PALS: Fluid Therapy and PALS: Fluid Therapy and MedicationsMedications

Robert S. Cole

Paramedic, CCEMT-P

PALS: Fluid therapy and PALS: Fluid therapy and medicationsmedications

Fluid Therapy for shock, including septic shock and trauma

Priorities for resuscitation drugsHow to give those drugsHow to prepare drug infusions

IV Fluids: Basic factsIV Fluids: Basic facts

Used primarily for volume replacement and medication delivery.

Primarily Crystalloids in the Pre-hospital arena

Large volumes may be needed, especially in septic shock

CrystaloidsCrystaloids

Normal Saline: Good for Fluid Boluses, compatible with blood products, most drugs. 0.9% NaCl has an osmolarity of 308 mOsm/liter, slightly greater than that of plasma

Lactated Ringers: Good for fluid boluses but is mildly hypo-osmolar when compared to plasma, resulting in approximately 114 ml of free water per liter of LR

D5W: Mainly for Hypoglycemia in the stable pt or for infants.

Dextrose containing solutions should not be used for boluses as they will likely cause Hyperglycemia Hyperglycemia is associated with poor neurological outcomes.

ColloidsColloids

Colloid refers to a liquid that exerts osmotic pressure due to large MW (greater than 30,000) particles in solution. A variety of colloid solutions are seen for in hospital use:

Hydroxyethyl starch (Hespan): hetastarch can cause a coagulopathy, through hemodilution of clotting factors, inhibition of platelet function and reduction of the activity of factor VIII

Pentastarch (Pentaspan):Pentastarch differs from hetastarch in that it has a lower mean MW. Preliminary studies also suggest that pentastarch may have fewer adverse effects on coagulation than hetastarch.25. No clear pediatric value yet.

ColloidsColloids

Dextran solutions (dextran 40 and dextran 70): Similar osmotic pressure to plasma. Dextrans interfere with normal coagulation partly by hemodilution of clotting factors and partly by “coating” platelets and the vascular endothelium. May promote renal failure.

5% Human serum albumin: Protein based solution, falling out of favor in some circles secondary to reports of increased mortality in the critically ill adult population, and some debate still lays in its use outside of the neonatal arena.

Medications: Basic FactsMedications: Basic Facts

Ultimate Goal is to get Drug to the central circulation.

Severe shock may sometimes inhibit that goal.

Intravascular is usually the route of choice.“Common” routes include IV, IO, ET and

central lines.

IV access and Meds : Basic IV access and Meds : Basic FactsFacts

In the critical pediatric Pt, Time to establish access should be kept to a minimum.

A General rule is “3 sticks in 90 seconds”Do not delay drugs to await IV access, give

ET if required.If traditional access is unlikely, proceed to

alternative means (IO in the child under 6)

IV access and Meds: Basic IV access and Meds: Basic factsfacts

Use of a Braslow tape , Pedi Wheel , or other aid is highly recommended

The rule of 6: 6 mg x wt in kg; add to Volutrol and dilute to 100 cc total, X cc/hr equals X mcg/kg/min

Use 0.6 mg/kg for Epi

Intraosseous Lines (IO’s)Intraosseous Lines (IO’s)

Will be covered in the skill stationAll resuscitation meds can be given IO.Valium is preferred PR.Low risk of perm. Complications if done

correctly.

Endotracheal (ET)Endotracheal (ET)

Lipid soluble drugs can be given. 2-2.5 times standard IV dose. (except for

Epi) Should be diluted to a volume of 3-5 mlShould be hyperventilated afterA use a 5 fr Cath to deliver the med

depending on size of ETT, then flush w/ 3-5 ml after.

EndotrachealEndotracheal

L- LidocaineE- EPIA- AtropineN- Narcan (No established data regarding

use in peds)

The DrugsThe Drugs

Common PALS DrugsCommon PALS Drugs

Drips Epi Dopamine Lidocaine

Resuscitation Drugs Epi Atropine Sodium Bicarb CaCl Narcan Lidocaine Bretylium D50 Adenocard

EpinephrineEpinephrine

Most commonAlpha and Beta Adrenergic effects2 standard concentration 1:1K and 1:10KUsed in PALS in your “Collapse Rhythms”

(Asystole, PEA, refractory Bradycardia)

Epinephrine (Continued) Epinephrine (Continued)

1st IV Dose 0.01 mg/kg of 1:10 K 2nd IV Dose 0.1 mg/kg of 1:1K ALL ETT doses same as 2nd IV Dose ET Dose 0.1 mg/kg of 1:1K diluted to3-5 ml “The dose is changed but the volume remains the same”.

( 0.1ml/kg) Once IV access is gained, start w/ 1st IV dose and move up

(Page 6-6) One single study of 20 children (very small) recommended

High doses of Epi 0.2mg/kg All of these children experienced witnessed arrest with ALS w/in 7 minutes

AtropineAtropine

Parasympatholytic May or may not be truly effective in small children in

arrest/Asystole Good for vagus suppression during ETT attempts 0.02 mg/kg dose Max 0.5 mg Minimum dose (no matter weight) is 0.1 mg to avoid

refractory bradycardia Remember that most bradycardia in children are

hypoxic related.

Sodium BicarbSodium Bicarb

Used to treat metabolic acidosis during resuscitation.

Poor perfusion and ventilation are largest contributors to acidosis

Used after adequate ventilation has been restored. 0.1 meq/kg IV/IO, repeated at 0.5 meq/kg every

10 minutes Half strength is used for infants younger than 3

months

Calcium Calcium

Calcium is indicated in documented /suspected Hypocalcaemia,, Hypermagnesemia, and Calcium Channel Blocker overdose

Available in Calcium Chloride or Calcium Gluconate. CaCl is generally considered more reliable and predictable in its metabilization, thus it is used more often in the critically ill.

If Calcium Gluconate is used , its dose and volume should be approx. 3 times that of CaCl to produce similar effects.

Calcium (Continued)Calcium (Continued)

CaCl dosing is based on adult data, and little Pediatric data exist.

1st dose should be 20 mg/kg (0.2 ml/kg) given slowly (no greater than 100 mg/min)

Repeated doses of CaCl are associated with increased mortality, so repeat once in 10 minutes only if lab findings indicate it is needed.

Do not mix with bicarb Rapid administration may cause Asystole or

refractory bradycardia.

NarcanNarcan

Narcotic Antagonist. Rapid onset (w/in 2 minutes) and about 30 to 45 minute

effective duration Doses given are for total reversal. May use smaller doses if desired based on situation < 5 years: 0.1 mg/kg >5 years of age: up to 2 mg (use adult dosing.) Infusion: 0.004-0.16 mg/hour for total reversal

maintenance. Should be used in caution in newborns from addicted

mothers as it may cause withdrawal SZ.

LidocaineLidocaine

Anti-arrhythmicIndicated for VF/pulse less VT and post

defibrillation arrhythmic suppressant.Used in Tachycardia algorithm for WIDE

complex TachycardiaDose : 1 mg/kg max 3 mg/kgIf successful,proceed to infusion

BretyliumBretylium

No data regarding use in pediatricsMay be given IF Defib and Lidocaine are

ineffective under old guidelines, Dose is 5 mg/kg, repeated at 10 mg/kgHas been removed from NEW 2000

“Asystole/Pulseless arrest”guidelinesReplaced with Mag in algorithm.

D50D50

Critical children (especially infants may rapidly deplete their glycogen stores, especially during Cardiopulmonary distress

Glucose is especially important to the neonatal heart.

All peds in distress should have their BG checked. Dose 1.0 GM/KG IV/IO, max concentration of

25% (D25) used . A 10 % concentration may be advisable for neonate (D10) , or D50 diluted 4:1 to make D12.5 .

AdenocardAdenocard

Adenocard is indicated in Pediatric SVT for NARROW complex Tachycardia and wide complex Tachycardia AFTER lidocaine is ineffective.

Infants >220 b/minute Children > 180 BPM Dose 0.1 mg/kg repeated at 0.2mg/kg once. Follow with Flush (5 ml in infant) The two syringe technique is recommended.\ Max dose 12 mg regardless of weight.

Epinephrine InfusionEpinephrine Infusion

Indicated in refractory shock, with a stable rhythm and adequate volume.

May also be indicated for severe symptomatic bradycardia

May be initiated in the pulse less arrest refractory to Bolus Epi use

Epinephrine Infusion (cont)Epinephrine Infusion (cont)

Use a Volutrol Follow the rule of 6, except use 0.6 (not 6)

0.6 mg x wt in kg; add to Volutrol and dilute to 100 cc total, X cc/hr equals .X mcg/kg/min

Dose : 0.1 to 1 mc/kg/minA pump would be recommended if

available.

Lidocaine InfusionLidocaine Infusion

Use a VolutrolInfusion: use rule of 6, give 20-50

mcg/kg/minRe-bolus 1 mg/kg with infusion if last dose

was > 5 minutes prior (do not exceed Max dose )

A Pump would be recommended if available.

DopamineDopamine

Vasopressor of choice for pre hospital use Dose Dependant (2-5 mcg/kg/min increases renal blood

flow 5-10 mcg/kg/min cause Beta adrenergic effects, may be

decreased in sick hearts due to norepinephrine stores depleted.

10-20 mcg/kg/min both alpha and beta effects Greater than 20 mcg/kg/min not routinely

recommended, mimics norepinephrine. Used in shock with out hypo-volemia or after it has been

treated.

Dopamine (Continued)Dopamine (Continued)

Use VolutrolUse rule of 6Dose is 2-20 mcg/kg/min (may start at 5-10

mcg/kg/min)Do not mix with Bicarb or other alkaline

solution

Questions?Questions?