PALS: Fluid Therapy andPALS: Fluid Therapy and
Robert S. Cole
PALS: Fluid therapy andPALS: Fluid therapy and
Fluid Therapy for shock, including septic
shock and trauma
Priorities for resuscitation drugs
How to give those drugs
How to prepare drug infusions
IV Fluids: Basic factsIV Fluids: Basic facts
Used primarily for volume replacement and
Primarily Crystalloids in the Pre-hospital
Large volumes may be needed, especially in
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
Dextrose containing solutions should not be used for
boluses as they will likely cause Hyperglycemia
Hyperglycemia is associated with poor neurological
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
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.
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
Medications: Basic FactsMedications: Basic Facts
Ultimate Goal is to get Drug to the central
Severe shock may sometimes inhibit that
Intravascular is usually the route of choice.
“Common” routes include IV, IO, ET and
IV access and Meds : BasicIV access and Meds : Basic
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: BasicIV access and Meds: Basic
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 station
All resuscitation meds can be given IO.
Valium is preferred PR.
Low risk of perm. Complications if done
Endotracheal (ET)Endotracheal (ET)
Lipid soluble drugs can be given.
2-2.5 times standard IV dose. (except for
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
N- Narcan (No established data regarding
use in peds)
Alpha and Beta Adrenergic effects
2 standard concentration 1:1K and 1:10K
Used in PALS in your “Collapse Rhythms”
(Asystole, PEA, refractory Bradycardia)
Epinephrine (Continued)Epinephrine (Continued)
IV Dose 0.01 mg/kg of 1:10 K
IV Dose 0.1 mg/kg of 1:1K
ALL ETT doses same as 2nd
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
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
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
Sodium BicarbSodium Bicarb
Used to treat metabolic acidosis during
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
Half strength is used for infants younger than 3
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
Calcium (Continued)Calcium (Continued)
CaCl dosing is based on adult data, and little
Pediatric data exist.
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
Rapid onset (w/in 2 minutes) and about 30 to 45 minute
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
Should be used in caution in newborns from addicted
mothers as it may cause withdrawal SZ.
Indicated for VF/pulse less VT and post
defibrillation arrhythmic suppressant.
Used in Tachycardia algorithm for WIDE
Dose : 1 mg/kg max 3 mg/kg
If successful,proceed to infusion
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
Replaced with Mag in algorithm.
Critical children (especially infants may rapidly
deplete their glycogen stores, especially during
Glucose is especially important to the neonatal
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 .
Adenocard is indicated in Pediatric SVT for
NARROW complex Tachycardia and wide
complex Tachycardia AFTER lidocaine is
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
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
Dose : 0.1 to 1 mc/kg/min
A pump would be recommended if
Lidocaine InfusionLidocaine Infusion
Use a Volutrol
Infusion: use rule of 6, give 20-50
Re-bolus 1 mg/kg with infusion if last dose
was > 5 minutes prior (do not exceed Max
A Pump would be recommended if
Vasopressor of choice for pre hospital use
Dose Dependant (2-5 mcg/kg/min increases renal
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 rule of 6
Dose is 2-20 mcg/kg/min (may start at 5-10
Do not mix with Bicarb or other alkaline