HW medicine · 14 min read · 2,740 words

Pharmacy Supply Management Training Data

- Adult Dose: 500-1000 mg PO/IV Q4-6H, max 3-4 g/day (3 g/day if >65 yr) - Pediatric Dose: 15 mg/kg PO Q4-6H, max 5 doses/day; <2 yr: 10-15 mg/kg - Route: PO, IV, rectal - Frequency: Q4-6H - Max Daily Dose: 3-4 g - Major SE: Hepatotoxicity at overdose, rash, nausea - Contraindications: Severe...

By William Le, PA-C

Pharmacy Supply Management Training Data

Small Hospital/Clinic Operations Manual

1. ESSENTIAL MEDICATIONS LIST

1.1 ANALGESICS

Acetaminophen (Paracetamol)

  • Adult Dose: 500-1000 mg PO/IV Q4-6H, max 3-4 g/day (3 g/day if >65 yr)
  • Pediatric Dose: 15 mg/kg PO Q4-6H, max 5 doses/day; <2 yr: 10-15 mg/kg
  • Route: PO, IV, rectal
  • Frequency: Q4-6H
  • Max Daily Dose: 3-4 g
  • Major SE: Hepatotoxicity at overdose, rash, nausea
  • Contraindications: Severe hepatic disease, G6PD deficiency, hypersensitivity
  • Notes: Safest antipyretic in pregnancy (Cat B). Monitor LFTs with chronic use

Ibuprofen

  • Adult Dose: 200-400 mg PO Q4-6H (OTC), 400-800 mg Q6-8H (Rx), max 3200 mg/day
  • Pediatric Dose: 4-10 mg/kg Q6-8H, max 40 mg/kg/day or 1200 mg/day
  • Route: PO
  • Frequency: Q4-6H to Q6-8H
  • Max Daily Dose: 3200 mg
  • Major SE: GI ulceration, renal impairment, cardiovascular events, angioedema
  • Contraindications: Active GI bleeding, CrCl <30, perioperative CABG, pregnancy (3rd tri)
  • Notes: Give with food. Increased CV risk in elderly with chronic use

Morphine Sulfate

  • Adult Dose: 5-10 mg IV/IM/SC Q2-4H; 10-30 mg PO Q3-4H (immediate release), Q12H (ER)
  • Pediatric Dose: 0.05-0.2 mg/kg IV Q2-4H; 0.3-0.6 mg/kg PO Q3-4H
  • Route: IV, IM, SC, PO, rectal
  • Frequency: Q2-4H acute; Q3-4H chronic
  • Max Daily Dose: Titrate to effect
  • Major SE: Respiratory depression, hypotension, constipation, pruritis, dependence
  • Contraindications: Respiratory depression, increased ICP, paralytic ileus, hypersensitivity
  • Notes: Reduce 25-50% in elderly/renal failure. Use naloxone for overdose (0.4-2 mg IV Q2-3min)

Ketamine

  • Adult Dose: 1-2 mg/kg IV (induction), 0.5-1 mg/kg IM; 1-2 mcg/kg/min IV infusion (analgesia)
  • Pediatric Dose: 0.5-1 mg/kg IV, 4-5 mg/kg IM, 1-2 mcg/kg/min infusion
  • Route: IV, IM, intranasal (emerging)
  • Frequency: Single dose or infusion
  • Major SE: Dissociation, hypertension, tachycardia, increased ICP, laryngospasm, psychomimetic effects
  • Contraindications: Uncontrolled hypertension, coronary artery disease, hypersensitivity, conditions where ICP increase dangerous
  • Notes: Maintains airway reflexes better than opioids. Use benzodiazepine for emergence delirium

Lidocaine

  • Adult Dose: 1-1.5 mg/kg IV bolus (max 100 mg), then 1-4 mg/min infusion; Local: 4.5 mg/kg without epi, 7 mg/kg with epi
  • Pediatric Dose: 0.5-1 mg/kg IV; local 4.5 mg/kg max
  • Route: IV, infiltration, topical, inhalation, epidural
  • Frequency: Single to continuous
  • Major SE: Cardiac arrhythmias, seizures, methemoglobinemia, cardiac arrest
  • Contraindications: 2nd/3rd degree AV block, Wolff-Parkinson-White, hypersensitivity, severe hepatic disease
  • Notes: Requires cardiac monitoring. Reduce dose 50% in elderly/liver disease

1.2 ANTIBIOTICS

Amoxicillin

  • Adult Dose: 250-500 mg PO Q8H or 875 mg Q12H; max 3-4 g/day
  • Pediatric Dose: 25-45 mg/kg/day divided Q8H; 90 mg/kg/day for otitis media
  • Route: PO
  • Frequency: Q8H or Q12H
  • Max Daily Dose: 3-4 g
  • Major SE: Rash (maculopapular), diarrhea, nausea, pseudomembranous colitis, anaphylaxis
  • Contraindications: Penicillin allergy, mononucleosis (high rash risk), severe renal impairment
  • Notes: Beta-lactamase resistant. Safe in pregnancy (Cat A). Take with/without food

Ceftriaxone

  • Adult Dose: 500 mg-2 g IV/IM Q12H; up to 4 g/day for meningitis
  • Pediatric Dose: 50-80 mg/kg/day divided Q12H; meningitis 80-100 mg/kg/day
  • Route: IV, IM
  • Frequency: Q12H
  • Max Daily Dose: 2-4 g
  • Major SE: Rash, diarrhea, phlebitis, hemolytic anemia, biliary sludge, C. diff
  • Contraindications: Cephalosporin allergy, septic arthritis (if concurrent meningitis)
  • Notes: 10% cross-reactivity with PCN if non-IgE reaction. Reconstitute with 1% lidocaine IM

Ciprofloxacin

  • Adult Dose: 250-750 mg PO Q12H; 400 mg IV Q12H, max 1500 mg/day
  • Pediatric Dose: Restrict to ages >18 yr (FDA) except serious infections; 10-15 mg/kg Q12H if used
  • Route: PO, IV, ophthalmic
  • Frequency: Q12H
  • Max Daily Dose: 1500 mg
  • Major SE: Tendinopathy, QT prolongation, C. diff, photosensitivity, peripheral neuropathy, CNS effects
  • Contraindications: QT prolongation, Myasthenia Gravis, tendon rupture history, hypersensitivity
  • Notes: Excellent lung penetration. Food delays absorption. Black box: tendonitis/rupture

Doxycycline

  • Adult Dose: 100 mg PO Q12H (loading 200 mg day 1), max 200 mg/day; IV 100-200 mg daily
  • Pediatric Dose: >8 yr: 2-4 mg/kg/day divided; <8 yr contraindicated (teeth staining)
  • Route: PO, IV
  • Frequency: Q12H
  • Max Daily Dose: 200 mg
  • Major SE: Esophageal ulceration, photosensitivity, Candida overgrowth, hepatotoxicity
  • Contraindications: Pregnancy, children <8 yr, severe hepatic disease, hypersensitivity
  • Notes: Take with full glass water, not supine. Avoid dairy/antacids (chelation). Sun protection mandatory

Metronidazole

  • Adult Dose: 250-500 mg PO Q6-8H; 500 mg IV Q6-8H, max 4 g/day
  • Pediatric Dose: 7.5 mg/kg Q6-8H
  • Route: PO, IV, rectal
  • Frequency: Q6-8H
  • Max Daily Dose: 4 g
  • Major SE: Metallic taste, disulfiram-like reaction with alcohol, neuropathy (chronic), seizures
  • Contraindications: Disulfiram use, severe hepatic disease, 1st trimester pregnancy
  • Notes: Excellent anaerobic coverage. Absolutely no alcohol during/7 days after treatment

Azithromycin

  • Adult Dose: 500 mg day 1, then 250 mg daily x4 days (Z-pack); 500 mg PO Q24H
  • Pediatric Dose: 10 mg/kg day 1, then 5 mg/kg daily x4 days
  • Route: PO, IV
  • Frequency: Q24H or Q12H IV
  • Max Daily Dose: 500 mg
  • Major SE: QT prolongation, torsades de pointes, GI upset, hepatotoxicity, C. diff
  • Contraindications: QT prolongation, electrolyte abnormalities, severe hepatic disease, hypersensitivity
  • Notes: Cardiac monitoring if risk factors. Excellent for atypical pneumonia/pertussis

Clindamycin

  • Adult Dose: 150-450 mg PO Q6-8H; 300-600 mg IV/IM Q6-8H, max 4.8 g/day
  • Pediatric Dose: 3-6 mg/kg Q6-8H (IV/IM), 8-12 mg/kg Q6-8H (PO)
  • Route: PO, IV, IM
  • Frequency: Q6-8H
  • Max Daily Dose: 4.8 g
  • Major SE: C. difficile infection, rash, hepatotoxicity, thrombophlebitis
  • Contraindications: Clostridial infection, diarrhea, hypersensitivity
  • Notes: Excellent anaerobic/MRSA coverage. High risk for C. diff

Vancomycin

  • Adult Dose: 15-20 mg/kg IV Q8-12H (adjust for renal function); 125-500 mg PO Q6H for C. diff
  • Pediatric Dose: 10-15 mg/kg Q6H IV; 40 mg/kg/day for meningitis
  • Route: IV, PO
  • Frequency: Q6-12H
  • Max Daily Dose: Monitor trough levels
  • Major SE: Nephrotoxicity, ototoxicity, red man syndrome, thrombophlebitis, thrombocytopenia
  • Contraindications: Hypersensitivity
  • Notes: Target trough 15-20 mcg/mL. Infuse over 1-2 hr. Give antihistamine for red man syndrome

Meropenem

  • Adult Dose: 500 mg-1 g IV Q8H; meningitis 2 g Q8H, max 6 g/day
  • Pediatric Dose: 10-40 mg/kg Q8H; meningitis 40 mg/kg Q8H
  • Route: IV
  • Frequency: Q8H
  • Max Daily Dose: 2-6 g
  • Major SE: Rash, diarrhea, nausea, CNS toxicity, seizures, hepatotoxicity
  • Contraindications: Carbapenembeta-lactam allergy, hypersensitivity
  • Notes: Broad spectrum. 1-3% cross-reactivity with penicillins if non-anaphylactic. Infuse 15-30 min

Trimethoprim-Sulfamethoxazole (TMP-SMX)

  • Adult Dose: 1-2 DS tabs Q12H (160/800 mg), max 15 mg/kg TMP daily
  • Pediatric Dose: 4-6 mg/kg TMP Q12H
  • Route: PO, IV
  • Frequency: Q12H
  • Max Daily Dose: 15 mg/kg TMP
  • Major SE: Stevens-Johnson syndrome, TEN, G6PD hemolysis, hyperkalemia, bone marrow suppression
  • Contraindications: Sulfonamide allergy, G6PD deficiency, severe renal/hepatic disease, pregnancy (3rd tri)
  • Notes: Excellent for PCP, UTI, Listeria. Monitor K+ in renal impairment

1.3 CARDIOVASCULAR MEDICATIONS

Aspirin

  • Adult Dose: 81-325 mg PO daily (cardio protection); 650-1000 mg Q4-6H for pain/fever, max 4 g/day
  • Pediatric Dose: Avoid in children <16 yr with viral illness (Reye syndrome); 10-15 mg/kg Q4-6H pain
  • Route: PO
  • Frequency: Daily or Q4-6H
  • Max Daily Dose: 4 g
  • Major SE: GI bleeding, Reye syndrome, anaphylaxis, bronchospasm, tinnitus
  • Contraindications: Active bleeding, severe hepatic disease, Reye syndrome risk, hypersensitivity
  • Notes: Irreversible COX inhibition. Continue pre-op for ACS. Delayed bleeding risk

Atenolol

  • Adult Dose: 25-100 mg PO daily; 5 mg IV Q5min x3 for acute MI, max 10 mg
  • Pediatric Dose: 0.5-1 mg/kg/dose Q12-24H
  • Route: PO, IV
  • Frequency: Daily
  • Max Daily Dose: 100 mg
  • Major SE: Bradycardia, heart block, fatigue, hypotension, dyslipidemia, bronchospasm
  • Contraindications: 2nd/3rd AV block, cardiogenic shock, asthma/COPD, uncompensated CHF
  • Notes: Renal excretion. Taper over 1-2 weeks. Beta-1 selective. Monitor HR <50

Amlodipine

  • Adult Dose: 2.5-5 mg PO daily, max 10 mg/day
  • Pediatric Dose: >6 yr: 0.05-0.1 mg/kg/day, max 5 mg/day
  • Route: PO
  • Frequency: Daily
  • Max Daily Dose: 10 mg
  • Major SE: Peripheral edema, headache, flushing, hypotension, reflex tachycardia
  • Contraindications: Hypotension, cardiogenic shock, hypersensitivity
  • Notes: Dihydropyridine. Long half-life (30-50 hr). No reflex tachycardia if combined with beta-blocker

Lisinopril

  • Adult Dose: 5-40 mg PO daily; MI: start 5 mg day 1, then 10 mg daily
  • Pediatric Dose: 0.07 mg/kg/day, max 5 mg/day
  • Route: PO
  • Frequency: Daily
  • Max Daily Dose: 40 mg
  • Major SE: Hyperkalemia, cough (20%), angioedema, renal impairment, hypotension
  • Contraindications: Pregnancy, bilateral renal artery stenosis, K+ >5.5, hypersensitivity
  • Notes: Check K+, Cr before/1-2 weeks after initiation. ACE inhibitor class effect: dry cough

Furosemide

  • Adult Dose: 20-80 mg PO daily/BID; 20-40 mg IV Q1-2H acute, max 600 mg/day
  • Pediatric Dose: 0.5-1 mg/kg Q6-12H, max 6 mg/kg/day
  • Route: PO, IV, IM
  • Frequency: Daily to Q6H
  • Max Daily Dose: 600 mg
  • Major SE: Hypokalemia, ototoxicity (high doses IV), hyperuricemia, hyperglycemia, hypotension
  • Contraindications: Anuria, severe electrolyte imbalance, hypersensitivity
  • Notes: Loop diuretic. Monitor K+, Mg2+, Cr. IV diuresis faster than PO. Ototoxicity with high IV doses

Nitroglycerin (NTG)

  • Adult Dose: 0.4 mg SL Q5min x3; infusion 5-400 mcg/min titrated; patch 0.2-0.8 mg/hr daily
  • Pediatric Dose: 0.25-0.5 mcg/kg/min IV
  • Route: SL, IV, transdermal, ointment
  • Frequency: Q5min SL; continuous IV
  • Major SE: Hypotension, reflex tachycardia, headache, syncope, methemoglobinemia
  • Contraindications: Sildenafil/tadalafil use (within 24-48 hr), hypotension, hypersensitivity, RV infarction
  • Notes: Tolerance develops with continuous use. Require 10-14 hr nitrate-free interval. Dilate in dextrose, not NS

Epinephrine (Adrenaline)

  • Adult Dose: IV 0.1-0.5 mg Q3-5min (cardiac arrest); infusion 1-4 mcg/min; IM 0.3-0.5 mg (anaphylaxis)
  • Pediatric Dose: IV 0.01 mg/kg Q3-5min; IM 0.01 mg/kg; infusion 0.1 mcg/kg/min
  • Route: IV, IM, inhalation, intraosseous
  • Frequency: Q3-5min or continuous
  • Major SE: Myocardial ischemia, arrhythmias, hypertension, pulmonary edema, tremor
  • Contraindications: Hyperthyroidism, pheochromocytoma, coronary artery disease (relative)
  • Notes: Alpha/beta agonist. Use high-dose IV in cardiac arrest (10x standard). Auto-injectors for anaphylaxis

Norepinephrine (Noradrenaline)

  • Adult Dose: 0.5-1.4 mcg/kg/min IV (initial), titrate to BP goal, max 3-4 mcg/kg/min
  • Pediatric Dose: 0.05-1.4 mcg/kg/min
  • Route: IV (central line preferred)
  • Frequency: Continuous
  • Major SE: Reflex bradycardia, tissue necrosis (extravasation), myocardial ischemia, hypertension
  • Contraindications: Uncorrected hypoxemia, hypovolemia, hypersensitivity
  • Notes: Alpha-dominant/beta. First-line septic shock. Dilate in dextrose or NS. Requires central line

Dopamine

  • Adult Dose: 2-5 mcg/kg/min (dopaminergic), 5-10 (beta), 10-20 (alpha); max 50 mcg/kg/min
  • Pediatric Dose: 2-20 mcg/kg/min
  • Route: IV (central line preferred)
  • Frequency: Continuous
  • Major SE: Tachycardia, arrhythmias, myocardial ischemia, tissue necrosis, hypertension
  • Contraindications: Pheochromocytoma, hypersensitivity
  • Notes: Dose-dependent effects. Dilate in dextrose/NS. Monitor HR, BP closely

Dobutamine

  • Adult Dose: 2.5-15 mcg/kg/min IV, max 40 mcg/kg/min
  • Pediatric Dose: 2-20 mcg/kg/min
  • Route: IV (central line preferred)
  • Frequency: Continuous
  • Major SE: Tachycardia, arrhythmias, myocardial ischemia, hypotension, hypertension
  • Contraindications: Pheochromocytoma, HOCM, hypersensitivity
  • Notes: Beta-1 selective. Inotrope/chronotrope. Tolerance within 72 hr. Dilute in dextrose/NS

Amiodarone

  • Adult Dose: Loading IV 150 mg over 10 min, then 1 mg/min x6 hr, then 0.5 mg/min; PO load 800-1600 mg/day x1-3 wk, maint 200-400 mg/day
  • Pediatric Dose: IV 5 mg/kg Q10min (cardiac arrest), max 15 mg/kg; PO 10-15 mg/kg/day
  • Route: IV, PO
  • Frequency: Loading then maintenance
  • Major SE: Pulmonary fibrosis, thyroid dysfunction, corneal deposits, photosensitivity, LFT elevation, QT prolongation
  • Contraindications: Severe bradycardia, AV block, baseline QT prolongation, hypersensitivity, iodine allergy
  • Notes: Class I-IV antiarrhythmic. Long half-life (26-107 days). Requires baseline PFTs, LFTs, TSH. Photosensitivity protection

Atropine

  • Adult Dose: 0.5-1 mg IV Q3-5min, max 3 mg (bradycardia/asystole); 0.4-0.6 mg IM for anticholinergic poison
  • Pediatric Dose: 0.02 mg/kg IV Q5-10min; min 0.1 mg, max 0.5 mg
  • Route: IV, IM, SC, intraosseous
  • Frequency: Q3-5min or single dose
  • Major SE: Tachycardia, mydriasis, urinary retention, CNS excitation, paradoxical bradycardia (low doses)
  • Contraindications: Angle-closure glaucoma, acute MI with hypotension, hypersensitivity
  • Notes: Anticholinergic. Caution in cardiac patients. Low doses (<0.5 mg) may cause bradycardia

Heparin

  • Adult Dose: IV bolus 5000-10,000 units, then 1000-2000 units/hr infusion (target aPTT 1.5-2.5x baseline)
  • Pediatric Dose: Initial 100 units/kg IV, then 28 units/kg/hr infusion
  • Route: IV, SC
  • Frequency: Continuous or Q8-12H
  • Max Daily Dose: Titrate to aPTT
  • Major SE: Bleeding, HIT (heparin-induced thrombocytopenia), thrombosis, hyperkalemia
  • Contraindications: Active bleeding, severe thrombocytopenia, hypersensitivity
  • Notes: Check baseline platelets/aPTT/Cr. Monitor aPTT q6h initially. Reverse with protamine (1 mg/100 units)

Enoxaparin (LMWH)

  • Adult Dose: 1 mg/kg SC Q12H, or 1.5 mg/kg daily; prophylaxis 40 mg daily
  • Pediatric Dose: 1 mg/kg Q12H, max 100 mg/dose
  • Route: SC
  • Frequency: Q12H or daily
  • Major SE: Bleeding, HIT (less than UFH), pain at injection site, hyperkalemia
  • Contraindications: Active bleeding, severe renal disease (CrCl <30), HIT
  • Notes: Predictable kinetics. No monitoring required. 30 min peak. Caution renal <30 (accumulates)

Warfarin

  • Adult Dose: 5 mg PO daily x2-4 days, then titrate by INR (target 2-3 for most, 2.5-3.5 for mechanical valve)
  • Pediatric Dose: 0.1-0.3 mg/kg/day initial, titrate to INR
  • Route: PO
  • Frequency: Daily
  • Major SE: Bleeding, necrosis, teratogenicity, purple toe syndrome
  • Contraindications: Active bleeding, severe hepatic disease, hypersensitivity, pregnancy (esp 1st tri)
  • Notes: Vitamin K antagonist. Drug/food interactions. INR baseline then 3-5 days, then weekly x2-4, then monthly

1.4 RESPIRATORY MEDICATIONS

Albuterol (Salbutamol)

  • Adult Dose: Inhaled 2 puffs Q4-6H PRN (90 mcg/puff); nebulized 2.5 mg Q4-6H; IV 5 mcg/min titrate to 20
  • Pediatric Dose: Inhaled 1-2 puffs Q4-6H; nebulized 0.15 mg/kg per dose (min 2.5 mg); IV 0.1 mcg/kg/min
  • Route: Inhaled, nebulized, IV, PO, SC
  • Frequency: Q4-6H or continuous
  • Major SE: Tachycardia, tremor, hypokalemia, hyperglycemia, palpitations, anxiety
  • Contraindications: Hypersensitivity, uncontrolled arrhythmias, thyroid disease
  • Notes: Beta-2 agonist. Quick-relief medication. Use spacer for MDI. Nebulized takes 5-15 min

Ipratropium Bromide

  • Adult Dose: Inhaled 2 puffs Q6H (17 mcg/puff); nebulized 250-500 mcg Q6-8H
  • Pediatric Dose: Similar to adult
  • Route: Inhaled, nebulized
  • Frequency: Q6-8H
  • Major SE: Dry mouth, tremor, urinary retention, palpitations, headache
  • Contraindications: Narrow-angle glaucoma, soy/peanut allergy, hypersensitivity
  • Notes: Anticholinergic/muscarinic antagonist. Longer acting than albuterol. Often combined with albuterol

Prednisone

  • Adult Dose: 0.5-1 mg/kg/day initial (max 80 mg); taper over 1-2 weeks
  • Pediatric Dose: 0.5-2 mg/kg/day, max 60 mg/day
  • Route: PO
  • Frequency: Daily, divided or single morning dose
  • Major SE: Hyperglycemia, hypertension, immunosuppression, GI upset, insomnia, myopathy (chronic)
  • Contraindications: Systemic fungal infection, live vaccine, uncontrolled infection
  • Notes: Systemic corticosteroid. Glucocorticoid effect. Taper to avoid adrenal crisis. GI prophylaxis if high-dose

Dexamethasone

  • Adult Dose: 0.5-1 mg Q6-8H; croup 0.15 mg/kg single dose (max 10 mg); meningitis 10 mg Q6H
  • Pediatric Dose: 0.15 mg/kg/day (croup), 0.6 mg/kg/day Q6H (meningitis)
  • Route: PO, IV, IM
  • Frequency: Q6-8H or single dose
  • Major SE: Hyperglycemia, immunosuppression, hypertension, insomnia, psychosis
  • Contraindications: Systemic fungal infection, live vaccine, hypersensitivity
  • Notes: Long-acting glucocorticoid (36-54 hr half-life). Minimal mineralocorticoid activity

1.5 GI MEDICATIONS

Omeprazole

  • Adult Dose: 20 mg PO daily, max 40 mg/day; IV 40 mg Q12H
  • Pediatric Dose: >1 yr: 0.7-1.4 mg/kg/day, max 20 mg/day
  • Route: PO, IV
  • Frequency: Daily or Q12H
  • Max Daily Dose: 40 mg
  • Major SE: Hypomagnesemia (chronic), vitamin B12 deficiency, C. diff, bone fractures (chronic), SIADH
  • Contraindications: Clopidogrel cotherapy, hypersensitivity
  • Notes: PPI. Irreversible proton pump inhibition. Take 30-60 min before meal. IV infusion over 15-30 min

Ondansetron

  • Adult Dose: 4-8 mg IV/IM/PO Q8H, max 32 mg/day; single dose 8 mg IV pre-op
  • Pediatric Dose: 0.1 mg/kg IV Q4H, max 4 mg/dose
  • Route: IV, IM, PO
  • Frequency: Q4-8H or single dose
  • Max Daily Dose: 32 mg
  • Major SE: Headache, constipation, QT prolongation, serotonin syndrome
  • Contraindications: Apomorphine use, QT prolongation, hypersensitivity
  • Notes: 5-HT3 antagonist. Effective for chemo/post-op nausea. IV over 30 sec to 15 min

Metoclopramide

  • Adult Dose: 10 mg PO/IM/IV Q6-8H, max 40 mg/day; 10 mg IV before meals
  • Pediatric Dose: 0.1 mg/kg Q6-8H
  • Route: PO, IM, IV
  • Frequency: Q6-8H
  • Max Daily Dose: 40 mg
  • Major SE: Tardive dyskinesia (black box), restlessness, diarrhea, QT prolongation, methemoglobinemia
  • Contraindications: GI perforation, pheochromocytoma, QT prolongation, hypersensitivity
  • Notes: Prokinetic/antiemetic. Black box: tardive dyskinesia with chronic use. Infuse IV over 15 min

Oral Rehydration Solution (ORS)

  • Adult Dose: 75 mL/kg over 4 hours for mild-moderate dehydration
  • Pediatric Dose: 50-100 mL/kg over 4 hours
  • Route: PO, NG tube
  • Frequency: Continuous during rehydration
  • Composition: Sodium 75 mEq/L, potassium 20 mEq/L, glucose 75 mmol/L, chloride 65 mEq/L, bicarbonate 10 mEq/L
  • Major SE: Hypernatremia (if excess), fluid overload, diarrhea
  • Notes: WHO/UNICEF recommended formulation. Equal glucose:sodium molar ratio optimizes absorption

Lactulose

  • Adult Dose: 15-30 mL PO daily/BID, titrate to 2-3 soft stools/day
  • Pediatric Dose: 1-7 mL daily divided
  • Route: PO, rectal (enema)
  • Frequency: Daily to BID
  • Major SE: Flatulence, cramping, bloating, diarrhea, electrolyte loss
  • Contraindications: Galactose intolerance, colostomy/ileostomy
  • Notes: Non-absorbed disaccharide. Laxative/ammonia reducer. Onset 24-48 hr. Osmotic effect

1.6 CNS MEDICATIONS

Diazepam

  • Adult Dose: 2-10 mg PO Q6-8H, or 5-10 mg IV/IM Q3-4H; seizure 5-10 mg IV Q5-10min, max 30 mg
  • Pediatric Dose: 0.04-0.2 mg/kg IV/IM Q2-4H; PO 0.12-0.8 mg/kg/day divided
  • Route: PO, IV, IM, rectal
  • Frequency: Q3-12H or PRN
  • Major SE: Respiratory depression, hypotension, ataxia, paradoxical excitation, dependence
  • Contraindications: Acute angle-closure glaucoma, sleep apnea, severe respiratory disease, hypersensitivity
  • Notes: Long-acting benzodiazepine (t1/2 30-60 hr). IV infuse slow (<5 mg/min). Status epilepticus: lorazepam preferred

Phenytoin

  • Adult Dose: Loading 15-20 mg/kg IV (1.5-2 mg/kg/min max) or PO divided; maint 5 mg/kg/day divided Q12H
  • Pediatric Dose: Loading 15-20 mg/kg; maint 4-7 mg/kg/day divided
  • Route: PO, IV
  • Frequency: Loading then Q12H maintenance
  • Major SE: Gingival hyperplasia, hirsutism, megaloblastic anemia, teratogenicity, Stevens-Johnson, hypersensitivity, neuropathy
  • Contraindications: 2nd/3rd degree AV block, sinoatrial block, hypersensitivity, pregnancy
  • Notes: Aromatase. Narrow therapeutic index (10-20 mcg/mL). Saturation kinetics. IV in dextrose/NS only

Levetiracetam

  • Adult Dose: 500-1000 mg PO/IV Q12H, start low, titrate weekly, max 3000 mg/day
  • Pediatric Dose: 10-20 mg/kg/day divided
  • Route: PO, IV
  • Frequency: Q12H
  • Max Daily Dose: 3000 mg
  • Major SE: Irritability, somnolence, ataxia, mood changes, behavioral disturbance
  • Contraindications: Hypersensitivity
  • Notes: Broad-spectrum antiepileptic. Renally excreted. No drug interactions. IV infusion 15 min

Haloperidol

  • Adult Dose: 0.5-5 mg PO/IM Q8-12H, or IV slow push 0.5-5 mg Q30min, max 100 mg/day
  • Pediatric Dose: 0.05-0.15 mg/kg/day divided
  • Route: PO, IM, IV
  • Frequency: Q8-12H or Q30min
  • Major SE: Extrapyramidal effects, tardive dyskinesia, neuroleptic malignant syndrome, QT prolongation, orthostasis
  • Contraindications: Pheochromocytoma, prolonged QT, Parkinson disease, hypersensitivity
  • Notes: Typical antipsychotic. High potency. Monitor EPS/NMS. IV over 5 min

Midazolam

  • Adult Dose: 0.5-2 mg IV Q2-3min (anxiety/sedation); 0.1-0.15 mg/kg IM (preop); 1-4 mg/kg PO max 20 mg (preop)
  • Pediatric Dose: IV 0.05-0.1 mg/kg; IM 0.05-0.1 mg/kg max 4 mg; PO 0.25-0.5 mg/kg
  • Route: PO, IV, IM, intranasal, buccal
  • Frequency: Q2-3min IV or single IM/PO
  • Major SE: Respiratory depression, hypotension, paradoxical excitement, dependence
  • Contraindications: Acute angle-closure glaucoma, severe respiratory disease, hypersensitivity
  • Notes: Short-acting benzodiazepine. IV onset 1-3 min. Reverse with flumazenil (0.2 mg IV, repeat Q1min)

1.7 ANESTHESIA

Lidocaine (see Analgesics)

Bupivacaine

  • Adult Dose: 0.5-1.5 mL of 0.5-0.75% per site (max 3 mg/kg or 300 mg total)
  • Pediatric Dose: 2 mg/kg without epi, 3 mg/kg with epi
  • Route: Infiltration, nerve block, epidural, spinal
  • Frequency: Single dose or continuous
  • Major SE: CNS toxicity (seizures, coma), cardiac arrhythmias, cardiac arrest, methemoglobinemia
  • Contraindications: Hypersensitivity, 2nd/3rd degree AV block, severe cardiac disease
  • Notes: Long-acting amide (4+ hr). Cardiotoxic if overdosed. Can add epinephrine 1:200,000

Propofol

  • Adult Dose: Induction 1-2.5 mg/kg IV; sedation 25-75 mcg/kg/min infusion
  • Pediatric Dose: Induction 2-3.5 mg/kg; infusion 100-300 mcg/kg/min
  • Route: IV
  • Frequency: Single dose or continuous infusion
  • Major SE: Apnea, hypotension, bradycardia, propofol infusion syndrome (PRIS), pain on injection
  • Contraindications: Hypersensitivity, egg allergy, cardiopulmonary instability
  • Notes: Egg-based emulsion. PRIS: metabolic acidosis/myopathy/renal failure with prolonged high-dose. Use BIS monitor

Etomidate

  • Adult Dose: 0.2-0.3 mg/kg IV for induction
  • Pediatric Dose: 0.2-0.3 mg/kg
  • Route: IV
  • Frequency: Single dose
  • Major SE: Adrenal suppression, myoclonus, postoperative nausea, hypotension, pain on injection
  • Contraindications: Hypersensitivity
  • Notes: Minimal respiratory/hemodynamic depression. Suppresses 11-beta-hydroxylase (one dose). Adrenal monitoring if infusion

Succinylcholine (Suxamethonium)

  • Adult Dose: 1-1.5 mg/kg IV; IM 3-4 mg/kg (max 150 mg)
  • Pediatric Dose: 1 mg/kg IV, 4-5 mg/kg IM
  • Route: IV, IM
  • Frequency: Single dose
  • Major SE: Hyperkalemia, malignant hyperthermia, myalgia, fasciculations, increased ICP/intraocular pressure
  • Contraindications: Malignant hyperthermia history, severe burns/crush injury, upper motor neuron disease, acute MI, hypersensitivity
  • Notes: Depolarizing agent. Rapid onset (30-60 sec). Short duration (5-10 min). Pseudocholinesterase deficiency prolongs paralysis

Rocuronium

  • Adult Dose: Intubation 0.6-1 mg/kg IV; infusion 10-12 mcg/kg/min
  • Pediatric Dose: 0.6-1 mg/kg; infusion 10-12 mcg/kg/min
  • Route: IV
  • Frequency: Single dose or continuous
  • Major SE: Anaphylaxis, histamine release, bronchospasm, vagal stimulation (avoid in RSI)
  • Contraindications: Hypersensitivity
  • Notes: Non-depolarizing intermediate-acting. Onset 30-60 sec. Reverse with sugammadex (2-4 mg/kg)

1.8 ENDOCRINE MEDICATIONS

Insulin (Multiple Formulations)

Rapid-Acting (Lispro, Aspart, Glulisine)

  • Adult/Pediatric Dose: 0.05-0.1 units/kg subQ immediately before meals
  • Route: SC, IV
  • Onset/Peak/Duration: 10-15 min / 1-2 hr / 3-5 hr

Short-Acting (Regular/NPH Humulin R)

  • Dose: 0.05-0.1 units/kg SC before meals
  • Onset/Peak/Duration: 30 min / 2-4 hr / 5-8 hr

Intermediate-Acting (NPH)

  • Dose: 0.1-0.2 units/kg SC daily/BID
  • Onset/Peak/Duration: 1-3 hr / 5-8 hr / 13-20 hr

Long-Acting (Glargine, Detemir)

  • Dose: 0.1-0.2 units/kg SC daily at same time

  • Onset/Peak/Duration: 1-4 hr / minimal / 24 hr

  • Major SE: Hypoglycemia, lipodystrophy, allergic reaction, hypokalemia (high-dose IV)

  • Contraindications: Hypoglycemia, hypersensitivity

  • Notes: Monitor BGL q4h initially. Subcutaneous injection sites: abdomen, thigh, arm. IV rapid-acting in dextrose/NS only

Metformin

  • Adult Dose: 500 mg PO BID/TID, max 2000-2550 mg/day; extended-release 500-2000 mg daily
  • Pediatric Dose: 500 mg PO BID, titrate to max 2000 mg/day
  • Route: PO
  • Frequency: BID-TID with meals
  • Max Daily Dose: 2000-2550 mg
  • Major SE: Lactic acidosis, B12 deficiency, GI upset, metallic taste, diarrhea
  • Contraindications: eGFR <30, acute illness with dehydration, heart failure, liver disease, hypersensitivity
  • Notes: Biguanide. Hold before contrast/surgery. Check B12 annually. Monitor renal function

Levothyroxine

  • Adult Dose: Start 25-50 mcg daily, titrate by 25-50 mcg Q6-8 weeks to target TSH; maint 75-150 mcg/day
  • Pediatric Dose: 10-15 mcg/kg/day (infants), titrate to TSH
  • Route: PO, IV
  • Frequency: Daily (empty stomach 30-60 min before food)
  • Major SE: Myocardial ischemia, tachycardia, tremor, anxiety, insomnia, bone loss (over-replacement)
  • Contraindications: Untreated thyrotoxicosis, acute MI, hypersensitivity
  • Notes: Synthetic T4. Long half-life (7 days). Steady state in 4-6 weeks. Check TSH Q6-8 weeks initially

Hydrocortisone

  • Adult Dose: 50-100 mg IV Q6-8H (acute); 15-20 mg PO daily maintenance
  • Pediatric Dose: 1-2 mg/kg Q6H IV (shock), 0.5-1 mg/kg daily (maint)
  • Route: PO, IV, IM
  • Frequency: Q6-8H acute; daily maint
  • Major SE: Hyperglycemia, hypertension, immunosuppression, GI upset, insomnia, myopathy
  • Contraindications: Systemic fungal infection, live vaccine, hypersensitivity
  • Notes: Glucocorticoid/mineralocorticoid. Short-acting (8-12 hr). Adrenal insufficiency replacement

1.9 ANTIDOTES

Naloxone

  • Adult Dose: 0.4-2 mg IV/IM/SC Q2-3min; intranasal 4 mg single dose
  • Pediatric Dose: 0.01 mg/kg IV, repeat Q2-3min
  • Route: IV, IM, SC, intranasal
  • Frequency: Q2-3min as needed
  • Major SE: Withdrawal syndrome, hypertension, tachycardia, pulmonary edema
  • Contraindications: Hypersensitivity
  • Notes: Mu receptor antagonist. Shorter half-life than opioids (30-90 min). May require repeat dosing/infusion (0.4-0.8 mg/hr)

N-Acetylcysteine (NAC)

  • Adult Dose: Acetaminophen poisoning: load 150 mg/kg IV over 1 hr, then 50 mg/kg Q4H, then 100 mg/kg Q16H
  • Pediatric Dose: Same as adult
  • Route: IV, PO, inhalation
  • Frequency: Loading then Q4H, Q16H
  • Major SE: Nausea, vomiting, flushing, anaphylactoid reaction, angioedema
  • Contraindications: Hypersensitivity
  • Notes: Precursor to glutathione. Most effective if given <8 hr after OD. Adjust for weight

Atropine (see Cardiovascular)

Pralidoxime (2-PAM)

  • Adult Dose: 1-2 g IV slow push, repeat after 1 hr if needed; 600 mg IM for exposure
  • Pediatric Dose: 20-40 mg/kg IV, max 2 g
  • Route: IV, IM, SC
  • Frequency: Single dose, repeat after 1 hr
  • Major SE: Dizziness, headache, diplopia, hyperventilation, muscle rigidity
  • Contraindications: Carbamate insecticide poisoning (atropine only), hypersensitivity
  • Notes: Acetylcholinesterase reactivator. Use with atropine for OP poisoning. Time-dependent (most effective <24 hr)

Flumazenil

  • Adult Dose: 0.2 mg IV, repeat Q1min up to 1 mg; infusion 0.1-0.4 mg/hr
  • Pediatric Dose: 0.01 mg/kg IV
  • Route: IV
  • Frequency: Q1min or continuous
  • Major SE: Seizures, withdrawal, resedation, cardiac arrhythmias, hypertension
  • Contraindications: Tricyclic antidepressant overdose, benzodiazepine-dependent patients, hypersensitivity
  • Notes: Competitive antagonist. Shorter half-life than some benzos. Risk of seizures in dependent patients. Caution

Calcium Gluconate

  • Adult Dose: 10% solution, 5-10 mL IV slow push (10-20 mEq Ca), repeat Q1-2min PRN; max 10 ampules
  • Pediatric Dose: 0.2-0.3 mL/kg of 10% solution IV
  • Route: IV (preferable), IM (tissue necrosis risk)
  • Frequency: Q1-2min PRN
  • Major SE: Tissue necrosis (extravasation), bradycardia, cardiac arrhythmias, hypercalcemia
  • Contraindications: Hypercalcemia, digitalis toxicity, hypersensitivity
  • Notes: For hyperkalemia, hypocalcemia, hydrofluoric acid. Infuse over 2-5 min with cardiac monitor

Glucagon

  • Adult Dose: 0.5-1 mg IM/SC/IV, repeat Q1min if needed, max 5 mg; infusion 1-5 mg/hr
  • Pediatric Dose: 0.03-0.1 mg/kg IM/SC/IV, max 1 mg
  • Route: IV, IM, SC
  • Frequency: Single dose or Q1min, then infusion
  • Major SE: Nausea, vomiting, hyperglycemia, hypokalemia, anaphylaxis
  • Contraindications: Pheochromocytoma, hypersensitivity, insufficient glycogen (prolonged fast)
  • Notes: Beta-adrenergic agonist. For hypoglycemia/beta-blocker OD. Reconstitute with provided diluent

Vitamin K (Phytonadione)

  • Adult Dose: 1-10 mg IV/IM/SC (reverse warfarin), max 10 mg; oral 5-10 mg daily
  • Pediatric Dose: 1-2 mg IM/SC/IV
  • Route: PO, IV, IM, SC
  • Frequency: Single dose to daily
  • Major SE: Hypersensitivity (IV), tissue necrosis (IM), flushing, chest tightness
  • Contraindications: Hypersensitivity
  • Notes: IV infusion slow (1 mg/min). IM preferred if IV unavailable. INR corrects in 12-24 hr

1.10 FLUIDS AND ELECTROLYTES

Normal Saline (0.9% NaCl)

  • Composition: Sodium 154 mEq/L, chloride 154 mEq/L
  • Adult Dose: Varies by indication, typically 500-1000 mL bolus or 50-200 mL/hr maintenance
  • Route: IV
  • Major SE: Hyperchloremic acidosis (large volumes), hypernatremia
  • Notes: Isotonic. Gold standard for resuscitation and maintenance. Can be used for dilution

Lactated Ringer’s (LR)

  • Composition: Sodium 130 mEq/L, potassium 4 mEq/L, calcium 3 mEq/L, chloride 109 mEq/L, lactate 28 mEq/L
  • Adult Dose: 500-1000 mL bolus or 50-200 mL/hr maintenance
  • Route: IV
  • Major SE: Hyperkalemia (renal failure), lactic acidosis (hepatic dysfunction)
  • Notes: Isotonic, more physiologic. Preferred for burns/trauma. Lactate converted to HCO3 by liver

5% Dextrose in Water (D5W)

  • Composition: Dextrose 50 g/L, osmolality 252 mOsm/L
  • Adult Dose: 500-1000 mL maintenance or per protocol
  • Route: IV
  • Major SE: Hyponatremia (SIADH), hyperglycemia, hypoglycemia (after metabolism)
  • Notes: Hypotonic after dextrose metabolism. Avoid in hyperglycemia/head injury. For TPN/medication dilution

Potassium Chloride (KCl)

  • Adult Dose: 10-40 mEq PO Q4-6H, or 10-20 mEq IV over 1 hr (max 40 mEq/L concentration, infuse 10 mEq/hr)
  • Pediatric Dose: 0.3-0.5 mEq/kg Q4-6H
  • Route: PO, IV (diluted)
  • Frequency: Q4-6H or continuous
  • Major SE: Hyperkalemia, cardiac arrhythmias, GI irritation
  • Contraindications: Hyperkalemia, renal failure, severe hemolysis
  • Notes: Never push IV. Maximum concentration 40 mEq/L for peripheral, 60 mEq/L central. Monitor K+, EKG

Magnesium Sulfate (MgSO4)

  • Adult Dose: 1-2 g IV over 5-30 min, repeat Q4-6H; seizure prophylaxis 4-6 g load, then 1-2 g/hr infusion
  • Pediatric Dose: 25-50 mg/kg IV slow
  • Route: IV, IM
  • Frequency: Q4-6H or continuous
  • Major SE: Hypotension, flushing, hypermagnesemia, cardiac arrhythmias, respiratory depression
  • Contraindications: Severe renal impairment, heart block, hypersensitivity
  • Notes: Vasodilator. IV over 5-30 min. Reflux hyperreflexia/respiratory depression = overdose. Monitor Mg, reflexes

Sodium Bicarbonate (NaHCO3)

  • Adult Dose: 1-2 mEq/kg IV over 5-30 min for acidosis; 50-100 mL 8.4% for cardiac arrest
  • Pediatric Dose: 0.5-1 mEq/kg IV
  • Route: IV
  • Frequency: Single dose, may repeat
  • Major SE: Alkalosis, hypokalemia, hypernatremia, hyperosmolarity, tissue necrosis (infiltration)
  • Notes: 8.4% = 1 mEq/mL, 4.2% = 0.5 mEq/mL. Calculate: mEq = 0.3 x BW x base deficit. Give 1/2 calculated dose

2. PHARMACOLOGY PRINCIPLES

2.1 RENAL DOSE ADJUSTMENTS

CrCl Calculation (Cockcroft-Gault)

CrCl (mL/min) = [(140 - age) x BW(kg) x (0.85 if female)] / (72 x Cr)

Renally Excreted Drugs Requiring Adjustment:

  • CrCl 60-90 mL/min (mild): Amoxicillin, ciprofloxacin, metformin, enoxaparin
  • CrCl 30-60 mL/min (moderate): Reduce TMP-SMX 50%, vancomycin target trough 15-20, doxycycline OK, heparin Q8H, lisinopril Q24H
  • CrCl <30 mL/min (severe): Avoid metformin, azithromycin Q48H, vancomycin Q12-24H, enoxaparin 30 mg daily, digoxin 0.125 mg daily
  • Dialysis patients: Redose after dialysis: vancomycin, aminoglycosides, metformin, cephalosporins

2.2 HEPATIC DOSE ADJUSTMENTS

Drugs Requiring Adjustment in Cirrhosis/Hepatic Failure:

  • Morphine: reduce 25-50%
  • Diazepam: reduce 25-50%, avoid IV
  • Propofol: reduce 25-40%
  • Warfarin: smaller loading/maintenance doses
  • Metformin: avoid if decompensated
  • Amiodarone: reduce maintenance 25-50%
  • ACE inhibitors: monitor K+, Cr closely
  • NSAIDs: contraindicated in portal hypertension

2.3 PEDIATRIC DOSING PRINCIPLES

Clark’s Rule (Weight-Based):

Pediatric Dose = (Child's weight in lbs / 150) x Adult dose

Young’s Rule (Age-Based):

Pediatric Dose = [Age / (Age + 12)] x Adult dose

Common Pediatric Calculations:

  • Acetaminophen: 15 mg/kg Q4-6H (max 5 doses/day, <2yr max 4 doses/day)
  • Ibuprofen: 5-10 mg/kg Q6-8H (max 40 mg/kg/day)
  • Amoxicillin: 25-45 mg/kg/day divided Q8H
  • Ceftriaxone: 50-80 mg/kg/day divided Q12H
  • Morphine: 0.05-0.2 mg/kg IV Q2-4H

2.4 GERIATRIC CONSIDERATIONS

  • Start Low, Go Slow: Begin 25-50% of standard adult doses, titrate gradually
  • Polypharmacy: Monitor for drug-drug interactions (average >5 meds at age >65)
  • CNS Sensitivity: Benzodiazepines, opioids cause excess sedation, delirium
  • Cardiovascular: Beta-blockers, ACE inhibitors more sensitive; monitor BP closely
  • Renal Function: eGFR often lower than calculated; use Cockcroft-Gault, not MDRD in elderly
  • Volume of Distribution: Increased for lipophilic drugs (longer t1/2); decreased for hydrophilic drugs
  • Acetaminophen: Max 3 g/day (down from 4 g)
  • NSAIDs: Highest GI/renal risk; avoid if possible
  • Avoid List: Diphenhydramine, long-acting benzodiazepines, NSAIDs, tricyclic antidepressants, anticholinergics

2.5 DRUG INTERACTIONS (HIGH-RISK)

Warfarin Interactions:

  • Increases effect: NSAIDs, antibiotics (TMP-SMX, ciprofloxacin, metronidazole), aspirin, metronidazole, amiodarone
  • Decreases effect: Barbiturates, rifampin

Metformin + Contrast:

  • Hold metformin day of procedure and 48 hr after (lactic acidosis risk)
  • Restart if Cr stable

ACE Inhibitors:

  • NSAIDs: reduce effectiveness, increase hyperkalemia/renal failure risk
  • Potassium-sparing diuretics: severe hyperkalemia
  • Diuretics: hypotension, syncope

Fluoroquinolones (Cipro):

  • Theophylline: increases theophylline levels
  • Warfarin: increases anticoagulation
  • NSAIDs: CNS stimulation risk

Macrolides (Azithromycin):

  • Increase QT prolongation risk with amiodarone, TCA, antipsychotics
  • CYP3A4 inhibition

Serotonin Syndrome Risk:

  • SSRIs + Tramadol, doxycycline, metoclopramide, linezolid

3. DRUG STORAGE AND STABILITY

3.1 TEMPERATURE REQUIREMENTS

Room Temperature (20-25°C / 68-77°F):

  • Acetaminophen, ibuprofen, amoxicillin (PO), ciprofloxacin, metformin, omeprazole, haloperidol, diazepam

Refrigerated (2-8°C / 36-46°F):

  • Insulin (once opened 28 days), some biologics, reconstituted vancomycin (7 days), reconstituted ceftriaxone (3 days if room temp, 10 days refrigerated)

Light Sensitive (protect from light):

  • Nitroglycerin, doxycycline, warfarin, midazolam, diazepam (store in amber vials)

Frozen (-20°C / -4°F):

  • Vaccines, certain biologics, some investigational drugs

3.2 SHELF LIFE POST-RECONSTITUTION

  • IV fluids (NS, LR, D5W): 30 days unopened; single-use vials discarded after withdrawal
  • Ceftriaxone IV: 3 days room temperature, 10 days refrigerated (1-2 g vial)
  • Vancomycin IV: 7 days refrigerated (10-50 mg/mL)
  • Morphine infusions: 24 hrs room temp (D5W), 7 days refrigerated
  • Heparin infusions: 24-48 hrs room temp in NS/D5W
  • Nitroglycerin infusions: 4-12 hrs (glass or Teflon only, not PVC)
  • Dopamine/norepinephrine: 24 hrs once diluted in D5W/NS

3.3 RECONSTITUTION REQUIREMENTS

Ceftriaxone 1 g vial:

  • Add 2.1 mL sterile water or 1% lidocaine for IM
  • Add 10 mL D5W/NS for IV push = 100 mg/mL
  • Shake well, solution clear within 15 min

Vancomycin 500 mg vial:

  • Add 5 mL sterile water = 100 mg/mL
  • Further dilute in 100-250 mL NS/D5W for infusion
  • Infuse over 30-60 min

Morphine 10 mg/mL vial:

  • For infusion: add 1 mg/mL morphine in D5W or NS
  • Calculate mL/hr = (desired dose in mg/hr) / concentration in mg/mL

3.4 IV COMPATIBILITY CHART (SELECTED)

Compatible together:

  • Norepinephrine + Heparin + Magnesium sulfate
  • Dopamine + Heparin + Dextrose
  • Potassium chloride + Heparin (separate lines in same IV)

Incompatible (separate lines):

  • Heparin + Vancomycin (forms precipitate)
  • Ceftriaxone + Vancomycin (incompatible)
  • Calcium + Sodium bicarbonate (precipitation)
  • Diazepam + Heparin (adsorbs to tubing)

Always Use Separate Lines:

  • Blood products with medications
  • Vasopressors with incompatible agents
  • Calcium with phosphate/bicarbonate

3.5 COLD CHAIN MEDICATIONS

Vaccines (2-8°C mandatory):

  • Never freeze
  • Discard if frozen
  • Use within 28 days of opening multi-dose vials
  • Record lot, expiration on administration record

Insulin:

  • Store unopened boxes 2-8°C
  • Current vial/pen room temperature up to 28 days (rapid-acting, regular), 14 days (NPH), 42 days (long-acting)
  • Never freeze
  • Cloudy insulins: mix gently (don’t shake)

3.6 USING EXPIRED MEDICATIONS IN EMERGENCY

Acceptable if recent expiration (<6 months) and proper storage:

  • Acetaminophen, ibuprofen, amoxicillin tablets
  • Topical antibiotics, creams

Generally acceptable (extended shelf-life military study):

  • Amoxicillin tablets: 1-5 years beyond expiration
  • Tetracycline: avoid (photodegradation risk)

Never use expired:

  • Insulin (efficacy degrades)
  • Liquid antibiotics (bacterial growth)
  • Nitroglycerin (potency loss rapid)
  • Tetracyclines (toxicity risk)
  • Time-sensitive anticoagulants

Document in emergency records: Medication name, expiration date, clinical justification, patient consent if possible

4. COMPOUNDING AND PREPARATION

4.1 IV FLUID PREPARATION

Calculating Maintenance Fluids (Holliday-Segar):

First 10 kg: 100 mL/kg/day
Second 10 kg: 50 mL/kg/day
Each kg >20: 20 mL/kg/day

Example (25 kg child): (10 x 100) + (10 x 50) + (5 x 20) = 1600 mL/day
Per hour: 1600 mL / 24 = 67 mL/hr

Bolus Resuscitation:

  • 20 mL/kg NS or LR rapid IV push over 5-15 min
  • Reassess perfusion, repeat if needed
  • Maximum 60 mL/kg in initial 1 hour for hypovolemic shock

Deficit Replacement (Dehydration):

Deficit (L) = BW (kg) x % dehydration x 10
Example: 30 kg child, 5% dehydration = 30 x 5 x 0.1 = 15 L

Replace 50% in first 8 hours, 50% in next 16 hours using 1/4-1/2 NS

4.2 DILUTION CALCULATIONS

Morphine Infusion:

10 mg/mL vial diluted to 1 mg/mL in 250 mL D5W
Desired dose: 2 mg/hr
mL/hr = (2 mg/hr) / (1 mg/mL) = 2 mL/hr

Heparin Infusion:

25,000 units in 250 mL NS = 100 units/mL
Patient weight 70 kg, goal aPTT 1.5-2.5x baseline

Initial: 5000 units bolus, then 18 units/kg/hr = 1260 units/hr = 12.6 mL/hr

Insulin Infusion:

50 units regular insulin in 50 mL NS = 1 unit/mL
Start 0.1 units/kg/hr for DKA
70 kg patient: 7 units/hr = 7 mL/hr
Increase 0.5-1 units/hr based on glucose decline

4.3 DRIP RATE CALCULATIONS

Drops per Minute (gravity infusion):

Drop rate = (Volume in mL x Drop factor in gtt/mL) / Time in minutes

Example: 500 mL NS Q6H with 15 gtt/mL set
Drop rate = (500 mL x 15) / 360 min = 20.8 gtt/min ≈ 21 gtt/min

Drop factors: Macro 10, 15, 20 gtt/mL; Micro 60 gtt/mL

mL per Hour (pump infusion):

mL/hr = Total volume (mL) / Hours

Example: 500 mL Q6H = 500 / 6 = 83.3 mL/hr

mcg/kg/min (vasopressor drips):

(Dose in mcg/kg/min x Weight in kg x 60) / (Concentration in mcg/mL)

Example: Norepinephrine 1 mcg/kg/min, 70 kg patient, concentration 16 mcg/mL
(1 x 70 x 60) / 16 = 262.5 mL/hr

Standard: 8 mg in 250 mL = 32 mcg/mL, so 131 mL/hr

Titration of Vasopressors:

  • Start at 0.5-1 mcg/kg/min
  • Increase by 0.5-1 mcg/kg/min every 5-10 minutes
  • Titrate to goal MAP (≥65 mmHg for sepsis)
  • Maximum before escalating therapy: 3-4 mcg/kg/min norepinephrine

4.4 ORS PREPARATION FROM SCRATCH

WHO/UNICEF Recommended Formulation (2002):

Sodium chloride: 2.6 g/L
Potassium chloride: 1.5 g/L
Glucose (anhydrous): 13.5 g/L
Trisodium citrate dihydrate: 2.9 g/L

Result: Na+ 75 mEq/L, K+ 20 mEq/L, Cl- 65 mEq/L, glucose 75 mmol/L
Osmolarity: 245 mOsm/L (low osmolarity, <270)

Household Preparation if Commercial ORS Unavailable:

1 liter clean water
6 teaspoons (30 mL) sugar
1/2 teaspoon (2.5 mL) salt
OR

1 liter clean water
1 cup (240 mL) rice/coconut water (for potassium)
1 teaspoon salt (5 mL NaCl)

Administration:

  • Frequent, small amounts (5-10 mL) every 5-10 min
  • Reassess for continued losses
  • 50-100 mL/kg over 4 hours for mild-moderate dehydration

4.5 ANTISEPTIC PREPARATION

Chlorhexidine 0.5%:

  • For skin antisepsis pre-procedure
  • Alcohol-based formulation preferred (faster, better coverage)
  • Dry 30 sec before needle insertion
  • Avoid mucous membranes

Povidone-Iodine 10%:

  • For skin antisepsis
  • Requires 2 min contact time
  • Effective against bacteria, fungi, viruses
  • Allergic reaction risk (iodine allergy)
  • Avoid prolonged contact (skin irritation)

Alcohol 70%:

  • Quick drying antiseptic
  • Less residual activity than chlorhexidine
  • Avoid use in febrile patients (temp reduction artifact)
  • Flammable

Sterile Technique Protocol:

  1. Hand hygiene with soap/water or alcohol-based sanitizer
  2. Don sterile gloves
  3. Clean skin 2x with antiseptic in circular motion
  4. Allow to dry completely
  5. Proceed with aseptic technique

5. SUPPLY CHAIN AND INVENTORY

5.1 PAR LEVELS (SMALL HOSPITAL/CLINIC)

High-Turnover Acute Meds (Par = 2-4 weeks supply):

  • Acetaminophen PO, ibuprofen
  • Common antibiotics (amoxicillin, ceftriaxone, azithromycin)
  • Antiemetics (ondansetron, metoclopramide)
  • IV fluids (NS, LR: 50-100 units)

Critical/Code Meds (Par = 1 month supply + emergency backup):

  • Epinephrine (minimum 5 vials)
  • Atropine (minimum 5 vials)
  • Naloxone (minimum 10 units)
  • Calcium gluconate (minimum 10 vials)
  • Dextrose 50% (minimum 5 amps)
  • Defibrillator pads

Maintenance Meds (Par = 1-3 months):

  • Insulin glargine, NPH
  • Levothyroxine
  • Lisinopril, atenolol, amlodipine
  • Metformin

Anesthesia (Par = 2-4 weeks):

  • Propofol (stock daily per case load)
  • Etomidate (minimum 2 vials)
  • Succinylcholine (minimum 3 vials)
  • Rocuronium (minimum 3 vials)
  • Lidocaine, bupivacaine vials

5.2 FIFO ROTATION (First-In, First-Out)

Practice:

  • When restocking shelf, place new stock BEHIND existing stock
  • Always pull from front (oldest first)
  • Mark expiration dates clearly (permanent marker)
  • Check dates during regular inventory (weekly for high-turnover, monthly for others)

Documentation:

  • Lot numbers and expiration on receiving log
  • Segregate nearing-expiration meds (180 days from expiry)
  • Identify near-expiry for use in high-acuity settings where appropriate
  • Dispose according to medication waste protocol

Seasonal Adjustments:

  • Increase fluids/electrolytes par during summer/diarrhea season
  • Increase respiratory meds (albuterol) during winter/asthma season
  • Maintain antibiotics steady year-round

5.3 ESSENTIAL SUPPLIES LIST

Resuscitation Kit (kept accessible, checked daily):

  • Epinephrine 1 mg/mL (5 vials)
  • Atropine 0.5 mg/mL (5 vials)
  • Naloxone 0.4 mg/mL (10 vials)
  • Calcium gluconate 10% (10 vials)
  • Dextrose 50% 25 mL (5 amps)
  • Sodium bicarbonate 8.4% (5 amps)
  • Defibrillator pads x2, monitor cables
  • Ambu bag x2, mask set (all sizes: neonatal-adult)
  • Laryngoscope + endotracheal tubes
  • Suction catheters (14-18 Fr)
  • IV access: 18-20 G needles, tourniquets, tape

Ongoing Medications (reorder weekly/bi-weekly):

  • Antibiotics (see Par Levels)
  • Analgesics
  • IV fluids (minimum 50 units NS/LR)
  • Electrolytes (KCl, MgSO4)
  • Antiemetics
  • Antipyretics
  • Antihistamines

Respiratory Equipment:

  • Oxygen delivery (nasal cannula, non-rebreather, face tents)
  • Nebulizer setup
  • Medications (albuterol, ipratropium, epinephrine nebules)

5.4 EMERGENCY STOCKPILE

For 1-month supply without resupply (disaster preparedness):

Antibiotics:

  • Amoxicillin 500 mg tabs: 60-100 tablets
  • Ceftriaxone 500 mg vials: 20 vials
  • Ciprofloxacin 500 mg tabs: 40 tablets
  • Metronidazole 250 mg tabs: 60 tablets
  • Doxycycline 100 mg tabs: 30 tablets
  • TMP-SMX DS tabs: 40 tablets

Analgesics/Antipyretics:

  • Acetaminophen 500 mg: 300 tablets
  • Ibuprofen 400 mg: 200 tablets
  • Morphine 10 mg/mL: 10 vials

Cardiovascular:

  • Aspirin 325 mg: 200 tablets
  • Nitroglycerin SL 0.3 mg: 1 bottle (50 tabs)
  • Heparin 5000 units/mL: 10 vials
  • Epinephrine 1 mg/mL: 10 vials

Fluids/Electrolytes:

  • NS 1 L bags: 50 units
  • D5W 500 mL: 20 units
  • KCl 20 mEq/20 mL: 10 ampules
  • MgSO4 50%: 10 vials

Respiratory:

  • Albuterol nebules: 50 units
  • Prednisone 50 mg: 60 tablets

GI:

  • Ondansetron 4 mg: 100 tablets
  • Omeprazole 20 mg: 100 capsules
  • ORS packets: 200 packets

5.5 MEDICAL WASTE SEGREGATION

Yellow (Hazardous Biomedical):

  • Syringes with patient blood/body fluids
  • Contaminated gauze, dressings
  • Sharps in yellow sharps containers
  • Expired antibiotics, biologics

Red (Chemical/Pharmaceutical):

  • Expired medications
  • Hazardous drug vials (chemotherapy if used)
  • Contaminated medications

Black (General Waste):

  • Non-contaminated packaging
  • Administrative waste
  • Glass bottles without biological hazard

Special Handling:

  • Sharps: never recap, use needle-safe devices
  • Cytotoxic drugs: designated container, chemotherapy trained staff
  • Controlled substances: destruction log with witness
  • Pharmaceutical waste: follow local regulations (incineration or authorized disposal)

Documentation:

  • Waste log with date, quantity, type
  • Staff initials
  • Disposal method and date
  • Chain of custody for hazardous materials

6. COMMON MEDICATION PROTOCOLS

6.1 RSI PROTOCOL (Rapid Sequence Intubation)

Indication: Emergency airway with aspiration risk

Sequence:

  1. Preparation (Pre-oxygenation 3-5 min 100% O2)

    • Confirm IV access (18 G or larger)
    • Suction, airway equipment at bedside
    • Induction/paralytic drugs drawn up
    • Position head of bed elevated if possible

  2. Preoxygenation (3 min apneic oxygenation with high-flow)

    • Nasal cannula 15 L/min continuous
    • Goal SpO2 >95%

  3. Defasciculation (prevent myalgias with sux)

    • Rocuronium 0.01 mg/kg IV (or skip if rapid onset critical)

  4. Induction (simultaneous cricoid pressure by assistant)

    • Etomidate 0.2-0.3 mg/kg IV (most common for hemodynamic instability)
    • OR Propofol 1-2.5 mg/kg IV (if normotensive)
    • OR Ketamine 1-2 mg/kg IV (if hypotension risk)

  5. Paralysis (high-dose rocuronium or succinylcholine)

    • Rocuronium 1-1.2 mg/kg IV (non-depolarizing, onset 30-60 sec)
    • OR Succinylcholine 1-1.5 mg/kg IV (depolarizing, onset 30-40 sec, shorter duration)
    • Expect fasciculations, hyperkalemia with sux

  6. Intubation

    • Attempt within 30 sec of paralysis
    • Confirm tube position (auscultation, capnography, CXR)
    • Document tube size, depth, cuff pressure 20-30 cm H2O

  7. Post-Intubation Sedation

    • Propofol 1-2 mg/kg load, then 0.5-2 mg/kg/hr infusion
    • OR Midazolam 0.05-0.1 mg/kg IV, then 0.02-0.1 mg/kg/hr
    • Consider parallel analgesia (morphine 2-10 mg IV Q2-4H)

6.2 SEDATION SCALES

Richmond Agitation-Sedation Scale (RASS):

+4  Combative
+3  Very agitated (pulls at tubes)
+2  Agitated (frequent non-purposeful movement)
+1  Restless (shifting, occasional purposeful movement)
 0  Alert and calm
-1  Drowsy (awakens to verbal stimuli, ≤10 sec)
-2  Light sedation (awakens to verbal stimuli but <10 sec)
-3  Moderate sedation (movement or eye opening to verbal stimuli)
-4  Deep sedation (movement/eye opening to physical stimuli only)
-5  Unarousable (no response to stimuli)

Target: RASS -1 to 0 for cooperative patients, -2 to -3 for intubated

Glasgow Coma Scale (GCS):

Eye Opening (E):    4 spontaneous, 3 to voice, 2 to pain, 1 none
Verbal Response (V): 5 oriented, 4 confused, 3 inappropriate, 2 incomprehensible, 1 none
Motor Response (M):  6 obeys, 5 localizes, 4 withdraws, 3 abnormal flexion, 2 abnormal extension, 1 none

Total: 3-15 (15 = normal, 8 = intubation criteria)

6.3 WHO PAIN LADDER

Step 1 (Mild Pain 1-3/10):

  • Non-pharmacologic: relaxation, distraction, positioning
  • Acetaminophen 500-1000 mg Q4-6H, OR
  • Ibuprofen 400-800 mg Q6-8H

Step 2 (Moderate Pain 4-6/10):

  • Continue Step 1 agents, PLUS
  • Weak opioid: Codeine 15-30 mg Q4-6H with acetaminophen 500 mg (max 4000 mg/day)
  • OR Tramadol 50-100 mg Q4-6H (max 400 mg/day)

Step 3 (Severe Pain 7-10/10):

  • Continue non-opioid + opioid, switch to strong opioid:
  • Morphine 5-10 mg IV Q2-4H, titrate by 25-50%
  • OR Morphine 10-30 mg PO Q3-4H
  • Ensure breakthrough doses available (10-25% total 4-hour requirement)

Adjuncts at Any Step:

  • NSAIDs (reduce Step 3 opioid by 25-30%)
  • Anticonvulsants (neuropathic pain): gabapentin, pregabalin
  • Antidepressants (chronic pain): amitriptyline, duloxetine
  • Topical: lidocaine patches for localized pain
  • Non-pharmacologic: physical therapy, counseling, heat/cold

6.4 HEPARIN DRIP PROTOCOL

Initial Setup:

25,000 units heparin in 250 mL NS = 100 units/mL
Weight-based: Initial bolus 5000 units IV push (or 80 units/kg for acute MI)
Initial rate: 18 units/kg/hr (for 70 kg = 1260 units/hr = 12.6 mL/hr)

Nomogram (aPTT-Based Dosing):

aPTT (sec)   Ratio   Action
<35          <1.2    Bolus 80 units/kg, increase rate by 4 units/kg/hr
35-45        1.2-1.5 Bolus 40 units/kg, increase rate by 2 units/kg/hr
46-70        1.5-2.3 No change
71-90        2.3-3.0 Decrease rate by 2 units/kg/hr
>90          >3.0    Hold 1 hour, decrease rate by 3 units/kg/hr

Monitoring:

  • Baseline aPTT, Cr, CBC, platelet count
  • Repeat aPTT 6 hours after bolus, then 24 hours, then Q24H
  • Target aPTT 1.5-2.5x baseline (approximately 46-70 sec)
  • Daily platelet count (HIT screening)

Dose Adjustments:

  • Significant change: recheck aPTT 6 hr after adjustment
  • Stable patient: Q24H checks
  • Transition to warfarin when aPTT therapeutic x24 hr, then overlap 4-5 days before discontinuing heparin

6.5 INSULIN PROTOCOLS

Type 1 Diabetes (Basal-Bolus Regimen):

Basal: Long-acting insulin (glargine/detemir) 0.1-0.2 units/kg daily
Bolus: Rapid-acting (lispro/aspart) 0.05-0.1 units/kg per meal

Example (70 kg):
Basal: 10-14 units glargine daily
Bolus: 3.5-7 units per meal (adjust for carbs and pre-meal glucose)

Type 2 Diabetes (Initiation):

  • Metformin 500 mg BID first-line
  • Add glargine 10 units daily if A1C persistently >7% on max metformin
  • Titrate glargine by 2 units every 3 days to goal fasting glucose 80-130 mg/dL

Perioperative/Acute Illness (NPO Status):

  • Hold rapid-acting insulin
  • Continue 50% of basal insulin dose
  • Use IV dextrose with insulin infusion if needed

DKA Protocol:

  • Bolus: 0.1 units/kg IV regular insulin
  • Infusion: 0.1 units/kg/hr (70 kg = 7 units/hr)
  • Increase by 0.5-1 units/hr based on glucose decline rate (goal 50-100 mg/dL/hr)
  • When glucose <250: switch to D5W with insulin (prevents hypoglycemia)
  • Continue insulin until bicarbonate >18 mEq/L

Hypoglycemia (glucose <70 mg/dL):

  • Conscious: 15 g fast carbs (4 oz juice, 3-4 glucose tablets)
  • Unconscious: Glucagon 0.5-1 mg IM/SC, then dextrose 25-50 g IV
  • Recheck glucose 15 min after treatment

6.6 ELECTROLYTE REPLACEMENT

Hypokalemia (K+ <3.5 mEq/L):

Deficit calculation: K+ deficit = 0.6 x BW x (3.5 - current K+)
Example: 70 kg, K+ 2.5 = 0.6 x 70 x 1.0 = 42 mEq deficit

IV replacement:
- Mild (3.0-3.4): 20 mEq over 2-4 hours
- Moderate (2.5-2.9): 20-40 mEq over 1-2 hours
- Severe (<2.5): 40-60 mEq over 1 hour (monitor cardiac rhythm)
Maximum: 10 mEq/100 mL (peripheral), 20 mEq/100 mL (central line)

Hyperkalemia (K+ >5.5 mEq/L):

EKG Changes (peaked T waves, prolonged PR, wide QRS, ST depression):
- Calcium gluconate 10%: 5-10 mL IV over 2-5 min (membrane stabilization, onset 1-3 min)
- Insulin + dextrose: 10 units regular insulin + 25-50 g dextrose IV (K+ shift, onset 10-20 min)
- Albuterol: 10-20 mg nebulized (K+ shift, onset 30 min)
- Sodium bicarbonate: 1 mEq/kg IV if acidotic (K+ shift)
- Diuretics: furosemide 40-80 mg IV (if renal function adequate)
- Cation exchange resin: sodium polystyrene sulfonate 15 g PO/PR TID (chronic)
- Dialysis: if renal failure, K+ >7, refractory symptoms

Hypomagnesemia (Mg <1.7 mg/dL):

Replacement: MgSO4 1-2 g IV over 5-30 min
Maintenance: 1-2 g IV Q4-6H or continuous infusion 1-2 g/hr
PO: Magnesium glycinate 400 mg daily (better tolerance than oxide)

Hyponatremia (Na+ <130 mEq/L):

Acute symptomatic (<130, seizures):
- 3% NaCl: 100 mL IV over 10-20 min
- Goal: increase Na+ by 4-6 mEq/L acutely, then slower
- Calculate: mEq needed = 0.6 x BW x (desired Na - current Na)
- Maximum 8-10 mEq/L per day (risk of CPM if faster)

Chronic (>130):
- Fluid restriction 500-1000 mL daily
- Hypertonic saline only if symptomatic
- Slow correction (4-8 mEq/L per day)

6.7 STRESS ULCER PROPHYLAXIS

High-Risk Patients (ICU, mechanical ventilation, major surgery, coagulopathy, large burn):

First-Line:

  • Omeprazole 20-40 mg IV Q12H, OR
  • Pantoprazole 40 mg IV daily

Alternative:

  • Famotidine 20 mg IV Q12H (H2-blocker, less effective than PPI)

Duration:

  • Continue until high-risk period resolves
  • Discharge on PPI 20 mg daily if recurrent GI bleeding history

6.8 DVT PROPHYLAXIS

Pharmacologic Prophylaxis (if not anticoagulated):

Low Risk (outpatient surgery <1 hr): None required

Moderate Risk (surgery >1 hr, >40 yr, one risk factor):

  • Enoxaparin 40 mg SC daily (start post-op evening)
  • Duration: 7-10 days minimum

High Risk (trauma, orthopedic surgery, cancer, stroke):

  • Enoxaparin 40 mg SC BID or 30 mg BID (renal failure)
  • OR Unfractionated heparin 5000 units SC Q8H
  • Duration: 10-35 days based on risk

Mechanical Prophylaxis:

  • Sequential compression devices (SCDs) for bedridden patients
  • Continue until fully ambulatory

Assessment:

  • Calf swelling (>2 cm difference vs. other leg)
  • Homans sign (calf pain with dorsiflexion)
  • D-dimer if suspicious, confirm with ultrasound

6.9 VASOPRESSOR TITRATION

Septic Shock Protocol (target MAP ≥65 mmHg):

  1. Initial Resuscitation (First 1 Hour)

    • IV fluid bolus 30 mL/kg crystalloid
    • Vasopressor if hypotensive after fluids

  2. Vasopressor Initiation

    • Norepinephrine first-line: start 0.5-1 mcg/kg/min, titrate by 0.5-1 mcg/kg/min Q5min
    • Goal: adequate perfusion (urine output >0.5 mL/kg/hr, lactate clearance)

  3. Second-Line Agents

    • If insufficient response to 3 mcg/kg/min norepi: add vasopressin 0.04 units/min (fixed dose, non-titrated)
    • OR add epinephrine 0.5-1 mcg/kg/min

  4. Titration

    • Blood pressure response typically within 5-10 min
    • Maintain MAP 65-75 mmHg (higher in baseline hypertension)
    • Continue vasopressor taper as volume status improves

  5. Weaning

    • Decrease by 25-50% when MAP stable >65 with reduced fluid requirements
    • Discontinue when <0.05 mcg/kg/min

6.10 CODE BLUE MEDICATIONS (ACLS Protocol)

Initial Rhythm: Ventricular Fibrillation/Pulseless VT

Start: CPR immediately, attach defibrillator
Shock: Initial defibrillation attempt (120-200 J biphasic, 360 J monophasic)

Medication Sequence (every 3-5 min of CPR):
1st cycle: Epinephrine 1 mg IV push (0.01 mg/kg peds)
3rd cycle: Epinephrine 1 mg IV push OR Vasopressin 40 units IV single dose

If no response after 2 shocks:
- Amiodarone 300 mg IV push (first dose), then 150 mg after 3-5 min CPR
- OR Lidocaine 1-1.5 mg/kg IV initial, then 0.5-0.75 mg/kg Q5-10min, max 3 mg/kg

Continue CPR for minimum 2 min between reassessment

Asystole/PEA

Start: CPR immediately
Epinephrine 1 mg IV push every 3-5 min during CPR
Consider treatable causes: Hypovolemia, Hypoxia, Hydrogen ion (acidosis), Hypokalemia/Hyperkalemia, Hypothermia, Tension pneumothorax, Tamponade, Thromboembolism, Toxins

PEA with perfusing rhythm: Address underlying cause
- If severe bradycardia: Atropine 0.5-1 mg Q3-5min, max 3 mg + pacing
- If severe hypotension: Epinephrine infusion, dopamine, norepinephrine

Post-Resuscitation Care

  • Targeted temperature management 32-36°C for 12-24 hr (ROSC after VF)
  • Goal PaO2 100-300 mmHg, FiO2 minimum to achieve
  • Goal PaCO2 40-50 mmHg
  • Avoid hypoglycemia, maintain <180 mg/dL
  • Seizure prophylaxis: levetiracetam 500 mg IV Q12H

APPENDIX: QUICK REFERENCE TABLES

Common Pediatric Weight-Based Dosing

DrugDose
Acetaminophen15 mg/kg Q4-6H
Ibuprofen5-10 mg/kg Q6-8H
Amoxicillin25-45 mg/kg/day Q8H
Ceftriaxone50-80 mg/kg/day Q12H
Morphine IV0.05-0.2 mg/kg Q2-4H
Albuterol neb0.15 mg/kg per dose
Prednisone0.5-2 mg/kg/day
Epinephrine (cardiac arrest)0.01 mg/kg IV
Heparin bolus100 units/kg IV
Propofol2-3.5 mg/kg IV

Pregnancy Safety Categories (FDA Legacy)

  • Category A: No risk in human studies (acetaminophen, prenatal vitamins)
  • Category B: No risk in animal studies, no human data (amoxicillin, cephalosporins, insulin)
  • Category C: Risk in animals, no human data (antibiotics: fluoroquinolones, azithromycin)
  • Category D: Evidence of fetal risk, but may use in life-threatening (warfarin, phenytoin)
  • Category X: Contraindicated in pregnancy (methotrexate, ACE inhibitors 3rd tri, misoprostol)

End of Document Version 1.0 | Last Updated: 2026-02-19

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