2. PALS Fluid therapy and Medications

3. Fluid therapy and medications Fluid resuscitation Specific drug therapy –delivery –infusion

4. Resuscitation fluids Used for volume replacement delivery of medications Fluids of choice normal saline lactated Ringer’s solution

5. AVPU A = Awake and alert V = Responsive only to verbal stimuli P = Responsive only to painful stimuli U = Completely unresponsive

6. SAMPLE S= signs and symptoms A = allergies M = medications P = past medical history L = last meal E = events surrounding illness or injury

7. Dextrose containing solutions Indication: Hypoglycemia

8. Post Arrest Shock Treatment Fluid Maintenance Requirements Infants < 10 kg: 4ml/kg/hr of D5 NS 8 kg baby is 4 x 8 = 32 ml/hr Children 10 – 20 kg infuse NS @ 40ml/hr + 2 ml/hr for each kg between 10 -20 kg. A 15 kg child will get: 40ml/hr + 2 ml/kg x 5 kg = 50 ml/hr Weight estimate (kg)=8 + 2(age in years)

9. Post Arrest Shock Treatment Fluid Maintenance Requirements Children > 20 kg infuse NS @ 60 ml/hr + 1 ml/kg/hr for each kg above 20 kg. For example a 30 kg child would get 60 ml/hr + 1 ml/hr x 10 kg = 70 ml/hr. Short cut for pts > 20 kg is Weight in kg + 40 ml/hr 1500ml x BSA in meters squared.

10. Holliday-Segar Method 1st 10kg 100ml/kg/day = 4ml/kg/hr 2 nd 10kg 50ml/kg/day = 2ml/kg/hr > 20kg 20ml/kg/day = 1ml/kg/hr 8 year old weighing 25 kg: 10kg=1,000ml/day 4 x 10kg= 40ml/hr 10kg=500ml/day 2 x 10kg= 20ml/hr 5kg=100ml/day 1 x 5kg= 5 ml/hr 25kg 1600ml/day 65ml/hr

11. Circulating Blood Volume Infants 90 ml/kg Children 80 ml/kg Adults 70 ml/kg Infants have higher cardiac outputs than adults. Myocardium is less compliant with less contractile mass and limited stroke volume. Takes 25% blood loss to show signs of shock. Capillary refill is the best indicator.

12. Drug delivery drugs must ultimately reach the central circulation central venous access is not required intravascular drug bolus should be followed by at least a 5-ml normal saline bolus

13. Sites for drug administration Peripheral veins Intraosseuos Central veins Endotracheal

14. Use of Intraosseuos access Indications cardiopulmonary arrest shock intractable seizures

15. Drugs that can be given endotracheally lidocaine epinephrine atropine naloxone

16. Endotracheal drug doses epinephrine dose is 10 times IV dose: 0.1 mg/kg (use 1:1000) epinephrine decreases pulmonary flow. Capnography maybe inaccurate. other drug doses are increased 2 to 3 times IV dose ET tube size 16 + age in years /4 Insertion depth 3 times tube size.

17. Epinephrine doses IndicationIV/IO DoseET Dose Bradycardia0.01 mg/kg0.1 mg/kg 0.1 ml/kg of0.1mL/kg of 1:10 000 1:1000 Asystole/VF/VT Initial dose0.01 mg/kg0.1 mg/kg 0.1 ml/kg 0.1 ml/kg of 1:10 000 1:1000 Subsequent doses0.1 mg/kg0.1 mg/kg0.1 ml/kg of 1:1000 1:1000

18. Other resuscitation drugs Drug Atropine Sodium Bicarbonate Naloxone Calcium Chloride Indication for use Symptomatic bradycardia ? asystole Documented acidosis when serum alkalinization required Narcotic-induced respiratory depression Hypocalcemia, hyperkalemia, hypermagnesemia, calcium channel blocker overdose

19. Types of shock Hypovolemic shock is the most common in children Distributive shock results from vasodialation in the peripheral vasculature (infection) Obstructive shock results from inadequate circulating volume due to an obstruction in or compression on the great veins, aorta, pulmonary arteries or heart. Cardiogenic shock rare but may follow open heart surgery.

20. Inotropes in shock the initial priority is fluid resuscitation use inotropes to treat myocardial depression Peripheral vasculature resistance drives your systolic blood pressure. Cardiac output drives your diastolic blood pressure

21. Normal vital signs Systolic 70 + age in years x 2 Diastolic 50 + age in years x 2 Pain is the 5 th vital sign in adults Glucose is the 5 th vital sign in infants and children Urine output infant 2ml/kg/hr, children 1-2 ml/kg/hr, adolescents 0.5-1 ml/kg/hr

22. Comparison of inotropic drugs Drug Epinephrine Dobutamine Dopamine Low High Uses symptomatic bradycardia shock (including anaphylactic) hypotension cardiopulmonary arrest Normotensive cardiogenic shock improve renal, splanchnic blood flow hypotension

23. Caveats of drug infusion therapy drug delivery is delayed at slower infusion rates titrate the infusion prn monitor heart rate and blood pressure continuously the rule of 6 has limitations in larger patients; adjust calculations Length base tapes are more accurate than numerical formulas in children < 35 kg

24. Review of Inotrope Use DrugDosage Remarks epinephrine begin at 0.1 tirate to infusionmcg/kg per desired effect minute higher infusion dose used during CPR

25. Review of inotrope (cont.) DrugDosageRemarks Dobutamine2 to 20 mcg/kgtirate to per minutedesired effect

26. Review of inotrope (cont.) Drug DosageRemarks Dopamine 2 to 20 mcg/kgadrenergic hydrochloride per minuteaction dominates at 15 to 20 mcg/kg per minute

27. Adenosine Symptomatic SVT and monomorphic v- tach 0.1 mg/kg rapid push via IV/IO Maximum 1 st dose 6 mg Second dose 0.2 mg/kg rapid push Maximum single dose 12 mg

28. Amiodarone Can be used for treatment of atrial and ventricular arrhythmias in children, particularly ectopic atrial tachycardia, junctional ectopic tachycardia and venricular tachycardia. Dose for perfusing rhythm 5mg/kg IV/IO over 20 to 60 minutes. Maximum single dose 300 mg. Dose for non perfusing rhythm 5mg/kg IV/IO bolus; can repeat up to total dose of 15mg/kg IV per 24 hours. Precautions; may produce hypotension, prolong QT interval, neonatal gasping syndrome, polymorphic ventricular arrhythmias

29. Atropine Symptomatic bradycardia unresponsive to oxygenation, ventilation and epinephrine. 0.02 mg/kg IV/IO; may double for second dose. Minimum single dose 0.1mg Maximum child dose 0.5 mg – 1mg. Adolescent dose 1mg – 2mg. Higher doses may be needed in organophosphate poisioning. Only given if you can feel a pulse

30. Calcium Chloride Treatment of documented or suspected: Hypocaclemia, Hyperkalemia, Hypermagnesemia, Calcium channel blocker overdose. Dosage is 20 mg/kg (0.2ml/kg) slow IV/IO push. Rapid IV administration may cause hypotension, bradycardia or asystole if patient is receiving digoxin DO NOT MIX with or infuse before or after NaHCO3 without intervening flush

31. Calcium Gluconate Treatment of documented or suspected: Hypocaclemia, Hyperkalemia, Hypermagnesemia, Calcium channel blocker overdose. Dosage is 60 - 100 mg/kg (0.6 - 1ml/kg) slow IV/IO push. Rapid IV administration may cause hypotension, bradycardia or asystole if patient is receiving digoxin DO NOT MIX with or infuse before or after NaHCO3 without intervening flush

32. Etomidate For rapid sedation with no untoward cardiovascular or respiratory depression. Dosage 0.2 to 0.4 mg/kg infused over 30 – 60 seconds will produce rapid sedation that lasts 10 - 15 minutes Maximum dose: 20 mg. DO NOT USE IN CHILDREN < 10 YRS OLD. Lowers seizure threshold and suppresses the adrenal gland in septic shock

33. Glucose Treatment of hypoglycemia Dosage 0.5 to 1 g/kg IV/IO 50% (0.5 g/ml); give 1-2 ml/kg 25% (0.25 g/ml); give 2-4 ml/kg 10% (0.1 g/ml); give 5-10 ml/kg 5% (0.1 g/ml); give 10 – 20 ml/kg if volume tolerated

34. Amrinone CHF in postoperative cardiovascular surgical patients, shock with high systemic or pulmonary vascular resistance, myocardial dysfunction. Loading dose 0.75 to 1mg/kg IV/IO over 5 minutes; may repeat twice (max 3mg/kg. Infusion dose 2 to 20µg/kg per minute IV/IO DO NOT MIX with dextrose containing solutions. May produce hypotension in volume depleted patients

35. Lidocaine Maybe considered as an alternative treatment for wide-complex tachycardia of VF/ pulseless VT Dosage 1 mg/kg rapid IV/IO. Maximum dose 100 mg. Infusion 20 to 50 µg/kg per minute Endotracheal dose 2 to 3 mg/kg. Contraindicated for wide complex ventricular escape beats associated with bradycardia.

36. MgSO4 Polymorphic VT or suspected hypomagnesia, status asthmaticus not responsive to β-adrenergic drugs. Dose for asthma or a perfusing rhythm 25 to 50 mg/kg over 10 20 minutes max dose 2 grams IV/IO. Non perfusing rhythm given as a bolus. Contraindicated in renal failure

37. Milrinone CHF in postoperative cardiovascular surgical patients, shock with high systemic or pulmonary vascular resistance, myocardial dysfunction. Loading dose 50-75 µg/kg IV/IO over 10 -60 minutes; (longer infusion times reduce risk of hypotension) Infusion dose 0.5 to 0.75 µg/kg per minute IV/IO May produce hypotension in volume depleted patients Shorter half-life and less effect on platelets, but more risk for ventricular arrhythmia than Amrinone.

38. Narcan To reverse the effects of narcotic toxicity Give 0.1 mg/kg up to 2 mg bolus IV/IO Infusion 0.04 to 0.16 mg/kg per hour. Administration to infants of addicted mothers may precipitate seizures or other withdrawal symptoms

39. Nitroprusside Cardiogenic shock characterized by high vascular resistance. Severe hypertension. Children ≤40 kg: 1 to 8 µg/kg per minute IV/IO. Children ≥40 kg: 0.1 to 5 µg/kg per minute Metabolized into cyanide and thiocyanate. Monitor thiocyanate levels in patients receiving >2 µg/kg minute. Do ABG’s and monitor methhemoglobin levels. PLEASE NOTE POSSIBLE ERROR IN BEGINNING DOSE. IT is 10 times higher than the adult dose 2010 update 0.3 to 1mcg/kg per minute initially then titrate up to 8 mcg/kg per minute

40. NIPRIDE The Handbook gives a range of doses, starting as low as 0.1 mcg/kg/min and going up to 5 mcg/kg/min. In the ACLS drug information (page 59) it says to start at 0.1 mcg/kg/min and titrate upward. As you know, most adults weigh much more than 40 kg. In the more typical 80 kg adult, this would be a starting infusion of 8 mcg/min. On the other hand, I think we should have probably made the dosing range for children <40 kg from 0.5 to 8 mcg/kg/min. In the example given, at 32 kg, this would be 16 mcg/min. Unfortunately the kinetics of nitroprusside in children are not well defined, but the clinical experience is that younger children need a higher dose/kg whereas a smaller per kg dose is needed in adolescents and adults. This is likely related to differences in the volume of distribution and clearance of the drug. Many adult units start at 10 mcg/min and titrate the infusion from there, meaning that they usually start at closer to 0.2 mcg/kg/min. It is interesting to note that Lexi-Comp recommends a starting dose of 0.3- 0.5 mcg/kg/min. In an 80 kg adult, a starting dose of 0.5 mcg/kg/min (40 mcg/min) may be too much.

41. Norepinephrine Treatment of shock and hypotension characterized by low systemic vascular resistance and unresponsive to fluid resuscitation. Dosage 0.1 to 2 µg/kg per minute Extravasation may cause tissue necrosis (treat with phentolamine)

42. OXYGEN DOSE: –FiO2 100% until ROSC then wean FiO2 tks SPO2 > 94%. Avoid hyperoxia. Hyperoxemia after ROSC accelerates oxidative injury reserve after ischemic reperfusion. Stuns the ventricles. ROUTE: –Inhalation. Maximum flow rates 10 – 15 liters per minute. Increase chance of fire if arc occurs during defibrillation SPECIAL NOTES: –THE MOST IMPORTANT DRUG IN ACLS & ECC. –When administering to COPD patients, monitor for respiratory depression & be prepared to assist ventilations. –HYPERVENTILATION KILLS – CEREBRAL ISCHEMIA.

43. Hyperoxemia injury Reactive oxygen species (ROS) are formed at an accelerated rate in postischemic myocardium. Cardiac myocytes, endothelial cells, and infiltrating neutrophils contribute to this ROS production. Exposure of these cellular components of the myocardium to exogenous ROS can lead to cellular dysfunction and necrosis.

44. Oxygen Should be administered during stabilization of all serious ill or injured patients With ROSC titrate FiO2 tks > 94% Contraindicated in palliated congenital heart defects. Glenn Physiology. Single ventricle PA to RV shunts keep SPO2 80% NRP begin bagging with room air hyperoxia is bad. Place probe on right finger only. Due pda sats are lower on left side of body. Fontan & hemifontan use negative pressure ventilation or ECMO

45. Nalmefene (Revex) Opioid reversal, post op. Dosage 0.5-1.5mg/70kg IM,SQ,IV Long acting Narcan

46. Fontan Kawashimi Hypoplastic left or right heart syndrome Tricuspid or pulmonary atresia Glenn Physiology complex congenital heart disease where a bi-ventricular repair is impossible or inadvisable. It involves diverting the venous blood from the right atrium to the pulmonary arteries without passing through the morphologic pulmonary ventriclevenousbloodright atriumpulmonary arteries pulmonary ventricle

47. Single Ventricle

48. Glenn Physiology

49. Pulmonary Atresia

50. Pulmonary atresia with VSD

51. Hypoplastic right heart

52. Hypoplastic left heart

53. Fontan

54. Hemi-Fontan

55. Fontan for Tricuspid Atresia

56. Procanimide Recurrent or refractory VT with pulses, SVT. Not appropriate agent for non perfusing rhythms Dose is 15mg/kg IV/IO over 30 to 60 minutes Routine use in combination with cordarone not recommended without expert consultation. May prolong QT interval

57. Prostaglandin E (PGE1) To maintain the patency of ductus arteriosus in newborns with cyanotic congenital heart disease. Continuous infusion: 0.05 to 0.1 µg/kg per minute; titrate to effect Vasodilation, hypotension, apnea, hyperpyrexia, agitation, seizures, hypoglycemia, hypocalcemia.

58. NaHCO3 Treatment of severe metabolic acidosis, hyperkalemia, TCA overdoses 1 mEq/kg per dose IV/IO administer as a slow bolus preceded and followed by adequate ventilation. Infuse slowly Do not mix with any resuscitation drugs 2010 NOT RECOMMENDED in an arrest, it contributes to cerebral anoxia by causing left shift to O2 disassociation curve