Review by Randy Young, MD
Column organized by Evan Schwarz, MD
Division of Emergency Medicine
Citation: Nieman CT, Manacci CF, et al. Use of the Broselow
tape may result in the underresuscitaiton of children. Acad Emerg Med.
Oct 2006; 13(10):1011-01019.
You hear the report from the medics at a scene of a male child, “between the ages of 8 and 14, involved in a rollover MVC, child was unrestrained, initially A&O x 3 but now becoming progressively more lethargic, not intubated, coming in 5 minutes”. Now after you change your shorts, you remember your trusty Broselow tape. But as you shake the dust off of the tape, you also remember something one of your pediatric colleagues said about the Broselow tape not being accurate anymore.
Well your colleague might in fact be correct. The Broselow tape was originally developed in the 1970’s by Dr. Jim Broselow, a family practice physician to help approximate children’s weight based on the child’s height. The system was widely adopted in emergency departments throughout the country due to its simplicity of a color-coded system used to divide children into weight categories.
Over the past three decades the prevalence of obesity in American children has increased at an alarming rate. The National Health and Nutritional Examination Survey (NHANES) III suggested that approximately 14% of US children are considered obese by body mass index standards. Even though previous studies have showed that a length based system used during resuscitation is better than when no calculation aids are used, the authors of this article believe that with the increase in obesity in US children that the current Broselow tape based off of the NHANES III data might underestimate the actual weight of children. Therefore it would provide inaccurate information for resuscitation purposes.
The authors designed a cross-sectional, descriptive study comparing actual and Broselow tape predicted cohorts in children underless than 12 years of age. The subjects consisted of a suburban cohort from eastern and western suburbs of Cleveland, Ohio and an urban cohort from Metrohealth Medical Center in Cuyahoga County. The authors evaluated the accuracy of the 2002A Broselow tape based on the NHANES III data and the 1998 tape based on the NHANES II data against actual weight. The biggest changes from the 1998 tape to the 2002A tape were alterations in the “orange and green zones” usually associated with school-aged children.
In total there were over 7,000 children used to evaluate each of the 1998 and 2002A tapes against actual weight. The length-based system estimated within 10% of the child’s actual weight in 55.3% (2002A tape) and 60% (1998 tape) of the children. This was in comparison to the 80% accuracy of a parent’s estimation of their child’s weight. This inaccuracy of weight predicted accurate drug dosages based on Broselow tape only 55-60% of the time with the system more likely to underestimate rather than overestimate drug dosages. In fact both tapes were 2 to 5 times more likely to underestimate than to overestimate drug dosages. Although for drugs based on lean body mass this effect might be negligible, certain lipophilic drugs used in resuscitation (e.g. midazolam, amiodarone) could be significantly underdosed. The length based system of the Broselow tape has also been used to estimate endotracheal tube size. Comparing the Broselow tape and the alternative age based system, the Broselow tape was more likely to estimate a smaller tube size than the age-based guidelines.
While there currently is no perfect system available for pediatric resuscitation, many of us still rely on the Broselow tape. While the authors of this article do not dissuade the use of the length-based guidelines, they do caution on the blind use of the tape especially when a child is obviously obese and may fall in with the one-third of children whom the Broselow tape underestimated actual body weight in.
For the full article please go to http://pmid.us/17015417