We developed this publication as a method to develop consistency in the care of acutely ill and injured children who present to our medical center. As noted in the Disclaimer, while this publication may be consulted for guidance, it is not intended for use as a substitute for independent professional medical judgment, advice, diagnosis, or treatment. This publication consists of a set of 29 weight-based dosing cards for commonly used drugs in emergency, life-threatening situations as well as equipment sizing for the specific weights which are currently being used in our emergency department (ED).
As is often the case in emergency care, critically ill or injured children present without their parents, guardians or other care providers as they are transported by ground or air emergency medical services. A caveat to pediatric care is knowledge of a patient’s weight, as medication dosing is usually provided on a per kilogram basis. Equipment selection, use of cardioversion and defibrillation, and intravenous fluid administration is also based on patient weight and/or length. To remove some of the "guesswork" or estimation of patient weight, we looked retrospectively at 110,000 visits to our emergency department to develop mean weights for each age range. Our means were then compared to the growth charts provided by the CDC1 to establish a consistent weight selection based on patient age. When our mean weight at a specific age differed significantly from the published growth charts, we used our mean weight as we felt it was more representative of our community. Use of this publication in a different community must take this into consideration for their pediatric population. As an end result, each dosing page in this publication has both an age and a weight listed at the top. When a patient’s weight is known, the dosing page should be selected based on the known weight. When the weight is unknown and cannot be obtained, then the page can be selected based on age.
The Pediatric Dosage Handbook2 was used as the main resource for medication dosing recommendations. When there were areas of uncertainty, we used the published medical literature and local, expert opinions among leaders in our critical care divisions (Emergency Medicine, Critical Care, and Trauma Services) to determine final recommendations. Additionally, at times we used professional judgment and adult dosing standards when deciding on maximum doses (see Medication Dose Reference sheet for details on maximum doses selected). We would consider this book a current reflection of the best available evidence that exists at the time of its development.
On each dosing sheet the final column on the right side has notes that are specific for that medication. These "Notes" are not all encompassing, but provide important information related to administration time, repeat doses or drug pharmacodynamics. Dilutions used in this publication are based on package inserts, the Pediatric Dosage Handbook2, Pediatric Injectable Drugs3, and our institution’s standard. We were limited to drug concentrations currently stocked by our institution. Thus, if other institutions choose to use our dosing recommendations, they must ensure that the identical drug concentrations are stocked as listed in the book. Volumes listed
in the "Volume to withdraw from vial" column are rounded to a measurable amount to withdraw from the stock bottle. If a drug needs dilution prior to administration, the amount of diluent to add and resulting dose, volume, and concentration are stated in the "Preparation" column. Of note, we chose to use Normal Saline (0.9% NS) as the recommended diluent whenever possible. Infusion or administration times are based on Pediatric Advanced Life Support4 recommendations, the Pediatric Dosing Handbook2, and Pediatric Injectable Drugs3.
Drugs are separated on each dosing sheet into tables based on indication and by route of administration. The first three tables on each dosing sheet are medications to be delivered intravenously (IV) and separated into emergency drugs, drugs for rapid sequence intubation, and then additional IV medications. The next three tables on each dosing sheet provide drugs that can be delivered by the endotracheal tube (ETT), intramuscular (IM) and intranasal (IN) routes.
The equipment sizing is based on experience, local expert opinion, consultation with our subspecialists in Critical Care and Trauma Services, and recommendations from the companies and manufacturers from whom we purchase our equipment. Of note, the doses recommended for defibrillation and cardioversion are specifically based on available Joules on our defibrillators. We have the Phillips HeartStart MRx ALS Monitor/Defibrillator which, once over 10 Joules, only allows selection of the following specific doses: 15, 20, 30, 50, 70, 100, 120, 150, 170, or 200 Joules. Thus, the recommendations on each dosing page are rounded to the nearest available dose. An example is for a 3-year old patient with an estimated weight of 16 kg. The dosing recommendation for an initial defibrillation attempt is 2 Joules/kg, requiring 16 kg x 2 J/kg = 32 J. As our defibrillators do not allow us to select 32 J, we recommended 30 J for the first defibrillation attempt