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)
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
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