Luten/Wylie - managing chaos - Broselow tape

Emergency and Trauma Care Symposium
Managing Chaos in Pediatric Resuscitations and the
Broselow-Luten System
Todd Wylie, MD
Associate Professor, Emergency Medicine
Department of Emergency Medicine
UFCOM-Jacksonville
Robert C. Luten, MD, FAAP, FACEP
Professor, Emergency Medicine & Pediatrics
Department of Emergency Medicine
UFCOM-Jacksonville
Medical Director, eBroselow Medication
Safety System

Disclosures and Confidentiality
• Dr. Luten is a shareholder in
eBroselow LLC and a
consultant with Carefusion
• Dr. Wylie has consulted for
UpToDate Inc.

Objectives
• Identify the factors that contribute to chaos in a pediatric
resuscitation
• Describe a reliable means for initial assessment of a pediatric patient
• Identify the tools and resources to reduce the complexity of a
pediatric resuscitation

A Tale of Two Populations: Addressing Pediatric Needs
in the Continuum of Emergency Care
• Nationally, 27% of all ED visits are pediatric related
• Majority of these 31 million children and adolescents access
emergency and trauma care in nonpediatric facilities and have
different clinical presentations and needs than adults.
• 75-85% seen in general EDs
• 50% of EDs see <15 children/day
A Tale of Two Populations: Addressing Pediatric Needs in the Continuum of Emergency Care. Schenk, Ellen et al. Annals of Emergency Medicine,
Volume 65, Issue 6, 673-678. 2015
Pediatric Readiness and Facility Verification. Remick, Katherine et al. Annals of Emergency Medicine , 2016. Volume 67 , Issue 3 , 320 - 328.e1
Gausche-Hill M, Ely M, Schmuhl P, et al. A national assessment of pediatric readiness of emergency departments. JAMA Pediatr. Published online
April 13, 2015. doi:10.1001/jamapediatrics.2015.138

Pediatric EMS Epidemiology- National

UF Health – Jacksonville Pediatric Resuscitation Study:
Unpublished Data
Mode of Arrival - all resuscitations
41 %
52 %
6 %

Chaos
Definition - complete disorder and confusion

Contributors to Chaos
• Challenges associated with pediatric patients
• Size and weight based differences
• Communication and maturity
• Physiologic/anatomical differences
• Evaluation and familiarity

• Challenges associated with
pediatric patients
• Size and weight based differences

• Physiologic/anatomical differences
Age Respiratory
Rate
(breaths/min)
Infant 30 to 60
Toddler 24 to 40
Preschooler 22 to 34
School-aged child 18 to 30
Adolescent 12 to 16
Age Normal Heart
Rate (beats/min)
Infant 100 to 160
Toddler 90 to 150
Preschooler 80 to 140
School-aged child 70 to 120
Adolescent 60 to 100

• Communication and maturity
• Evaluation and familiarity

Pediatric Assessment
Recognition of the Sick Child

SHOCK
RF
Cardiac
Arrest
Gastroenteritis
Hemorrhage
Infection
Anaphylaxis
Cardiac Ds
Pneumonia
Asthma
Bronchiolits
Croup
UndifferentiatedPatients
Sick kids

SHOCK
RF
Cardiac
Arrest
Pneumonia
Asthma
Bronchiolits
Croup
UndifferentiatedPatients
Sick kids
Gastroenteritis
Hemorrhage
Infection
Anaphylaxis
Cardiac Dz

Initial assessment
(Assessment Triangle)
Continued monitoring
(Perfusion and Respiratory
Assessment Tools)
Tools
Observation
Observation + Examination
Evaluation
The approach to recognition of the critically ill child is not complicated; it requires an
organized approach utilizing the skills of observation and examination.

Normal Abnormal
MS Normal TICLS* Abnl TICLS*
WOB Normal WOB Retractions, nasal flaring, head bobbing
Skin Normal appearance Pallor, mottling, cyanosis
Assessment Triangle
Only
Observation
(Mental Status)
*Tone: good tone/moving around or decreased
Interactive: alert, listless, lethargic or unresponsive
Consolability: consolable or inconsolable
Look or gaze: looking around or fixed
Speech or cry: strong cry, whimper, slurred speech or unable to talk

Normal Resp
Distress
Resp
Failure
Early
Shock
Late
Shock
CNS
Appearance nl nl abnl nl/abnl abnl abnl
WOB nl abnl abnl nl nl/abnl nl
Circulation nl nl nl abnl abnl nl
(Mental Status)
Regardless of chief complaint, if from across the room, the child’s mental status, work
of breathing, and circulation to skin is normal, the patient is not significantly
compromised and there is time for more in depth evaluation.

Normal Resp
Distress
Resp
Failure
Early
Shock
Late
Shock
CNS
(Mental Status)
The triad of increased work of breathing with a normal mental status (appearance)
and normal circulation to skin is respiratory distress.

Normal Resp
Distress
Resp
Failure
Early
Shock
Late
Shock
CNS
(Mental Status)
The triad of increased work of breathing with an abnormal mental status (appearance)
and normal circulation to skin is respiratory failure.

Normal Resp
Distress
Resp
Failure
Early
Shock
Late
Shock
CNS
(Mental Status)
The triad of abnormal circulation to skin combined with varying degrees of changes in
appearance, with normal work of breathing suggest the presence of shock. In both
early, and certainly in late shock there may be an increase in respiratory rate, though
it is not usually associated with an obvious increase in work of breathing.

Normal Resp
Distress
Resp
Failure
Early
Shock
Late
Shock
CNS
(Mental Status)
The triad of abnormal circulation to skin combined with varying degrees of changes in
appearance, with otherwise normal work of breathing suggest the presence of shock.

Normal Resp
Distress
Resp
Failure
Early
Shock
Late
Shock
CNS
(Mental Status)
The triad of normal work of breathing, a normal circulation to skin, with an abnormal
mental status (appearance) means that the mental status did not result from shock or
respiratory failure. Causes should be sought in the processes that effect the CNS, such
as meningitis, encephalitis and medication overdoses.

Normal Resp
Distress
Resp
Failure
Early
Shock
Late
Shock
CNS
(Mental Status)
The initial evaluation of respiratory failure and shock using the Assessment Triangle
points the health care provider in the appropriate direction for initiation and ongoing
monitoring of treatment

Mental Status
Alert
Verbal response
Painful response
Unresponsive
Skin
Pulse Rate
Pulse Quality
Distal Pulses
Proximal Pulses
Capillary Refill
Color/Temperature
Evolution
Resolution
These figures demonstrate how shock evolves progressively. On the left we will list the normal patient …alert,
strong proximal and distal pulses, normal rate, CRT < 2 seconds. The figure will demonstrate clinical
progression. Note that with these parameters this is a “hands on” only evaluation, and blood pressure,
which is a late indicator of shock, is not included.
nl---------------------abnl

Case for Consideration
• 5-year-old, previously healthy boy is struck by a car while crossing street.
• He is thrown 5 meters from the vehicle.
• Patient is: unresponsive, tachypneic, and pale.

What is your general impression of this patient?
What are your initial management priorities?
What diagnostic tests would you want to perform?
What other interventions do you want to perform?

• Patient is:
• Unresponsive
• Tachypneic
• Pale

Normal Resp
Distress
Resp
Failure
Early
Shock
Late
Shock
CNS
WOB nl abnl abnl nl nl/abnl bl
(Mental Status)
The triad of abnormal circulation to skin combined with varying degrees of changes in appearance, with normal
work of breathing suggest the presence of shock. In both early, and certainly in late shock there may be an
increase in respiratory rate, though it is not usually associated with an obvious increase in work of breathing.

• Patient is:
• Unresponsive, tachypneic, pale
• Interventions
– How do you estimate patient’s weight?
– How do you identify drug dosing?
– How do you identify appropriate equipment size?

Potential for Chaos
• Need organized system to identify:
• Estimated weight
• Appropriate drug dosing
• Appropriate equipment size
Take it away
Dr. Luten

Why is pediatric resuscitation chaotic?

Cognitive Load
Automatic vs. non-automatic processes
Critical thinking time
Reducing cognitive load with resuscitation aids

My experience:
Peds, then EM, then hope for a solution

Luten R JEM circa 1985
.
Pediatric resuscitation chart and equipment shelf: aids to mastery of
age-related problems.
Luten RC. J Emerg Med. 1986;4(1):9-14

The Luten SystemThe Luten System

A new idea…Jim Broselow
It works…

Medication Safety in Acute CareIt works…

Luten et al-Equipment shelf and Pre-calculated meds
Lubitz et al-tape weight estimation, produced weight zones
Luten et al-ET tube selection produced color zones for equipment…later
combined into med/weight color zones
Epidemic of obesity- 2011 “bump” a zone
Challenge to tape for trauma resuscitation + a million more studies
Answer- Luten, Zaritsky, et al. The Sophistication of Simplicity
Bottom line:
Measure kid
Use color for equipment and bump one zone if overweight and you
want actual weight for dosing
Forget about it, and take care of the kid

Medication Safety in Acute Care
Adding colors…

51
The Broselow Tape
The Broselow-Luten Zones
The Broselow-Luten System

The gold vs. the lead standard

DEMONSTRATION of BOTH eBroselow and SafeDose

Case Review Fentanyl
RSI
Fentanyl Infusion
Midazolam Infusion
Epinephrine Infusion
Norepinephrine Infusion

Bottom line:
Measure kid
Use color for equipment and bump one zone if overweight and you
want actual weight for dosing, then…
Forget about it, and take care of the kid

Managing the unique size-related issues of pediatric
resuscitation: reducing cognitive load with resuscitation
aids.
Luten R, Wears RL, Broselow J, Croskerry P, Joseph MM,
Frush K.Acad Emerg Med. 2002 Aug;9(8):840-7
The sophistication of simplicity...optimizing emergency
dosing.
Luten R, Zaritsky A. Acad Emerg Med. 2008
May;15(5):461-5

COLOR WEIGHT AGE
PINK 6-7 kg 3-5 mos
RED 8-9 kg 6-11 mos
PURPLE 10-11 kg 12-24 mos
YELLOW 12-14 kg 2 yrs
WHITE 15-18 kg 3-4 yrs
BLUE 19-23 kg 5-6 yrs
ORANGE 24-29 kg 7-9 yrs
GREEN 30-36 kg 10-11 yrs
http://www.buzzle.com/articles/average-weight-for-children-by-age.html
Otten JJ, Helwig JP, Meyers LD, eds. Dietary Reference Intakes The essential
Guide to Nutrient Requirements. Washington DC. National Academies Press. 2006.
World Health Organization Growth Charts 2014
AGE ESTIMATION CHART

RAPID SEQUENCE INTUBATION – IV
3 KG 4 KG 5 KG
PINK
(6-7 KG)
RED
(8-9 KG)
PURPLE
(10-11 KG)
YELLOW
(12-14 KG)
WHITE
(15-18 KG)
BLUE
(19-22 KG)
Orange
(24-28 KG)
GREEN
(30-36 KG)
PREMEDICATIONS - IV
Atropine (0.1 mg/mL)
Dose: 0.02 mg/kg/dose
0.1 mg
(1 mL)
0.1 mg
(1 mL)
0.1 mg
(1 mL)
0.13 mg
(1.3 mL)
0.17 mg
(1.7 mL)
0.21 mg
(2.1 mL)
0.26 mg
(2.6 mL)
0.33 mg
(3.3 mL)
0.42 mg
(4.2 mL)
0.5 mg
(5 mL)
0.5 mg
(5 mL)
Lidocaine 2% (20 mg/mL)
Dose: 1.5 mg/kg
4.5 mg
(0.23 mL)
6 mg
(0.3 mL)
7.5 mg
(0.38 mL)
10 mg
(0.5 mL)
13 mg
(0.65 mL)
15 mg
(0.75 mL)
20 mg
(1 mL)
25 mg
(1.3 mL)
32 mg
(1.6 mL)
40 mg
(2 mL)
50 mg
(2.5 mL)
Fentanyl (50 mcg/mL)
Dose: 3 mcg/kg/dose
9 mcg
(0.18 mL)
12 mcg
(0.24 mL)
15 mcg
(0.3 mL)
19 mcg
(0.38 mL)
25 mcg
(0.5 mL)
31 mcg
(0.62 mL)
39 mcg
(0.78 mL)
50 mcg
(1 mL)
62.5 mcg
(1.25 mL)
77.5 mcg
(1.55 mL)
100 mcg
(2 mL)
INDUCTION AGENTS - IV
Etomidate (2 mg/mL)
Dose: 0.3 mg/kg/dose
0.9 mg
(0.45 mL)
1.2 mg
(0.6 mL)
1.5 mg
(0.75 mL)
2 mg
(1 mL)
2.5 mg
(1.3 mL)
3.2 mg
(1.6 mL)
4 mg
(2 mL)
5 mg
(2.5 mL)
6.3 mg
(3.2 mL)
8 mg
(4 mL)
10 mg
(5 mL)
Ketamine (10 mg/mL)
Dose: 2 mg/kg/dose
6 mg
(0.6 mL)
8 mg
(0.8 mL)
10 mg
(1 mL)
13 mg
(1.3 mL)
17 mg
(1.7 mL)
20 mg
(2 mL)
26 mg
(2.6 mL)
33 mg
(3.3 mL)
42 mg
(4.2 mL)
50 mg
(5 mL)
66 mg
(6.6 mL)
Propofol (10 mg/mL)
Dose: 3 mg/kg/dose
9 mg
(0.9 mL)
12 mg
(1.2 mL)
15 mg
(1.5 mL)
20 mg
(2 mL)
25 mg
(2.5 mL)
32 mg
(3.2 mL)
40 mg
(4 mL)
50 mg
(5 mL)
63 mg
(6.3 mL)
80 mg
(8 mL)
100 mg
(10 mL)
PARALYTIC AGENTS – IV
Succinylcholine (20 mg/mL)
Dose: 2 mg/kg/dose
6 mg
(0.3 mL)
8 mg
(0.4 mL)
10 mg
(0.5 mL)
13 mg
(0.65 mL)
17 mg
(0.85 mL)
20 mg
(1 mL)
26 mg
(1.3 mL)
33 mg
(1.65 mL)
40 mg
(2 mL)
53 mg
(2.65 mL)
66 mg
(3.3 mL)
Rocuronium (10 mg/mL)
Dose: 1 mg/kg/dose
3 mg
(0.3 mL)
4 mg
(0.4 mL)
5 mg
(0.5 mL)
7 mg
(0.7 mL)
9 mg
(0.9 mL)
10 mg
(1 mL)
13 mg
(1.3 mL)
17 mg
(1.7 mL)
21 mg
(2.1 mL)
27 mg
(2.7 mL)
33 mg
(3.3 mL)

EPIC ALARIS eBroselow Trauma
<8 kg 50 mcg/mL
100 mcg/mL
50 mcg/mL
100 mcg/mL
50 mcg/mL
100 mcg/mL
50 mcg/mL
8-36 kg 50mcg/mL
100 mcg/mL
50 mcg/mL
50 mcg/mL
100 mcg/mL 100 mcg/mL
EPINEPHRINE
EPIC ALARIS eBroselow Trauma
<8 kg 50 mcg/mL
100 mcg/mL
50 mcg/mL 50 mcg/mL 50 mcg/mL
8-36 kg 50mcg/mL
100 mcg/mL
100 mcg/mL 100 mcg/mL 100 mcg/mL
NOREPINEPHRINE

Trauma
<8 kg 50 mcg/mL
8-36 kg 100 mcg/mL
EPINEPHRINE
Trauma
<8 kg 50 mcg/mL
8-36 kg 100 mcg/mL
NOREPINEPHRINE

PINK 6-7 kg
EPINEPHrine: Infusion IV - 50 mcg/mL 0.1 - 2 mcg/kg/min
*standard concentration for less than 8 kg
GREY 5 kg
• Start with 100 mL NaCl bag
• remove 5 mL NaCl
• Add 5mL of Epinephrine (1mg/mL)
5 mg in 0.9%NaCl 100mL

WHITE 15-18 kg BLUE 19-23 kg
EPINEPHrine: Infusion IV - 100 mcg/mL 0.1 - 2 mcg/kg/min
10 mg in 0.9%NaCl 100 mL• Start with 100 mL NaCl bag
• remove 10 mL NaCl
• Add 10mL of Epinephrine (1mg/mL)

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