There are plenty of reasons for these findings.

• In stressful situations, math is hard.
• Infancy and childhood is a rapid stage of development and change. Drugs that are safe and effective in one group of kids may be ineffective or toxic in another, which makes us nervous.
• Ultimately we do not see enough pediatric patients to become familiar with the use of their drugs and dosages.

Studying drugs used in the EMS world on children is doubly difficult when there is poor data reporting. Our EMSC advisory board requested that our pharmacist take a look at the drugs Utah's EMS providers are using on kids. Consider what the data shows. Can you improve your use of these lifesaving medications?

Prehospital Medication Administration-What Do the Numbers Show?

Over the past 10 years since electronic prehospital records have been used, regular evaluations have been made on the patterns of medication administered by prehospital providers to pediatric patients. The most recent of these studies covered the period of January 2015 through March 2018 and involved 8,089 records. To be included in the study the patient had to have received at least one drug during an EMS response and instances where only IV fluids or oxygen were administered were excluded. Using these criteria, the final number of cases analyzed was 3,167. Each record was then reviewed and the data tabulated for each drug by route of administration and outcome.

Of all the data collected, outcome data is the most important since without it, there is no way to determine whether any intervention, including the administration of a drug, has improved the patient’s condition. Nearly two thirds of the patients improved while about one out of five had no improvement. Unfortunately, in 15% of the records, the only outcome listed was: “Not Applicable,” “Not Available,” “Not Known,” “Not Recorded,” “Not Reporting,” and “Null.”

The following system of drug categorization was used to group the drugs into 11 drug classes:

• Analgesics/Antipyretics-Oral: Acetaminophen, Ibuprofen

• Analgesics-IV: Fentanyl, Meperidine (Demerol), Morphine

• Antidotes: Activated Charcoal, Naloxone (Narcan)

• Antiemetics: Ondansetron (Zofran), Promethazine (Phenergan)

• Antiepileptic Agents: Lorazepam (Ativan), Midazolam (Versed)

• Antihistamines: Diphenhydramine (Benadryl), Promethazine (Phenergan)

• Antipsychotics: Haloperidol (Haldol)

• Cardiovascular Agents: Adenosine, Aspirin, Atropine, Dopamine, Epinephrine, Lidocaine, Nitroglycerin, Sodium Bicarbonate

• Glycemic Agents: Dextrose, Glucagon

• Respiratory Agents: Albuterol, Ipatropium (Atrovent)

• RSI Agents: Etomidate, Succinylcholine, Vecuronium

Time and space do not permit a detailed discussion regarding each category. However, the following observations provide a summary of the data:

• Six drugs were responsible for approximately 75% of the drug dosages:

o Morphine-22%

o Albuterol-18%

o Fentanyl-13%

o Epinephrine-8%

o Ondansetron-7%

o Midazolam-6%

• The most common route of administration was intravenous (IV), accounting for 45% of the total doses given. The next most common routes were inhalation (IN) at 9% of the time followed by oral at 7%. More than a quarter of the time, 27%, there was no route of administration documented. Intramuscular and intranasal were used about 2% of the time.
• When the outcomes for morphine and fentanyl were compared, 72% of the patients improved with fentanyl compared with 62% from morphine.
• The two antiepileptic drugs given in prehospital treatment for seizures were lorazepam (Ativan) and midazolam (Versed). Midazolam was given to 95% of the patients with an almost equal number of doses being given intravenously and intranasally.
• The antipsychotic medication, haloperidol, was given very rarely, only 11 times.
• Epinephrine was given at the rate of ten times that of any other cardiovascular agent with more doses being given by the IO route followed by IV.
• The IN route of administration can be used for midazolam, fentanyl, and naloxone but only the midazolam was consistently used. This is a fantastic and under-used route. Study up, it can become one of your most valuable tools.

The use of prehospital medications in pediatric patients is an important part of delivering care to this patient population. The drugs given and the routes used are very similar to those in a pediatric emergency room with the control of pain and treatment of breathing disorders being the most common. The intranasal route of medication administration is increasing in use as can be seen by the rise in the frequency of its use to deliver medications when no intravenous access can be found.

Future efforts to understand the use of medications in EMS in the treatment of pediatric patients will require better data, especially improved outcome data. There are also several drug categories where there is a duplication of agents which raises the question about the need for more than one drug with basically the same therapeutic action. As these issues are discussed, it will be through the collection of adequate data and a thorough analysis that improvements can be made.

Shoot an email to the address below and look for her response in our next newsletter.

tdickson@utah.gov

The Emergency Medical Services for Children Day is observed to promote the medical services available for children in the case of an emergency along with the importance and need for medical services. A survey estimated that nearly 50 percent of deaths are avoided every year because of emergency medical services in the country. It includes both psychological and physical factors. We are in need of such emergency medical service centers in the all parts of the country for the further improvement in the ratio of avoidance.

• There are an estimated 6,500 accidents involving ambulances each year.
• 35% of crashes resulted in injury or fatality to at least one occupant of a vehicle involved.
• When injuries occur, there are, on average, three unique injuries per accident.
• On average, 29 fatal ambulance accidents result in 33 fatalities each year.
• On average, 2,600 people are injured in 1,500 ambulance accidents each year.
• Of those killed in an ambulance accident, 63% were occupants of a passenger vehicle, 21% were passengers in the ambulance, 4% were ambulance drivers, and 12% were non-occupants.
• Nearly 60% of ambulance accidents occur during the course of emergency use.
• Emergency medical personnel are at a higher risk of crashing when compared with other first responders.

I know it doesn’t feel like it yet, but hot summer weather will be upon us soon. The National Child Heatstroke Prevention campaign starts May 27, 2019. There are some great resources available from the U.S. Department of Transportation Traffic Safety Marketing at this website address: https://www.trafficsafetymarketing.gov/get-materials/child-safety/heatstroke-prevention.

There are posters, logos, social media information, and infographics that can be used in various community venues. “Look before you lock” and “Be a hero! A child in a hot car needs rescuing” are just two of the slogans being used to address this preventable tragedy. The site offers English and Spanish versions.

Between 1998 and today, 798 children have died after being left in a hot vehicle and suffering heatstroke. That’s nearly 40 children every year. In 2018, there were 51 children who died from vehicular heatstroke. As a parent or guardian, there are so many distractions these days. This can happen to anyone.

Emergency Medical Services personnel have a key role in helping keep kids safe. You can share resources and tips within your communities:

• Never leave a child unattended in a car.
• Lock the vehicle when its not in use.
• Keep keys out of the reach of children.
• Put something you may need in the backseat.
• Look before you lock.
• Put a stuffed animal in your passenger seat.
• If you see something, do something and call 911.

As always, the EMS for Children program would like to thank you for your continued support and efforts to save the lives of children in Utah. You make a difference every day. We greatly appreciate all that you do. Be safe.

Jolene Whitney

jrwhitney@utah.gov

EMSC Pediatric Education for Prehospital Providers

Register online at peppsite.org. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($18.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at eandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth