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 for Fluid Resuscitation:
- Hypovolemic shock (e.g., dehydration, hemorrhage).
- Septic shock (distributive shock from infection).
- Cardiac arrest requiring volume expansion (certain cases).
Fluid Choice for Resuscitation
Isotonic Crystalloids:
- Normal Saline (0.9% NaCl) – First-line choice.
- Lactated Ringer’s (LR) – Preferred in sepsis (better acid-base balance).
Avoid Hypotonic Fluids (e.g., D5W, 0.45% NaCl) → Can cause hyponatremia and cerebral edema.
Bolus Administration for Shock
Initial Fluid Bolus:
- 20 mL/kg of isotonic crystalloid (NS or LR) over 5-10 minutes.
- Reassess perfusion (HR, BP, capillary refill, mental status).
- Repeat boluses as needed up to 60 mL/kg total (except in cardiogenic shock).
Monitor for Fluid Overload:
Pulmonary edema (crackles, tachypnea, worsening oxygenation). Hepatomegaly (suggests fluid overload in infants). Worsening work of breathing (may need diuretics or inotropes).
Septic Shock Considerations:
- Give 40-60 mL/kg within the first hour, then reassess.
- If shock persists despite fluids, start vasopressors (e.g., epinephrine, norepinephrine).
MEDICATION ADMINISTRATION IN PEDIATRIC RESUSCITATION
Weight-Based Dosing: Why It Matters
- Pediatric medication dosing is based on mg/kg or mL/kg.
- Overdosing can cause toxicity, while underdosing may lead to ineffective treatment.
- Use color-coded resuscitation charts (e.g., Broselow tape) for quick, accurate dosing.
Common Pediatric Emergency Medications
Medication Indication Pediatric Dose Route
Epinephrine (1:10,000) Cardiac Arrest 0.01 mg/kg IV/IO (max 1 mg/dose) every 3-5 min IV/IO
Epinephrine (1:1,000) Anaphylaxis 0.01 mg/kg IM (max 0.3 mg/dose) 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) Rapid IV push
Amiodarone VT/VF (refractory) 5 mg/kg IV over 20-60 min (max 300 mg/dose) IV
Lidocaine VT/VF (alternative to amiodarone) 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/dose) IV/IM
Calcium Gluconate Hypocalcemia 60 mg/kg IV over 5-10 min IV
Epinephrine is the first-line medication in cardiac arrest and anaphylaxis.
ROUTES OF ADMINISTRATION: IV, IO, IM, ET
If IV access is delayed or unavailable, alternative routes should be used:
Route When to Use Example Medications
IV (Intravenous) First-line for resuscitation All PALS drugs, fluids
IO (Intraosseous) When IV access is not available Epinephrine, fluids, antibiotics
IM (Intramuscular) Rapid absorption for specific emergencies Epinephrine for anaphylaxis
ET (Endotracheal) If no IV/IO access, last resort NAVEL drugs (Naloxone, Atropine, Vasopressin, Epinephrine, Lidocaine)
Endotracheal (ET) route requires higher doses (2-3x IV dose) due to variable absorption.
SPECIAL CONSIDERATIONS: PEDIATRIC DRUG SAFETY
Avoid These High-Risk Errors:
Miscalculating weight-based doses → Always double-check with a second provider. Wrong medication concentration → Verify standard pediatric formulations. Administering IV push medications too fast → Some drugs require slow infusion (e.g., amiodarone, magnesium). Using incorrect fluid types → Avoid hypotonic fluids in resuscitation.
SUMMARY: KEY TAKEAWAYS FOR PEDIATRIC FLUID AND MEDICATION ADMINISTRATION
Fluid resuscitation starts with 20 mL/kg boluses of isotonic fluids (NS or LR). Use weight-based dosing (mg/kg) for all medications. Epinephrine is the first-line drug in cardiac arrest and anaphylaxis. If IV access fails, use IO (fastest alternative). Monitor for fluid overload (crackles, hepatomegaly) in resuscitated patients.
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.