Post on 11-Nov-2014
description
Pediatric Transport
Darin Aranwutikul, MD.
Goal
Early stabilization and initiation of advanced care
at the referring institution, with continuation of
critical care therapies and monitoring en route.
Recognition & assessment of
the sick child
Pediatric assessment triangle(PAT): A-B-C
Appearance :
TICLS Mnemonic
Tone Refers to child’s muscle tone
Interactivity Refers to degree of interaction the child has with his/her
environment or those attempting to interact with the child
Consolability Refers to the child’s response to parents or caregivers
Look /gaze Identifies whether the child tracks things appropriately
with his/her eyes or has a nonfocused gaze.
Speech/cry Refers to how the child vocalizes
Primary assessment
• Airway
• Breathing
• Circulation
• Disability
• Exposure
A
D
CE
B
Airway
• Patency
• Need simple management
positioning
head tilt-chin lift
Use airway adjuncts ( oral airway)
• Require advanced intervention
ET intubation
cricothyroidotomy
CPAP
Breathing
• Respiratory rate
• Respiratory effort
• Airway and lung sounds
• Pulse oximetry
Normal respiratory rates
by age
Age Breaths per minutes
Infant (<1 year) 30 to 60
Todler( 1-3 yrs) 24 to 40
Preschooler ( 4-5 yrs) 22 to 34
School age ( 6-12 yrs) 18 to 30
Adolescent ( 13-18 yrs) 12 to 16
Respiratory rate
• Apnea
• Tachypnea
• Bradypnea
Bradypnea or irregular respiratory rate in an
accutely ill infant or child often signals impending arrest
Abnormal lung and airway sounds
• Stridorupper airway obstruction
• Wheezinglower airway obstruction
• Grunting lung tissue disease
• Crackles lung tissue disease
Pulse oximetry
• Above 94% in room air
• Additional intervention is required if O2 sat<90%
in child receiving 100% oxygen .
• Be careful to interpret pulse oximetry in
conjunction with clinical assessment and other
signs.
Circulation
• Evaluate cardiovascular
function
heart rate and rhythm
pulses
capillary refill time
blood pressure and pulse pressure
• Evaluate end-organ
function
brain perfusion
skin perfusion
renal perfusion
Normal heart rates in children
Age Awake rate Mean Sleep rate
NB to 3 mo 85-205 140 80-160
3 mo to 2 y 100-190 130 75-160
2 y to 10 y 60-140 80 60-90
>10 y 60-100 75 50-90
Typical physiologic response to a fall in cardiac output is tachycardia.
Blood pressure
Definition of hypotension
Age Systolic BP (mmHg)
Term neonates <60
Infants <70
Children 1-10 yr
5th BP percentile <70 + (age in years x 2)
Children > 10 yr <90
Systemic perfusion
• Peripheral Pulses
– Present/Absent
– Strength
• Skin Perfusion
– Capillary refill time
– Temperature
– Color
– Mottling
Systemic perfusion
• CNS Perfusion
– Level of
consciousness
• Renal Perfusion
– Urine 1-2 cc/kg/hr
Disability
• Establish the child's level of consciousness
• Standard evaluations are
AVPU pediatric response scale
Glasgow Coma Scale (GCS)
pupillary responses
AVPU pediatric response scale
Glasgow Coma Scale(GCS)
-
Pupillary response
Exposure
• Remove clothing as necessary
• Palpate the extremities to assess for injury
• Measure core temperature
• Keep the child warm
• Use spine precautions when suspect spine
injury
Life threatening condition
• Complete /severe airway obstructionAirway
• Apnea,significant work of breathing, bradypneaBreathing
• Absence pulses, poor perfusion, hypotension, bradycardiaCirculation
• Unresponsiveness, depressed consciousDisability
• Hypothermia, significant bleeding, purpura with septic shock, acute abdomen
Exposure
Secondary assessment
• Signs and Symptoms
• Allergies
• Medications
• Past medical history
• Last meal
• Events leading to presentation
Pediatric assessment flow chartGeneral assessment
PAT
Primary assessment
A-B-C-D-E
Secondary assessment :
SAMPLE
Tertiary assessment
Respiratory +circulatory
Respiratory
Respiratory distress
Respiratory Failure
Circulatory
Compensated shock
Hypotensive shock
If any time during the assessment
and categorization process You identify a
life-threatening condition
Immediately initiate life-saving interventions
and activate the
emergency response system
Breathing is everything to a child
• The common denominator for unexpected deaths
in children is hypoxia.
• Do not increase the child's level of anxiety
Not only the child
• Needs of parents or caregivers must
be addressed.
• Be calm and confident.
• Written information and involve them
in plan of care.
Children don’t have less pain than adult
Numeric and FACES scale
FLACC scale
Drugs Dose (mg/kg) Route comments
Analgesics
Morphine 0.1-0.2 ;infusion 20-50 mcg/kg/hr IV Histamine
release
Fentanyl 1-2 mcg/kg;infusion 2-5 mcg/kg/hr IV,IO Chest wall
rigidity
Sedatives
Diphenhydramine 0.1 IV,PO
Ketamine 1-2 IV,IO,IM Increased ICP
lorazepam 0.1-0.2 IV,IO,IM Hypotension
Midazolam 0.1-0.2 IV Hypotension
Propofol 1-3; infusion 1-3 mg/kg/hr IV Hypotension
Pentobarbital 2-4 IV Apnea
YOU CANNOT REMEMBER
NORMAL WEIGHTS, RESPIRATORY
RATES, BLOOD PRESSURES, HEART
RATES, AND CALCULATE DRUG DOSES
IN YOUR HEAD SO DON'T TRY
Broselow tape
HOW TO STABILIZE THE CHILD
Stabilization of the respiratory
system
• Well oxygenated and ventilating prior to transfer
• Consider the need for intubation and mechanical
ventilation.
• Confirm ETT placement and secure the tube.
• Obtain blood gases while ventilating on the transport
ventilator before leaving
• Consider the need for sedation and paralysis
Stabilization of the
cardiovascular system
• Hemodynamically stable before departure.
• Treat compensated shock before departure.
• Invasive arterial blood pressure monitoring in
patients with inotropic support.
• At least 2 good, working points of IV access.
• Ensure availability of emergency or special drugs
Medications to Maintain Cardiac Output and for
Postresuscitation Stabilization
Medication Dose Range Comment
Inamrinone 0.75–1 mg/kg IV/IO over 5
minutes; may repeat × 2
then 5-10 mcg/kg/min
Inodilator
Dobutamine 2–20 mcg/kg/min IV/IO Inotrope; vasodilator
Dopamine 2–20 mcg/kg/min IV/IO Inotrope; chronotrope; renal and
splanchnic vasodilator in low doses; pressor in high doses
Epinephrine 0.1–1 mcg/kg/min IV/IO Inotrope; chronotrope; vasodilator in low doses; pressor in higher doses
Milrinone Loading dose: 50 mcg/kg IV/IO
over 10–60 min
then 0.25-0.75 mcg/kg/minInodilator
Norepinephrine 0.1–2 mcg/kg/min Vasopressor
Sodium nitroprusside
Initial: 0.5–1 mcg/kg/min; titrate
to effect up to 8 mcg/kg/min
Vasodilator
Prepare only in D5W
Stabilization of the central nervous
system
• Minimize secondary brain injury due to
hypotension and hypoxia
• Appropriate treatment of prolonged seizures
• Adequate sedation
Stabilization of the gastrointestinal
system
• Placement of a nasogastric tube and left
on free drainage.
• Stop feeding and aspirate the stomach
before transfer.
Stabilization of the renal system
• Consider urethral catheterisation in
children
– with shock
– who are paralysed and sedated
– who have received diuretics or mannitol
Transport team assessment and
initial stabilization
• Rapid assessment
• Urgent therapy and manage life-threatening
conditions is priority
• Have patient as stable as possible before
loading into the transport vehicle.
EQUIPMENT USED IN PEDIATRIC
TRANSPORT
General features of all
equipment
• Self-contained, lightweight and portable
• Durable and robust
• Long battery life and short recharge time
• Clear displays
• Suitable for all ages
• Visible and audible alarms
• Data storage and download capability
• Secure
Batteries
• Use external sources of power when
available.
• Choose equipment that is not solely
reliant on internal rechargeable batteries.
• Do not rely on leaving them charging all
the time.
Trolleys
Ventilators
Humidification
Heat and moisture exchangers (HMEs):
Temperature maintenance
Infusion pumps
• Able to deliver flow rates from 0.1 cc/hr
• Able to bolus dose
• Should be light, compact and robust
• Easy to use
• Have alarms
• Long battery life
Suction equipment
• Portable suction units with battery power
• Foot pump suction units
Defibrillators
• Portable defibrillator or AED
Monitoring
Others
Reference
• American Academy of Pediatrics. Guidelines for Air and Ground
Transport of neonatal and pediatric patients, 3rd edition.
• David G. Jaimovich . Handbook of Pediatric and Neonatal
transport medicine, 2nd edition.
• Peter Barry.Paediatric and Neonatal critical care transport, BMJ
2003
• American Academy of Pediatrics. Pediatric Advanced life Support
provider manual 2006