Several studies have demonstrated the high frequency of medication errors in pediatric patients by prehospital providers during both patient care and simulation. In 2015, our hospital-based urban EMS ...system introduced the Handtevy
Field Guide that provides precalculated pediatric doses in milliliters (mL) by patient age. We hypothesized that implementation of the Field Guide would increase the percentage of correct pediatric medication doses to greater than 85%.
We performed a single center retrospective cohort study of medications administered to patients < 13 years of age from August 2017 to July 2019 compared to 2014 baseline data through electronic medical record review. We excluded nebulized medications and online medication direction cases. Our primary outcome was the percentage of correct doses defined as a dose within 80-120% of the Field Guide dose recommendation. Each dosing error was reviewed by two investigators.
We analyzed 483 drug administrations in 375 patients for the Field Guide study period. Doses were correct in 89.4% of medication administrations with 68.5% reportedly administered exactly as dictated by the Field Guide compared to 51.1% in the baseline period (
< 0.001). During the Field Guide study period, the following medications had 100% appropriate dosing: adenosine, dextrose 10%, diphenhydramine, epinephrine 1:10,000, glucagon, naloxone and oral ondansetron. Overdoses accounted for 4.4% of medication errors and underdoses accounted for 6.2% of medications errors. The most overdosed medications were intranasal (IN) midazolam (11.8%) and intravenous fentanyl (9.4%). The most underdosed medications were IN midazolam (23.5%) and intramuscular epinephrine 1:1000 (12.5%). The highest percentage of errors (20%) were seen in the zero to one-year-old age group.
After implementation of a precalculated mL dose system by patient age for EMS providers, most pediatric medications were reportedly administered within the appropriate dose range. A field guide with precalculated doses (in mL) may be an effective tool for reducing pediatric medication dosing errors by EMS providers.
Abstract Purpose Shock index (SI), the ratio of heart rate to systolic blood pressure, has found to outperform conventional vital signs as a predictor of shock. Although age-specific vital sign norms ...are recommended in screening for shock, there are no reported age- or sex-specific norms for SI. Our primary goal was to report age- and sex-specific SI normal values for a nationally representative population 10 years and older by 5-year age groups. A secondary goal was to report SI normal values for children ages 8 to 19 years by 1-year age groups. Basic procedures Weighted data from the National Health and Nutrition Examination Survey 1999-2008 data sets were used to generate age- and sex-specific percentile curves of SI for subjects 8 years and older. Main findings The primary analysis included 33 906 subjects (101 837 weighted) 10 years and older. The secondary analysis included 13 393 subjects (37 983 weighted) 8 to 19 years old. Normalized SI values for each percentile decreased with increasing age and were higher for females across all ages. The most commonly cited SI threshold of 0.9 exceeded the 97th percentile for males younger than 25 years and for females younger than 40 years. Conclusions This first report of age- and sex-specific normal values for SI indicates that SI norms vary by age and sex. Just as age-specific vital sign norms are recommended in screening for shock, our findings suggest that age- and sex-specific SI norms may be more effective in screening for shock than a single-value threshold.
Background: The use of a length/weight-based tape (LBT) for equipment size and drug dosing for pediatric patients is recommended in a joint statement by multiple national organizations. A new system, ...known as Handtevy™, allows for rapid determination of critical drug doses without performing calculations. Objective: To compare two LBT systems for dosing errors and time to medication administration in simulated prehospital scenarios. Methods: This was a prospective randomized trial comparing the Broselow Pediatric Emergency Tape™ (Broselow) and Handtevy LBT™ (Handtevy). Paramedics performed 2 pediatric simulations: cardiac arrest with epinephrine administration and hypoglycemia mandating dextrose. Each scenario was repeated utilizing both systems with a 1-year-old and 5-year-old size manikin. Facilitators recorded identified errors and time points of critical actions including time to medication. Results: We enrolled 80 paramedics, performing 320 simulations. For Dextrose, there were significantly more errors with Broselow (63.8%) compared to Handtevy (13.8%) and time to administration was longer with the Broselow system (220 seconds vs. 173 seconds). For epinephrine, the LBTs were similar in overall error rate (Broselow 21.3% vs. Handtevy 16.3%) and time to administration (89 vs. 91 seconds). Cognitive errors were more frequent when using the Broselow compared to Handtevy, particularly with dextrose administration. The frequency of procedural errors was similar between the two LBT systems. Conclusion: In simulated prehospital scenarios, use of the Handtevy LBT system resulted in fewer errors for dextrose administration compared to the Broselow LBT, with similar time to administration and accuracy of epinephrine administration.
Mycoplasma pneumoniae is a common cause of community-acquired respiratory illness in the adolescent population. Stevens-Johnson syndrome is an extrapulmonary manifestation that has been associated ...with M. pneumoniae infections. Three adolescent males presented within a 1-month period with M. pneumoniae respiratory illnesses and severe mucositis but without the classic rash typical of Stevens-Johnson. Diagnosis was facilitated by the use of a polymerase chain reaction-based assay. This case series highlights the potential for M. pneumoniae-associated Stevens-Johnson syndrome to occur without rash and supports the use of polymerase chain reaction for early diagnosis.
Abstract Objectives Prehospital pediatric airway management is difficult and controversial. Options include bag-mask ventilation (BMV), endotracheal tube (ETT), and laryngeal mask airway (LMA). ...Emergency Medical Services personnel report difficulty assessing adequacy of BMV during transport. Capnography, and capnograph tracings in particular, provide a measure of real-time ventilation currently used in prehospital medicine but have not been well studied in pediatric patients or with BMV. Our objective was to compare pediatric capnographs created with 3 airway modalities. Methods This was a prospective study of pediatric patients requiring ETT or LMA ventilation during elective surgical procedures. Data were collected during BMV using 2 bag types (flow-inflating and self-inflating). The ETT or LMA was placed and ventilation with each bag type repeated. Ten- to 14-second capnographs were reviewed by 2 blinded anesthesiologists who were asked to assess ventilation and identify the airway and bag type used. Descriptive statistics, κ , and risk ratios were calculated. Results Twenty-nine patients were enrolled. Median age was 4.4 years (2 months to 16.8 years). One hundred sixteen capnographs were reviewed. Reviewers were unable to differentiate between airway modalities and agreed on adequacy of ventilation 77% of the time ( κ = 0.6, P < .001). Bag-mask ventilation was rated inadequate more frequently than ETT or LMA ventilation. There were no difference between ETT and LMA ventilation and no difference between the 2 bag types. Conclusion Capnographs are generated during BMV and are virtually identical to those produced with ETT or LMA ventilation. Attention to capnographs could improve outcomes during emergency treatment and transport of critically ill pediatric patients requiring ventilation with any of these airway modalities.
Advocacy for maintaining and expanding Emergency Medical Services for Children is needed on many fronts. Pediatric emergency medicine (PEM) physicians are uniquely qualified to serve this role due to ...their expertise in the acute care of sick or injured pediatric patients. Given this, in addition to maintaining the highest standards in the emergency departments in which they work, PEM physicians also have responsibilities in the education, training, and practice of emergency medical services providers in their region. These providers are also well positioned to advocate for Emergency Medical Services for Children on a policy level at local, regional, and state governments and in organizations that deal with the care of children in both the prehospital and hospital arenas. Greater engagement by PEM physicians in such activities is required to optimize pediatric care across the spectrum of emergency services.
This is a joint policy statement from the American Academy of Pediatrics, American College of Emergency Physicians, Emergency Nurses Association, National Association of Emergency Medical Services ...Physicians, and National Association of Emergency Medical Technicians on pediatric readiness in emergency medical services systems.
Ill and injured children have unique needs that can be magnified when the child's ailment is serious or life-threatening. This is especially true in the out-of-hospital environment. Providing ...high-quality out-of-hospital care to children requires an emergency medical services (EMS) system infrastructure designed to support the care of pediatric patients. As in the emergency department setting, it is important that all EMS agencies have the appropriate resources, including physician oversight, trained and competent staff, education, policies, medications, equipment, and supplies, to provide effective emergency care for children. Resource availability across EMS agencies is variable, making it essential that EMS medical directors, administrators, and personnel collaborate with outpatient and hospital-based pediatric experts, especially those in emergency departments, to optimize prehospital emergency care for children. The principles in the policy statement "Pediatric Readiness in Emergency Medical Services Systems" and this accompanying technical report establish a foundation on which to build optimal pediatric care within EMS systems and serve as a resource for clinical and administrative EMS leaders.
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