Transcript 3.Stabilization and Transfer

For age /
weight
based sizes
Refer
SOS -HOPE
APP
Airway & Breathing
•
ET tubes 2.5 - 6mm
•
Portable Oxygen Cylinder
•
Laryngoscope 0,1,2,3
•
Oxygen masks
blades
•
Oropharyngeal airway 00 – 5
Bag Mask Resuscitator Self
•
Pulse-oximeter
Inflating 450ml
•
Nebulizer
Laryngeal mask airway 1,
•
MDI with spacer & face mask
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•
1.5, 2, 2.5, 3
•
Suction bulb
Vascular access and fluids
• Sphygmomanomater with
infant , child and adult cuffs
• IV drip set
• Normal saline
• Tourniquet
• 10% dextrose
• IV canula 14 guage to 24
• Sterile dressing
guage
• Introosseous needle or bone
marrow needle
• splints
For age /
weight
based sizes
Refer
SOS-HOPE
APP
Personal protective equipment
• Gloves
• Face mask
For age /
weight
based sizes
Refer
SOS-HOPE
APP
Miscellaneous
• NG tubes
• Torch
• Digital Thermometer
• Tongue depressor
• Glucometer
• Foreign body removal
• Splints to stabilize fracture
or snake bite
• Cervical neck collar
forceps
• Otoscope
• Suture set
Stabilization is vital
• Golden hour
• Initial management will determine outcome
• Stabilization is possible at any level
• To stabilize effectively –Be Prepared
Be Prepared Everyday With
MEDICATIONS
Check list and daily
check
MET
With regular mock
drills
TRAINED STAFF
Check list check working
condition
EQUIPMENT
In Every Sick/Potentially Sick Child
TRIAGE
CATEGORIZE
ACT
Emergency Needing Stabilize & transfer
Resuscitation
Potentially sick,
can deteriorate fast
Stabilize & Observe
closely / Transfer
Non Urgent
Treat and Follow up
Stabilization
• Always starts in assessing and correcting deranged
parameters in a systematic manner (A, B, C…….G)
A - Airway
B - Breathing
C - Circulation
D - Disability
E - Expose
F - Farhenheit
G - Glucose
A - Airway
• Stable
• Unstable but maintainable
Positioning + minimal airway adjuncts + Oxygen
administration - free flow
• Unstable and Not maintainable
Position,
Bag and Mask / LMA oxygenate & ventilate
B - Breathing
• Assess noisy breathing
• Consider nebulization
with epinephrine for
stridor and salbutamol
for wheeze
• Hypoxemia
• Supplemental oxygen
• Poor respiratory effort
• Bag & mask or LMA
ventilation
C - Circulation
• Shock – compensated
(perfusion is poor but BP is
maintained)
• Shock – decompensated
or hypotensive (Perfusion
is poor and BP is not
maintained)
• Intravascular/Intraosseous access
• Normal Saline bolus of 20ml/kg
over 10-15 minutes & smaller
aliquots of 5-10 ml/kg over 20-30
minutes in cardiogenic shock
• Reassess circulation after each
bolus
• Free flow oxygen
• Check oxygen saturation
• Check glucose
• First dose of Inj ceftriaxone 100mg/Kg Slow IV / IM
• Anticipate deterioration to
hypotensive shock
D - Disability or Neurological Exam
• Assess neurological status by observation
• Appearance
• Pupillary responses to light
• Careful assessment of Tone and disability
Level of consciousness
A - Alert
V - Verbal responsiveness
P - Painful responsiveness
U - Unresponsive
Expose
Fahrenheit
E
F
Glucose
G
 Expose in selected
 Check the temperature  Check glucose in all
cases of trauma,
patients who appear
burns & poisoning.
Unstable.
Respect privacy and
 Correct both hypo (
keep the patient warm
<35C) & hyperthermia
(> 38 C)
 Splint obvious
fractures, arrest
external bleeding with
compression
 Both are serious in
newborns,
malnourished and
immunosuppressed.
 Correct values <
50mg/dl With 5ml / kg
of 10% Dextrose IV
or IO
Case 1
• 3 year old child has been playing in the place where
dad keeps his tools including kerosene.
• The family has found the child with kerosene all
over himself and are not sure if he has ingested
any?
• He has been brought to your office
Case Progression
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Interact!
Behavior playful but smells of kerosene
Breathing normal 25/min
HR = 90/min
Peripheral pulses good volume pulses
CRT 2 secs
BP is Normal
Temp 38.5 deg C
Saturation: 95%
What is the triage category and how do you stabilize
Case Progression Response
• Any potential poisoning should
be observed for at least six
hours
• Remove clothes, and clean the
patient, this will reduce dermal
absorption
• There is no role for gastric
lavage or activated charcoal
what parameters do you want to
Interact!
stabilize
A – Airway
Y
N
B – Breathing
Y
N
C – Circulation
Y
N
D – Disability
Y
N
E – Exposure
Y
N
F – Fahrenheit
Y
N
G – Glucose
Y
N
Case 2
• 8 year old ill looking child walks into the office
• Your receptionist is trained to triage and since the
child is breathing fast, he is sent to you on priority
basis.
• History reveals that he has lost weight but is eating
and drinking well.
• Since this morning he is complaining of abdominal
pain and is breathing fast
Progression
Interact!
• Alert and interactive but
• His CRT 3 secs
Ill looking
• Breathing fast 40/min
• HR = 130/min
• Peripheral pulses are
normal
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• What is the triage
category
BP 90/60mm hg
Temp 39 deg C
Saturation: 96%
RBS is 500 mg/dl
Case 2 – Response
• This child is an emergency.
Resuscitation should be started
immediately pending transport to
hospital
• How will you stabilize if your
facility or office is
A. within 15 minutes from a tertiary
care center
B. 6 hours from a tertiary care center
Interact!
Case 2 – Response
continued
• Situation A
• Administer normal saline 10 ml/kg/1hour
• Maintain oxygenation and arrange transfer
• Situation B
• Administer normal saline 10 ml/kg/1hour
• Maintain oxygenation
• Start insulin drip at 0.1 unit/kg/hour in normal saline
With glucose monitoring and arrange transfer with
medical supervision
what parameters do you want to
Interact!
stabilize
A – Airway
Y
N
B – Breathing
Y
N
C – Circulation
Y
N
D – Disability
Y
N
E – Exposure
Y
N
F – Fahrenheit
Y
N
G – Glucose
Y
N
Case 3
• 4 year old who has been having fever for three
days is brought to your office because he is
breathing fast and mom feels that he is not his usual self
• He is seen by your assistant Dr. who has been trained
to check capillary refill and respiratory rate
• Both are high and hence the child gets seen ahead of
others
Case Progression
Interact!
• He appears sick and has a glazed look. He also looks dusky
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He is grunting , tachypneic to 50/min
Mild to moderate respiratory distress
Decreased air entry on the left side
O2 Saturation is 80 on RA
Heart rate 180/min, Pulse volume feeble
His capillary refill is 5 sec
BP - 80/50 mm Hg
GRBS is 100 mg/dl
What is your triage category and how do you stabilize
Case 3 - Response
• He has got life threatening lung
infection, with significant hypoxia and
decompensated shock. Key issues in
stabilization would be…….
what parameters do you want to
Interact!
stabilize
A – Airway
Y
N
B – Breathing
Y
N
C – Circulation
Y
N
D – Disability
Y
N
E – Exposure
Y
N
F – Fahrenheit
Y
N
G – Glucose
Y
N
Case 3 – Response
continued
• Free flow oxygen with NRM
• IV access/ IO acce ss
• Administer 20 ml/kg of normal saline and reassess CRT, HR
and BP
• Up to 3 boluses of normal saline may be administered
• Constant monitoring of circulatory status by evaluating CRT
pulse rate and BP and oxygen saturation will guide further
management.
• Ceftriaxone 100mg/kg should be given after collecting Blood
Culture, and arrangement for transport should be done
Transport - When,
Where, & How ?
You want to shift him ,what are the key
issues?
• Pre transport
• Transport
• Post transport
Minimal Documentation
Patient…………………………………Date……………………….Time in………………….Time
transferred……………………………..
Diagnosis……………………………………………………………………………………………………………..
Time
Vitals
RR
HR
BP
SpO2
Intervention
Sensorium
Medication
Fluids
Oxygen/Ventilation
Transferring physician Name…………………………….Signature…………………………. Phone
……………………….……………
Accepting physician Name
………………………………..................................................Phone……………………………
Informed consent of parents/ care giver………………………………………………………..
Conclusion
Stabilization
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Be prepared
Daily checks
Assign triage categories
Stabilize in an orderly
fashion (a…….G)
• Monitor constantly to decide
further course of action
• Communicate, document
and plan shift
Transport
• Consider pre-transport condition,
transport requirements, and post
transport follow up
• Communication with parents is
vital
• Communication with the receiving
unit will optimize outcome
• Document all treatment given
• If transfer is going to be delayed
continue stabilization efforts at
your facility