Pharmacology is one of the most heavily tested areas on the PALS written exam — and one of the most common sources of lost points. Drug doses, routes, and indications are exact, and the exam will test whether you know them precisely. This guide covers every medication you need to know for PALS, organized by clinical situation.
Why Pharmacology Is High-Stakes on the PALS Exam
Unlike many exam topics where partial knowledge can help you reason through a question, pharmacology questions require precise recall. Knowing that epinephrine is used in cardiac arrest isn't enough — you need to know the exact dose (0.01 mg/kg IV/IO), the concentration to use (1:10,000), and the dosing interval (every 3–5 minutes). Off-by-one errors in drug dosing can be the difference between a correct and incorrect answer.
A critical distinction: all PALS drug doses are weight-based. This is a key difference from adult ACLS protocols, which use fixed doses. If you also hold ACLS certification, be deliberate about keeping the two sets of dosing rules separate in your mind.
Cardiac Arrest Medications
These are the drugs used during active resuscitation for pulseless rhythms (VF, pVT, PEA, asystole).
| Drug | Dose | Route | Indication / Notes |
|---|---|---|---|
| Epinephrine | 0.01 mg/kg (max 1 mg) | IV/IO | All pulseless rhythms. Repeat every 3–5 min. Use 1:10,000 concentration. |
| Amiodarone | 5 mg/kg (max 300 mg) | IV/IO | Shock-refractory VF/pVT only. Can repeat up to 2 additional doses. |
| Lidocaine | 1 mg/kg | IV/IO | Alternative to amiodarone for shock-refractory VF/pVT. |
Common exam trap
The exam may ask about epinephrine concentration. In PALS, you always use the 1:10,000 concentration (0.1 mg/mL) for IV/IO administration. The 1:1,000 concentration (1 mg/mL) is used for IM injection in anaphylaxis — not cardiac arrest. This is one of the most frequently tested distinctions in PALS pharmacology.
Bradycardia Medications
Bradycardia drugs are used when a child has symptomatic bradycardia with a pulse — meaning the rhythm is causing hemodynamic compromise (poor perfusion, hypotension, altered mental status). Epinephrine is the first-line drug, with atropine reserved for vagally mediated or AV block causes.
| Drug | Dose | Route | Notes |
|---|---|---|---|
| Epinephrine | 0.01 mg/kg (max 1 mg) | IV/IO | First-line for symptomatic bradycardia unresponsive to CPR + oxygenation. |
| Atropine | 0.02 mg/kg (min 0.1 mg, max 0.5 mg) | IV/IO | Used for increased vagal tone or AV block. The minimum dose of 0.1 mg is critical — sub-therapeutic doses can paradoxically worsen bradycardia. |
Tachycardia Medications
Tachycardia management depends on whether the rhythm is stable or unstable, and whether QRS is narrow or wide. The two primary drugs are adenosine (for SVT) and amiodarone (for stable wide-complex tachycardia).
| Drug | Dose | Route | Notes |
|---|---|---|---|
| Adenosine | First dose: 0.1 mg/kg (max 6 mg) Second dose: 0.2 mg/kg (max 12 mg) | IV rapid push | SVT with pulse. Must be given as a rapid IV push followed by a saline flush. Short half-life (~10 seconds). |
| Amiodarone | 5 mg/kg (max 300 mg) | IV/IO over 20–60 min | Stable wide-complex tachycardia. Give slowly when patient has a pulse (unlike cardiac arrest bolus). |
| Procainamide | 15 mg/kg | IV/IO over 30–60 min | Alternative for stable SVT or wide-complex tachycardia. Do not use with amiodarone simultaneously. |
Shock and Fluid Resuscitation
Fluid bolus dosing is one of the most exam-tested numbers in PALS. The standard isotonic crystalloid bolus is 20 mL/kg, given over 5–20 minutes depending on urgency. For septic shock, AHA guidelines support reassessment after each bolus, with titration based on clinical response.
| Drug/Fluid | Dose | Indication |
|---|---|---|
| Normal Saline / LR | 20 mL/kg IV/IO bolus | Hypovolemic or distributive shock. Reassess after each bolus. |
| Epinephrine infusion | 0.1–1 mcg/kg/min | Cardiogenic or fluid-refractory distributive shock. |
| Dopamine infusion | 2–20 mcg/kg/min | Hemodynamic support in cardiogenic shock. |
Defibrillation and Cardioversion Energy Doses
These aren't technically "drugs," but energy dosing is tested just as precisely as pharmacology on the PALS exam.
| Intervention | Energy Dose | Notes |
|---|---|---|
| Defibrillation (unsynchronized) | First: 2 J/kg Second: 4 J/kg Subsequent: 4–10 J/kg (max 10 J/kg or adult dose) | VF and pulseless VT only. |
| Synchronized cardioversion | First: 0.5–1 J/kg Subsequent: 2 J/kg | Unstable SVT or unstable VT with a pulse. Must enable sync mode. |
How to Study Pharmacology for PALS
Memorizing a table isn't enough — you need to be able to retrieve drug doses under pressure, in the context of a scenario. Here's what works:
Use flashcards for dose recall
Create one card per drug: front shows drug name + clinical scenario, back shows dose, route, and key note. Quiz yourself until you can answer instantly without hesitation.
Practice with scenario questions
The exam presents pharmacology in clinical context. A question won't say "what is the adenosine dose?" — it will say "a 4-year-old with SVT at 230 bpm has IV access established. What is the correct initial drug and dose?" Practice retrieving doses from within scenarios, not just from lists.
Know the "why" behind each drug
Understanding the mechanism helps you reason through tricky distractors. Knowing that adenosine works by briefly blocking AV conduction (which is why it terminates SVT) helps you understand why it won't work for VT — and why the exam might use that as a wrong answer choice.