An Analysis of Prehospital Pediatric Medication Dosing Errors after Implementation of a State-Wide EMS Pediatric Drug Dosing Reference

Prehospital Ketamine Administration in Benzodiazepine Refractory Status Epilepticus: A Case Series Review

OBJECTIVES

Benzodiazepines are the treatment for seizures in prehospital settings, but fail in up to 40% of cases, leading to benzodiazepine refractory status epilepticus (BRSE). Early treatment of BRSE is essential to prevent neurological damage and death. Ketamine, an N-methyl-D-aspartate receptor antagonist used by emergency medical services (EMS) for a variety of indications, has potential as a safe, effective prehospital treatment for BRSE. However, safety and efficacy data for early treatment of patients with seizures are limited.

METHODS

We retrospectively analyzed patients treated by EMS clinicians with ketamine for BRSE at a single urban ground-based EMS system between September 1, 2021, and December 1, 2023. Ketamine dose and route, patient characteristics, and airway interventions are described. Data were gathered from EMS records.

RESULTS

Forty-two patients aged 8 months to 79 years, were included. Ketamine was administered intramuscularly in 22 with an average dose of 3.3 mg/kg, and intravenously or intraosseous in 20, with an average dose of 2.2 mg/kg. Ketamine stopped seizures in 38 patients (90.5%). Transient hypoxia occurred in 9 patients (22%). Respirations were supported with bag-valve-mask ventilation in 13 patients (31%), a supraglottic airway in three (7%), and one patient was endotracheally intubated (2.4%).

CONCLUSIONS

Ketamine appears safe and effective for prehospital treatment of BRSE. Monitoring and intervention for respiratory complications appears necessary, but rates of these complications are consistent with expected rates from seizures and appropriate benzodiazepine dosing. These findings support ketamine's use in EMS for BRSE. Larger prospective studies are needed to confirm safety and efficacy.

Use of Standardized Dosing Sheets in Pediatric Emergency Care: Experience in a Third-Level Hospital

OBJECTIVES

Medication errors are one of the main causes of avoidable injuries in health care. With the aim of reducing them, a set of sheets with precalculated doses (by weight intervals) and preparation guidelines of the most common drugs in emergencies (Farmacards) was implemented in a Pediatric Emergency Department, replacing the previous manual calculation system. The aim of the study is to assess the staff's perception of safety and usefulness of the new dosing system.

STUDY DESIGN

Pre-post intervention comparative analysis was performed by distributing an opinion questionnaire to pediatric emergency department staff in 2017 (manual calculation in situ) and 2023 (Farmacards). We obtained 60 and 55 responses, respectively, and analyzed the characteristics of the sample and the perception of the new method.

RESULTS

Five years after its introduction, 88.5% were aware of its existence, 86.9% knew where to find it, and 76% used it "always or almost always" for critically ill patients. Greater use was observed among personnel with more years of work experience (Spearman, P = .057) and among nurses (Mann-Whitney, P < .001). The new method improved the level of perceived safety, especially for nurses (Mann-Whitney, P = .008).

CONCLUSIONS

Standardized medication dosing systems in emergency situations aim to reduce medical errors and minimize iatrogenesis, participating in safety culture. According to the results of our study, the implementation of Farmacards shows a good acceptance by the staff and in the perception of patient safety, which is a good starting point to further optimize the quality of care. specialties: emergency medicine, general pediatrics, toxicology, and critical care.

Adverse Safety Events in Emergency Medical Services Care of Children With Out-of-Hospital Cardiac Arrest

Importance

Survival for children with out-of-hospital cardiac arrest (OHCA) remains poor despite improvements in adult OHCA survival.

Objective

To characterize the frequency of and factors associated with adverse safety events (ASEs) in pediatric OHCA.

Design, Setting, and Participants

This population-based retrospective cohort study examined patient care reports from 51 emergency medical services (EMS) agencies in California, Georgia, Oregon, Pennsylvania, Texas, and Wisconsin for children younger than 18 years with an OHCA in which resuscitation was attempted by EMS personnel between 2013 and 2019. Medical record review was conducted from January 2019 to April 2022 and data analysis from October 2022 to February 2023.

Main Outcomes and Measure

Severe ASEs during the patient encounter (eg, failure to give an indicated medication, 10-fold medication overdose).

Results

A total of 1019 encounters of EMS-treated pediatric OHCA were evaluated; 465 patients (46%) were younger than 12 months. At least 1 severe ASE occurred in 610 patients (60%), and 310 patients (30%) had 2 or more. Neonates had the highest frequency of ASEs. The most common severe ASEs involved epinephrine administration (332 [30%]), vascular access (212 [19%]), and ventilation (160 [14%]). In multivariable logistic regression, the only factor associated with severe ASEs was young age. Neonates with birth-related and non-birth-related OHCA had greater odds of a severe ASE compared with adolescents (birth-related: odds ratio [OR], 7.0; 95% CI, 3.1-16.1; non-birth-related: OR, 3.4; 95% CI, 1.2-9.6).

Conclusions and Relevance

In this large geographically diverse cohort of children with EMS-treated OHCA, 60% of all patients experienced at least 1 severe ASE. The odds of a severe ASE were higher for neonates than adolescents and even higher when the cardiac arrest was birth related. Given the national increase in out-of-hospital births and ongoing poor outcomes of OHCA in young children, these findings represent an urgent call to action to improve care delivery and training for this population.

Emergency Medical Services Management of Bronchospasm in the United States: A Cross-Sectional Analysis and Nationwide Quality Assessment

Background/Objective: Bronchospasm, caused by asthma and other related conditions, is a significant cause of morbidity and mortality commonly managed by emergency medical services (EMS). We aimed to evaluate the quality of prehospital management of bronchospasm by EMS in the US.Methods: The National EMS Information System Public Release Research dataset, a nationwide convenience sample of prehospital patient care report data from 2018 to 2019, was used to capture 9-1-1 activations where patients aged ≥2 years were treated and transported by EMS for suspected bronchospasm. First, we described the extent to which EMS care met eight quality measures identified from available statewide EMS protocols, existing quality measures, and national guidelines. Second, we quantified the extent of risk-standardized agency-level variation in administration of inhaled beta agonists and systemic corticosteroids using logistic regression models, accounting for patient characteristics, severity, and clustering by agencies. Third, we compared rates of completed prehospital interventions between pediatric (age <18 years) versus adult patients using two-sample t-tests.Results: A total of 1,336,988 EMS encounters for suspected bronchospasm met inclusion criteria. Median age of patients was 66 years, with only 4% pediatric; 55% were female. Advanced life support (ALS) units managed 94% of suspected bronchospasm. Respiratory rate (98%) and pulse oximetry (96%) were documented in nearly all cases. Supplemental oxygen was administered to hypoxic patients by 65% of basic life support (BLS) and 73% of ALS units. BLS administered inhaled beta-agonist therapy less than half the time (48%), compared to 77% by ALS. ALS administered inhaled anticholinergic therapy in 38% of cases, and systemic corticosteroids in 19% of cases. Pediatric patients were significantly less likely to receive supplemental oxygen when hypoxic, inhaled beta-agonists, inhaled anticholinergics, or systemic corticosteroids.Conclusions: We found important gaps in recent EMS practice for prehospital care of suspected bronchospasm. We highlight three targets for improvement: inhaled beta-agonist administration by BLS, systemic corticosteroid administration by ALS, and increased interventions for pediatric patients. These findings indicate important areas for research, protocol modification, and quality improvement efforts to improve EMS management of bronchospasm.