Was Child Brought to ED by EMS? Medication Dosages May Be Incorrect
By Stacey Kusterbeck
Emergency medical services (EMS) clinicians do not interact with children compared to adults.1 EMS also may lack knowledge due to a lack of training.2 Additionally, EMS must obtain the child’s weight or length and refer to standardized protocols, all in a fast-moving vehicle.
“There are also differences in concentration of medications among manufacturers — and differences among EMS agency-specific protocols vs. nationally accepted clinical guidelines,” observes Christian Martin-Gill, MD, MPH, FACEP, FAEMS, associate professor of emergency medicine and chief of the division of EMS at the University of Pittsburgh Medical Center.
In light of all these challenges, Martin-Gill and colleagues decided to evaluate doses of emergency medications administered to pediatric patients in the prehospital setting. The researchers analyzed data on nearly 1 million pediatric encounters from 2,000 EMS agencies. They considered the dosing for 10 commonly used medicines.3
Of the 990,497 patients, 3.4% received one of the medicines studied. Pediatric drug dosing deviations from national guidelines were common. Of the 80% of patients with a documented weight in the medical record, 58% of their medications were given at a dose that was not consistent with national guidelines (defined as at least 20% over or under the weight-appropriate dose). “Our findings highlight that there is variability in the dosing of medications provided to pediatric patients among EMS personnel,” Martin-Gill says.
IV epinephrine was the medication most frequently overdosed. Seizure and sedating medications were frequently given in incorrect amounts, with most deviations representing an underdose. Only about 20% of doses of diazepam and lorazepam were given in the correct dose. “Appropriate dosing is important to ensure the correct treatment of individual conditions and to avoid the potential for harm,” Martin-Gill says.
Consistency of dosing varied widely depending on the medication administered. This is likely because some recommended medication dosages are different in EMS protocols compared to those in national guidelines, according to Martin-Gill. Another explanation is some medications pose additional challenges because EMS providers have to calculate and administer the correct weight-based dose.
ED personnel should ensure a good handoff report is received from EMS providers, and that the dose of any medications administered by EMS is recorded. “EMS medical directors and ED directors may want to consider our findings when planning training, performing quality assessments, or implementing tools, such as standardizing dosing references, to ensure the correct doses are administered, and reduce the potential for errors,” Martin-Gill says.
Interventions in the ED can be adjusted as needed to account for the dosages actually received by children before arrival. For example, if the dose of a medication was lower than recommended for treatment of a condition, the full dose could be completed after patient arrival in the ED. In the ED, similar challenges in weight-based dose administration for children are likely.
“ED personnel should be mindful in carrying out weight-based dosing calculations, and should follow recommendations of national guidelines,” Martin-Gill says.
1. Ramgopal S, Elmer J, Escajeda J, Martin-Gill C. Differences in prehospital patient assessments for pediatric versus adult patients. J Pediatr 2018;199:200-205.e6.
2. Hansen M, Meckler G, Dickinson C, et al. Children’s safety initiative: A national assessment of pediatric educational needs among emergency medical services providers. Prehosp Emerg Care 2015;19:287-291.
3. Ramgopal S, Martin-Gill C. Deviation from national dosing recommendations for children having out-of-hospital emergencies. Pediatrics 2023;152:e2023061223.
ED personnel should ensure a good handoff report is received from EMS providers, and that the dose of any medications administered by EMS is recorded. ED personnel should be mindful in carrying out weight-based dosing calculations, and should follow recommendations of national guidelines.
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