Littleton Regional Healthcare · Emergency Department

Pediatric Emergencies

Enter a weight once above — every card below calculates its doses live from it. Weight and timers live only on this device, clear on RESET FOR NEXT CASE, and auto-clear after an hour of inactivity — still, always tap RESET between patients.

02Anaphylaxis

EPINEPHRINE IS FIRST-LINE — DON'T DELAY IT

NAME

"This is anaphylaxis — epi IM now." Say it out loud.

CLAIM

Epi/IM injection · airway watch · IV fluids · antihistamine/steroid adjuncts — assign aloud.

AIM

IM epinephrine immediately — everything else is an adjunct. Watch the airway if there's angioedema/stridor.

EPINEPHRINE — CALCULATED FROM WEIGHT ABOVE

Route	Dose	Max	Repeat
IM (1:1000), anterolateral thigh	0.01 mg/kg = enter weight above	0.5 mg (WAO 2020)	q5–15min

SINCE LAST EPI DOSE

—

Tap each button when that dose is given — each is time-stamped to the case timeline.

IV BOLUS DOSE 1 mcg/kg = enter weight above max 50 mcg

The 2023 AAAAI/ACAAI update caps the pediatric/teen dose at 0.3 mg instead of 0.5 mg — the two major sources disagree on the ceiling; this tool uses the WAO 2020 figure (0.5 mg) but confirm which cap your pharmacy/EMS protocol uses. Auto-injector fixed doses (for reference, not a substitute for a weight-based calculation when you can draw one up): 0.1 mg for 7.5–15 kg, 0.15 mg for 15–30 kg, 0.3 mg for ≥30 kg — some bodies now favor switching to the 0.3 mg device closer to 25 kg to avoid underdosing.

IF NOT RESPONDING TO IM EPI

Crystalloid 20 mL/kg = enter weight above (max 1 L). Repeat for persistent hypotension.
Refractory: epinephrine 1 mcg/kg slow IV = enter weight above (max 50 mcg), then 0.1–1 mcg/kg/min.
Angioedema or stridor progressing? Take the airway early and electively. → sizes: card 16

ADJUNCTS — CALCULATED FROM WEIGHT ABOVE — NOT FIRST-LINE, DON'T DELAY EPI FOR THESE

Drug	Dose	Max
Diphenhydramine IV/IM	1 mg/kg = enter weight above	50 mg
Famotidine IV	1 mg/kg = enter weight above	20 mg
Dexamethasone IV/IM/PO	0.6 mg/kg = enter weight above	10 mg (PowerPlan)
Albuterol nebulizer (bronchospasm/wheeze)	unit-dose neb, may repeat q20min ×3	— (PowerPlan)
Racemic epinephrine 2.25% neb (stridor/upper-airway edema)	0.5 mL in 3 mL NS (0.25 mL if <5 kg)	— (PowerPlan)

These relieve itch/hives (antihistamine), blunt a biphasic reaction (steroid), or treat bronchospasm/stridor (albuterol, racemic epi) — none replace IM epinephrine for the airway/hemodynamic compromise. Doses per the originating hospital's Pediatric General PowerPlan (Cerner order set) where marked; otherwise institutional pediatric ED pathways.

Observation after treatment: a large 2025 pediatric ED cohort (5,641 patients, 31 sites) found only 4.7% needed repeat epinephrine after 2 hours and 1.9% after 4 hours — suggesting 2 hours is likely sufficient for children without cardiovascular involvement, 4 hours for those with cardiovascular symptoms. Older institutional pathways still specify a flat 4–6 hour observation; a small rural ED without close follow-up access may reasonably choose the more conservative standard.

Sources: World Allergy Organization Anaphylaxis Guidance 2020 (epinephrine 0.01 mg/kg IM, max 0.5 mg, repeat q5–15min; 20 mL/kg fluid bolus); AAAAI/ACAAI Anaphylaxis: A 2023 Practice Parameter Update (0.3 mg pediatric epinephrine cap — conflicts with WAO's 0.5 mg, noted above); Johns Hopkins All Children's Hospital Anaphylaxis Clinical Pathway 2023 (adjunct dosing); Dribin TE, et al., "Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods," Lancet Child Adolesc Health 2025;9(7):484-496. The originating hospital's Pediatric General PowerPlan (Cerner order set) — dexamethasone 0.6 mg/kg (max 10 mg), albuterol nebulizer q20min ×3, racemic epinephrine 2.25% 0.5 mL neb (0.25 mL if <5 kg, dilute in 3 mL NS), and the epinephrine IM 0.01 mg/kg <15 kg / EpiPen Jr 15–29.9 kg / EpiPen ≥30 kg tiering. IV-epinephrine bolus/infusion figures are standard pediatric-resuscitation references, not PowerPlan values — confirm with pharmacy.

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.

03Asthma Exacerbation

DEXAMETHASONE-FIRST · PASS SEVERITY

NAME

"Pediatric asthma exacerbation — [mild/moderate/severe], starting weight-based albuterol." Say it out loud.

CLAIM

Nebulizer/MDI setup · dexamethasone · IV access if severe · monitoring — assign aloud.

AIM

Determine PASS severity first — it decides everything downstream. Dexamethasone up front, weight-based albuterol, escalate fast if severe.

SEVERITY (PASS) & TRIAGE

Mild (ESI 4): dexamethasone + albuterol MDI 2–4 puffs. Spacer teaching, discharge.
Moderate (ESI 3): dexamethasone + albuterol neb q20min ×3 PRN. Allow ≥2 h before disposition.
Severe (ESI 1–2): dexamethasone + albuterol/ipratropium neb. Consider magnesium.
Critical: resus room, NIPPV 10/5 cmH₂O with RT, Tier 1 PICU alert. → sizes: card 16
Supplemental O₂ for persistent SpO₂ <90%.

ALBUTEROL & IPRATROPIUM — WEIGHT-TIERED (nebulized)

Weight	Albuterol (0.5%) unit dose	MDI puffs	Continuous (1h uniNeb)
5–10 kg	2.5 mg (0.5 mL)	4	7.5 mg/hr
>10–20 kg	3.75 mg (0.75 mL)	6	11.25 mg/hr
>20 kg	5 mg (1 mL)	8	15 mg/hr

Weight	Ipratropium (0.02%) unit dose	MDI puffs
5–10 kg	500 mcg over 1h in uniNeb, or 250 mcg q20min ×2	4
>10–20 kg	1000 mcg over 1h in uniNeb, or 500 mcg q20min ×2	6
>20 kg	1000 mcg over 1h in uniNeb, or 500 mcg q20min ×2	8

STEROIDS — CALCULATED FROM WEIGHT ABOVE

Dexamethasone: 5–8 kg → 4 mg · >8–12 kg → 6 mg · >12 kg → 8 mg. Repeat in 24–48 h.
Prednisone/methylprednisolone (alternative): 2 mg/kg PO/IV = enter weight above, max 60 mg.

ESCALATION MEDICATIONS — CALCULATED FROM WEIGHT ABOVE

Magnesium 50 mg/kg = enter weight above (max 2 g) + saline 20 mL/kg. Vitals q15min, observe 60 min.
Terbutaline 10 mcg/kg IV over 5 min = enter weight above (max 250 mcg), q15–30min, max 3 doses.

Sources: Children's Hospital of Philadelphia, Emergency Department Clinical Pathway for Evaluation/Treatment of Children with Asthma, last revised May 2026 — PASS severity triage, weight-tiered albuterol/ipratropium dosing, dexamethasone weight-band dosing, magnesium/terbutaline escalation dosing, and the overall dexamethasone-first pathway structure. The originating hospital's Pediatric General PowerPlan (Cerner order set) — albuterol nebulizer/DuoNeb q20min ×3, albuterol HFA 4 puffs, dexamethasone 0.6 mg/kg (max 10 mg) and prednisolone 2 mg/kg (max 60 mg) as the originating hospital's ordered equivalents of the CHOP weight bands.

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.

04Airway Obstruction (Choking)

FOREIGN BODY ASPIRATION

NAME

"Choking — complete/partial obstruction, [age]." Say it out loud.

CLAIM

BLS maneuvers · airway equipment/Magill forceps ready · surgical airway backup — assign aloud.

AIM

Effective cough = don't intervene, watch closely. Ineffective/absent cough = act immediately, technique differs by age.

PARTIAL VS. COMPLETE OBSTRUCTION

Effective cough → do not intervene. Let them cough and watch.
Weak cough, cyanosis, stridor, poor air movement → intervene now.
Unresponsive, any age: start CPR. Look in the mouth before each set of breaths.

TECHNIQUE BY AGE (2025 AHA/AAP update)

Infant <1 yr: 5 back blows, then 5 chest thrusts. NO abdominal thrusts.
Child ≥1 yr and adults: alternate 5 back blows with 5 abdominal thrusts.
Continue cycling until the object is expelled or the victim becomes unresponsive.

IF BLS MANEUVERS FAIL — PROVIDER ESCALATION

Above the cords: direct laryngoscopy, Magill forceps or suction. → sizes: card 16
At or below the cords and removal fails → needle cricothyrotomy with jet ventilation.
Judge by anatomic size, not by age. Do not rely on one cutoff number.

Sources: AHA/AAP 2025 Guidelines for CPR and ECC, Part 6: Pediatric BLS, Circulation 2025 (CIR.0000000000001370) — back-blow/thrust technique by age, contraindication of abdominal thrusts in infants; American Red Cross FBAO Guidelines Database. StatPearls, Foreign Body Airway Obstruction and Cricothyroidotomy; WikEM and LITFL, needle cricothyrotomy age/size discussion — presented as an area of genuine guideline disagreement, not a fixed cutoff.

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.

05Epiglottitis / Upper Airway Emergency

DO NOT AGITATE · DO NOT EXAMINE THE AIRWAY

NAME

"Possible epiglottitis — keeping the child calm with the parent, calling for airway backup now." Say it out loud.

CLAIM

Minimal-handling protocol · blow-by O₂ · transfer team call · surgical airway kit at bedside — assign aloud.

AIM

Disturb the least, prepare for the worst. Don't touch the airway or agitate the child — call for transport and an airway team in parallel.

Do not lay the child flat. Do not place an IV. Do not examine the oropharynx with a tongue depressor. Do not force a mask onto the face. Any of these can precipitate sudden complete obstruction via a ball-valve effect.

CLASSIC PRESENTATION

Abrupt fever, toxic, tripod or sniffing position, drooling, muffled voice, stridor.

RURAL ED — WHAT TO DO WHILE AWAITING TRANSFER

Keep the child sitting up with the parent. Blow-by oxygen only.
Call the PICU transport team and the receiving ED now, in parallel.
Open a pediatric cric kit and have a BVM at the bedside. Do not laryngoscope. → sizes: card 16
Monitor continuously without repeated exams. Do not send the child to CT.
Disturb the least, prepare for the worst.

MEDICAL ADJUNCTS — ONLY IF GIVABLE WITHOUT AGITATING THE CHILD

Racemic epinephrine 2.25%: 0.5 mL in 3 mL NS as blow-by (0.25 mL if <5 kg).
Dexamethasone 0.6 mg/kg IV/IM (max 10 mg) = enter weight above — after the airway, or at induction.

ANTIBIOTICS ONCE AIRWAY IS SECURED

Ceftriaxone 50–100 mg/kg/day IV (max 2 g/day). Add vancomycin 15 mg/kg q6h if MRSA.
Immunocompromised: cefepime 50 mg/kg IV q8h (max 2 g) + vancomycin 15 mg/kg IV q6h.
Hib vaccination does not rule it out.

CROUP vs. EPIGLOTTITIS vs. BACTERIAL TRACHEITIS

	Croup	Epiglottitis	Bacterial tracheitis
Age	6mo–3y	2–7y (shifting older)	6mo–14y
Cause	Viral	Bacterial	Bacterial (post-viral)
Onset	Gradual	Very rapid (hours)	Rapid
Cough	Barking	Suppressed/absent	Present, brassy
Drooling	No	Yes	No
Position	Comfortable supine	Tripod, neck extended	Can lie supine, toxic
Imaging	Steeple sign (AP)	Thumbprint sign (lateral)	Steeple + irregular tracheal air

Imaging should never delay airway management or be attempted in an unstable, tripoding, drooling child — clinical gestalt overrides radiographic confirmation.

Sources: StatPearls, Epiglottitis (NBK430960); WikEM, "Epiglottitis" and antibiotic dosing template; EMCrit IBCC, "Epiglottitis" (Farkas); RCEMLearning, croup/epiglottitis/tracheitis comparison. Post-Hib epidemiology per PubMed 23076559 and PMC2870429. No rural-specific stabilize-and-transfer guideline exists for this condition — that section is a synthesis of general principles, not a direct quote from a named protocol. Racemic epinephrine and dexamethasone doses per the originating hospital's Pediatric General PowerPlan (Cerner order set); their use in epiglottitis specifically is temporizing/low-evidence — the do-not-agitate principle overrides both.

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.

06Bronchiolitis

SUPPORTIVE CARE — NOT ASTHMA, DON'T TREAT IT LIKE ASTHMA

NAME

"Bronchiolitis — supportive care, watching for respiratory failure." Say it out loud.

CLAIM

Suction · oxygen/HFNC · hydration · intubation backup if apneic — assign aloud.

AIM

Supportive care is the treatment — bronchodilators/epi/steroids don't work here. Watch closely for apnea/respiratory failure, especially in young infants.

Bronchiolitis is a clinical diagnosis in a typical presentation (viral prodrome, then increased work of breathing with crackles/wheeze in an infant <24 months) — routine labs and chest imaging are not needed in a straightforward case and mainly add noise/false reassurance.

Sources: Friedman JN, Rieder MJ, Walton JM; Canadian Paediatric Society, Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age, 2021 (cps.ca/en/documents/position/bronchiolitis) — supportive-care-only framework, discouraging bronchodilators/steroids/chest physio/routine hypertonic saline, and the SpO₂ target discussion. Bronchiolitis-vs-asthma distinction and apnea/respiratory-failure progression pattern cross-checked against a University of British Columbia Department of Emergency Medicine simulation case (Salehmohamed, 2022), used here only as a teaching-scenario cross-check, not as an independent clinical source.

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.

07Diabetic Ketoacidosis (DKA)

SLOW, STEADY CORRECTION · WATCH FOR CEREBRAL EDEMA

NAME

"Suspected pediatric DKA — starting fluids, watching for cerebral edema." Say it out loud.

CLAIM

2 PIV access · fluids/insulin timing · hourly glucose/q2h labs · neuro checks — assign aloud.

AIM

Rehydrate first, start insulin only after the first bolus, correct slowly (50–100 mg/dL/hr glucose drop), and watch for cerebral edema the whole time.

Cerebral edema occurs in 0.3–0.9% of pediatric DKA with 21–24% mortality, and can appear before, during, or after treatment (typically within 12h). Watch for new headache, recurrent vomiting, altered mental status, urinary incontinence, or a Cushing triad (bradycardia, irregular respirations, hypertension) — treat empirically on high suspicion, don't wait for imaging.

DIAGNOSIS & INITIAL ASSESSMENT

DKA confirmed: glucose >200 mg/dL AND beta-hydroxybutyrate >3 mmol/L AND (pH <7.3 OR HCO₃ <15 mmol/L).
Two IVs. VBG, BMP, Mg, phosphate, HgbA1c, CBC. POC glucose and ketones at triage.
Assess mental status, vitals, dehydration and cerebral-edema risk. Start the flowsheet.

FLUIDS — CALCULATED FROM WEIGHT ABOVE

Bolus 20 mL/kg NS over 1 hour = enter weight above.
Then NS at 1.5× maintenance. No dextrose yet.
Insulin starts only after the first NS bolus is completed — never before.

2-BAG DEXTROSE SYSTEM (by blood glucose)

Blood glucose	Dextrose in IVF
<200 mg/dL	All D10 0.9% NaCl
200–299 mg/dL	Half D10 0.9% NaCl, half 0.9% NaCl
≥300 mg/dL	All 0.9% NaCl

If glucose is needed before electrolyte results are back, use D10 0.45% NaCl. Rate: 1.5× maintenance. Goal glucose drop: 50–100 mg/dL/hr — adjust the dextrose concentration to hit this, don't just stop insulin to slow the drop.

POTASSIUM REPLACEMENT (by serum K⁺)

Serum K⁺	KCl in IVF	KPhos in IVF
<4 mEq/L	30 mEq	30 mEq (20.4 mM)
4–5.4 mEq/L	20 mEq	20 mEq (13.6 mM)
5.5–6 mEq/L	10 mEq	10 mEq (6.8 mM)
>6 mEq/L	None	None

Get an ECG if K⁺ <2.5 or >6 mEq/L. Sodium bicarbonate is not recommended for DKA acidosis correction.

INSULIN & MONITORING

Insulin 0.1 units/kg/hr = enter weight above, after the bolus finishes.
Labs: POC blood glucose hourly; BMP/Mg/phos and POC beta-hydroxybutyrate q2h; VBG q2h until pH >7.0.
Monitoring: full cardiorespiratory monitoring; vitals and neuro assessment hourly.
Resolved: HCO₃ ≥15, gap <10, improved and drinking → SC insulin, wait 20 min, then stop the drip.

SMALL RURAL ED — ICU ADMISSION / TRANSFER

No pediatric ICU here? Start the protocol above and arrange transfer early.
Suspected cerebral edema: treat FIRST — hypertonic saline or mannitol, head up.

Sources: Children's Hospital of Philadelphia, Emergency Department, ICU and Inpatient Clinical Pathway for Evaluation/Treatment of Children with Suspected Diabetic Ketoacidosis (DKA), last revised May 2026 — diagnostic criteria, fluid bolus/2-bag dextrose system, potassium replacement table, insulin timing/infusion rate, monitoring cadence, and resolution/transition criteria. ISPAD Clinical Practice Consensus Guidelines 2022: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State (cerebral edema epidemiology/warning signs, cited within the CHOP pathway's own evidence page).

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.

08Altered Mental Status

GLUCOSE FIRST · DON'T MISS THE RED FLAGS

NAME

"Altered mental status — checking glucose first." Say it out loud.

CLAIM

Airway/GCS · glucose/dextrose · naloxone if suspected opioid · red-flag workup — assign aloud.

AIM

Airway/breathing/circulation, then glucose immediately. Work the differential fast — several causes (hypoglycemia, meningitis, abusive head trauma) are time-critical.

INITIAL STABILIZATION

ABCs first — GCS ≤8 or non-protective airway reflexes → intubate (equipment sizes: card 16).
POC glucose immediately. Treat if <60 mg/dL, or <40 in a neonate.

DEXTROSE DOSING — CALCULATED FROM WEIGHT ABOVE ("5/2/1–50" rule)

Concentration	Dose	Calculated
D10W	5 mL/kg	enter weight above
D25W	2 mL/kg	enter weight above
D50W	1 mL/kg	enter weight above

Each row delivers the same "glucose dose" regardless of which concentration is on hand (5×10 = 2×25 = 1×50). D10/D25 preferred over D50 peripherally in children — extravasation/phlebitis risk. This is a widely-used educational convention, not a numbered society-guideline value — sensible but not independently graded evidence.

NALOXONE IF OPIOID EXPOSURE SUSPECTED

Neonates: 0.01 mg/kg IV/IM/SC, repeat q2–3min.
Children: naloxone 0.01 mg/kg IV, up to 0.1 mg/kg if no response. Auto-injector 0.4 mg.
Naloxone 0.01 mg/kg IV initial. Escalate up to 0.1 mg/kg if the response is inadequate — do not under-dose a clear overdose or respiratory arrest.

RED FLAGS TO RULE OUT FAST

Abusive head trauma — unexplained AMS with no reported trauma. See card 12.
“One pill can kill”: opioids, sulfonylureas, TCAs, CCB/beta-blockers, clonidine.
Meningitis/encephalitis — fever + AMS ± nuchal rigidity/bulging fontanelle in an infant.
DKA / cerebral edema — see card 07.
Unexplained lethargy in a neonate → think inborn error of metabolism.

The mnemonic AEIOU-TIPS (alcohol/acidosis, epilepsy/electrolytes, insulin, overdose, uremia, trauma, infection, psychiatric/poisoning, stroke/shock/seizure) is widely taught for organizing this differential — it's an educational convention, not an issued guideline.

Sources: Song JL, Wang VJ, "Altered Level of Consciousness in the Pediatric Patient," Pediatric Emergency Medicine Practice, EB Medicine, Jan 2017 (AEIOU-TIPS, GCS≤8 intubation threshold, initial-stabilization sequence); PEMBlog, "5/2/1–50" dextrose rule; AAP Technical Report, "Abusive Head Trauma in Infants and Children," Pediatrics 2025;155(3):e2024070457; ISPAD 2018 DKA/cerebral-edema criteria; Drugs.com pediatric naloxone dosing, cross-checked against the 1990 AAP addendum on naloxone dosing (conflict noted above — verify against a current pharmacy reference before printing a fixed number).

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.

09Behavioral Agitation

DE-ESCALATE FIRST · MEDS ARE THE FALLBACK, NOT THE FIRST MOVE

NAME

"Acute agitation — de-escalating first, low-stimulation space." Say it out loud.

CLAIM

Verbal de-escalation lead · environment/family liaison · medication if needed · safety/monitoring — assign aloud.

AIM

Non-pharmacologic de-escalation is first-line, attempted before, during, and after any medication — never simply replaced by it. Restraint is a last resort.

Sources: Gerson R, et al., "Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department," American Association for Emergency Psychiatry consensus statement, West J Emerg Med 2019; Foster AA, et al., "Standardizing and Improving Care for Pediatric Agitation Management in the Emergency Department," Pediatrics 2023;152(1):e2022059586 — de-escalation framework, medication choices/cautions, and restraint principles. Weight/age-banded dosing cross-checked against Children's Minnesota and Children's Hospital of Richmond institutional pediatric agitation guidelines. The originating hospital's Pediatric General PowerPlan (Cerner order set) — lorazepam 0.05 mg/kg PO (max 2 mg; avoid in autism spectrum disorder), olanzapine 2.5 mg (<30 kg)/5 mg (≥30 kg) PO, midazolam 0.3 mg/kg IN, droperidol or haloperidol 0.05 mg/kg IM (max 5 mg; continuous EKG/SpO₂ after), diphenhydramine 1 mg/kg IV (max 50 mg) PRN dystonia. Restraint time limits per 42 CFR §482.13, CMS Hospital Conditions of Participation.

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.

10Status Epilepticus

CHILDREN >1 MONTH · MAX 2 BENZO DOSES

NAME

"Pediatric status epilepticus — starting the clock, benzo now." Say it out loud.

CLAIM

Airway/glucose · benzo push (max 2 doses) · second-line load · pediatric referral center call — assign aloud.

AIM

Benzodiazepine as early as possible — before you even check glucose. Never give more than 2 benzo doses; move to a second-line agent instead.

0:00

Tap START at seizure onset (>5 min continuous, or 2+ seizures without full recovery of consciousness = status epilepticus).

0–5 min
STABILIZE
5–15 min
BENZO ×2 MAX
15+ min
2ND-LINE

0–5 MIN — INITIAL MANAGEMENT

ABCs, cardiorespiratory/BP monitoring, O₂ 10–15 L/min via non-rebreather.
Give the first benzodiazepine dose as early as possible — before checking glucose, not after.
If febrile: acetaminophen 15 mg/kg/dose PR = enter weight above (max 650 mg).

FIRST-LINE (BENZODIAZEPINE) — CALCULATED FROM WEIGHT ABOVE — MAX 2 DOSES TOTAL

Route	Weight tier	Dose	Max
Midazolam IM/IN (no IV/IO)	≤13 kg	0.2 mg/kg = enter weight above	10 mg
	13–40 kg	5 mg fixed dose	10 mg
	>40 kg	10 mg fixed dose	10 mg
Lorazepam IV/IO	—	0.1 mg/kg = enter weight above	4 mg
Midazolam IV/IO	—	0.1 mg/kg = enter weight above	10 mg

Prehospital: midazolam IM/IN per the weight tiers above; check glucose; if still seizing after 5 min, give a second midazolam dose (max cumulative 10 mg prehospital). ED: give a benzodiazepine if two doses haven't already been given prehospital; check glucose if not done; give a second dose 5 min after the first if still seizing, switching to IV/IO route once access is available. CAUTION: do not give more than 2 doses of benzodiazepines total.

SECOND-LINE (if still seizing after 2 benzo doses) — CALCULATED FROM WEIGHT ABOVE

Drug	Dose	Age	Key caution
Levetiracetam IV/IO (5 min infusion)	60 mg/kg = enter weight above (max 3000 mg)	Any age	↓ side effects/interactions, low psychosis risk
Fosphenytoin IV/IO/IM (10 min infusion)	20 mg PE/kg = enter weight above (max 1000 mg PE)	Any age, less common <6mo	↓BP, ↓HR, arrhythmia; avoid in toxicologic seizures
Valproic acid IV/IO (10 min infusion)	40 mg/kg = enter weight above (max 3000 mg)	≥2 years	Caution: liver dysfunction, mitochondrial disease, urea-cycle disorder, thrombocytopenia, unexplained developmental delay
Phenytoin IV/IO (20 min infusion)	20 mg/kg = enter weight above (max 1000 mg)	Any age, less common <6mo	Same as fosphenytoin; use only if fosphenytoin unavailable
Phenobarbital IV/IO (20 min infusion)	20 mg/kg = enter weight above (max 1000 mg)	<6 months	Respiratory depression, especially with benzodiazepines

If still seizing after the first second-line agent, reassess ABCs and give an alternative second-line agent (e.g., if fosphenytoin was given, switch to levetiracetam) — don't just repeat the same drug.

PEDIATRIC REFERRAL CENTER DISCUSSION — if still seizing

Call the pediatric referral center now. Do not intubate for hypercapnia alone. → sizes: card 16
Consider additional workup: full septic workup, antibiotics/antivirals, brain imaging.
Persistent altered LOC may reflect non-convulsive status epilepticus or a severe underlying brain disorder.
Third-line: an infusion — midazolam, pentobarbital, propofol or ketamine.

Sources: EIIC (EMSC Innovation and Improvement Center), Pediatric Status Epilepticus Algorithm, Version 5.0, published August 2025 (original material developed by TREKK, modified by EIIC) — full timed algorithm, weight-tiered dosing, max-2-benzodiazepine-doses caution, second-line agent table, and pediatric-referral-center discussion points. For children over 1 month of age.

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.

11Neonatal / Young Infant Fever

≥38.0°C · TERM, WELL-APPEARING, 8–60 DAYS

NAME

"Febrile infant, [X] days old — starting the age-based workup." Say it out loud.

CLAIM

Cultures/UA · empiric antibiotics if indicated · transfer coordination · recorder — assign aloud.

AIM

Age band decides the workup. Any infant <8 days or ill-appearing at any age gets the full workup regardless of these bands.

This card covers well-appearing, term (≥37 weeks) infants 8–60 days old with fever ≥38.0°C (100.4°F) and no focal source. Infants <8 days old, and any ill-appearing infant of any age, are outside this pathway — treat as high-risk: full workup, empiric antibiotics, admit.

WORKUP BY AGE BAND

Age	Workup	Disposition
8–21 days	Blood culture, UA+urine culture, and LP — full workup mandatory for all	Admit — mandatory for this entire band, regardless of results
22–28 days	Blood culture, UA+culture, inflammatory markers (ANC, CRP, procalcitonin) always. LP depends on marker/UA results — can be deferred only if all markers negative and follow-up (~24h) is assured.	If LP deferred: one dose empiric parenteral antibiotic + admit, or shared-decision discharge with close follow-up
29–60 days	Blood culture, UA, inflammatory markers. LP is selective — reserved for abnormal markers or positive UA in some pathways.	If UA and all markers negative → may forgo LP/antibiotics with close (24–36h) follow-up

"ABNORMAL" INFLAMMATORY MARKER THRESHOLDS (AAP 2021 CPG)

Inflammatory markers: CRP >20 mg/L · procalcitonin >0.5 ng/mL · ANC >4,000/mm³.
Any one abnormal marker triggers escalation of workup for that band.
61–90 days: PECARN, not this algorithm. Do not mix thresholds.

EMPIRIC ANTIBIOTICS, 8–28 DAYS

Ampicillin + gentamicin. Add acyclovir if there are HSV risk factors.
Ampicillin (meningitis dosing): ≤7 days old — 100 mg/kg/dose IV q8h; >7 days old — 75 mg/kg/dose IV q6h.
Gentamicin interval: ask pharmacy or NICU. Do not use a fixed bedside number.
🚫 No ceftriaxone in neonates. Never with IV calcium.
29–60 days going home (e.g. UTI): ceftriaxone, or oral cephalexin or cefixime.

SMALL RURAL ED — NO LOCAL LP/CSF CAPABILITY

LP not done, traumatic, or deferred → treat as if the CSF were positive.
Cultures if they do not delay transfer. First antibiotic dose now. Then transfer.
Get your medical director's sign-off before treating this as protocol.

Sources: Pantell RH, et al., "Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old," AAP Clinical Practice Guideline, Pediatrics 2021;148(2):e2021052228 — age bands, workup requirements, inflammatory-marker thresholds, and the "treat as CSF-positive if LP unobtainable" principle. Kuppermann N, et al. (PECARN Febrile Infant Rule), 2019, for reference on the 29–60/61–90 day rules outside this guideline's scope. Neonatal antibiotic dosing per standard neonatal formulary references (e.g. UW NICU dosing guide) — gentamicin dosing intentionally not reduced to a single number here; confirm with pharmacy/NICU. The originating hospital's ED Infant Care <90 Days PowerPlan (Cerner order set) — ampicillin 100 mg/kg + gentamicin 4 mg/kg IV (0–28 d; + acyclovir 20 mg/kg if HSV risk), ceftriaxone 50 mg/kg IV (non-meningitis) or 100 mg/kg + vancomycin 20 mg/kg (meningitis dosing), PECARN-based 29–60 d low-risk pathway (negative UA, ANC <4000, procalcitonin ≤0.5 ng/mL), acetaminophen IV 12.5 mg/kg (<29 d) / 15 mg/kg (≥29 d), D10W 2 mL/kg for hypoglycemia, NS 10–20 mL/kg boluses.

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.

12Non-Accidental Trauma

SUSPECTED CHILD PHYSICAL ABUSE

NAME

"This injury pattern is concerning for abuse — starting the standard workup and involving social work." Say it out loud.

CLAIM

Exam/documentation · imaging orders · social work/CPS liaison · law enforcement if indicated — assign aloud.

AIM

"Those who don't cruise rarely bruise." Any bruising/injury in a non-mobile infant deserves a full workup, not reassurance — document objectively, report, and let a comprehensive workup rule things in or out.

Sources: Pierce MC, et al., TEN-4-FACESp clinical decision rule (Lurie Children's Hospital/TRICAM), validated age <4 years. Sheets LK, et al., "Sentinel Injuries in Infants Evaluated for Child Physical Abuse," Pediatrics 2013;131(4):701-707. AAP Clinical Report, "Evaluating Young Children With Fractures for Child Abuse," Pediatrics 2025;155(2):e2024070074 (skeletal survey). AAP Technical Report, "Abusive Head Trauma in Infants and Children," Pediatrics 2025;155(3):e2024070457 (head imaging). American Academy of Ophthalmology/AAPOS Clinical Statement, "The Eye Examination in the Evaluation of Child Abuse" (2018, verify current version). AAP Clinical Reports, "Evaluation for Bleeding Disorders in Suspected Child Abuse" and companion report, Pediatrics 2022;150(4):e2022059276/77. NH RSA 169-C:29-31 (verify current text locally). No single validated NAT-specific imaging decision rule exists analogous to PECARN — the imaging-overlay section above synthesizes institutional consensus protocols (UCSF Benioff, Mary Bridge, Nationwide Children's), not one named guideline.

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.

13Death of a Child in the ED

NOTIFICATION · FAMILY PRESENCE · LOGISTICS

NAME

"We need to notify the family — gathering the team and chaplaincy first." Say it out loud.

CLAIM

Family notification lead · chaplaincy/social work · ME/OPO notification · staff debrief coordination — assign aloud.

AIM

Use the word "died," not "passed" or "didn't make it." Notify the medical examiner and organ-procurement organization for every death — these are not optional or family-permission-gated.

Sources: Hobgood C, et al., "The Educational Intervention 'GRIEV_ING' Improves the Death Notification Skills of Residents," Acad Emerg Med 2005;12(4):296-301. Emergency Nurses Association, Family Presence During Resuscitation and Invasive Procedures Clinical Practice Guideline (2019, synopsis 2024); Society of Trauma Nurses, position statement on family presence during pediatric trauma resuscitation, 2022. AAP/ACEP, "Death of a Child in the Emergency Department," Pediatrics 2014;134(1):e313 (pull full text locally — access-restricted during this research pass). AAP/ACEP/NAEMSP joint policy, "Withholding or Termination of Resuscitation in Pediatric Out-of-Hospital Traumatic Cardiopulmonary Arrest," Pediatrics 2014;133(4):e1104. 42 CFR §482.45(a)(1), CMS Hospital Conditions of Participation (OPO notification). NH RSA 611-B (verify locally). "Unexplained Pediatric Deaths," Academic Forensic Pathology International, 2019 (evidence preservation).

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.

14Procedural Sedation

NPO STATUS NO LONGER GATES SEDATION

NAME

"Procedural sedation for [procedure] — monitoring and airway equipment ready first." Say it out loud.

CLAIM

Proceduralist · dedicated monitoring person (no other duties) · airway/rescue equipment ready — assign aloud.

AIM

Two-person minimum — one proceduralist, one monitoring only. Fasting time doesn't need to delay you; monitoring and a rescue plan do the safety work.

PRE-SEDATION — MONITORING & PERSONNEL, NOT A FASTING CLOCK

Do not delay sedation for NPO time.
Continuous pulse oximetry and cardiac monitoring. Capnography for deep sedation.
Two people: proceduralist, plus a PALS-trained monitor with no other job. Vitals q10min, q5min deep.
Airway rescue equipment and reversal agents at hand before you start.

AGENT DOSING — CALCULATED FROM WEIGHT ABOVE

Agent	Route/dose	Onset / duration
Ketamine	IV: 1–2 mg/kg = enter weight above–enter weight above (max 100 mg), repeat 0.5–1 mg/kg q5–15min	<30 sec / 5–10 min
Ketamine IM	4–5 mg/kg = enter weight above–enter weight above (max 200 mg)	3–5 min / 15–25 min
Propofol	1–2 mg/kg = enter weight above–enter weight above, then 0.5–1 mg/kg q3–5min	<50 sec / 3–10 min
Etomidate (≥6mo)	0.2–0.3 mg/kg = enter weight above–enter weight above	30–60 sec / 2–5 min
Fentanyl	1–2 mcg/kg = enter weight above–enter weight above (max 50 mcg), repeat q3–5min	2–4 min / 30–60 min
Midazolam	0.025–0.1 mg/kg (max 6 mg <6y, 10 mg ≥6y) = up to enter weight above	1–5 min / 0.5–2 hr
Intranasal midazolam (imaging)	~0.3 mg/kg = enter weight above (max 10 mg)	7–10 min

By procedure: fracture/dislocation reduction → IV ketamine alone, ketamine+propofol ("ketofol"), or propofol+fentanyl. Laceration repair → local/topical anesthesia first, then nitrous oxide ± oral/intranasal midazolam for anxiety. Non-painful imaging → intranasal midazolam first-line. Ketamine is relatively contraindicated under 3 months (higher laryngospasm risk); it preserves airway reflexes and is favored if unfasted or in reactive airway disease, and does not raise ICP.

COMPLICATIONS

Laryngospasm: jaw thrust, 100% O₂, positive-pressure BVM. Failing → sux + tube. → sizes: card 16
Apnea: reposition the airway, oxygen, BVM. Reversal agents rarely needed.
Do NOT give prophylactic midazolam with ketamine.

RECOVERY / DISCHARGE CRITERIA

Return to age-appropriate baseline mental status.
Airway patent, protective reflexes intact, adequate spontaneous ventilation.
Vital signs (including room-air SpO₂) at or near baseline.
No need to prove they tolerate oral intake before discharge.

Sources: American College of Emergency Physicians, Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department, Ann Emerg Med 2014;63(2):247-258 (current standing ACEP policy — NPO-status finding). Bhatt M, et al., "Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline" (11-society consensus incl. Society for Pediatric Sedation), Ann Emerg Med 2019;73(5):e51-e65. Coté CJ, Wilson S; AAP/AAPD, "Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation," Pediatrics 2019;143(6):e20191000 (2016 update, reaffirmed 2025). StatPearls, Pediatric Procedural Sedation (NBK572100). Sherwin TS, et al., ketamine/midazolam emergence-reaction trial, Ann Emerg Med 2000. The originating hospital's Pediatric General PowerPlan (Cerner order set) — ketamine 2 mg/kg IV (max 100 mg) / 4 mg/kg IM (max 200 mg) initial procedural-sedation dosing, ondansetron 0.15 mg/kg IV 20 min pre-ketamine, midazolam 0.3 mg/kg IN (max 10 mg) / 0.5 mg/kg PO (max 20 mg) anxiolysis.

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.

15Croup

DEX FOR ALL · RACEMIC EPI IF STRIDOR AT REST

NAME

"This looks like croup — barky cough, [no] stridor at rest." Say it out loud.

CLAIM

Dexamethasone · nebulizer setup if stridor at rest · keep child calm with parent — assign aloud.

AIM

Dexamethasone for every croup. Stridor at rest → racemic epi and observe 3–4 h after the last neb. Agitation worsens everything.

SEVERITY & TREATMENT — CALCULATED FROM WEIGHT ABOVE

All croup: dexamethasone 0.6 mg/kg PO/IV/IM, max 10 mg = enter weight above. One dose.
Stridor at rest: racemic epinephrine 2.25%, 0.5 mL in 3 mL NS (0.25 mL if <5 kg).
Keep the child calm — parent's lap, blow-by. No tongue blade, no IV.
Drooling or tripoding? Think epiglottitis or tracheitis instead. → sizes: card 16

DISPOSITION

Home if no stridor at rest 3–4 h after the last epi, drinking, reliable caregivers.
Admit for recurrent stridor at rest, >1–2 epi doses, hypoxia, poor PO, or uncertainty.

Sources: The originating hospital's Pediatric General PowerPlan (Cerner order set) — dexamethasone 0.6 mg/kg PO/IV/IM max 10 mg (0.3 mg/kg PO listed as an alternative), racemic epinephrine 2.25% 0.5 mL nebulized (0.25 mL if <5 kg, dilute in 3 mL NS). General croup framework (dex-for-all, racemic epi for stridor at rest, 3–4 h post-epi observation, night-2–3 natural history) per standard pediatric EM references (WikEM/StatPearls croup; Bjornson & Johnson, Lancet croup reviews). Westley score intentionally omitted — severity here is the practical stridor-at-rest split, not a formal score.

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.

16Airway Equipment Sizes

ETT · BLADE · SUPRAGLOTTIC · SUCTION

SIZES FOR THIS PATIENT — FROM THE WEIGHT ABOVE

FULL LADDER — EVERY CART DRAWER

BEFORE AND AFTER THE TUBE

Cuffed tube first-line at every age. Half-size either side within reach.
Confirm placement with waveform capnography plus chest rise and auscultation; reconfirm after every move.
Sudden deterioration in a tubed child — run DOPE: Displacement, Obstruction, Pneumothorax, Equipment failure.
Under 3 kg → newborn tool. Over 36 kg → adult airway tool.

Sources: AHA 2020 Guidelines, Part 4: Pediatric Basic and Advanced Life Support (Topjian et al., Circulation 2020;142:S469–S523; carried forward in the 2025 update) — cuffed tubes preferred at every age, cuffed size age/4 + 3.5 (Khine formula), uncuffed age/4 + 4, depth ≈ 3 × tube ID, capnography confirmation, DOPE. Suction catheter 2 × tube ID (Fr) and supraglottic weight ranges per standard airway references (Walls, Manual of Emergency Airway Management; manufacturer sizing). Color zones are the Broselow-Luten system (band boundaries per WikEM, as elsewhere on this page) — wayfinding to the cart drawer only; every displayed size comes from this page's own config, and the drawer's packed contents win over any formula. Verify against the tape at the bedside.

— personal/unofficial aid, not part of the hospital IT system/EHR, not a substitute for clinical judgment. Verify all values locally.