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