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!"

Medication Errors in Prehospital Management of Simulated Pediatric Anaphylaxis.

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 The authors were generous, and allowed SQ as an acceptable route, but this is an outdated practice. 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!

The Cardiac Save Pin

I’ll admit, I don’t understand why the stork pin is so popular. 

The mother is doing all the pushing and tearing, while the medic or EMT isn’t really doing any work besides not dropping the newborn. That’s not really an advanced medical skill, you have to admit.

"Good job holding a human off the floor!"

Our new “Cardiac Save” lapel pin, on the other hand, recognizes the judgement that medics use in identifying a STEMI, and then communicating effectively with the ED and cardiology. These skills aren’t as dramatic as, say, sinking an ET tube or needle decompression, but they are arguably far more important.

And they're made in New England! (site)

I wanted to illustrate this with a few recent STEMI cases. Basically, I just want to brag about EMS in Bridgeport!

Case #1 - Not an obvious STEMI

See what you think about the ECG. Older female, late at night, chest pain:

Kind of a tough one, since the RBBB mucks up the QRS. Unlike LBBB, however, the ST segments should be basically normal in RBBB. The paramedic, Gordon MacCalla, from VEMS, also thought this was a STEMI, despite the fact that the computer took a little longer coming to that conclusion than he had. 

Once in the ED, this ECG had the cardiology fellow scratching their chin, but the interventional cardiologist only needed about 0.25 seconds to verify the STEMI before heading to the cath lab with the patient. Since this all happened late at night, the cath team needed to be called in from home, so Gordon's prehospital activation saved plenty of time and myocardium!

Case #2 - Bypassing the ED

It’s not always possible for EMS to go directly to the cath lab, since the cardiac team may not have assembled by the time EMS gets to the hospital (as in case #1). Case #2 was the first time where the timing worked out, and paramedic Erin Smith, of Stratford EMS, got to skip the ED.

This middle-aged gentleman was actually hypotensive when EMS arrived. He complained of chest discomfort, and the first ECG showed:

Not subtle. Yeah, it was the RCA. By calling this in from the field and skipping the ED, medic Smith helped save this guy some heart muscle. The patient did well, spending less time admitted to the hospital than do most women after childbirth!

Case #3 - STEMI and cardiac arrest

Paramedic David Rodriguez of AMR had his hands full on this call! A not-old male had some chest discomfort, and called EMS instead of waiting it out. Good move.

Dave obtained the first ECG:

Nasty ST segment elevations in the anterior leads, eh?

That was bad enough, but then the patient went into VF! Fortunately, the time to first shock was minimal, since they were in the back of the ambulance at that point, with the defibrillator an arms-length away. After just one 200 joule shock* the patient was back in NSR, with a pretty brisk return to consciousness. At the hospital, he went immediately to the cath lab, where a proximal LAD lesion was opened.

This case is a good reminder - always think of STEMI with a cardiac arrest! Once you get a pulse and a blood pressure back, do an ECG if it hasn’t already been done.

Case #4 - Fantastic Door-to-Balloon times

Sorry, no ECG, but in a way that’s a good thing. Let me explain…

Paramedic Dane Johansson from Stratford EMS responded to a call for a middle-aged male with chest pain. On-scene he quickly performed an ECG, found a large anterior STEMI, and immediately called for a cath lab activation.

Despite a brief stop in the ED (again, EMS beat the cath lab team!), the door to balloon time was a stunning 36 minutes. That’s incredible - the national goal is 90 minutes, so Dane beat that by almost 2/3s!

So why is the "missing" ECG a good thing? Well, no hospital ECG exists because nobody needed one - all the cardiologist needed was the EMS ECG. The patient was discharged from the hospital before I could copy the EMS ECG, so we just have the “after” ECGs stored in our system!

The Bottom Line
Earn a Cardiac Save pin yourself! All you have to do is follow the the SHCGB guidelines for a prehospital AMI alert.

* Sorry Barry! It's just that shock has fewer syllables!