IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau Pediatric Transport &...
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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]
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
RECEIVINGREFERRING
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
PATIENT CENTERED
•Partnership
•Team work
•Communication
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
• 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?
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
Considerations
• Airway management– Space limitations– Light limitations
• IV access
• Temperature control
• Pertinent labs: – glucose, updated ABG/CBG
• OG/NG
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
• 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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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
• 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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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
• 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
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
Disease process that can potentially worsen in flight?
Pressurized aircraft (Lear or Turbo-prop)?
If not pressurized, flight altitude?
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
Bellingham (Airlift 5)
Arlington (Airlift 6)
Seattle (Airlift 2)
Olympia (Airlift 3)
ALNW: Rotary BasesALNW: Rotary Bases
Arlington
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
CHANGES
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
CURRENT TRENDS IN PEDIATRICS
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
• 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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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
KEY TEACHING FOCUS • Can know the differences between pediatric
patients & Adults BUT …
• IF LACK OF TIMELY & CORRECT INTERVENTION OF
RESUSCITATION, IT DOESN’T MATTER…..
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
• 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
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
• 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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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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….
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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.
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
Literature• Use of the LMA is included in:
– The guidelines for cardiopulmonary resuscitation – ACLS/PALS
– NRP– Difficult Airway Algorithm
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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.
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
• 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
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• ABSENCE OF BLOOD PRESSURE MONITORING WAS ASSOCIATED WITH YOUNG AGE, INCREASED SEVERITY OF ILLNESS & POOR OUTCOME
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
• 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
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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.
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
• 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
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle IN ALASKA: Juneau
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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; 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.
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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