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Acem 2011 pediatric transport darin

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For ACEM 2011 participation : Critical Care transfer

For ACEM 2011 participation : Critical Care transfer

Published in: Education, Health & Medicine
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  • 1. Pediatric Transport Darin Aranwutikul, MD.
  • 2. GoalEarly stabilization and initiation of advanced care at the referring institution, with continuation of critical care therapies and monitoring en route.
  • 3. Recognition & assessment ofthe sick childPediatric assessment triangle(PAT): A-B-C
  • 4. 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
  • 5. Primary assessment A B • Airway • Breathing • Circulation E C • Disability • Exposure D
  • 6. Airway• Patency• Need simple management  positioning  head tilt-chin lift  Use airway adjuncts ( oral airway)• Require advanced intervention  ET intubation  cricothyroidotomy  CPAP
  • 7. Breathing • Respiratory rate • Respiratory effort • Airway and lung sounds • Pulse oximetry
  • 8. 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
  • 9. Respiratory rate • Apnea • Tachypnea • Bradypnea Bradypnea or irregular respiratory rate in anaccutely ill infant or child often signals impending arrest
  • 10. Abnormal lung and airway sounds • Stridor upper airway obstruction • Wheezinglower airway obstruction • Grunting lung tissue disease • Crackles  lung tissue disease
  • 11. 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.
  • 12. 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
  • 13. 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.
  • 14. 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
  • 15. Systemic perfusion• Peripheral Pulses – Present/Absent – Strength• Skin Perfusion – Capillary refill time – Temperature – Color – Mottling
  • 16. Systemic perfusion• CNS Perfusion – Level of consciousness• Renal Perfusion – Urine 1-2 cc/kg/hr
  • 17. Disability • Establish the childs level of consciousness • Standard evaluations are  AVPU pediatric response scale  Glasgow Coma Scale (GCS)  pupillary responses
  • 18. AVPU pediatric response scale
  • 19. Glasgow Coma Scale(GCS) -
  • 20. Pupillary response
  • 21. Exposure• Remove clothing as necessary• Palpate the extremities to assess for injury• Measure core temperature• Keep the child warm• Use spine precautions when suspect spine injury
  • 22. Life threatening condition Airway • Complete /severe airway obstruction Breathing • Apnea,significant work of breathing, bradypnea Circulation • Absence pulses, poor perfusion, hypotension, bradycardia Disability • Unresponsiveness, depressed conscious • Hypothermia, significant bleeding, Exposure purpura with septic shock, acute abdomen
  • 23. Secondary assessment• Signs and Symptoms• Allergies• Medications• Past medical history• Last meal• Events leading to presentation
  • 24. 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
  • 25. Breathing is everything to a child• The common denominator for unexpected deaths in children is hypoxia.• Do not increase the childs level of anxiety
  • 26. 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.
  • 27. Children don’t have less pain than adult
  • 28. Numeric and FACES scale
  • 29. FLACC scale
  • 30. Drugs Dose (mg/kg) Route commentsAnalgesicsMorphine 0.1-0.2 ;infusion 20-50 mcg/kg/hr IV Histamine releaseFentanyl 1-2 mcg/kg;infusion 2-5 mcg/kg/hr IV,IO Chest wall rigiditySedativesDiphenhydramine 0.1 IV,POKetamine 1-2 IV,IO,IM Increased ICPlorazepam 0.1-0.2 IV,IO,IM HypotensionMidazolam 0.1-0.2 IV HypotensionPropofol 1-3; infusion 1-3 mg/kg/hr IV HypotensionPentobarbital 2-4 IV Apnea
  • 31. YOU CANNOT REMEMBERNORMAL WEIGHTS, RESPIRATORYRATES, BLOOD PRESSURES, HEARTRATES, AND CALCULATE DRUG DOSESIN YOUR HEAD SO DONT TRY
  • 32. Broselow tape
  • 33. HOW TO STABILIZE THE CHILD
  • 34. 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
  • 35. 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
  • 36. 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
  • 37. Stabilization of the central nervoussystem • Minimize secondary brain injury due to hypotension and hypoxia • Appropriate treatment of prolonged seizures • Adequate sedation
  • 38. Stabilization of the gastrointestinalsystem • Placement of a nasogastric tube and left on free drainage. • Stop feeding and aspirate the stomach before transfer.
  • 39. Stabilization of the renal system • Consider urethral catheterisation in children – with shock – who are paralysed and sedated – who have received diuretics or mannitol
  • 40. 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.
  • 41. EQUIPMENT USED IN PEDIATRICTRANSPORT
  • 42. 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
  • 43. 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.
  • 44. Trolleys
  • 45. Ventilators
  • 46. Humidification Heat and moisture exchangers (HMEs):
  • 47. Temperature maintenance
  • 48. Infusion pumps • Able to deliver flow rates from 0.1 cc/hr • Able to bolus dose • Should be light, compact and robust • Easy to use • Have alarms • Long battery life
  • 49. Suction equipment • Portable suction units with battery power • Foot pump suction units
  • 50. Defibrillators• Portable defibrillator or AED
  • 51. Monitoring
  • 52. Others
  • 53. 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

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