistant organisms. Inpatient Care Hospitalization is necessary for pyelonephritis in any of the following situations:

Toxicity or sepsis

Signs of urinary obstruction or significant underlying disease

Inability to tolerate adequate oral fluids or medications

Infants and children younger than age 2 years with febrile UTI, presumed pyelonephritis

All infants younger than age 3 months Outpatient Care: Patients treated exclusively in the outpatient setting should be reevaluated in 48 hours to ensure adequate hydration and an appropriate response to therapy. For a first infection, perform renal ultrasonography. Manage constipation and voiding dysfunction.

31

Croup: Summary for Inpatient treatment:

Oxygen for severe respiratory distress.

Dexamethasone: single dose of 0.15-0.6 mg/kg IV, IM, PO.

Nebulized epinephrine: 0.4 mg/kg (max. per dose 5 mg) of 1:1000 epinephrine solution. Dose to be repeated after 30 minutes if necessary.

Antibiotics: Lack of improvement or worsening of symptoms can be due to a secondary bacterial process.

Details: Outpatient treatment:

Treat fever with an antipyretic such as acetaminophen or ibuprofen.

Encourage oral intake.

Cool mist from a humidifier and/or sitting with the child in a bathroom (not in the shower) filled with steam generated by running hot water from the shower, help minimize symptoms.

Engaging the child in a calming activity, such as reading a favorite book, can help decrease the child's anxiety and minimize crying, which can worsen stridor.

Persistent crying increases oxygen demands

Coughing can be treated with warm, clear fluids to loosen mucus in the oropharynx

Frozen juice popsicles also can be given to ease throat soreness

Avoid smoking in the home; smoke can worsen a child's cough.

Keep the child's head elevated: o An infant can be placed in a car seat. o A child may be propped up in bed with an extra pillow. o Pillows should not be used with infants younger than 12 months of age.

At nighttime, parents/caregivers should stay in close proximity to the ill child so that they can immediately assist the child, if he or she begins to have difficulty breathing.

Monitoring for respiratory distress:

Tachypnea, tachycardia, chest wall retractions, and hypoxia.

Inpatient treatment: Steroids:

Dexamethasone 0.15-0.6 mg/kg have proven beneficial in severe, moderate, and even mild croup.

The long half-life of dexamethasone (36-54 h) often allows for a single injection or dose to cover the usual symptom duration of croup.

Dexamethasone has shown the same efficacy if administered intravenously, intramuscularly, or orally.

Nebulized epinephrine:

Its effectiveness is immediate with evidence of therapeutic benefit within the first 30 minutes and then, a lasting effect from 90-120 minutes (1.5-2 h).

Patients who receive nebulized racemic epinephrine in the emergency department should be observed for at least 3 hours post last treatment because of concerns for a return of bronchospasm, worsening respiratory distress, and/or persistent tachycardia.

32

Antibiotics:

Lack of improvement or worsening of symptoms can be due to a secondary bacterial process, which requires the use of antimicrobials for treatment.

Typically, patients with a bacterial component would have had moderate-to-severe croup assessment scores, requiring inpatient care and observation.

Oxygen:

Severe respiratory distress may require oxygenation with ventilation support, initially with a bag-valve-mask device.

If the airway and breathing require further stabilization due to increasing respiratory fatigue and hence, worsening hypercarbia (as evident by ABG), the patient should be intubated with an endotracheal tube. Intubation should be accomplished with an endotracheal tube that is 0.5-1 mm smaller than predicted.

Epiglottitis: Summary:

Paracetamol: 10-15 mg/kg X 4-6

Ceftriaxon: 50-100 mg/kg ÷ 1-2

Avoid agitating the patient. Let the patient take a position in which he or she feels comfortable.

Equipment for endotracheal intubation, cricothyroidotomy, or percutaneous transtracheal jet ventilation should be made available at the bedside.

Details: Supportive:

Avoid agitating the patient with acute epiglottitis. Let the patient take a position in which he or she feels comfortable.

Orotracheal intubation may be required with little warning. Equipment for intubation, cricothyroidotomy, or percutaneous transtracheal jet ventilation should be made available at the bedside.

Avoid therapy such as sedation, inhalers, or racemic epinephrine.

Administer supplemental humidified oxygen if possible, but do not force the patient, as the resultant agitation could worsen the condition.

Clinical pitfalls include the following: o Underestimating the potential for sudden deterioration (most common error) o Inadequate monitoring in which deterioration goes unnoticed (second most

common error) o Rushing intubation without proper support (ensure the availability of an

anesthesiologist or other individual experienced in difficult intubation) o Performing unnecessary medical procedures that result in agitation and respiratory

collapse

Indications for intubation:

Respiratory distress

Stridor

Sitting erect

Inability to swallow

Drooling

33

Airway compromise on examination

Deterioration within 8-12 hours. -Enlarged epiglottis on radiographs is associated with airway obstruction. When in doubt, securing the airway is likely the safest approach. -Obstruction in acute epiglottitis can be reduced by using dexamethasone therapy or budesonide aerosols to treat pharyngeal edema. Antibiotics:

Ceftriaxone is the antibiotic of choice.

Amoxicillin/clavulanic acid

Chloramphenicol is used if patients are allergic to penicillin and cephalosporins.

Clindamycin Therapy should begin after blood and epiglottic cultures have been obtained. Analgesic Antipyretic

Treatment of contacts:

Close contacts of patients in whom Haemophilus influenzae type b is isolated should receive rifampin prophylaxis (20 mg/kg; not to exceed 600 mg/d for 4 d).

Note: Racemic epinephrine, corticosteroids, and beta-agonists have not been proven to be helpful in epiglottitis.

Bronchiolitis: Position: Held in a parent’s arms or sitting in the position of comfort

Supportive Therapy

Humedified oxygen: using of high-flow nasal cannulas to maintain saturation higher than 90%

Hydration: patients are usually mildly dehydrated. Avoid excessive fluid administration

because of risk of SIADH.

Oral therapy is preferred. Parenteral therapy may be necessary in those patients who are

unable to take fluids by mouth or who have a respiratory rate higher than 70 breaths/min.

Bronchodilators: continue the use of bronchodilators only in patients who demonstrate

clinical improvement after initial use of these agents.

Nebulized racemic epinephrine: 0.4 mg/kg (max. per dose 5 mg) dose to be repeated after

30 minutes if necessary.

Steroids: corticosteroids may be useful in patients with history of reactive airway disease.

Steroids used are: prednisolone, methylprednisolone, & dexamethasone.

Hypertonic saline: nasal spray or nebulized 3% hypertonic saline, or nasal drops.

Nasal drops may be used 2-3 times a day for no more than 3 days.

Then perform nasal and oral suctioning. Deep oral and nasal suctioning is not routinely

needed.

Antibiotics: In patients who are febrile or who appear toxic at presentation, leukocytosis,

or positive bacterial cultures).Concomitant otitis media is common and may be treated

with oral antibiotics

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Intranasal Decongestants: Nebulized epinephrine may be primarily beneficial as a nasal decongestant. Oxymetazoline (Afrin, 12 Hour Nasal Relief): Oxymetazoline is applied directly to mucous membranes, where it stimulates alpha-adrenergic receptors and causes vasoconstriction. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac stimulation.

Pediatric Pneumonia: Summary:

Humidified inspired air

If severe respiratory distress: tracheal intubation

Fluids

Antibiotics:

First line Amoxicillin: 45 mg/kg oral X 2 for 10 days

Second- or third-generation cephalosporins:

Ceftriaxone: 50-75 mg/kg/day IV/IM ÷ 1-2 for 7-14 days

Cefotaxime: 200 mg/kg/day IV ÷ 3

Azithromycin useful in most school-aged children: 10 mg/kg oral on day 1, followed by 5

mg/kg on days 2-5

Children who are toxic appearing should receive antibiotic therapy that includes

vancomycin 40 mg/kg IV ÷ 4 along with a second- or third-generation cephalosporin.

Newborns and young infants: Initially ampicillin plus either gentamicin or cefotaxime.

Salbutamol (Ventolin): for infants or children with reactive airway disease or asthma may

react to a viral infection with bronchospasm, which responds to bronchodilators.

Details: Investigations: Chest radiography should be performed to identify the presence of an effusion/empyema.

Inpatient treatment:

Younger than 2 months or premature because of the risk of apnea in this age group.

Children younger than 5 years are hospitalized more often because of their toxic

appearance or hydration status.

It is indicated for patients who are toxic or hypoxic enough to require supplemental

oxygen.

Unless they are vomiting and toxic, they do not require intravenous fluids or antibiotics.

Management:

Emergency Respiratory Management:

Grunting, flaring, severe tachypnea, and retractions should prompt immediate

respiratory support.

Children who are in severe respiratory distress should undergo tracheal intubation if

they are unable to maintain oxygenation or have decreasing levels of consciousness.

Supportive care:

Hb should be 13-16 g/dl

Fluids

Humidified inspired air

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Chest percussion may be used (although studies have proven it is not effective)

Antibiotics:

High-dose amoxicillin is the first line.

Second- or third-generation cephalosporins

Azithromycin useful in most school-aged children

Children who are toxic appearing should receive antibiotic therapy that includes

vancomycin along with a second- or third-generation cephalosporin.

Newborns and young infants: Initially ampicillin plus either gentamicin or cefotaxime.

Steroids: Antimicrobial agents directed at killing invasive organisms may transiently worsen

inflammatory cascades.

Steroids are of greater importance in pneumonia resulting from noninfectious causes

Bronchodilators: for infants or children with reactive airway disease or asthma may react to

a viral infection with bronchospasm, which responds to bronchodilators.

Management of Pleural Effusions:

When a child with pneumonia develops a pleural effusion, thoracentesis should be performed for diagnostic and therapeutic purposes.

Notes:

Influenza pneumonia that is particularly severe or when it occurs in a high-risk patient

may be treated with zanamivir or oseltamivir.

A second-line alternative is a combination of oseltamivir plus rimantadine rather than

oseltamivir alone.

Herpes simplex virus pneumonia is treated with parenteral acyclovir.

CMV pneumonitis should be treated with intravenous ganciclovir or foscarnet.

Invasive fungal infections, such as those caused by Aspergillus or Zygomycetes species,

are treated with amphotericin B or voriconazole.

Tonsillitis and Pharyngitis Empiric Therapy: Analgesics antipyretics: for a limited time (≤ 2-3 days)

Acetaminophen 15 mg/kg X 4-6 orally

Ibuprofen 10 mg/kg X 3 orally Antibiotics:

Penicillin V 25-50 mg/kg/day ÷ 4 for 10d

Benzathine penicillin G 25,000 U/kg IM once (maximum 1.2 million U)

Amoxicillin 50 mg/kg/day PO ÷ 2-3 for 10d

Amoxicillin-clavulanate 500-875 mg PO ÷ 2 for 10d

Cefdinir 14 mg/kg PO once daily for 10d or

Cefuroxime axetil 10 mg/kg PO BID for 4-10d If penicillin allergic:

Azithromycin 12 mg/kg PO once daily for 5d or

Clarithromycin 250 mg PO q12h for 10d or

Erythromycin succinate 20 mg/kg PO X 2 for 10d

Clindamycin 7 mg/kg/day PO ÷ 3 (maximum 1.8 g/d) for 10d

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Steroids: Steroid use, dexamethasone in particular, may reduce pain and decrease symptom duration for both viral pharyngitis and streptococcal pharyngitis. This has been primarily shown in the adult population. In children, a single dose of oral dexamethasone (0.6 mg/kg) only marginally hastened the onset of pain relief. Infectoius mononucleosis: Corticosteroids may shorten the duration of fever and pharyngitis. Note: Airway obstruction due to tonsillitis may require management by placing a nasal airway device, using intravenous corticosteroids, and administering humidified oxygen.

Acute Bronchitis: Analgesics antipyretics.

Acetaminophen 15 mg/kg X 4-6 orally

Ibuprofen 10 mg/kg X 3 orally Antibiotics: In otherwise healthy individuals, the use of antibiotics has not demonstrated any consistent benefit in relieving symptoms or improving the natural history of acute bronchitis. Bronchodilators: A trial of inhaled albuterol may be worthwhile because it may provide significant relief of symptoms for many pediatric patients, not for adults. Antitussives and expectorants: They are often prescribed but have not been demonstrated to be useful. Preliminary studies suggest a possible role for Pelargonium sidoides roots extracts, in the treatment of pediatric patient with bronchitis. Supportive: Febrile patients should increase oral fluid intake.

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Pediatric Gastroenteritis: Summary:

Mild-to-moderate dehydration: 50-100 mL/kg of ORS over a 2- to 4-hour period Note:

ORS should be given slowly at the rate of 5 mL every 1-2 minutes

For patients who do not tolerate ORS by mouth, nasogastric (NG) feeding is a safe and effective alternative.

In developing countries, homemade solution of 1 tsp salt and 6 tsp sugar added to 1 liter of clean water can be used.

Severe dehydration:

RL or NS 20-30 mL/kg over 60 minutes (may be repeated according to response)

Then LR or NS 70 mL/kg over

Infants: 5 hours

Older children: 2.5 hours

Once resuscitation is complete shift to ORS.

Serum electrolytes, bicarbonate, urea/creatinine, and glucose levels should be tested. Ongoing fluid losses should be replaced with:

10 mL/kg body weight of additional ORS for each loose stool

2 mL/kg body weight of additional ORS for each episode of emesis Feeding and nutrition: Children with gastroenteritis should be returned to a normal diet as rapidly as possible. Fatty foods and foods high in simple sugars should be avoided. Medications:

Antiemetics: ondansetron (oral or IV) and metoclopramide (IV).

Antidiarrheal are contraindicated.

Probiotics are (especially Lactobacillus GG) effective in reducing the duration of diarrhea in children presenting with acute gastroenteritis.

Zinc supplementation: 10-20 mg/day for 10-14 days for all children younger than 5 years.

Antibiotics:

They are not indicated, even in cases of dysentery

Cholera: tetracycline (50 mg/kg/day PO ÷ 4 for 3 days) and doxycycline (6 mg/kg PO as a single dose). Although generally not recommended for children younger than 8 years.

Giardia: metronidazole (15 mg/kg/day PO ÷ 3. Monitoring: Children with mild-to-moderate dehydration, children younger than 6 months, or children with a high frequency of stools/vomits should be monitored in the emergency department for a minimum of 4-6 hours before discharge.

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Details:

Minimal or no dehydration:

If the child is breastfed: breastfeed more frequently.

If the child is not exclusively breastfed: then oral maintenance fluids (including clean water, soup, rice water, yogurt drink, or other culturally appropriate fluid) should be given at a rate of approximately:

<2 years: 500 mL/day

2-10 years: 1000 mL/day

>10 years: 2000 mL/day Mild-to-moderate dehydration Children should be given 50-100 mL/kg of ORS over a 2- to 4-hour period to replace their estimated fluid deficit. Severe dehydration

Bolus of 20-30 mL/kg lactated Ringer (LR) or normal saline (NS) solution over 60 minutes.

If pulse, perfusion, and/or mental status do not improve, a second bolus should be administered.

After this, the patient should be given an infusion of 70 mL/kg LR or NS over:

Infants: 5 hours

Older children: 2.5 hours

Once resuscitation is complete and mental status returns to normal, rehydration should continue with ORS as described above, as it has been shown to decrease the rate of hyponatremia and hypernatremia when compared with IV rehydration.

Serum electrolytes, bicarbonate, urea/creatinine, and glucose levels should be tested. Ongoing fluid losses should be replaced with:

10 mL/kg body weight of additional ORS for each loose stool

2 mL/kg body weight of additional ORS for each episode of emesis ORS: ORS should be given slowly at the rate of 5 mL every 1-2 minutes using a teaspoon, syringe, or medicine dropper. If tolerated by the patient, the rate of ORS delivery can be increased slowly over time For patients who do not tolerate ORS by mouth, nasogastric (NG) feeding is a safe and effective alternative. Multiple clinical trials have found NG rehydration to be as efficacious as IV rehydration, but more cost effective and with fewer adverse events. A large Cochrane meta-analysis confirmed several earlier studies showing that reduced-osmolarity ORS is better. In developing countries, homemade solution of 1 tsp salt and 6 tsp sugar added to 1 liter of clean water can be used. Feeding and nutrition In general, children with gastroenteritis should be returned to a normal diet as rapidly as possible. Formula-fed infants should restart feeding at full strength as soon as the rehydration phase is complete (ideally in 2-4 hours). Fatty foods and foods high in simple sugars should be avoided.

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Medications: Antiemetics: oral ondansetron reduced vomiting and the need for intravenous (IV) rehydration and hospital admission, IV ondansetron and metoclopramide reduced the number of episodes of vomiting and hospital admission, and dimenhydrinate suppository reduced the duration of vomiting. Antidiarrheal (ie, kaolin-pectin) and antimotility agents (ie, loperamide) are contraindicated. Probiotics are (especially Lactobacillus GG) effective in reducing the duration of diarrhea in children presenting with acute gastroenteritis. Zinc supplementation (10-20 mg/day for 10-14 days) for all children younger than 5 years with acute gastroenteritis may be effective in reducing the duration of diarrhea. Antibiotics:

They are not indicated. even in cases of dysentery may prolong the carrier state (Salmonella infection) or may increase the risk of developing hemolytic-uremic syndrome (enterohemorrhagic Escherichia coli infection).

In patients with positive stool assays or high clinical suspicion for C difficile infection, the offending antibiotic should be stopped immediately. Metronidazole (30 mg/kg/day ÷ 4 for 7 days) can be used as a first-line agent, with oral vancomycin reserved for resistant infections.

Cholera: tetracycline (50 mg/kg/day PO ÷ 4 for 3 days) and doxycycline (6 mg/kg PO as a single dose). Although generally not recommended for children younger than 8 years. Alternative treatments with good efficacy include erythromycin and ciprofloxacin.

Giardia: metronidazole (35-50 mg/kg/day PO ÷ 3) remains the drug of choice. Further Outpatient Care Parents should seek medical attention if dehydration returns, oral intake is inadequate, or if their child develops worsening abdominal pain, fever greater than 101°F, or prolonged diarrhea lasting longer than 14 days. Further Inpatient Care Inpatient admission should be considered for all children with acute gastroenteritis in the following situations:

Signs of severe dehydration are present

Caregivers are unable to manage oral rehydration or provide adequate care at home

Substantial difficulties exist in administering oral rehydration solution (ORS), such as intractable vomiting or inadequate ORS intake

Treatment failure, such as worsening diarrhea or dehydration despite adequate ORS intake, occurs

Factors are present necessitating closer observation, such as young age, decreased mental status, or uncertainty of diagnosis

Children with mild-to-moderate dehydration, children younger than 6 months, or children with a high frequency of stools/vomits should be monitored in the emergency department for a minimum of 4-6 hours before discharge.

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Bacterial Meningitis (adults and pediatrics): Dexamethasone: 0.15 mg/kg X 4 for 2-4 days, initiated 10-20 minutes before (or at least concomitant with) the first antimicrobial dose. Antibiotics: -Neonate: Ampicillin 100 mg/kg plus either:

Cefotaxime 50 mg/kg q6h

Aminoglycoside (gentamicin 2.5 mg/kg or tobramycin 2.5 mg/kg) X 3

-Pediatrics (1 month – 18 years): Vancomycin 15 mg/kg X 4 plus a third-generation cephalosporin (ceftriaxone 75-100 mg/kg X 1-2 or cefotaxime 75-100 mg/kg X 3-4)

-Adults: Vancomycin 1g X 2 plus a third-generation cephalosporin (ceftriaxone 2 g X 2 or cefotaxime 2 g X 6) Note: Vancomycin dose for adults in some references is 15 mg/kg X 2 (max 2g per dose)

Older than 50 years: Same adult regimen plus ampicillin 2 g X 6 (if Listeria is suspected) Treatment according to predisposing conditions

Pregnancy: commonly due to Listeria. Ampicillin 2 g X 6 or penicillin G 4 mU X 6

Basilar skull fracture: same as adults regimen

Penetrating trauma or post neurosurgery or CSF shunt:

Vancomycin 15 mg/kg q8h plus cefepime 2 g X 3 or ceftazidime 2 g X 3 or meropenem 2 g X 3

Immunecompromized (chemotherapy, steroids): same as elderly regimen.

Duration of therapy: o Neisseria meningitidis - 7 days o Haemophilus influenzae - 7 days o Streptococcus pneumoniae - 10-14 days o S agalactiae (GBS) - 14-21 days o Aerobic gram-negative bacilli - 21 days or 2 weeks beyond the first sterile culture

(whichever is longer) o Listeria monocytogenes - 21 days or longer

Prevention Preventive therapy has been shown to reduce mortality and morbidity and consists of the following:

Causative Organism Drug Name Age of Contact Dosage

Haemophilus influenzae

Rifampin

Adults >600 mg PO qd for 4 days

=1 month 20 mg/kg PO qd for 4 days; not to exceed 600 mg/dose

< 1 month >10 mg/kg PO qd for 4 days

Neisseria meningitidis

Rifampin

Adults 600 mg PO q12h for 2 days

>1 month 10 mg/kg PO q12h for 2 days; not to exceed 600 mg/dose

=1 month >5 mg/kg PO q12h for 2 days

Ceftriaxone >15 years 250 mg IM once

=15 years >125 mg IM once

Ciprofloxacin =18 years >500 mg PO once