Determining correct dose for children is a challenge in the ED

Memorization leads to error, experts say. Easy access to accurate dosage information is crucial when treating critically ill or injured children

Pediatric dosages present unique challenges for ED nurses, according to Linda Manley, RN, BSN, CEN, CCRN, EMS coordinator and flight nurse for MED Flight at Children’s Hospital in Columbus, OH. "Any time you are working with a child who is critical or crashing,’ the emotional component is very high, which may interfere with clear thinking," she says. "Thus, easy access to dosage information is imperative. You never want people to memorize these—that’s when errors occur."

The smaller doses required by pediatric patients are also a challenge. "You have to be aware of what is appropriate for a child and what is not," says Lynn Daum, RN, an emergency nurse at Children’s Hospital Medical Center in Cincinnati, OH. "You can’t just administer a whole ampule of something as you would in an adult. You have to make the adjustment to thinking in smaller doses."

Ways to facilitate pediatric dosages

Reference cards with dosage listings. ED nurses at Children’s in Cincinnati carry cards listing ages and average weights along with commonly used trauma drugs and other medications. "We guesstimate’ the child’s weight and then pull the drugs according to those charts, so it’s already figured out for us ahead of time," says Daum. "Also, they are nice round numbers, so we don’t have to worry about figuring out the dose for a child that weighs 12.3 kilos."

One limitation of the charts is going by the ages of children who aren’t of average weight, Daum acknowledges. "Not all six-year-olds are the same size—some with eating disorders might weigh much more, while a child with cerebral palsy would weigh much less," she notes. "Initially, we go by the weight on the charts, but many times we do have to adjust."

The ED at Children’s uses "code cards" that are kept in the pockets of nurses, physicians, and EMS providers for easy access. "We also have a very large reference poster with similar information in our trauma resuscitation unit as well, and a pharmacist responds to all critical events in the ED—we want to make sure the drugs and dosages are always rechecked," Manley stresses.

Name badges. ED nurses at Children’s in Cincinnati wear name badges with resuscitation drug dosage listed on the reverse side. "Our ED nurses respond to all the codes in the house, and we’re the ones responsible for drawing up medications," says Daum. "The name badges come in handy because when you’re responding to a code outside of the ED, you can turn it over, and the information you need is right there."

Medications used for various injuries such as conscious sedation for reductions of fractures can be looked up on a color-coded sheet, which begins at 5 kg and goes up to an adult dose. "It has the maximum dose that can be given and how many ccs in the column next to it, and that is all we draw up and go into the room with," Daum explains.

Creative inservicing. At Children’s in Columbus, education on dosages is given on an ongoing basis. Every month, nurses practice intubating, including inservicing on dosages. "Before, during, and after they intubate, I have them tell me the drugs and dosages they’re going to use," says Manley.

The ED’s innovative teaching strategies help nurses retain dosage information. A Jeopardy game is played, with degrees of difficulty ranging from 10-50. A 10-point question might be: "What is the first drug of choice in arrest (asystole) codes in children? Answer: Epinephrine." Fifty-point questions are more difficult, such as "A physician decides to do a rapid sequence intubation on a 3-year old who weighs 15 kg. List the medications he/she would use, drug dosages and route of administration."

"Another 50-point question might have to do with intraosseous infusion: state the indications, contraindications, equipment needed, complications, and for good measure, spell it!" says Manley. "We always include fun questions in the game to keep it light, and give out prizes at the end, often candy."