Abstracts

Rationale: Pediatric seizures are a common medical emergency, often requiring rapid assessment and treatment prior to hospital arrival. Timely administration of antiepileptic drugs (AEDs) is essential to minimize seizure duration and associated brain injury as the risk of both consequences rise with delayed treatment. Optimal pediatric drug dosing is also critical to treatment, but error rates for prehospital dosing are reported to be >30%.To assess prehospital treatment of seizures in Columbus, Ohio, we surveyed Emergency Medical Services (EMS) providers transporting children to Nationwide Children’s Hospital (NCH) Emergency Department (ED).  We also performed chart review for accuracy of weight based dosing in children who received prehospital benzodiazepines. The investigations were part of a PDSA cycle in an ongoing quality improvement project to optimize prehospital seizure treatment. Methods: This project did not require IRB approval as it is part of an ongoing Quality Improvement initiative.  We surveyed EMS providers in the NCH ED after transporting a child (age 0-18) for chief complaint of seizure. Research assistants approached EMS providers after hand off of care to request they complete a 15-question survey. Questions addressed decision making strategies for determining patient weight, calculating medication dose, and access to various tools. 115 surveys were completed between October 2016 and May 2017. We then cross-referenced patients’ medical charts to determine patient weight upon arrival to the ED and calculated prehospital benzodiazepine dosage in milligrams/kilogram. Results: There were 16 encounters where a benzodiazepine was given for active seizure upon EMS arrival or seizure lasting greater than five minutes during transport. Routes of administration included intravenous, intranasal, and intramuscular. Only 4 out of 16 patients received adequate weight-based benzodiazepine doses (Table 1). Survey answers also identified lack of standardized weight-based dosing strategies. To determine the child’s weight, 60% of paramedics asked a parent/caregiver, 10% guessed, and 5% (1 responder) used a Broselow tape. For dose calculation, 55% followed their EMS protocol, 15% followed direction from the parent/caregiver and 10% called NCH for physician support. Of all 115 survey responders, 81% had access to Broselow tape in their EMS vehicle, 91% had MAD, and 93% had midazolam available for use. Conclusions: Our data corroborates the national high percentage of errors made in prehospital pediatric drug dosing for acute seizure care. 70% of children were under dosed with benzodiazepine for first line seizure rescue treatment.Weight-based dosing inherently raises the margin for error in the pediatric population. The variation in methods for calculating accurate weight and determining weight-based dose reflected in our survey results likely contribute to error. The accuracy of existing protocols may also contribute to dosing errors among paramedics in our community. The majority of responders cited their EMS protocol for guidance. Despite evidence-based benzodiazepine dose recommendation of 0.2 mg/kg for all non-IV forms, the three protocols we reviewed had a universal dose of 0.1 mg/kg regardless of route.Optimal benzodiazepine dosing is essential in minimizing prolonged seizure and sequelae. Our findings present strong evidence that significant gaps exist in knowledge and a practice approach to prehospital treatment of prolonged or repetitive seizures.  Limitations include small sample size and potential for reporting bias in the survey information collected. Specific aims to improve accurate weight assessment and streamline dosing calculation are needed to improve outcomes. Funding: None