Appearance : TICLS MnemonicTone Refers to child’s muscle toneInteractivity Refers to degree of interaction the child has with his/her environment or those attempting to interact with the childConsolability Refers to the child’s response to parents or caregiversLook /gaze Identifies whether the child tracks things appropriately with his/her eyes or has a nonfocused gaze.Speech/cry Refers to how the child vocalizes
Primary assessment A B • Airway • Breathing • Circulation E C • Disability • Exposure D
Airway• Patency• Need simple management positioning head tilt-chin lift Use airway adjuncts ( oral airway)• Require advanced intervention ET intubation cricothyroidotomy CPAP
Normal respiratory ratesby age Age Breaths per minutesInfant (<1 year) 30 to 60Todler( 1-3 yrs) 24 to 40Preschooler ( 4-5 yrs) 22 to 34School age ( 6-12 yrs) 18 to 30Adolescent ( 13-18 yrs) 12 to 16
Respiratory rate • Apnea • Tachypnea • Bradypnea Bradypnea or irregular respiratory rate in anaccutely ill infant or child often signals impending arrest
Pulse oximetry • Above 94% in room air • Additional intervention is required if O2 sat<90% in child receiving 100% oxygen . • Be careful to interpret pulse oximetry in conjunction with clinical assessment and other signs.
Circulation• Evaluate cardiovascular • Evaluate end-organ function function heart rate and rhythm brain perfusion pulses skin perfusion capillary refill time renal perfusion blood pressure and pulse pressure
Normal heart rates in children Age Awake rate Mean Sleep rate NB to 3 mo 85-205 140 80-160 3 mo to 2 y 100-190 130 75-160 2 y to 10 y 60-140 80 60-90 >10 y 60-100 75 50-90 Typical physiologic response to a fall in cardiac output is tachycardia.
Blood pressureDefinition of hypotension Age Systolic BP (mmHg) Term neonates <60 Infants <70 Children 1-10 yr 5th BP percentile <70 + (age in years x 2) Children > 10 yr <90
Systemic perfusion• Peripheral Pulses – Present/Absent – Strength• Skin Perfusion – Capillary refill time – Temperature – Color – Mottling
Secondary assessment• Signs and Symptoms• Allergies• Medications• Past medical history• Last meal• Events leading to presentation
Pediatric assessment flow chart General assessment PAT If any time during the Primary assessment assessment A-B-C-D-E and categorization process You identify a Secondary assessment : life-threatening condition SAMPLE Tertiary assessment Immediately initiate Respiratory Circulatory life-saving interventions and activate theRespiratory distress Compensated shockRespiratory Failure Hypotensive shock emergency response systemRespiratory +circulatory
Breathing is everything to a child• The common denominator for unexpected deaths in children is hypoxia.• Do not increase the childs level of anxiety
Not only the child• Needs of parents or caregivers must be addressed.• Be calm and confident.• Written information and involve them in plan of care.
Stabilization of the respiratorysystem • Well oxygenated and ventilating prior to transfer • Consider the need for intubation and mechanical ventilation. • Confirm ETT placement and secure the tube. • Obtain blood gases while ventilating on the transport ventilator before leaving • Consider the need for sedation and paralysis
Stabilization of thecardiovascular system• Hemodynamically stable before departure.• Treat compensated shock before departure.• Invasive arterial blood pressure monitoring in patients with inotropic support.• At least 2 good, working points of IV access.• Ensure availability of emergency or special drugs
Medications to Maintain Cardiac Output and for Postresuscitation Stabilization Medication Dose Range Comment 0.75–1 mg/kg IV/IO over 5Inamrinone minutes; may repeat × 2 Inodilator then 5-10 mcg/kg/minDobutamine 2–20 mcg/kg/min IV/IO Inotrope; vasodilator 2–20 mcg/kg/min IV/IO Inotrope; chronotrope; renal andDopamine splanchnic vasodilator in low doses; pressor in high dosesEpinephrine 0.1–1 mcg/kg/min IV/IO Inotrope; chronotrope; vasodilator in low doses; pressor in higher doses Loading dose: 50 mcg/kg IV/IOMilrinone over 10–60 min Inodilator then 0.25-0.75 mcg/kg/minNorepinephrine 0.1–2 mcg/kg/min VasopressorSodium Initial: 0.5–1 mcg/kg/min; titrate Vasodilator to effect up to 8 mcg/kg/minnitroprusside Prepare only in D5W
Stabilization of the central nervoussystem • Minimize secondary brain injury due to hypotension and hypoxia • Appropriate treatment of prolonged seizures • Adequate sedation
Stabilization of the gastrointestinalsystem • Placement of a nasogastric tube and left on free drainage. • Stop feeding and aspirate the stomach before transfer.
Stabilization of the renal system • Consider urethral catheterisation in children – with shock – who are paralysed and sedated – who have received diuretics or mannitol
Transport team assessment andinitial stabilization • Rapid assessment • Urgent therapy and manage life-threatening conditions is priority • Have patient as stable as possible before loading into the transport vehicle.
General features of allequipment• Self-contained, lightweight and portable• Durable and robust• Long battery life and short recharge time• Clear displays• Suitable for all ages• Visible and audible alarms• Data storage and download capability• Secure
Batteries• Use external sources of power when available.• Choose equipment that is not solely reliant on internal rechargeable batteries.• Do not rely on leaving them charging all the time.
Reference • American Academy of Pediatrics. Guidelines for Air and Ground Transport of neonatal and pediatric patients, 3rd edition. • David G. Jaimovich . Handbook of Pediatric and Neonatal transport medicine, 2nd edition. • Peter Barry.Paediatric and Neonatal critical care transport, BMJ 2003 • American Academy of Pediatrics. Pediatric Advanced life Support provider manual 2006