Transportation for critically ill pediatric

Transportation for critically ill pediatric

Supaporn Roymanee 18 May 2018

Pediatric Cardiology, Department of Pediatrics,Prince of Songkla University, Hat Yai, Songkhla

‘Safest place’‘Critically ill pediatric’

‘Transportation’

May increased risk and adverse events by

• Disconnecting from the equipment in the ICU to some kind of transport gear

• Shifting them to another stretcher

• Reducing the personal and the equipment around

‘Transportation’

Supaporn R.

‘Safest place’continuity of care

‘Types of transport’

• Intrahospital

• Interhospital

• Scene run: transport from non medical site to nearest available or designated hospital

Supaporn R.

‘สาเหตท่ีุต้องส่งต่อ’• โรคท่ีซบัซ้อนสงู ต้องการแพทยเ์ฉพาะทาง

• ขาดเครือ่งมือแพทย ์การตรวจเพ่ิมเติม การผา่ตดั

• ต้องการทีมงานท่ีช่วยดแูล

• ไม่มีความมัน่ใจในการรกัษาโรคนัน้

• ผูป่้วยมีความต้องการรกัษาแพทยเ์ฉพาะทาง

• ความไม่พรอ้มเฉพาะกิจในวนันัน้ๆ

Supaporn R.

Minimized risks & improved outcomes by:

เตรียมการส่งต่อให้มีประสิทธิภาพและต่อเน่ือง

1. Communication

2. Personnel

3. Equipment

4. Monitoring

5. Stabilization

Supaporn R.

Continuity of patient care

Physician-to-physician

Nurse-to-nurse

- Review patient condition

- Treatment plan

Communication

วนิิจฉยัการรกัษา

ผลการรกัษาผลการตรวจ

เหตุผลในการสง่ต่อปญัหาทีอ่าจเกดิขึน้

At least two persons

May include respiratory therapist, registered nurse, critical care technician

Accompanying person

Able to care airway, PBLS, PALS training, Critical care training

การจ าแนกระดบัความรนุแรงในปฏิบติัการส่งต่อผูป่้วย

• U : unstable eg. post arrest

• H: stable with high risk of deterioration

• M: stable with medium risk of deterioration

• L: stable with low risk of deterioration

• N: stable with no risk of deterioration

Supaporn R.

‘หน้าท่ีและความรบัผิดชอบ’

Supaporn R.

‘หน้าท่ีและความรบัผิดชอบ’

Supaporn R.



1. Communication

2. Personnel

3. Equipment

4. Monitoring

5. Stabilization

Supaporn R.

‘อปุกรณ์ท่ีใช้ในการดแูลรกัษาผูป่้วย’• Defibrillator: pacemaker

• Portable Multi-parameter monitor: ECG, SpO2, NIBP, IBP

• Portable Ventilator with oxygen supply

• Infusion Pump, Syringe Pump

• Portable Suction Device

• Drug Bag

• Airway management set

• Emergency set for chest decompression, surgical airways set, intra-osseous devices

• Other supplies bag

Supaporn R.

AMT Samitivej Hospital 20

‘Defibrillator with multi parameter monitor’

‘Multi parameter Monitor’


If possible: a memory-capable monitor

Respiratory Equipment

• Oxygen delivery (50 psi with system)

• Flow meter 1-15 LPM

• Ventilator; Neonate - Pediatric – Adult

• Access to high PEEP system

• Bag valve mask (BVM) device, Self inflating (neonate, Pediatric, adult)

• Clear face mask

• Laryngoscope, blades (curved, straight), light bulbs and batteries

Supaporn R.

‘Video Laryngoscope’

Respiratory Equipment (continue)

• Endotracheal tubes

• Magill forceps

• ET styletes

• Oral airways

• Chest tube, placement equipment and Heimlich valve

• Portable air and oxygen cylinders

• Nebulizer

• Suction: Bulb syringe, portable electric suction

• Suction cathetersSupaporn R.

‘Ventilation’

• Bag-valve ventilation is most commonly employed

• Portable mechanical ventilation

Supaporn R.

‘Medical bag’

All battery operated equipment is fully charged and capable of

functioning during transportation

‘Pediatric arrest’

• Primary cardiac arrest in infants and children is rare

• Pediatric cardiac arrest is often preceded by respiratory failure and/or shock and it is rarely sudden

• Early intervention and continued monitoring can prevent arrest


• The terminal rhythm in children is usually bradycardia that progresses to PEA and asystole

• Septic shock is the most common form of shock in the pediatric population

• 80% of children in septic shock will require intubation and mechanical ventilation within 24 hours of admission


‘Pediatric arrest’

‘Goal of Transport critically ill pediatric’

• Early direction and initiation of advanced care

• Treatment and monitoring with the expected expertise and capabilities of the tertiary care center while the patient is still in the referring facility

• Improve safety of the transport and patient outcome.


ขอบคุณรปูจาก คุณจรยิา สายวารแีละทมี PICU




ขอบคุณรปูจาก คุณมทันาและทมี PICU




Case discussion


• U : unstable





Supaporn R.



1. Communication

2. Personnel

3. Equipment

4. Monitoring

5. Stabilization

Supaporn R.

‘Stabilization'

Specific treatments should be considered :

• Myocarditis care

• Post resuscitation care

• Antibiotic treatment?

• Volume support or inotrope support?

• Analgesia, sedation, paralysis?

• Any special treatment required?

Supaporn R.

Myocarditis treatment

1. Control CHF

2. Recognize and prompt treat arrhythmia

3. Immunosuppression

4. Consider mechanical respirator and circulatory support

Supaporn R.

Supply

Demand

Overcoming CHF

Minimize O2 requirement

Overcoming CHF

• Antipyretic

• Surface cooling

“avoid shivering”

No fever !!!

Minimize O2 requirement

• Mild hypothermia

• Sedation

• Paralysis

• Intubation

↑ Inotropic↓ Preload↓ Afterload

↑ Oxygen↑ Oxygen carrier

Overcoming CHF

• HR • EKG• BP•CVP• RR•SaO2

Adequate and continuous monitor

Treatment

1. Control CHF



4. Consider mechanical respirator and

circulatory support

Supaporn R.

5/31/2018 60

Make a diagnosis

Make a diagnosis

1. Control CHF



4. Consider mechanical respirator and

circulatory support

Supaporn R.

Immunomodulation

Supaporn R.

Supaporn R.

‘Stabilization’

• Secure central line

• Restrict fluid

• Ambu bag with PEEP

• Beware of secretion and pulmonary edema

• Keep K > 4, normal Mg, normal Ca, No acidosis

• Prepare for activate ECMO team

• Prepare CPR/antiarrhythmic drug and defibrillator

• Inform family

Supaporn R.

Bag valve mask and PEEP valve

Supaporn R.

AmiodaroneLidocaineMgSO4

Case discussion


• U : unstable





Supaporn R.

Tetralogy of Fallot

• RVOT obstruction

• Large

malaligned VSD

• Overriding

aorta RVH

Tetralogy of Fallot (TOF)

Hypoxic spell

Imbalance of systemic and

pulmonary blood flow

(SBF and PBF)

Imbalance of systemic and pulmonary vascular resistance

(SVR and PVR)

What’s a mechanism of hypoxic spell?

Hypoxic spell

• Infundibular spasm (Max. increase PVR): cathecholamine

• Decrease SVR: morning, post nap,

fever, infection, drug• Tachycardia• Decrease RV volume

Hypoxic spell

• Audible and visible distress

• Deep breath

• Rapid breath

• Pallor

• More blue

• No murmur• Loss of tone

• Loss of conscious

Right to left shunt

pO2

pCo2pH

Hyperpnea

Systemic venous return

Systemic vascular resistanceSpasm of RVOT

HR

Hypovolemia

Hypoxic spell

Right to left shunt

pO2

pCo2pH

Hyperpnea

Systemic venous return

SVRSpasm of RVOT

HR• Hold & calm• Propranolol• Morphine• Volume, PRC• No diuretic

• Knee-chest • Ketamine• Vasoconstrictor• Norepinephrine

• Knee-chest position• O2• NaHCO3• Intubation

• Morphine/FentanylKetamine

การรกัษาอย่างเร่งด่วน เหตผุล

Knee-chest position เพ่ิม systemic vascular resistance ลดsystemic venous return

Morphine 0.1 mg/kg IV or IM

Ketamine 0.5-1 mg/kg IV or IM Calm, sedation

ลด hyperventilation

PRC transfusionให้ปริมาณ RBC มากขึน้

ให้มีการพา oxygen มากขึน้

100% O2 supplement เพ่ิม O2 ในเลือด

pulmonary vascular resistance

NaHCO3 1-2 mEq/kg IV ลดภาวะ acidemia

ลด infundibular stenosis

Aramine 0.02 mg/Kg IV bolus เพ่ิม systemic vascular resistance

‘Stabilization’

• Secure central line

• Adequate fluid

• Sedation (with increase SVR drug)

• Levophed

• Prepare NaHCO3

• Inform family

Supaporn R.

NaHCO3NSS loading



1. Communication

2. Personnel

3. Equipment

4. Monitoring

5. Stabilization

Supaporn R.

‘สาเหตท่ีุต้องส่งต่อ’• โรคทีซ่บัซอ้นสงู ตอ้งการแพทยเ์ฉพาะทาง

• ขาดเครือ่งมอืแพทย ์การตรวจเพิม่เตมิ การผา่ตดั

• ตอ้งการทมีงานทีช่ว่ยดแูล

• ไมม่คีวามมัน่ใจในการรกัษาโรคนัน้

• ผูป้ว่ยมคีวามตอ้งการรกัษาแพทยเ์ฉพาะทาง

• ความไมพ่รอ้มเฉพาะกจิในวนันัน้ๆ

Supaporn R.

ระบบ consultation, teleconference

ระบบการส่งต่อท่ีมีประสิทธิภาพ one stop service

ระบบการส่งกลบั แนวทางการรกัษา

ระบบการเย่ียมเยียนโรงพยาบาลชมุชน แพทยเ์ฉพาะทาง

ระบบ home health care

Thank youPICU team ^^อ. ธมัพรรษ

อ. อุเทน

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Transportation for critically ill pediatric