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William Fales, MD, FACEP Michigan State University Kalamazoo Center for Medical Studies
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Plan Ahead – Minimizing the Risk of Pediatric Medication
ErrorsImplications for Disaster
Medicine William Fales, MD, FACEP
Michigan State University Kalamazoo Center for Medical Studies5th District Medical Response Coalition
Kalamazoo County Medical Control Authority
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Acknowledgment
Funding for the MI PEEDS Study was provided by the:
US Department of Health and Human Services
Health Resources and Services Administration
Bureau of Maternal and Child Health EMS for Children Program
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Disclosures
Nothing to Disclose
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Kids in Disasters
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Fortunately
Mass Casualty IncidentsInvolving Children Are Relatively Uncommon
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Also, Fortunately
Isolated Incidents Involving Critically Ill and Injured
Infants and ChildrenAre Relatively Uncommon
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Fundamental Disaster Medicine Concepts
Effective response to an MCI involves application of basic and advanced skills and critical clinical decision making with limited resources.
Being able to respond to day-to-day incidents improves (but does not guarantee) your ability to respond to the “big ones”.
Corollary: If you can’t handle the “little ones” effectively, you sure won’t be able to handle the “big ones”. So How Well Do We
Handle the “Little Ones”?
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Pediatric Medication Errors
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Medication Challenges in EMS
(A Tail of 4 Michigan Studies)
Hoyle Study: EMS Med Dosing Errors in Peds
Lammers Study: Root Cause Analysis of Errors in Simulated Peds Emergency
Michigan EMS Information System Peds Seizure Study
RAMPART Study
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Med Dosing Errors in Peds Treated by EMS
Prehospital Emergency Care Hoyle, et al January/March 2012
Retrospective review of MERMaID Records Jan 1, 2004 to
March 31, 2006 Correct Dose = +/-
20% of protocol dose
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Weight vs. Age
95th %ile 50th
%ile
5th %ile
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Age Distribution
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Incorrect Medication Doses, Overdoses and
Underdoses
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Conclusion
Medications delivered to children in the prehospital setting by paramedics were frequently administered at doses outside of the proper range when compared with documented patient weights. EMS systems should develop strategies to reduce pediatric medication dosing errors.
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MI PEEDS Study
MI Pediatric Excellence and Error Detection with Simulation Study EMS-C Targeted Issues
Grant
Academic Emergency Medicine Lammers, et al January 2012
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Participating Agencies
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Mobile Pediatric Simulation Unit
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Seizing InfantBenzo Dosing (N=45)
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Drug AdministrationDrug Administration
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Needleend
Needleend
Plunger direction
Diazepam
Volume delivered
Volume remaining
Drug Administration Drug Administration
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Toddler with Anaphylactic Shock
Epinephrine 1:1000 IM/SQ Correct dose in 15 of 57 cases (26%) 14 of 57 (25%) gave >10x protocol dose 9 of 57 (16%) gave IV Epi (4 pushing 1:1000) 3 of 5 agencies carried 30 mg multi-dose vials (1:1000)
Diphenhydramine IV/IO/IM Correct dose in 7 of 54 cases (7%)
Solumedrol IV/IO Only attempted by 3 of 60 crews (5%) None with correct dose.
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MI-EMSIS Peds Seizure Study
Retrospective review of Michigan EMS Information System
2010 Statewide data 944,415 EMS records (all ages) 9,168 Under 2 years old (~1%) 63 received a benzodiazepines (<7%) for
seizure
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Benzo Dosing
Midazolam (N=28)
IV/IO 2 of 8 (25%) Correct
Dose IM
3 of 11 (27%) Correct Dose
Rectal 5 (18%) (wrong route)
Active Error Rate=79%
Diazepam (N=35) IV/IO
2 of 6 (33%) Correct Dose Rectal
5 of 13 (38%) Correct Dose
IM (wrong route) 1 patient
Active Error Rate=65%
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Summary of Studies
Hoyle Study: 23% to 100% dosing error rate MI PEEDS Study: 25% to 93% dosing error rate MI EMSIS Study: 62% to 75% dosing error rate
Studies limited to EMS (high performance EMS) Do other health professionals do better?
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Implications in Disaster Medicine
Higher than usual level of emotional stress Emergency personnel task overloaded Use of non-emergency personnel for augmentation
e.g., Ortho nurse pulled to ED Need for highly potent meds with significant risks
Analgesics, sedatives, neuromuscular blockers, ACLS meds
Use of alternative, unfamiliar meds Unknown pediatric patient weights
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Plan Ahead – Minimizing Risk of Pediatric
Medication Errors People Practice and Practices Protocols Paraphernalia
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People Training and Education
Increased use of existing standardized courses (PALS/PEPP) Increased emphasis on safe med administration
More frequent, brief continuing education sessions 60 minutes twice a year vs. 4 hours every 2
years Simulation-based training
High intensity, small group Does not require high-fidelity simulators
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Knowledge Assessment
Q. “What is the dose of Benadryl for an 8 kg infant who is in anaphylaxis?”
A. 1 mg/kg IM or IV
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Performance-Based
Assessment
Q. “This simulated infant is in anaphylaxis and has received epinephrine. An IV line is in place. Give another drug.”
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Performance-Based
AssessmentAnswer:
1. Recall “Benadryl.” 2. Recall or look up the dose: 1
mg/kg IV.3. Calculate the dose in mgs:
1 mg/kg x 8 kg = 8 mg
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4. Find the concentration on the bottle.
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5. Convert a weight dose to a volume dose. 8 mg
50 mg/mL
= 0.16 mL
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6. Draw 0.16 mL out of the vial with a 1 mL syringe.
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7. Find the closest port on the IV line.8. Attach the syringe without contaminating the line.
9. Clamp the line upstream.10. Deliver the entire volume.
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Practice and Practices Practice (Exercising)
Include peds in EMS and hospital exercises Require simulated med administration Use wireless ped simulators
Practices Mandatory buddy-check for all pediatric med
administration Requires culture change Challenges with single paramedic crews
No fault med error reporting systems Provide info on near misses/hits >>>> Safety solutions
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Protocols
Greatly simplify dosing protocols Avoid non-whole numbers Broad, simple doses
Epi-Pen vs. Epi-Pen Jr. Use single doses when appropriate
Glucagon IM for hypoglycemia Can this be done safely?
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~.4 mg/kg
RAMPART Study
Rapid Anticonvulsant Medications Prior to Arrival Trial
New England Journal of Medicine Silbergliet, et al Feb 16, 2012
Multi-Center Randomized Trial Including Detroit EMS Compare
Midazolam 10 mg IM (13-40 kg 5 mg IM)
Lorazepam 4 mg IV (13-40 kg 2 mg IV)
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RAMPART Findings
Conclusion: For subjects in status epilepticus, intramuscular midazolam is at least as safe and effective as intravenous lorazepam for prehospital seizure cessation.
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Paraphernalia
Autoinjectors Limited availability (Epi Pen, AtroPen,
Glucagon +/-) Broselow® Pediatric Emergency Tape
Limitations Pediatric Dosing Cards
Under development
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Thematic Qualitative AssessmentThematic Qualitative Assessment
Wrong end
of tape used
End of tape
not alignedwith head
Forgot to use
Broselow tape
WrongWeight
Equipment:Use of Broselow tape for weight estimate:
Cognitiveerror
Procedureerror
Procedureerror
Used mother’s
estimate ra
ther than
Broselow tape
Cognitiveerror
Unfamiliar with
Broselow tape
Cognitiveerror
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Thematic Qualitative AssessmentThematic Qualitative Assessment
Volume measured fro
m
wrong end of
pre-filled sy
ringe
Mg to mL
conversion error DrugDoseError
Wrong weight
Mg/kg to
mg
calcu
lation error
Unaided calculations
Failure to cross-check
calculations
Impaire
d calcu
lation
ability under s
tress
Affectiveerror
Teamworkerror
Cognitiveerror
Procedureerror
Cognitiveerror Cognitive
errorCognitive
and/orprocedure
error
Drug Delivery:
Wrong mg/kg
dose
for ro
ute
Cognitiveerror
DrugDosingCards?
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LA County Peds Cards
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6-7 Kg6-7 (13-15 Lbs)/ 3-6 Months(Pink)
Resuscitation Medication Dose VolumeEPINEPHRINE 1:10,000 (1mg/10mL prefill) .07 mg 0.7 mlAMIODARONE (150mg/3mL) 25 mg 0.5 mlLIDOCAINE (100mg/5mL) 5 mg 0.25 mlMAGNESIUM SULFATE (1gm/2mL) 250 mg 0.5 mlCALCIUM CHLORIDE (1gm/10mL) 100 mg 1 mlADENOSINE (6mg/2mL) – 1st Dose .65 mg 0.2 mlADENOSINE (6mg/2mL) – 2nd Dose 1.3 mg 0.4 mlElectrical Therapy Initial RepeatDefibrillation 15 J 25 JCardioversion (synchronized) 10 J 15 J
MI Peds Card (Prototype)
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MI Peds Card (Prototype) 6-7 Kg (13-15 Lbs)/ 3-6 Months
(Pink)Assessment Normal Vitals: HR: 100-160, RR: 30-60, SBP: >70,
Development: Rolls from front to back, back to side. Carries object to mouth Drug Dose Volume Drug Dose Volume
AsthmaAnaphylaxis
Albuterol (2.5 mg/3 ml) 2.5 mg 3 ml Epinephrine (1 mg/ml) IM 0.1 mg 0.1 ml
Diphenhydramine (50 mg/ml) 10 mg 0.2 ml Solumedrol (125 mg/2 ml) 19 mg 0.3 ml
Seizure Midazolam IM (5 mg/1 ml) 1 mg 0.2 ml Diazepam PR (10 mg/2 ml) 3 mg 0.6 ml
Midazolam IV slow (5 mg/1 ml+4 ml NSS=1 mg/ml))
.5 mg 1 ml (diluted)
Diazepam IV slow (10 mg/2 ml + 8 ml NSS=1 mg/ml)
1 mg 1 ml(diluted
)Hypoglycemia
Dextrose 25% Slow IV 15 ml Glucagon IM (1 mg/ml) 1 mg 1 ml
Pain Control Fentanyl IV (100 mcg/2 ml) 5 mcg 0.1 ml Morphine IV (10 mg/ml + 9 ml NSS=10mg/10 ml)
0.5 mg .5 ml (diluted
)
Fentanyl IN(100 mcg/ml) 10 mcg .2 ml Morphine IM (10 mg/ml) 1 mg 0.1 ml
Narcotic OD Naloxone IV/IM (2 mg/2 ml) 1 mg 1 ml Naloxone IN (2 mg/2 ml) 1 mg 1 ml
Fluid Bolus Normal Saline IV/IO 130 ml 130 ml May repeat NSS x2 PRN 130 ml 130 ml
Equipment OPA: 50mm, NPA: 14F, BVM: Infant, Laryngoscope: 1 (straight), ET Tube: 3.5, ET Depth: 11 cm
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Summary
Caring for critically ill and injured kids is extremely stressful Disasters greatly increase stress
Pediatric medication errors are common During a disaster med errors could significantly increase
There are many ways to potentially reduce ped med errors By reducing pediatric medication errors on a “routine”
basis, we will provide safer, more effective care in a disaster
Thanks! [email protected]