PALS Provider: Course
Fluid and Medication Administration in Pediatric Emergencies
Fluid and medication administration is a cornerstone of pediatric resuscitation, essential for managing shock, sepsis, respiratory failure, and cardiac arrest. Given children’s smaller circulating volume and unique physiology, precise dosing and careful volume management are required to prevent complications like fluid overload or medication errors.
Key Goals
- Restore circulation and perfusion in shock and cardiac arrest.
- Deliver life-saving medications safely and effectively.
- Use weight-based dosing to avoid toxicity or under-dosing.
Fluid Resuscitation in Pediatrics
Indications: Hypovolemic shock, septic shock, cardiac arrest (select cases).
Fluid Choice:
- Normal Saline (0.9% NaCl): First-line choice.
- Lactated Ringer’s (LR): Preferred in sepsis for better acid-base balance.
- Avoid: Hypotonic fluids like D5W or 0.45% NaCl.
Bolus Administration: 20 mL/kg of isotonic crystalloid over 5–10 minutes. Reassess and repeat up to 60 mL/kg if needed (except in cardiogenic shock).
Monitor for Fluid Overload: Pulmonary edema, hepatomegaly, or increased work of breathing.
Septic Shock: Deliver 40–60 mL/kg within the first hour. If shock persists, initiate vasopressors.
Medication Administration in Pediatric Resuscitation
Weight-Based Dosing: All medications should be dosed by weight (mg/kg). Use Broselow tape or resuscitation charts for accuracy.
| Medication | Indication | Pediatric Dose | Route |
|---|---|---|---|
| Epinephrine (1:10,000) | Cardiac Arrest | 0.01 mg/kg IV/IO (max 1 mg) every 3–5 min | IV/IO |
| Epinephrine (1:1,000) | Anaphylaxis | 0.01 mg/kg IM (max 0.3 mg) every 5–15 min | IM |
| Atropine | Bradycardia | 0.02 mg/kg IV/IO (min 0.1 mg, max 0.5 mg) | IV/IO |
| Adenosine | SVT | 0.1 mg/kg IV push (max 6 mg), repeat 0.2 mg/kg (max 12 mg) | IV |
| Amiodarone | VT/VF (refractory) | 5 mg/kg IV over 20–60 min (max 300 mg) | IV |
| Lidocaine | VT/VF (alternative) | 1 mg/kg IV bolus | IV |
| Magnesium Sulfate | Torsades de Pointes | 25–50 mg/kg IV (max 2 g) | IV |
| Dextrose | Hypoglycemia | D10: 5 mL/kg (neonates); D25: 2 mL/kg (infants/children) | IV |
| Naloxone | Opioid overdose | 0.1 mg/kg IV/IM (max 2 mg) | IV/IM |
| Calcium Gluconate | Hypocalcemia | 60 mg/kg IV over 5–10 min | IV |
Routes of Administration: IV, IO, IM, ET
| Route | When to Use | Example Medications |
|---|---|---|
| IV (Intravenous) | First-line in emergencies | All PALS drugs, fluids |
| IO (Intraosseous) | When IV fails | Epinephrine, fluids, antibiotics |
| IM (Intramuscular) | Rapid absorption for emergencies | Epinephrine (anaphylaxis) |
| ET (Endotracheal) | Last resort if no IV/IO | Naloxone, Atropine, Vasopressin, Epinephrine, Lidocaine |
Note: ET route requires 2–3x the IV dose due to variable absorption.
Special Considerations: Pediatric Drug Safety
- Double-check all weight-based dosing with a second provider.
- Verify correct medication concentrations.
- Follow infusion guidelines—do not push drugs like amiodarone or magnesium too fast.
- Use only isotonic fluids in resuscitation settings.
Summary: Key Takeaways for Pediatric Fluid and Medication Administration
- Begin fluid resuscitation with 20 mL/kg isotonic boluses (NS or LR).
- All meds should be dosed by weight (mg/kg).
- Epinephrine is first-line for cardiac arrest and anaphylaxis.
- If IV fails, IO is the fastest and most effective alternative.
- Always monitor for fluid overload and reassess frequently.
Takeaway: In pediatric emergencies, precise fluid and medication administration is essential for survival. Using accurate dosing strategies and the correct administration routes ensures the best outcomes.