Too tall for the tape: the weight of schoolchildren who do not fit the Broselow tape.

BACKGROUND: In paediatric resuscitation, for a rapid and accurate estimate of children's weight, the Broselow tape can be used in children who are 46-144 cm tall. The Broselow tape has previously been found to provide the most accurate estimate of children's weight internationally, but it is not known how many fall outside the range of the tape, or whether such children can be assumed to be of adult weight, or how otherwise to estimate the weight of these children. OBJECTIVES: To determine what proportion of children in different age groups falls outside the limits of the Broselow tape, how their weight compares with that of the adults and what correlates most strongly with weight in these children. METHODS: This was a population-based prospective observational study of Chinese children up to 12 years old, from schools in Hong Kong. Weight was measured to the nearest 0.2 kg, and the height, foot-length and mid-arm circumference (MAC) were measured to the nearest 0.1 cm. RESULTS: 40% of 10-year olds and 70% of 11-year olds were too tall for the tape. Their median weight was 41.9 kg. This was significantly less than the median weight of 18-year olds (55 kg, p<0.0001) in Hong Kong. The strongest correlate with weight in these children was MAC. CONCLUSIONS: The Broselow tape is inappropriate for use in most children over 10 years old. Children too tall for the tape cannot be assumed to be of adult weight; to do so would imply an average overestimate of 30%. Weight estimates in older children could be based on MAC.

THERM: the Resuscitation Management score. A prognostic tool to identify critically ill patients in the emergency department.

INTRODUCTION: Prognostic scores are widely used in the emergency department (ED) to stratify risk for critically ill patients. The Prince of Wales ED Score (PEDS) was derived specifically for patients in an ED resuscitation room to predict death or intensive care unit (ICU) admission. We aimed to validate and refine this score, in comparison with other scores including the National Early Warning Score (NEWS). METHODS: This was a single-centre prospective study of adult resuscitation-room patients over 3 months. Comparison of scores was made using receiver operating characteristic analysis. Physiological and blood test variables were compared according to the composite primary outcome: admission to ICU or death within 7 days of attendance. Multivariate logistic regression was used to derive a new prediction score, which was validated in comparison with NEWS using the historic dataset from which PEDS had been derived. RESULTS: 234 patients were included; 37 were admitted to ICU or died within 7 days. PEDS performed adequately but was not superior to other scores. A simple pragmatic score, The Resuscitation Management score (THERM) was derived which outperformed NEWS in derivation and validation sets. CONCLUSIONS: PEDS is at least as good as other scores, including NEWS. However, it is unwieldy and relies on results not immediately accessible in the ED. THERM is a new score, derived and validated in an ED setting, using variables readily available, and simple to calculate and stratify. THERM outperforms NEWS and could be used in preference in critically ill ED patients.

Assessment of quality of life and functional outcome in patients sustaining moderate and major trauma: a multicentre, prospective cohort study.

BACKGROUND: Trauma care systems aim to reduce both death and disability, yet there is little data on post-trauma health status and functional outcome. OBJECTIVES: To evaluate baseline, discharge, six month and 12 month post-trauma quality of life, functional outcome and predictors of quality of life in Hong Kong. METHODS: Multicentre, prospective cohort study using data from the trauma registries of three regional trauma centres in Hong Kong. Trauma patients with an ISS≥9 and aged≥18 years were included. The main outcome measures were the physical component summary (PCS) score and mental component summary (MCS) scores of the Short-Form 36 (SF36) for health status, and the extended Glasgow Outcome Scale (GOSE) for functional outcome. RESULTS: Between 1 January 2010 and 31 September 2010, 400 patients (mean age 53.3 years; range 18-106; 69.5% male) were recruited to the study. There were no statistically significant differences in baseline characteristics between responders (N=177) and surviving non-responders (N=163). However, there were significant differences between these groups and the group of patients who died (N=60). Only 16/400 (4%) cases reported a GOSE≥7. 62/400 (15.5%) responders reached the HK population norm for PCS. 125/400 (31%) responders reached the HK population norm for MCS. If non-responders had similar outcomes to responders, then the percentages for GOSE≥7 would rise from 4% to 8%, for PCS from 15.5% to 30%, and for MCS from 31% to 60%. Univariate analysis showed that 12-month poor quality of life was significantly associated with age>65 years (OR 4.77), male gender (OR 0.44), pre-injury health problems (OR 2.30), admission to ICU (OR 2.15), ISS score 26-40 (OR 3.72), baseline PCS (OR 0.89), one-month PCS (OR 0.89), one-month MCS (OR 0.97), 6-month PCS (OR 0.76) and 6-month MCS (OR 0.97). CONCLUSION: For patients sustaining moderate or major trauma in Hong Kong at 12 months after injury<1 in 10 patients had an excellent recovery, ≤3 in 10 reached a physical health status score≥Hong Kong norm, although as many as 6 in 10 patients had a mental health status score which is≥Hong Kong norm.

Anthropometric and physiological measurements in healthy children.

1. Normal ranges for ultrasonic cardiac output monitor-derived cardiovascular indices are derived for Chinese children aged 1 to 12 years in Hong Kong. 2. A simple formula for calculating stroke volume is constructed, but the error varies from 8 to 40%. 3. Stroke volume index and, to a lesser extent, the cardiac index generally increase from ages 1 to 5 years, but plateau or fall slightly thereafter.

Validation of the APLS age-based vital signs reference ranges in a Chinese population.

UNLABELLED: Reference ranges for vital signs may differ significantly among children of different ethnic origins. AIM: (1) To validate the Advanced Paediatric Life Support (APLS) age-based vital signs reference ranges in Chinese children in Hong Kong. (2) To derive age-based centile curves for systolic blood pressure, heart rate and respiratory rate for Chinese children. (3) To summarize the reference ranges in a table format appropriate for applying APLS to ethnic Chinese patients. METHOD: A cross-sectional study was performed on a population of healthy Chinese children recruited from 8 kindergartens and 6 primary schools in Hong Kong. Trained operators visit the sites to obtain measurements. Age-groups: small toddlers (12-23 months); pre-school (24-59 months); and school (60-143 months). Z-test was used to assess statistical significance for proportions of each parameter falling outside the APLS reference range. One-sample t-test was used for comparison with APLS means according to age-groups. LMS Chartmaker Pro v2.3 software was used to describe the data in centile curves. RESULTS: A total of 1353 patients (55.1% boys) were included. For heart rate, systolic blood pressure and respiratory rate respectively, 34.1%, 55.9% and 55.7% of corresponding measurements were outside the APLS age-based reference ranges. In the 'pre-school' and 'school' age-groups, the mean value for blood pressure is significantly higher, and the mean values for heart rate and respiratory rate significantly lower, in comparison to APLS mean values. CONCLUSION: Independently derived vital signs reference ranges are more appropriate for use when applying APLS to Chinese patients in Hong Kong.

Age-based formulae to estimate children's weight in the emergency department.

OBJECTIVE: To develop an age-based weight estimation rule in a Chinese population and to compare its performance with existing formulae. DESIGN: Population-based observational study. SETTING: Schools and kindergartens in Hong Kong. SUBJECTS: Healthy Chinese children aged 1-10 years old on their last birthday. INTERVENTIONS: Weight was measured to the nearest 0.2 kg. MAIN OUTCOME MEASURES: Linear regression was used to derive a simple formula relating weight to the child's age on his or her last birthday. The accuracy and precision of different age-based weight formulae was compared using coefficient of variation, Bland Altman plots, and by determining the proportion of children with estimates >30% outside the actual weight. RESULTS: The Chinese Age Weight Rule is a simple linear formula that is more accurate than and at least as precise as any other age-based weight estimation rule: weight in kg=(3 × age last birthday)+5. It is accurate and precise in children <7 years old, but all age-based weight estimates are imprecise in older children. CONCLUSIONS: The Chinese Age Weight Rule should be used in a Chinese population in preference to any other age-based weight estimation rule. Caution should be taken when using it in older children in whom other weight-estimation tools may be more appropriate.

Mid-arm circumference can be used to estimate children's weights.

INTRODUCTION: Accurate measurement of children's weight is rarely possible in paediatric resuscitation, and rapid estimates are made to ensure appropriate drug and fluid doses and equipment selection. Weight is commonly estimated from formulae based on children's age, or from their height using the Broselow tape. Foot-length and mid-arm circumference have also been suggested as the basis of weight-estimation formulae. OBJECTIVES: To determine which of age, height, foot-length or mid-arm circumference had the strongest relationship with weight in healthy children, to derive a simple weight-estimation formula from the strongest correlate, and to compare its performance with existing weight-estimation tools. METHODS: This was a population-based prospective observational study of Hong Kong Chinese children aged 1-11 years old last birthday. Weight was measured to the nearest 0.2 kg; height, foot-length and mid-arm circumference to the nearest 0.1 cm. Multiple regression analysis was used to determine the strongest independent relationships with weight, and linear regression analysis derived a weight-estimation formula. Accuracy and precision of this formula were compared with standard age-based and height-based weight-estimation methods. RESULTS: Mid-arm circumference had the strongest relationship with weight, and this relationship grew stronger with age. The formula, weight [kg]=(mid-arm circumference [cm]-10) x 3, was at least as accurate and precise as the Broselow method and outperformed the age-based rule in school-age children, but was inadequate in pre-school children. CONCLUSION: This weight-estimation formula based on mid-arm circumference is reliable for use in school-age children, and an arm-tape could be considered as an alternative to the Broselow tape in this population.

Pseudo myocardial infarction.

The case is presented of a 66 year old woman who attended the emergency department with severe abdominal pain subsequent to a bout of coughing, following a week's history of productive cough. She was known to have chronic obstructive pulmonary disease and was also on warfarin for recurrent deep vein thromboses. She had no history of ischaemic heart disease. She was found to have a rectus sheath haematoma and an international normalised ratio of 7.7, and admission was arranged for coagulation control and analgesia. However, a routine electrocardiograph (ECG) demonstrated an ST elevation pattern consistent with an acute inferior infarction. Subsequent ECGs showed no ST elevation, although the axis and chest lead QRS morphology remained the same throughout the first 12 hours. Over the next three days, R wave progression decreased in the chest leads. Troponin I at admission and 24 hours later were both <0.2 ng/ml. ECG changes compatible with acute myocardial infarction have been reported in association with a number of non-cardiac presentations; however, to our knowledge, it has never been reported in relation to a rectus sheath haematoma. We speculated on the possible mechanism of such "pseudo myocardial infarction" and the importance of treating the patient, not the ECG.