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PALS fluids and meds 2000

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  • 1. PALS: Fluid Therapy andPALS: Fluid Therapy and MedicationsMedications Robert S. Cole Paramedic, CCEMT-P
  • 2. PALS: Fluid therapy andPALS: Fluid therapy and medicationsmedications Fluid Therapy for shock, including septic shock and trauma Priorities for resuscitation drugs How to give those drugs How to prepare drug infusions
  • 3. 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
  • 4. 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.
  • 5. 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.
  • 6. 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.
  • 7. 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.
  • 8. IV access and Meds : BasicIV 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)
  • 9. IV access and Meds: BasicIV 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
  • 10. Intraosseous Lines (IO’s)Intraosseous Lines (IO’s) Will be covered in the skill station All resuscitation meds can be given IO. Valium is preferred PR. Low risk of perm. Complications if done correctly.
  • 11. 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 ml Should be hyperventilated after A use a 5 fr Cath to deliver the med depending on size of ETT, then flush w/ 3-5 ml after.
  • 12. EndotrachealEndotracheal L- Lidocaine E- EPI A- Atropine N- Narcan (No established data regarding use in peds)
  • 13. The DrugsThe Drugs
  • 14. Common PALS DrugsCommon PALS Drugs Drips  Epi  Dopamine  Lidocaine Resuscitation Drugs  Epi  Atropine  Sodium Bicarb  CaCl  Narcan  Lidocaine  Bretylium  D50  Adenocard
  • 15. EpinephrineEpinephrine Most common Alpha and Beta Adrenergic effects 2 standard concentration 1:1K and 1:10K Used in PALS in your “Collapse Rhythms” (Asystole, PEA, refractory Bradycardia)
  • 16. 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
  • 17. 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.
  • 18. 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
  • 19. CalciumCalcium  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. 
  • 20. 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.
  • 21. 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.
  • 22. LidocaineLidocaine  Anti-arrhythmic Indicated for VF/pulse less VT and post defibrillation arrhythmic suppressant. Used in Tachycardia algorithm for WIDE complex Tachycardia Dose : 1 mg/kg max 3 mg/kg If successful,proceed to infusion
  • 23. BretyliumBretylium No data regarding use in pediatrics May be given IF Defib and Lidocaine are ineffective under old guidelines, Dose is 5 mg/kg, repeated at 10 mg/kg Has been removed from NEW 2000 “Asystole/Pulseless arrest”guidelines Replaced with Mag in algorithm.
  • 24. 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 .
  • 25. 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.
  • 26. 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
  • 27. 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/min A pump would be recommended if available.
  • 28. Lidocaine InfusionLidocaine Infusion Use a Volutrol Infusion: use rule of 6, give 20-50 mcg/kg/min Re-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.
  • 29. 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.
  • 30. Dopamine (Continued)Dopamine (Continued) Use Volutrol Use rule of 6 Dose is 2-20 mcg/kg/min (may start at 5-10 mcg/kg/min) Do not mix with Bicarb or other alkaline solution
  • 31. Questions?Questions?