Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

More Bad Airway Instruction.

Entertainment from PALS (Pediatric Advanced Life Support) classes?

How about pediatric intubation?

Kids are pretty scary, especially when they are really sick.

Then the idea of doing math while preparing to intubate a child is less than appealing to you?

Absolutely. Why would I want to do that?

Well, the PALS teaching includes using a formula:


Endotracheal Tube Size

The internal diameter of the appropriate endotracheal tube for a child will roughly equal the size of that child’s little finger, but this estimation may be difficult and unreliable.33,34 Several formulas such as the ones below allow estimation of proper endotracheal tube size (ID, internal diameter) for children 1 to 10 years of age, based on the child’s age:

Uncuffed endotracheal tube size (mm ID) =(age in years/4) + 4

In general, during preparation for intubation using the above formula, providers should have the estimated tube size available, as well as uncuffed endotracheal tubes that have internal diameters that are 0.5 mm smaller and 0.5 mm larger than the size estimated ready at the bedside for use.

The formula for estimation of a cuffed endotracheal tube size is as follows30:

Cuffed endotracheal tube size (mm ID) = (age in years/4) + 3 [1]


They include at least one test question to stress the importance of this.

Then in the last sentence in that section – the only sentence I did not include above – they write:

Endotracheal tube size, however, is more reliably based on a child’s body length. Length-based resuscitation tapes are helpful for children up to approximately 35 kg.35 [1]


I still get people arguing with me that the formula is more accurate than the length-based tape. They argue that the child’s airway grows at a rate determined by the formula, regardless of how quickly the rest of the body grows. The tape accounts for this difference, the formula caters to fools.

What is a length-based resuscitation tape?


This image is from the FDA Patient Safety News from October 2004 a bit more than half way down the page.[2]

You need to get a length-based resuscitation tape (Broselow or generic), become familiar with the tape, become familiar with the information that is on the tape, and use the tape a few times to feel comfortable with it.

This is a way to avoid having people calculate formulas or guess at weights when dealing with unstable children. Most doctors don’t calculate well under these circumstances. The same is true for nurses, medics, and even mathematicians. It is a very bad idea to avoid using something that simply and more accurately arrives at the answer.

Except when intubating during PALS.


Maybe they needed to get another multiple choice question for the test. Why try to explain dangerous foolishness?

Looking at the tape, you can see the Red to Head attempt to avoid confusion can be confusing in itself. There is a red section of the tape for 8 – 9 kg patients.

Nobody would make that mistake.

Nobody properly trained and supervised by competent people would, but the FDA does not look at things that way. Instead they try to require a fool proof tool. Only a fool would do that. Nobody has made the FDA fool proof.

Dr. Deborah Peel must love them, since they approach things the same way.[3],[4]

Here is what the FDA wrote:

Determining the dose of medication to give a child in an emergency can be a challenge. In most cases the dose is based on the child’s weight, and this can be very difficult to estimate. Even parents can be far off the mark when they’re asked their child’s weight. And even if the estimate is accurate, there’s the added chore of looking up the dose for a child of that weight.

Some clinicians avoid these difficulties by using a Broselow Tape, which measures the child from head to toe and uses this measurement to estimate the child’s weight, and thus the dose. The tape is divided into color-coded segments based on the child’s length, and each of the colored segments shows the approximate weight for that length child, along with the dose for commonly used emergency drugs for children of that weight. [2]


Here is one of the problems. They act as if the only way to measure the child is to start at the head and stretch the tape down to the feet. Would it be wrong, or unanticipated, to start at the fee and move to the head? What part of the body would a podiatrist start at?

The only thing that matters, whether you start at the feet or start at the head, is that the bright red/orange color on one end of the tape is the starting point. Starting at the other end of the tape is wrong – you will be using a different measurement.

You can use this tape for finding the dose of common resuscitation drugs and for finding the size of various pediatric equipment, such as an endotracheal tube.

But errors are often made using Broselow tapes. In a recent Medication Safety Alert, the Institute for Safe Medication Practices notes that the tapes can be placed alongside the child upside down, which would give the wrong length for the child and thus the wrong dose.[2]


It does not matter if the tape is “right side up,” what matters is that you start from the bright red/orange color on one end of the tape. The other end of the tape does not have this. It gets worse.

ISMP also says that the 1998 edition of the tape can be confusing in several respects, and that some of these problems were corrected in the newer 2002 version. They also point out that errors can occur if physicians wrongly assume that the listing of drugs on the tape means that they’re to be given in sequence. [2]


If you are a doctor and you don’t know anything about resuscitation get out of the way of the people who do. No amount of fool proofing will work for you. You are a danger to everyone else present. The same is true for nurses and medics who don’t know what they are doing.

If you do not know what medications to give, don’t give any medications.

If you are giving medications in the order that they are listed on the tape you are a dangerous idiot and should be bundled up and sent to Osama bin Laden as a Hanukkah present for him to torture.


I do what I can.

Of course, if you do not know the difference between the 8 – 9 kg section of the tape and the part marked MEASURE FROM THIS END, you probably don’t know what medication to give, when to give a medication, or why to give a medication.

Here are some of the measures ISMP recommends to prevent errors when using Broselow tape.

First, replace outdated Broselow tapes with the most recent edition, issued in 2002.

To prevent using the tapes upside down, hang them with the red arrow that says “Measure from this end” at the top. Teach staff to remember “RED TO HEAD” when placing the tape alongside the child’s body. [2]


And they repeat their misleading suggestion.

And if the tape is laminated in plastic, be sure the plastic doesn’t extend beyond the red arrow, which could change the measurement starting point.

For in-service training on how to properly use Broselow tapes, the Duke University Medical Center has a comprehensive programmed instruction course under its program for enhancing pediatric safety. [2]


A comprehensive programmed instruction course?

Give them the tape, let the doctors, nurses, and medics ask questions. Let them use the tape. Correct them when they make mistakes. As long as they do not resemble 2 monkeys with a football, things are pretty good.

Or is that too comprehensive for such a fine medical and educational institution.

Duke did a study that found that morphine is bad for chest pain, suggested that only NTG (nitroglycerin) should be used for the chest pain. Meanwhile, other researchers at Duke are trying to show that NTG is bad for chest pain. Does anyone at Duke communicate?

More on length based resuscitation tapes here:

A Pediatric Bag Separate From the Adult Gear

Weight based tube size here:

Bariatric Endotracheal Tubes for Adults?


[1] Endotracheal Tube Size
2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
Part 12: Pediatric Advanced Life Support
Breathing: Oxygenation and Assisted Ventilation
Free Full Text from Circulation

[2] FDA Patient Safety News from October 2004
Archived FDA Patient Safety News
Link to PDF of archived printed information from October 2004 that does not include the image in its current form.

[3] Deborah Peel is the antidote to HIPAA
Mon, 17 Mar 2008
Rogue Medic

[4] Calling Dr. Deborah Peel – Anyone Home?
Wed, 26 Mar 2008
Rogue Medic



  1. So proctologists have Bi-directional tape measures? ;)I thought I heard my tape measure whistling a Streisand tune, perhaps it was formerly owned by a proctologist. 😉


  1. […] and repeat until 1 g/kg is in. Or use a length based resuscitation tape, which I wrote about in More Bad Airway Instruction. And everybody dead gets epi, so 0.01 mg/kg epinephrine, and repeat epinephrine every 3 – 5 […]

  2. […] already mentioned, in More Bad Airway Instruction, the lack of utility of an age-based formula for calculating ETT (EndoTracheal Tube) size in […]