13.4 Weight-Based Dosing Aids & Drugs to Avoid Routinely

AHA PALS Provider Pediatric Advanced Life Support

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1 Chapter 1: Course Overview & Exam Logistics

1.1 Current Exam Facts 1.2 Audience, Prerequisites & Study Plan

2 Chapter 2: Systematic Pediatric Assessment

2.1 Pediatric Assessment Triangle (PAT) 2.2 Evaluate–Identify–Intervene Sequence 2.3 Primary Assessment: ABCDE 2.4 Secondary Assessment, SAMPLE & Vitals by Age

3 Chapter 3: Respiratory Distress & Failure

3.1 Respiratory Distress vs Failure 3.2 Recognition & Immediate Intervention Priorities 3.3 Oxygen Delivery & Basic Airway Support

4 Chapter 4: Airway Problems & Ventilation Strategies

4.1 Upper Airway Obstruction 4.2 Lower Airway, Lung Tissue Disease & Disordered Control 4.3 Bag-Mask Ventilation & Advanced Airways During CPR

5 Chapter 5: Shock Fundamentals & Hypovolemia

5.1 Compensated vs Hypotensive (Decompensated) Shock 5.2 Hypovolemic Shock 5.3 Isotonic Fluid Bolus 10–20 mL/kg & Reassessment

6 Chapter 6: Distributive, Cardiogenic & Obstructive Shock

6.1 Distributive & Septic Shock Pathway 6.2 Cardiogenic Shock 6.3 Obstructive Shock

7 Chapter 7: Pediatric BLS & High-Quality CPR

7.1 High-Quality CPR Metrics 7.2 Compression-Ventilation Ratios 7.3 CPR Quality Monitoring: ETCO2 & Diastolic BP

8 Chapter 8: Pediatric Cardiac Arrest Algorithm

8.1 Arrest Recognition & Systematic Approach 8.2 VF/pVT & Defibrillation Energy 8.3 Asystole & PEA 8.4 Epinephrine in Arrest: Dose & Timing

9 Chapter 9: Bradycardia & Narrow-Complex Tachycardia

9.1 Bradycardia with Poor Perfusion 9.2 Sinus Tachycardia vs SVT 9.3 Stable SVT: Vagal Maneuvers & Adenosine

10 Chapter 10: Unstable Tachycardia & Wide-Complex Rhythms

10.1 Unstable Tachycardia & Synchronized Cardioversion 10.2 Wide-Complex Tachycardia & VT with Pulse 10.3 Antiarrhythmics for Tachycardia with Pulse

11 Chapter 11: Reversible Causes & Special Circumstances

11.1 Reversible Causes: The H's and T's 11.2 Special Circumstances at Exam Level 11.3 Extracorporeal CPR (ECPR) Overview

12 Chapter 12: Post–Cardiac Arrest Care

12.1 Post-ROSC Oxygenation & Ventilation 12.2 Post-Arrest Hemodynamic Support 12.3 Temperature Control & Glucose 12.4 Neuroprognostication & Transport

13 Chapter 13: Vascular Access & Core Pharmacology

13.1 IV and Intraosseous Access 13.2 Epinephrine Dosing in Depth 13.3 Amiodarone, Lidocaine & Adenosine 13.4 Weight-Based Dosing Aids & Drugs to Avoid Routinely

14 Chapter 14: Team Dynamics & Megacode Readiness

14.1 High-Performance Team Roles 14.2 Closed-Loop Communication 14.3 Constructive Intervention, Debriefing & Exam Integration

13.4 Weight-Based Dosing Aids & Drugs to Avoid Routinely

Key Takeaways Explain This Topic AI

Use a length-based resuscitation tape (e.g., Broselow-type systems) to estimate weight and pre-lookup doses when actual weight is unknown.

When a recent accurate weight is known, prefer it for dose calculations over tape estimates.

Cognitive aids (tapes, cards, apps, independent double-checks) reduce medication error under stress—use them on purpose, not as a crutch you ignore.

2025 teaching: routine sodium bicarbonate is not recommended in cardiac arrest except special circumstances (e.g., hyperkalemia, sodium-channel blocker toxicity).

Routine calcium is not recommended in arrest except specific indications (hypocalcemia, calcium-channel blocker overdose, hyperkalemia).

Last updated: August 2026

Pediatric Doses Are Weight-Based—So Weight Must Be Right Enough

Almost every critical PALS number scales with body size: epinephrine 0.01 mg/kg , amiodarone 5 mg/kg , adenosine 0.1/0.2 mg/kg , defibrillation 2 then 4 J/kg , cardioversion 0.5–1 then 2 J/kg , fluid boluses 10–20 mL/kg . A wrong weight multiplies into a wrong dose. In emergency care you often lack a scale. PALS therefore expects fluency with estimation tools and the judgment to use known weights when available.

Length-based tapes (Broselow and similar systems)

A length-based tape is laid alongside the supine child from crown to heel. Color zones or length marks correlate with an estimated weight and often list pre-calculated doses, equipment sizes (ETT, blade, suction), and defibrillation energies. These systems are designed for the stress of resuscitation , when mental arithmetic fails.

• Principle Practice
• Measure length correctly Child fully extended; tape used as trained
• Read the matching zone Use the dose/equipment list for that color/length

Still think clinically Morbid obesity, severe growth failure, or amputation may need clinical adjustment and expert input

Combine with team process One provider measures/reads; another draws; closed-loop confirms

Length-based systems are estimates . They outperform wild guessing in most emergency settings and are strongly preferred over "looks like a 2-year-old, give adult epi."

Prefer actual weight when known

If the parent states a recent scale weight , the clinic chart lists today’s weight, or a bed scale reading is available and trusted, use the actual weight for calculations. Do not ignore a known accurate weight merely because the tape is open. Conversely, if the stated weight is obviously wrong or unknown, the tape (or other validated estimate) is safer than paralysis.

• Other cognitive aids that save lives
• Code cards / PALS pocket references with dose tables
• Pre-calculated dose sheets printed at triage for the estimated weight
• Smart IV pumps and pharmacy-prepared infusions in hospital settings
• Independent double-checks for high-alert drugs (vasoactives, concentrated electrolytes)
• Closed-loop communication : "Epinephrine 0.01 mg/kg—0.14 mg—1.4 mL of 0.1 mg/mL IO" → "1.4 mL IO now"

Under megacode stress, humans default to error . Cognitive aids are not cheating; they are professional practice. Teams that refuse tools because "I memorized everything" still make decimal mistakes.

Drugs NOT Recommended Routinely in Arrest (2025 Emphasis)

Not every ampule on the code cart belongs in every pediatric arrest. Two classic examples— sodium bicarbonate and calcium —are frequent distractors. Both have narrow, indication-based roles . Neither is a default "metabolic fix" for every prolonged code.

Sodium bicarbonate — not routine

2025-aligned PALS teaching: Routine sodium bicarbonate is not recommended during cardiac arrest.

Why the old habit is wrong:

Bicarbonate generates CO2 that the poorly perfused lung may not eliminate during CPR.

It can worsen intracellular acidosis in some contexts.

It does not replace ventilation, high-quality CPR, or cause-specific therapy.

Special circumstances where bicarbonate may be considered (exam-level list):

• Situation Why bicarbonate may be considered
• Hyperkalemia Part of a broader hyperkalemia bundle (with calcium, insulin/glucose, etc., per protocol)

Sodium-channel blocker toxicity (e.g., many tricyclic antidepressants, some other Na-channel agents) Alkalinization / sodium load strategies in toxicology-directed care

Selected documented severe metabolic acidosis pathways under expert guidance Not "because the code is long" alone

If the stem is ordinary asystole/PEA without those features, do not pick "give bicarb now" as the next best step over CPR, epinephrine, ventilation, and reversible-cause search.

Calcium — not routine

Routine calcium administration is not recommended in pediatric cardiac arrest.

Consider calcium when:

Indication Clinical clue examples

Documented or strongly suspected hypocalcemia Massive transfusion, known endocrine/renal disease, specific lab confirmation when available

Calcium-channel blocker overdose History, bradycardia/hypotension/shock pattern consistent with CCB toxicity

Hyperkalemia ECG changes (peaked T waves, wide QRS), renal failure, rhabdomyolysis—with calcium used to stabilize myocardial membranes as part of therapy

Calcium is a high-alert drug. Wrong-dose or wrong-salt errors occur. Use dosing aids and indication discipline.

Contrast table for rapid exam review

• Agent Routine in pediatric arrest? When to consider
• Epinephrine Yes—core drug All pediatric arrest on interval
• Amiodarone / lidocaine Situational Refractory VF/pVT
• Sodium bicarbonate No HyperK, Na-channel blocker toxicity, selected special cases
• Calcium No Hypocalcemia, CCB overdose, hyperK
• Fluids Situational Hypovolemia/distributive physiology
• Hyperkalemia package (ties Chapters 11 and 13)

When hyperkalemia is the reversible cause, think membrane stabilization + shift + removal , not a single magic drug:

• Calcium to antagonize cardiac effects of high K+
• Sodium bicarbonate may be part of some pathways
• Insulin with glucose, β-agonists, and definitive removal (dialysis) per advanced care
• Stop potassium sources; treat the cause

The exam point is indication-driven use—not sprinkling calcium and bicarb into every PEA.

Loading diagram... Weight Aids and Avoid-Routine Drugs

• Putting Safety Systems Together on a Real Code
• A practical dosing workflow

Estimate or obtain weight (scale > recent known weight > length-based tape > last-resort visual guess).

Open the cognitive aid for that weight (tape zone, card, app).

Select the drug and indication (arrest epi vs anaphylaxis IM vs antiarrhythmic).

Confirm concentration on the vial.

Calculate mg, then mL ; have a second provider verify when possible.

Deliver via IV/IO , flush, document time.

Reassess rhythm, pulse, perfusion—not only the syringe empty light.

• Megacode behaviors instructors reward
• Assigning a medication role who narrates doses aloud
• Using the tape early rather than after three dosing arguments
• Refusing "just give some bicarb" without an indication
• Catching a peer’s ten-fold epinephrine concentration error before injection
• Transitioning to infusions and charts post-ROSC instead of repeated random pushes
• Clinical scenarios

Scenario A — Unknown weight: Unresponsive toddler-length child, VF arrest. Team pulls length-based tape , estimates 12 kg, defibrillates 2 J/kg (24 J) , places IO, gives epinephrine 0.01 mg/kg (0.12 mg = 1.2 mL of 0.1 mg/mL) . After refractory VF, considers amiodarone 5 mg/kg (60 mg) . No routine bicarb.

Scenario B — Known weight: Parent reports 16.0 kg from this morning’s clinic visit. Use 16 kg even if the tape color suggests nearby. Dose epi 0.16 mg .

Scenario C — Hyperkalemia PEA: Child with renal failure, peaked T waves before arrest, wide complex PEA. Alongside CPR and epinephrine, treat hyperkalemia —including calcium for membrane stabilization and other shift/removal therapies per protocol; bicarbonate may be considered in this special circumstance. This is the opposite of "bicarb for every long code."

Scenario D — TCA overdose: Wide-complex toxicity from sodium-channel blockade— sodium bicarbonate is indication-based toxicologic care, not a generic PEA reflex.

Link forward

Access and pharmacology only work inside team dynamics (Chapter 14): clear roles, closed-loop communication, constructive intervention when someone reaches for the wrong concentration, and debrief that includes medication safety. The best dose math still fails if nobody flushes the IO or if CPR stops for three minutes of drug debate.

Bottom line for 13.4: Use length-based tapes when weight is unknown and actual weight when known; lean on cognitive aids to prevent error; and remember the 2025 rules— no routine sodium bicarbonate and no routine calcium in arrest without special indications such as hyperkalemia, sodium-channel blocker toxicity, hypocalcemia, or calcium-channel blocker overdose .