Phenergan Supp given to toddler; child dies

  1. 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
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    About Mom23

    Joined: Sep '04; Posts: 3

    61 Comments

  3. by   missmercy
    Our pedi unit frequently gave phenergan --both supp and po -- (supp most frequently). Rarely more than 12.5 dose and I can't recal giving to any little ones under two. That doesn't mean that it never happened, but I can't recall any instances when we had trouble r/t phenergan --

    Just another reason that ER staff should have solid pedi knowledge base in addition to all the other stuff they need to know!!! Dosages, drip rates, assessment parameters, etc. are often so vastly different from adult standards!!! Pedi patients are NOT just little adults -- their little systems are in constant states of grwoth and change -- so delicately balanced!

    My heart goes out to you and your friend! It is sad when any patient dies in that kind of situation -- but truly terrible when a child dies! May God comfort and sustain you and your friend in this time of loss!
  4. by   LaNorteBellaRN
    Well there are some other questions that come to my mind when I read your post.

    How long had the child been vomiting? To what degree was this child dehydrated? Indicators such as sunken eyes, dry mucous membranes and last void would be indicative of that. I worked in the ER for many years. We saw kids all the time with GI bugs, vomiting and very often would give them phenergan supps to alleviate the symptoms. Not all children who are vomiting need a full work up, IV and admission, however, a thorough assessment has to be done to come to that decision.

    The pediatric dosing for a child with vomiting is 0.25-1 mg/kg with a max of 25mg PO/PR/IM. The biggest thing with Phenergan is that it has a sedating effect. So if the child was on any other medication that caused CNS depression or was lethargic to begin with this could pose respiratory depression issues.

    If the dosing was accurate based on the child's accurate weight (you said under two years old, how much under two?) And the accurate amount was indeed given, and the child was not on any other meds that are contraindicated or was not allergic, I would be more inclined to think that there was an underlying reason for the child's death. I wouldn't think the Epi is an issue at all since I assume they only gave that onces the childed coded.

    More things I would ask are:

    Was the child lethargic?
    Fever?
    Did the child arrest in the ER?
    Past medical history etc...

    I have never had any problems with phenergan in pediatric patients.

    My heart goes out to your friend. How devastating it must be to lose a child.

    Robin



    Quote from 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
  5. by   tiredfeetED
    wow...
    in the ED i work at, we tend to give phenergan PR often. With symptoms worsening as was described to you (vomiting blood?) There should be other intervention. The epi is pretty much out of the question ( The child had arrested) What I have seen in the ED with kids usually has to be extreme dehydration. I have seen kids that are lethargic turn right around with the old 20cc/kg bolus or if needed repeated... Anytime the ED that has a kid crumps it rips everyone apart. There is so much more info needed.
    my heartaches for the family....
  6. by   Mom23
    This toddler came into the ER at approx. 1630, with vomiting since o600. Was lethargic and dehydrated. How is triaging handled in the ER? Why would they withold IV fluids for so long? Heplock started at 1830 but no fluids? Doesn't this sound negligent from the beginning with no complete assessment? The questions about the phenergan are just one issue in this case.
  7. by   TraumaInTheSlot
    Quote from Mom23
    This toddler came into the ER at approx. 1630, with vomiting since o600. Was lethargic and dehydrated. How is triaging handled in the ER? Why would they withold IV fluids for so long? Heplock started at 1830 but no fluids? Doesn't this sound negligent from the beginning with no complete assessment? The questions about the phenergan are just one issue in this case.
    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.
  8. by   Mom23
    Thanks! I'll pass it on.





    Quote from TraumaInTheSlot
    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.
  9. by   thanatos
    First of all, I am extremely sorry for your friend's loss.

    A few things regarding phenergan and peds:

    1) We used to give it all the time to kids under 2. We would even cut a 12.5 in half (not the best practice because the medication is not equally distributed throughout the suppository).

    2) I thought it strange that my child's pediatrician would not prescribe phenergan for n/v because she was < 2 years old. Yet we gave it all time in the ER.

    3) We now have a policy in the hospital that Phenergan is not to be given to toddlers younger than 2. By the way, I never saw a negative outcome from it. The worst case I saw was a ~ 9 y.o. who experienced some dyskinthesia.

    4) Here is the link to the pharmaceutical label stating that Phenergan is CONTRAINDICATED in children younger than 2:

    http://www.wyeth.com/content/ShowLabeling.asp?id=127

    5) What is the purpose in starting a hep lock on a dry kid? That part makes absolutely no sense. If you are going to go to the trouble to start a line, you might as well give a 20ml/kg bolus and see how the kid responds.

    6) As far as the suppository being a 50mg one, our Phenergan supp's are all the same size. They are different colors (I think).

    Again, my condolences.
    Last edit by thanatos on Sep 25, '04
  10. by   TraumaInTheSlot
    regarding the cutting of the supp, the supp is supposed to be cut lengthwise, from the point of "the bullet" down. if you cut them in half, the medicine isnt even. i hope this makes sense.
  11. by   Gompers
    Quote from TraumaInTheSlot
    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.
    Yep, yep, yep. When learning the emergency care of children, that is one of the things they drill into your head. Kid's vital signs can be completely normal for a very long time as their bodies compensate for things like hypovolemia. Then they get to a point where they can't compensate anymore...and they just crash. So I agree, any child that has been vomiting that much (to the point of vomiting blood) and had a heplock already in place should have gotten some IV fluids. A bolus, a running line, something, anything. Dehydration is deadly in children, and the smaller they are, the harder it can hit them. This stands out to me much more than the phenergan suppository.
  12. by   RNin92
    Quote from Gompers
    Yep, yep, yep. When learning the emergency care of children, that is one of the things they drill into your head. Kid's vital signs can be completely normal for a very long time as their bodies compensate for things like hypovolemia. Then they get to a point where they can't compensate anymore...and they just crash. So I agree, any child that has been vomiting that much (to the point of vomiting blood) and had a heplock already in place should have gotten some IV fluids. A bolus, a running line, something, anything. Dehydration is deadly in children, and the smaller they are, the harder it can hit them. This stands out to me much more than the phenergan suppository.
    I agree. By the time kids crash...it is far too late for intervention.

    I am so sorry for our friends loss.
    I cannot even make myself go there.
  13. by   thanatos
    Quote from TraumaInTheSlot
    regarding the cutting of the supp, the supp is supposed to be cut lengthwise, from the point of "the bullet" down. if you cut them in half, the medicine isnt even. i hope this makes sense.
    My point is that suppositories are not designed to be cut. There is no 'score' to delineate equate amounts of med and to facilitate breakage into two equal pieces. I have found it very difficult to cut a cold suppository lengthwise (the correct way, I agree) and end up with two perfect halves. Probably that not big a deal, but it is not best practice.
  14. by   hotrodrn
    Quote from TraumaInTheSlot
    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.

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