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
Specializes in ER/Nuero/PHN/LTC/Skilled/Alzheimer's.
Um, it doesn't sound to me like the triage nurse had anything to do with it. Our standing protocol for vomitting states that for peds vomitting, IV may be started and labs sent, but any boluses or meds are up to provider discretion. In my ER when we triage, with children or any patient, we can talk to the doc and tell them what we see and ask to start boluses, but that order is still up to the doc. The triage nurse may have recognized the bad signs and talked to the doc or nurse assigned to the patient but if no order was given we can't just start medicating at our own will (scope of practice and all). I only know of one doc that I work with that might not have started the bolus until he had seen the patient, but without looking at the chart and seeing the presenting symptoms, orders, and nurses' notes I can't really say for sure who would be to blame if anyone would be at all. Usually for little guys we give ODT Zofran to kids for vomitting. They don't have to chew it, less sedating side effects, and generally kids seem to respond to it better. However, at my hospital, the admin has restricted phenergan use IV because of some incidences where someone didn't push the drug correctly or didn't dilute it or didin't verify that a site hadn't infiltrated and one or tow pts' ended up with tissue damage from the phenergan. Our max dose is 12.5mg IV diluted in 5-10 cc NS given over 5 minutes. I'd rather give ZOfran any day.
But any time a child dies, we all want to know why. It seems so senseless to lose a child. Older people, well, they've lived and had families, memories, that sort of thing, but with any child death I think it is human nature to want to rationalize, understand, even blame our way through it. My heart goes out to that family.
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
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:
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.
I'm going to post again on Monday, but in school they are teaching us that you never give Phenergan to a child under the age of 2 right now and for the life of me, I can't remember what drug they are saying is better...works like Phenergan but minus the sedative effect.
I research and get back :)
My condolences to the family...you never take your kid to the ER for something like vomiting and expect to go home minus one child.
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
haven't ever given Phenergan suppository to a child. What a horrible experience. No IV? Vomiting blood, no exam?? There are worse things going on here... IMHO.
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.
I think the Phenergan is not the first issue, but the fluid issue is paramount. There has to be more to the story - perhaps this child was sicker longer and the mom brought the child in too late.... there are pieces missing here that would have to be known to get a clear picture....
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.
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.
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.
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.
So it sounds like the Triage nurse is at fault for not recognizing that the child should have been bolused quickly and been evaluated more quickly. Very sad, very scary. I'm so sorry for the pain and sadness and I hope they will take legal action because this was a preventable death and calling attention to it will help prevent similar events in the future, I hope.
lupin
153 Posts
Um, it doesn't sound to me like the triage nurse had anything to do with it. Our standing protocol for vomitting states that for peds vomitting, IV may be started and labs sent, but any boluses or meds are up to provider discretion. In my ER when we triage, with children or any patient, we can talk to the doc and tell them what we see and ask to start boluses, but that order is still up to the doc. The triage nurse may have recognized the bad signs and talked to the doc or nurse assigned to the patient but if no order was given we can't just start medicating at our own will (scope of practice and all). I only know of one doc that I work with that might not have started the bolus until he had seen the patient, but without looking at the chart and seeing the presenting symptoms, orders, and nurses' notes I can't really say for sure who would be to blame if anyone would be at all. Usually for little guys we give ODT Zofran to kids for vomitting. They don't have to chew it, less sedating side effects, and generally kids seem to respond to it better. However, at my hospital, the admin has restricted phenergan use IV because of some incidences where someone didn't push the drug correctly or didn't dilute it or didin't verify that a site hadn't infiltrated and one or tow pts' ended up with tissue damage from the phenergan. Our max dose is 12.5mg IV diluted in 5-10 cc NS given over 5 minutes. I'd rather give ZOfran any day.
But any time a child dies, we all want to know why. It seems so senseless to lose a child. Older people, well, they've lived and had families, memories, that sort of thing, but with any child death I think it is human nature to want to rationalize, understand, even blame our way through it. My heart goes out to that family.