ALS &ALS & PP--ALS: Fluid TherapyALS: Fluid Therapyand Medicationsand Medications

ALS: Fluid therapy andALS: Fluid therapy andmedicationsmedications

Fluid Therapy for shock, including septicshock 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 andmedication delivery.

Primarily Crystalloids in the Pre-hospitalarena

Large volumes may be needed, especially inseptic shock

CrystaloidsCrystaloids

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

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

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

Dextrose containing solutions should not be used forboluses as they will likely cause HyperglycemiaHyperglycemia is associated with poor neurologicaloutcomes.

CrystaloidsCrystaloids

10% NaCl: Boluses, in serious hypovolemia, 1 ml/kg upto 100 ml. 10% NaCl has an osmolarity of 3080mOsm/liter, much more greater than that of plasma, itmakes extravascular (tissue) water go into the circulation,it is called „auto-transfusion). It is used in haemorrhagicshock. Can be added to other fluids.

ColloidsColloids

Colloid refers to a liquid that exerts osmotic pressuredue to large MW (greater than 30,000) particles insolution. A variety of colloid solutions are seen for inhospital use:

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

Pentastarch (Pentaspan):Pentastarch differs fromhetastarch in that it has a lower mean MW. Preliminarystudies also suggest that pentastarch may have feweradverse effects on coagulation than hetastarch.25. No clearpediatric value yet.

ColloidsColloids

Dextran solutions (dextran 40 and dextran 70): Similarosmotic pressure to plasma. Dextrans interfere with normalcoagulation partly by hemodilution of clotting factors andpartly 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 ofincreased mortality in the critically ill adult population, andsome debate still lays in its use outside of the neonatalarena.

Medications: Basic FactsMedications: Basic Facts

Ultimate Goal is to get Drug to the centralcirculation.

Severe shock may sometimes inhibit thatgoal.

Intravascular is usually the route of choice.

“Common” routes include IV, IO, ET andcentral lines.

IV access and Meds : BasicIV access and Meds : BasicFactsFacts

In the critical Pt, Time to establish accessshould be kept to a minimum.

A General rule is “3 sticks in 90 seconds”

Do not delay drugs to await IV access, giveET if required.

If traditional access is unlikely, proceed toalternative means (IO)

Intraosseous Lines (Intraosseous Lines (IOIO’’ss))

All resuscitation meds can be given IO.

Low risk of perm. Complications if donecorrectly.

Endotracheal (ET)Endotracheal (ET)

Lipid soluble drugs can be given.

2-2.5 times standard IV dose. (except forEpi)

Should be diluted to a volume of 3-5 ml

Should be hyperventilated after

A use a 5 fr Cath to deliver the meddepending on size of ETT, then flush w/ 3-5ml after.

EndotrachealEndotracheal

L- Lidocaine

E- EPI

A- Atropine

N- Narcan (No established data regardinguse in peds)

The DrugsThe Drugs

Common ALS DrugsCommon ALS Drugs

Drips Epi Dopamine Lidocaine

Resuscitation Drugs Epi/Adrenaline Atropine Sodium Bicarb CaCl Naloxin/Narcan Lidocaine Amiodarone/Bretylium D50 Adenosine/Adenocard Magnesium

EpinephrineEpinephrine

Most common

Alpha and Beta Adrenergic effects

2 standard concentration 1:1K and 1:10K

Used in all situations for CPR

In P-ALS for “Collapse Rhythms”(Asystole, PEA, refractory Bradycardia)

EpinephrineEpinephrine -- ALSALSDose:

1 mg intravenous 10 ml 1:10,000 (1 ml 1:1,000) every4-6 mins during resuscitation

2-3 mg via tracheal tube

Infusion 2–10 mcg min-1 for atropine resistantbradycardia

0.5ml 1:1,000 i.m., 3-5 ml 1:10,000 i.v.

in anaphylaxis, depending on severity

Epinephrine (Epinephrine (PP--ALSALS))

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 thesame”. ( 0.1ml/kg)

Once IV access is gained, start w/ 1st IV dose

One single study of 20 children (very small)recommended High doses of Epi 0.2mg/kg All of thesechildren experienced witnessed arrest with ALS w/in 7minutes

AtropineAtropine (ALS)(ALS)

Parasympatholytic

Dose:

Asystole / PEA (rate < 60 beats min-1)– 3 mg i.v., once only

– 6 mg via tracheal tube

Bradycardia– 0.5 mg i.v., repeated as necessary, maximum 3 mg

AtropineAtropine ((PP--ALSALS))

May or may not be truly effective in smallchildren 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 toavoid refractory bradycardia

Remember that most bradycardia in children arehypoxic related.

SodiumSodium BicarbBicarb ((PP--ALSALS))

Used to treat metabolic acidosis duringresuscitation.

Poor perfusion and ventilation are largestcontributors to acidosis

Used after adequate ventilation has been restored.

0.1 meq/kg IV/IO, repeated at 0.5 meq/kg every10 minutes

Half strength is used for infants younger than 3months

Sodium BicarbonateSodium Bicarbonate -- ALSALS

Dose:

50 mmol (50 ml of 8.4% solution) i.v.

CalciumCalcium

Calcium is indicated in documented /suspectedHypocalcaemia,, Hypermagnesemia, and CalciumChannel Blocker overdose

Available in Calcium Chloride or CalciumGluconate. CaCl is generally considered morereliable and predictable in its metabilization, thusit is used more often in the critically ill.

If Calcium Gluconate is used , its dose and volumeshould be approx. 3 times that of CaCl to producesimilar effects.

CalciumCalcium

Indications:

Pulseless electrical activity caused by:– severe hyperkalaemia

– severe hypocalcaemia

– overdose of calcium channel blocking drugs

Dose

10 ml 10% calcium chloride (6.8 mmol)

Do not give immediately before or after sodiumbicarbonate

Calcium (Continued)Calcium (Continued)

CaCl dosing is based on adult data, and littlePediatric data exist.

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

Repeated doses of CaCl are associated withincreased mortality, so repeat once in 10 minutesonly if lab findings indicate it is needed.

Do not mix with bicarb

Rapid administration may cause Asystole orrefractory bradycardia.

NarcanNarcan

Narcotic Antagonist.

Rapid onset (w/in 2 minutes) and about 30 to 45 minuteeffective 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 reversalmaintenance.

Should be used in caution in newborns from addictedmothers as it may cause withdrawal SZ.

LidocaineLidocaine ((PP--ALSALS))

Anti-arrhythmic

Indicated for VF/pulse less VT and postdefibrillation arrhythmic suppressant.

Used in Tachycardia algorithm for WIDEcomplex Tachycardia

Dose : 1 mg/kg max 3 mg/kg

If successful,proceed to infusion

LidocaineLidocaine (ALS)(ALS)

Dose:

Refractory VF / Pulseless VT– 100 mg i.v.

– further boluses of 50 mg, max 200 mg

Haemodynamically stable VT– 50 mg i.v.

– further boluses of 50 mg, max 200 mg

Reduce dose in elderly or hepatic failure

AmiodaroneAmiodarone

Indications:

Refractory VF / Pulseless VT

Haemodynamically stable VT

Other resistant tachyarrhythmias

AmiodaroneAmiodaroneDose:

Refractory VF / Pulseless VT– 300 mg in 20 ml 5% dextrose, bolus i.v.

Stable tachyarrhythmias– 150 mg in 20 ml 5% dextrose over 10 mins

– Repeat 150 mg if necessary

– 300 mg in 100 ml 5% dextrose over 1 hour

AmiodaroneAmiodarone

Actions:

Lengthens duration of action potential

Prolongs Q-T interval

Mild negative inotrope - may cause hypotension

BretyliumBretylium ((PP--ALSALS))

No data regarding use in pediatrics

May be given IF Defib and Lidocaine areineffective 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.

MagnesiumMagnesium

Indications:

Shock refractory VF

(with possible hypomagnesaemia)

Ventricular tachyarrhythmias

(with possible hypomagnesaemia)

Torsades de pointes

MagnesiumMagnesium

Dose:

Shock Refractory VF

• 2–4 ml 50% (4–8 mmol) i.v. over 1-2 mins

• Can be repeated after 10-15 minutes

Other circumstances

• 5 ml of 50% (10 mmol) i.v. over 30 mins

MagnesiumMagnesium

Actions:

Depresses neurological and myocardialfunction

Acts as a physiological calcium blocker

D50D50

Critical children (especially infants may rapidlydeplete their glycogen stores, especially duringCardiopulmonary distress

Glucose is especially important to the neonatalheart.

All peds in distress should have their BG checked.

Dose 1.0 GM/KG IV/IO, max concentration of25% (D25) used . A 10 % concentration may beadvisable for neonate (D10) , or D50 diluted 4:1 tomake D12.5 .

AdenocardAdenocard

Adenocard is indicated in Pediatric SVT forNARROW complex Tachycardia and widecomplex Tachycardia AFTER lidocaine isineffective.

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 stablerhythm and adequate volume.

May also be indicated for severesymptomatic bradycardia

May be initiated in the pulse less arrestrefractory to Bolus Epi use

Epinephrine Infusion (cont)Epinephrine Infusion (cont)

Dose : 0.1 to 1 mc/kg/min

A pump would be recommended ifavailable.

Lidocaine InfusionLidocaine Infusion

Infusion: 20-50 mcg/kg/min

Re-bolus 1 mg/kg with infusion if last dosewas > 5 minutes prior (do not exceed Maxdose )

A Pump would be recommended ifavailable.

DopamineDopamine

Vasopressor of choice for pre hospital use

Dose Dependant (2-5 mcg/kg/min increases renalblood flow

5-10 mcg/kg/min cause Beta adrenergic effects,may be decreased in sick hearts due tonorepinephrine stores depleted.

10-20 mcg/kg/min both alpha and beta effects

Greater than 20 mcg/kg/min not routinelyrecommended, mimics norepinephrine.

Used in shock with out hypo-volemia or after ithas been treated.

Dopamine (Continued)Dopamine (Continued)

Dose is 2-20 mcg/kg/min (may start at 5-10mcg/kg/min)

Do not mix with Bicarb or other alkalinesolution

Questions?Questions?