Antiarrhythmic Drug Guide

ANTIARRHYTHMIC DRUG DOSAGES
AND PREPARATIONS FOR CHILDREN

Sixth Edition

2004-2005

Compiled by:
George F. Van Hare, M.D.
Pediatric Arrhythmia Center at UCSF and Stanford
Lucile Packard Children's Hospital, and the UCSF Children's Hospital

Table of Contents

Disclaimers

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DISCLAIMERS:

This Antiarrhythmic Drug Guide was put together as a set of notes derived from elsewhere, with a focus on pediatric considerations. In particular, it answers the most frequent questions that I get concerning the use of these agents in children, and is handy when writing prescriptions or in-patient orders. The purpose was not to be exhaustive in the scope of data included, particularly with respect to interactions and cautions. The PDR is available and should be used if a complete account of prescribing information is desired. Don't sue me.

This guide is not a substitute for a cardiology fellowship or consult. It is organized using the Vaughn Williams classification of antiarrhythmic drug effects. If this is unfamiliar, you could look it up.

Also, I may have misspelled a few things.

CONTENTS:

Class Ia
Procainamide
Quinidine
Disopyramide

Class II
Propranolol
Atenolol
Nadolol
Metoprolol
Pindolol
Esmolol

Others
Bretylium
Digoxin
Adenosine
Phenylephrine
Midodrine
Fludrocortisone

Class Ib
Lidocaine
Mexiletine
Phenytoin
Moricizine

Class III
Ibutalide
Sotalol
Amiodarone

Class 1c
Flecainide
Propafenone

Class IV
Verapamil
Diltiazem

Tables and Diagrams
Tim Garson's ECG interpretation criteria
ECG standards

Recommended follow-up tests in patients taking amiodarone Gallagher diagram-AP locations by ECG in WPW In utero SVT treatment Electrophysiologic effects of drugs Body surface area nomogram Electricity for cardiologists How to reach us: Pediatric Arrhythmia Center

Back to top

PROCAINAMIDE

IV dose Loading dose: 10-15 mg/kg (yes, milligrams)maximum 1.0 gram maximum rate 50 mg/min or 0.5 mg/kg/min Drip: 30-80 ug/kg/min (yes, micrograms)

Oral dose: 50-100 mg/kg/day divided q 3-4 hours (q 6 hours for slow release forms)

Levels: PC 4-8, may go up to 12 ug/ml NAPA <40 ug/ml is well tolerated. ?usefulness.

Kinetics: Peak levels at 1 hour after oral dose. Increased volume of distribution in heart failure. Elimination half-life of PC: 2.5-4.7 hours in adults.13.5 hours in neonates.7 hours in 7-12 year olds.1st order to at least to 26 ug/ml. For slow release forms, t 1/2 = 6-7 hours. Elimination half-life of NAPA: 6-8 hours.

Cautions: QRS >25% prolongation: no further dosage increases QTc >= 0.500 : stop drug

Interactions Amiodarone increases PC and NAPA levels by 57% and 32% respectively. Cimetidine increases PC half-life. Propranolol decreases t 1/2, increases Vd. Digoxin: no known interaction.

Preparations:

Pronestyl non-scored tabs: 250, 375, 500 mg.

Capsules 250, 375, 500 mg.

Pronestyl SR non-scored matrix tabs: 500 mg.

Procan SR wax matrix tabs: 250, 500, 750, 1000
mg.(>500 tabs scored)

Pronestyl injection 1000 mg vials:100 mg/cc or 500 mg/cc.

FDA approval
in children: no

QUINIDINE

IV dose Don't! Frequent occurrence of hypotension and cardiovascular collapse!

Oral dose:
Quinidine sulfate: 30-60 mg/kg/day (450-900 mg/m2/day) in children, 10 mg/kg/day in adults, divided q 6 hours.

20% higher for gluconate, given q 8-12 hours

Levels: 2-6 ug/ml >7 ug/ml highly correlated with toxicity.

Kinetics: Peak levels 1-3 hours for sulfate, 4 hours for gluconate after oral dose. Elimination half-life 6.3 hours in adults. 4.7 hours in 4-6 year olds, 6 hours in neonates.

Cautions: Similar to those for procainamide

Interactions Potentiation of warfarin effect. Mean 100-150% increase in digoxin levels. (Probably doesn't occur under 2 months of age.) Levels increased in congestive heart failure. Elimination impaired by cimetidine, amiodarone. Elimination accelerated by phenytoin, propranolol, rifampin. Contraindicated with verapamil: cardiovascular collapse and hypotension frequent.

Preparations:

Quinidine sulfate tablets: 200, 300 mg.

Quinidex Extentabs (Q. sulfate): 1/3 released immediately, 2/3 slow release in GI tract. 300 mg tablets.

Quiniglute Duratabs: non-scored tablets: 324 mg

FDA approval
in children: no

DISOPYRAMIDE

IV dose No IV form

Oral dose: < 2 yr.: 23-33 mg/kg/day (mean 30)
2-10 yr.: 9-24 mg/kg/day (mean 20)
>10 yr.: 5-13 mg/kg/day (mean 8)
divided q 6 hours, or q 12 hours for CR forms.
Maximum 1200 mg/day.

Levels: 2-5 ug/ml, poorly correlated with efficacy

Kinetics: Peak levels at 0.5-3 hours after oral dose. (3.4-4.0
hours after controlled release form).
Nonlinear kinetics due to protein binding.
Elimination half-life 5-6 hours at therapeutic levels.
Large Vd in children.

Cautions: Causes significant decreases in contractility!
In renal failure, active metabolite (NMD)
accumulates, which is even more anticholinergic
than parent compound.

Interactions None with digoxin.
Atenolol decreases clearance and is synergistic
in decreasing cardiac output. (Probably true for all
beta blockers).
Phenytoin increases clearance and decreases levels.

Preparations:

Norpace capsules: 100, 150 mg

Norpace CR: controlled release capsules: 100, 150 mg

FDA approval
in children: yes

LIDOCAINE

IV dose Loading does: 1 mg/kg, given no faster than 50 mg/min.
May repeat twice q 5-10 mins.
Drip 20-50 ug/kg/min.
Decrease rate by 50% at 24 hours!

Oral dose: No PO form

Levels: 1.5-5 ug/ml.
Toxicity (esp. confusion) frequent >6 ug/ml.

Kinetics: Elimination half-life 1.8 hours in adults and children aged 6 m- 3 years, 3.2 hours in neonates.
Decreased clearance in congestive heart failure.

Cautions: Vertigo, paraesthesias, slurred speech and confusion
are the first signs of toxicity.

Interactions Propranolol decreases liver blood flow and lidocaine clearance.
Isoproterenol, phenobarbital, phenytoin increase clearance.

Preparations: Xylocaine injection, 100 mg/5 cc (amps or syringes).

FDA approval
in children: yes

MEXILETINE

IV dose No IV form

Oral dose: Children: 1.4-5.1 mg/kg/dose, given q 8 hours. May increase to 8.0 mg/kg/dose in infants.
Adults: 450-1200 mg/day divided TID

Levels: 0.8-2.0 ug/ml
Poor correlation with therapeutic efficacy.

Kinetics: Elimination half-life 6.3-11.8 hours in adults
Increased to 15.4 hours in heart failure.
Peak levels 1-3 hours after oral dose

Cautions:

Interactions Phenytoin, rifampin increase clearance

Preparations: Mexitil capsules: 150, 200, 250 mg

FDA-approved
in children: no

PHENYTOIN

IV dose Loading: 10-15 mg/kg to maximum of 1.0 gram.
1/13 given IV bolus every 5 mins, flushed with NS.
(D5W will precipitate drug in line)

Oral dose:
Loading: 15 mg/kg divided QID x 24 hours, then 7.5 mg/kg divided QID x 24 hours.
Additional day of 7.5 optional, depending on response and levels.

Maintenance: By age:
0-2 wk.: 4-8 mg/kg/d divided q 12 hours
Infants > 2 wk.: 8-12 mg/kg/d divided q 8 hours
Children: 5-6 mg/kg/d divided q 12 hours
Adults: 300-400 mg/day divided q 12 hours.

Levels: 10-25 ug/ml
Toxicity common at > 20 ug/ml.

Kinetics: Zero-order (t 1/2 depends on concentration)
e.g. At high levels, additional dose increases may raise levels drastically.
Average t 1/2 = 22 hours at therapeutic levels (range 7-40 hours) in adults, 8 hours at 1 month, 21 hours in full term newborns, 75 hours in prematures.
Peak levels at 1.5-3 hours after oral dose of Infatabs, 4-12 hours for Kapseals.

Cautions:

In pregnancy, 11% incidence of fetal hydantoin syndrome, 31% incidence of lesser impairments.

Interactions Amiodarone increases levels
Phenobarbital decreases levels.
Phenytoin potentiates warfarin anticoagulation.
Phenytoin decreases digoxin half-life.

Preparations:

Dilantin suspension SHOULD NEVER BE GIVEN.

Dilantin Infatabs- best absorbed. 50 mg

Dilantin Kapseals: 30, 100 mg.

FDA approval
in children: yes

MORICIZINE

IV dose No IV form

Oral dose: 200 mg/m2/day (5 mg/kg/day) divided q 8 hours.
Increase slowly to 600 mg/m2/day

Levels: Not useful

Kinetics: Elimination half-life 2-5 hours

Cautions: 3.7% risk of proarrhythmia

Interactions None known.

Preparations: Ethmozine non-scored tablets 200, 250, 300 mg

FDA approval
in children: no

FLECAINIDE

IV dose No IV form

Oral dose:
50-200 mg/m2/day divided q 12 hours
Maximum 400 mg/day.

Or

6.7-9.5 mg/kg/d divided tid in Japanese study

Acta Paediatr Jpn 1994 Feb;36(1):44-8
Improved efficacy with TID dosage in young children and patients with toxicity.
Increase in 50 mg/m2 increments every 4 days
Decrease by 50% when used with amiodarone

Levels: Therapeutic effects at 0.200-1.000 ug/ml.
Increased proarrhythmia and toxicity at > 1.0 ug/ml.

Kinetics: Elimination half-life 7-19 hours (mean 13). in adults, and 7-12 hours (mean 8.7) in children aged 1 month to 13 years.
Reduced clearance in congestive heart failure.
Peak levels at 2-3 hours after oral dose.

Cautions: Proarrhythmic effect worst in poor LV function.
Significant negative inotropic effect.

Interactions Amiodarone increases levels by 100%.
Additive negative inotropic effect when used with propranolol, verapamil, or disopyramide.
Increases digoxin levels 24% average.

Preparations: Tambocor scored tablets: 50, 100 mg.

FDA-approved
in children: no

PROPAFENONE

IV dose
0.2 mg/kg q 10 min to 2.0 mg/kg maximum. Give with volume.
Drip 0.004-0.007 mg/kg/min

(IV preparation not available in USA)

Oral dose: 300-400 mg/m2/day divided q 6 hours

Levels: Not yet proven to be useful.

Kinetics: Nonlinear, saturable kinetics
Variable elimination half-life: 2.4-11.8 hours (Up to 26 hours in slow metabolizers).
Peak levels 2-3 hours after oral dose.

Cautions: 1/40 propranolol beta-blocking effect, 50 times the normally achievable propranolol concentrations.

Interactions Increases digoxin levels by 40-100%.
Aggravates ventricular arrhythmias, especially torsades de pointes, when used with amiodarone.

Preparations: Rythmol scored tablets, 150 mg, 300 mg

FDA-approved
in children: no

PROPRANOLOL

IV dose 0.02 mg/kg every 5 min to 0.1 mg/kg total dose.

Oral dose: 2 mg/kg/day divided q 6 hours to start. Increase routinely to 5 mg/kg/day. May in rare circumstances go to 14 mg/kg/day, watching levels.
Inderal LA should be given BID in children

Levels: 25-150 nanograms/ml for beta blockade.
150-1000 ng/ml for control of VT.

Kinetics: Large first-pass metabolism in liver.
Elimination half-life 4-6 hours. (T 1/2 of 4-hydroxy-P 5.2-7.5 hours, active).
Peak levels at 2-3 hours after oral dose.

Cautions: Contraindicated in asthma, congestive heart failure.
Beware hypoglycemia in infants and diabetics

Interactions Levels increased by cimetidine.
Contraindicated with verapamil, due to synergistic
negative inotropic effect and cardiovascular collapse
Increases hepatic lidocaine metabolism.

Preparations: Inderal scored tabs: 10, 20, 40, 60, 80, 90 mg.
Inderal LA capsules: 60, 80, 120, 160 mg.
Inderal injection, 1 mg/1 ml ampules.

FDA-approved
in children: yes

ATENOLOL

IV dose No IV form

Oral dose: 1 mg/kg/day, up to 2 mg/kg/day given QD.

Levels: Not helpful

Kinetics: Elimination half-life 5-9 hours in adults, 16 hours in neonates.
Peak levels 2-3 hours after oral dose.

Cautions: Similar to propranolol. More cardioselective, less problems with asthma and hypoglycemia.

Interactions No effect on hepatic lidocaine metabolism.

Preparations:
Tenormin non-scored tablets: 25, 100 mg.

scored tablets, 50 mg.

FDA-approved
in children: no

NADOLOL

Oral dose: 1-2 mg/kg/day, given QD. Adjust up or down after 5 days based on side effects, sinus rate, and efficacy.

Levels: Not yet clinically useful.

Kinetics: Elimination half-life 12-24 hours. Peak levels at 3-4 hours after oral dose.

Cautions: Similar to propranolol. Not particularly cardioselective, but fewer CNS side effects.

Preparations: Corgard non-scored tabs: 20, 40, 80 mg scored tablets: 120, 160 mg

FDA-approved
in children: No.

METOPROLOL

IV dose 5 mg q 2 minutes to total 15 mg in adults post MI

Oral dose: 100-450 mg/day in adults divided qd or bid

Levels: unknown

Kinetics: Plasma half-life 3-7 hours in adults

Cautions: Similar to propranolol. Fairly cardioselective.

Interactions similar to propranolol

Preparations:
Lopressor scored tabs: 50, 100 mg

Lopressor injection, 1 mg/cc, 5 cc ampuls

FDA-approved
in children: No.

PINDOLOL

Oral dose: Drug of choice in vasodepressor syncope, because of intrinsic sympathomimetic activity. 10-60 mg/day in adults divided bid

Levels: Unknown

Kinetics: Plasma half-life 3-4 hours. Clearance reduced in uremia

Cautions: Similar to other beta blockers.

Interactions ISA may be blocked by other beta blockers

Preparations: Visken "heart-shaped" non-scored tabs: 5, 10 mg.

FDA-approved
in children: no

ESMOLOL

IV dose
500 ug/kg/min for 1 minute, then 50 ug/kg/min.

Repeat bolus in 5 minutes, increase infusion to 100 ug/kg/min if no effect. Further increases with boluses up to 200 ug/kg/min as necessary

Levels: Unknown

Kinetics: Elimination half-life 9 minutes.

Cautions: Hypotension occurs transiently in 44%. CNS side effects are common, esp. emesis (16%).

Interactions Increases digoxin levels by 10-19%. Levels increased by warfarin, morphine.

Preparations: Breviblock injection, 2.5 grams/10 ml ampule

FDA-approved
in children: No.

IBUTALIDE FUMARATE

IV dose:
0.01 mg/kg over 10 minutes (under 60 kg)

1-2 mg over 10 minutes (over 60 kg)

Kinetics: Highly variable. Half-life averages 6 hours (2-12 hours)

Cautions: VT or torsades de pointes in 9% as late as 4 hours after the dose. Do not give if there is hypokalemia or preexisting QT prolongation. Requires electrocardiographic monitoring in a critical care setting >4 hours.

Interactions Do not give with Class I or III antiarrhythmics

Preparations: Corvert injection, 0.1 mg/cc., 10 cc vial = 1 mg

FDA-approved
in children: No

SOTALOL

Oral dose:
Adults: 80 mg B.I.D. to start, adjusting upwards every 2-3 days to 160 mg B.I.D. Maximum 640 mg daily in life-threatening arrhythmias.

Children: 2-8 mg/kg/day divided B.I.D.

Levels: unknown

Kinetics: Mean elimination half-life 12 hours. Excreted in urine

Cautions: Class II/III actions, so similar to other beta-blockers. Dose, QTc interval and incidence of Torsades are related: QTc should be followed. In particular, maintain normal potassium and magnesium levels, as Torsades is much more common with hypokalemia and/or hypomagnesemia.

Interactions No effect on digoxin. Do not use with class !a agents,as QTc will be further prolonged. As with other beta blockers, will further decrease cardiac function is used with calcium channel blockers

Preparations: Betapace scored tablets 80, 160, 240 mg

FDA-approved
in children: No.

AMIODARONE

IV dose 5 mg/kg over 15-30 mins.. Repeat if necessary in 15 minutes. Drip 10-20 mg/kg/day. Must be given by central line in D5W.

Oral dose: Loading: 5 mg/kg given BID x 10 days (max 1.2grams/day) Then 5 mg/kg QD for 1-2 months. Attempt to decrease progressively to 2.5 mg/kg in small changes every 4-6 months.

Levels: Useful to document gross noncompliance. Therapeutic > 1.0 ug/ml. Toxicity common at > 2.5 ug/ml.

Kinetics: Complex and obscure. Extensive rapid uptake by adipose tissue, slow uptake by myocardium, concentrates in both. Elimination half-life about 30 days with chronic oral therapy. (Range 8-107 days) Levels detectable 9 months after stopping Rx. Therapeutic effect seen 1-3 hours after IV dose. Peak serum level at 5 hours after oral dose

Cautions: Many. In particular, extreme sinus bradycardia requiring a pacemaker is frequent. 25% incidence of marked hypotension and decreased contractility with IV administration only.

Interactions Potentiates warfarin action. Digoxin levels progressively rise 70-100%. With beta blockers and calcium channel blockers, causes severe sinus bradycardia.Potentiates tendency of quinidine, propafenone and mexiletine to cause Torsades de pointes. Increases levels of quinidine, procainamide, phenytoin, flecainide, and cyclosporin.

Preparations:
Cordarone scored tablets, 200 mg.

Cordarone injection, 50 mg/cc, 3 cc ampuls

FDA-approved
in children: No

VERAPAMIL

IV dose 0.075-0.150 mg/kg (max 10 mg) over 1-2 minutes.

Oral dose: 4-17 mg/kg/day divided q 8 hours (BID or QD with slow release form)

Levels: 0.1-0.3 ug/ml.

Kinetics: Zero-order (half-life related to dose). Extensive first-pass metabolism. Elimination half-life 12 hours on chronic oral therapy, but 6 hours after single dose.

Cautions: Do not use under 12 months of age, especially under 3 months, hypotension, CV collapse, death). Use with caution long-term in patients with manifest preexcitation. (conversion of SVT is OK). Do not pre-treat with calcium chloride, as it interferes with the therapeutic effect. Be prepared with calcium, fluids and dopamine if hypotension occurs following administration.

Interactions Contraindicated with beta blockers, due to synergistic negative inotropy. Contraindicated with quinidine, due to synergistic negative inotropy. Increases digoxin levels 40-75% (quinidine-like). Therapeutic effect blocked by anticholinergic properties of disopyramide

Preparations:

Calan scored tablets: 80, 120 mg.

Calan SR scored tablets: 240 mg.

Calan injection: 5 mg/2 ml, 10 mg/4 ml amps, vials.

Isoptin: same

Verelan pellet-filled capsules: 120, 240 mg. (QD dosing)

FDA-approved
in children: No.

DILTIAZEM

IV dose

Initial bolus 0.25 mg/kg over 2 min (average 20 mg in adults). Second dose of 0.35 mg/kg over 2 minutes may be given (average 25 mg)

Continuous infusion: 5-15 mg/hr (usual 10 mg/hour) in adults. No pediatric dose. (suggest 0.125 mg/kg/hr = 2 ug/kg/min).

Oral dose:
30-90 mg QID of short-acting preparation

60-180 mg BID of "SR" preparation.

180-360 mg QD of "CD" preparation.

Levels: Therapeutic range undefined

Kinetics: Maximum effect 2-5 minutes after bolus injection. Plasma half-life 3-4.5 hours. Metabolized in lever, excreted in urine.

Cautions: Same cautions as with verapamil. May be better tolerated with beta blockers than verapamil. Avoid in young children.

Interactions Increases levels of propranolol, digoxin (20%), cyclosporin, carbamazepine. Levels increased by cimetidine

Preparations:
Cardizem injectable, vials 25 mg/5 cc or 50 mg/10 cc.

Cardizem tablets, 30 mg (non-scored), 60, 90, 120 mg
(scored).

Cardizem SR capsules, 60, 90, 120 mg

Cardizem CD capsules, 120, 180, 240, 300 mg.

FDA-approved
in children: No

BRETYLIUM TOSYLATE

IV dose
5-10 mg by rapid push for VF resistant to DC cardioversion. Dilute in D5W and infuse over 10-20 minutes for treatment of other arrhythmias, to avoid hypotension.

May repeat once after 1/2 to 2 hours.

Drip 15-30 ug/kg/min or 5-10 mg/kg q 6 hours.

Maximum 30 mg/kg/day.

Levels: Therapeutic range undefined

Kinetics: Actions delayed up to 1 hour after IV dose, because of slow accumulation in myocardium. Elimination half-life 6.3-13.6 hours. Half-life greatly increased in renal failure.

Cautions: Hypotension, particularly with rapid IV bolus.

Interactions Additive AVN blocking effect with quinidine. Antagonizes local anaesthetic effect of quinidine. Worsens digoxin toxic arrhythmias, via release of norepinephrine. Effects are blocked by tricyclic antidepressants.

Preparations: Bretylol injection: 500 mg/10 ml ampules, vials.

FDA-approved
in children: No

DIGOXIN

IV dose Any IV dose should be 75% of corresponding oral dose (see below)

Oral dose:
Dosing guidelines are largely a theological issue among pediatric cardiologists.

Total oral digitalizing dose (TDD) given over 24 hours:

Prematures: 20 ug/kg

Full term newborns: 30 ug/kg

Infants < 2years: 40-50 ug/kg

Children >2 years: 30-40 ug/kg

Adults: 1.25-1.5 mg total dose.

Maintenance: 25% of TDD, daily divided BID.

Levels:
Life is too short to argue about whether digoxin levels are meaningful, other than in toxicity.

Column-separated levels in infants.

O.7-2.0 nanograms/ml in adults.

Levels up to 3.5 are well tolerated in infants

Kinetics:
Infants and children have high volumes of distribution.

Elimination half-life by age:

Prematures: 61 hours.

Full term newborns: 35 hours.

Infants: 18 hours.

Children: 37 hours.

Adults: 35-48 hours.

Cautions: Most common arrhythmias due to toxicity are PVCs and VT in adults, PAT with block in children

Interactions
Levels increased by erythromycin, quinidine, amiodarone, verapamil and aldactone. (!)

Levels decreased by phenytoin.

Digoxin toxic arrhythmias exacerbated by bretylium due to initial catechol release from nerve terminals

Preparations:
Lanoxin scored tablets: 0.125, 0.250. 0.500 mg

Lanoxicaps (solution in capsule): 50, 100, 200 ug.

Lanoxin elixir (60 cc dropper bottle): 50 ug/ml.

Lanoxin injection, Adult: 500 ug/2 ml

Pediatric:100 ug/1 ml.

FDA-approved
in children: One of the few!

ADENOSINE

IV dose
0.050 or 0.10 mg/kg IV as initial dose. Double dose every several minutes, up to 0.40 mg/kg or arrhythmia termination. Upper limit 20 mg in adults. Give fast and flush. Works best when given by central line.

"If nothing happens, you didn't give enough"

Levels: Action too short too measure

Kinetics: Serum half-life <10 seconds. All effects gone in 20-30 secs.

Cautions: Principally effective in SVT utilizing AV node as part of reentrant circuit (AVRT, AVNRT). May be weak bronchoconstrictor, so be cautious in patients with severe asthma. Often causes atrial ectopy, including atrial fibrillation. Use only in setting where immediate electrical cardioversion is possible.

Interactions Digoxin, verapamil may potentiate effect

Preparations: Adenocard 6 mg/cc ampule

FDA-approved
in children: No

PHENYLEPHRINE

IV dose
Adults: 0.2-0.5 mg IV bolus over 30 seconds. May go up to 1.0 mg bolus to raise BP acutely.

Drip: 40-60 ug/min.

Tetralogy spells: 20-100 ug/kg bolus, 1-5 ug/kg/min IV infusion

Levels: Therapeutic range undefined

Kinetics: Acute increase in blood pressure within a minute of intravenous administration. Effects last about 20 minutes.

Cautions: Hypertension

Interactions Extreme caution when used with halothane anesthesia.

Preparations: Neo-synephrine injection, 1% solution: 10 mg/1 ml
vials, 20 mg/2 ml syringes

FDA-approved
in children: Yes

MIDODRINE

Oral dose: Adults: 10 mg TID recommended, 3rd dose not later than 6 pm.

Kinetics: Direct effect of metabolite on alpha receptors. Peak levels of metabolite at 1-2 hours, half-life of 3-4 hours.

Cautions: Supine and/or sitting hypertension should be checked for after initiation of therapy. Symptoms may include heart pounding, headache, blurred vision.

Interactions
May potentiate vagal bradycardia with digoxin.

Avoid other vasoconstrictors (e.g. phenylephrine, phenylpropanolamine, dihydroergotamine)

Effects antagonized by prazosin)

Preparations: ProAmatine scored tablets, 2.5, 5 mg

FDA-approved
in children: No

FLUODROCORTISONE ACETATE

Oral dose: 0.10 mg orally QD for adults, 0.05 mg QD for children up to 0.15 mg/day

Cautions: Hypertension, hypokalemia, edema

Interactions

Preparations:
Florinef acetate scored tablets, 0.10 mg.

Use with salt, 1 Gram sodium tablets TID

FDA-approved
in children: Yes

TIM GARSON'S PEDIATRIC ELECTROCARDIOGRAPHIC CRITERIA

Right Ventricular Hypertrophy:
1) qR pattern in V4R, V3r or V1 (r/o L-TGA, WPW, anteroseptal infarct

2) Upright T wave in V4R, V3R, or V1 (8 days - 8 years of age.)

3) Abnormal R/S ratio in V1

4) >95th%ile S in V6, or R in V1.

Left Ventricular Hypertrophy
1) R in V6 plus S in V1 > 60 mm Don't use transition leads. Use V5 if R is larger than in V6

2) S in V1 > twice the R in V5.

3) Abnl R/S ratio in V1 or V6.

4) > 95th%ile S in V1 or R in V6.

5). T wave inversion in lateral leads

Biventricular Hypertrophy:
1) RVH plus >50%ile S in V1 or R in V6.

2) LVH plus >50%ile R in V1 or S in V5.

3) Large equiphasic mid-precordial voltages: > 65 mm in 1 lead, or > 45 mm in 4 leads ("Katz-Wachtel")

Right Atrial Enlargement P amplitude > 3 mm under 6 months, or 2.5 mm over 6 months

Left Atrial Enlargement:
1) P duration in II > 90 msecs

2) Late negative V1 deflection > 40 msecs and 1 mm (1 small square).

Normal ECG Standards for Children by Age

0-1 d

1-3 d

3-7 d.

7-30 d.

1-3 mo.

3-6 mo.

6-12 mo.

1-3 years

3-5 years

5-8 years

8-12 yrs

12-16 yrs

HR/min
94-155 (122)

91-158 (122)

90-166 (128)

106-182 (149)

120-179 (149)

105-185 (141)

108-169 (131)

89-152 (119)

73-137 (109)

65-133 (100)

62-130 (91)

60-120 (80)

Frontal plane QRS axis (degrees)
59-189 (135)

64-197 (134)

76-191 (133)

70-160 (109)

30-115 (75)

7-105 (60)

6-98

(55)

7-102 (55)

6-104 (56)

10-139 (65)

6-116 (60)

9-128

(59)

PR. Lead II (sec)
.08-.16 (.107)

.08-.14 (.108)

.07-.15

(.102)

.07-.14 (.100)

.07-.13 (.098)

.07-.15 (.105)

.07-.16 (.106)

.08-.15 (.113)

0.08-.16 (.119)

.09-.16 (.123)

.09-.17 (.128)

.09-.18

(.135)

QRS duration, V5 (sec)
.02-.07

(.05)

.02-.07 (.05)

.02-.07 (.05)

.02-.08

(.05)

.02-.08 (.05)

.02-.08

(.05)

.03-.08

(.05)

.03-.08 (.06)

.03-.07

(.06)

.03-.08 (.06)

.04-.09 (.06)

.04-.09 (.07)

P wave amplitude, lead II
.5-2.8

(1.6)

.3-2.8

(1.6)

.7-2.9

(1.7)

.7-3.0

(1.9)

.7-2.6

(1.5)

.4-2.7

(1.6)

.6-2.5

(1.6)

.7-2.5

(1.5)

.3-2.5

(1.4)

.4-2.5

(1.4)

.3-2.5

(1.4)

.3-2.5

(1.4)

Q wave amplitude, aVF
.1-3.4

(1.0)

.1-3.3

(1.0)

.1-3.5

(1.1)

.1-3.5

(1.2)

.1-3.4

(.9)

0-3.2

(.9)

0-3.3

(1.0)

0-3.2

(.9)

0-2.9

(.6)

0-2.5

(.6)

0-2.7

(.5)

0-2.4

(.4)

Q wave amplitude, V6
0-1.7

.(1)

0-2.2 (.1)

0-2.8

(.1)

0-2.8

(.4)

0-2.6

(.3)

0-2.6

(.3)

0-3.0

(.4)

0-2.8 (.6)

.1-3.3

(.8)

.1-4.6 (.8)

.1-2.8 (.6)

0-2.9

(.4)

R amplitude V1
5-26

(13)

5-27 (15)

3-25

(12)

3-12

(10)

3-19

(10)

3-20

(10)

2-20

(9)

2-18

(8)

1-18

(8)

1-14

(7)

1-12

(5)

1-10

(4)

S amplitude V1
1-23

(8)

1-20

(9)

1-17

(7)

0-11

(4)

0-13

(5)

0-17

(6)

1-18

(7)

1-21

(8)

2-22

(10)

3-23 (12)

3-25 (12)

3-22

(11)

R amplitude V6
0-12

(4)

0-12

(5)

1-12

(5)

3-16

(8)

5-21

(12)

6-22

(13)

6-23

(13)

6-23 (13)

8-25

(15)

8-26 (16)

9-25 (16)

7-23

(14)

S amplitude V6
0-10

(4)

0-9

(3)

0-10

(4)

0-10

(3)

0-7

(3)

0-10

(3)

0-8

(2)

0-7

(2)

0-6

(2)

0-4

(1)

0-4

(1)

0-4

(1)

R/S ratio

V1

.1-9.9

(2.2)

.1-6

(2.0)

.1-9.8

(2.8)

1.0-7.0

(2.9)

.3-7.4

(2.2)

.1-6.0

(2.3)

.1-4.0

(1.8)

.1-4.3

(1.4)

.03-2.7

(.9)

.02-2.0

(.8)

.02-1.9

(.6))

.02-1.8

(.5)

RS ratio

V6

.1-9

(2)

.1-12

(3)

.1-10

(2)

.1-12

(4)

.2-14

(5)

.2-18

(7)

.2-22

(8)

.3-27

(10)

.6-30

(11)

.9-30

(12)

1.5-33

(14)

1.4-39

(15)

All values are 2nd percentile -98th percentile, (mean). All amplitudes of waves are given in millimeters at full standardization, i.e. 1 mm=10 mv.

Derived from percentile charts in Davignon A, Rautaharju P, Boisselle E, Soumis F, Megelas M, Choquette A. Normal ECG standards for infants and children. Pediatr Cardiol 1979; 1:123-1

Pediatric Arrhythmia Center at UCSF and Stanford

How to reach us:

Beeper

e-mail

George Van Hare, M.D.

415-607-1549

vanhare@leland.stanford.edu

Anne Dubin, M.D.

415-607-0224

amdubin@leland.stanford.edu

Kathy Collins, M.D.

415-607-2542

kcollins@pedcard.ucsf.edu

Debra Hanisch, R.N.

650-723-8222, #18151

debra.hanisch@LPCH.stanford.edu

Nancy Chiesa, R.N.

415-719-9755

chiesa@itsa.ucsf.edu

Lucile Packard Children's Hospital
UCSF Children's Hospita, Box 0632

750 Welch Road, #305
505 Parnassus

Palo Alto, CA 94304
San Francisco, CA 94143

Phone 650-723-7913
Phone 415-476-1040

Facsimile 650-725-8343
Facsimile 415-476-3112

Class Ia Procainamide Quinidine Disopyramide	Class II Propranolol Atenolol Nadolol Metoprolol Pindolol Esmolol	Others Bretylium Digoxin Adenosine Phenylephrine Midodrine Fludrocortisone
Class Ib Lidocaine Mexiletine Phenytoin Moricizine	Class III Ibutalide Sotalol Amiodarone
Class 1c Flecainide Propafenone	Class IV Verapamil Diltiazem

IV dose	Loading dose: 10-15 mg/kg (yes, milligrams)maximum 1.0 gram maximum rate 50 mg/min or 0.5 mg/kg/min Drip: 30-80 ug/kg/min (yes, micrograms)
Oral dose:	50-100 mg/kg/day divided q 3-4 hours (q 6 hours for slow release forms)
Levels:	PC 4-8, may go up to 12 ug/ml NAPA <40 ug/ml is well tolerated. ?usefulness.
Kinetics:	Peak levels at 1 hour after oral dose. Increased volume of distribution in heart failure. Elimination half-life of PC: 2.5-4.7 hours in adults.13.5 hours in neonates.7 hours in 7-12 year olds.1st order to at least to 26 ug/ml. For slow release forms, t 1/2 = 6-7 hours. Elimination half-life of NAPA: 6-8 hours.
Cautions:	QRS >25% prolongation: no further dosage increases QTc >= 0.500 : stop drug
Interactions	Amiodarone increases PC and NAPA levels by 57% and 32% respectively. Cimetidine increases PC half-life. Propranolol decreases t 1/2, increases Vd. Digoxin: no known interaction.
Preparations:	Pronestyl non-scored tabs: 250, 375, 500 mg. Capsules 250, 375, 500 mg. Pronestyl SR non-scored matrix tabs: 500 mg. Procan SR wax matrix tabs: 250, 500, 750, 1000 mg.(>500 tabs scored) Pronestyl injection 1000 mg vials:100 mg/cc or 500 mg/cc.
FDA approval in children:	no

IV dose	Don't! Frequent occurrence of hypotension and cardiovascular collapse!
Oral dose:	Quinidine sulfate: 30-60 mg/kg/day (450-900 mg/m2/day) in children, 10 mg/kg/day in adults, divided q 6 hours. 20% higher for gluconate, given q 8-12 hours
Levels:	2-6 ug/ml >7 ug/ml highly correlated with toxicity.
Kinetics:	Peak levels 1-3 hours for sulfate, 4 hours for gluconate after oral dose. Elimination half-life 6.3 hours in adults. 4.7 hours in 4-6 year olds, 6 hours in neonates.
Cautions:	Similar to those for procainamide
Interactions	Potentiation of warfarin effect. Mean 100-150% increase in digoxin levels. (Probably doesn't occur under 2 months of age.) Levels increased in congestive heart failure. Elimination impaired by cimetidine, amiodarone. Elimination accelerated by phenytoin, propranolol, rifampin. Contraindicated with verapamil: cardiovascular collapse and hypotension frequent.
Preparations:	Quinidine sulfate tablets: 200, 300 mg. Quinidex Extentabs (Q. sulfate): 1/3 released immediately, 2/3 slow release in GI tract. 300 mg tablets. Quiniglute Duratabs: non-scored tablets: 324 mg
FDA approval in children:	no

IV dose	No IV form
Oral dose:	< 2 yr.: 23-33 mg/kg/day (mean 30) 2-10 yr.: 9-24 mg/kg/day (mean 20) >10 yr.: 5-13 mg/kg/day (mean 8) divided q 6 hours, or q 12 hours for CR forms. Maximum 1200 mg/day.
Levels:	2-5 ug/ml, poorly correlated with efficacy
Kinetics:	Peak levels at 0.5-3 hours after oral dose. (3.4-4.0 hours after controlled release form). Nonlinear kinetics due to protein binding. Elimination half-life 5-6 hours at therapeutic levels. Large Vd in children.
Cautions:	Causes significant decreases in contractility! In renal failure, active metabolite (NMD) accumulates, which is even more anticholinergic than parent compound.
Interactions	None with digoxin. Atenolol decreases clearance and is synergistic in decreasing cardiac output. (Probably true for all beta blockers). Phenytoin increases clearance and decreases levels.
Preparations:	Norpace capsules: 100, 150 mg Norpace CR: controlled release capsules: 100, 150 mg
FDA approval in children:	yes

IV dose	Loading does: 1 mg/kg, given no faster than 50 mg/min. May repeat twice q 5-10 mins. Drip 20-50 ug/kg/min. Decrease rate by 50% at 24 hours!
Oral dose:	No PO form
Levels:	1.5-5 ug/ml. Toxicity (esp. confusion) frequent >6 ug/ml.
Kinetics:	Elimination half-life 1.8 hours in adults and children aged 6 m- 3 years, 3.2 hours in neonates. Decreased clearance in congestive heart failure.
Cautions:	Vertigo, paraesthesias, slurred speech and confusion are the first signs of toxicity.
Interactions	Propranolol decreases liver blood flow and lidocaine clearance. Isoproterenol, phenobarbital, phenytoin increase clearance.
Preparations:	Xylocaine injection, 100 mg/5 cc (amps or syringes).
FDA approval in children:	yes

IV dose	Loading: 10-15 mg/kg to maximum of 1.0 gram. 1/13 given IV bolus every 5 mins, flushed with NS. (D5W will precipitate drug in line)
Oral dose:	Loading: 15 mg/kg divided QID x 24 hours, then 7.5 mg/kg divided QID x 24 hours. Additional day of 7.5 optional, depending on response and levels. Maintenance: By age: 0-2 wk.: 4-8 mg/kg/d divided q 12 hours Infants > 2 wk.: 8-12 mg/kg/d divided q 8 hours Children: 5-6 mg/kg/d divided q 12 hours Adults: 300-400 mg/day divided q 12 hours.
Levels:	10-25 ug/ml Toxicity common at > 20 ug/ml.
Kinetics:	Zero-order (t 1/2 depends on concentration) e.g. At high levels, additional dose increases may raise levels drastically. Average t 1/2 = 22 hours at therapeutic levels (range 7-40 hours) in adults, 8 hours at 1 month, 21 hours in full term newborns, 75 hours in prematures. Peak levels at 1.5-3 hours after oral dose of Infatabs, 4-12 hours for Kapseals.
Cautions:	In pregnancy, 11% incidence of fetal hydantoin syndrome, 31% incidence of lesser impairments.
Interactions	Amiodarone increases levels Phenobarbital decreases levels. Phenytoin potentiates warfarin anticoagulation. Phenytoin decreases digoxin half-life.
Preparations:	Dilantin suspension SHOULD NEVER BE GIVEN. Dilantin Infatabs- best absorbed. 50 mg Dilantin Kapseals: 30, 100 mg.
FDA approval in children:	yes

IV dose	0.2 mg/kg q 10 min to 2.0 mg/kg maximum. Give with volume. Drip 0.004-0.007 mg/kg/min (IV preparation not available in USA)
Oral dose:	300-400 mg/m2/day divided q 6 hours
Levels:	Not yet proven to be useful.
Kinetics:	Nonlinear, saturable kinetics Variable elimination half-life: 2.4-11.8 hours (Up to 26 hours in slow metabolizers). Peak levels 2-3 hours after oral dose.
Cautions:	1/40 propranolol beta-blocking effect, 50 times the normally achievable propranolol concentrations.
Interactions	Increases digoxin levels by 40-100%. Aggravates ventricular arrhythmias, especially torsades de pointes, when used with amiodarone.
Preparations:	Rythmol scored tablets, 150 mg, 300 mg
FDA-approved in children:	no

IV dose	0.02 mg/kg every 5 min to 0.1 mg/kg total dose.
Oral dose:	2 mg/kg/day divided q 6 hours to start. Increase routinely to 5 mg/kg/day. May in rare circumstances go to 14 mg/kg/day, watching levels. Inderal LA should be given BID in children
Levels:	25-150 nanograms/ml for beta blockade. 150-1000 ng/ml for control of VT.
Kinetics:	Large first-pass metabolism in liver. Elimination half-life 4-6 hours. (T 1/2 of 4-hydroxy-P 5.2-7.5 hours, active). Peak levels at 2-3 hours after oral dose.
Cautions:	Contraindicated in asthma, congestive heart failure. Beware hypoglycemia in infants and diabetics
Interactions	Levels increased by cimetidine. Contraindicated with verapamil, due to synergistic negative inotropic effect and cardiovascular collapse Increases hepatic lidocaine metabolism.
Preparations:	Inderal scored tabs: 10, 20, 40, 60, 80, 90 mg. Inderal LA capsules: 60, 80, 120, 160 mg. Inderal injection, 1 mg/1 ml ampules.
FDA-approved in children:	yes

Oral dose:	1-2 mg/kg/day, given QD. Adjust up or down after 5 days based on side effects, sinus rate, and efficacy.
Levels:	Not yet clinically useful.
Kinetics:	Elimination half-life 12-24 hours. Peak levels at 3-4 hours after oral dose.
Cautions:	Similar to propranolol. Not particularly cardioselective, but fewer CNS side effects.
Preparations:	Corgard non-scored tabs: 20, 40, 80 mg scored tablets: 120, 160 mg
FDA-approved in children:	No.

IV dose	5 mg q 2 minutes to total 15 mg in adults post MI
Oral dose:	100-450 mg/day in adults divided qd or bid
Levels:	unknown
Kinetics:	Plasma half-life 3-7 hours in adults
Cautions:	Similar to propranolol. Fairly cardioselective.
Interactions	similar to propranolol
Preparations:	Lopressor scored tabs: 50, 100 mg Lopressor injection, 1 mg/cc, 5 cc ampuls
FDA-approved in children:	No.

Oral dose:	Drug of choice in vasodepressor syncope, because of intrinsic sympathomimetic activity. 10-60 mg/day in adults divided bid
Levels:	Unknown
Kinetics:	Plasma half-life 3-4 hours. Clearance reduced in uremia
Cautions:	Similar to other beta blockers.
Interactions	ISA may be blocked by other beta blockers
Preparations:	Visken "heart-shaped" non-scored tabs: 5, 10 mg.
FDA-approved in children:	no

IV dose	500 ug/kg/min for 1 minute, then 50 ug/kg/min. Repeat bolus in 5 minutes, increase infusion to 100 ug/kg/min if no effect. Further increases with boluses up to 200 ug/kg/min as necessary
Levels:	Unknown
Kinetics:	Elimination half-life 9 minutes.
Cautions:	Hypotension occurs transiently in 44%. CNS side effects are common, esp. emesis (16%).
Interactions	Increases digoxin levels by 10-19%. Levels increased by warfarin, morphine.
Preparations:	Breviblock injection, 2.5 grams/10 ml ampule
FDA-approved in children:	No.

IV dose:	0.01 mg/kg over 10 minutes (under 60 kg) 1-2 mg over 10 minutes (over 60 kg)
Kinetics:	Highly variable. Half-life averages 6 hours (2-12 hours)
Cautions:	VT or torsades de pointes in 9% as late as 4 hours after the dose. Do not give if there is hypokalemia or preexisting QT prolongation. Requires electrocardiographic monitoring in a critical care setting >4 hours.
Interactions	Do not give with Class I or III antiarrhythmics
Preparations:	Corvert injection, 0.1 mg/cc., 10 cc vial = 1 mg
FDA-approved in children:	No

Oral dose:	Adults: 80 mg B.I.D. to start, adjusting upwards every 2-3 days to 160 mg B.I.D. Maximum 640 mg daily in life-threatening arrhythmias. Children: 2-8 mg/kg/day divided B.I.D.
Levels:	unknown
Kinetics:	Mean elimination half-life 12 hours. Excreted in urine
Cautions:	Class II/III actions, so similar to other beta-blockers. Dose, QTc interval and incidence of Torsades are related: QTc should be followed. In particular, maintain normal potassium and magnesium levels, as Torsades is much more common with hypokalemia and/or hypomagnesemia.
Interactions	No effect on digoxin. Do not use with class !a agents,as QTc will be further prolonged. As with other beta blockers, will further decrease cardiac function is used with calcium channel blockers
Preparations:	Betapace scored tablets 80, 160, 240 mg
FDA-approved in children:	No.

IV dose	5 mg/kg over 15-30 mins.. Repeat if necessary in 15 minutes. Drip 10-20 mg/kg/day. Must be given by central line in D5W.
Oral dose:	Loading: 5 mg/kg given BID x 10 days (max 1.2grams/day) Then 5 mg/kg QD for 1-2 months. Attempt to decrease progressively to 2.5 mg/kg in small changes every 4-6 months.
Levels:	Useful to document gross noncompliance. Therapeutic > 1.0 ug/ml. Toxicity common at > 2.5 ug/ml.
Kinetics:	Complex and obscure. Extensive rapid uptake by adipose tissue, slow uptake by myocardium, concentrates in both. Elimination half-life about 30 days with chronic oral therapy. (Range 8-107 days) Levels detectable 9 months after stopping Rx. Therapeutic effect seen 1-3 hours after IV dose. Peak serum level at 5 hours after oral dose
Cautions:	Many. In particular, extreme sinus bradycardia requiring a pacemaker is frequent. 25% incidence of marked hypotension and decreased contractility with IV administration only.
Interactions	Potentiates warfarin action. Digoxin levels progressively rise 70-100%. With beta blockers and calcium channel blockers, causes severe sinus bradycardia.Potentiates tendency of quinidine, propafenone and mexiletine to cause Torsades de pointes. Increases levels of quinidine, procainamide, phenytoin, flecainide, and cyclosporin.
Preparations:	Cordarone scored tablets, 200 mg. Cordarone injection, 50 mg/cc, 3 cc ampuls
FDA-approved in children:	No

IV dose		0.075-0.150 mg/kg (max 10 mg) over 1-2 minutes.
Oral dose:	4-17 mg/kg/day divided q 8 hours (BID or QD with slow release form)
Levels:	0.1-0.3 ug/ml.
Kinetics:	Zero-order (half-life related to dose). Extensive first-pass metabolism. Elimination half-life 12 hours on chronic oral therapy, but 6 hours after single dose.
Cautions:	Do not use under 12 months of age, especially under 3 months, hypotension, CV collapse, death). Use with caution long-term in patients with manifest preexcitation. (conversion of SVT is OK). Do not pre-treat with calcium chloride, as it interferes with the therapeutic effect. Be prepared with calcium, fluids and dopamine if hypotension occurs following administration.
Interactions	Contraindicated with beta blockers, due to synergistic negative inotropy. Contraindicated with quinidine, due to synergistic negative inotropy. Increases digoxin levels 40-75% (quinidine-like). Therapeutic effect blocked by anticholinergic properties of disopyramide
Preparations:	Calan scored tablets: 80, 120 mg. Calan SR scored tablets: 240 mg. Calan injection: 5 mg/2 ml, 10 mg/4 ml amps, vials. Isoptin: same Verelan pellet-filled capsules: 120, 240 mg. (QD dosing)
FDA-approved in children:	No.

IV dose	Initial bolus 0.25 mg/kg over 2 min (average 20 mg in adults). Second dose of 0.35 mg/kg over 2 minutes may be given (average 25 mg) Continuous infusion: 5-15 mg/hr (usual 10 mg/hour) in adults. No pediatric dose. (suggest 0.125 mg/kg/hr = 2 ug/kg/min).
Oral dose:	30-90 mg QID of short-acting preparation 60-180 mg BID of "SR" preparation. 180-360 mg QD of "CD" preparation.
Levels:	Therapeutic range undefined
Kinetics:	Maximum effect 2-5 minutes after bolus injection. Plasma half-life 3-4.5 hours. Metabolized in lever, excreted in urine.
Cautions:	Same cautions as with verapamil. May be better tolerated with beta blockers than verapamil. Avoid in young children.
Interactions	Increases levels of propranolol, digoxin (20%), cyclosporin, carbamazepine. Levels increased by cimetidine
Preparations:	Cardizem injectable, vials 25 mg/5 cc or 50 mg/10 cc. Cardizem tablets, 30 mg (non-scored), 60, 90, 120 mg (scored). Cardizem SR capsules, 60, 90, 120 mg Cardizem CD capsules, 120, 180, 240, 300 mg.
FDA-approved in children:	No

IV dose	5-10 mg by rapid push for VF resistant to DC cardioversion. Dilute in D5W and infuse over 10-20 minutes for treatment of other arrhythmias, to avoid hypotension. May repeat once after 1/2 to 2 hours. Drip 15-30 ug/kg/min or 5-10 mg/kg q 6 hours. Maximum 30 mg/kg/day.
Levels:	Therapeutic range undefined
Kinetics:	Actions delayed up to 1 hour after IV dose, because of slow accumulation in myocardium. Elimination half-life 6.3-13.6 hours. Half-life greatly increased in renal failure.
Cautions:	Hypotension, particularly with rapid IV bolus.
Interactions	Additive AVN blocking effect with quinidine. Antagonizes local anaesthetic effect of quinidine. Worsens digoxin toxic arrhythmias, via release of norepinephrine. Effects are blocked by tricyclic antidepressants.
Preparations:	Bretylol injection: 500 mg/10 ml ampules, vials.
FDA-approved in children:	No

IV dose	Any IV dose should be 75% of corresponding oral dose (see below)
Oral dose:	Dosing guidelines are largely a theological issue among pediatric cardiologists. Total oral digitalizing dose (TDD) given over 24 hours: Prematures: 20 ug/kg Full term newborns: 30 ug/kg Infants < 2years: 40-50 ug/kg Children >2 years: 30-40 ug/kg Adults: 1.25-1.5 mg total dose. Maintenance: 25% of TDD, daily divided BID.
Levels:	Life is too short to argue about whether digoxin levels are meaningful, other than in toxicity. Column-separated levels in infants. O.7-2.0 nanograms/ml in adults. Levels up to 3.5 are well tolerated in infants
Kinetics:	Infants and children have high volumes of distribution. Elimination half-life by age: Prematures: 61 hours. Full term newborns: 35 hours. Infants: 18 hours. Children: 37 hours. Adults: 35-48 hours.
Cautions:	Most common arrhythmias due to toxicity are PVCs and VT in adults, PAT with block in children
Interactions	Levels increased by erythromycin, quinidine, amiodarone, verapamil and aldactone. (!) Levels decreased by phenytoin. Digoxin toxic arrhythmias exacerbated by bretylium due to initial catechol release from nerve terminals
Preparations:	Lanoxin scored tablets: 0.125, 0.250. 0.500 mg Lanoxicaps (solution in capsule): 50, 100, 200 ug. Lanoxin elixir (60 cc dropper bottle): 50 ug/ml. Lanoxin injection, Adult: 500 ug/2 ml Pediatric:100 ug/1 ml.
FDA-approved in children:	One of the few!

IV dose	0.050 or 0.10 mg/kg IV as initial dose. Double dose every several minutes, up to 0.40 mg/kg or arrhythmia termination. Upper limit 20 mg in adults. Give fast and flush. Works best when given by central line. "If nothing happens, you didn't give enough"
Levels:	Action too short too measure
Kinetics:	Serum half-life <10 seconds. All effects gone in 20-30 secs.
Cautions:	Principally effective in SVT utilizing AV node as part of reentrant circuit (AVRT, AVNRT). May be weak bronchoconstrictor, so be cautious in patients with severe asthma. Often causes atrial ectopy, including atrial fibrillation. Use only in setting where immediate electrical cardioversion is possible.
Interactions	Digoxin, verapamil may potentiate effect
Preparations:	Adenocard 6 mg/cc ampule
FDA-approved in children:	No

IV dose	Adults: 0.2-0.5 mg IV bolus over 30 seconds. May go up to 1.0 mg bolus to raise BP acutely. Drip: 40-60 ug/min. Tetralogy spells: 20-100 ug/kg bolus, 1-5 ug/kg/min IV infusion
Levels:	Therapeutic range undefined
Kinetics:	Acute increase in blood pressure within a minute of intravenous administration. Effects last about 20 minutes.
Cautions:	Hypertension
Interactions	Extreme caution when used with halothane anesthesia.
Preparations:	Neo-synephrine injection, 1% solution: 10 mg/1 ml vials, 20 mg/2 ml syringes
FDA-approved in children:	Yes

Oral dose:	Adults: 10 mg TID recommended, 3rd dose not later than 6 pm.
Kinetics:	Direct effect of metabolite on alpha receptors. Peak levels of metabolite at 1-2 hours, half-life of 3-4 hours.
Cautions:	Supine and/or sitting hypertension should be checked for after initiation of therapy. Symptoms may include heart pounding, headache, blurred vision.
Interactions	May potentiate vagal bradycardia with digoxin. Avoid other vasoconstrictors (e.g. phenylephrine, phenylpropanolamine, dihydroergotamine) Effects antagonized by prazosin)
Preparations:	ProAmatine scored tablets, 2.5, 5 mg
FDA-approved in children:	No

Oral dose:	0.10 mg orally QD for adults, 0.05 mg QD for children up to 0.15 mg/day
Cautions:	Hypertension, hypokalemia, edema
Interactions
Preparations:	Florinef acetate scored tablets, 0.10 mg. Use with salt, 1 Gram sodium tablets TID
FDA-approved in children:	Yes

Right Ventricular Hypertrophy:	1) qR pattern in V4R, V3r or V1 (r/o L-TGA, WPW, anteroseptal infarct 2) Upright T wave in V4R, V3R, or V1 (8 days - 8 years of age.) 3) Abnormal R/S ratio in V1 4) >95th%ile S in V6, or R in V1.
Left Ventricular Hypertrophy	1) R in V6 plus S in V1 > 60 mm Don't use transition leads. Use V5 if R is larger than in V6 2) S in V1 > twice the R in V5. 3) Abnl R/S ratio in V1 or V6. 4) > 95th%ile S in V1 or R in V6. 5). T wave inversion in lateral leads
Biventricular Hypertrophy:	1) RVH plus >50%ile S in V1 or R in V6. 2) LVH plus >50%ile R in V1 or S in V5. 3) Large equiphasic mid-precordial voltages: > 65 mm in 1 lead, or > 45 mm in 4 leads ("Katz-Wachtel")
Right Atrial Enlargement	P amplitude > 3 mm under 6 months, or 2.5 mm over 6 months
Left Atrial Enlargement:	1) P duration in II > 90 msecs 2) Late negative V1 deflection > 40 msecs and 1 mm (1 small square).

	Beeper	e-mail
George Van Hare, M.D.	415-607-1549	vanhare@leland.stanford.edu
Anne Dubin, M.D.	415-607-0224	amdubin@leland.stanford.edu
Kathy Collins, M.D.	415-607-2542	kcollins@pedcard.ucsf.edu
Debra Hanisch, R.N.	650-723-8222, #18151	debra.hanisch@LPCH.stanford.edu
Nancy Chiesa, R.N.	415-719-9755	chiesa@itsa.ucsf.edu

Lucile Packard Children's Hospital	UCSF Children's Hospita, Box 0632
750 Welch Road, #305	505 Parnassus
Palo Alto, CA 94304	San Francisco, CA 94143
Phone 650-723-7913	Phone 415-476-1040
Facsimile 650-725-8343	Facsimile 415-476-3112