1. Magical Salty Water: An Overview of Pediatric Fluid Resuscitation

2. 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

3. Objectives  Pediatric assessment  Fluid resus – indications  Fluid resus – contra-indications

4. Compensated Shock  Tachycardia  Cool & pale distal extremities  Prolonged (>2 seconds) capillary refill  Weak peripheral pulses compared to central pulses  Normal systolic blood pressure Circulation.Circulation. 2010 Nov 2;122(18 Suppl 3):S876-908. doi: 10.1161/CIRCULATIONAHA.110.971101.

5. Decompensated Shock  Decreased mental status  Decreased urine output  Tachypnea  Weak central pulses  Deterioration in colour Circulation.Circulation. 2010 Nov 2;122(18 Suppl 3):S876-908. doi: 10.1161/CIRCULATIONAHA.110.971101.

6. What does normal mean? AgeHeart Rate (Beats/min)  Infant100-160  Toddler90-150  Preschooler80-140  School-age70-120  Adolescent60-100 AAP/ACEP APLS The Pediatric Emergency Medicine Resource (2007) Sudbury, MA pg.40

7. 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.Circulation. 2010 Nov 2;122(18 Suppl 3):S876-908. doi: 10.1161/CIRCULATIONAHA.110.971101.

8. Because I feel like it… Resuscitation vs. rehydration (Treatment vs. diagnostic) Quick & Dirty Assessment  Heart Rate  Skin colour/condition  Level Of Consciousness

9. 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.Circulation. 2010 Nov 2;122(18 Suppl 3):S876-908. doi: 10.1161/CIRCULATIONAHA.110.971101.

10. 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

11. 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?

12. 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

13. Oops, I didn’t know that would happen… Cerebral edema  Frequency 1%  Most important cause of mortality  Presents with headache and/or altered level of consciousness AAP/ACEP APLS The Pediatric Emergency Medicine Resource (2007) Sudbury, MA pg.189 Cerebral herniation/ICP  Obtundation  Papilledema  Pupillary dilation  Anisocoria  BP variability  Bradycardia  Apnea

14. 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.) – 11 th edition (2009) Toronto

15. I am calling about your ducts…  High Index of Suspicion!  BP  Pre-Ductal  Post-Ductal  Sp02  Pre-Ductal  Post-Ductal  Hypoxia without dyspnea

16. So what? I sweat when I eat too..  Who is at risk of CHF?  What is exertional dyspnea  Hepatomegaly vs pulmonary edema

17. Cardiac Anomalies  NS 5-10cc/kg  Consider Lasix  Consider Dopamine

18. 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

19. 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)

20. Questions Jonathan Lee jlee@ornge.ca @thatjonlee