Pediatric Transport

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Pediatric Transport Considerations in
Pediatric Care

• Jo Price RN, ARNP, DNP
• ALNW QI Education Department
• Joanne.price_at_airliftnw.org

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RECEIVING
REFERRING
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PATIENT CENTERED

• Partnership
• Team work
• Communication

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WHO ARE THESE KIDS?

• 10-18 pre-hospital calls pediatric
• 25-34 emergency room
• Airlift statistics
• 20 of flights are children lt 21 years
• Of this, 57 are trauma
• CSHCN represent 35 to 60 pediatric ALNW TX
• Often higher than AAP statistics
• Reflects use of medical home and survival
• Use of AAP Emergency Sheet?

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Ground versus Air Considerations

• How important is time?
• Time sensitive conditions ischemic stroke,
  ischemic limb
• Potential to quickly decompensate (ICH,
  intra-abdominal injuries, chest trauma, etc)
• Unstable patients
• Realistic transport time
• Distance
• Geography (mountain passes, peninsula, islands)
• Traffic patterns

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Air versus Ground Considerations

• Safety risk benefit analysis
• Out of hospital time
• What will the actual uncontrolled time be?
• Crew Capabilities not all ALS crews are the same
• Capacity of ALS crew in community can they
  leave?
• Altitude
• Cost

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Considerations

• Airway management
• Space limitations
• Light limitations
• IV access
• Temperature control
• Pertinent labs
• glucose, updated ABG/CBG
• OG/NG

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• OR CAN IT WAIT?
• Will it change therapy?
• Hospital CT scan/x-ray Can it be pushed through
  in a timely manner or need to be repeated?

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Specific considerations

• Infection/sepsis antibiotics priority
• Lactate and recent blood gas
• Trauma splinting/BB/Pediboard
• Changes occurring in who gets boarded
• Nexus criteria, Canadian C-spine
• Bronchiolitics suctioning
• RESPONSE

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• Asthma dexamethasone early. High dosing
  albuterol
• Croup dexamethasone early. Racemic if stridor at
  rest. Humidity minimal evidence
• DKA over fluid resuscitation common issue
• 40cc/kg high risk PICU admission

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Medically complex

• CSHCN numbers rising
• Multisystem involvement
• Home equipment?
• significant fraction of health care resources
• More likely to receive advance life support
  prehospital procedures
• Increased focus of care coordination EIF forms

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Education Resource

• http//depts.washington.edu/pedtraum/
• Online curriculum in the acute assessment and
  management of pediatric trauma patients, hosted
  by Harborview Medical Center (Seattle, WA)
• EMSC (Emergency medical services for children)
  National Resource CENTER www.childrensnational.or
  g/EMSC (search for prehospital)
• SCOPE Special Childrens Outreach prehospital
  education. The center for prehospital pediatrics
  at Childrens National Medical Center
• http//www.childrensnational.org/emsc/pubres/oldto
  olboxpages/prehospitaleducation.aspx

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The principle effects that flight has on the
human body

• Hypoxia
• Gas expansion
• Temperature changes
• Noise
• Vibration

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• Disease process that can potentially worsen in
  flight?

• Pressurized aircraft (Lear or Turbo-prop)?

• If not pressurized, flight altitude?

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ALNW Rotary Bases

• Bellingham (Airlift 5)
• Arlington (Airlift 6)
• Seattle (Airlift 2)
• Olympia (Airlift 3)

Arlington
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Dedicated Rotary Aircraft
EC 135 (Eurocopter)
Augusta A109 A model
Cruise speed 160 mph, range 200 miles Single
pilot, twin engine. instrument flight capable.
Different stretchers
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Dedicated Fixed Wing Aircraft

• Turbo Commander
• 12 hour based in Yakima
• Lands on shorter runways
• Serves smaller airports Ellensburg, Omak,
  Tonasket, Chelan, Sunnyside

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Dedicated fixed wing aircraft

• Two Lear 31 A jets based at Boeing Field
• Serves Eastern Washington, Montana, and Southeast
  Alaska
• Cruise speed 500 mph, range 1200 miles
• Lear 31A based in Juneau, Alaska
• Serves southeast Alaska
• Cruise speed 500 mph, range 1200 miles

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Rotary/FW Aircraft ALS Equipment

• Transport ventilator (Draeger Oxylog 3000)
• Invasive and non-invasive monitor
• Cardiac monitor/defibrillator with pacing and 12
  lead ECG.
• Multi-channel infusion pump
• I-Stat
• Glide Scope video-laryngoscopy

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Flight team

• Two critical care nurses
• Pediatric/Neonatal Intensive Care experienced
• Adult Critical Care experienced/Adult Certified
  Emergency Nurse
• Cross-trained to manage and transport all age
  patients, ill or injured
• Neonates, pediatrics, adults, high-risk
  obstetrics
• Trained in altitude flight physiology, aircraft
  safety
• Certifications ACLS, PALS, NRP, BLS, ATCN
• Airway management adjuncts surgical cric

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What to expect of crew

• Accurate ETA.if no fog, no snow etc..
• Door closed lt 10 min (RW), Wheels up lt 15
• AIDET
• Prioritization for our circumstances
• Time Management
• lt10 minute field
• lt30 minute interfacility (age specific)
• Medical control contact
• Protocol driven

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Hand-off

• SAMPLE hx. if time or
• D-MIVT report style focus
• Medical necessity Form
• Films/chart with face sheet
• Parental information if ride along (to Comm.)
• Complete name
• Weight
• Priority meds and/or blood products ready to go

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CHANGES
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CURRENT TRENDS IN PEDIATRICS
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Color Coding Tools

• Tools that help clinicians quickly assess
  pediatric patients
• select medications, doses, and equipment
• Has the potential to improve pediatric patient
  outcomes during resuscitation IF USED CORRECTLY
• Broselow Pediatric Emergency Tape and/or the
  Broselow Pediatric Emergency Cart.
• shown to decrease time to mobilize resuscitation
  equipment, and increase the accurate selection of
  equipment (Agarwal et.al, 2005).

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Safe Practice Recommendations

• Update tapes. Replace outdated Broselow tapes
  with the most recent edition (2011)
• ADJUSTMENTS FOR WEIGHT CHANGES
• Standardize concentrations. Provide standard
  concentrations for resuscitation medications
  stocked
• Stock Shortages communication re what is
  replaced
• Organize carts.

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Simulation training

• Simulation on in-hospital pediatric medical
  emergencies trial
• Significant delays deviations occur in major
  components of pediatric resuscitation
• Median time to airway assessment 1.3 minutes
• To administering O2 2 minutes
• To recognize need for IO 3 minutes
• To assess circulation 4 minutes
• To arrival of physician on to floor 3 minutes
• Arrival of first member of actual code team 6
  minutes
• CPR scenarios elapsed time to starting
  compressions 1.5 minutes

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• 75 of codes deviated from AHA PALS
• Communication error 100 of mock codes
• DELAYS WERE NORM NOT EXCEPTION LACK OF TIMELY
  INITIATION OF RESUSCITATION MANEUVERS
• Importance of floor staff initiating actions
• Leadership important component of successful
  teamwork

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KEY TEACHING FOCUS

• Can know the differences between pediatric
  patients Adults BUT
• IF LACK OF TIMELY CORRECT INTERVENTION OF
  RESUSCITATION, IT DOESNT MATTER..

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Airway Controversies

• Cuffed versus Uncuffed Tubes
• Historically not recommended in children under
  the age of 8 to 10 years until the mid-1990s.
• Pediatric anesthetists intensivists use
  2000-2001
• Current evidence demonstrates this recommendation
  is outdated.

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• Two recent transports
• Received 4 yr old with 5.5 cuffed ETT
• Received 2 year old 5 cuffed tube
• Both had significant stridor on extubation with
  use of raecemic epi, dexamethasone, heliox
• The 4 year old needed emergent re-intubation in
  the OR severe sub-glottic stenosis could pass a
  4 uncuffed tube only

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International Liaison Committee on Resuscitation
BUT THE CUFF WAS NOT THE PROBLEM.

• Cuffed tracheal tubes are as safe as uncuffed
  tubes for infants (except newborns) and children
  if rescuers use the correct tube size and cuff
  inflation pressure and verify tube position.
  Under certain circumstances (e.g., poor lung
  compliance, high airway resistance, and large
  glottic air leak), cuffed tracheal tubes may be
  preferable. The International Liaison Committee
  on Resuscitation (ILCOR) Consensus on Science
  with Treatment Recommendations for Pediatric and
  Neonatal Patients Pediatric Basic and Advanced
  Life Support

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Pros of cuffed tubes

• The presence of a leak is not a reliable
  indicator that there is no undue pressure from
  the tube on the cricoid mucosa
• The contours of the airway and of the tube are
  different.
• Using a cuffed tube would permit the use of a
  smaller tube, reducing the dangers of pressure
  damage at the laryngeal inlet and cricoid.
• The presence of a cuff may ease tube tip away
  from anterior tracheal wall reducing the
  incidence of tube tip damage.
• Cuffed ETTs protect better against aspiration
  than an uncuffed ETT.

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Cuffed Tube Safety

• For the safe use of the cuffed tracheal tube, the
  following rules should be respected
• On Broselow, ½ size down if cuffed tube
• An air leak to be present after intubation at
  20 cm H2O airway pressure with the cuff not
  inflated.
• Feeling cuff not adequate method to check
  inflation
• Check with a manometer
• Should use bags with inbuilt manometer AND PEEP

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Literature

• Use of the LMA is included in
• The guidelines for cardiopulmonary resuscitation
  ACLS/PALS
• NRP
• Difficult Airway Algorithm

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Advantages to use

• Speed and ease of placement
• Avoidance of endo-bronchial and/or esophageal
  intubation
• Regurgitation and gastric distention is less
  likely
• Avoidance of sympathetic response to DL
• Does not require head/neck/jaw manipulation
• Minimal training required

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Disadvantages

• Failure to protect from aspiration
• Inability to provide high-pressure seal
• Unable to ventilate poorly compliant lungs
• Difficult to suction the airway
• Cannot reliably administer intra-tracheal
  medications
• Additional training and
• skill maintenance

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Approximately 650,000 children evaluated in ED
each year for head trauma with 475, 000 confirmed
TBIs in children lt 15 yrs. Greater than 2000
children die from TBI and 42,000 require
hospitalization.
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Primary brain injury at time of impact. 50 of
those that die with TBI do so within the first 2
hrs.
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Secondary brain injury evolving over the next few
minutes, hours days, resulting in disability
mortality. POST INJURY HYPOTENSION AND HYPOXIA
BELIEVED TO INDUCE SECONDARY BRAIN INJURY ARE
ASSOCIATED WITH INCREASED MORBIDITY MORTALITY
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Hypotension Findings 2008 Study

• 31 not monitored for Hypotension
• Most often occurred during scene EMS time
• In children w/o documented hypotension, those not
  fully monitored had a Relative Risk of
  in-hospital death of 4.5 compared to those fully
  monitored
• Hypotension documented in 39 of children
• Least likely to be treated at the scene (only
  treated 12 of time at scene) more likely to be
  treated on arrival to hospital
• Children not fully monitored younger smaller

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• ABSENCE OF BLOOD PRESSURE MONITORING WAS
  ASSOCIATED WITH YOUNG AGE, INCREASED SEVERITY OF
  ILLNESS POOR OUTCOME

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HYPOXIA

• 34 of children not monitored for O2 sat or apnea
  during portion of their early care
• Hypoxia or apnea documented in 44 of children in
  the study
• Hypoxia/apnea also occurred most often at scene
• EMS personnel treated noticed hypoxia or apnea
  87. Air-medical ED treated 100

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Hypoxia

• Children with hypoxia were significantly younger
  smaller than children without documented
  hypoxia.
• I dont need numbers, I go by the LOC
• Problem.
• Those not monitored had lower median GCS scores
  than children who were fully monitored.

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Take Home Message on TBI Monitoring

• Study showed that early hypotension and
  hypoxia/apnea are common events in pediatric TBI
  and are strongly associated with worse outcomes
• QA Opportunity Chart/Systems Reviews
• BP documented in specified time period
• If not why not?
• Saturation documented within specified time
  period
• Appropriate Interventions?

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References

• Agarwal, Swanson, Murphy, Yaeger, Sharek,
  Halamek, (2005). Comparing the utility of a
  standard pediatric resuscitation cart with a
  pediatric resuscitation cart based on the
  Broselow tape a randomized, controlled,
  crossover trial involving simulated resuscitation
  scenarios. Pediatrics. 116 (3) e326-33
• Cox, R.G. (2005). Should cuffed endotracheal
  tubes be used routinely in children? Canadian
  Journal of Anesthesia, 52(7), 669-674
• Felten, M.L., Schmautz, E., Delaporte-Cerceau,
  S., Orliaguet, G.A., Carli, P.A. (2003).
  Endotracheal tube cuff pressure is unpredictable
  in children. Anesthesia Analgesia, 97,
  1612-1616.
• Hohenhaus SM, Frush KS. Pediatric patient safety
  common problems in the use of resuscitative aids
  for simplifying pediatric emergency care. J Emerg
  Nurs 2004 3049-51.
• Hohenhaus S. Assessing competency the
  Broselow-Luten resuscitation tape. J Emerg Nurs
  2002 2870-2.
• Golden, S. (2005). Cuffed vs. uncuffed
  endotracheal tubes in children a review. Society
  for Pediatric Anesthesia, Winter 2005, 10.

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• James, I. (2001). Cuffed tubes in children.
  Paediatric Anaesthesia, 11, 259-263.
• Neonatal hypoglycemia initial and follow-up
  management. National Guideline Clearinghouse
  www.guideline.gov
• Wagner, C., Mazurek, P. (2006). Current Practices
  in Pediatric Immobilization- An Editorial. Air
  Medical Journal , 25 (4) 144-148
• Weeks, D., Molsberry, D. (2008). Pediatric
  advanced life support re-training by
  videoconferencing compared to face-to-face
  instruction A planned non-inferiority trial.
  Resuscitation, 79 p 109-117
• Zebrack, M., Dandoy, C., Hansen, K., Scaife, E.,
  Clay Mann, N., Bratton, S. (2009). Pediatrics,
  124 56-64