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Monday, January 13, 2014

Pediatric Anaphylaxis: Medication errors by EMS

You are called for a 5-year-old child with trouble breathing. 

The mother states the child has had 1 hour of progressive respiratory distress after being stung by a bee. The initial vitals are BP 76/40, P 120, R 45, and SpO 91% on room air. The patient is sitting upright, speaking in short sentences, and has audible wheezing. The physical exam reveals hives over the chest and arms.  If you don't act in 2 minutes, your patient will decompensate. What do you do?

(By the way, this is a HIPAA-compliant picture of your patient:)

Yup, it’s a replicant, and just like Roy Batty, he was programmed to die in this EMS simulation study performed in Michigan. 

Unlike Roy Batty, however, this replicant will live if he is given epinephrine in time!

"I've seen things you people wouldn't believe...  And I need some epi!"

The authors used a high-fidelity simulation manikin, in a well-equipped simulation center, as well as the scenario described above. They allowed the EMS crews to use their own medication and equipment, but they all had to follow the state EMS protocol for pediatric anaphylaxis. 

Michigan EMS protocols
 If the crews gave the right medications and interventions, the kid got better. If not....

So what happened? 

Before I answer that, let me point out that the EMTs and medics volunteered for this study. This suggests that these folks were motivated enough to participate in research, aware they were going to observed, and fairly confidant in their knowledge and skills. In other words, probably some good, smart people.

So, it's all the more distressing what the study found.

1. Three out of 62 crews (5%) did not give epi 
For true anaphylaxis, epinephrine is the required treatment, with essentially no contraindications. 

2. Epi was often given by the wrong route. 
The protocol spelled out that epinephrine should be given IM, in line with several national and international guidelines. Despite this, only 37 out of 59 (63%) crews gave epinephrine IM. The authors were generous, and allowed SQ as an acceptable route, but this is an outdated practice. 

3. An epi dose of > 1 mg was given by 20% of crews. 
‘Nuff said about that... 

4. Epi was given intravenously by 15% of crews 
Although IV epi is listed in the protocol, even "low" doses of IV bolus epi can cause badness. With that in mind, the protocol allowed for IV epinephrine only “in cases of profound anaphylactic shock (near cardiac arrest).” 

Because the patient was initially sitting upright, speaking, and perfusing, IV epi was considered a major error.

5. Less than half of the crews gave epi by the right dose and route. 
As shown in this table:

So why did this happen?
It's hard to manage a rare medical event, using a drug that is available in multiple concentrations, and can be given by multiple routes, but must be dosed accurately by weight.

And as I said before, these were engaged and motivated EMS providers. Furthermore, the errors that they committed have been demonstrated to occur in a number of prior studies and case reports, involving a wide range of medical personnel.

In other words, you can’t respond to this study by saying “Well, our guys would never screw up like this!” Or by saying “We’ve been doing it this way for years without a problem.” This study should force all of us to reevaluate how we teach, protocolize, and practice treatment of anaphylaxis.

If you have the patience, download the author’s summary (the picture below) of the types of errors that were committed, and the rationale of the medics who committed them. Very informative!


  1. The last bit, in Table 5, is a pretty interesting look at where even with a "checklist" (of sorts) and challenge-response, you can still end up with the wrong decision.

    Not sure how much it would solve anything, but standardized tables of weights and volumes for epi may help. (Now you have the table reading failure where your eyes gloss over column/row details)

    I'm reminded of NASA's great (free) eBook "Breaking the Mishap Chain", which should be a required reading for anybody in a Human Performance job.

    1. Standardized tables are great, but I'm also concerned about the eye-glossing possibility. But perhaps the "Broselow tape for anaphylaxis" doesn't HAVE to have a dose for every 5-kg breakpoint. After all, the Epi-Pen Jr already covers a good swath of pediatric patients, and the adult pen covers 30 kg and up. Really, we just figure what to do with the sub-15 kg kids.

  2. Interesting study.
    Regarding point 1, I think we are not doing a good enough job of defining when a person actually has anaphylaxis. My son's allergist defines anaphylaxis as any reaction that involves two or more body systems. That is a much lower threshold than is typically taught in the EMS classroom or found in our protocols. We tend to wait for hemodynamic compromise or airway issues. We also oversell the dangers of epi far too much.

    Looking at the Michigan protocol, it seems like the dose for IV epi is kind of high. The article you linked to also had a fairly high dose. The patient is hypotensive due to anaphylaxis so wouldn't an epi infusion at a rate of 1-10 mcg/min also be safe and effective?

    1. Your points about the high threshold in EMS to diagnose anaphylaxis, and the high degree of concern about giving epi, are well taken. These issues were also reflected in another recent EMS study on anaphylaxis - see my review at

      In one of the few prospective anaphylaxis trials, an epi infusion at 2-20 mcg/minute was safe and very effective in adults. There is no similar trial involving children, but the PALS dose is 0.1 to 1 mcg/kg/min for hypotension.


  3. I am somewhat dumbfounded by this study... Hard to imagine. This is not really a complex disease process or protocol.

    Ironic that an EMT will not make any dose/route errors by administering an EpiPen Jr., but ALS makes all sorts of errors attempting to administer the same medication for the same complaint?? That is some bad mojo right there!

    1. It's not just EMT-B versus medic. Many people think that the pre-filled syringes (e.g. EpiPen) should be used in the hospital by MDs and RNs, since errors with dosing and route continue to occur.

  4. Later in my active career I became a firm advocate for use of the Epi Pen and Epi Pen Jr by all pre hospital providers regardless of level. One of my partners lead me to this epiphany by not only using them himself, but by overseeing BLS personnel while they administered them under his supervision.

    He did that based on his observation that many BLS personnel were very reluctant to use Epi Pens on even very ill patients. He attributed that to poor training and a lack of expectation by management that Epi Pens would be used.

    He also reasoned that in cases of true anaphylaxis time was of the essence, so wasting time drawing up the proper dose from those little glass vials was potentially injurious to the patient.

    Eventually our agency and then the state adopted his practice. Not that they followed his example, but eventually they drew the same conclusions that he had drawn five years earlier.

    1. You've mentioned this before. Frankly, I can't think of a practice that works so well, on so many levels.

      Not only were you encouraging ALS to use the "BLS" treatment modality (which may be the optimal method, regardless of the color of your patch), but you used these calls to reinforce the expectation that BLS could handle these patients competently by themselves.

      Working to change the medical culture of both BLS and ALS is the goal of a true idealist, despite your cynical nom de plume!

  5. I recently got shot down with my suggestion that we switch over to Epi Pens in my medium volume ED that only sees maybe two true cases of anaphylaxis a year, but I think I'll give it another go with this study in-hand. We're well within the shelf-life for keeping two in the Pyxis until at least one gets used and the cost of an anaphylaxis disaster would well outweigh the price of premium for branded autoinjectors for the life of our newly built department. Wonderful review Brooks, thanks for doing this.