American AMERICAN

ASSOCIATION
Heart ofCRITICAL-CARE
Association® NURSES

PALS
Vital Signs in Children
Respiratory Rate
Heart Rate (per minute) (breaths/min)*
Sleeping Age Rate
Age Awake Rate Rate Infant 30 to 60
Newborn to 3 months 85 to 205 80 to 160 Toddler 24 to 40
3 months to 2 years 100 to 190 75 to 160 Preschooler 22 to 34
2 to 10 years 60 to 140 60 to 90 School-aged child 18 to 30
>10 years 60 to 100 60 to 90 Adolescent 12 to 16

Definition of Hypotension by Systolic Blood Pressure and Age

Age Systolic Blood Pressure (mm Hg)
Term neonates (0 to 28 days) <60
Infants (1 to 12 months) <70
Children 1 to 10 years (5th BP percentile) <70 + (age in years x 2)
Children >10 years <90

Modified Glasgow Coma Scale for Infants and Children

Child Infant Score
Eye Spontaneous Spontaneous 4
opening To speech To speech 3
To pain To pain 2
None None 1
Best Oriented, appropriate Coos and babbles 5
verbal Confused Irritable, cries 4
response Inappropriate words Cries in response to pain 3
Incomprehensible sounds Moans in response to pain 2
None None 1
Best Obeys commands Moves spontaneously and purposely 6
motor Localizes painful stimulus Withdraws in response to touch 5
response Withdraws in response to pain Withdraws in response to pain 4
Flexion in response to pain Abnormal flexion posture to pain 3
Extension in response to pain Abnormal extension posture to pain 2
None None 1
*Reproduced from Hazinski MF. Children are different. In: Manual of Pediatric Critical Care. 1999:1-13. From
Hazinski MF. Children are different. In: Nursing Care of the Critically III Child. 2nd ed. 1992:1-17. Both © Elsevier.
Modified from Davis RJ et al. Head and spinal cord injury. In: Rogers MC, ed. Textbook of Pediatric Intensive Care.
1987:649-699, © Lippincott Williams & Wilkins; James HE, Trauner DA. The Glasgow Coma Scale. In: James HE et
al, eds. Brain Insults in Infants and Children. 1985:179-182; and Hazinski MF. Neurologic disorders. In: Nursing Care
of the Critically III Child. 2nd ed. 1992:521-628, © Elsevier.
If the patient is intubated, unconscious, or preverbal, the most important part of this scale is motor response. Providers should
carefully evaluate this component.
90-1053 10/11 © 2011 American Heart Association ISBN 978-1-61669-110-3 Printed in the USA
Summary of Steps of CPR
for Adults, Children, and Infants

Recommendations
Component
Adults Children Infants

Unresponsive (for all ages)

No breathing
or no normal
Recognition No breathing or only gasping
breathing
(ie, only gasping)

No pulse felt within 10 seconds

CPR sequence Chest compressions, Airway, Breathing (C-A-B)

Compression
At least 100/min
rate

At least At least
At least 1 1
Compression /3 AP diameter /3 AP diameter
2 inches 1
depth About 2 inches About 1 /2 inches
(5 cm)
(5 cm) (4 cm)

Chest wall Allow complete recoil between compressions

recoil Rotate compressors every 2 minutes

Compression Minimize interruptions in chest compressions

interruptions Attempt to limit interruptions to <10 seconds

Airway Head tilt chin lift (suspected trauma: jaw thrust)

Compression- 30:2
to-ventilation Single rescuer
30:2
ratio (until
1 or 2 rescuers 15:2
advanced
airway placed) 2 rescuers

1 breath every 6-8 seconds (8-10 breaths/min)

Ventilations
with advanced Asynchronous with chest compressions
airway About 1 second per breath
Visible chest rise

Attach and use AED as soon as available.

Minimize interruptions in chest compressions before and
Defibrillation
after shock; resume CPR beginning with compressions
immediately after each shock.

Abbreviations: AED, automated external defibrillator; AP, anterior-posterior; CPR, cardiopulmonary

resuscitation.
Pediatric Septic Shock Algorithm

Recognize altered mental status and perfusion

Give oxygen and support vantilation; establish vascular access
and begin resuscitation according to PALS guidelines
Consider VBG or ABG, lactate, glucose, ionized calcium, cultures, CBC
First hour

First hour: Push repeated 20 mL/kg boluses of isotonic crystalloid to treat

shock. Give up to 3, 4, or more boluses unless rales, respiratory distress, or
hepatomegaly develops.
Additional therapies:
Correct hypoglycemia and hypocalcemia
Administer first-dose antibiotics STAT
Consider ordering STAT vasopressor drip and stress-dose hydrocortisone*
Establish second vascular access site if vasoactive infusion anticipated

Yes Fluid responsive (ie, normalized perfusion/hemodynamics)? No

Begin vasoactive drug therapy and titrate to correct

hypotension/poor perfusion; consider establishing
Consider ICU arterial and central venous access
monitoring Normotensive: Begin dopamine
Hypotensive vasodilated (warm) shock:
Begin norepinephrine
Hypotensive vasoconstricted (cold) shock:
Begin epinephrine rather than norepinephrine

Evaluate Scvo2; goal Scvo2 sat >70%?

Scvo2 >70%, low Scvo2 <70%, normal Scvo2 <70%, low BP and
BP ("warm shock") BP but poor perfusion poor perfusion ("cold shock")

Additional fluid Transfuse to Hgb >10 g/dL Transfuse to Hgb >10 g/dL
boluses Optimize arterial oxygen Optimize arterial oxygen
Norepinephrine saturation saturation
vasopressin Additional fluid boluses Additional fluid boluses
Consider milrinone or Consider epinephrine
nitroprusside or dobutamine +
Consider dobutamine norepinephrine

*Fluid-refractory and dopamine- or norepinephrine-dependent shock

defines patient at risk for adrenal insufficiency.

If adrenal insufficiency is suspected Draw baseline cortisol; consider

give hydrocortisone ~2 mg/kg bolus IV; ACTH stimulation test if unsure
maximum 100 mg of need for steroids

Modified from Brierley J, Carcillo JA, Choong K, et al. Crit Care Med. 2009;37(2):666-688.
Drugs Used in PALS

Drug Indications/Dosages
Adenosine SVT
0.1 mg/kg IV/IO rapid push (max 6 mg), second dose 0.2 mg/kg IV/IO rapid push
(max 12 mg)
Albumin Shock, trauma, burns
0.5 to 1 g/kg (10 to 20 mL/kg of 5% solution) IV/IO rapid infusion
Albuterol Asthma, anaphylaxis (bronchospasm), hyperkalemia
MDI: 4 to 8 puffs via inhalation q 20 minutes PRN with spacer (OR ET if intubated)
Nebulizer: 2.5 mg/dose (wt <20 kg) OR 5 mg/dose (wt>20 kg) via inhalation q
20 minutes PRN
Continuous nebulizer: 0.5 mg/kg per hour via inhalation (max 20 mg/h)
Amiodarone SVT, VT (with pulses)
5 mg/kg IV/IO load over 20 to 60 minutes (max 300 mg), repeat to daily max 15 mg/kg
(2.2 g in adolescents)
Pulseless arrest (ie, VF/pulseless VT)
5 mg/kg IV/IO bolus (max 300 mg), repeat to daily max 15 mg/kg (2.2 g in adolescents)
Atropine sulfate Bradycardia (symptomatic)
0.02 mg/kg IV/IO (min dose 0.1 mg, max single dose child 0.5 mg, max single dose
adolescent 1 mg), may repeat dose once, max total dose child 1 mg, max total dose
adolescent 3 mg
0.04 to 0.06 mg/kg ET
Toxins/overdose (eg, organophosphate, carbamate)
<12 years: 0.02 to 0.05 mg/kg IV/IO initially, then repeat IV/IO q 20 to 30 minutes
until muscarinic symptoms reverse
>12 years: 2 mg IV/IO initially, then 1 to 2 mg IV/IO q 20 to 30 minutes until
muscarinic symptoms reverse
Calcium Hypocalcemia, hyperkalemia, hypermagnesemia, calcium channel blocker overdose
chloride 10% 20 mg/kg (0.2 mL/kg) IV/IO slow push during arrest, repeat PRN
Dexamethasone Croup
0.6 mg/kg PO/IM/IV (max 16 mg)
Dextrose Hypoglycemia
(glucose) 0.5 to 1 g/kg IV/IO (D25 W 2 to 4 mL/kg; D10W 5 to 10 mL/kg)
Diphen- Anaphylactic shock
hydramine 1 to 2 mg/kg IV/IO/IM q 4 to 6 hours (max single dose 50 mg)
Dobutamine Congestive heart failure, cardiogenic shock
2 to 20 mcg/kg per minute IV/IO infusion; titrate to desired effect
Dopamine Cardiogenic shock, distributive shock
2 to 20 mcg/kg per minute IV/IO infusion; titrate to desired effect
Epinephrine Pulseless arrest, bradycardia (symptomatic)
0.01 mg/kg (0.1 mL/kg of 1:10 000 standard concentration) IV/IO q 3 to 5 minutes
(max single dose 1 mg)
0.1 mg/kg (0.1 mL/kg of 1:1000 high concentration) ET q 3 to 5 minutes
Hypotensive shock
0.1 to 1 mcg/kg per minute IV/IO infusion (consider higher doses if needed)
Anaphylaxis
IM autoinjector 0.3 mg (for patient weighing >30 kg) or IM junior autoinjector 0.15 mg
(for patient weighing 10 to 30 kg)
0.01 mg/kg (0.01 mL/kg of 1:1000 high concentration) IM q 15 minutes PRN (max
single dose 0.3 mg)
0.01 mg/kg (0.1 mL/kg of 1:10 000 standard concentration) IV/IO q 3 to 5 minutes
(max single dose 1 mg) if hypotensive
0.1 to 1 mcg/kg per minute IV/IO infusion if hypotension persists despite fluids and
IM injection
Asthma
0.01 mg/kg (0.01 mL/kg) 1:1000 subcutaneously q 15 minutes (max 0.3 mg or 0.3 mL)
Croup
0.25 to 0.5 mg racemic solution (2.25%) mixed in 3 mL NS via inhalation
3 mL of 1:1000 epinephrine mixed with 3 mL NS (which yields 0.25 mL racemic
epinephrine solution) via inhalation
Drugs Used in PALS (continued)

Drug Indications/Dosages
Etomidate RSI
0.2 to 0.4 mg/kg IV/IO infused over 30 to 60 seconds (max 20 mg) will produce rapid
sedation that lasts for 10 to 15 minutes
Hydrocortisone Adrenal insufficiency
2 mg/kg IV bolus (max 100 mg)
Ipratropium Asthma
bromide 250 to 500 mcg via inhalation q 20 minutes PRN x 3 doses
Lidocaine VF/pulseless VT, wide-complex tachycardia (with pulses)
1 mg/kg IV/IO bolus
Maintenance: 20 to 50 mcg/kg per minute IV/IO infusion (repeat bolus dose if
infusion initiated >15 minutes after initial bolus)
2 to 3 mg/kg ET
Magnesium Asthma (refractory status asthmaticus), torsades de pointes, hypomagnesemia
sulfate 25 to 50 mg/kg IV/IO bolus (max 2 g) (pulseless VT) OR over 10 to 20 minutes
(VT with pulses) OR slow infusion over 15 to 30 minutes (status asthmaticus)
Methyl- Asthma (status asthmaticus), anaphylactic shock
prednisolone Load: 2 mg/kg IV/IO/IM (max 60 mg); only use acetate salt IM
Maintenance: 0.5 mg/kg IV/IO q 6 hours (max 120 mg/d)
Milrinone Myocardial dysfunction and increased SVR/PVR
Loading dose: 50 mcg/kg IV/IO over 10 to 60 minutes followed by 0.25 to
0.75 mcg/kg per minute IV/IO infusion
Naloxone Narcotic (opiate) reversal
Total reversal required (for narcotic toxicity secondary to overdose): 0.1 mg/kg
IV/IO/IM/subcutaneous bolus q 2 minutes PRN (max 2 mg)
Total reversal not required (eg, for respiratory depression associated with therapeutic
narcotic use): 1 to 5 mcg/kg IV/IO/IM/subcutaneously; titrate to desired effect
Maintain reversal: 0.002 to 0.16 mg/kg per hour IV/IO infusion
Nitroglycerin Congestive heart failure, cardiogenic shock
Initiate at 0.25 to 0.5 mcg/kg per minute IV/IO infusion; titrate by 1 mcg/kg per
minute q 15 to 20 minutes as tolerated. Typical dose range 1 to 5 mcg/kg per
minute q 15 to 20 minutes as tolerated. Typical dose range 1 to 5 mcg/kg per
In adolescents, start with 5 to 10 mcg per minute (not per kilogram per minute) and
increase to max 200 mcg per minute
Nitroprusside Cardiogenic shock (ie, associated with high SVR), severe hypertension
0.3 to 1 mcg/kg per minute initial dose; then titrate up to 8 mcg/kg per minute as needed
Norepinephrine Hypotensive (usually distributive) shock (ie, low SVR and fluid refractory)
0.1 to 2 mcg/kg per minute IV/IO infusion; titrate to desired effect
Procainamide SVT, atrial flutter, VT (with pulses)
15 mg/kg IV/IO load over 30 to 60 minutes (do not use routinely with amiodarone)
Prostaglandin Ductal-dependent congenital heart disease (all forms)
E1 (PGE1) 0.05 to 0.1 mcg/kg per minute IV/IO infusion initially, then 0.01 to 0.05 mcg/kg per
minute IV/IO
Sodium Metabolic acidosis (severe), hyperkalemia
bicarbonate 1 mEq/kg IV/IO slow bolus
Sodium channel blocker overdose (eg, tricyclic antidepressant)
1 to 2 mEq/kg IV/IO bolus until serum pH is >7.45 (7.50 to 7.55 for severe poisoning)
followed by IV/IO infusion of 150 mEq NaHCO3/L solution titrated to maintain alkalosis
Terbutaline Asthma (status asthmaticus), hyperkalemia
0.1 to 10 mcg/kg per minute IV/IO infusion; consider 10 mcg/kg IV/IO load over
5 minutes
10 mcg/kg subcutaneously q 10 to 15 minutes until IV/IO infusion is initiated (max
single dose 0.4 mg)
Vasopressin Cardiac arrest
0.4 to 1 unit/kg bolus (max 40 units)
Catecholamine-resistant hypotension
0.0002 to 0.002 unit/kg per minute (0.2 to 2 milliunits/kg per minute) continuous infusion
 GRAY* PINK RED PURPLE YELLOW WHITE BLUE ORANGE GREEN
Equipment Small Infant Infant Toddler Small Child Child Child Large Child Adult
3-5 kg
6-7 kg 8-9 kg 10-11 kg 12-14 kg 15-18 kg 19-23 kg 24-29 kg 30-36 kg

Resuscitation
Infant/child Infant/child Child Child Child Child Child Adult
bag

Oxygen mask Pediatric/

Pediatric Pediatric Pediatric Pediatric Pediatric Pediatric Pediatric
(NRB) adult

Oral airway 50 50 60 60 60 70 80 80
(mm)

Laryngoscope 2 Straight 2 Straight 3 Straight

1 Straight 1 Straight 1 Straight 2 Straight 2 Straight
Resuscitation Tape

blade (size) or curved or curved or curved

ET tube 3.5 Uncuffed 3.5 Uncuffed 4.0 Uncuffed 4.5 Uncuffed 5.0 Uncuffed 5.5 Uncuffed
6.0 Cuffed 6.5 Cuffed
(mm) 3.0 Cuffed 3.0 Cuffed 3.5 Cuffed 4.0 Cuffed 4.5 Cuffed 5.0 Cuffed

ET tube 3 kg 9-9.5
insertion 4 kg 9.5-10 10.5-11 10.5-11 11-12 13.5 14-15 16.5 17-18 18.5-19.5
length (cm) 5 kg 10-10.5

Suction 8 8 10 10 10 10 10 10-12
catheter (F)

Neonatal Infant/child Infant/child Child Child Child Child Child Small adult
BP cuff
#5/infant

IV catheter (ga) 22-24 22-24 20-24 18-22 18-22 18-20 18-20 16-20
Pediatric Color-Coded Length-Based

IO (ga) 18/15 18/15 15 15 15 15 15 15

NG tube (F) 5-8 5-8 8-10 10 10 12-14 14-18 16-18

Urinary 8 8 8-10 10 10-12 10-12 12 12

5
catheter (F)

Chest tube (F) 10-12 10-12 16-20 20-24 20-24 24-32 28-32 32-38

Abbreviations: BP, blood pressure; ET, endotracheal; F, French; IO, intraosseous; IV, intravenous; NG, nasogastric; NRB, nonrebreathing.
*For Gray column, use Pink or Red equipment sizes if no size is listed.
Per 2010 AHA Guidelines, in the hospital cuffed or uncuffed tubes may by used (see below for sizing of cuffed tubes).
Adapted from Broselow™ Pediatric Emergency Tape. Distributed by Armstrong Medical Industries, Lincolnshire, IL. Copyright 2007 Vital Signs, Inc. All rights reserved.
Pediatric Cardiac Arrest Algorithm

Shout for Help/Activate Emergency Response

1
Start CPR
Give oxygen
Attach monitor/defibrillator

Yes No
2 Rhythm shockable?

VF/VT 9 Asystole/PEA

3
Shock

4
CPR 2 min
IO/IV access

No
Rhythm shockable?

Yes
5
Shock

10
6 CPR 2 min
CPR 2 min
IO/IV access
Epinephrine every 3-5 min
Epinephrine every 3-5 min
Consider advanced airway
Consider advanced airway

No Yes
Rhythm shockable? Rhythm shockable?

Yes
7 Shock No

8 11
CPR 2 min CPR 2 min
Amiodarone Treat reversible causes
Treat reversible causes

No Yes
Rhythm shockable?
12
Asystole/PEA 10 or 11
Go to
Organized rhythm check pulse
5 or 7
Pulse present (ROSC) post cardiac arrest care
Doses/Details for the
Pediatric Cardiac Arrest Algorithm

CPR Quality Advanced Airway

Push hard ( / of anterior-posterior
>1 3 Endotracheal intubation or
diameter of chest) and fast (at least supraglottic advanced airway
100/min) and allow complete chest Waveform capnography or
recoil capnometry to confirm and monitor
Minimize interruptions in ET tube placement
compressions Once advanced airway
Avoid excessive ventilation in place, give 1 breath
Rotate compressor every every 6-8 seconds
2 minutes (8-10 breaths per minute).
If no advanced airway, 15:2
Return of Spontaneous
compression-ventilation ratio.
Circulation (ROSC)
If advanced airway, 8-10 breaths
Pulse and blood pressure
per minute with continuous chest
Spontaneous arterial
compressions
pressure waves with
Shock Energy intra-arterial monitoring
for Defibrillation
Reversible Causes
First shock 2 J/kg,
Hypovolemia
second shock 4 J/kg,
Hypoxia
subsequent shocks >4 J/kg,
Hydrogen ion (acidosis)
maximum 10 J/kg or adult dose.
Hypoglycemia
Drug Therapy Hypo-/hyperkalemia
Epinephrine IO/IV Dose: Hypothermia
0.01 mg/kg (0.1 mL/kg of 1:10 000 Tension pneumothorax
concentration). Repeat every 3-5 Tamponade, cardiac
minutes. If no IO/IV access, may Toxins
give endotracheal dose: Thrombosis, pulmonary
0.1 mg/kg (0.1 mL/kg of 1:1000 Thrombosis, coronary
concentration).
Amiodarone IO/IV Dose:
5 mg/kg bolus during cardiac
arrest. May repeat up to 2 times
for refractory VF/pulseless VT.
PALS Systematic Approach Algorithm

Initial Impression
(consciousness, breathing, color)

Is child unresponsive with no breathing or only gasping?

Yes No

Shout for Help/

Activate Emergency
Response
(as appropriate
for setting)

Yes Open airway and begin

Is there
a pulse? ventilation and oxygen
as available

No

Is the pulse <60/min

Yes No
with poor perfusion
despite oxygenation
and ventilation?

If at any time
you identify
cardiac arrest
Evaluate
Start CPR Primary assessment
(C-A-B) Secondary assessment
Diagnostic tests

Go to
Pediatric Cardiac Arrest Intervene
Algorithm
Identify

After ROSC, begin

Evaluate-Identify-Intervene
sequence (right column)
Pediatric Bradycardia With a Pulse
and Poor Perfusion Algorithm

Identify and treat underlying cause

Maintain patent airway; assist breathing as necessary
Oxygen
Cardiac monitor to identify rhythm; monitor blood pressure and oximetry
IO/IV access
12-Lead ECG if available; don't delay therapy

No Cardiopulmonary Cardiopulmonary
compromise Compromise
continues? Hypotension
Acutely altered mental
status
Yes Signs of shock

CPR if HR <60/min
with poor perfusion despite
oxygenation and ventilation

Support ABCs
Give oxygen No Bradycardia
Observe persists?
Consider expert
consultation
Yes
Doses/Details
Epinephrine
Epinephrine IO/IV Dose:
Atropine for increased vagal
0.01 mg/kg (0.1 mL/kg
tone or primary AV block of 1:10 000 concentration).
Consider transthoracic Repeat every 3-5 minutes.
pacing/transvenous pacing If IO/IV access not
Treat underlying causes available but endotracheal
(ET) tube in place, may
give ET dose: 0.1 mg/kg
(0.1 mL/kg of 1:1000).

If pulseless arrest Atropine IO/IV Dose:

develops, go to Cardiac 0.02 mg/kg. May repeat
once. Minimum dose
Arrest Algorithm
0.1 mg and maximum
single dose 0.5 mg.
Pediatric Tachycardia With a Pulse
and Poor Perfusion Algorithm

Doses/Details
Identify and treat underlying cause
Synchronized
Maintain patent airway; assist breathing as necessary Cardioversion:
Oxygen Begin with 0.5-1
Cardiac monitor to identify rhythm; monitor blood J/kg; if not effective,
pressure and oximetry increase to 2 J/kg.
Sedate if needed,
IO/IV access
but don't delay
12-Lead ECG if available; don't delay therapy cardioversion.
Adenosine
Narrow Wide IV/IO Dose:
Evaluate First dose:
(<0.09 sec) (>0.09 sec)
0.1 mg/kg rapid
QRS bolus (maximum:
duration 6 mg). Second
Evaluate rhythm dose: 0.2 mg/kg
rapid bolus
with 12-lead ECG (maximum second
or monitor dose: 12 mg).
Amiodarone
IV/IO Dose:
5 mg/kg over
Probable Probable Possible 20-60 minutes
sinus supraventricular ventricular or
tachycardia tachycardia tachycardia Procainamide
IV/IO Dose:
Compatible Compatible history
15 mg/kg over
history (vague, nonspecific); 30-60 minutes
consistent with history of abrupt Do not routinely
known cause rate changes administer
P waves P waves absent/ amiodarone and
present/normal abnormal procainamide
Variable R-R; HR not variable together.
constant PR
Infants: Infants: rate usually Cardiopulmonary
rate usually >220/min compromise?
<220/min Hypotension No
Children: rate Children: rate Acutely altered
usually<180/min usually >180/min mental status
Signs of shock

Yes

Search for Consider Synchronized Consider

and vagal cardioversion adenosine
treat cause maneuvers if rhythm regular
(No delays) and QRS
monomorphic

If IO/IV access present, give adenosine Expert

OR consultation
If IO/IV access not available, or if adenosine advised
ineffective, synchronized cardioversion Amiodarone
Procainamide
PALS Postresuscitation Care

Management of Shock After ROSC Estimation of

Maintenance Fluid
Optimize Ventilation and Oxygenation Requirements
Titrate FIO2 to maintain oxyhemoglobin saturation Infants <10 kg:
94%-99%; if possible, wean FIO2 if saturation is 100% 4 mL/kg per hour
Consider advanced airway placement and Example: For an 8-kg infant,
waveform capnography estimated maintenance
fluid rate
4 mL/kg per hour x 8 kg
32 mL per hour
Assess for and *Possible
Children 10-20 kg:
Treat Persistent Contributing Factors 4 mL/kg per hour for the
Shock Hypovolemia first 10 kg 2 mL/kg per
Identify, treat Hypoxia hour for each kg above 10 kg
contributing Hydrogen ion (acidosis) Example: For a 15-kg child,
factors.* Hypoglycemia estimated maintenance
Consider 20 mL/kg Hypo-/hyperkalemia fluid rate
IV/IO boluses of Hypothermia (4 mL/kg per hour x
isotonic crystalloid. Tension pneumothorax 10 kg) (2 mL/kg per
Consider smaller Tamponade, cardiac hour x 5 kg)
boluses (eg, Toxins 40 mL/hour 10 mL/hour
10 mL/kg) if poor Thrombosis, pulmonary 50 mL/hour
cardiac function Thrombosis, coronary Children >20 kg: 4 mL/kg
suspected. Trauma per hour for the first 10 kg
Consider the need 2 mL/kg per hour for kg
for inotropic and/ 11-20 1 mL/kg per hour for
or vasopressor each kg above 20 kg.
support for fluid- Example: For a 28-kg child,
refractory shock. estimated maintenance
fluid rate
(4 mL/kg per hour x
10 kg) (2 mL/kg per
hour x 10 kg) (1 mL/kg
Hypotensive Shock Normotensive Shock per hour x 8 kg)
40 mL per hour 20 mL
Epinephrine Dobutamine
per hour 8 mL per hour
Dopamine Dopamine 68 mL per hour
Norepinephrine Epinephrine
Following initial stabilization,
Milrinone adjust the rate and composi-
tion of intravenous fluids
based on the patient's clinical
condition and state of hydra-
tion. In general, provide a con-
Monitor for and treat agitation and seizures tinuous infusion of a dextrose-
Monitor for and treat hypoglycemia containing solution for infants.
Assess blood gas, serum electrolytes, calcium Avoid hypotonic solutions in
If patient remains comatose after resuscitation critically ill children; for most
from cardiac arrest, consider therapeutic patients use isotonic fluid such
as normal saline (0.9% NaCI) or
hypothermia (32-34°C)
Iactated Ringer's solution with
Consider consultation and patient transport to or without dextrose, based on
tertiary care center the child's clinical status.