pediatric transport & considerations in pediatric care

IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau

Pediatric Transport & Considerations in Pediatric Care

Jo Price RN, ARNP, DNP

ALNW QI & Education [email protected]


RECEIVINGREFERRING


PATIENT CENTERED

•Partnership

•Team work

•Communication


• 10%-18% pre-hospital calls pediatric

• 25-34% emergency room

• Airlift statistics• 20% of flights are children < 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?

WHO ARE THESE KIDS?


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

Ground versus Air: Ground versus Air: ConsiderationsConsiderations


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

Air versus Ground: Air versus Ground: ConsiderationsConsiderations


Considerations

• Airway management– Space limitations– Light limitations

• IV access

• Temperature control

• Pertinent labs: – glucose, updated ABG/CBG

• OG/NG


• 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?


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


• 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


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


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.org/EMSC (search for prehospital)

• SCOPE: Special Children’s Outreach & prehospital education. The center for prehospital pediatrics at Children’s National Medical Center

• http://www.childrensnational.org/emsc/pubres/oldtoolboxpages/prehospitaleducation.aspx


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

The principle effects that flight has The principle effects that flight has on the human bodyon the human body


Disease process that can potentially worsen in flight?

Pressurized aircraft (Lear or Turbo-prop)?

If not pressurized, flight altitude?


Bellingham (Airlift 5)

Arlington (Airlift 6)

Seattle (Airlift 2)

Olympia (Airlift 3)

ALNW: Rotary BasesALNW: Rotary Bases

Arlington


EC 135 (Eurocopter) Augusta A109 A model

Dedicated Rotary AircrafDedicated Rotary Aircraftt

Cruise speed 160 mph, range 200 milesSingle pilot, twin engine. instrument flight capable. Different stretchers


Turbo Commander 12 hour based in Yakima

Lands on shorter runways

Serves smaller airports: Ellensburg, Omak, Tonasket, Chelan, Sunnyside

Dedicated Fixed Dedicated Fixed Wing AircraftWing 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

Dedicated fixed wing aircraftDedicated fixed wing aircraft


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

Rotary/FW Aircraft ALS EquipmentRotary/FW Aircraft ALS Equipment


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

Flight team Flight team


What to expect of crew

• Accurate ETA….if no fog, no snow etc…..

• Door closed < 10 min (RW), Wheels up < 15

• AIDET

• Prioritization for our circumstances

• Time Management– <10 minute field– <30 minute interfacility (age specific)

• Medical control contact

• Protocol driven


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


CHANGES


CURRENT TRENDS IN PEDIATRICS


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).


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.


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


• 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


KEY TEACHING FOCUS • Can know the differences between pediatric

patients & Adults BUT …

• IF LACK OF TIMELY & CORRECT INTERVENTION OF

RESUSCITATION, IT DOESN’T MATTER…..


• Cuffed versus Uncuffed Tubes– Historically not recommended in children under the age

of 8 to 10 years until the mid-1990’s.– Pediatric anesthetists & intensivists use: 2000-2001

• Current evidence demonstrates this recommendation is outdated.

Airway Controversies


• 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


International Liaison Committee on Resuscitation

• “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

BUT THE CUFF WAS NOT THE PROBLEM….


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 ETT’s protect better against aspiration than an uncuffed ETT.


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


Literature• Use of the LMA is included in:

– The guidelines for cardiopulmonary resuscitation – ACLS/PALS

– NRP– Difficult Airway Algorithm


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


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


Approximately 650,000 children evaluated in ED each year for head trauma with 475, 000 confirmed TBIs in children < 15 yrs.

Greater than 2000 children die from TBI and 42,000 require hospitalization.


Primary brain injury at time of impact. 50% of those that die with TBI do so within the

first 2 hrs.


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


• 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

Hypotension Findings 2008 Study


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


• 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%

HYPOXIA


Hypoxia

• Children with hypoxia were significantly younger & smaller than children without documented hypoxia.

• “I don’t need numbers, I go by the LOC…”– Problem….

• Those not monitored had lower median GCS scores than children who were fully monitored.


• 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?

Take Home Message on TBI & Monitoring


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; 30:49-51.

• Hohenhaus S. Assessing competency: the Broselow-Luten resuscitation tape. J Emerg Nurs 2002; 28:70-2.

• Golden, S. (2005). Cuffed vs. uncuffed endotracheal tubes in children: a review. Society for Pediatric Anesthesia, Winter 2005, 10.


• 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

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