18.4 Neonatal and Pediatric Pharmacology
Key Takeaways
- Every pediatric dose is milligrams per kilogram drawn into a pump-ready syringe; adult ampule dumps are mixing errors, not shortcuts.
- Intraosseous access is a real line; some pediatric RSI protocols still use atropine, ketamine or etomidate follow physiology, and succinylcholine is taught at a higher milligram-per-kilogram dose than in adults.
- Cardiac-arrest epinephrine is 0.01 mg/kg of the 1:10,000 concentration; neonates get dextrose 10 percent, not an adult D50 dump.
- Prostaglandin E1, midazolam, 10 versus 20 mL/kg fluids, and tranexamic acid if protocol are pump-and-reassess problems in a vibrating cabin.
- Every number in this section is clinical teaching, not a BCEN dose table; infusion pumps are mandatory.
A vibrating cabin turns an unlabeled syringe into a wrong-patient event. Domain 5.B of the August 2026 Board of Certification for Emergency Nursing (BCEN) Certified Flight Registered Nurse (CFRN) outline tests neonatal and pediatric pharmacological care because every dose is milligrams per kilogram, because adult ampules do not scale by hope, and because infusions that look "about right" on the ramp become lethal when the aircraft shakes the cassette. The numbers below are typical pediatric critical-care teaching. They are not BCEN-published doses. Follow your program formulary.
Milligrams per kilogram, not adult ampule dumps
Draw from the child's kilogram weight, not from the nearest adult prefilled syringe. Dumping a 1 mg adult epinephrine ampule, a 25 g dextrose 50 percent (D50) syringe, or a full adult midazolam vial into a toddler is a mixing error with a professional-looking label. Use a pump-ready syringe, a second-person check when the cabin allows, and a written milligram and milliliter on the tape.
Intraosseous (IO) access is a real line in a child you cannot cannulate. Proximal tibia, distal femur, and proximal humerus are the usual sites. Anything you would push intravenous (IV) you may push IO, including resuscitation drugs and fluids. Do not wait for a third failed foot stick at the landing zone.
Infusion pumps are mandatory for vasoactives, prostaglandin E1, concentrated electrolytes, and any drip you would not want to free-flow during turbulence. Gravity drips in a climbing, vibrating cabin are not a plan.
Airway drugs: atropine, ketamine, etomidate, succinylcholine
Some pediatric rapid sequence intubation (RSI) protocols still use atropine more often than adult protocols, especially in infants, because vagal stimulus and hypoxia slow the child's heart rate first. That is protocol teaching, not a reason to delay oxygen.
Ketamine is a common pediatric induction: dissociation, bronchodilation, and usually preserved blood pressure. Etomidate is hemodynamically quiet; adrenal suppression is a later intensive-care concern and a reason some septic-child protocols prefer ketamine. Cut the induction dose in shock the same way you would in an adult (Chapter 7).
Succinylcholine is still taught at a higher milligram-per-kilogram dose in children than in adults (classic teaching is about 2 mg/kg versus 1–1.5 mg/kg). The contraindications do not shrink: burns after the first day, crush and denervation after a delay, known hyperkalemia, many myopathies, and malignant hyperthermia risk. Rocuronium remains the nondepolarizing alternative.
| Drug (clinical teaching, not a BCEN table) | Typical pediatric idea | Cabin trap |
|---|---|---|
| Atropine | Still appears in some pediatric RSI protocols | Skipping oxygenation to "get the atropine in" |
| Ketamine | Induction and analgesia; useful in bronchospasm | Full dose in a catecholamine-empty septic child |
| Etomidate | Hemodynamically quiet induction | Treating it as consequence-free in every septic child |
| Succinylcholine | Higher mg/kg than the adult RSI dose | Same hyperkalemia contraindications as adults |
| Epinephrine 1:10,000 | 0.01 mg/kg (0.1 mL/kg) in cardiac arrest | Using 1:1,000 IV as if it were the arrest dose |
| Dextrose | D10 in the neonate | D50 ampule dump |
Arrest epinephrine, dextrose, prostaglandin, midazolam
Concentrations you must read twice
Cardiac-arrest epinephrine is 0.01 mg/kg of the 1:10,000 concentration. That is 0.1 mL/kg of 1:10,000. Confirm the label twice. The 1:1,000 product is a different use (anaphylaxis intramuscular in many protocols) and a classic mix-up when both live in the same pouch.
Neonates get dextrose 10 percent (D10), not D50. A neonate's vein and osmolality do not forgive a 25 g adult syringe. Older children may get D10 or D25 depending on protocol; if you only stock D50, dilute rather than push the adult load. Recheck glucose after the dose; one number is not a voyage.
Prostaglandin E1 (alprostadil) keeps a ductus arteriosus open in ductal-dependent lesions. The transport risk is apnea. Start it on a pump, bag-mask ready, and do not interrupt the drip for a "quick move" to the aircraft unless you have a plan to restart immediately. Fever and flushing can occur; apnea is the one that kills on the ramp.
Midazolam treats seizures and provides sedation. Intranasal midazolam is a real option when you have no line yet. Watch blood pressure and ventilation after any benzodiazepine, especially stacked on magnesium or opioids.
Fluids, TXA, and mixing errors
Twenty milliliters per kilogram is the usual septic or hypovolemic bolus, with a reassess after each. Ten milliliters per kilogram is the usual more cautious aliquot for neonates, cardiogenic shock, and many congenital heart lesions. Write which rule you used.
Tranexamic acid (TXA) appears in some pediatric trauma protocols. If your program uses it, it is a timed, weight-based mix—not an adult 1 g vial emptied because the child "looks big." If your program does not carry pediatric TXA, do not invent a dose from memory in cruise.
Mix errors love this environment:
- Look-alike epinephrine concentrations in a dim cabin.
- A Broselow color that does not match the sending NICU weight.
- An unlabeled ketamine syringe next to midazolam.
- A prostaglandin cassette that free-flows when the pump is unplugged for loading.
Two-person check when you can. Pump always. Recalculate if the number looks like an adult number.
A 3-day-old neonate is limp and hypoglycemic on the ramp. Which dextrose plan is correct?
A 14-kg child is in cardiac arrest. Which epinephrine statement matches typical pediatric teaching (not a BCEN dose table)?
A neonate with a ductal-dependent lesion is being loaded. The prostaglandin cassette is running by gravity "for the walk to the aircraft." Which statement is correct?