Magical Salty Water:
An Overview of Pediatric Fluid Resuscitation
11.5 hours into a night shift…
 2 week old male 5kg
 911 for tachypnea and decreased level of consciousness
 Eyes to voice, withdraws from pain, weak cry
 HR – 205, BP 80 sys, RR-60
Objectives
 Pediatric assessment
 Fluid resus – indications
 Fluid resus – contra-indications
Compensated Shock
 Tachycardia
 Cool & pale distal extremities
 Prolonged (>2 seconds) capillary refill
 Weak peripheral pulses compared to central pulses
 Normal systolic blood pressure
Circulation. 2010 Nov 2;122(18 Suppl 3):S876-908. doi:
10.1161/CIRCULATIONAHA.110.971101.
Decompensated Shock
 Decreased mental status
 Decreased urine output
 Tachypnea
 Weak central pulses
 Deterioration in colour
Circulation. 2010 Nov 2;122(18 Suppl 3):S876-908. doi:
10.1161/CIRCULATIONAHA.110.971101.
What does normal mean?
Age
Heart Rate (Beats/min)
 Infant
100-160
 Toddler
90-150
 Preschooler
80-140
 School-age
70-120
 Adolescent
60-100
AAP/ACEP APLS The Pediatric Emergency Medicine Resource (2007) Sudbury, MA
pg.40
They told me not to worry about the BP
 Neonates (0-28days): <60mmHg systolic
 Infants (1-12 monthes): <70mmHg
 Children (1-10 y/o): < 70mmHg (+ 2 x age)
 Children (>10y/o): <90mmHg
Circulation. 2010 Nov 2;122(18 Suppl 3):S876-908. doi:
10.1161/CIRCULATIONAHA.110.971101.
Because I feel like it…
Resuscitation vs. rehydration (Treatment vs. diagnostic)
Quick & Dirty Assessment
 Heart Rate
 Skin colour/condition
 Level Of Consciousness
The magic of the salty water
 NRP Guidelines
Under 28 days 10cc/kg over 20 minutes
 PALS Guidelines
20cc/kg NS as a resus bolus: 60cc/hr then dopamine
 Sepsis – Crystalloid (NS or RL) :Class IIa LOE C
 Hypovolemia – Crystalloid (NS or RL): Class I LOE A
Circulation. 2010 Nov 2;122(18 Suppl 3):S876-908. doi:
10.1161/CIRCULATIONAHA.110.971101.
She got legs…
Do you know how to use them?
 Proximal Humerus
 Proximal Tibia
 Distal Tibia
 Distal Femur
 Consider Lidocaine
http://www.teleflex.com/en/usa/ezioeducation/index.html
Special Considerations:
Diabetic Ketoacidosis:
 What does DKA Look like?
 Why not give fluid?
 What should I do?
Cardiac Anomalies:
 What do cardiac problems look like?
 Why not give fluid?
 What do I do?
No, actually, I haven’t dipped the urine…
 History of polyuria, polydipsia, weight loss, nausea and
vomiting
 Signs of Dehydration
 Breath with fruity odor
 Abdominal pain
 Tachypnea
 Lethargy
AAP/ACEP APLS The Pediatric Emergency Medicine Resource (2007) Sudbury, MA pg.188
Oops, I didn’t know that would happen…
Cerebral edema
Cerebral herniation/ICP
 Frequency 1%
 Obtundation
 Most important cause of
 Papilledema
mortality
 Presents with headache
and/or altered level of
consciousness
 Pupillary dilation
 Anisocoria
 BP variability
AAP/ACEP APLS The Pediatric Emergency
Medicine Resource (2007) Sudbury, MA pg.189
 Bradycardia
 Apnea
But you said he was dehydrated?
What do I do?
 Minimally dehydrated?
 Oral rehydration
 No vascular decompensation? (clinically dehydrated, vomiting)
 7cc/kg 0.9% NaCl over the first hour; then 3.5-5cc/kg/hr
 Vascular Decompensation? (Hypotension, +/- coma)
 10cc/kg 0.9% NaCl over the first hour, then 5cc/kg/hr
The hospital for Sick Children handbook of pediatrics/editors, Anne I. Dipchand … (et. Al.) – 11th
edition (2009) Toronto
I am calling about your ducts…
 High Index of Suspicion!
 BP
 Pre-Ductal
 Post-Ductal
 Sp02
 Pre-Ductal
 Post-Ductal
 Hypoxia without dyspnea
So what? I sweat when I eat too..
 Who is at risk of CHF?
 What is exertional dyspnea
 Hepatomegaly vs pulmonary edema
Cardiac Anomalies
 NS 5-10cc/kg
 Consider Lasix
 Consider Dopamine
Back to the night shift…
 3 week old male 5kg
 911 for tachypnea and decreased level of consciousness
 Eyes to voice, withdraws from pain, weak cry
 HR – 205, BP 80 sys, RR-60
Summary
 Big picture assessment!
 Don’t be scared of the IO
 Treatment vs. diagnostic
 20cc/kg NS or LR (give more!!! Kids need fluid)
 5-10cc/kg NS or LR (Careful of cardiac & DKA)
Questions
Jonathan Lee
jlee@ornge.ca
@thatjonlee