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The Harriet Lane Handbook

AManualforPediatricHouseOfficers

TWENTY-FIRST EDITION

The Harriet Lane Service at The Charlotte R Bloomberg Children's Center of The Johns Hopkins Hospital

EDITORS

HELEN K. HUGHES, MD, MPH

LAUREN K. KAHL, MD

2

Activity Score Child/Adult Score Infant Eye opening 4 Spontaneous 4 Spontaneous 3 To speech 3 To speech/sound 2 To pain 2 To painful stimuli 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 movement 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 (flaccid) AdaptedfromHuntEA,Nelson-McMillanK,McNamaraL TheJohnsHopkinsChildren'sCenterKidsKard,2016 IVINFUSIONS* 24

Tables for first two pages GLASGOWCOMASCALE

(mcg/kg/min)

Alprostadil (prostaglandin E1) 0 05–0 1

0 01–0 2, up to 1 in severe circumstances

Lidocaine, post resuscitation 20–50

Phenylephrine 0 05–2, up to 5 in severe circumstances

Terbutaline 0 1–4 (up to 10 has been used) 0

Vasopressin (pressor) 0 5–2 milliunits/kg/min 6 milliunits/kg

*Standardizedconcentrationsarerecommendedwhenavailable Foradditionalinformation,seeLarsenGY,ParkHBet al Standarddrugconcentrationsandsmart-pumptechnologyreducecontinuous-medication-infusionerrorsinpediatricpatients

Pediatrics 2005;116(1):e21-e25

RESUSCITATIONMEDICATIONS

Adenosine

Supraventricular tachycardia

Amiodarone

Ventricular tachycardia

Ventricular fibrillation

Atropine

Bradycardia (increased vagal tone)

Primary AV block

Calcium chloride (10%)

Hypocalcemia

0 1 mg/kg IV/IO RAPID BOLUS (over 1-2 sec), Flush with 10 mL normal saline

May repeat at 0 2 mg/kg IV/IO, then 0 3 mg/kg IV/IO after 2 min

Max first dose 6 mg, max subsequent dose 12 mg

Administer using a 3-way stopcock attached to a 10 ml NS flush

5 mg/kg IV/IO

No Pulse: Push Undiluted

Pulse: Dilute and give over 20-60 minutes

Max first dose 300 mg, max subsequent dose 150 mg

Monitor for hypotension

Strongly consider pretreating with IV calcium in patients with a pulse to prevent hypotension

0.02 mg/kg IV/IO/IM, 0.04–0.06 mg/kg ETT

Max single dose 0 5 mg

Repeat in 5 minutes if needed (up to twice) to max total dose 1 mg

20 mg/kg IV/IO

Max dose 1 gram

Calcium Gluconate (10%) 60 mg/kg IV/IO

Dextrose

Epinephrine

Pulseless arrest

Bradycardia (symptomatic)

Anaphylaxis

Insulin (Regular or Aspart)

Hyperkalemia

Magnesium sulfate

Torsades de pointes

Hypomagnesemia

Naloxone

Opioid overdose Coma

Sodium Bicarbonate (8 4% = 1 mEq/mL)

Administer only with clear indication:

Metabolic acidosis

Hyperkalemia

Max dose 3 grams

<5 kg: 10% dextrose 10 mL/kg IV/IO

5-44 kg: 25% dextrose 4 mL/kg IV/IO

≥45 kg: 50% dextrose 2 mL/kg IV/IO, max single dose 50 grams = 100 mL

0 01 mg/kg (0 1 mL/kg) 1:10,000 IV/IO every 3–5 min (max single dose 1 mg)

0 1 mg/kg (0 1 mL/kg) 1:1000 ETT every 3–5 min (max single dose 2 5 mg)

Anaphylaxis: 0 01 mg/kg (0 01 mL/kg) of 1:1000 IM (1 mg/mL) in thigh every 5-15 min PRN; max single dose 0 5 mg

Standardized/Autoinjector:

<10 kg: no Autoinjector, see above

10-30 kg: 0.15 mg IM

>30 kg: 0 3 mg IM

0.1 units/kg IV/IO with 0.5 gram/kg of dextrose Max single dose 10 units

50 mg/kg IV/IO No Pulse: Push Pulse: Give over 20-60 minutes Max single dose 2 grams

Monitor for hypotension/bradycardia

Respiratory Depression: 0 001-0 005 mg/kg/dose IV/IO/IM/Subcut (max 0 1 mg first dose, may titrate to effect) Full Reversal/Arrest Dose: 0.1 mg/kg IV/IO/IM/Subcut (max dose 2 mg) ETT dose 2–3 times IV dose May give every 2 min PRN

Tricyclic antidepressant overdose 1 mEq/kg IV/IO

Dilute 8 4% sodium bicarbonate 1 : 1 with sterile water for patients <10 kg to a final concentration of 4 2% = 0 5 mEq/mL

Hyperkalemia: Max single dose 50 mEq

Vasopressin 0 4 units/kg/dose IV/IO

Max single dose 40 units

ETTMeds(NAVEL:naloxone,atropine,vasopressin,epinephrine,lidocaine) dilutemedsto5mLwithNS,followwithpositivepressureventilation

SpecialthankstoLeAnnMcNamara,ClinicalPharmacySpecialist,andElizabethA Hunt,MD,MPH,PhD,fortheirexpert guidancewithIVinfusionandresuscitationmedicationguidelines

AdaptedfromHuntEA,Nelson-McMillanK,McNamaraL TheJohnsHopkinsChildren'sCenterKidsKard,2016andtheAmerican HeartAssociation,PALSPocketCard,2010

Dose

Dilution

Fluid IV Infusion Rate

Medication

in 100 mL in a Compatible IV

1 mL/hr

05

Amiodarone 5–15 6 mg/kg 1 mL/hr

1 mcg/kg/min DOPamine 5–20 6 mg/kg 1 mL/hr 1 mcg/kg/min DOBUTamine 2–20 6 mg/kg 1 mL/hr = 1 mcg/kg/min

6 mg/kg 1 mL/hr 0 1 mcg/kg/min

0 3 mg/kg

0

mcg/kg/min

=

EPINEPHrine

0

1 mL/hr

1 mcg/kg/min

6 mg/kg

=

1 mL/hr

05 mcg/kg/min

0 3 mg/kg

= 0

1 mL/hr

1 mcg/kg/min

6 mg/kg

0

1 mL/hr

1

=

milliunit/kg/min

25

26

Copyright

1600 John F. Kennedy Blvd. Ste 1800

Philadelphia, PA 19103-2899

THE HARRIET LANE HANDBOOK, 21ST EDITION

INTERNATIONAL EDITION

ISBN: 978-0-323-39955-5

ISBN: 978-0-323-47373-6

No part of this publication may be reproduced or transmitted in any form or by any means, electronic 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 experience 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 2015, 2012, 2009, 2005, 2002, 2000, 1996, 1993, 1991, 1987, 1984, 1981, 1978, 1975, 1972, and 1969.

Library of Congress Cataloging-in-Publication Data

Names: Harriet Lane Service (Johns Hopkins Hospital), author | Hughes, Helen (Helen Kinsman), editor. | Kahl, Lauren, editor.

Title: 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, Helen Hughes, Lauren Kahl

Description: Twenty-first edition. | Philadelphia, PA : Elsevier, [2018] | Includes bibliographical references and index.

27

Identifiers: LCCN 2016048390 | ISBN 9780323399555 (pbk : alk paper) | ISBN 9780323473736 (international edition)

Subjects: | MESH: Pediatrics | Handbooks

Classification: LCC RJ48 | NLM WS 29 | DDC 618 92 dc23 LC record available at https://lccn loc gov/2016048390

Executive Content Strategist: Jim Merritt

Senior Content Development Specialist: Jennifer Ehlers

Publishing Services Manager: Patricia Tannian

Senior Project Manager: Cindy Thoms

Book Designer: Ashley Miner

Printed in United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

28

Dedication

To our families

Emily Fairchild, you are my selfless champion, cheerleader, and role model Stephen Kinsman, thank you for giving me your unwavering support and infectious love of pediatrics. Andrew Hughes, you have given me a better life and family than I ever thought possible Oliver, you are the light of my life

Lorraine Kahl, my loving mother, thank you for your endless encouragement and example of insurmountable strength Richard Kahl, my wonderful father, may everything I do be a reflection of you; I miss you every day. Richie Kahl, your resilience is an inspiration. Michael Untiet, thank you for your unconditional love and support that continues to challenge me and push me forward

To our patients and their families

We will be forever grateful for the trust that you have placed in us.

To our residents

We are inspired daily by your hard work, resilience, and commitment to this noble profession.

To the consummate pediatricians and educators

George Dover and Julia McMillan

To our role model, teacher, and friend

Janet Serwint And to

Tina Cheng, Pediatrician-in-Chief,

The Johns Hopkins Hospital, Fearless advocate for children, adolescents, and families

In loving memory of Dr. Idoreyin P. Montague

29

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The harriet lane handbook mobile medicine series johns hopkins hospital

The Harriet Lane Handbook

AManualforPediatricHouseOfficers

TWENTY-FIRST EDITION

HELEN K. HUGHES, MD, MPH

LAUREN K. KAHL, MD

Table of Contents

Chapter 19 Nephrology

Chapter 20 Neurology

Chapter 21 Nutrition and Growth

Chapter 22 Oncology

Chapter 23 Palliative Care

Chapter 24 Pulmonology

Chapter 25 Radiology

RESUSCITATIONMEDICATIONS

Copyright

Notices

Library of Congress Cataloging-in-Publication Data

Dedication