# Pediatric drug dosages



## COmedic17 (Mar 7, 2015)

Just wanted to share an easy method to remember pediatric drug dosages. 


Use this outline. 
1yo = 10kg
2yo = 12kg
3yo = 15kg
4yo = 17kg
5yo = 20kg
6yo = 22kg
7yo = 25kg
8yo = 27kg
9yo = 30kg

Epi 1:10,000= Move decimal 1
Amio= Move decimal 1 over
Dfib= double weight 1&2nd dose
BiCarb= The weight
Dextrose = double weight

This tells you the exact ML to push, so you don't need to waste time figuring out the dosage per kg and the dosage in each ML. 



So for example= a 3 year old. 
3yo = 15kg

Epi dose= 1.5ml
Amio= 1.5ml
DFib- 30j, then 60j
BiCarb- 15
Dextrose (d25)- 30ml


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## Flight-LP (Mar 7, 2015)

Um, no..............

Anything less than accurately dosing your medications based on the child's actual weight is completely unacceptable. This is a cool little trick to show your friends, but horrible advice to give any practitioner. Do it right the first time and every time.


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## Burritomedic1127 (Mar 7, 2015)

Always check the concentrations of the medications because they change the prefilled doses and ratios


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## COmedic17 (Mar 7, 2015)

Flight-LP said:


> Um, no..............
> 
> Anything less than accurately dosing your medications based on the child's actual weight is completely unacceptable. This is a cool little trick to show your friends, but horrible advice to give any practitioner. Do it right the first time and every time.



I'm going to assume you carry a scale and weigh all your patients....no? Oh. 

It's not a cool "trick".
I'm going to assume you go by a Braslow tape for your "accurate dosages". It would behoove you to know the epi dose is not an IV dose, but a ET tube dose. The tape has a very long list of issues. 

Also,if this "horrible advice" to give to any practitioner, I suggest you speak to Dr. Peter Antevy, a pediatric emergency physician- whom also is the CEO of Pediatric Emergency Standards. He is who created this system for figuring pediatric drug dosages. He's also medical director of Broward county FL ( a prestigious EMS system). Also, PALS is looking to implement this method into their program. Personally, I don't feel PALS would endorse it unless it held merit. 


And many EMS systems (including mine) are moving to this method. For the past handful months, it has been taught at national EMS conferences. It is also being implemented in many Emergency departments nation wide.

Studies have proven drug dosaging errors are cut down by over 30 percent then before the method was applied. And drugs are administered 5 times faster. 



So ummm...yes.


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## COmedic17 (Mar 7, 2015)

Burritomedic1127 said:


> Always check the concentrations of the medications because they change the prefilled doses and ratios


Correct. Then you adjust the equation.

Like if it's d50 as opposed to d25 you cut it in half. 

It's pretty cut and dry, thpugh.


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## CANMAN (Mar 7, 2015)

COmedic17 said:


> I'm going to assume you carry a scale and weigh all your patients....no? Oh.
> 
> It's not a cool "trick".
> I'm going to assume you go by a Braslow tape for your "accurate dosages". It would behoove you to know the epi dose is not an IV dose, but a ET tube dose. The tape has a very long list of issues.
> ...



Drugs being administered in the Peds world 5 times faster to me isn't necessarily a good thing. With the exception of say a PICU in which they normally draw up multiple doses of code meds based off patient weight to have on standby, drawing up and administering drugs 5 times faster will lead to medication errors. I can assure you in the Pediatric tertiary care facility I worked at all the medications were double checked by two providers, even in a code scenario. I don't understand what the struggle is with basic medication math. And to be honest, as someone who can do med math, looking at your system, regardless of who endorses it, will not apply to all pediatric scenarios. Concentrations vary widely in hospitals due to medication shortages or different manufacturers, as well as patient population size. The concentration for Bicarb for exam for a 3.5kg kid and a 15kg kid are going to be different.. So I do see some issues with your system. I have yet to hear any talk of this being brought into the PALS curriculum, and just recently went through an instructor update. 

End of the day if it works for you or your system thats great. I will continue to do my basic calculations and own med math. As far as a 911 setting I advocate using the tape to obtain a general weight if needed and thats it. Most of the times a parent is going to be a more accurate resource in providing an up to date weight based off the last doctor's visit anyway.


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## Flight-LP (Mar 7, 2015)

COmedic17 said:


> I'm going to assume you carry a scale and weigh all your patients....no? Oh.
> 
> It's not a cool "trick".
> I'm going to assume you go by a Braslow tape for your "accurate dosages". It would behoove you to know the epi dose is not an IV dose, but a ET tube dose. The tape has a very long list of issues.
> ...



You should never assume..........

No I do not use a BROSELOW tape, although it along with the pedi wheel, crash cards, or other reputable reference guides are significantly better than guesstimating and using false assumptions of weight based on age. Take that generalization and add it to a volume dose without any mention of concentration or consideration for fluid restriction and you have a bad outcome waiting to happen. 

Despite your poor attempt at sarcasm when it comes to weighing patients, it is actually a core necessity. This system proposes shortcuts, generalizations, and assumptions, while typical for our current state of EMS, it does not remotely promote adequate patient care. Again, we should do it right the first time and every time and stop taking shortcuts. 

I'll take your bait though, message Dr. Antevy's contact information and I'd be happy to contact him and provide feedback. 

In the meantime, please cite your reference for ILCOR recommending this exact system into the 2015 science update for AHA. When done, I'd love to see the evidence of reduction in medication errors again from this method. Speed of administration is irrelevant and not an end goal when it comes to administering medications in an efficient manner. 

Don't get all defensive and take it personally. You have your thoughts, I can have mine.


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## COmedic17 (Mar 7, 2015)

CANMAN said:


> Drugs being administered in the Peds world 5 times faster to me isn't necessarily a good thing. With the exception of say a PICU in which they normally draw up multiple doses of code meds based off patient weight to have on standby, drawing up and administering drugs 5 times faster will lead to medication errors. I can assure you in the Pediatric tertiary care facility I worked at all the medications were double checked by two providers, even in a code scenario. I don't understand what the struggle is with basic medication math. And to be honest, as someone who can do med math, looking at your system, regardless of who endorses it, will not apply to all pediatric scenarios. Concentrations vary widely in hospitals due to medication shortages or different manufacturers, as well as patient population size. The concentration for Bicarb for exam for a 3.5kg kid and a 15kg kid are going to be different.. So I do see some issues with your system. I have yet to hear any talk of this being brought into the PALS curriculum, and just recently went through an instructor update.
> 
> End of the day if it works for you or your system thats great. I will continue to do my basic calculations and own med math. As far as a 911 setting I advocate using the tape to obtain a general weight if needed and thats it. Most of the times a parent is going to be a more accurate resource in providing an up to date weight based off the last doctor's visit anyway.


Less then 50% of Pediatric cardiac arrests receive epi prior to arrival at hospitals. 
So I would venture to say meds not being pushed fast enough (if at all) is not only a problem,but a huge one. 


And yes bicarb for a 3kg of and a 15kg kid are going to be different. I feel that's common knowledge. This method also gives different dosages for each. So I'm not particularly sure how that is relevant/makes sense.


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## Flight-LP (Mar 7, 2015)

COmedic17 said:


> Less then 50% of Pediatric cardiac arrests receive epi prior to arrival at hospitals.
> So I would venture to say meds not being pushed fast enough (if at all) is not only a problem,but a huge one.



Again, cite a reputable source. Your numbers mean nothing unless substantiated by validated research and science.



COmedic17 said:


> And yes bicarb for a 3kg of and a 15kg kid are going to be different. I feel that's common knowledge. This method also gives different dosages for each. So I'm not particularly sure how that is relevant/makes sense.



Yet in your original post you cite "BiCarb = the weight". No mention of concentration (8.4% vs. 4.2%) or multiple options. Same thing for Dextrose, which by the way is moving away from a 25 - 50% concentration in favor of D10W.

I think a strong take away point is that many new medics (and seasoned ones!) come here for reliable knowledge, truths, and pointers. In my opinion as a seasoned provider and clinical lead for a PICU based urban transport team, this idea is not a sound one when it comes to advocating for patient safety and outcomes. You obviously disagree. That's fine, but unless you bring something to the table that is FACTUAL and proven, you may not get the wow factor you are looking for.

As an editorial piece, please also understand that Dr. Antevy is a Medical Dirctor in Broward County, but is NOT the medical director of BCSO EMS. Again, validation is in the attention to detail...............


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## COmedic17 (Mar 8, 2015)

"Epinephrine and atropine doses were incorrect up to 42%. Sedation and pain medication were incorrect up to 77%. succinylcholine incorrect up to 44%....56.5% of all drug dosages were incorrect.50.1% of paramedics did not administer a drug to pediatric patient. 
(www.michigan.gov/documents/mdch/Hoyle_pres_11_367667_7.pdf)

"Colorado Children’s Hospital conducted 272 pediatric simulations in a randomized cross-over trial evaluating the Handtevy Pediatric Box and found significant medication administration advantages over the current standard. Furthermore, in a post-simulation survey, the majority of participants perceived the Handtevy system as faster (91.1%), more accurate (88.2%) and preferable (91.1%). This research abstract will be presented at the 2014 NAEMSP Conference in January in Tucson, AZ."
(http://www.emsworld.com/article/11259512/pediatric-drug-dosing) 


"The Handtevy method was developed by Dr. Peter Antevy in response to the unacceptably high number of medication dosing errors; the popularity of the new method lies in using age instead of height to determine the weight of children and the proper dosage required. Antevy identified five categories of common patient ages and used an established formula to determine the average weight of children at these ages, which results in a 1 year old having an average weight of 10 kg; the scale increases by 2 year intervals and 5 kg for each category. In the final category, a 9 year old has an average weight of 30 kg using this method. The Handtevy method relies on these founding categories and simple math skills, resulting in quicker and more accurate medication dosages."
(https://www.lifesavered.com/Blog/curbing-dosaging-mistakes-in-children.aspx)


"The AHA reported 94% of pediatrics who sustain a cardiac arrest out of hospital will not survive. Why such poor outcomes? A collaborative research team lead out of Children's Hospital of Minnesota submitted new data for publication which exposes a significant gap in epinephrine administration for out of hospital cardiac arrests in the pediatric population compared to adults (31% vs 80%). "
(http://www.prweb.com/releases/2014/03/prweb11701924.htm) 

"Broeslow vs Handtevy abstract was presented at NAESMP annual meeting in January. Results: 2x more likely to make a mistake administering dextrose with Broeslow then with Handtevy." 
(http://www.emsccolorado.org/uploads/CPPQC Minutes 2-11-14.docx) 


"The 2010 Pediatric Advanced Life Support (PALS) Guidelines state that length based tapes are more accurate then age based methods in the prediction of body weight. A pediatric age and length based hybrid estimation method ( HandTevy ) has been described to significantly improve accuracy in pre-hospital compared to the Broselow system. The Handtevy preformed statistically better for underweight, normal weight, and obese children. No difference was found for overweight children. "
(http://www.pediatricemergencystandards.com/images/acep2014.pdf)



"The definition of medication error was non‐uniform across the studies. Dispensing and administering errors were the most poorly and non‐uniformly evaluated. Overall, the distributional epidemiological estimates of the relative percentages of paediatric error types were: prescribing 3–37%, dispensing 5–58%, administering 72–75%, and documentation 17–21%."
(http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2653149/#!po=0.609756)




I could go on, but If you want more info, you can search Dr. Peter Antevy, or the HandTevy system and get lots of results. 

Dr. Antevy also received the Raymond Alexander Medical Director of the year award, for the creation of the HandTevy method. (http://beforeitsnews.com/health/201...al-director-of-the-year-for-2014-2544364.html) 


We can all have our preferences, but it's a little silly to say how bad of an idea it is to tell people this method When it has been proven to provide better outcomes. I'm aware not everyone has been exposed to this, and may not be open to ideas when they have figured out their own working system, but that doesn't make every other method sub par. 
If it works, it works. And statistically, this method has worked better then people using drug calculations, or the Broeslow tape.


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## COmedic17 (Mar 8, 2015)

And I went back and added links, incase you would prefer to read directly from the sources.


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## systemet (Mar 8, 2015)

Edit: thanks for adding references!


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## COmedic17 (Mar 8, 2015)

Flight-LP said:


> No I do not use a BROSELOW tape, although it along with the pedi wheel, crash cards, or other reputable reference guides are significantly better than guesstimating and using false assumptions of weight based on age.


That's not what the studies provided.
Even your BROSELOW tape, pedi wheel, and crash cards are using false assumptions of weight, no? Your only going to have an exact weight with a scale. If you see a 2yo who looks more to be 15kg, then you go off of the 3yo/15kg base. It's really not that difficult. 



Flight-LP said:


> Again, cite a reputable source. Your numbers mean nothing unless substantiated by validated research and science.


I cited a handful. If you would like, you can do further research. 



Also, you stated you would like the Dr. Contact info. - http://www.mhs.net/physicians/physician-detail/Peter-Antevy-Md


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## Ewok Jerky (Mar 8, 2015)

In a cursory research of primary literature (as opposed to the mostly secondary literature already cited), it seams that there is an ongoing debate between length-based and age-based weight estimations.  I think the jury is still out and may always be out because our fat american children don't lend themselves to anything but a scale.

I think the larger issue with the OP's "short hand" is the fact that drug concentrations are not taken into account.  Med-math is not that difficult. Guessing the kids weight is harder than calculating the right dose.


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## COmedic17 (Mar 8, 2015)

6th cited article down. States it's more accurate, in studies, for normal weight, under weight, and obese children. 



Med math is easy, but mistakes happen. Hence the reason "all drug dosages for pediatrics are incorrect 50.1% of the time". As stated in the first cited article. 
I don't think over half of the people are incompetent and don't know how to set up a basic equation. I think in the moment if someone gets the wrong Answer they go with it- assuming their initial calculations were correct. If there's a pedi in cardiac arrest I'm sure people are rushing, and not going back to double check their calculations. Or they opt for the Broeslow tape. And a lot of providers don't feel comfortable administering drugs to peds in an emergent setting, so they dont. Hence why only 31% of peds receive epi in a pre hospital cardiac arrest as opposed to 80% of adults. Personally I'm going to use an app to plug in my approximate weight and the drug and how it's packaged, etc which takes three seconds, and is done by a calculator so I know there's no mathematical errors. However, some people don't have this option. All it takes is one mathematical error and your giving the complete wrong dose. This method has been proven to reduce that by reducing the rate of mathematical errors that would cause a significant alteration in how much of a medication is administered.

If a child is given an Epi administration meant for a 13kg patient, but is 12kg, I don't forsee that as being a huge issue- as if a child receives three times the Epi dose because the Broeslow epi dose is an ET tube dose, not an IV dose (why it's that way I have no idea. But it is. And it doesn't tell you it's sn ET tube dose either).

No system is 100% perfect ( including long handing it. Unless you have a scale for an EXACT weight and a calculator. I have never seen EMS carry a scale. If your doing IFT for a children's team, the facility has a correct weight to provide you. If your pulling a four year old out of a pond- not so much) but this system has been proven to significantly reduce pediatric drug dosing errors. 

The argument has somehow turned into "well that's not the EXACT weight so it's not the EXACT dose". Which is not the point. The point is it's very close, and provides less drug admin errors then any other system. 


And to say "you should never guess weights" is silly. Unless you are IFT and a weight was provided- we are ALL guessing weights. I have yet to come across a pt with an ID tag that says " I weight ____lbs"


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## paradoxicalmotion (Mar 8, 2015)

COmedic17 said:


> because the Broeslow epi dose is an ET tube dose, not an IV dose (why it's that way I have no idea. But it is. And it doesn't tell you it's sn ET tube dose either).



Gee whiz. I'm sure glad Dr. Antevy came along and edu-mah-cated me on pediatric dosing. I might have given some poor schmuck of a kid 10 times the appropriate dose of epinephrine because the Broselow tape doesn't make it perfectly clear which dose is for the tube.

... and if you believe that, then I have a bridge to sell you.


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## COmedic17 (Mar 8, 2015)

You really should of read the links I posted.
I think pretty much everyone is aware there's a difference between Epi 10,000,and Epi 1,000.

It's too bad no one ever edu-mah-cated you on the fact that the Broselow tapes are often printed differently. I'm glad your Broeslow tape stated " for IV, for ET tube, etc" but a lot don't. 

Some of the others state the following-

Epi 10,000= .21mg
Epi 1,000= 2.1 mg.

Or they will have a
"Epi first dose" and
"Epi high dose"

And yes, they are all BROSELOW tapes. 
So you really don't have anything to sell me. As not all "make it perfectly clear which is for the tube" as you stated.

You can research it if you want, I'm done posting links. Everyone has access to google.

But do you want to guess how many healthcare providers see the Epi 1,000 dose and aren't aware it's an ET dose as opposed to IM unless it's posted? In theory we should all see it and think "hey that's not right." But unfortunately, it frequently goes overlooked. 


I will include some additional pictures of other Broeslow  tapes for you. Feel free to google "Broselow tape" on your free time and see just how differently they are printed.


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## zzyzx (Mar 11, 2015)

An easier way to get an ESTIMATED pediatric weight is with the formula "Twice Age, Plus Eight." This is in kilograms.
Easy to remember and it works pretty well, but only as a rough estimate.


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## Carlos Danger (Mar 12, 2015)

Flight-LP said:


> Um, no..............
> 
> *Anything less than accurately dosing your medications based on the child's actual weight is completely unacceptable*. This is a cool little trick to show your friends, but horrible advice to give any practitioner. Do it right the first time and every time.



Dosing based on estimated weight is fine - assuming your estimate is reasonable, of course. There are settings where peds are routinely given many drugs without first measuring a precise weight, and the only "complications" that result is that maybe occasionally you have to give a little more of something because the initial dose didn't quite have the affect that you hoped, or maybe they wake up a little slow because they didn't need quite as much as you gave. No problem.

Dosages themselves are simply estimates of what you'll need, based on dose-response curves which are essentially just a bell curve. There are all sort of factors that can make an individual's dose requirement different from the average. 

Really, what do you think is going to happen if you give a little less or a little more than a perfectly precise, weight-based dose of something?


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## COmedic17 (Mar 12, 2015)

Remi said:


> Dosing based on estimated weight is fine - assuming your estimate is reasonable, of course. There are settings where peds are routinely given many drugs without first measuring a precise weight, and the only "complications" that result is that maybe occasionally you have to give a little more of something because the initial dose didn't quite have the affect that you hoped, or maybe they wake up a little slow because they didn't need quite as much as you gave. No problem.
> 
> Dosages themselves are simply estimates of what you'll need, based on dose-response curves which are essentially just a bell curve. There are all sort of factors that can make an individual's dose requirement different from the average.
> 
> Really, what do you think is going to happen if you give a little less or a little more than a perfectly precise, weight-based dose of something?


Thank you!!!

I understand not everyone will like or apply this method, but the constant argument in this was "its not an Estimated weight and you need an exact weight" when the reality is that unless you have a scale or your IFT and got the weight from a facility-we are ALL "estimating weight".


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## COmedic17 (Mar 13, 2015)

zzyzx said:


> An easier way to get an ESTIMATED pediatric weight is with the formula "Twice Age, Plus Eight." This is in kilograms.
> Easy to remember and it works pretty well, but only as a rough estimate.


You are aware that's what the Handtevy Method is based off a system almost identical to yours, right?if you read the first post you would of noticed the following 

Handtevy estimation= 1yo = 10kg
Your estimation = 1yo = 10kg

Handtevy estimation = 2yo = 12kg
Your estimation = 2yo = 12kg

Handtevy estimation = 3yo = 15k
Your estimation = 3yo =14kg

Handtevy estimation = 4yo = 17kg
Your estimation = 4yo = 16kg

Handtevy estimation = 5yo = 20kg
Your estimation = 5yo = 18kg

Handtevy estimation = 6yo = 22kg
Your estimation = 6yo = 20kg

Handtevy estimation = 7yo = 25kg
Your estimation = 7yo = 22kg

Handtevy estimation = 8yo = 27kg
Your estimation = 8yo = 24kg

Handtevy estimation = 9yo = 30kg
Your estimation =9yo = 26kg. 



Very similar. Now the actual weight estimation-
2yo =12kg 

4yo = 15kg

8yo = 26kg 
(Just looked up a handfuls of averages, but you can find the rest at  http://www.livestrong.com/article/328220-the-average-height-and-weight-by-age/ ) 


Both of the systems are almost identical. And based off of actual average weight. 


So I'm not sure why it's so taboo.
No one Willy-nilly made these estimations up with out research.


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## COmedic17 (Mar 13, 2015)

In addition, 
I used the drug cal ovulation method,
Broselow tape method, 
And Handtevy Method. 

And you guys can make your own opinions on the three. 


Epinephrine 1:10000 to a four year old using handtevyss method.
4yo =17 kg. 
Move decimal 
Answer- administer 1.7ml

Now I will "long hand" it as everyone is saying is the only reasonable method. 
4yo = 17kg
Dose = .01mg/kg
.01 x 17 =.17mg
Packaging for epinephrine 1:10,00 = 1mg per 10ml
So .1 mg per ML. 
So to reach designated dose of .17, you would push 1.7ML
.......same EXACT as Handtevy....... 


Now the Broselow tape- 
The average (4-5 year old falls into the white section) 
White section
EPI dose- .15
So you would push 1.5ml.

Which is so incredibly close. And supports the theory that broselow underestimates dosages.


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## DesertMedic66 (Mar 13, 2015)

Doesn't get much easier than this:


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## zzyzx (Mar 15, 2015)




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## zzyzx (Mar 15, 2015)

Yeah, neither any way of estimating pediatric weights, including the Broselow tape, would be accurate for this kid. Where we work, outside of the hospital, we can ask the parent if they are around, or we just have to estimate.

That said, have you ever wondered how they came up with recommended drug dosages for kids? For example, the recommended dose of epi for anaphylaxis. I'm quite sure that they did not do some randomized controlled trial giving peanuts to kids with nut allergies and then see what dose of epi worked the best. Rather, someone more or less guessed what might be the appropriate dose.


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## COmedic17 (Mar 16, 2015)

"I know he's ___age but looks like he weighs closer to _____kg"





So you use the weight. And base it off of that. No one said common sense wasn't allowed.


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