Drug Dilution

for EMS providers

By Daniel Lambert & Bethany Rajotte

Maine Medical Center Pharmacy

Portland, Maine
 The Drug Concentration Dilemma
• In EMS, patients are commonly 100 kg
It is also not uncommon to treat a 10 kg patient

• Many drugs are dosed as mg/kg and that dose is

the same for adults & children

• A 10 kg child often requires 1/10 the dose needed

by a 100 kg adult.

• For example, a drug dose that is 5ml in an adult

would be 0.5 ml in a child, no problem to measure
Drug Concentration Dilemma, Continued,
• A 0.5 ml dose in a 100 kg adult becomes a 0.05 ml
dose in a 10 kg child and that’s a problem. You
can’t measure 0.05 ml with a TB syringe in a
rescue.
• It’s impractical to carry two strengths of drugs in
an ambulance, so, in some cases, drugs must be
diluted
• The most practical dilution is the 1:10 dilution
For example, a 10 mg/ml adult concentration
becomes 1 mg/ml more suited for children
• Fortunately, 1:10 is suitable almost all the time
 A Practical Example
The Maine Midazolam quandary

• 5 mg vials of Midazolam are available as 5

mg/1ml or 5 mg/5 ml (1 mg/ml)

• The Maine EMS protocol calls for a 10 mg

intranasal Midazolam dose

• The 5 mg/1 ml strength is requires

1ml in each nostril. The 5 mg/5 ml
strength is requires a teaspoonful
in each nostril.
 A Practical Example, Continued
• The Maine EMS protocol also calls for a 0.02 mg/kg
IV Midazolam dose in a child.
• For a 5 kg child, that is
0.02 mg/kg x 5 kg = 0.1 mg dose
• If the 5 mg/ml concentration is used, draw up:
0.1 mg dose divided by 5 mg/ml = 0.02 ml
• If a 0.5 mg/ml dilution is used, draw up
0.1 mg dose divided by 0.5 mg/ml = 0.2 ml dose !!
 A Practical Solution
• In the preceding example, a 5 mg/1ml
concentration is necessary for adult intranasal
dosing.
• It is difficult and confusing to stock more than
one strength of a controlled drug on an
ambulance
• A 1:10 dilution provides a practical volume for
an IV dose in a TB syringe for a very small child
5kg x0.02
mg/kg div
5mg/ml
div10/1= dose
 Yet another example…
• A 5 kg child has swallowed his father’s Dilaudid
tablets…
• To treat the child, Naloxone must be administered
• Naloxone comes 1 mg/ml in the drug box
• The standard dose is 0.01 mg/kg for pediatric
patients
• For the 5 kg child,
0.01 mg/kg x 5 kg = 0.05 mg
 Naloxone cont…
• Using the naloxone in the drug box, the 0.05 mg
dose is:
0.05 mg divided by 1 mg/kg = 0.05 ml
• Its tough to accurately measure and administer a
0.05 ml dose in the back of a moving truck
• If 1 ml of the 1 mg/ml naloxone is diluted to 10
ml, the concentration becomes 0.1 mg/ml
• The 0.05 mg dose in this example becomes:
0.05 mg divided by 0.1 mg/ml = 0.5 ml
• That’s more like it, we can measure ½ cc
 How to do it with available
equipment & time
• Even simple skills have a few
wrinkles

• Especially when they

combine math and a very sick
child

• The following procedure

makes this a simple process
with available equipment
 A few simple steps
The following steps suggest a simple procedure with
available equipment

• The diluent can be a vial of saline or more

probably IV fluid

• A 10ml syringe and needle are the tools

• The following offers examples using a diluent vial

or direct access to an IV bag
 Can use just 4 items
Equipment if using vial
of diluent
• Diluent vial
• Drug to be diluted
• Syringe 10ml
• Needle
 First step is to draw up 9ml diluent

The simple method is

• put a needle on a
syringe
• draw from diluent vial
• either Sodium Chloride
0.9% or sterile water is
OK for Maine EMS
drugs
 Or, draw up diluent from an IV bag
• the other simple
method is to use a
needle and draw
directly from the bag
• D5W, NaCl 0.9% or
Lactated Ringers is
OK
 Add 1ml Drug

•Withdraw 1ml from the drug vial

or ampoule into the syringe
containing 9 ml of diluent
•This is a 1:10 dilution
•For example, if you have a vial
of Midazolam 5 mg/1 ml, you
now have a syringe of Midazolam
5 mg/10 ml or 0.5 mg/1ml
 Transfer drug to final syringe
• The last step is to transfer drug
to a syringe that can measure the Needle
Needle into
into the
the
dose. TB
TB syringe
syringe (left)
(left)

• You do this by placing a needle

on the syringe with the 1:10
dilution and inserting it into the
final syringe
• Be sure to transfer excess drug
so you can adjust volume to
exact dose
 Final step
• Making the dilution in a 10 ml syringe should
leave you with dilution for multiple doses

• This is one case where you carefully recap the

syringe. Its OK, it is a sterile product.

• Write the drug and concentration on a piece of

tape and LABEL THE SYRINGE.
 Practical Exercise
• Cyanocobalamin is available as a
1000mcg/ml Bright red solution.

• The dose to give is 1mcg/1ml

• Prepare the 1000x dilution

 Step 1
• Draw up 9ml diluent into 10ml syringe
• Draw up 1ml cyanocobalamin into same
syringe.
• Label B12 100 mcg/ml
 Step 2
• Draw up 9ml diluent into 10ml syringe
• Add 1ml of the 100mcg/ml dilution
• Label B12 10mcg/ml
 Step 3
• Draw up 9ml diluent into a 10ml syringe
• Add 1ml of the 10mcg/ml dilution
• Label B12 1mcg/ml
 Step 4
• Transfer 1ml of the 1mcg/ml dilution into a
TB syringe.
• Label B12 1mcg/ml
• Lay out the syringes in order on the table
and have the instructor check your work