Alexander R Schmidt et al. Medical Research Archives vol 8 issue 5.

Medical Research Archives

RESEARCH ARTICLE

The electronic Pediatric Emergency Ruler - A digital alternative to the

BroselowTape
Authors
1,2 1,2 1,2 1,2
Alexander R. Schmidt, Markus Weiss, Karl-Philipp Buehler, Joerg Thomas, 3Stefan Mueller,
1,2
Christian P. Both

Affiliations
1
Department of Anesthesia, University Children's Hospital Zurich, Zurich, Switzerland
2
Department of Anesthesia and Children's Research Centre, University Children’s Hospital, Zurich,
Switzerland
3
Prehospital emergency Organization, Schutz & Rettung Zürich, Zurich, Switzerland

Corresponding Author:
Alexander R Schmidt
Email: [email protected]

Abstract
Study objective: The Broselow® tape (BT) is a pediatric emergency tape (PET) supporting
medical teams during pediatric emergencies in estimating body weight, recommending drug
dosage and medical equipment. Publications have reported the risk of incorrect use and low
accuracy. A recently published digital algorithm for length-based body weight estimation showed
higher accuracy for weight estimation. A prototype for an electronic Pediatric Emergency Ruler
(ePER) utilizing this algorithm was developed for further testing. The aim of this study was to
compare the BT with the ePER in terms of time and correctness of identifying medical information
required during pediatric emergency treatment.
Methods: Voluntary participants were randomly assigned to use the BT or the ePER in a simulated
low-fidelity pediatric emergency manikin scenario and instructed to identify four parameters.
Outcomes were time required for identification of all parameters, correct determination of length-
based weight and erroneous reading of parameters for the selected weight category. Data are mean
or percent. T-test for statistical significance (p < 0.05) and standardized mean difference (SMD >
0.8) were calculated.
Results: Identifying medical information was significantly faster with the ePER than with the BT
(24.5 vs 36.7 sec, p<0.001; SMD 1.53). Both devices were used correctly in 77.8% of the cases.
Overall erroneous readings occurred in 1.9%.
Conclusion: The ePER represents a modern and comprehensive solution to support medical staff
during pediatric emergencies. This digital solution could be considered as an alternative to the BT.

Keywords: pediatric; body weight and measures; device development; emergency treatment;
resuscitation

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INTRODUCTION MATERIALS AND METHODS

Study design
Background
This study investigated the BT and the ePER
During pediatric emergencies adequate
in a simulated pediatric emergency scenario.
medical treatment of the injured or critically
After approval by the local ethics committee
ill child is challenging even for an
of Zurich (KEK-ZH-Nr.: Req-2017-00584)
experienced and skilled healthcare provider.
voluntary participants were included into this
Drug dosing and selection of medical
assessment. The trial was registered on
equipment is mostly based on the patient’s
ClinicalTrials.gov (NCT03953105) and
actual body weight. Unfortunately, this
performed in January and February 2019.
information is not always given in a pediatric
emergency. Therefore, pediatric emergency
Selection of participants
tapes (PETs) such as the Broselow® tape
In the city of Zurich, Switzerland ground-
(BT) were developed to assist medical
based prehospital pediatric emergency
providers. Based on the child’s body length
treatment is performed by “Schutz & Rettung
the BT estimates body weight, and drug
Zürich (SRZ)”. SRZ is the largest urban
dosing as well as sizes for medical equipment
prehospital emergency organization in
are suggested on a tape.
Switzerland and dispatches highly educated
paramedics to about 600 pediatric
Importance
emergencies annually. In the county of
Main limitations of the BT are the potential
Bulach, Switzerland (a neighboring county to
for incorrect use1-5 as well as the limited
Zurich) ground-based prehospital pediatric
accuracy regarding body weight estimation.6-
10 emergency treatment is performed by a
certified emergency medical service
In contrast, the recently presented digital
associated with the hospital of Bulach (EMS-
algorithm for Continuous Length-based
BL). Paramedics from SRZ (n=16) and
Algorithm for Weight & Age Rating
EMS-BL (n=2) who were unfamiliar with
(CLAWAR) revealed a higher accuracy than
any of the two devices were asked to
conventional PETs.11 A prototype of an
voluntarily participate in this study. Written
electronic PET (electronic Pediatric
informed consent was obtained from each
Emergency Ruler [ePER]) utilizing
participant.
CLAWAR was developed for further clinical
testing.
Devices investigated
The BT (Vital Signs, Inc, Totowa, NJ) is the
Goals of this investigation
most frequently used and so far best
The aim of the present study was to compare
investigated PET.12-18 The BT includes 26
the BT and the ePER with regard to the
length-based weight categories (LWCs) for
usability during a simulated life-threatening
patients with a body length ranging from 47
pediatric emergency scenario.
to 144 cm. Based on these LWCs, the
patient’s body weight is estimated and drug

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Alexander R Schmidt et al. Medical Research Archives vol 8 issue 5. May 2020 Page 3 of 12

dosing as well as medical equipment instruction manual, the selection of medical

suggested (figure 1). In addition, the BT equipment, as indicated on the back of the
advises considering the next higher color- tape, disregards body habitus and is based on
coded zone for drug dosing if the child the measured body length only.
appears overweight. According to the user’s

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Alexander R Schmidt et al. Medical Research Archives vol 8 issue 5. May 2020 Page 4 of 12

Figure 1: Photos by the author from the Broselow® tape. Top (A): length-weight category for 15-18 kg
body weight. Displayed are total amount of drug in mg to administer and in addition total mL to apply for
epinephrine. Bottom (B): sizes for medical equipment are provided on the other side, necessitating turning
the tape.

A prototype of the ePER (figure 2) was Version 1.0, University of Zurich,

developed by the Department of Anesthesia, Switzerland). This APP allows for length-
University Children’s Hospital, Zurich and based and habitus adapted weight estimation,
the University of Zurich, Switzerland. The drug dosing and size selection of medical
ePER uses an electronic measuring ruler for equipment for a body length from 42 to 160
length determination communicating with a cm. The algorithm of CLAWAR is described
tablet PC utilizing an application (APP) in detail in a previously published study.11
based on CLAWAR (CLAWAR APP.

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Alexander R Schmidt et al. Medical Research Archives vol 8 issue 5. May 2020 Page 5 of 12

Figure 2: Top: (A) The Electronic Pediatric Emergency Ruler (ePER) is placed next to the patient´s head
(B), the measuring tape (C) is pulled to the patient´s feet and the length is electronically measured by
activating the yellow button (D). Patient’s age and body weight are calculated from measured length based
on the CLAWAR algorithm. 11 Bottom: after confirmation of the initial demographic calculations first line
information mandatory for pediatric cardio-pulmonary resuscitation is displayed.

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 Alexander R Schmidt et al. Medical Research Archives vol 8 issue 5. May 2020 Page 6 of 12

Setting This setup was identical for both, the BT and

Each paramedic received individual the ePER group. In each scenario, the time
standardized instruction by the study required to identify the information and the
investigator (C.B.) on how to use the BT and answers given were recorded using an iPhone
the ePER. The paramedics received hands-on 8 (Apple Inc, Cupertino, USA) in the audio
time with each of the two devices. Using the tracking mode. Analysis of time to
Laerdal SIM Baby (Laerdal/Dräger Medical identification and correctness were
Switzerland AG, Liebefeld, Switzerland) performed afterwards from the audio tracking
they were able to practice until they felt file.
comfortable using both devices.
Randomization of the device was conducted Outcomes Measures
by the paramedics drawing a sealed envelope To investigate the usability and the clearness
containing a card with the name of one of the of the interface for each PET, the primary
two devices. Each paramedic was evaluated outcome was defined as the time required to
one at a time, without other paramedics be identify the four parameters listed above.
present. This setup prevented any bias or Secondary outcomes were correct use of the
teaching effects among participants. PET (defined as determination of the
manikin’s appropriate length-based weight)
A cardiac arrest was chosen as the simulated as well as erroneous reading of Joule amount,
low-fidelity pediatric emergency scenario epinephrine dose and ETT size for the related
and the Ambu® junior (Ambu® GmbH, Bad length-based weight and age respectively.
Nauheim, Germany) was used as a manikin
for assessment of the devices during the Primary Data Analysis
simulation. In this study habitus or gender Sample size calculation was performed a
adaptation was not included for both devices priori for comparison of two independent
since the Ambu® junior’s gender is undefined means estimating a clinically significant
and the body habitus is normal. Prior to difference for the primary outcome of 10 sec
initiation of each paramedic’s evaluation, the (±5 sec). For an α of 0.05 and a power of 0.8
paramedic stood aside from the Ambu® the suggested sample size was 4.
junior with the randomized PET in his hand. The collected data were compiled in
After a start signal the study investigator Microsoft Excel 2013 (Microsoft
asked the paramedic to identify the following Corporation, Redmond, WA, USA) and
set of information from the PET: processed using SPSS (IBM SPSS Statistics
I. Estimated body weight 22.0). Shapiro-Wilk was used to test for
II. Joule (first dose) suggested for normal distribution. Data are given as mean
defibrillation ± standard deviation (95% confidence
III. Recommended intravenous epinephrine interval) or as count (percent). A t-test was
dose performed for statistical significance and a p
IV. Suggested cuffed/uncuffed endotracheal < 0.05 was considered to be statistically
tube size (ETT) significant. In addition, standardized mean
difference (SMD) was calculated for

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evaluation of clinical significance, defining a five (27.8%) 6-10 years of experience, two
SMD > 0.8 as significant. (11.1%) 11-15 years of experience and seven
(38.9%) more than 15 years of experience as
RESULTS a paramedic. Demographic data for the two
A total of 18 paramedics (7 female and 11 groups is displayed in table 1. The Shapiro-
male) were included in this study. One Wilk test showed a normal distribution for
(5.5%) paramedic was in training, three the primary outcome in both groups (BT and
(16.7%) had less than 5 years of experience, ePER).

Table 1: Demographic data distribution for the participants between the two groups.
BT group ePER group
gender
male 4 (22.2%) 7 (38.9%)
female 5 (27.8%) 2 (11.1%)

Experience
in training 1 (5.6%) 0
1-5 years 3 (16.6%) 0
6-10 years 1 (5.6%) 4 (22.2%)
11-15 years 1 (5.6%) 1 (5.6%)
>15 years 3 (16.6%) 4 (22.2%)
BT: Broselow® tape ; ePER: electronic Pediatric Emergency Tape

The time until all four requested parameters cases (77.8%) using the BT and in seven
were identified using the BT was 36.7 ± 4.9 cases (77.8%) with the ePER. Overall
sec (33.1 – 40.6) and 24.5 ± 5.5 sec (20.3 – erroneous readings of joule amount,
28.7) with the ePER (p<0.001; SMD 1.53). epinephrine dose or ETT size from the
Detailed data are presented in table 2. devices occurred in only one of 54 (1.9%)
Correct use of the BT and ePER were equal, assessments (for ETT size using the BT).
the weight was identified correctly in seven

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Table 2: Time until of identification of each and all requested parameters.

time for (sec) BT ePER p SMD

ETT size 8,3 ±3,4 (5,7 - 10,9) 5,3 ±1,8 (3,9 - 6,6) 0.031 1.0

weight identification 12,0 ±4,9 (8,2 - 15,7) 8,2 ±2,5 (6,3 - 10,1) 0.054 0.9

joule amount 10,1 ±2,4 (8,3 - 12,0) 5,4 ±1,9 (3,9 - 6,9) <0.001 1.5

epinephrine dose 6,4 ±1,2 (5,5 - 7,4) 5,6 ±2,9 (3,4 - 7,8) 0.424 0.4

all parameters 36,9 ±4,9 (33,1 - 40,6) 24,5 ±5,5 (20,3 - 28,7) <0.001 1.5

BT: Broselow® tape; ePER: electronic Pediatric Emergency Ruler; ETT: endotracheal tube.
Displayed are mean ± standard deviation (95% confidence interval [minimum – maximum]).

LIMITATIONS The requirement of less time to identify

First, this study used a manikin simulation information using a digital device is in
and not clinical testing. In an in-vivo setting accordance with the findings of Jung et al
the results might be different, since the real- showing that a digital device allows for faster
life stress level of the caregivers during availability of important data compared to a
pediatric resuscitation is missing. Second, the conventional PET.19 Their digital device
work was performed in a single-center study consisted of an electronic ruler wirelessly
and the healthcare providers were highly connected to a personal computer with
motivated to participate in the study. It is length-based body weight and drug
likely, that the results could be different in a calculation. The authors reported that the
large population of subjects. mean time interval from the start of each
body length measurement to ordering an
DISCUSSION adrenaline dose, an endotracheal tube size
This study compared the BT and the ePER in and the defibrillation dose was significantly
a simulated pediatric emergency scenario in shorter for the digital device compared with
terms of time and correctness, assessing four the PET (digital device: 26 sec vs PET: 36
important parameters required for pediatric sec, p<0.001). These results are almost
cardiopulmonary resuscitation. The main exactly the same compared to the findings of
findings were that with the ePER the the present study (ePER: 24.5 vs BT: 36.9,
parameters studied were identified p<0.001). One reason for this might be a non-
significantly faster, however there was no easy-to-use interface of the PET. We assume
difference with regard to correct use of the the layout and total quantity of medical
device or erroneous readings. information given to the user might be the
reason why the parameters were identified

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Alexander R Schmidt et al. Medical Research Archives vol 8 issue 5. May 2020 Page 9 of 12

more quickly with the ePER than with the BT on the BT can lead to relevant under- or over-
(compare figure 1 vs figure 2). The dosing of drugs. If the BT is imprecisely
information given on the interface of the placed next to the patient a drug dosing
ePER is limited. Only the information weight of 13.0 kg (yellow category, 84.5 –
essentially needed during a resuscitation is 97.5 cm) might be selected instead of the
displayed on the initial page and one defined actually correct category of 17.0 kg (white
clear dosing recommendation is given. The category, 97.5 – 110.0 cm). The ePER uses a
ePER delivers further information after continuous length-based algorithm for body
selecting defined registers at the bottom of weight estimation. This algorithm results in a
the page (e.g. PAIN, ANESTHESIA, and lower impact of imprecisely measured body
PALS ALGORITHM). Time is crucial in a length on the body weight estimation. For
pediatric emergency situation and taking example, a patient with a body length of
more time to identify important information 102cm instead of 100cm will have an
may increase stress on medical staff, thus estimated bodyweight of 15.5 kg instead of
enhancing the risk of errors. 15.0 kg.
The incorrect use of a PET is a known The ePER is a digital device and therefore,
problem reported in prior publications. there are other advantages that should be
Heyming et al investigated the accuracy of mentioned. Firstly, the possibility of easy
the BT by comparing the length-based BT updating or adaptation of given information.
category selected by paramedics in a The user can be notified by a push-
prehospital setting with the length-based BT notification that an update is available. This
category assessed in the emergency is important if new guidelines or
department and found that from 384 recommendations are published. Paper-based
assessments a total of 115 (30%) were not products don’t easily allow for this option.
identical.1 The results of the present study They require reprinting and re-distribution,
showed a lower incidence of 22.2% for leading to higher costs for the consumer.
incorrect use in both devices. Concerns for Secondly, a software can be individually
erroneous reading with the ePER or BT could programmed, for example with regards to
not be found in this study. In only one of 54 language, drug names or concentrations,
cases (1.9%) a parameter (ETT size using the medical equipment and local medical
BT) was read incorrectly for the selected algorithms. Thirdly, the CLAWAR
length-based weight. This is in contrast to application on the ePER uses a growth chart
data published from other studies. Larose et for length-based weight estimation. Growth
al analyzed data from an experimental trial charts differ between ethnicities. With a
using simulated scenarios in which residents digital solution, the growth chart used for
were asked to estimate the weight of a estimation could be modified depending on
manikin using BT.2 Although most residents the country (ethnical area) in which the ePER
reported having experience with the BT, 40% is used.
of them made erroneous readings from the In conclusion, using the ePER to identify
BT. Incorrect selection of the length- important information for cardio-pulmonary
appropriate weight category for drug dosing resuscitation was faster than using the BT.

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Alexander R Schmidt et al. Medical Research Archives vol 8 issue 5. May 2020 Page 10 of 12

There was no difference with regard to Acknowledgment:

correct use or erroneous readings between the We would like to thank the paramedics of the
two devices. The ePER is a modern digital emergency medical service Bulach (Dr. K.
technology representing an interesting Homburg and J. Mezghini) and from the
comprehensive approach in supporting prehospital emergency organization Schutz
medical staff during in- and out-of-hospital & Rettung Zurich for participating in this
pediatric emergencies by length-based study.
estimation of weight, drug doses and size
selection of medical equipment.

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Alexander R Schmidt et al. Medical Research Archives vol 8 issue 5. May 2020 Page 11 of 12

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