Transcript ALNW Flights to CHRMC - North Region EMS & Trauma Care Council

Pediatric Transport
& Considerations in Pediatric Care
Jo Price RN, ARNP, DNP
ALNW QI & Education Department
[email protected]
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
REFERRING
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
RECEIVING
IN ALASKA: Juneau
PATIENT CENTERED
•Partnership
•Team work
•Communication
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
WHO ARE THESE KIDS?
• 10%-18% pre-hospital calls pediatric
• 25-34% emergency room
• Airlift statistics
• 20% of flights are children < 21 years
• Of this, 57% are trauma
• CSHCN represent 35% to 60% pediatric
ALNW TX
• Often higher than AAP statistics
– Reflects use of medical home and survival
– Use of AAP Emergency Sheet?
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Ground versus Air:
Considerations
 How important is time?
– Time sensitive conditions:
ischemic stroke, ischemic limb
– Potential to quickly
decompensate (ICH, intraabdominal injuries, chest
trauma, etc)
– Unstable patients
 Realistic transport time
– Distance
– Geography (mountain passes,
peninsula, islands)
– Traffic patterns
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Air versus Ground:
Considerations
 Safety: risk benefit analysis
 Out of hospital time:
– What will the actual
“uncontrolled” time be?
 Crew Capabilities: not all
ALS crews are the same
 Capacity of ALS crew in
community: can they leave?
 Altitude
 Cost
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Considerations
• Airway management
– Space limitations
– Light limitations
• IV access
• Temperature control
• Pertinent labs:
– glucose, updated ABG/CBG
• OG/NG
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
• OR CAN IT WAIT?
• Will it change therapy?
• Hospital: CT scan/x-ray: Can it be pushed
through in a timely manner or need to be
repeated?
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Specific considerations
• Infection/sepsis: antibiotics priority…
– Lactate and recent blood gas
• Trauma: splinting/BB/Pediboard
– Changes occurring in who gets boarded
• Nexus criteria, Canadian C-spine
• Bronchiolitics: suctioning
• RESPONSE
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
• Asthma: dexamethasone early. High dosing
albuterol
• Croup: dexamethasone early. Racemic if
stridor at rest. Humidity minimal evidence
• DKA: over fluid resuscitation common issue
– ≥ 40cc/kg = high risk =PICU admission
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Medically complex
• CSHCN numbers rising
– Multisystem involvement
– Home equipment?
• = significant fraction of health care resources
• More likely to receive advance life support &
prehospital procedures
– Increased focus of care coordination: EIF forms
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Education Resource
• http://depts.washington.edu/pedtraum/
Online curriculum in the acute assessment and management
of pediatric trauma patients, hosted by Harborview Medical
Center (Seattle, WA)
• EMSC (Emergency medical services for children)
National Resource CENTER:
www.childrensnational.org/EMSC (search for prehospital)
• SCOPE: Special Children’s Outreach & prehospital education. The
center for prehospital pediatrics at Children’s National Medical Center
• http://www.childrensnational.org/emsc/pubres/oldtoolboxpag
es/prehospitaleducation.aspx
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
The principle effects that flight has
on the human body
• Hypoxia
• Gas expansion
• Temperature changes
• Noise
• Vibration
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Disease process that can potentially worsen
in flight?
Pressurized aircraft (Lear or Turbo-prop)?
If not pressurized, flight altitude?
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
ALNW: Rotary Bases
 Bellingham (Airlift 5)
Arlington
 Arlington (Airlift 6)
 Seattle (Airlift 2)
 Olympia (Airlift 3)
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Dedicated Rotary Aircraft
EC 135 (Eurocopter)
Augusta A109 A model
Cruise speed 160 mph, range 200 miles
Single pilot, twin engine. instrument flight capable. Different stretchers
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Dedicated Fixed
Wing Aircraft
 Turbo Commander
12 hour based in Yakima
 Lands on shorter
runways
 Serves smaller
airports: Ellensburg,
Omak, Tonasket,
Chelan, Sunnyside
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Dedicated fixed wing aircraft
 Two Lear 31 A jets based at
Boeing Field
– Serves Eastern Washington,
Montana, and Southeast Alaska
– Cruise speed 500 mph, range
1200 miles
 Lear 31A based in Juneau, Alaska
– Serves southeast Alaska
– Cruise speed 500 mph, range
1200 miles
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Rotary/FW Aircraft ALS Equipment






Transport ventilator (Draeger Oxylog 3000)
Invasive and non-invasive monitor
Cardiac monitor/defibrillator with pacing and 12 lead ECG.
Multi-channel infusion pump
I-Stat
Glide Scope video-laryngoscopy
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Flight team
 Two critical care nurses
– Pediatric/Neonatal Intensive Care experienced
– Adult Critical Care experienced/Adult Certified Emergency Nurse
 Cross-trained to manage and transport all age
patients, ill or injured:
– Neonates, pediatrics, adults, high-risk obstetrics
 Trained in altitude & flight physiology, aircraft
safety
 Certifications: ACLS, PALS, NRP, BLS, ATCN
 Airway management: adjuncts & surgical cric
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
What to expect of crew
•
•
•
•
•
Accurate ETA….if no fog, no snow etc…..
Door closed < 10 min (RW), Wheels up < 15
AIDET
Prioritization for our circumstances
Time Management
– <10 minute field
– <30 minute interfacility (age specific)
• Medical control contact
• Protocol driven
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Hand-off
•
•
•
•
•
SAMPLE hx. if time or…
D-MIVT report style focus
Medical necessity Form
Films/chart with face sheet
Parental information if ride along: (to Comm.)
– Complete name
– Weight
• Priority meds and/or blood products ready to
go
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
CHANGES
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
CURRENT TRENDS IN
PEDIATRICS
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Color Coding Tools
• Tools that help clinicians quickly assess
pediatric patients
– select medications, doses, and equipment
– Has the potential to improve pediatric patient outcomes
during resuscitation IF USED CORRECTLY
• Broselow Pediatric Emergency Tape and/or the
Broselow Pediatric Emergency Cart.
– shown to decrease time to mobilize resuscitation equipment, and increase
the accurate selection of equipment (Agarwal et.al, 2005).
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Safe Practice
Recommendations
• Update tapes. Replace outdated Broselow
tapes with the most recent edition (2011)
– ADJUSTMENTS FOR WEIGHT CHANGES
• Standardize concentrations. Provide
standard concentrations for resuscitation
medications stocked
• Stock Shortages: communication re what is
replaced
• Organize carts.
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Simulation training
• Simulation on in-hospital pediatric medical
emergencies trial
– Significant delays & deviations occur in major
components of pediatric resuscitation
– Median time to airway assessment = 1.3 minutes
– To administering O2 = 2 minutes
– To recognize need for IO = 3 minutes
– To assess circulation = 4 minutes
– To arrival of physician on to floor = 3 minutes
– Arrival of first member of actual code team = 6 minutes
– CPR scenarios: elapsed time to starting compressions =
1.5 minutes
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
• 75% of codes deviated from AHA PALS
• Communication error: 100% of mock codes
• DELAYS WERE NORM NOT EXCEPTION
…LACK OF TIMELY INITIATION OF
RESUSCITATION MANEUVERS
• Importance of floor staff initiating actions
• Leadership important component of
successful teamwork
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
KEY TEACHING FOCUS
• Can know the differences between pediatric
patients & Adults BUT …
• IF LACK OF TIMELY & CORRECT
INTERVENTION OF
RESUSCITATION, IT DOESN’T
MATTER…..
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Airway Controversies
• Cuffed versus Uncuffed Tubes
– Historically not recommended in children under the age
of 8 to 10 years until the mid-1990’s.
– Pediatric anesthetists & intensivists use: 2000-2001
• Current evidence demonstrates this
recommendation is outdated.
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
• Two recent transports:
– Received 4 yr old with 5.5 cuffed ETT
– Received 2 year old 5 cuffed tube
• Both had significant stridor on extubation with use
of raecemic epi, dexamethasone, heliox
• The 4 year old needed emergent re-intubation in
the OR: severe sub-glottic stenosis: could pass a 4
uncuffed tube only
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
BUT THE CUFF WAS
NOT THE PROBLEM….
International Liaison Committee on Resuscitation
• “Cuffed tracheal tubes are as safe as uncuffed
tubes for infants (except newborns) and children
if rescuers use the correct tube size and cuff
inflation pressure and verify tube position.
Under certain circumstances (e.g., poor lung
compliance, high airway resistance, and large
glottic air leak), cuffed tracheal tubes may be
preferable.” The International Liaison Committee on Resuscitation (ILCOR)
Consensus on Science with Treatment Recommendations for Pediatric and Neonatal
Patients: Pediatric Basic and Advanced Life Support
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Pros of cuffed tubes
• The presence of a leak is not a reliable indicator that there is
no undue pressure from the tube on the cricoid mucosa
• The contours of the airway and of the tube are different.
• Using a cuffed tube would permit the use of a smaller tube,
reducing the dangers of pressure damage at the laryngeal
inlet and cricoid.
• The presence of a cuff may ease tube tip away from anterior
tracheal wall reducing the incidence of tube tip damage.
• Cuffed ETT’s protect better against aspiration than an
uncuffed ETT.
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Cuffed Tube Safety
• For the safe use of the cuffed tracheal tube, the
following rules should be respected:
– On Broselow, ½ size down if cuffed tube**
– An air leak to be present after intubation at ≤ 20 cm H2O airway
pressure with the cuff not inflated.
• Feeling cuff not adequate method to check
inflation
– Check with a manometer
• Should use bags with inbuilt manometer AND
PEEP
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Literature
• Use of the LMA is included in:
– The guidelines for cardiopulmonary
resuscitation – ACLS/PALS
– NRP
– Difficult Airway Algorithm
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Advantages to use
• Speed and ease of placement
• Avoidance of endo-bronchial and/or esophageal
intubation
• Regurgitation and gastric distention is less likely
• Avoidance of sympathetic response to DL
• Does not require head/neck/jaw manipulation
• Minimal training required
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Disadvantages
•
•
•
•
•
Failure to protect from aspiration
Inability to provide high-pressure seal
Unable to ventilate poorly compliant lungs
Difficult to suction the airway
Cannot reliably administer intra-tracheal
medications
• Additional training and
skill maintenance
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Approximately 650,000 children evaluated in ED each year for head
trauma with 475, 000 confirmed TBIs in children < 15 yrs.
Greater than 2000 children die from TBI and 42,000 require
hospitalization.
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Primary brain injury at time of impact.
50% of those that die with TBI do so within
the first 2 hrs.
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Secondary brain injury evolving over the next few minutes, hours
& days, resulting in disability & mortality.
POST INJURY HYPOTENSION AND HYPOXIA BELIEVED TO
INDUCE SECONDARY BRAIN INJURY & ARE ASSOCIATED
WITH INCREASED MORBIDITY & MORTALITY
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Hypotension Findings
2008 Study
• 31% not monitored for Hypotension
– Most often occurred during “scene” EMS time
– In children w/o documented hypotension, those not fully
monitored had a Relative Risk of in-hospital death of 4.5
compared to those fully monitored
• Hypotension documented in 39% of children
– Least likely to be treated at the scene (only treated
12% of time at scene) & more likely to be treated on
arrival to hospital…
• Children not fully monitored: younger & smaller
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
• ABSENCE OF BLOOD PRESSURE
MONITORING WAS ASSOCIATED WITH
YOUNG AGE, INCREASED SEVERITY
OF ILLNESS & POOR OUTCOME
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
HYPOXIA
• 34% of children not monitored for O2 sat or
apnea during portion of their early care
• Hypoxia or apnea documented in 44% of
children in the study
– Hypoxia/apnea also occurred most often at
scene
• EMS personnel treated noticed hypoxia or
apnea 87%. Air-medical & ED treated 100%
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Hypoxia
• Children with hypoxia were significantly
younger & smaller than children without
documented hypoxia.
• “I don’t need numbers, I go by the LOC…”
– Problem….
• Those not monitored had lower median
GCS scores than children who were fully
monitored.
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
Take Home Message on
TBI & Monitoring
• Study showed that early hypotension
and hypoxia/apnea are common events
in pediatric TBI and are strongly
associated with worse outcomes
• QA Opportunity Chart/Systems Reviews
– BP documented in specified time period
– If not why not?
– Saturation documented within specified time period
– Appropriate Interventions?
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
References
•
Agarwal, Swanson, Murphy, Yaeger, Sharek, & Halamek, (2005). Comparing the utility of
a standard pediatric resuscitation cart with a pediatric resuscitation cart based on the
Broselow tape: a randomized, controlled, crossover trial involving simulated resuscitation
scenarios. Pediatrics. 116 (3): e326-33
•
Cox, R.G. (2005). Should cuffed endotracheal tubes be used routinely in children?
Canadian Journal of Anesthesia, 52(7), 669-674
•
Felten, M.L., Schmautz, E., Delaporte-Cerceau, S., Orliaguet, G.A., & Carli, P.A. (2003).
Endotracheal tube cuff pressure is unpredictable in children. Anesthesia & Analgesia, 97,
1612-1616.
•
Hohenhaus SM, Frush KS. Pediatric patient safety: common problems in the use of
resuscitative aids for simplifying pediatric emergency care. J Emerg Nurs 2004; 30:49-51.
•
Hohenhaus S. Assessing competency: the Broselow-Luten resuscitation tape. J Emerg
Nurs 2002; 28:70-2.
•
Golden, S. (2005). Cuffed vs. uncuffed endotracheal tubes in children: a review. Society
for Pediatric Anesthesia, Winter 2005, 10.
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau
•
James, I. (2001). Cuffed tubes in children. Paediatric Anaesthesia, 11, 259263.
•
Neonatal hypoglycemia: initial and follow-up management. National
Guideline Clearinghouse www.guideline.gov
•
Wagner, C., Mazurek, P. (2006). Current Practices in Pediatric
Immobilization- An Editorial. Air Medical Journal , 25 (4) 144-148
•
Weeks, D., Molsberry, D. (2008). Pediatric advanced life support re-training
by videoconferencing compared to face-to-face instruction: A planned noninferiority trial. Resuscitation, 79: p 109-117
•
Zebrack, M., Dandoy, C., Hansen, K., Scaife, E., Clay Mann, N., Bratton, S.
(2009). Pediatrics, 124: 56-64
IN WASHINGTON: Arlington, Bellingham, Olympia, Seattle
IN ALASKA: Juneau