“Scoop and Run” or “Stay and Play”? Approach to pediatric stabilization and transport

1. “Scoop and Run” or “Stay and Play”? Approach to pediatric stabilization and transport Janis Rusin MSN, RN, CPNP-AC Pediatric Nurse Practitioner Children’s 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 IO’s 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 • Poiseuille’s 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 ETT’s • Cuffed ETT’s 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 ½ patient’s 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 can’t 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 don’t know why, find out!

24. Circulation • Compensated Shock • The body’s compensatory mechanisms are working and maintaining the body’s 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 ABC’s • 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 ABC’s, 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 IV’s • 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. 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 Disability and Dextrose

33. Exposure/Enviornment • Remember a naked child is a cold child! • Check child’s 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 IO’s 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 • It’s all about the ABC’s

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 isn’t 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