The Evolution of Excellence in Pediatric Emergency Care—Part 1: From Notes to Wheels to Tapes
This is the first in a three-part series.
The smaller the child, the higher the stress. The sicker the child, the higher the stress. The greater the need for precision, the higher the stress. The less common the situation, the higher the stress.
It should be no surprise that for most prehospital and ER professionals, caring for little kids who are crashing or coding is about as stressful as it comes. What could be worse? Try dealing with all that stress and critical work and add math calculations and complex memorization at the same time!
Why are pediatric emergencies stressful? Most of us work with big people every day, but we’re not asked to care for sick kids very often, and really, really sick kids even less. Kids are special. Every one of us either has a kid, knows someone who has a kid, or was a kid at some point. There’s so much stress involved because kids should be cute and cuddly, not critical or crashing.
So what’s a person to do? Stress can bring out the “fight or flight” response—not a good reaction in our business. To avoid it, start with practice and preparation. Add a little planning and a few products, and you’ll be amazed at the reduction in stress and the increase in confidence you’ll have in these very difficult situations.
Tried and True
Some of our more experienced colleagues in healthcare remember the (not so) good old days, before so many of the advances we might take for granted. In those days, if you wanted to remember something, it generally involved paper in a pocket rather than icons on an iPhone.
There are still several great nonelectronic pediatric “cheat sheets” out there, and we highly recommend you find one that works for you. Put it in your pocket, hang it from a monitor or IV pole, or even chain it to your crash cart—keep it wherever it can be easily retrieved and referenced. And since our work environments are subject to the occasional liquid exposures, including blood and bodily fluids, protecting these handy helpers from the elements is an important consideration.
These old-school memory minders provide the most commonly needed critical calculations at your fingertips. And they’ll never be rendered inoperable due to a drained battery.
The Broselow Tape
The original Broselow tape was introduced in 1986 by Drs. Jim Broselow and Robert Luten. If you’ve been in healthcare for fewer than 30 years, you probably have not known pediatric emergency care without the Broselow tape and corresponding Broselow-Luten color zones.
Utilized around the world and updated regularly (as recently as June 2017 to include the release of new ILCOR/AHA PALS guidelines), this system uses an easily recognizable measurement format for “color-coding” kids and guiding us through some of the most stressful calculations and “which one?” questions encountered in pediatric emergencies.
Key points to remember when utilizing both sides of the Broselow tape:
- Always remeasure and confirm the correct color when the child arrives at the ER, just to be safe;
- “R&R”: resuscitation and rapid sequence intubation (RSI) on one side, everything else on the other;
- “E&E”: epinephrine dose on one side, endotracheal tube size on the other;
- Approximate weight listed on the bottom of each color zone as determined by length;
- Color zones have weight ranges listed from 3–36 kg. The name of the color is printed on the top for color-blind professionals;
- Measure from the head to the heels, not to the toes. When we measure height, we do it from a standing position, not a “tippy-toe” one. If the foot is abnormally flexed or extended, the inaccurate measurement could move the child to a different color zone;
- And speaking of the head: At one end of the tape is a big red arrow. Red goes toward the head, meaning this is where to start measuring from to determine the child’s color and approximate ideal body weight.
What about kids who are not at their “ideal” weight?” With the epidemic of obesity in children, this is an important consideration. But here’s the good news: Most of the emergency drugs we give to kids are based on ideal body weight, not actual weight.
There are a couple of notable, though now rarely given, exceptions (specifically amiodarone and succinylcholine) that are dosed based on actual weight. So with that in mind, the ideal body weight based on the length (height) of the child is what we are looking for when determining medication amounts. Drugs such as epinephrine, dopamine, morphine, fentanyl, and ketamine are dosed based on what the kid should ideally weigh.
And the ideal weight rule extends to other administrations as well. The Parkland formula for calculating how much fluid a child should receive after a major burn is based on ideal weight, as opposed to actual or estimated weight.
But if the kid is obviously huge, the tape has a reminder indicating there may be situations in which you might bump them up a color for medications (but not equipment) if you feel it’s appropriate and your protocols or orders allow.
What do we mean, not equipment? This is important! Whether they’re skinny or fat, the child’s airway should be the same size. That’s why the child’s length is the best predictor of recommended emergency equipment (tubes, etc.) size. Just remember, inside stuff doesn’t expand like outside stuff does.
In the Broselow-Luten system, many EMS agencies and EDs use patient age or weight to estimate the color zone for medication preparation and equipment selection in advance. The estimation should be confirmed on arrival by a measurement with the Broselow tape.
Translating the Tape
Don’t be caught off guard by the terminology on the tape. Information without understanding is meaningless. If you see the term ET insertion length or lip to tip, you need to know this tells you where to tape the ET tube.
Remember that Foley is a trade name, and the generic term is urinary catheter. If you see the reference to volume expansion crystalloid: NS or LR, you should equate that to what we might call a fluid bolus. Bottom line: You have to know what it’s called in order to find it.
In stressful pediatric emergencies, professionals can simply start with “red to the head” and then measure head to heels; by doing so they’ll quickly determine the color that reveals the ideal body weight and find crucial pieces of information.
In some parts of the country, medics are taking that concept one step further and now include the Broselow-Luten color as part of their radio report to the ER. That way the ER staff can be better prepared for the patient’s arrival. Once the color is determined by EMS, they can grab the color-coded pediatric crash cart, open the appropriate drawer, and have anticipated equipment and medication calculations (in mg and mL) ready and waiting when the child hits the door.
In the second part of this series, we’ll take a look at another system for dealing with the stress and potential confusion related to pediatric emergency care: the Handtevy system.
Scott DeBoer, RN, MSN, CPEN, CEN, CCRN, CFRN, EMT-P, is an international pediatric seminar leader and nurse consultant with more than 25 years of nursing experience. He retired from flight nursing in 2015 following more than 20 years with the University of Chicago Hospitals’ UCAN flight team. He is the founder and primary seminar leader for Pedi-Ed-Trics Emergency Medical Solutions.
Emily Dawson, MD, is a pediatric emergency medicine and critical care attending physician at Advocate Children’s Hospital, Oak Lawn, Ill.
Lisa DeBoer is president and cofounder of Pedi-Ed-Trics Emergency Medical Solutions.
Julie Bacon, MSN-HCSM, RNC-LRN, NE-BC, CPN, CPEN, C-NPT, has more than 25 years of experience in emergency transport medicine, with expertise in pediatric and neonatal transport and critical care. She is program manager and chief flight nurse for Johns Hopkins All Children’s Life Line, St. Petersburg, Fla.
Michael Seaver, RN, BA, is a healthcare informatics consultant based in Chicago.