Pediatric patients (ALS) with suspected tricyclic poisoning should receive which Sodium Bicarbonate dose?

• A. Sodium Bicarbonate 50 mEq IV/IO
• B. Sodium Bicarbonate 0.5 mEq/kg IV/IO
• C. Sodium Bicarbonate 1 mEq/kg IV/IO
• D. Sodium Bicarbonate 5 mEq/kg IV/IO

Answer: (C)

When a child is suspected of tricyclic poisoning, the heart can be driven into dangerous sodium channel blockade. Giving sodium bicarbonate helps by alkalinizing the blood and increasing the sodium gradient, which reduces the drug’s blockade of cardiac sodium channels and improves conduction, helping to narrow the QRS and stabilize rhythm.

The recommended dose in this setting is a rapid IV/IO bolus of one milliequivalent per kilogram using the 8.4% sodium bicarbonate solution. Because that solution provides about one milliequivalent per milliliter, this dose is effectively one milliliter per kilogram. If the ECG or clinical signs of toxicity persist after the bolus, repeat the bolus and then consider a continuous infusion to maintain alkalemia, all while closely monitoring ECG, acid-base status, and electrolytes. Avoid overdoing alkalinization or fluid overload.

Fixed, non–weight-based doses or doses that are too small or too large do not provide the targeted effect needed to counteract tricyclic sodium channel blockade in a pediatric patient.