Tales of a Transport Doc: The ABC and D of Stabilizing Sick Kids for Transfer

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Tales of a Transport Doc The ABC and D of
Stabilizing Sick Kids for Transfer

• Frontiers in Pediatric Hospitalist Medicine
• September 11, 2008
• Steven Martel, MD, FAAP

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Brief History of Transport

• Military medical transport - Napolean
• Newborn U.S. interfacility transport - early
  1900s
• Assisted ventilation during transport - 1950s
• Modern pediatric interfacility transport - 1970
• First Guidelines for Air and Ground Transport of
  Pediatric Patients - AAP 1986

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Ground Transport
Train transport car
Horse drawn ambulance
Model T Ford transport ambulance
Modern ambulance
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Unique Transport Vehicles
Snowmobile with patient sled
ATV with patient sled
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Air Transport
Patient strapped to fuselage!
Modern rotor wing transport
Modern fixed wing transport
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Types of Transport

• Basic Life Support Team
• Advanced Life Support Team
• Critical Care Team

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Basic Life Support

• Basic life support consists of essential
  non-invasive life-saving procedures including
  CPR, bleeding control, splinting broken bones,
  artificial ventilation, and basic airway
  management.
• Basic life support level certifications include
  emergency medical technician (EMT) and certified
  first responders.

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Advanced Life Support

• Advanced life support consists of invasive
  life-saving procedures including the placement of
  advanced airway adjuncts, intravenous infusions,
  manual defibrillation, electrocardiogram
  interpretation, etc.
• Advanced life support certifications and licenses
  include emergency medical technician -
  intermediate (EMT-Intermediate) and paramedic.

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Critical Care Transport

• Any transport team whose members include at least
  one critical care or advanced practice RN,
  Physician or NP. Many teams may also include a
  respiratory therapist.

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Purpose

• Quality patient care before and during
  transportation from referring institution
• Swoop and Scoop vs. Stay and Play
• must balance external factors distance, need for
  subspecialist or radiologic intervention, time
  needed to perform tests, procedures or studies

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Guiding Principles to Stabilization of Sick Kids

• A is for Airway
• B is for Breathing
• C is for circulation and dont forget about .
• D is for dextrose

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Pulled from the Archives

• 12 yo with seizures- IV access- given Ativan 2
  mg, phenobarbital loading dose --gt RR slow --gt
  intubated with 6.0 ETT cuffed, vent settings Tv
  7 ml/kg, Rate 15, PEEP 0, FiO2 room air.
• Labs, including glucose, and urine tox screen
  negative.

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Mechanical Ventilation
Wheres the PEEP?!
Not this peep
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Why use PEEP?

• Correct ventilatory insufficiency due to
  atelectasis
• Increase FRC
• Decrease airway resistance
• Increase dynamic lung compliance

Improved oxygenation
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Pulled from the Archives

• Term infant with meconium at delivery. Intubated
  no meconium BTC. Received PPV for poor
  respiratory effort. Noted to be tachypneic in DR
  --gt brought to nursery. RR 70-80, pulse oximetry
  92. Placed on NC oxygen 1 lpm with pulse
  oximetry improved to 96.

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Pulled from the Archives

• Just before arrival- patient had acute
  decompensation with pulse oximetry mid-80s not
  improved with increased NC flow.
• Stat CXR obtained- film available and handed to
  transport team as walking into nursery.

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Pulled from the Archives
Tracheal deviation
Large left pneumothorax
Mediastinal shift
Flattened hemidiaphragm
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Pulled from the Archives

• Upon approach to bedside, heart rate decreasing
  and pulse oximetry reading falling.

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Tension Pneumothorax

• 1-2 of term neonates have pneumothorax
• Most resolve without invasive procedures
• Physical exam findings
• Decreased breath sounds affected side
• Increased percussion note affected side
• Increased heart and respiratory rate initially
• Hypoxia
• Transillumination of the affected side

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Needle Thoracentesis

• Equipment
• 21G butterfly needle
• 3 way stopcock
• 10 ml syringe
• Betadine swab
• 1 pair sterile gloves

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Needle Thoracentesis
Second rib
Neurovascular bundle
Third rib
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ConsiderationsGround vs. Air Transport
As pressure decreases, volume of gas will
increase.
altitude
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Pulled from the Archives

• 10 mos old male with respiratory distress
  requiring non-rebreather mask and pulse oximetry
  reading 90, RR 68.
• Upon arrival, extremely irritable child with no
  access.

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Pulled from the Archives

• Child upright in car seat - grunting, flaring,
  retracting, using accessory muscles, RR 71
• Oxygen saturation 88 on non-rebreather and cool
  mist

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The x-ray says it all!
Very narrow airway- yikes!
Classic steeple sign
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Why should we care about physics?
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This is why we care about physics!
Normal airway
Obstructed airway
5 mm
2.5 mm
Resistance
16x
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Considerations

• Anesthesiologist called in from home - 15 minutes
  away
• Patient brought to OR for intubation
• Intubation with inhaled anesthetic successful
• However, child still without circulatory access!

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Intraosseous Access
Those are so 80s
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Intraosseus Insertion
Now thats a tool!
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Intraosseus Insertion
Ouch!?

• Other possible insertion sites
• Femur
• Sternum
• Humerus
• Distal tibia
• Not a good insertion site

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Considerations

• Given NS bolus 20 ml/kg x 2
• Started D5-1/2NS at 1.25 maintenance
• Foley placed
• Perfusion improved, urine output adequate

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Pulled from the Archives

• 2 mo boy presents to ER with hypothermia and
  hypovolemia.
• Access and volume given.
• Cardiac and respiratory arrest in ER.
• Patient intubated, ventilated, chest compressions
  begun.

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Pulled from the Archives

• No spontaneous cardiac activity despite CPR,
  epinephrine, calcium, and bicarb to correct
  acidosis.
• Blood sugar not checked since arrest.

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Glucose considerations
Decreased glycogen stores increased metabolic
need

Hypoglycemia
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Pulled from the Archives

• One touch glucose 17.
• Bolus of 4 ml/kg of D10 given. OT 72.
• 5 dextrose solution Y-d in to fluids.
• Epinephrine given, resumption of regular cardiac
  rhythm, dopamine started.

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Considerations

• Glucose necessary for proper cardiac function
• Check glucose frequently in critically sick
  infants and children during stabilization.
• Check temperature frequently in infants.
• Previous temperature before arrest was 2 hrs
  before event - 98.9
• Temperature taken at time of arrest - 95.9

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Take home point
The stabilization of sick children is always
about the ABC and Ds!