transport_critically_ill_pediatrics.pptx

Important concept for transportation of critical I'll newborn

1. Pre-Hospital Transport of the
Critically Ill Pediatric Patient
Originally Developed by: Lynne W. Coule, MD
Pediatric Critical Care Medicine
Medical College of Georgia
Adapted for Oklahoma EMS Use by the Adapted for Oklahoma EMS Use by the
EMSC Resource CenterEMSC Resource Center

2. Issues of Concern for Education
•Limited Experience with Pediatrics
–6% of All Ambulance Runs
•Training in Pediatrics is Limited
•Diseases Unique to Children
•Absence of a Direct History
•Wide Ranges of Patient Ages and Sizes
•Need to Tailor Therapy to Size

3. What Am I Going to See?
•Most Common Critical Pediatric Problems
–Respiratory and Neurologic (55 %)
•Primary Cardiovascular Problems Rare
•Cardiac Arrest Most Often from Respiratory
Arrest
•Infants (<1 year) Most Common Age Group

4. Urgency of Stabilization
•Compensation is Extreme but Short-Lived.
•To Reverse Focus on Recognition of Pre-Arrest
•80% of Pediatric death from injury
–Do NOT Survive to Reach Hospital
–90% Attended by Pre-Hospital Providers

5. Intervention
•Oxygen Deficiency
–Primary Life-Threatening Problem
•Oxygen Delivery to Cells
–Rapidly Restore and Maintain
•Oxygen Supply MUST be
–Greater than Demand
•Use Measures to Reduce Oxygen Needs

6. Oxygen Delivery
•Achieved Through the Function of the:
–Respiratory System
–Cardiovascular System
–Hematologic System

7. Oxygen DeliveryOxygen Delivery
Hgb-bound O xygen
1.34 X Hgb X O 2 sat
Dissolved O xygen
PO 2 X 0.003
Cardiac O utput
O xygen Delivery

8. Respiratory SystemRespiratory System
Child vs. AdultChild vs. Adult
Larynx is More Cephalad
Epiglottis is Less Stiff
Narrowest Portion is Cricoid Ring

9. Examination - AirwayExamination - Airway
Air Entry
Noises Made
–Stridor
–Wheezing
–Any Air Movement

10. Examination - Breathing
•Respiratory Rate
•Work of Breathing / Position
•Color
•Mental Status

11. Therapy for Respiratory Distress
•Oxygen
•Maintain Airway
•Position Upright if Needed
•Despite Oxygen Begin PPV for
–Apnea
–Gasping
–Cyanosis

12. Methods of Administering Oxygen
•Oxy-Hood - 80-90%
•High Flow Face Mask - 100%
•Face Shield - 40%
•Nasal Cannula
–Varies with Age
•Mechanical Ventilation
–Up to 100%

13. Bag-Valve-Mask Technique
•Bag Method
–“Squeeze / Release / Release”
•Minimize Leak Around Mask
•DO NOT Obstruct Airway with your Fingers

14. Airway Management
JAMA February 2000 :
No difference in outcome overall when BVM
compared to ET intubation in pediatric patients
Pre-Hospital care. Improved outcome in the
BVM groups for foreign body aspiration, child
maltreatment, and respiratory arrest.

15. Endotracheal tube
•Size: 16 + age (yrs)
4
•Uncuffed in children less than 7 years
•Lip to tip distance is 3 times the ETT size
Broselow TapeBroselow Tape

16. Guidelines for Ventilator Settings
•FiO2: 1.0 (100%)
•Rate:
–Infants 30
–Toddler 20-30
–School age 16-20
•Tidal Volume: 10 - 15cc/kg
•Inspiratory Time:0.6 - 1 second
•Peak Inspiratory Pressure: 20 to 30 cm H2O
•PEEP: 4 to 5 cm H2O

17. Airway Maintenance
•Secure ETT
•NG/OG Tube
•Sedation
•Relaxants
•Suction ETT

18. Cardiovascular Interaction
B lood P ressu re
S V R
H g b -b ou n d O xyg en
1 .3 4 X H g b X O 2 sat
D issolved O xyg en
P O 2 X 0 .0 0 3
H eart R ate
P reload C on tractilityA fterload
S troke V olu m e
C ard iac O u tp u t
O xyg en D elivery

19. Examination - Circulation
•Heart Rate
•Perfusion
–Pulses - Presence and Quality
–Skin Perfusion
–Level of Consciousness
–Urine Output
•Blood Pressure
•Skin perfusion
–Temperature of Extremities
–Capillary Refill
–Color

20. Signs of Early Shock
•Tachycardia
•Cool Extremities
•Decreased Capillary Refill
•Diminished Distal Pulses
•Irritability
•Mild Oliguria

21. Causes of Shock
•Hypovolemic
•Cardiogenic
•Distributive
–Septic
–Neurogenic
–Anaphylactic

22. Treatment of Shock
•Increase Preload
•Improve Contractility
•Affect Afterload

23. Preload
•Palpate Liver Edge
•20 mL/kg of NS or LR IV Push within 20
Minutes
•Reassess
•Repeat Fluid Bolus
•Better Outcome if Hypovolemic Shock
Patients Receive 60cc/kg the First Hour of Tx

24. Interosseous Access
•Don’t Be Afraid of It!
•Most Useful with
–Severe Dehydration
–Nontraumatic Arrest

25. Inotropy
•May Need To Be Used When >80 mL/kg Used
With Minimal Response
•May Be Needed to Improve Contractility or
Adjust Afterload

26. Resuscitation Drugs
•Epinephrine
–Used for Asystole, PEA, or Bradycardia
–Dosage: 0.1 mL/kg IV/IO 1:10,000 1st Dose,
1:1000 2nd Dose
•Atropine
–Used for Bradycardia
–Dosage: 0.02 mg/kg IV/IO
–Minimum 0.1 mg

27. Central Nervous System
•Diagnostic and Therapeutic Interventions May
Have Limited Availability
•Critical Decisions Must Be Made Within The
Limits Afforded
•Basic Needs: Oxygen and Glucose
•Primary and Secondary Injury
•Brain’s Response to Injury

28. Brain’s Response to Injury
•Altered Mental Status
•Seizures
•Altered Respiratory Function
•Loss of Autoregulation of Blood Flow
•Cerebral Edema
•SIADH

29. Assessment of CNS
•Neurologic Examination with Pupillary
Response
•Levels of Responsiveness: AVPU
•GCS
•Signs of Increased ICP

30. Glasgow Coma Scale

31. Increased ICP - Early Signs
•Headache
•Vomiting
•Altered Mental Status

32. Prevention of
Secondary Brain Injury
•Maintain Oxygen Delivery
•Maintain Glucose
–Avoid Hyperglycemia
•Correct Circulation
–Then Limit Fluids
•Treat Seizures
•Decrease Metabolic Demands

33. Transport of Critically Ill Patients
Goals
•Maximize Oxygen Delivery
•Support Respiratory System as Needed
•Correct Shock
•Follow Neurological Exam
•DO NOT PANIC!