SECTION VI. INITIAL STABILIZATION AND TRANSPORT
Bradley A. Kuch and Michael McSteen
Pediatric critical care transport is a highly specialized area of medicine in which a critically ill infant or child is stabilized and transported to a facility specializing in his or her care. The need for patient transport is indicated by the specific elements of care that cannot be provided by the referring institution. These may include diagnostic procedures, airway management, mechanical ventilation, or ECMO. Transferring patients to a facility specializing in this type of care is often complicated by the severity of illness of pediatric patients and the increased risk of mortality found in the transport setting. These children require more interventions (e.g., endotracheal intubation, inotropic support) and continuous cardiovascular monitoring (both invasive and noninvasive), which warrants a crew with an in-depth understanding of pediatric disease pathology and care. It has been demonstrated that identification and rapid stabilization of the pediatric patients with septic shock decrease morbidity and morbidity rates in the transport setting (Carcillo et al., 2009; Han et al., 2003). In an effort to provide the same level of care found in the PICU, the pediatric critical care specialty transport team was created and continues to grow nationwide.
In 1991, Pollack et al. set the precedent for specialized care by establishing evidence showing an associated decrease in morbidity and mortality in patients who were treated for respiratory failure and head trauma in tertiary care centers versus nontertiary centers (Pollack et al., 1991). A later investigation found that nonspecialized EMS personnel underutilized basic therapies, such as oxygen administration, during the transport of pediatric patients with respiratory illness (Scribano, Baker, Holmes, & Shaw, 2000). More recent, Orr and colleagues demonstrated improved outcomes in patients who were transported by pediatric critical care specialty teams when compared with adult teams (Orr et al., 2009). These findings were validated in a large study of children transferred to a European PICU. They reported an increased survival was associated with the use of a specialized team (Ramnarayan et al., 2010).
In 1990, the AAP recognized this area of medicine as an integral part of the pediatric emergency care system and ultimately creating the section on Transport Medicine (Woodward et al., 2002). As the support for pediatric specialty care teams grows, so does the need for education and a complete understanding of the principles associated with the safe effective transport of the critically ill child (Stroud et al., 2013).
A. Principles and Philosophy of Pediatric Interfacility Transport
1. Goals of the Critical Care Transport Team
a. To provide an extension of the critical care unit (i.e., skills, equipment) to the referring facilities
b. To provide timely and safe transportation to a pediatric critical care center without an increase in morbidity or mortality
c. To provide the highest quality of care for critically ill infants and children who require interfacility transport
2. Trauma Versus Critical Care
a. Scoop and run is the term given to the concept of transport in which a patient is taken to a facility within the “golden hour,” described as the period immediately following a traumatic injury, if surgical intervention is needed or the patient is at risk of physiologic deterioration and needs to be moved quickly to a tertiary center for a higher level of care. The philosophy has never been validated, being developed in an era when prehospital personnel did not provide advanced airway management. Therefore, patients were at increased risk for adverse events, including death, during transport.
i. Nonspeciality care teams have adopted the “scoop and run” philosophy of patient transport as the standard of practice in the trauma setting. One reason is that there is little triage by a coordinating physician at the time of a trauma call. Most calls received are from local EMS personnel at the scene; thus all calls are considered critical and deserve immediate transport to a trauma care center.
ii. A clinical situation in which scoop and run would be appropriate would be, for example, a patient who had uncontrollable bleeding, significant head injury for which the immediate lifesaving intervention for a 845surgical emergency would be an emergent trip to the operating room.
iii. Time is critical in regard to the time of arrival to the scene or referral to a facility by a team that can provide critical care interventions.
b. Stay and play suggests that certain aspects of resuscitation must be delivered as quickly as possible (McCloskey & Orr, 1995). The initial trauma resuscitation of any patient starts with the ABCs and must be delivered at either the accident scene or the referring institution.
i. Increased survival rates have been documented in infants and children with shock who received early resuscitative interventions by community hospital physicians leading to shock reversal (Carcillo et al., 2009; Han et al., 2003).
ii. This goal-directed approach to transport care is supported by the American Heart Association PALS concept for treating shock and respiratory failure (Stroud et al., 2015).
3. Legal Issues
a. Consolidated Omnibus Budget Reconciliation Act (COBRA)/Emergency Medical Treatment and Active Labor Act (EMTALA). The COBRA passed in 1986 was intended to prevent patients with unstable medical conditions from being transferred without treatment from the initial hospital (Stroud et al., 2013). The statute is also known as EMTALA and more accurately describes the statute. Under EMTALA, physicians are obligated to stabilize patients with identified emergency conditions. EMTALA defines stabilized—a prerequisite for transport to mean no deterioration is likely to result from or occur during transfer (Stroud et al., 2013). Responsibilities of the referring physicians and hospitals include, but are not limited to, the following:
i. Provide all medical treatment within its capacity.
ii. Stabilize the patient prior to transfer.
iii. Identify a receiving hospital that will accept and provide qualified personnel to treat the patient’s clinical needs.
iv. Qualified personnel, with appropriate equipment, must accompany the patient.
b. The decision of who is best qualified to assist the referring hospital in the safe transport of the neonatal or pediatric patient is most often made by the common consent of the referring doctor and the receiving hospital physician.
4. Patient Family Issues. The transport team’s role in the area of family support has continued to undergo many changes (American Association of Critical-Care Nurses [AACN], 2016). Previously, most teams rarely allowed family members to travel with the patient and team. The psychological impact on families in acute or worsening medical conditions (see Chapter 1) has been considered in several studies. These studies support the value of parental presence in decreasing stress in both the patient as well as the parent (AACN, 2016). Woodward has stated that “allowing the presence of family members helps minimize the family’s fear of being left to wonder what is happening to their child” (AACN, 2016; Woodward & Flaegler, 2000). The concept of parental presence is becoming incorporated into many transport systems.
a. Woodward and colleagues conducted a survey of parents whose children were transported via ambulance to a large regional children’s hospital. They found that allowing the parent to accompany the child during transport was a positive experience that did not hinder intratransport medical care (Woodward & Flaegler, 2000).
b. In the incidence of neonatal transports, the possibility of parental presence is impacted by the inpatient status of the mother. Some programs address the issue of bonding while decreasing parental stress by using various plush bonding tools. Safe sleep standards should be considered in this process.
c. The transport team is the first specialized group of caretakers involved in the child’s care. Transport team members are the key participants in a child’s definitive medical care. Involving parents in the process benefits the family, patient, and transport system (AACN, 2016; Woodward & Flaegler, 2000).
B. Transport Physiology
The care of critically ill or injured patients during air medical transport is a complex, ever-changing situation that requires a firm knowledge of flight physiology and an understanding of fundamental laws of physics. These include atmospheric composition, basic gas 846laws, and transport-related stresses that affect both the patient and transport team.
1. Atmospheric composition is an important physical property of which an understanding is essential for building the foundation of the flight physiology. The atmosphere is composed of seven basic gases: nitrogen (78%), oxygen (21%), argon (0.94%), carbon dioxide (0.03%), hydrogen (0.01%), neon (0.0018%), helium (0.0005%), and trace amounts of methane, neon, and krypton. The percentage of each gas in the atmosphere remains constant up to approximately 70,000 feet above sea level. Each gas is responsible for a percentage of the total atmosphere that corresponds to its partial pressure.
2. Gas Laws. A complete understanding of gas laws as they relate to temperature, pressure, and volume is crucial for the safe, effective transport of a patient via either a helicopter or fixed-wing aircraft (Blumen & Rinnert, 1995; Nehrenz, 1997; Orsborn, Graham, Moss, Melguizo, & Stroud, 2016).
a. Boyle’s law states that “at a constant temperature, the volume of a given gas is inversely proportional to the pressure” (McCloskey & Orr, 1995, p. 144).
P1V1 = P2V2
In other words, a known volume of gas will expand as the pressure that surrounds it decreases. Boyle’s gas law affects any enclosed gas-filled space whether inside or outside the body cavity.
Example: An intubated 17-year-old trauma patient is being transported via a fixed-wing aircraft to a Level 1 trauma center. As the aircraft lifts off and climbs to 12,000 feet above sea level, the ETT cuff will increase in size, causing more pressure on the trachea walls. When the aircraft starts to descend for landing, the cuff will decrease to its size prior to landing, thus decreasing the pressure that was previously on the tracheal walls.
b. Dalton’s law describes the partial pressure of various gases, the effect that altitude has on them, which states “the total pressure of a gas mixture equals the sum of the individual (partial) pressures of all the gases in the mixtures” (McCloskey & Orr, 1995, p. 144).
Ptotal = P1 + P2 + P3 + P4 + Pn
Another illustration of Dalton’s law is as follows: Each gas present in a gas mixture exerts a partial pressure that equals the fractional volume of gas multiplied by the total pressure (Table 9.38).
TABLE 9.38 Level of Inspired Oxygen Related to Altitude
Altitude (ft) | Barometric Pressure (mmHg) | Inspired Oxygen Tension (mmHg) |
0 | 760 | 149 |
1,000 | 733 | 143 |
2,000 | 707 | 138 |
3,000 | 681 | 133 |
4,000 | 656 | 127 |
5,000 | 632 | 122 |
6,000 | 609 | 117 |
8,000 | 564 | 108 |
10,000 | 523 | 99 |
Example: What is the partial pressure of oxygen being delivered to a patient being mechanically ventilated at 2,000 feet above sea level (706 torr) with 50% oxygen?
Partial pressure = barometric pressure × gas concentration
Partial pressure = 706 torr × 0.5 oxygen
Partial pressure = 353 torr
c. Charles’s law states, “when pressure is constant, the volume of a gas is very nearly proportional to its absolute temperature” (McCloskey & Orr, 1995, p. 114).
Charles’s law explains the direct relationship between volume and temperature; as the temperature of a gas increases, so does the volume of that gas.
Example: You are transporting a 50-kg patient who is septic and receiving a 1 L bolus of fluid using large-bore tubing and a pressure bag. As you leave the building and assess your patient during the frigid 15°F winter day, you notice a drop in pressure on the manometer (pressure bag) and the volume stops running. Promptly add more air to the bag to ensure that the bolus continues to run. Adding gaseous volume to the pressure bag puts Charles’s law to work. 847The decrease in temperature causes a direct decrease in gaseous volume in the bag.
d. Gay-Lussac’s Law states that when a volume of gas is constant, the pressure of this gas is directly proportional to the absolute temperature for a constant volume of gas.
In simpler words, Gay-Lussac’s law illustrates the direct relationship between pressure and temperature.
Example: While completing the morning checks when the aircraft was in the heated hanger (74°F), the pressure of oxygen was 1,800 psi. Later that morning, the pilot moves the aircraft outside (32°F) so that the maintenance crew can clean the hanger. Before the first flight, the oxygen level is checked once more discovering a pressure of 1,550 psi. The change in pressure is explained by Gay-Lussac’s law of temperature and pressure. As the temperature decreases, so will the pressure.
e. Henry’s law states that “a quantity of gas dissolved in a liquid is proportional to the partial pressure of the gas in contact with that liquid” (McCloskey & Orr, 1995, p. 145). In other words, the partial pressure of a gas above the liquid equals the quantity of gas dissolved in the liquid.
Example: A 15-year-old scuba diver suffering from decompression sickness after a rapid ascent from a depth of 90 feet is being transported. The cause of this illness is the rapid ascent from an environment with a high pressure (i.e., a depth of 90 feet) to an area of relatively low pressure (sea level), causing a release of gas bubbles from the blood. If the teen would have slowly ascended from the depth allowing time for the gas–liquid interface to equilibrate, the situation could have been completely avoided.
3. Transport-related stresses can be placed into two distinct but related categories: environmental and self-imposed. Temperature, hypoxia, dehydration, noise, and vibration are stresses imposed by the environment. Self-imposed stresses can easily be remembered by the acronym DEATH; the components include drugs, exhaustion (fatigue), alcohol, tobacco, and hypoglycemia (Holleran, 2010). In combination with the environmental factors, the self-imposed stresses can magnify the physical and mental fatigue, leading to errors in judgment and decreasing the level of performance. To limit these factors, the transport team must have a solid understanding of the principles of transport-related stresses and the physiologic effects they have on both the patient and crew.
a. Hypoxia is described as the relative state of oxygen deficiency that tissues experience from a decreased oxygen supply. Hypoxia is one of the most important stresses that may be encountered during the air medical transport and is found within four physiologic categories (Table 9.39).
i. Hypoxic hypoxia is the oxygen deficiency that is present at the alveolar level. The transfer of gas from the alveolus to the arterial system is compromised, resulting in a low partial pressure of oxygen in the blood.
ii. Hyperemic hypoxia or anemic hypoxia occur when the oxygen-carrying capacity of the blood is decreased, resulting in a limited oxygen delivery to the tissues.
iii. Stagnant hypoxia is defined as the lack of adequate blood flow to the body or a specific area of the body. Stagnant hypoxia results from clinical situations with low cardiac output as a component of its pathophysiology.
iv. Histotoxic hypoxia (cellular/tissue poisoning) refers to the clinical situations that affect the cell’s ability to metabolize molecular oxygen. A patient may have a normal arterial partial pressure of oxygen (PaO2), but the tissue is unable to use it because of the cellular metabolic dysfunction.
b. Changing barometric pressure is the primary cause for many physical symptoms experienced by the flight crew. As an aircraft ascends, the barometric pressure decreases, in turn, gases within the body cavity expand. The expansion may cause complications such as barotitis media, barosinusitis, and barodontalgia. The GI system can hold a significant amount of gas (methane), which is a by-product of normal digestion. As the aircraft ascends, the volume of the gas in the GI tract expands (Boyle’s law of volume and pressure), resulting in discomfort and pain. The patient may release the expanded gas by either belching or flatus (Holleran, 2010). Nasogastric tubes should be vented, allowing excess gas to escape.
848TABLE 9.39 Clinical Effects and Treatment of Hypoxia
Systems | Signs and Symptoms | Treatment |
Cardiovascular | Tachycardia Arrhythmias Hypertension Hypotension (late) Bradycardia | 1. Identify which type of hypoxia is present • Hypoxic • Hyperemic • Stagnant • Histotoxic |
Pulmonary | Hyperventilation Dyspnea Tachypnea Cyanosis (late) | 2. Deliver supplemental oxygen • Depending on the severity, an FiO2 of 1.0 may be required • An increase may be needed in spontaneously breathing and mechanically ventilated patients alike |
3. Patient monitoring • Heart rate/rhythm • Respiratory rate • Blood pressure • End-tidal CO2 • Ventilator parameters | ||
Neurologic | Seizures Restlessness Euphoria Belligerence Unconsciousness | 4. Monitor equipment • Indwelling catheters and tubes • Mechanical ventilator • Invasive pressure monitoring equipment |
5. Descend • Increase the partial pressure of oxygen by descending to a lower altitude |
c. Thermal regulation. The transport environment exposes both the patient and crew to a wide range of temperatures. Prolonged exposure to this environment has been found to have negative physiologic effects. These effects include increased oxygen consumption, vasoconstriction or vasodilation, an increased susceptibility of motion sickness, disorientation, and an increased metabolic rate (Blumen & Rinnert, 1995; Holleran, 2010).
d. Humidity. As altitude increases, humidity in the ambient atmosphere decreases. The crew must be cognizant of the effects that this environmental change will have on both the patient and fellow team members. Effects include dry eyes, chapped lips, thickening of pulmonary secretions, and sore throat. Increasing fluid intake via the oral (crew) or IV routes (patient) will aid in replenishing the fluid lost during flight (Holleran, 2010; McCloskey & Orr, 1995).
e. Noise and vibration are common occurrences in the transport setting, dependent on the mode of transportation: ambulance, fixed-wing aircraft (airplane), or rotor-wing aircraft (helicopter; Sittig, Nesbitt, Krageschimidt, Sobczak, & Johnson, 2011). Noise and vibration may or may not affect patients. Some might experience anxiety, which can be exhibited by an increase in heart rate, blood pressure, or combativeness. Noise presents the crew with the added difficulty of patient assessment. It makes the use of a stethoscope for auscultation of breath sound virtually impossible (Tourtier et al., 2014).
f. Fatigue is the end product of all contributing stresses on transport personnel, which has been linked to judgment errors, narrowed attention span, limited response, and possibly the cause of several fatal accidents (Blumen & Rinnert, 1995; Holleran, 2010).
849C. Transport Equipment
The equipment routinely carried by the transport team should be able to provide ongoing intensive care until the team safely arrives at the receiving institution. The AAP Task Force on Interhospital Transport recommends the following guidelines for transport equipment (MacDonald & Ginzburg, 1999). The equipment will do the following:
1. Provide the capability for life support in the transport setting.
2. Be lightweight (loadable by two persons), portable, and self-contained, with a battery life twice the expected transport duration.
3. Be durable enough to withstand altitude and thermal changes, acute decompression vibration (20-g decelerative forces, both ground and air vehicles), and repeated use.
4. Have alternating current (AC)/direct current (DC) capabilities.
5. Have no electromagnetic field interference.
6. Be able to fit through standard hospital doors and into transport vehicles and be easily secured to prevent shifting while en route.
7. Supplies and medications carried should be sufficient to maintain ongoing critical care during the transport.
D. Team Configuration
The composition of a critical care transport team varies from institution to institution. Presently, the guidelines for training transport team personnel are designed and implemented by the program director. The goal is for team members to have the clinical skills and expertise needed to deliver the level of care found in the critical care area of the receiving hospital (Stroud et al., 2013).
TABLE 9.40 Examples of RN/RCP Configuration as Related to Clinical Situation
Type of Patient | Staff to Accompany and Remain With Patient |
Stable with one IV | RN/RCP team |
Stable with arterial line | RN/RCP team |
On mechanical ventilator | RN/RCP team |
Vasoactive drips/MV | RN/RCP team |
ECMO referral | RN/RCP/transport MD |
Sepsis shock w/o access | RN/RCP/transport MD |
ECMO, extracorporeal membrane oxygenation; IV, intravenous; MV, mechanical ventilation; RCP, respiratory care practitioner.
Note: Application of this specific triage strategy to other pediatric referral centers may be limited.
1. Configuration models that currently exist include RN/respiratory care practitioner (RCP), RN/RN, RN/paramedic, RN/MD, RN/RCP/MD, certified registered nurse practitioner (CRNP)/RN, and CRNP/RCP. A program may choose a constant configuration or change based on patient acuity (Table 9.40).
2. The Transport Section of the AAP recommends that an RN be a member (most likely the team leader) of the team during every transport (MacDonald & Ginzburg, 1999). The task force’s rationale behind this is that an RN offers the needed education, versatility, and license requirements needed to perform as the team leader.
E. Advanced Skills Training
It has become common practice in pediatric transport systems to use an RN/RT or RN/RN team without the addition of a physician after a period of specialized training. These individuals are expected to identify and manage problems that might and often do occur during transport. Frequently, the team is expected to intervene on arrival to a referring hospital where staff either is uncomfortable or lacks the skill to perform a specific procedure. The AAP Section on Transport medicine has published specific guidelines that address appropriate training procedures and other team-related issues (Stroud et al., 2013).
8501. Many programs require experience in the ED or critical care areas, which serve as a foundation for the development of advanced skills.
2. Many, if not most, programs require staff to have successfully completed one or more advanced life support courses (Advanced Cardiac Life Support [ACLS], PALS, Neonatal Resuscitation Program [NRP]). In general, advanced skill training focuses on (but is not limited to) interventional skills, such as advanced airway management, needle thoracotomy, chest tube placement, cannulation of umbilical vessels, and placing intraosseous (I/O) catheters.
3. Individual programs develop training sessions that not only address technical skills, but a didactic component, including core topics such as pathophysiology, diagnosis, assessment, therapy, and complications for each disease entity. The use of simulation is increasingly common to provide training for low-volume/high-risk procedures, and improve team dynamics and communication.
4. Following initial training, credentialing may occur within the medical structure of the institution. Ongoing competency assessment programs are expected by the AAP (MacDonald & Ginzburg, 1999).
5. Commission on Accreditation of Medical Transport Systems (CAMTSs) is a voluntary accreditation service focused around patient care, safety, and quality in the transport environment. CAMTS certification verifies that a transport program meets current standards, which are based on medical research, ground transport, and aviation developments.
INITIAL STABILIZATION OF THE NEONATAL OR PEDIATRIC PATIENT
A. Principles and Practice
Initial stabilization of any infant or child begins at the referring facility prior to the transfer request. This responsibility is federally mandated by EMTALA and COBRA laws. Patient assessment and therapeutic intervention should be focused on procurement of a patent airway, ensuring effective ventilation, stabilizing circulation, and assessing blood glucose status. These assessments and interventions are outlined in the American Heart Association’s PALS course (American Heart Association [AHA], 2016).
1. The transport team’s resuscitative efforts are focused on stabilizing the patient before transport, bringing ICU level of care to the patient. The “routine” delivery of intensive care to the critically ill child is complicated by numerous environmental factors during transport, including the following:
a. Cramped surroundings cause restricted access to the patient due to seatbelts of both the patient and the team members.
b. Limited access to all equipment and limited ability to carry anything but essential equipment are issues.
c. Low-light conditions, constant vibration, and/or noise produced by engines may decrease the ability to hear alarms and assess the patient. The low-light conditions may also affect readings of various monitoring devices. Combination of vibration, electronic distortion, and background sound challenges even the most technically advanced equipment.
d. Constant movement of the vehicle increases the risk of accidental extubation.
e. Low temperatures present a significant challenge to team members as they deliver care and also attempt to maintain adequate body temperatures.
B. Transport Population
The pediatric transport patient population differs greatly from that of the adult patient population. Figure 9.15 shows the diagnostic categories of 4,905 patients transported by five pediatric specialty care teams from different regions around the United States.
C. Initial Call and Triage
The initial call may be triaged by a command physician who collects patient information and gives recommendations for stabilization. Stabilization begins at the time of the call. An outline of the components for effective information gathering and therapeutic considerations are presented in Table 9.41.
D. Patient Assessment
1. Airway. Assessment of the pediatric airway includes airway patency and airway protection. Rapid assessment of these areas will determine the next intervention. It may be as simple as repositioning the child’s head (not recommended in patients with questionable cervical spine injury) or as complex as endotracheal intubation. The decision can be made based on the presence or absence of the following:
851
FIGURE 9.15 Database of five regional pediatric specialty care teams.
CNS, central nervous system.
TABLE 9.41 Information Outline for Initial Transport Triage Call
Initial Call (Stabilization Begins at the Time of Call) |
I.Report should include a brief but concise past medical history as well as a history of the present illness: Present condition Vital signs (ABCs) Patent airway Respiratory rate Heart rate Blood pressure Perfusion Neurologic assessment LOC GCS Presence of seizure activity Lab data Blood glucose level CBC Electrolytes Cultures Radiologic interpretations II.Treatment recommendations from the transport physician may include, but are not limited to, the following: Fluid resuscitation Inotropic support Aerosolized medication recommendation Anticonvulsant therapy Antibiotics III.Decision regarding mode of transportation and team composition: Patient condition Safety Distance Accordance with the referring physician recommendation on the patient’s medical necessity 852EMTALA laws |
ABCs, airway, breathing, and circulation; CBC, complete blood count; EMTALA, Emergency Medical Treatment and Active Labor Act; GCS, Glasgow Coma Scale; LOC, level of consciousness.
Note: Ultimately responsibility falls on the referring physician.
a. Patent airway (ventilation/CO2). Obstruction of the upper airway can be easily identified by the absence of audible or palpable airflow, upper airway stridor, or asynchronous chest and abdominal motion. If any of the aforementioned symptoms are present, the upper airway should be visually inspected. In this situation, the patient may require repositioning of the head, suctioning of the oral pharynx, or placement of a nasal pharyngeal airway (NPA) to ensure a patent pathway for respiration to occur.
b. Maintaining an airway. Patients with an altered level of consciousness or neuromuscular weakness may be unable to maintain their own airway. Presentation can include limited airflow (decreased breath sounds), “snoring respirations,” an inability to control secretions, or obstructive apneas. These patients are at risk for pulmonary insufficiency, leading to hypoxia, hypercarbia, respiratory acidosis, and ultimately respiratory insufficiency or failure.
c. Protective airway reflexes (cough and gag). Assessment of the upper airway reflexes are performed by using a soft-suction catheter to elicit a cough or gag. The presence of this protective reflex will illustrate whether the infant or child can protect his or her own airway in case of emesis during transport.
2. Breathing (oxygenation/O2). The initial step in the assessment of breathing is a visual inspection of the patient. Identifying the patient’s position (i.e., tripod position in epiglottitis); respiratory pattern; and rate, level of distress, and behavior (obtunded or anxiousness) will provide an immediate assessment of the severity of the situation.
a. Respiratory rate. An accurate respiratory rate should be obtained before interacting with the patient; interaction with a stranger often causes anxiety in the young child, leading to an elevated respiratory rate.
i. Tachypnea in a child can be a caused by pain, anxiety, shock, respiratory distress, metabolic acidosis (i.e., diabetic ketoacidosis), and increased body temperature. Identifying the exact cause is often difficult but may be assisted by the use of pulse oximetry, blood gas analysis, or measurement of the patient’s temperature.
ii. Bradypnea or gasping is uncommon; it may be caused by a head injury, hypothermia, medications such as narcotics, or impending respiratory failure.
iii. Apnea is relatively common in the premature infant population and can lead to cyanosis and bradycardia. It can be an ominous sign in an older infant and should be closely monitored. If apnea continues, treatment is recommended to ensure a positive neurologic outcome. The causes of apnea may be serious in nature and have been implicated as the first sign in the progression of life-threatening critical illness.
853b. Pattern. Respiratory pattern should be assessed along with the respiratory rate. Assessment should include the depth of each breath, the inspiratory and expiratory time (i.e., prolonged expiratory phase), and the presence of an increased work of breathing (WOB).
i. Increased WOB (respiratory distress) is explained with greater detail in Chapter 2.
ii. The following clinical findings are signs and symptoms of respiratory distress: grunting, nasal flaring, retractions, paradoxical respiration, and tachypnea. Oxygen is the drug of choice in most cases involving patients who present with signs of an increased WOB. Always obtain the patient’s normal pulse oximetry saturation (SpO2) level, especially with a history of cardiac disease (see Chapter 3, “Congenital Heart Disease” section for more information).
iii. Breathing patterns can aid in distinguishing the underlying cause of the clinical manifestations with which a particular patient presents:
1) Periodic breathing is defined by spurts of respiratory activity of 20 seconds or less separated by periodic pauses in the respiratory cycle lasting less than 10 seconds without associated cyanosis or bradycardia. This pattern is common in premature infants (Walsh, 2015).
2) Kussmaul breathing is a deep, continuous breathing pattern commonly observed in patients with diabetic ketoacidosis (DKA). This breathing pattern causes hyperventilation to partially compensate for profound metabolic acidosis.
3) Cheyne–Stokes breathing is a periodic breathing pattern characterized by periods of tachypnea and hyperpnea with periods of apnea, which occurs most often in patients with neurologic injury. It also has been associated with congestive heart failure (CHF) in the adult population.
c. Breath sounds. Auscultation of the chest in all lobular regions should be performed to determine whether any adventitious breath sounds are present. Proper breath sound assessment should include documentation of the amplitude of the sound produced, timing of the sound (i.e., early, late), and the quality of air movement. Some commonly used terms to describe adventitious breath sounds include wheezes, crackles or rales, rhonchi, and stridor. Chapter 2 describes the clinical assessment of pulmonary function in more detail.
d. Skin color. Assessment of skin color should focus on identifying the presence of cyanosis that may be found either centrally (lips) or peripherally (nail beds). The first line of treatment should be the administration of supplemental oxygen. Causes of cyanosis can be pulmonary and nonpulmonary (see Chapter 2).
3. Circulation/Peripheral Perfusion. Assessment of circulation and peripheral perfusion can be done simultaneously during the initial patient survey. The assessment should include heart rate, central versus peripheral pulses, capillary refill time, LOC, and urine output. Early identification and reversal of children with decreased or poor perfusion limits the adverse outcomes associated with uncompensated shock and multiorgan dysfunction syndrome (MODS; Scott, Donoghue, Gaieski, Marchese, & Mistry, 2014). The clinician must be mindful that the presence of one of these signs has been associated with increased risk of MODS, with the presence at least two signs having almost a fivefold increase in organ dysfunction (Kleinman et al., 2010; Scott et al., 2014).
a. Heart rate is evaluated for rate, rhythm, strength, and the presence of a murmur. Chapter 3 covers the clinical assessment of cardiovascular function in more detail.
b. Central and peripheral pulses are compared by evaluating the pressure differences and the quality between the central (i.e., femoral, carotid, axillary) and the peripheral pulses (i.e., radial, dorsalis pedis, posterior tibial):
• Narrowed pulse pressure is indicative of circulatory compromise.
• “Thready” pulse can occur as a result of a narrowing pulse pressure.
• “Wide pulse” pressures or “bounding pulses” are commonly found in early septic shock.
c. Capillary refill is assessed by applying pressure to an extremity and observing the time it takes for the blanched area to reperfuse. Less than 2 seconds is considered normal, whereas a capillary refill time longer than 2 seconds may indicate poor perfusion and may require medical intervention.
i. Flash or brisk capillary refill is present when the blanched area reperfuses in less 854than 1 second and is considered “warm shock” (Carcillo, 2003; Kleinman et al., 2010; Scott et al., 2014).
ii. Other indicators of poor skin perfusion include pallor, mottling, peripheral cyanosis, and cold extremities (Carcillo, 2003; Kleinman et al., 2010; Scott et al., 2014).
d. Altered level of consciousness is often found as an early sign of shock because of inadequate cerebral perfusion (Carcillo, 2003; Kleinman et al., 2010; Scott et al., 2014). See Chapter 4 for a detailed review of age-specific neurologic assessments.
e. Urine output is an indicator of renal perfusion and is considered inadequate when it is less than 1 mL/kg/hr (Carcillo, 2003; Kleinman et al., 2010; Scott et al., 2014). Low urine output may be present before any other sign of decreased perfusion. It may be helpful to ask the caregiver the number of diaper changes the patient had today. This will help discern whether the child is experiencing decreased urine output while in the care of the family.
f. Liver size should be assessed in any patient with signs of decreased cardiac output or respiratory distress of unknown etiology. The liver edge in a healthy child should be palpated less than 3 cm below the right costal margin. If the liver is enlarged, the patient may be in cardiogenic shock (Carcillo & Fields, 2002; McCloskey & Orr, 1995).
4. Neurologic. A brief neurologic evaluation should be part of the ongoing assessment, together with the ABCs. Focus should be directed to several areas:
a. LOC
i. Age-appropriate behavior. One can expect a child to be crying or frightened; however, irritability may be an early sign of neurologic deterioration.
ii. Alertness, level of activity, and quality of cry are all easily assessed at the time of transport.
iii. Ominous signs of neurodeterioration include a child’s failure to respond to parents or not crying during a noxious stimulus, such as starting an IV. Urgent medical intervention and support are warranted.
iv. Use of the GCS (see Chapter 4) or AVPU (awake, voice response, pain response, unresponsive) scale provides a brief ongoing method of evaluation of LOC.
b. Pupillary response
i. Observe for size, equality, and reactivity.
ii. Responses may indicate increased ICP, inadequate oxygenation, hypothermia, or ischemic encephalopathy.
iii. Pupillary changes may be a result of pharmacologic intervention.
c. Seizure activity
i. Seizures are a common occurrence in transport.
ii. Woodward and colleagues stated that “the etiologies of seizures and treatments required can be varied and complex. Familiarity with seizure etiologies and treatment options will allow one to manage the event effectively in the short run, while safely transporting the patient for definitive evaluation and therapy” (Woodward, Chun, & Miles, 1999, p. 155).
iii. Comprehensive review of seizures, classification, and defining characteristics are covered in Chapter 4.
d. Signs of increased ICP
i. Irritability progressing to lethargy
ii. Decreased ability to follow commands
iii. Changes in response to painful stimuli
iv. Pupillary changes, decreasing response to light
v. LOC and GCS can be used to evaluate neurologic changes
e. Pain assessment
i. Children with trauma or agitation should be assessed and treated for pain during transport.
ii. Ongoing evaluation and intervention can avert later signs of increased ICP (Figure 9.16).
5. GI Assessment. Clinical assessment should be focused on four main areas (see Chapter 7):
a. Inspection for abdominal distention, masses, and obvious loops of bowel
b. Auscultation for the presence or absence of bowel sounds
c. Palpation to note presence of guarding or pain
d. Percussion
e. Review of recent GI insensible losses
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FIGURE 9.16 Cushing’s triad.
6. Head-to-Toe Assessment
a. Brief head-to-toe assessment should be conducted in all patients.
b. Special areas of focus may be included based on the reason for transfer as well as team’s initial assessment. This may include abdominal survey or observing the skin for rashes or bruises.
E. Airway Management
The single most important intervention during the initial stabilization of any patient is the establishment of a functional patent airway. Understanding the clinical indications and techniques used during the stabilization of the pediatric airway is focused around the basic anatomic difference found between the pediatric and adult patient (see Chapter 2). Some of the more common airway interventions used in the pediatric population include NPAs, oropharyngeal airways (OPAs), laryngeal mask airways (LMAs), and endotracheal intubation. Each of these techniques has relative indications and contraindications that provide the practitioner with a useful means of deciding which maneuver is needed to ensure a safe, effective airway (Table 9.42).
1. NPAs (nasal trumpet) are used in the semiconscious patient with intact airway reflexes (cough and gag) to relieve the obstruction created by posterior pharynx. The appropriate-sized NPA is found by measuring the distance from the nares to the tragus for length and using the largest diameter that passes through the nasal passage without traumatizing the mucosa. The NPA should not be used with patients who have suspected head trauma or skull fractures. Always remember the following:
a. Lubricate the exterior of the tube with a water-soluble lubricant.
b. If the airway adjunct is too large, it may cause blanching of the exterior nares.
c. Placement may cause laryngospasm, nasal ulceration, or bleeding.
2. OPAs (oral airway) are used to relieve the obstruction created by the base of the tongue and the posterior portion of the oropharynx, thus providing a patent pathway for ventilation to occur. The devices are useful in unconscious patients with respiratory drive or to facilitate bag–mask ventilation prior to intubation. Sizing of the oral airway is done by aligning the selected airway on the corner of the mouth and the tip at the angle of the mandible. Use of the OPA provides no protection against aspiration of blood, stomach contents, or other material in a patient with an altered LOC. In the pediatric transport setting, patients who tolerate an oral airway may require endotracheal intubation before transfer to protect against aspiration. OPAs should not be used with patients who have oral trauma. Important issues to remember when caring for a patient with an OPA include the following:
a. A tongue depressor should be used to displace the tongue downward, which facilitates placement of the oral airway.
b. If the oral airway is too small, it may “push” the tongue into the posterior pharynx, exacerbating the airway obstruction.
c. If the oral airway is too large, the distal end may force the epiglottis into the entrance of the airway, causing obstruction.
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d. This type of airway is not well tolerated in patients with intact airway reflexes.
e. Oral airway does not protect against aspiration.
3. LMA is an airway adjunct often used in the operating room as the primary method of securing an artificial airway. The device consists of a tube with a large balloon or mask at the end that seals the hypopharynx. Placement of the LMA is relatively simple and is accomplished by blindly advancing it into the pharynx until resistance is met. The balloon is then inflated and ventilation is assessed. The AHA recognizes the device as an acceptable alternative to endotracheal intubation in unresponsive patients when performed by healthcare providers trained in its use. Important facts about the LMA include the following:
a. A relative ease of placement (Guyette, Roth, Lacovey, & Rittenberger, 2007; Pennant & Walker, 1992).
b. It is contraindicated in conscious patients with intact gag reflex (Chameides, Samson, Schexnayder, & Hazinski, 2011).
c. Sedation or neuromuscular blockade may be required to prevent coughing or gagging during placement (Martin, Ochsner, & Jarman, 1999; Tung, 2005).
d. Does not protect against aspiration (Chameides et al., 2011; Martin et al., 1999; Tung, 2005.
e. Limited use in patients who require high ventilatory pressures as leaks at higher pressures are common (Guyette et al., 2007; Martin et al., 1999).
857f. Correct placement of the LMA is difficult to maintain when moving a patient.
g. An LMA is an acceptable method of initial airway stabilization; an ETT is the recommended method of airway management during transport (Warren, Fromm, Orr, Rotello, & Horst; American College of Critical Care Medicine, 2004).
4. Oral Endotracheal Intubation (OETI), when performed by the skilled practitioner, is considered the gold standard in the patient with respiratory failure. Endotracheal intubation can be complicated by a number of undesirable factors, potentially leading to catastrophic pulmonary and neurologic complications. These factors include prolonged hypoventilation resulting in decreased cardiopulmonary reserve, increased ICP, hemodynamic instability (shock), and the potential of a full stomach. Successful endotracheal intubation is defined by the limitation of the adverse effects that may occur as a result of airway manipulation in the critically ill patient. To limit these effects, many pediatric emergency care systems have adopted the technique of rapid sequence intubation (RSI) for all patients requiring OETI (Algie et al., 2015; Goto et al., 2016; Sagarin et al., 2002). RSI is a systematic approach to OETI, which has a 3- to 5-minute period of breathing 100% oxygen, the simultaneous administration of an induction agent and neuromuscular blockade, and when intubating conditions are present, a proper-sized ETT is passed into the trachea (Figure 9.17). It has been associated with a higher success rate and lower rate of serious adverse effects (Goto et al., 2016; Sagarin et al., 2002; Smith et al., 2015). When assisting with the endotracheal intubation of the pediatric patient, the practitioner should remember a few important points:
a. Always gather the equipment first. Intubation equipment includes a high FiO2 delivery appliance, functional proper-sized resuscitation bag (bag–valve–mask [BVM]), proper-sized laryngoscope blades with functional bulbs and handle, ETTs (one proper size and one size smaller) and a stylet, monitoring equipment, suction and suction equipment, clinically indicated drugs for induction and paralysis, a device to secure the ETT, and an end-tidal carbon dioxide detection device (for secondary confirmation).
b. Complete a team pause. This is final verification that the correct patient, procedure, staff, equipment, and medications are present.
c. Use sedation first, neuromuscular blockade second.
d. Always confirm ETT placement by multiple methods. Equal bilateral breath sounds, no air entry into the stomach (epigastric region), end-tidal carbon dioxide detection, effective chest rise, oxygen saturation (SpO2), condensation in the ETT tube, and CXR (especially in neonates) are effective ways to identify an appropriately placed ETT. Confirmation should be used as a quality-improvement measure, which is discussed later in the chapter.
F. Vascular Access
1. Establishing peripheral vascular access via a peripheral intravenous line (PIV) before transport is essential.
2. In the presence of cardiovascular collapse, PIV access may be difficult. PALS guidelines advocate that peripheral access be obtained rapidly. The term rapidly is defined by the patient’s acuity rather than by a 90-second time frame as previously published.
3. If PIV access cannot be obtained, I/O vascular access in the proximal tibia or distal femur should be initiated. Updated 2016 guidelines state the I/O access is acceptable for
a. Delivery of all IV medications, including epinephrine, adenosine, fluids, blood products, and catecholamines (Kleinman et al., 2010). Each medication should be followed by saline flush to promote entry to the central circulation (Kleinman et al., 2010). To maintain patency, consider a continuous infusion to keep the line open.
b. Onset of action is comparable to venous administration (Kleinman et al., 2010).
c. Can be used to obtain blood samples for analysis, including type and crossmatch and blood gases during CPR (Kleinman et al., 2010). Acid–base analysis is inaccurate after sodium bicarbonate administration via an I/O cannula (Kleinman et al., 2010).
4. Central venous access is not advocated as a first choice. However, it may be attempted by qualified personnel after initial access is obtained.
5. In the neonatal population, umbilical venous access is the preferred means of access, and it is easily located and cannulated by trained healthcare practitioners.
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