Epinephrine is the one drug proven beneficial in cases of cardiac arrest. It is specifically indicated for hypoxia- or ischemia-induced slow rates that fail to respond to adequate oxygenation and ventilation and to pulseless arrest situations (i.e., asystole, pulseless electrical activity, and ventricular fibrillation). If the initial dose of epinephrine is not effective, 10 to 20 times that dose should be given subsequently. However, the use of high-dose epinephrine (0.1 mg/kg of the 1:1000 concentration) for resuscitation in infants and children has not been associated with increased survival rate in any controlled prospective studies. PALS has recommended,4 and at the time of this writing continues to recommend, that high-dose epinephrine be used if there is no response to the initial standard dose. Studies addressing this issue that are currently concluding are not expected to show an increase in neurologically intact survival. Adverse effects associated with the use of high-dose epinephrine in the clinical setting include intracranial hypertension, myocardial hemorrhage, and myocardial necrosis. 5 Epinephrine, rather than dopamine, is the vasopressor infusion of choice in children, because dopamine requires release of endogenous norepinephrine. In children with cardiac arrest, norepinephrine stores may be low.
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