PALS Provider: Course

Medications in PALS: Dosing & Use in Pediatric Emergencies

Medications play a critical role in pediatric resuscitation by supporting circulation, treating arrhythmias, and stabilizing patients in shock or cardiac arrest. In PALS, accurate weight-based dosing is essential to maximize effectiveness and minimize harm.

Key Goals of PALS Pharmacologic Management

  • Support circulation and oxygen delivery
  • Correct life-threatening arrhythmias
  • Restore hemodynamic stability
  • Treat the underlying cause of deterioration

1. Cardiac Arrest Medications

Epinephrine is the cornerstone drug for cardiac arrest and bradycardia with poor perfusion.

  • Indications: Asystole, PEA, VF/pVT, symptomatic bradycardia
  • IV/IO Dose: 0.01 mg/kg (1:10,000) every 3–5 min (max: 1 mg)
  • ETT Dose: 0.1 mg/kg (1:1,000) diluted in 3–5 mL NS

Amiodarone is used for shock-refractory VF or pulseless VT.

  • IV/IO Dose: 5 mg/kg over 3–5 min (max 300 mg); may repeat 2x
  • Alternative: Lidocaine 1 mg/kg IV/IO (max 100 mg)

2. Bradycardia Medications

Atropine is used if bradycardia is due to vagal tone or AV block.

  • IV/IO Dose: 0.02 mg/kg (min 0.1 mg, max 0.5 mg); may repeat once
  • Not first-line — only after oxygenation + epinephrine

3. Tachycardia Medications

Adenosine is first-line for stable SVT with a narrow QRS.

  • Initial Dose: 0.1 mg/kg IV push (max 6 mg)
  • Second Dose: 0.2 mg/kg (max 12 mg)
  • Flush immediately after with saline

Amiodarone or Procainamide may be used for stable VT.

  • Amiodarone: 5 mg/kg IV over 20–60 min (max 300 mg)
  • Procainamide: 15 mg/kg IV over 30–60 min
  • Warning: Never combine amiodarone and procainamide

4. Shock & Hypotension: Vasoactive Drugs

Condition First-Line Drug Dose
Hypotensive Shock Epinephrine or Dopamine Epi: 0.1–0.3 mcg/kg/min
Dopa: 5–10 mcg/kg/min
Cardiogenic Shock Dobutamine or Epinephrine Dobut: 5–20 mcg/kg/min
Septic Shock (Cold) Epinephrine 0.1–0.3 mcg/kg/min
Septic Shock (Warm) Norepinephrine 0.05–0.1 mcg/kg/min

5. Fluid Resuscitation

  • Indication: Hypovolemic, distributive, or septic shock
  • Dose: 20 mL/kg boluses of NS or LR over 5–10 minutes
  • In cardiogenic shock: use smaller boluses (5–10 mL/kg)

6. Metabolic & Electrolyte Medications

Dextrose (for hypoglycemia)

  • Neonates: D10W 5 mL/kg
  • Infants/Children: D25W 2 mL/kg
  • Adolescents: D50W 1 mL/kg

Calcium Gluconate (for hypocalcemia or hyperkalemia)

  • 60 mg/kg IV (max 2 g)
  • Calcium Chloride (more potent): 20 mg/kg (max 1 g)
  • Warning: Never mix with bicarbonate

Sodium Bicarbonate (for severe acidosis or hyperkalemia)

  • 1 mEq/kg IV slow push
  • Use only in prolonged arrest or pH <7.1

PALS Medication Summary Table

Drug Indication Dose
Epinephrine Arrest, bradycardia, shock 0.01 mg/kg IV q3–5 min
Atropine Bradycardia (vagal, AV block) 0.02 mg/kg IV
Adenosine SVT 0.1 → 0.2 mg/kg IV push
Amiodarone VF, VT 5 mg/kg IV
Dextrose Hypoglycemia D10, D25, or D50 by age