GLASGOW COMA SCALE Activity Score Child/Adult Score Infant Eye opening 4 Spontaneous 4 Spontaneous 3 To speech 3 To speech/sound 2 To pain 2 To pain 1 None 1 None Verbal 5 Oriented 5 Coos/babbles 4 Confused 4 Irritable cry 3 Inappropriate 3 Cries to pain 2 Incomprehensible 2 Moans to pain 1 None 1 None Motor 6 Obeys commands 6 Normal spontaneous 5 Localizes to pain 5 Withdraws to touch 4 Withdraws to pain 4 Withdraws to pain 3 Abnormal flexion 3 Abnormal flexion (decorticate) 2 Abnormal extension 2 Abnormal extension (decerebrate) 1 None 1 None Adapted from Hunt B, Nelson K. The Johns Hopkins Children’s Center Kids Kard, 2014. IV INFUSIONS* Medication Dose (mcg/kg/min) Dilution in 100 mL D5W IV Infusion Rate Alprostadil (prostaglandin E1) 0.05–0.1 0.3 mg/kg 1 mL/hr = 0.05 mcg/kg/min Amiodarone 5–15 6 mg/kg 1 mL/hr = 1 mcg/kg/min DOPamine 2–20 6 mg/kg 1 mL/hr = 1 mcg/kg/min DOBUTamine 2–20 6 mg/kg 1 mL/hr = 1 mcg/kg/min EPINEPHrine 0.1–1 0.6 mg/kg 1 mL/hr = 0.1 mcg/kg/min Lidocaine 20–50 6 mg/kg 1 mL/hr = 1 mcg/kg/min Phenylephrine 0.05–2 0.3 mg/kg 1 mL/hr = 0.05 mcg/kg/min Terbutaline 0.1–10 0.6 mg/kg 1 mL/hr = 0.1 mcg/kg/min Vasopressin (pressor) 0.5–2 milliunits/kg/min 6 milliunits/kg 1 mL/hr = 1 milliunit/kg/min * Standardized concentrations are recommended when available. RESUSCITATION MEDICATIONS Adenosine 0.1 mg/kg IV/IO RAPID BOLUS (over 1-2 sec), Flush with 10 mL normal Supraventricular tachycardia saline May repeat at 0.2 mg/kg IV/IO after 2 min Max first dose 6 mg, max subsequent dose 12 mg Amiodarone 5 mg/kg IV/IO Ventricular tachycardia No Pulse: Push Undiluted Ventricular fibrillation Pulse: Dilute and give over 30 minutes Max first dose 300 mg, max subsequent dose 150 mg Monitor for hypotension Atropine 0.02 mg/kg IV/IO, 0.04–0.06 mg/kg ETT Bradycardia (increased vagal tone) Max single dose 0.5 mg Primary AV block Repeat once if needed Calcium chloride (10%) 20 mg/kg IV/IO Hypocalcemia Max dose 1 g Dextrose <5 kg: 10% dextrose 10 mL/kg 5-44 kg: 25% dextrose 4 mL/kg ≥45 kg: 50% dextrose 2 mL/kg, max single dose 50 g = 100 mL Epinephrine 0.01 mg/kg (0.1 mL/kg) 1:10,000 IV/IO every 3–5 min (max single dose Pulseless arrest 1 mg) Bradycardia (symptomatic) 0.1 mg/kg (0.1 mL/kg) 1:1000 ETT every 3–5 min (max single dose 2.5 mg) Anaphylaxis Anaphylaxis: 0.01 mg/kg (0.01 mL/kg) of 1:1000 IM (max 0.5 mg) in thigh every 15 min PRN Standardized/Autoinjector: <10 kg: 0.01 mg/kg (0.01 mL/kg) of 1:1000 IM 10-30 kg: 0.15 mg IM >30 kg: 0.3 mg IM Insulin (Regular or Aspart) 0.1 units/kg IV/IO with 1 g/kg of dextrose Hyperkalemia Max single dose 10 units Magnesium sulfate 50 mg/kg IV/IO Torsades de pointes No Pulse: Push Hypomagnesemia Pulse: Give over 15-20 minutes Max single dose 2 g Monitor for hypotension/bradycardia Naloxone Respiratory Depression: 0.001-0.005 mg/kg/dose IV/IO/IM/SubQ (max Opioid overdose 0.08 mg first dose, may titrate to effect) Coma Full Reversal/Arrest Dose: 0.1 mg/kg IV/IO/IM/SubQ (max dose 2 mg) ETT dose 2–3 times IV dose. May give every 2 min PRN Sodium Bicarbonate (8.4%) 1 mEq/kg IV/IO Metabolic acidosis Dilute 1:1 with sterile water for <10 kg Hyperkalemia Hyperkalemia: Max single dose 50 mEq Tricyclic antidepressant overdose Vasopressin 0.5 units/kg/dose IV/IO Max single dose 40 units ETT Meds (NAVEL: naloxone, atropine, vasopressin, epinephrine, lidocaine)—dilute meds to 5 mL with NS, follow with positive-pressure ventilation. Special thanks to LeAnn McNamara and Angela Helder, Clinical Pharmacy Specialists, for their expert guidance with IV infusion and resuscitation medications guidelines. Adapted from Hunt B, Nelson K. The Johns Hopkins Children’s Center Kids Kard, 2014, and the American Heart Association, PALS Pocket Card, 2010. TWENTIETH EDITION THE HARRIET LANE HANDBOOK A Manual for Pediatric House Officers This page intentionally left blank TWENTIETH EDITION THE HARRIET LANE HANDBOOK A Manual for Pediatric House Officers The Harriet Lane Service at The Charlotte R. Bloomberg Children’s Center of The Johns Hopkins Hospital EDITORS Branden Engorn, MD Jamie Flerlage, MD 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 THE HARRIET LANE HANDBOOK, TWENTIETH EDITION ISBN: 978-0-323-09644-7 Copyright © 2015 by Saunders, an imprint of Elsevier Inc. International Edition: 978-0-323-1124-4 No part of this publication may be reproduced or transmitted in any form or by any means, elec- tronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experi- ence broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2012, 2009, 2005, 2002, 2000, 1996, 1993, 1991, 1987, 1984, 1981, 1978, 1975, 1972, 1969 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Library of Congress Cataloging-in-Publication Data Harriet Lane Service (Johns Hopkins Hospital), author. The Harriet Lane handbook : a manual for pediatric house officers / the Harriet Lane Service, Children’s Medical and Surgical Center of the Johns Hopkins Hospital ; editors, Jamie Flerlage, Branden Engorn. -- Twentieth edition. p. ; cm. Preceded by the Harriet Lane handbook / editors, Megan M. Tschudy, Kristin M. Arcara. 19th ed. c2012. Includes bibliographical references and index. ISBN 978-0-323-09644-7 (pbk. : alk. paper) I. Flerlage, Jamie, editor of compilation. II. Engorn, Branden, editor of compilation. III. Title. [DNLM: 1. Pediatrics--Handbooks. WS 29] RJ48 618.92--dc23 2014003506 Senior Content Strategist: Jim Merritt Publishing Services Manager: Anne Altepeter Content Development Manager: Lucia Gunzel Project Manager: Cindy Thoms Senior Content Development Specialist: Andrea VosburghManager, Art and Design: Steven Stave Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 To all who use this book May the work you do better the lives of children everywhere. To our patients May we serve you well and learn from you each day. To our families To Anne and Bob Laubisch and my entire family, thank you for your endless encouragement in my life that has allowed me to follow my dreams. To Jayne and Steven Engorn and my entire family, thank you for teaching me to work hard and never give up, and that family gets us through both the good times and the bad times. To our spouses To Tim Flerlage, my amazing husband and best friend, thank you for your daily support that allows me to do what I love, and for that I am forever grateful. To Kristin Moosmann Engorn, my wonderful wife and best friend, coming home to you is the perfect ending to every day. To our mentors To Julia McMillan, may you know that your mentorship has shaped our lives and that you are the physician we will always strive to be. To George Dover, The Johns Hopkins Children’s Center will forever be indebted to you for all the love, compassion, dedication, and time that you have given to enhance the lives of countless children and families. This page intentionally left blank