Epinephrine Dosing by Emergency Medicine Residents During a Simulated Prehospital Pediatric Cardiac Arrest.
AEM Education and Training · 2025-07-23 · Observational study
Abstract
BACKGROUND: Pediatric prehospital dosing errors occur at high rates, up to 60% for epinephrine. Senior emergency medicine residents (EMR) in the Western Michigan University Homer Stryker MD School of Medicine (WMed) residency respond as EMS physicians to cardiac arrests in Kalamazoo County. We sought to determine error rates for weight estimation, epinephrine doses, dose administration mechanics, and esophageal intubation (EI) recognition by EMRs at the end of the PGY-1 year, during EMS physician training summative testing. METHODS: Sixteen PGY-1 EMRs were observed during a simulation: 5-year-old with an EMS EI in asystole requiring multiple epinephrine administrations by the EMR. All EMRs had completed Pediatric Advanced Life Support (PALS). Two observers scored performance. Scenarios were recorded. Recordings and scores were reviewed and discussed by observers. Any disagreements were resolved by consensus. Dosing error was defined as > 20% difference from the correct dose. RESULTS: All EMRs obtained correct weight with 15 (94%; 72.0%, 99.0%) using length-based tape (LBT) and one (6%) guessing. Four near-miss errors occurred with the LBT. Four (25%) and two (12.5%) of the first and second epinephrine doses, respectively, were incorrect. Five (50%) errors occurred using graduations on the preloaded syringe, and five (50%) were due to air bubbles in the administration syringe. There were no ten-fold errors. Three (19%) EMRs took 3 attempts to assemble the preloaded syringe, six (38%) did not screw the preloaded syringe together correctly, seven (44%) had difficulty attaching a stopcock to the preloaded syringe, and 14 (88%) did not prime the stopcock. One (6%) failed to recognize EI. CONCLUSIONS: PALS-certified PGY-1 EMRs, accurately estimated patient weight, had a high rate of epinephrine dosing errors and frequent difficulty assembling preloaded syringes. To address these errors, training will be developed that includes a checklist, LBT use, weight determination hierarchy, assembling epinephrine preloaded syringes, techniques for appropriate dose administration, and recognition of EI.
Abstract © the authors or publisher, via PubMed. Reuse and removal
Tags
Adrenaline · Cardiovascular drugs · Children · Endotracheal intubation · Prehospital physicians
Related articles
- The CPR outcomes of online medical video instruction versus on-scene medical instruction using simulated cardiac arrest stations. (BMC Emerg Med, 2016)
- Sequence of advanced airway management and epinephrine administration for paediatric patients with non-shockable out-of-hospital cardiac arrest. (Emerg Med J, 2026)
- Evaluating pediatric advanced life support in emergency medical services with a performance and safety scoring tool. (Am J Emerg Med, 2021)
- Safety events in pediatric out-of-hospital cardiac arrest. (Am J Emerg Med, 2018)
- No small matter: pediatric resuscitation. (Curr Opin Crit Care, 2017)
- The International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: pediatric basic and advanced life support. (Pediatrics, 2006)