Pediatric Resuscitation Pediatric Resuscitation PharmacologyPharmacology

ObjectivesObjectives

Review the pharmacology, dosing, and Review the pharmacology, dosing, and indications for RSI medicationsindications for RSI medications

Discuss the side-effects and contraindications Discuss the side-effects and contraindications for RSI medicationsfor RSI medications

Discuss medications for specific patientsDiscuss medications for specific patients

Pearls of Resuscitation MedicationPearls of Resuscitation Medication

Determine diagnosis and verbalize to teamDetermine diagnosis and verbalize to team Verbalize medications that might be used Verbalize medications that might be used Special circumstances in pediatric age groupsSpecial circumstances in pediatric age groups

RSI MedicationsRSI Medications

SedativesSedatives EtomidateEtomidate MidazolamMidazolam ThiopentalThiopental KetamineKetamine FentanylFentanyl PropofolPropofol

ParalyticsParalytics SuccinylcholineSuccinylcholine RocuroniumRocuronium VecuroniumVecuronium

Pre-medsPre-meds AtropineAtropine LidocaineLidocaine

Pre-medicationsPre-medications

AtropineAtropine Inhibits acetylcholine receptors in parasympathetic system. Inhibits acetylcholine receptors in parasympathetic system.

Inhibits histamine and serotonin receptorsInhibits histamine and serotonin receptors Used to decrease airway secretionsUsed to decrease airway secretions Used to decrease reflex bradycardiaUsed to decrease reflex bradycardia Dose: 0.02mg/kg (min of 0.1mg; max of 1mg)Dose: 0.02mg/kg (min of 0.1mg; max of 1mg)

Pre-medicationsPre-medications

LidocaineLidocaine Inhibits sodium channelsInhibits sodium channels Used to decrease ICPUsed to decrease ICP Dose: 1-1.5mg/kgDose: 1-1.5mg/kg

SedativesSedatives EtomidateEtomidate

Ultra-short acting imidazole (non-barbiturate) hypnoticUltra-short acting imidazole (non-barbiturate) hypnotic Duration 10-15 minutesDuration 10-15 minutes

Advantages:Advantages: Decreases ICP and cerebral metabolic rateDecreases ICP and cerebral metabolic rate Minimal hemodynamic effects (maintains blood pressure)Minimal hemodynamic effects (maintains blood pressure)

Disadvantages:Disadvantages: Adrenal suppressionAdrenal suppression May cause myoclonus, cough, vomitingMay cause myoclonus, cough, vomiting

Dose: 0.3mg/kg (max of 20mg)Dose: 0.3mg/kg (max of 20mg) What to remember: What to remember:

Reduces ICP without systemic involvementReduces ICP without systemic involvement Can cause myoclonus-resembles seizuresCan cause myoclonus-resembles seizures Caution use in patients with adrenal insufficiencyCaution use in patients with adrenal insufficiency

SedativesSedatives MidazolamMidazolam

Binds to and activates benzodiazipine receptor in GABABinds to and activates benzodiazipine receptor in GABA Causes less cardiovascular and respiratory depression than Causes less cardiovascular and respiratory depression than

thiopentalthiopental Used less often in RSI due to need to titrate for sedation Used less often in RSI due to need to titrate for sedation

effect and wide response rangeeffect and wide response range Advantages:Advantages:

Can facilitate intubation without paralyticCan facilitate intubation without paralytic Rapid onsetRapid onset

Disadvantages:Disadvantages: HypotensionHypotension

Usually combined with opiate for RSIUsually combined with opiate for RSI Dose: 0.1mg/kg (max of 5mg for 1st dose)Dose: 0.1mg/kg (max of 5mg for 1st dose)

SedativesSedatives Thiopental SodiumThiopental Sodium

Binds to and activates barbiturate receptor on GABABinds to and activates barbiturate receptor on GABA Ultra-shourt acting barbiturateUltra-shourt acting barbiturate

Duration 5-10 minDuration 5-10 min Onset of action 10-20 secondsOnset of action 10-20 seconds Contraindicated in porphyria and status asthmaticusContraindicated in porphyria and status asthmaticus Advantages:Advantages:

Decreases ICP and cerebral metabolismDecreases ICP and cerebral metabolism Reduces cerebral oxygen demandReduces cerebral oxygen demand AnticonvulsantAnticonvulsant

Disavantages:Disavantages: Causses hypotensionCausses hypotension Myocardial depressionMyocardial depression Causes vasodilationCauses vasodilation Can cause bronchospasm (do not use in asthmatic patients)Can cause bronchospasm (do not use in asthmatic patients)

Dose: 3-5 mg/kg (max of 500 mg)Dose: 3-5 mg/kg (max of 500 mg) What to remember: What to remember:

Reduces ICP but also reduces systemic blood pressureReduces ICP but also reduces systemic blood pressure Is a barbiturate so will help to reduce seizure activityIs a barbiturate so will help to reduce seizure activity Ultra short actingUltra short acting

SedativesSedatives KetamineKetamine

produces dissociative anesthesiaproduces dissociative anesthesia Rapid sedation, amnesia and analgesiaRapid sedation, amnesia and analgesia Advantages:Advantages:

Analgesia and amnesiaAnalgesia and amnesia BronchodilationBronchodilation Maintains blood pressure and cardiac outputMaintains blood pressure and cardiac output

Disadvantages:Disadvantages: Increases intraocular pressureIncreases intraocular pressure Increases secretionsIncreases secretions May cause laryngospasmMay cause laryngospasm

Dose: 1-2mg/kg/doseDose: 1-2mg/kg/dose What to remember: What to remember:

No longer contraindicated in head traumaNo longer contraindicated in head trauma Causes bronchodilation so good choice in asthmaticsCauses bronchodilation so good choice in asthmatics Maintains blood presure so good choice in shock patientsMaintains blood presure so good choice in shock patients Has an anxiolytic propertyHas an anxiolytic property

SedativesSedatives FentanylFentanyl

Binds to opioid receptor in brainBinds to opioid receptor in brain Shortest acting opioidShortest acting opioid Useful adjuvant in induction agents lacking analgesic effect (etomidate, Useful adjuvant in induction agents lacking analgesic effect (etomidate,

thiopental, propofol)thiopental, propofol) Advantages:Advantages:

Hemodynamic stabilityHemodynamic stability May blunt sympathetic response to laryngoscopyMay blunt sympathetic response to laryngoscopy Useful for post-intubation sedation/analgesiaUseful for post-intubation sedation/analgesia

Disadvantages:Disadvantages: Lacks amnestic propertyLacks amnestic property Can cause rigid chestCan cause rigid chest

Dose: 1-2mcg/kg/doseDose: 1-2mcg/kg/dose

SedativesSedatives

PropofolPropofol Short-acting hypnotic agentShort-acting hypnotic agent Advantages:Advantages:

Can facilitate intubation without paralysisCan facilitate intubation without paralysis Rapid onsetRapid onset

Disadvantages: Disadvantages: Apnea in childrenApnea in children Cardiovascular depression Cardiovascular depression HypotensionHypotension No analgesia properties (must use opiate with propofol)No analgesia properties (must use opiate with propofol)

Dose: 2.5-3.5mg/kgDose: 2.5-3.5mg/kg

ParalyticsParalytics

SuccinylcholineSuccinylcholine Blocks cholinergic receptor sitesBlocks cholinergic receptor sites Depolarizing agentDepolarizing agent Onset 30-60 secondsOnset 30-60 seconds Lasts 3-12 minutesLasts 3-12 minutes Dose: 1-2mg/kg/doseDose: 1-2mg/kg/dose Caution:Caution:

Avoid use in Duchenne's muscular dystrophy, trauma, burns, crush Avoid use in Duchenne's muscular dystrophy, trauma, burns, crush injury, renal failure and genetic disordersinjury, renal failure and genetic disorders

Can cause hyperkalemia, rhabdomyolysis, malignant hyperthermia, Can cause hyperkalemia, rhabdomyolysis, malignant hyperthermia, hypertension and arrhythmiashypertension and arrhythmias

Contraindicated in glaucoma, penetrating eye injuries, myopathies, Contraindicated in glaucoma, penetrating eye injuries, myopathies, neuromuscular disease, pseudocholinesterdase deficiencyneuromuscular disease, pseudocholinesterdase deficiency

ParalyticsParalytics

RocuroniumRocuronium Blocks cholinergic receptor sitesBlocks cholinergic receptor sites Non-depolarizing agentNon-depolarizing agent Fasting onset and shortest duration of Fasting onset and shortest duration of

nondepolarizing agentsnondepolarizing agents Onset 30-90 secondsOnset 30-90 seconds Lasts 25-60 minutes Lasts 25-60 minutes Reversal agent now available (sugammedex)Reversal agent now available (sugammedex) Dose: 1mg/kg/doseDose: 1mg/kg/dose

ParalyticsParalytics

Vecuronium Vecuronium Blocks cholinergic receptor sitesBlocks cholinergic receptor sites Non-depolarizing agentNon-depolarizing agent 0.1mg/kg/dose0.1mg/kg/dose Onset 90-120 secondsOnset 90-120 seconds Longest acting paralytic (60-90min) Longest acting paralytic (60-90min)

Better in use to maintain paralysis rather than RSIBetter in use to maintain paralysis rather than RSI

Dose: 0.2mg/kg/doseDose: 0.2mg/kg/dose