Phenergan Supp given to toddler; child dies

[Mom23]

I WAS an RN in NICU (taking some time off to raise a family). I am unfamiliar with Phenergan. Obviously we did not use it in my area.

I have a very tragic situation....A very good friend of mine brought her toddler to our local ER for vomitting and dehydration from viral Gastroenteritis. The child was under two and small for her age (9.5 kg). After waiting more than two hours with symptoms worsening (vomitting blood), her child was given a Phenergan suppository 12.5. No IV was given. No exam was performed. My friend think it was actually the 50 dose based on the color of the packaging and size of the supp. Later, when her daughter coded, the child was given Epinephrine (excessive dose). I have been able to find out that Epi contraindicates with the Phenergan (Lippincott). Her child died. She had me look over the records and the Phenergan stuck out.

What has been your experience with Phenergan supp in pediatric patients? Thanks for your input.....Mom23

[hotrodrn]

Children tend to show signs of decompensating hypovolemic shock later than adults, when they go "off the deep end". Pals teaches you to prevent the arrest. it doesnt hurt to give the child a bolus or even two.

any child with vomiting should be given IV fluids, or a PO challenge with pedialyte. it sounds to me like this child got lost in the shuffle. either that, or they gave the kid the wrong sized supp, maybe a 50.

my sincerest condolences to you and your friend.

Kids actually show improvement before they decompensate and crump.

The kid probabley couldnt have holded the pedialyte down if you gave him/her a challenge with it anyway.

Our protocol for my hospital is As Follows:

IV/500ML/NS or/LR maybe D5 depending on the doc.

Check labs for electrolyte defiecensies.

Abd. Work up/x-rays/ct/ultrasound to rule out a hot appy.

We use one of the follwing for an Anti-Emetic and generally give it IV push,

we use to give IV phenegran tell we found out it necrosis veins and causes phlebitis. And an IM of it stings like crazy.

These are the anti-emetics we usually give-

Composine/Reglan/Vistaril/Anzemet/ and sometimes Benedryl works as a good one.

Comfort measures.

Try to get them to suck on Ice Chips.

If they are vomiting blood one of our physicians usually has us drop an NG and Lavage with cool saline just to make sure that they arent bleeding internally.

[needsmore$]

agree with the other posters-if child was dehydrated and no intervention was given w/ ivf boluses, that would lead to shock, then eventually cardiopulmonary failure and death. this is why any ed nurse who cares for pediatric patients be certified in at least pediatric advanced life support, maybe apls and/or enpc. someone did not provide the standard of care with this patiet in that regards. also, suppositories should not be cut in half- again because the medicine is put into a gel and you have no way of knowing how it is distributed in the suppository.

anne

[jannecdote]

My 10 month old grandson went in to the ER with N&V, and was diagnosed with gastroenteritis. Got very lethargic after we finally got him back to a room. After reading these posts, it makes me realize how lucky we were that they started fluids on him right away and gave him a Phenergan supp. about an hour later with no ill affects.

This is such a devastating situation for your friend. My heart goes out to her. The loss of a child is overwhelming, to say the least.

[tridil2000, MSN, RN]

even if there was an error in the dosage of phenergan, whether it was the order itself, or the nurse's error, i truly believe this child's demise was a result of lack of fluids. dehydration kills children. they simply can not handle a lot of volume loss bc of their size. the child should have received iv fluids promptly and before any other intervention.

it is the pals standard of care.

my sympathy to you, your friend and her family.

trish

pals cert

[cadillac05]

This thread is an example of how much I appreciate the information/expertise shared that enhances my knowledge base in areas not readily familiar to me as an OR nurse.

[OriginalWmn]

In all of the facilities where I've worked we never give phenergan with suspected gastroenteritis. We don't give anything to stop diarrhea if they have that either. We make the childe NPO, start an IV to give a bolus and then start maintanence fluids. Then maybe we start attempting po with pedialyte, if they continue to vomit then we make them NPO again and maybe try later. I'm talking with the toddler age set. I work peds floor so maybe in ER with kids that are not as dehydrated as the ones that get admitted to the floor they try this so they can send them home.

I've understood that with Gastroenteritis we just do supportive care until the virus (most likely cause) runs its course and the body's way of getting rid of it is vomiting and pooping it out. If stool cultures come back with something like salmonella or if it is suspected antibx are started too.

[NYCRN16]

I am so sorry about your loss, my heart breaks for your friend.

A comment to all other posters: What great info you all have given! I rarely float to Peds ER, and when I am over there I am scared as hell! I always double and triple check any meds that I am giving to any child because I am not a peds nurse, and I am not familiar. I will check the order against my drug book, and confirm with the attending that this is what he/she wants given.

[poor.er.doc]

I was taught in residency never to give phenergan to a child less than 3.

I believe there are valid reasons:

1. It makes the child too dorwsy to orally rehydrate/maintain hydration...

2. How can you tell if the child is lethargic if they are drugged from phenergan?

This is why I order so much fluids on vomiting children despite the eeevil glares I occasionally get from our nursing staff:p

I agree that dehydration killed this child, not the phenergan. I am terribly sorry for your friend's loss.

[newfloridaRN]

First off... The issue with medicine not being equally distributed. Our pharmacy tells us that this is an old school thought and not true at all. They say that it IS evenly distributed... well, according to our pharmacy.

Second... we almost NEVER give phenergan to little ones under 3-- we almost always give TIGAN instead. Less side effects.

[twinmom0704]

My condolences to you and your friend for the loss of a child. I had a somewhat similar experience. My toddler who was 2 1/2 was vomitting in the morning on and off for weeks and we were told by the pediatrician that it was most likely Motrin induced gastritis. I had been giving him motrin and tylenol on and off because he had been cutting molars and kept complaining that his "mouth hurts." After a few more weeks of vomiting we went back to the pediatrician and he gave my son a phenergan injection for the vomiting. He told me it would make him very drowsy for several hours. My son indeed was very drowsy all afternoon and barely woke up to get into pjs for the night and take little fluids so as not to dehydrate. I fully expected him to wake up in the middle of the night ready to go for the day. He did not. At 6:30am when his twin woke up we could not wake the other toddler. He was completely unresponsive. We called the doctors office and 911 and began CPR as he started to turn blue in our arms. He went into respiratory depression and into a coma. We also found out at the same time that he had a brain tumor as well. He went into multiple cardia arrests and respiratory arrests all day long. We took him off of life support two days after. The pediatrician at the childrens hospital was very upset that the pediatrician had given my son phenergan as she said it was contraindicated for a child that small. I realize my child had a terminal illess that we did not know about, but I do believe the respiratory arrest led to his immediate death.

I understand and can sympathize with loss of a child so unexpectedly. Its been very difficult for our family.

God Bless.

[mamalle]

WOW Im so sorry. I dont think I have ever given my kids more than 6.25mg of rectal phenergan. I hate to use it anyhow due to the sedating effect. our pediatricians office gave it to our daughter when she was 4 since they told me she was vomiting from her bilateral ear infections.(which wasnt true, along with 500mg of rocephin IM) she had the rotovirus but they blew it off. They gave her 12.mg of phenergan IM and she was 28lbs. I was pretty upset that they gave that much. we kept her in our room and constantly aroused her and tried to get her to drink. took her back at 4pm for a recheck and was told I hadnt tried to force fluids that she was too drowsy from the phenergan. they gave her water and she vomited all the way home. the next day I took her to my ER and had the pedi ER look at her and she got a IV line with fluids immediately and labwork sent off. did fine with IV fluids- her glucose level was 59 so they gave her some dextrose and she perked right up. started taking fluid challanges. Of course the office called in a panic monday morning and said her stool came back positive with the rotovirus. I said oh really? they called for 3 days straight after that to check on her...

[bjr3645]

phenergan drops blood pressure, no?

And all my condolences:(