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E-PREP emergency procedure education program
The procedural skills accreditation pathway for ED registrars
Introduction
Transporting a critically ill patient is one of the most
challenging and potentially risky procedures an ED trainee
will undertake
This learning package aims to provide a brief overview of
key issues and safety aspects of performing a transport
A mentored transport is the best way of learning practical
aspects such as equipment placement in the CT
Minimum requirements
Background Knowledge and skills (Mandatory
before being eligible for Transport Assessment)
Intubation Accreditation
Retrieval Pack contents demonstrated
ACLS
Arterial Line Accreditation
Basic Ventilation accreditation
Considerations
Do I need to transport this patient (what are the risks/benefits of my transport?)
Where am I taking the patient?
How long do I anticipate I will be out of the dept for?
What do I need to do before I go?
What will I need to take with me (What is the diagnosis, how stable is my patient, what could possibly go wrong)??
Who will look after my other patients while I am gone?
Checklist before leaving: ABCDE for all
Airway: secure and patent
Breathing: ventilator, sats and pressures are safe for transport
Circulation: haemodynamic parameters are acceptable, Lines are working and identified
Disability: Check pupils and sedation adequacy and paralysis
E: Limb splints are applied, haemorrhage is contained
Ensure transport rationale is appropriate ;
Eg: a haemodynamically unstable multi trauma should
be transported to theatre not the CT room
Lines and tubes
Place all necessary lines and tubes prior to leaving, but
avoid delays by placing unneccessary devices
Eg
delaying a coning patient to CT to place an IDC is dangerous and
unneccessary
Delaying a GCS 5 patient to place an ETT is appropriate and
necessary
Arterial lines are almost never required for a CT trip and are the
commonest source of delay
Patient preparation
Optimize your patients physiology and pharmacology prior to leaving
Eg
Weaning the Fi02 prior to transport reduces your patients physiological reserve if a problem occurs
Keep the patient paralysed and sedated for the transfer if appropriate
Start the Norad infusion before leaving if the BP is borderline
Anticipation
Run through a mental checklist of all the problems you may encounter and prepare in advance
Eg
If you think the patient’s propofol may need increasing in the CT, bring some metaraminol to counteract the post bolus hypotension
If the N/S is half way through, bring another bag
Equipment
Minimum equipment to bring is mandatory and includes
Assembled & Checked
Retrieval Pack
Self inflating bag and mask
Oxygen (tank full)
Suction
Airway adjuncts
Ventilator Circuit: Assembly,Basic Checks,Settings
Monitor: NIBP, ECG, SaO2, IBP, ETCO2
Infusion Pumps
Batteries / Power
Staff
A nurse and wardsperson are mandatory additional
personnel
Ensure you have briefly handed over your other
patients before leaving
Ask for senior assistance if you patient is very
unwell and you are out of your comfort zone
Untangle all your leads and lines before you
go…optimize everything in the safe environment,
minimize delays in the unsafe place
Position the monitors so you can always see them; a
visible end tidal, sats and ECG tracing are
absolutely critical
Always take personal responsibility for the airway
Use a firm loud and clear voice when leading the transfers
Give advance warning before changing anything: “We are
going to move across on 3”, then “1 2 3”
Stay focused on the patient and monitor, avoid
distractors…drugs, lines, CT images
Moving the patient from bed to bed, bed to CT
Disconnect the ventilator from the ETT for all
transfers UNLESS:
PEEP is a requirement for ventilation (eg ARDS or CCF).
Sudden loss of PEEP can be catastrophic
The patient has respiratory failure and you think the brief
disconnection may be dangerous
There is raised intracranial pressure and you are controlling
CO2 (relative risk)
Moving the patient from bed to bed, bed to CT
Place your ventilator on the rail at the head of the bed whilst moving the patient over (ensures enough tubing length, allows access to patient for all staff)
Move the monitor to the foot of the receiving bed prior to moving the patient (ensures enough line length, allows access to patient for all staff)
Move the patient half way across , check your lines
and tubes, then complete the transfer
Move the IMEDs and A-Line pressure bags across to
a pole on the far side of the head end of the
receiving bed prior to moving the patient
In the CT room
Ask the radiographer to manually move the patient
in the scanner to the far limit required.
Check you have enough tubing length with a safety
margin
Only then can you leave the room
Avoid unneccessary exposure
Keep blankets on, keep fluid warmers going
For raised ICP patients
Keep at 30 degrees head up until just before moving
across
MCQs
1. What is the correct transport decision for an intubated 50
year old male with a blown R pupil from a presumed
subdural haemorrhage.
A. Place an arterial line and IDC prior to CT to ensure appropriate
monitoring
B. Take the patient to CT ASAP with full non invasive monitoring
C. Take the patient to CT ASAP even if non invasive monitoring is not
applied yet.
2. What is the correct transport decision for a 27 M post MVA with Sats of 83% immediately post intubation who the surgeons want an urgent panscan for.
A. Take to CT now on a bag and mask with PEEP valve and 100% O2.
B. Take to CT now on a transport ventilator with PEEP of 10 and 100% O2.
C. Delay in ED until a CXR is seen and the patients saturations are improved.
D. Refuse to transport the patient under any circumstances.
3. What is the correct transport decision for an this 8 year old female?
The treating team have requested a CT chest to look for pleural effusions. She is ventilated for severe ARDS and has FiO2 of 95%, PEEP of 25 , PIP of 50 and P02 of 51? A. Transport to CT with transport ventilator
B. Ask anaesthetics to transport to CT
C. Refuse to transport to CT
D. Arrange urgent transfer to ICU, and liaise with the treating team regarding your decision
4. What is the most appropriate transport decision for a patient who has just been intubated, with Sats of 98% and the post intubation CXR shows a 30% R pneumothorax?
A. Transport the patient to the ICU and handover the CXR findings.
B. Delay the transport to ICU until an ICC can be placed.
C. Delay the transport to ICU until a needle thoracostomy can be placed, and then transport.
5. Where should the ventilator be placed when
transferring a patient from bed to CT table?
A. On the rail at the foot of the bed
B. On the side bed rail
C. On the patient’s chest
D. On the rail at the head of the bed.