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1. Scoop and Run or Stay and Play? Approach to pediatric stabilization and transport Janis Rusin MSN, RN, CPNP-AC
Pediatric Nurse Practitioner
Childrens Memorial Hospital
Transport Team
2. Case Study 2 month old infant found in full cardiac arrest at home
Paramedics initiated CPR and continued CPR for 10 minutes until arrival in ED
3. Communication Center Call Patient arrived to ED with CPR in progress
Intubated with 3.0 ETT and being bagged
Epinephrine given X 2
Atropine given X 2
Heart rate resumed
Sodium Bicarb given X 2
Current vitals: HR-140 RR-40 BP-52/11 Temp- 90F
Vent settings: FiO2 1.0, Rate 40, PIP 20 PEEP 3
Pupils 3mm and sluggish
Cap refill 5 seconds
ABG 6.93/74.4/259/14.8/-16.9
4. On Arrival Unresponsive
Lungs clear and equal bilaterally
Capillary refill 4 seconds
Color pale/gray with cool extremities
Peripheral pulses palpable
Abdomen full and soft to palpation
Fontanel soft and flat
2 tibial IOs in place bilaterally and one PIV with maintanance and dopamine infusing at 5 mcg/kg/min
Glucose-47, K-7.0 non-hemolyzed
Succinylcholine given by ED staff but patient with gasping respiratory effort
6. The Golden Hour Concept originated in 1973 by Cowley et al.
Referred to Army helicopter use
Goal for soldiers to be within 35 minutes of definitive life-saving care
Reported a 3 fold increase in mortality with every 30 minutes away from definitive care
Resulted in less field intervention in favor of speed of transport
Interventions on transport in 1973, not comparable to our capabilities today
7. Initiation of definitive care Definitive care begins with the arrival of the transport team
Early goal directed treatment improves outcomes
Needs to begin with the local emergency departments and continue with the transport team
Early aggressive interventions to reverse shock can increase survival by 9 fold if proper interventions are done early!
Hypotension and poor organ perfusion worsens outcomes
Further improvement in the outcome of critical illness is likely if the scoop-and-run mentality is replaced by protocol driven, early goal-directed therapy in the pretertiary hospital setting
Stroud et al., (2008)
8. Initiation of definitive care Ramnarayan (2009)
Urgent vital interventions such as CPR, intubation or central venous access required in the first hour after arrival in an ICU
May indicate that inadequate stabilization was completed during transport
McPhearson and Graf (2009)
Attention to small details makes significant difference in pediatric transport
Securing ETT
Early recognition and treatment of shock
Adequate IV access
9. Adverse Events Orr et al. (2009)
Sample size 1085 pediatric patients
5% had at least one unplanned event
Airway events-Most common
Cardiac arrest
Sustained hypotension
Loss of IV line needed for inotropic support
Hypothermia
Pediatric specialized teams had longer transport times, but lower incidents of adverse events, major interventions and deaths
10. Not so fun facts Primary cardiac arrest in infants and children is rare
Pediatric cardiac arrest is often preceded by respiratory failure and/or shock and it is rarely sudden
Early intervention and continued monitoring can prevent arrest
The terminal rhythm in children is usually bradycardia that progresses to PEA and asystole
Septic shock is the most common form of shock in the pediatric population
80% of children in septic shock will require intubation and mechanical ventilation within 24 hours of admission
11. Method to the madness Stabilization goals on transport
Airway/Breathing
Respiratory distress and failure
Circulation
Shock identification and management
Disability
ICP management
Exposure
Avoid hypothermia
12. Airway The respiratory systems continues to develop until 8-10 years of age
The pediatric airway is considerably smaller than the adult airway
Poiseuilles Law: If radius of airway is reduced by half, the resistance in increased by 16 fold!
The cricoid cartilage is the most narrow point of airway
Serves as a natural cuff for ETTs
Cuffed ETTs may be used in young children but only inflate cuff to minimize air leak
13. Respiratory Distress A compensated state in which oxygenation and ventilation are maintained
Define oxygenation and ventilation
How will the blood gas look?
Characterized by any increased work of breathing
Flaring, retractions, grunting
What is grunting?
14. Respiratory Failure Compensatory mechanisms are no longer effective
Inadequate oxygenation and/or ventilation resulting in acidosis
Abnormal blood gas with hypercapnia and/or hypoxia
Medical emergency! Must protect airway!
Strongly consider intubation
15. Respiratory Failure Major events that lead to respiratory failure:
Hypoventilation
Decreased LOC
Diffusion impairment
Alveolar collapse or obstruction
Pulmonary edema
Pneumonia
Intrapulmonary shunting and V/Q mismatch
Alveoli are ventilated but not perfused-raising FiO2 may not improve PaO2
Lungs perfused but not ventilated
Asthma, ARDS, pneumonia, PPHN
16. Endotracheal Tubes Size
Pediatric patient:
16 + age in years
4
Compare to little finger
Neonates
See table
17. Endotracheal Tubes Length of tube estimated by the following:
Children > 1 year of age:
13 plus patients age
Infants < 1 year of age:
Estimated 3x ETT size
18. Respiratory assessment and management on transport Across the room
As you approach patient
Alert, pink, restless, combative?
Airway
Assess positioning
Airway noise?
Intubated?
ETT secure and in proper position
T2-T4-Above carina
19. Respiratory assessment and management on transport Tired appearance/decreased or altered LOC
Children have thin chest walls that make it relatively easy to hear their lung sounds. If you cant hear them, something is wrong!
Anxiety-Air hunger
Cyanosis does not become clinically apparent until
< 88%
Stridor/snoring respirations
Head bobbing
Prolonged expiration
20. Respiratory assessment and management on transport 100% oxygen via NRB mask
Wean O2 as patient stabilizes using face mask or nasal cannula
Provide bag valve mask ventilation for children who are not breathing effectively
Unable to maintain O2 sats on oxygen
Cyanosis
Unable to protect airway
Bag with enough force to make chest rise
1 breath every 3 seconds
CE hand position
Do not occlude airway with your fingers!
21. Rapid Sequence Intubation Goals of RSI
Induce anesthesia and paralysis to facilitate rapid completion of procedure
Minimize elevations of ICP and blood pressure
Prevention of aspiration and ventilation of stomach
Sellick Maneuver
Compression of the cricoid cartilage
Compresses esophogus to prevent aspiration
Improves visualization of vocal cords
22. Rapid Sequence Intubation Procedure
Oxygenate with FiO2 of 1.0
Administer atropine
Prevents vagally induced bradycardia
Minimizes secretions
Administer an opiate and benzodiazepine
Sedation
Administer paralytic
Relaxes all muscles allowing ease of opening airway and controlling breathing
Proceed with intubation
23. Circulation Shock
An abnormal condition of inadequate blood flow to the body tissues, with life threatening cellular dysfunction
Remember: CO = HR X SV
Oxygen delivery to the tissues is the product of cardiac output
Mortality rate varies from 25-50%
Earliest symptom is tachycardia
Tachycardia in a child always has a cause-if you dont know why, find out!
24. Circulation Compensated Shock
The bodys compensatory mechanisms are working and maintaining the bodys most important functions
Blood pressure is maintained
Symptoms of early shock include:
Mild tachycardia
Mild tachypnea
Slightly increased capillary refill time
Weak peripheral pulses
Decrease in urine output and bowel sounds
Cool/mottled extremities
25. Circulation Decompensated Shock
The compensatory mechanisms are no longer effective
Blood pressure begins to deteriorate-this is what distinguishes compensated from decompensated shock!
Symptoms become more pronounced:
Tachycardia/tachypnea
Diminished or absent peripheral pulses
Very delayed capillary refill and cold extremities
Pallor
Poor or absent urine output
Fluid shifts causing generalized edema
Petichiae: DIC
Hypothermia
26. Types of shock Hypovolemic Shock
Occurs from loss of blood or body fluid volume from the intravascular space
Causes can be injury, vomiting or diarrhea
Cardiogenic Shock
Pump Failure
Inability of the heart to maintain adequate cardiac output
SVT, arrhythmias, cardiomyopathy, heart block
Support ABCs
Treat the cause
27. Types of shock Obstructive Shock
Inadequate cardiac output due to an obstruction of the heart or great blood vessels
Cardiac tamponade
Tension Pneumothorax
Mediastinal mass
Support ABCs, but fluids may not be the best option. The obstruction must be relieved
28. Distributive Shock Septic shock
Systemic infection as evidenced by a positive blood culture
Clinical presumptive diagnosis important
Patient in early septic shock will have bounding pulses and warm extremities
Also known as warm shock
29. Distributive Shock Septic shock:
Bacterial organisms release toxins, which results in an inflammatory response and cellular damage
Bacterial toxins serve as vasodilators resulting in loss of vascular tone
Increased capillary permeability
Fluid shifts to extracellular space
Hypotension may not respond to fluid resuscitation
Inotropic support
Early antibiotics
80% of children in septic shock will require intubation and mechanical ventilation within 24 hours of admission
30. Distributive Shock Neurogenic shock:
Severe head or spinal injury
Decreased sympathetic output from the CNS
Decreased vascular tone
Anaphylactic shock:
Antibody-antigen reaction stimulates histamine release
Histamine is a powerful vasodilator
Loss of vascular tone
31. Shock Management Venous access: Ideally 2 large bore IVs
Fluid resuscitation: 20ml/kg bolus of NS or LR
Reassess patient after each bolus
Convert to blood bolus if patient is bleeding
Inotropic support for hypotension that persists despite fluid resuscitation-Beware of catecholamine resistant shock!
Treat hypothermia
Correct F/E imbalances
Find the cause and fix it!
32. Disability and Dextrose AVPU scale
Alert: Patient is A & O X 3
Verbal: Patient requires verbal stimulation to wake and respond
Pain: Patient requires painful stimuli to wake and respond
Unresponsive: Patient does not respond to any stimuli Dextrose
Children in distress become hypoglycemic quickly
Altered mental status can be a sign of hypoglycemia
Check accucheck or i-Stat
Treat hypoglycemia with 2ml/kg of D10W
Recheck accucheck q 15-30 minutes
33. Exposure/Enviornment Remember a naked child is a cold child!
Check childs temperature
Warm IV fluids if possible: room temperature fluids are about 20 degrees colder than normal body temperature
Warm blankets for transport
Portawarmer mattress: Can use more than one for an older child
Place under blanket to avoid burns to skin
Hypothermia exacerbates acidosis!
34. Family Presence On transport, the family is almost always present either at the OSH or in the ambulance
The literature shows that most clinicians are concerned that parents will interfere with care if allowed to be present during resuscitation
However, this is rarely the case
In fact, some studies show that care is improved when a parent is present
There is no evidence to suggest that the legal risk increases with parental presence
What would you want if it were your child?
Dingeman et al. (2007)
35. X-Ray evaluation Systematic approach
Check patient name
Check time of film-use most recent
Air is black and solid structures are white due to increase density
Ribs should be same length on both sides
Asymmetry may indicate rotated position
Check for ETT placement, line placements and for immediate life threats
36. X-Ray evaluation
37. X-Ray evaluation
38. X-Ray evaluation
39. X-Ray evaluation
40. Back to the case study Current vitals: HR-140 RR-40 BP-52/11 Temp- 90F
Vent settings: FiO2 1.0, Rate 40, PIP 20 PEEP 3
Cap refill 5 seconds
ABG 6.93/74.4/259/14.8/-16.9
2 tibial IOs in place bilaterally and one PIV with maintanance and dopamine infusing at 5 mcg/kg/min
Glucose-47, K-7.0 non-hemolyzed
Succinylcholine given by ED staff but patient with gasping respiratory effort
41. Interventions Re-tape and pull back ETT 1 cm
Increase PEEP to +5
Sedation with Fentanyl 1-2 mcg/kg
Treat hypoglycemia-2ml/kg of D10W
Provide adequate paralysis with pavulon
Give Calcium Chloride-Why?
Give dextrose to increase accucheck to 100, then give regular insulin 0.1u/kg-Why?
42. What happened? Patient sedated and paralyzed appropriately
CaCl and bicarb given as ordered
Recheck of accucheck after dextrose =112
Insulin given as ordered
Accucheck dropped to 42 so D10W repeated
One IO was infiltrated so new PIV started
Repeat ABG 6.94/92.1/233/18.8/-13.1
BP dropped after pavulon, so dopamine titrated up-to 20mcg/kg/min
Pt diagnosed with Influenza A
43. Summary Transporting critically ill children requires a systematic approach
Attention to details will help to avoid adverse events
Be prepared before you move
Minimize major interventions in ambulance or helicopter
Its all about the ABCs
44. References Ajizian, S.J., Nakagawa, T.A., Interfacility Transport of the Critically Ill Pediatric Patient. Chest. 2007; 132: 1361-1367
Cowley, R.A., Hudson, F., Scanlan, E., Gill. W., Lally, R.J., Long, W., et al. An Economical and Proved Helicopter Program for Transporting the Emergency Critically Ill and Injured Patient in Maryland. The Journal of Trauma. 1973; 13(12): 1029-1038
Dingeman, R.S., Mitchell, E.A., Meyer, E.C., Curley, M.A.Q. Parent Presence during Complex invasive Procedures and Cardiopulmonary Resuscitation: A Systematic Review of the Literature. Pediatrics. 2007; 120(4): 842-854
Horowitz, R., Rozenfeld, R.A., Pediatric Critical Care Interfacility Transport. Pediatric Emergency Medicine. 2007; 8: 190-202
45. References Kliegman, R.M., Behrman, R.E., Jenson, H.B., Stanton, B.F. (eds.), Nelson Textbook of Pediatrics, 18th ed., 2004, Philadelphia, Saunders Elsevier
McCloskey, K.A.L., Orr, R.A. Pediatric Transport Medicine, 1995, St. Louis, Mosby
McPherson, M.L., Graf, J.M., Speed isnt Everything in Pediatric Medical Transport. Pediatrics. 2009;124(1): 381-383
Orr, R.A., Felmet, K.A., Han, Y., McCloskey, K.A., Drogotta, M.A., Bills, D.M., et al. Pediatric Specialized Transport Teams are Associated with Improved Outcomes. Pediatrics. 2009; 124: 40-48
Stroud, M.H., Prodhan, P., Moss, M.M., Anand, K.J.S. Redefining the Golden Hour in Pediatric Transport. Pediatric Critical Care Medicine. 2008; 9(4): 435-437