1 / 28

Transport of the Critically Ill Child: The Essentials

Transport of the Critically Ill Child: The Essentials. Allan de Caen MD FRCP Pediatric Critical Care Medicine Stollery Children's Hospital Edmonton, Canada. Objectives. Case illustration Starting the transport process: who, how, what team, and why… Stabilization pre-transport.

kiana
Download Presentation

Transport of the Critically Ill Child: The Essentials

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Transport of the Critically Ill Child: The Essentials Allan de Caen MD FRCP Pediatric Critical Care Medicine Stollery Children's Hospital Edmonton, Canada

  2. Objectives • Case illustration • Starting the transport process: • who, how, what team, and why… • Stabilization pre-transport

  3. Conflict of Interest Statement • Medical Director of Stollery PICU Transport Team • Co-Chair of CAPHC (National) Pediatric Interfacility Transport Steering Committee No Financial COI

  4. A previously well 9 year old presents to a rural hospital with a 24 hour history of fever, malaise, myalgias. She has had increased lethargy and respiratory distress over the last 6 hours. Upon ER presentation, the child appears mottled, is acting confused, and has moderately increased work of breathing. Her ER vitals are T 39°C, HR 150, BP 70/50, RR 35, and a RA 02 saturation of 89%. It is apparent to the referral hospital team that her medical care will ultimately require tertiary care admission.

  5. Starting resuscitation and calling for help • Identify early whether the patient will require transfer, and call for help early (time to transport might be hours…) • 1800-282-9911 for RAAPID North • 1800-661-1700 for RAAPID South • Air transport of critically ill children (or those at risk of being so) is coordinated through local Children's Hospital PICU (provincial dividing line at Red Deer) • Pediatric Intensivst can not only facilitate getting help to the referral hospital (transporting team or otherwise), but supporting the referral center while help is en route

  6. Pediatric Transport: Weighing Priorities • Referring Hospital • limited MD/ RN resources • limited technical skills/ experience • limited equipment • Accepting Hospital • MD/ RN resources • abundant technical skills/ experience • limitless equipment • Patient Care • Time to tertiary care • Transport team composition • Transport mode • Disease specific issues

  7. Who should transport the patient? • Referral hospital/ regional team (MD/ RN/ Medic) • Removing local resources • Do they have setting specific cognitive and technical skills/ equipment? • ALS/ adult critical care flight team (eg. STARS) • Predominantly adult-focused • Limited (non-trauma) pediatric experience • Pediatric critical care • Best option for critically ill child (mortality) • Limited resource • Prolonged time to patient bedside (av. 90-120 min)

  8. How is the decision made as to what kind of team transports? • Patient acuity (acuity scores vs. gut feeling) • Age (<5 years age vs. adolescence) • Distance to tertiary care center • Disease specific • Expanding intracranial mass • Traumatic shock (refractory-only) • <5% ped trauma needs surgical intervention • Time to tertiary care support more important than time to trauma center • Team availability Never accept a step-down in care for your patient

  9. Alberta Air Ambulance Network • ~9000 Air Ambulance flights in Alberta annually • ~10% (~800-900) provincial air tpts are Pediatric trips • 70% provincial flight activity is in Central/ Northern Alberta • 150-200 Stollery PICU Air Ambulance trips • ~500 advice/ transport calls to Stollery PICU intensivists/ year

  10. Before the patient is transported… Does the airway need to be secured? • General indications: • altered LOC/ resp distress or decreased effort/ shock • its more than just ABG/ 02 saturations • Specific disease states (idiopathic vs. post-traumatic seizure) • Patient age/ size • Does the patient have co-morbidities? • What is the trend? • Do I need to intubate, or can it wait for the tertiary care team?

  11. Assessment/ Management In the Transport Setting Ability (or not) to clinically assess the patient • Ambient lighting: is the patient blue/ pink/ white/ grey? • Noise: the stethoscope is useless • ETT position, pneumothorax • Motion artifact (BP cuff, 02 saturation monitor) What is the transport distance?

  12. Assessment/ Management In the Transport Setting • What is the mode of transport? • It’s difficult to intubate in the cramped space of a helicopter or plane • A ground ambulance can always pull off to the side of the road

  13. Intubation Pre-Transport • With oxygenation difficulties, lung compliance/ inflation is often compromised • A cuffed ETT allows for consistent application of TV and PEEP • ETT (cuffed) size is 0.5 size smaller than non-cuffed choice • Oxygenation and ventilation can be provided with less toxic Fi02/ airway pressures

  14. CXR post-intubation • Pneumothorax: small becomes big at altitude/ with positive pressure ventilation • ETT position post-intubation • Capnography: intra-airway (still either high or low…) • Brazelow tape: length not always = weight • Clinical assessment is unreliable in small children • Decompression of the stomach • Gastric distention at altitude compromises ventilation, with or without ETT

  15. Ventilating the Small Child Pre-transport • Suction post-ETI • Small airway and thick secretions • Humidvent/ humidification • Once the ETT is in, ventilate (sub-physiologic rate) • 3 months: 30 BPM • 2 yrs. age: 20 BPM • 10 yrs. Age: 12 BPM • TV 5-7 cc/ kg or PiP<30/ move the chest • PEEP 5 • Titrate Fi02 to 02 sat>94% • Baseline (CBG) and trend (EtC02 30-35mm Hg)

  16. Hemodynamic Stabilization Pre-Transport • IV/ IO X 2 • Not just trauma • 2nd IV allows for a back-up plan in the transport setting • Shock states, repeated assessment every 10cc/ kg of fluid (NS): liver size, lung fields (creps) • Titrate fluids not just to BP, but reversal of shock S/S (perfusion/ cap refill, HR,…) • Tendency is to undertreat with fluids; most septic states require at least 60cc/ kg in first hr. of resusc’n

  17. Hemodynamic Stabilization Pre-Transport • On-going fluid requirements due to vasodilation/ capillary leak • If hypotension refractory to 60cc/ kg fluid, remember BS/ Cai/ inotropes • Reassess, reassess, reassess; fluid/ drug requirements change over time

  18. Has enough resuscitation fluid been given? Systolic Wave Variation/ Pulse Pressure Variability:check your pulse oximetry tracing (audio or visual)

  19. Mixing Inotropes: The Rule of 6’svs. Pre-mixed bags of inotropes Run drugs dilute and titrate to BPs > 70 + (ageX2) Dopamine • 6mg X (pt. weight) in 100cc D5W/ NS • 1cc/ hr = 1 mcg/ kg/ min • Start at 10mcg/ kg/ min (10cc/hr) Epinephrine • 0.6mg X (pt. weight) in 100cc D5W/ NS • 1cc/ hr = 0.1 mcg/ kg/ min • Start at 0.1 mcg/ kg/ min

  20. Once the ETT is in, keeping it in… • Avoid benzodiazepines/ propofol due to vasodilatory effects • Serial dosing of analgesic agents • Fentanyl: 1-2 mcg/ kg q30-60 min • Ketamine 0.5-1 mg/ kg q1hr • Morphine 0.05-0.1 mg/ kg q1-2hr • The patient with residual paralysis • Titrate sedative/ analgesic dosing to jumps in HR/ BP • Even these agents have vasodilator effects… • Rocuronium 01.mg/ kg q30-60 min with patient movement

  21. Temperature Management of the Pediatric Patient on Transport • Small children lose significant heat (radiant/ evaporative/ conductive losses) • Hypothermia increases SVR/ myocardial stress • The importance of temperature (fever) control is disease specific • Cardiac arrest: Avoid fever; don’t cool • TBI: Avoid fever; don’t cool (harmful) • The earlier fever is managed, the better for the patient (window of dose effect starts early)

  22. ICU transport teams take longer to stabilize… Significant difference in stabilization times comparing kinds of transport teams ALS 0.44+/-0.15 hr ALS (peds) 0.98+/-0.21 hr PICU 1.24+/-0.34 hr McNabb, J Trauma, 1991

  23. Transport stabilization times for neonatal and pediatric patients prior to interfacility transferWhitfield, Children’s Emergency Transport Service, Denver,1993 Pediatric Stabilization Times 1988-1990 All transports (n = 1106) 55 (10-419) Ventilated (n = 157) 88 (18-419) Ventilated with Inotropes (n = 13) 156 (55-419)

  24. Summary of PICU tpt data • Sick patients get sicker on transport • Longer transports, sicker patients • Sicker patients take longer to stabilize, and that is usually OK

  25. Tex Kissoon’s Golden Rules of Transport • Plan ahead • Transports are palliative, not curative • No form of transport is ideal for every patient • Any hospital is a better hospital than an airplane or ambulance • If it is possible for a sick person to become sicker, he probably will • Big problems are simply small problems you have not anticipated • Nothing lasts forever (eg. Air 02, battery, etc)

  26. Keeping in touch Remember: • This is your patient until you hand over to the transport team • Reassess, reassess, reassess… • Call PICU (through RAPID) if patient condition deteriorates; we are there to help • No question is a stupid question

  27. Thanks for your attention.Questions?

More Related