Came across this great post on Academic Life in Emergency Medicine from Drs. Delhine Huang and Sony Tat recently that was too good not to share here as well. I’ve always been slightly vexed by stress dose steroids in the ED. Here are some take home points followed by the embedded video.
Who needs them?
Any patient on chronic steroids, Addison’s disease, or something wrong with their hypothalamic/pituitary axis and are sick. Recall that the daily “physiologic” dose of hydrocortisone is hydrocortisone is 6-12 mg/m2/day. Many children will be on chronic daily steroids – commonly prednisone and hydrocortisone. In general 5mg of prednisone is roughly equivalent to 20mg of hydrocortisone. For trivia’s sake 0.75mg of dexamethasone equals 5mg of prednisone.
How much do I give?
I really like the simplified version from ALiEM – they call it the “coin method”
- For small-sized kids (neonates to 3 years old), give 25 mg IV/IM (or think of a quarter)
- For medium-sized kids (3-12 years old), give 50 mg IV/IM (or think of a half-dollar)
- For large-sized kids (12+ years old), give 100 mg IV/IM (or think of a dollar coin)
How do I calculate the body surface area on a sick child?
Use an online calculator, ask the parent for height, or just estimate – remember you are giving steroids to prevent/treat adrenal crisis in the face of a serious illness. Plus, this is #Merica so MOAR IS BETTER! No one will fault you for giving a higher single dose of a steroid for a child in crisis. More precise adjustments can be made after initial stabilization.
As a parent of a child with Addison’s disease, I’m glad you shared this. I haven’t heard of the coin method for stress dosing. My daughter is sixteen and her emergency Solu-Cortef vial is 250 mg. Her endocrinologist said the whole vial should be given. That varies quite a bit from the standard 100mg teenage/adult stress dose.
Thank you for the comment Julia – Ultimately, the initial precision of the first dose for a sick patient is less important than remembering to give it in the first place.
Thank goodness! My greatest fear is that she won’t get what she needs in an emergency situation. It has made me very vigilant … in her eyes, overprotective. I didn’t realize there aren’t many EMS offices with emergency protocols for patients with Addison’s disease, so I’ve found that to be worrisome.