pals fluids and meds
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PALS: Fluid Therapy and MedicationsRobert S. Cole Paramedic, CCEMT-P
PALS: Fluid therapy and medicationsFluid Therapy for shock, including septic shock and traumaPriorities for resuscitation drugsHow to give those drugsHow to prepare drug infusions
IV Fluids: Basic factsUsed primarily for volume replacement and medication delivery.Primarily Crystalloids in the Pre-hospital arena Large volumes may be needed, especially in septic shock
CrystaloidsNormal 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 plasmaLactated 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.
ColloidsColloid 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 VIIIPentastarch (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.
ColloidsDextran 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 FactsUltimate 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 FactsIn the critical pediatric Pt, Time to establish access should be kept to a minimum.A General rule is 3 sticks in 90 secondsDo 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 factsUse of a Braslow tape , Pedi Wheel , or other aid is highly recommendedThe 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/minUse 0.6 mg/kg for Epi
Intraosseous Lines (IOs)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) 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.
EndotrachealL- LidocaineE- EPIA- AtropineN- Narcan (No established data regarding use in peds)
Common PALS DrugsDripsEpiDopamineLidocaine
Resuscitation DrugsEpiAtropineSodium BicarbCaClNarcanLidocaineBretyliumD50Adenocard
EpinephrineMost commonAlpha and Beta Adrenergic effects2 standard concentration 1:1K and 1:10KUsed in PALS in your Collapse Rhythms (Asystole, PEA, refractory Bradycardia)
Epinephrine (Continued) 1st IV Dose 0.01 mg/kg of 1:10 K2nd IV Dose 0.1 mg/kg of 1:1KALL ETT doses same as 2nd IV DoseET Dose 0.1 mg/kg of 1:1K diluted to3-5 mlThe 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
AtropineParasympatholyticMay or may not be truly effective in small children in arrest/AsystoleGood for vagus suppression during ETT attempts0.02 mg/kg dose Max 0.5 mgMinimum dose (no matter weight) is 0.1 mg to avoid refractory bradycardiaRemember that most bradycardia in children are hypoxic related.
Sodium BicarbUsed to treat metabolic acidosis during resuscitation. Poor perfusion and ventilation are largest contributors to acidosisUsed after adequate ventilation has been restored.0.1 meq/kg IV/IO, repeated at 0.5 meq/kg every 10 minutesHalf strength is used for infants younger than 3 months
Calcium Calcium is indicated in documented /suspected Hypocalcaemia,, Hypermagnesemia, and Calcium Channel Blocker overdoseAvailable 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)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 bicarbRapid administration may cause Asystole or refractory bradycardia.
NarcanNarcotic Antagonist.Rapid onset (w/in 2 minutes) and about 30 to 45 minute effective durationDoses 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.
Lidocaine 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
BretyliumNo 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 arrestguidelinesReplaced with Mag in algorithm.
D50Critical children (especially infants may rapidly deplete their glycogen stores, especially during Cardiopulmonary distressGlucose 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 is indicated in Pediatric SVT for NARROW complex Tachycardia and wide complex Tachycardia AFTER lidocaine is ineffective.Infants >220 b/minuteChildren > 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 InfusionIndicated in refractory shock, with a stable rhythm and adequate volume. May also be indicated for severe symptomatic bradycardiaMay be initiated in the pulse less arrest refractory to Bolus Epi use
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/minDose : 0.1 to 1 mc/kg/minA pump would be recommended if available.
Lidocaine InfusionUse 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.
DopamineVasopressor of choice for pre hospital useDose Dependant (2-5 mcg/kg/min increases renal blood flow5-10 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 effectsGreater 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)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