1. Pediatric ResuscitationPediatric Resuscitation
PharmacologyPharmacology

2. ObjectivesObjectives
 Review the pharmacology, dosing, andReview the pharmacology, dosing, and
indications for RSI medicationsindications for RSI medications
 Discuss the side-effects and contraindicationsDiscuss the side-effects and contraindications
for RSI medicationsfor RSI medications
 Discuss medications for specific patientsDiscuss medications for specific patients

3. Pearls of Resuscitation MedicationPearls of Resuscitation Medication
 Determine diagnosis and verbalize to teamDetermine diagnosis and verbalize to team
 Verbalize medications that might be usedVerbalize medications that might be used
 Special circumstances in pediatric age groupsSpecial circumstances in pediatric age groups

4. RSI MedicationsRSI Medications
 SedativesSedatives
 EtomidateEtomidate
 MidazolamMidazolam
 ThiopentalThiopental
 KetamineKetamine
 FentanylFentanyl
 PropofolPropofol
 ParalyticsParalytics
 SuccinylcholineSuccinylcholine
 RocuroniumRocuronium
 VecuroniumVecuronium
 Pre-medsPre-meds
 AtropineAtropine
 LidocaineLidocaine

5. 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)

6. 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

7. 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

8. SedativesSedatives
 MidazolamMidazolam
 Binds to and activates benzodiazipine receptor in GABABinds to and activates benzodiazipine receptor in GABA
 Causes less cardiovascular and respiratory depression thanCauses less cardiovascular and respiratory depression than
thiopentalthiopental
 Used less often in RSI due to need to titrate for sedationUsed 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)

9. 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

10. 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

11. 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

12. 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 depressionCardiovascular 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

13. 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, crushAvoid 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

14. ParalyticsParalytics
 RocuroniumRocuronium
 Blocks cholinergic receptor sitesBlocks cholinergic receptor sites
 Non-depolarizing agentNon-depolarizing agent
 Fasting onset and shortest duration ofFasting onset and shortest duration of
nondepolarizing agentsnondepolarizing agents
 Onset 30-90 secondsOnset 30-90 seconds
 Lasts 25-60 minutesLasts 25-60 minutes
 Reversal agent now available (sugammedex)Reversal agent now available (sugammedex)
 Dose: 1mg/kg/doseDose: 1mg/kg/dose

15. ParalyticsParalytics
 VecuroniumVecuronium
 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