Children commonly receive wrong doses of medicine during EMS encounters
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Key takeaways:
- Medications given to children during EMS encounters are often not guideline concordant.
- Research in this area has been limited.
Children treated during prehospital encounters with emergency medical services often do not receive medication doses that are concordant with national guidelines, according to a study published in Pediatrics.
“It’s important to ensure that children treated with out-of-hospital emergencies are given the appropriate dose of medication, particularly for ones that might be considered high stakes, like for seizures or cardiac arrest, as inaccurate dosing — either too high or too low — can adversely affect patient outcomes,” Sriram Ramgopal, MD, a pediatric emergency physician at Lurie Children’s Hospital of Chicago, told Healio.
Ramgopal said previous researchers have suggested that there is substantial variation in the dosing of medications given to children by emergency medical services (EMS) clinicians.
“However, most of those studies have been regional in nature or limited to disease states,” Ramgopal said. “The availability of large, national datasets with detailed dosing data provides an opportunity to study this on a larger scale. ...There's also been a lot of research evaluating differences in EMS protocols regionally.”
Ramgopal and co-author Christian Martin-Gill, MD, MPH, from the department of emergency medicine at the University of Pittsburgh School of Medicine, studied a dataset of electronic health records from approximately 2,000 U.S.-based EMS and 990,497 pediatric encounters, and included records of patients who received lorazepam, diazepam, midazolam, fentanyl, hydromorphone, morphine, ketorolac, epinephrine, diphenhydramine and methylprednisolone in their analysis.
“We used a database that was provided to us by a vendor of a widely used prehospital electronic health record to evaluate dosing of commonly used pediatric prehospital medications,” Ramgopal said. “Dosing for medications in children is weight based, so we used guidelines that are nationally recognized — the Pediatric Advanced Life Support guidelines and the National Association of State EMS Officials Model Guidelines. We looked at how often these medications were given in amounts that were either too low or too high.”
In a final sample that included non-nebulized doses of study drugs administered to patients with a documented weight, only 42.6 per 100 administrations of 10 commonly used medications were consistent with national guidelines.
“This shows the need for more improvement and standardization of dosing for children with medical emergencies,” Ramgopal said.
Most deviations represented an underdose — especially sedating medications, including benzodiazepines and morphine — the researchers reported.
Ramgopal suggested the findings may have multiple causes, including differences in protocols and errors in dosing, and suggested that future educational, quality improvement and research activities be undertaken to improve adherence to national dosing guidelines.
“There's been some research looking at high-fidelity simulations to improve knowledge about this topic,” Ramgopal said. “While education is always a good thing, I think there are opportunities for systems-level changes to reduce the cognitive burden on paramedics — there is some important research that can be done in this space. In addition, it will be important to better standardize this across protocols. Even providing a dosing range can make the job too challenging. We need to remember that these are uncommon and high-stakes situations, so taking out ambiguity is critical.”
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