““Scoop and Run” or “Stay Scoop and Run” or “Stay and Play”? and Play”?

Approach to pediatric Approach to pediatric stabilization and transportstabilization and transport

Janis Rusin MSN, RN, CPNP-ACJanis Rusin MSN, RN, CPNP-ACPediatric Nurse PractitionerPediatric Nurse Practitioner

Children’s Memorial HospitalChildren’s Memorial HospitalTransport TeamTransport Team

Case StudyCase Study

• 2 month old infant 2 month old infant found in full found in full cardiac arrest at cardiac arrest at homehome

• Paramedics Paramedics initiated CPR and initiated CPR and continued CPR for continued CPR for 10 minutes until 10 minutes until arrival in EDarrival in ED

Communication Center CallCommunication Center Call

• Patient arrived to ED with CPR in progressPatient arrived to ED with CPR in progress• Intubated with 3.0 ETT and being baggedIntubated with 3.0 ETT and being bagged• Epinephrine given X 2 Epinephrine given X 2 • Atropine given X 2Atropine given X 2• Heart rate resumedHeart rate resumed• Sodium Bicarb given X 2Sodium Bicarb given X 2• Current vitals: HR-140 RR-40 BP-52/11 Temp- 90FCurrent vitals: HR-140 RR-40 BP-52/11 Temp- 90F• Vent settings: FiO2 1.0, Rate 40, PIP 20 PEEP 3Vent settings: FiO2 1.0, Rate 40, PIP 20 PEEP 3• Pupils 3mm and sluggishPupils 3mm and sluggish• Cap refill 5 secondsCap refill 5 seconds• ABG 6.93/74.4/259/14.8/-16.9ABG 6.93/74.4/259/14.8/-16.9

On ArrivalOn Arrival

• UnresponsiveUnresponsive• Lungs clear and equal bilaterallyLungs clear and equal bilaterally• Capillary refill 4 secondsCapillary refill 4 seconds• Color pale/gray with cool extremitiesColor pale/gray with cool extremities• Peripheral pulses palpablePeripheral pulses palpable• Abdomen full and soft to palpationAbdomen full and soft to palpation• Fontanel soft and flatFontanel soft and flat• 2 tibial IO’s in place bilaterally and one PIV with 2 tibial IO’s in place bilaterally and one PIV with

maintanance and dopamine infusing at 5 mcg/kg/minmaintanance and dopamine infusing at 5 mcg/kg/min• Glucose-47, K-7.0 non-hemolyzedGlucose-47, K-7.0 non-hemolyzed• Succinylcholine given by ED staff but patient with Succinylcholine given by ED staff but patient with

gasping respiratory effortgasping respiratory effort

The Golden HourThe Golden Hour

• Concept originated in 1973 by Cowley et al.Concept originated in 1973 by Cowley et al.• Referred to Army helicopter useReferred to Army helicopter use

– Goal for soldiers to be within 35 minutes of Goal for soldiers to be within 35 minutes of definitive life-saving caredefinitive life-saving care

• Reported a 3 fold increase in mortality with Reported a 3 fold increase in mortality with every 30 minutes away from ‘definitive care’every 30 minutes away from ‘definitive care’

• Resulted in less field intervention in favor of Resulted in less field intervention in favor of speed of transportspeed of transport

• Interventions on transport in 1973, not Interventions on transport in 1973, not comparable to our capabilities todaycomparable to our capabilities today

Initiation of ‘definitive’ careInitiation of ‘definitive’ care

• Definitive care begins with the arrival of the Definitive care begins with the arrival of the transport teamtransport team

• Early goal directed treatment improves outcomesEarly goal directed treatment improves outcomes– Needs to begin with the local emergency departments and Needs to begin with the local emergency departments and

continue with the transport teamcontinue with the transport team– Early aggressive interventions to reverse shock can increase Early aggressive interventions to reverse shock can increase

survival by 9 fold if proper interventions are done early!survival by 9 fold if proper interventions are done early!– Hypotension and poor organ perfusion worsens outcomesHypotension and poor organ perfusion worsens outcomes

““Further improvement in the outcome of critical illness is likely Further improvement in the outcome of critical illness is likely if the scoop-and-run mentality is replaced by protocol if the scoop-and-run mentality is replaced by protocol driven, early goal-directed therapy in the pretertiary driven, early goal-directed therapy in the pretertiary hospital setting”hospital setting”

Stroud et al., (2008)Stroud et al., (2008)

Initiation of ‘definitive’ careInitiation of ‘definitive’ care

• Ramnarayan (2009) Ramnarayan (2009) – Urgent vital interventions such as CPR, Urgent vital interventions such as CPR,

intubation or central venous access required in intubation or central venous access required in the first hour after arrival in an ICUthe first hour after arrival in an ICU

– May indicate that inadequate stabilization was May indicate that inadequate stabilization was completed during transportcompleted during transport

• McPhearson and Graf (2009)McPhearson and Graf (2009)– Attention to small details makes significant Attention to small details makes significant

difference in pediatric transportdifference in pediatric transport• Securing ETTSecuring ETT• Early recognition and treatment of shockEarly recognition and treatment of shock• Adequate IV accessAdequate IV access

Adverse Events Adverse Events

• Orr et al. (2009)Orr et al. (2009)– Sample size 1085 pediatric patientsSample size 1085 pediatric patients– 5% had at least one unplanned event5% had at least one unplanned event

• Airway events-Most commonAirway events-Most common• Cardiac arrestCardiac arrest• Sustained hypotensionSustained hypotension• Loss of IV line needed for inotropic supportLoss of IV line needed for inotropic support• HypothermiaHypothermia• Pediatric specialized teams had longer transport Pediatric specialized teams had longer transport

times, but lower incidents of adverse events, major times, but lower incidents of adverse events, major interventions and deathsinterventions and deaths

Not so fun facts…Not so fun facts…

• Primary cardiac arrest in infants and children is rarePrimary cardiac arrest in infants and children is rare• Pediatric cardiac arrest is often preceded by Pediatric cardiac arrest is often preceded by

respiratory failure and/or shock and it is rarely suddenrespiratory failure and/or shock and it is rarely sudden• Early intervention and continued monitoring can Early intervention and continued monitoring can

prevent arrestprevent arrest• The terminal rhythm in children is usually bradycardia The terminal rhythm in children is usually bradycardia

that progresses to PEA and asystolethat progresses to PEA and asystole• Septic shock is the most common form of shock in the Septic shock is the most common form of shock in the

pediatric populationpediatric population• 80% of children in septic shock will require intubation 80% of children in septic shock will require intubation

and mechanical ventilation within 24 hours of and mechanical ventilation within 24 hours of admissionadmission

Method to the madnessMethod to the madness

• Stabilization goals on Stabilization goals on transporttransport– Airway/Breathing Airway/Breathing

• Respiratory distress Respiratory distress and failureand failure

– CirculationCirculation• Shock identification Shock identification

and managementand management– DisabilityDisability

• ICP managementICP management– ExposureExposure

• Avoid hypothermiaAvoid hypothermia

AirwayAirway

• The respiratory systems The respiratory systems continues to develop until 8-continues to develop until 8-10 years of age10 years of age

• The pediatric airway is The pediatric airway is considerably smaller than the considerably smaller than the adult airwayadult airway

• Poiseuille’s Law: If radius of Poiseuille’s Law: If radius of airway is reduced by half, the airway is reduced by half, the resistance in increased by 16 resistance in increased by 16 fold!fold!

• The cricoid cartilage is the The cricoid cartilage is the most narrow point of airway most narrow point of airway

• Serves as a natural cuff for Serves as a natural cuff for ETT’sETT’s

• Cuffed ETT’s may be used in Cuffed ETT’s may be used in young children but only inflate young children but only inflate cuff to minimize air leakcuff to minimize air leak

Respiratory DistressRespiratory Distress

• A compensated state A compensated state in which oxygenation in which oxygenation and ventilation are and ventilation are maintainedmaintained– Define oxygenation and Define oxygenation and

ventilationventilation– How will the blood gas How will the blood gas

look?look?• Characterized by Characterized by anyany

increased work of increased work of breathingbreathing– Flaring, retractions, Flaring, retractions,

gruntinggrunting– What is grunting?What is grunting?

Respiratory FailureRespiratory Failure

• Compensatory mechanisms Compensatory mechanisms are no longer effectiveare no longer effective

• Inadequate oxygenation Inadequate oxygenation and/or ventilation resulting and/or ventilation resulting in acidosisin acidosis– Abnormal blood gas with Abnormal blood gas with

hypercapnia and/or hypercapnia and/or hypoxiahypoxia

• Medical emergency! Must Medical emergency! Must protect airway!protect airway!

• Strongly consider intubationStrongly consider intubation

Respiratory FailureRespiratory Failure

• Major events that lead to respiratory Major events that lead to respiratory failure:failure:– HypoventilationHypoventilation

• Decreased LOCDecreased LOC– Diffusion impairmentDiffusion impairment

• Alveolar collapse or obstructionAlveolar collapse or obstruction• Pulmonary edemaPulmonary edema• PneumoniaPneumonia

– Intrapulmonary shunting and V/Q mismatchIntrapulmonary shunting and V/Q mismatch• Alveoli are ventilated but not perfused-raising FiO2 Alveoli are ventilated but not perfused-raising FiO2

may not improve PaO2may not improve PaO2• Lungs perfused but not ventilated Lungs perfused but not ventilated • Asthma, ARDS, pneumonia, PPHNAsthma, ARDS, pneumonia, PPHN

Endotracheal TubesEndotracheal Tubes

• SizeSize– Pediatric patient:Pediatric patient:

16 + age in years16 + age in years

44– Compare to little Compare to little

fingerfinger– NeonatesNeonates

• See tableSee table

Tube Tube

SizeSizeWeightWeight

(grams)(grams)

GestationGestational al

AgeAge

2.52.5 < 1000< 1000 < 28< 28

3.03.0 1000-1000-20002000

28-3428-34

3.53.5 2000-2000-30003000

34-3834-38

3.5-4.03.5-4.0 > 3000> 3000 > 38> 38

Endotracheal TubesEndotracheal Tubes

• Length of tube Length of tube estimated by the estimated by the following:following:– Children > 1 year of Children > 1 year of

age:age:• 13 plus ½ patient’s 13 plus ½ patient’s

ageage

– Infants < 1 year of Infants < 1 year of age:age:• Estimated 3x ETT sizeEstimated 3x ETT size

Respiratory assessment and Respiratory assessment and management on transportmanagement on transport

• Across the roomAcross the room– As you approach patientAs you approach patient– Alert, pink, restless, Alert, pink, restless,

combative?combative?

• AirwayAirway– Assess positioningAssess positioning– Airway noise?Airway noise?– Intubated?Intubated?– ETT secure and in ETT secure and in

proper positionproper position• T2-T4-Above carinaT2-T4-Above carina

Respiratory assessment and Respiratory assessment and management on transportmanagement on transport• Tired appearance/decreased Tired appearance/decreased

or altered LOCor altered LOC• Children have thin chest Children have thin chest

walls that make it relatively walls that make it relatively easy to hear their lung easy to hear their lung sounds. If you can’t hear sounds. If you can’t hear them, something is wrong!them, something is wrong!

• Anxiety-Air hungerAnxiety-Air hunger• Cyanosis does not become Cyanosis does not become

clinically apparent until clinically apparent until < 88%< 88%• Stridor/snoring respirationsStridor/snoring respirations• Head bobbingHead bobbing• Prolonged expirationProlonged expiration

Respiratory assessment and Respiratory assessment and management on transportmanagement on transport• 100% oxygen via NRB mask100% oxygen via NRB mask

– Wean O2 as patient stabilizes using face mask or Wean O2 as patient stabilizes using face mask or nasal cannulanasal cannula

• Provide bag valve mask ventilation for children Provide bag valve mask ventilation for children who are not breathing effectivelywho are not breathing effectively– Unable to maintain O2 sats on oxygenUnable to maintain O2 sats on oxygen– CyanosisCyanosis– Unable to protect airwayUnable to protect airway– Bag with enough force to make chest riseBag with enough force to make chest rise– 1 breath every 3 seconds1 breath every 3 seconds

• CE hand positionCE hand position– Do not occlude airway with your fingers!Do not occlude airway with your fingers!

Rapid Sequence IntubationRapid Sequence Intubation

• Goals of RSIGoals of RSI– Induce anesthesia and Induce anesthesia and

paralysis to facilitate rapid paralysis to facilitate rapid completion of procedurecompletion of procedure

– Minimize elevations of ICP Minimize elevations of ICP and blood pressureand blood pressure

– Prevention of aspiration Prevention of aspiration and ventilation of stomachand ventilation of stomach

• Sellick Maneuver Sellick Maneuver – Compression of the cricoid Compression of the cricoid

cartilagecartilage– Compresses esophogus to Compresses esophogus to

prevent aspirationprevent aspiration– Improves visualization of Improves visualization of

vocal cordsvocal cords

Rapid Sequence IntubationRapid Sequence Intubation

• ProcedureProcedure– Oxygenate with FiO2 of 1.0Oxygenate with FiO2 of 1.0– Administer atropineAdminister atropine

• Prevents vagally induced bradycardiaPrevents vagally induced bradycardia• Minimizes secretionsMinimizes secretions

– Administer an opiate and benzodiazepineAdminister an opiate and benzodiazepine• Sedation Sedation

– Administer paralyticAdminister paralytic• Relaxes all muscles allowing ease of opening airway Relaxes all muscles allowing ease of opening airway

and controlling breathingand controlling breathing

– Proceed with intubationProceed with intubation

CirculationCirculation

• ShockShock– An abnormal condition of inadequate blood An abnormal condition of inadequate blood

flow to the body tissues, with life threatening flow to the body tissues, with life threatening cellular dysfunctioncellular dysfunction

– Remember: CO = HR X SVRemember: CO = HR X SV– Oxygen delivery to the tissues is the product of Oxygen delivery to the tissues is the product of

cardiac outputcardiac output– Mortality rate varies from 25-50%Mortality rate varies from 25-50%– Earliest symptom is tachycardiaEarliest symptom is tachycardia– Tachycardia in a child always has a cause-if Tachycardia in a child always has a cause-if

you don’t know why, find out!you don’t know why, find out!

CirculationCirculation

• Compensated ShockCompensated Shock– The body’s compensatory mechanisms are The body’s compensatory mechanisms are

working and maintaining the body’s most working and maintaining the body’s most important functionsimportant functions

– Blood pressure is maintainedBlood pressure is maintained– Symptoms of early shock include:Symptoms of early shock include:

• Mild tachycardiaMild tachycardia• Mild tachypneaMild tachypnea• Slightly increased capillary refill timeSlightly increased capillary refill time• Weak peripheral pulsesWeak peripheral pulses• Decrease in urine output and bowel soundsDecrease in urine output and bowel sounds• Cool/mottled extremitiesCool/mottled extremities

CirculationCirculation

• Decompensated ShockDecompensated Shock– The compensatory mechanisms are no longer effectiveThe compensatory mechanisms are no longer effective– Blood pressure begins to deteriorate-this is what Blood pressure begins to deteriorate-this is what

distinguishes compensated from decompensated shock!distinguishes compensated from decompensated shock!

• Symptoms become more pronounced:Symptoms become more pronounced:– Tachycardia/tachypneaTachycardia/tachypnea– Diminished or absent peripheral pulsesDiminished or absent peripheral pulses– Very delayed capillary refill and cold extremitiesVery delayed capillary refill and cold extremities– PallorPallor– Poor or absent urine outputPoor or absent urine output– Fluid shifts causing generalized edemaFluid shifts causing generalized edema– Petichiae: DICPetichiae: DIC– HypothermiaHypothermia

Types of shockTypes of shock

• Hypovolemic ShockHypovolemic Shock– Occurs from loss of blood or Occurs from loss of blood or

body fluid volume from the body fluid volume from the intravascular spaceintravascular space

– Causes can be injury, Causes can be injury, vomiting or diarrheavomiting or diarrhea

• Cardiogenic ShockCardiogenic Shock– Pump FailurePump Failure

• Inability of the heart to Inability of the heart to maintain adequate maintain adequate cardiac outputcardiac output

• SVT, arrhythmias, SVT, arrhythmias, cardiomyopathy, heart cardiomyopathy, heart blockblock

• Support ABC’s Support ABC’s • Treat the causeTreat the cause

Types of shockTypes of shock

• Obstructive ShockObstructive Shock– Inadequate cardiac Inadequate cardiac

output due to an output due to an obstruction of the heart obstruction of the heart or great blood vesselsor great blood vessels• Cardiac tamponadeCardiac tamponade

• Tension PneumothoraxTension Pneumothorax

• Mediastinal massMediastinal mass

• Support ABC’s, but Support ABC’s, but fluids may not be the fluids may not be the best option. The best option. The obstruction must be obstruction must be relievedrelieved

Distributive ShockDistributive Shock

• Septic shockSeptic shock– Systemic infection as Systemic infection as

evidenced by a positive evidenced by a positive blood cultureblood culture

– Clinical presumptive Clinical presumptive diagnosis importantdiagnosis important

– Patient in early septic Patient in early septic shock will have shock will have bounding pulses and bounding pulses and warm extremitieswarm extremities

– Also known as warm Also known as warm shockshock

Distributive ShockDistributive Shock

• Septic shock:Septic shock:– Bacterial organisms release toxins, which results in Bacterial organisms release toxins, which results in

an inflammatory response and cellular damagean inflammatory response and cellular damage– Bacterial toxins serve as vasodilators resulting in Bacterial toxins serve as vasodilators resulting in

loss of vascular toneloss of vascular tone– Increased capillary permeabilityIncreased capillary permeability– Fluid shifts to extracellular spaceFluid shifts to extracellular space– Hypotension may not respond to fluid resuscitationHypotension may not respond to fluid resuscitation– Inotropic support Inotropic support – Early antibiotics Early antibiotics – 80% of children in septic shock will require 80% of children in septic shock will require

intubation and mechanical ventilation within 24 intubation and mechanical ventilation within 24 hours of admissionhours of admission

Distributive ShockDistributive Shock

• Neurogenic shock:Neurogenic shock:– Severe head or spinal Severe head or spinal

injuryinjury– Decreased sympathetic Decreased sympathetic

output from the CNSoutput from the CNS– Decreased vascular Decreased vascular

tonetone• Anaphylactic shock:Anaphylactic shock:

– Antibody-antigen Antibody-antigen reaction stimulates reaction stimulates histamine releasehistamine release

– Histamine is a powerful Histamine is a powerful vasodilatorvasodilator

– Loss of vascular toneLoss of vascular tone

Shock ManagementShock Management

• Venous access: Ideally 2 large bore IV’sVenous access: Ideally 2 large bore IV’s•Fluid resuscitation: 20ml/kg bolus of NS or LRFluid resuscitation: 20ml/kg bolus of NS or LR•Reassess patient after each bolusReassess patient after each bolus•Convert to blood bolus if patient is bleedingConvert to blood bolus if patient is bleeding• Inotropic support for hypotension that persists Inotropic support for hypotension that persists

despite fluid resuscitation-Beware of despite fluid resuscitation-Beware of catecholamine resistant shock!catecholamine resistant shock!

•Treat hypothermiaTreat hypothermia•Correct F/E imbalancesCorrect F/E imbalances•Find the cause and fix it!Find the cause and fix it!

Disability and DextroseDisability and Dextrose

• AVPU scaleAVPU scale– Alert: Patient is A & O X Alert: Patient is A & O X

33– Verbal: Patient requires Verbal: Patient requires

verbal stimulation to verbal stimulation to wake and respondwake and respond

– Pain: Patient requires Pain: Patient requires painful stimuli to wake painful stimuli to wake and respondand respond

– Unresponsive: Patient Unresponsive: Patient does not respond to any does not respond to any stimulistimuli

• DextroseDextrose– Children in distress Children in distress

become hypoglycemic become hypoglycemic quicklyquickly

– Altered mental status Altered mental status can be a sign of can be a sign of hypoglycemiahypoglycemia

– Check accucheck or i-Check accucheck or i-StatStat

– Treat hypoglycemia with Treat hypoglycemia with 2ml/kg of D10W2ml/kg of D10W

– Recheck accucheck q 15-Recheck accucheck q 15-30 minutes 30 minutes

Exposure/EnviornmentExposure/Enviornment

• Remember a naked child is a cold child!Remember a naked child is a cold child!– Check child’s temperatureCheck child’s temperature– Warm IV fluids if possible: room temperature Warm IV fluids if possible: room temperature

fluids are about 20 degrees colder than normal fluids are about 20 degrees colder than normal body temperaturebody temperature

– Warm blankets for transport Warm blankets for transport – Portawarmer mattress: Can use more than one Portawarmer mattress: Can use more than one

for an older childfor an older child– Place under blanket to avoid burns to skinPlace under blanket to avoid burns to skin

• Hypothermia exacerbates acidosis!Hypothermia exacerbates acidosis!

Family PresenceFamily Presence

• On transport, the family is almost always present On transport, the family is almost always present either at the OSH or in the ambulanceeither at the OSH or in the ambulance

• The literature shows that most clinicians are The literature shows that most clinicians are concerned that parents will interfere with care if concerned that parents will interfere with care if allowed to be present during resuscitationallowed to be present during resuscitation

• However, this is rarely the caseHowever, this is rarely the case• In fact, some studies show that care is improved when In fact, some studies show that care is improved when

a parent is presenta parent is present• There is no evidence to suggest that the legal risk There is no evidence to suggest that the legal risk

increases with parental presenceincreases with parental presence• What would you want if it were your child?What would you want if it were your child?

Dingeman et al. (2007)Dingeman et al. (2007)

X-Ray evaluationX-Ray evaluation

• Systematic approachSystematic approach– Check patient nameCheck patient name– Check time of film-use most recentCheck time of film-use most recent– Air is black and solid structures are white Air is black and solid structures are white

due to increase densitydue to increase density– Ribs should be same length on both sidesRibs should be same length on both sides

•Asymmetry may indicate rotated positionAsymmetry may indicate rotated position

– Check for ETT placement, line placements Check for ETT placement, line placements and for immediate life threatsand for immediate life threats

X-Ray evaluationX-Ray evaluation

X-Ray evaluationX-Ray evaluation

X-Ray evaluationX-Ray evaluation

X-Ray evaluationX-Ray evaluation

Back to the case studyBack to the case study

• Current vitals: HR-140 RR-40 BP-52/11 Temp- 90FCurrent vitals: HR-140 RR-40 BP-52/11 Temp- 90F• Vent settings: FiO2 1.0, Rate 40, PIP 20 PEEP 3Vent settings: FiO2 1.0, Rate 40, PIP 20 PEEP 3• Cap refill 5 secondsCap refill 5 seconds• ABG 6.93/74.4/259/14.8/-16.9ABG 6.93/74.4/259/14.8/-16.9• 2 tibial IO’s in place bilaterally and one PIV with 2 tibial IO’s in place bilaterally and one PIV with

maintanance and dopamine infusing at 5 maintanance and dopamine infusing at 5 mcg/kg/minmcg/kg/min

• Glucose-47, K-7.0 non-hemolyzedGlucose-47, K-7.0 non-hemolyzed• Succinylcholine given by ED staff but patient with Succinylcholine given by ED staff but patient with

gasping respiratory effortgasping respiratory effort

InterventionsInterventions

• Re-tape and pull back ETT 1 cmRe-tape and pull back ETT 1 cm

• Increase PEEP to +5Increase PEEP to +5

• Sedation with Fentanyl 1-2 mcg/kgSedation with Fentanyl 1-2 mcg/kg

• Treat hypoglycemia-2ml/kg of D10WTreat hypoglycemia-2ml/kg of D10W

• Provide adequate paralysis with pavulonProvide adequate paralysis with pavulon

• Give Calcium Chloride-Why?Give Calcium Chloride-Why?

• Give dextrose to increase accucheck to Give dextrose to increase accucheck to 100, then give regular insulin 0.1u/kg-Why?100, then give regular insulin 0.1u/kg-Why?

What happened?What happened?

• Patient sedated and paralyzed appropriatelyPatient sedated and paralyzed appropriately• CaCl and bicarb given as orderedCaCl and bicarb given as ordered• Recheck of accucheck after dextrose =112Recheck of accucheck after dextrose =112• Insulin given as orderedInsulin given as ordered• Accucheck dropped to 42 so D10W repeatedAccucheck dropped to 42 so D10W repeated• One IO was infiltrated so new PIV startedOne IO was infiltrated so new PIV started• Repeat ABG 6.94/92.1/233/18.8/-13.1Repeat ABG 6.94/92.1/233/18.8/-13.1• BP dropped after pavulon, so dopamine titrated BP dropped after pavulon, so dopamine titrated

up-to 20mcg/kg/minup-to 20mcg/kg/min• Pt diagnosed with Influenza APt diagnosed with Influenza A

SummarySummary

• Transporting critically Transporting critically ill children requires a ill children requires a systematic approachsystematic approach

• Attention to details Attention to details will help to avoid will help to avoid adverse eventsadverse events

• Be prepared before Be prepared before you moveyou move

• Minimize major Minimize major interventions in interventions in ambulance or ambulance or helicopterhelicopter

• It’s all about the ABC’sIt’s all about the ABC’s

ReferencesReferences

• Ajizian, S.J., Nakagawa, T.A., Interfacility Transport of the Ajizian, S.J., Nakagawa, T.A., Interfacility Transport of the Critically Ill Pediatric Patient. Critically Ill Pediatric Patient. Chest. Chest. 2007; 132: 1361-13672007; 132: 1361-1367

• Cowley, R.A., Hudson, F., Scanlan, E., Gill. W., Lally, R.J., Cowley, R.A., Hudson, F., Scanlan, E., Gill. W., Lally, R.J., Long, W., et al. An Economical and Proved Helicopter Long, W., et al. An Economical and Proved Helicopter Program for Transporting the Emergency Critically Ill and Program for Transporting the Emergency Critically Ill and Injured Patient in Maryland. Injured Patient in Maryland. The Journal of Trauma.The Journal of Trauma. 1973; 1973; 13(12): 1029-103813(12): 1029-1038

• Dingeman, R.S., Mitchell, E.A., Meyer, E.C., Curley, M.A.Q. Dingeman, R.S., Mitchell, E.A., Meyer, E.C., Curley, M.A.Q. Parent Presence during Complex invasive Procedures and Parent Presence during Complex invasive Procedures and Cardiopulmonary Resuscitation: A Systematic Review of the Cardiopulmonary Resuscitation: A Systematic Review of the Literature. Literature. Pediatrics. Pediatrics. 2007; 120(4): 842-8542007; 120(4): 842-854

• Horowitz, R., Rozenfeld, R.A., Pediatric Critical Care Horowitz, R., Rozenfeld, R.A., Pediatric Critical Care Interfacility Transport. Interfacility Transport. Pediatric Emergency Medicine. Pediatric Emergency Medicine. 2007; 2007; 8: 190-2028: 190-202

ReferencesReferences

• Kliegman, R.M., Behrman, R.E., Jenson, H.B., Stanton, B.F. Kliegman, R.M., Behrman, R.E., Jenson, H.B., Stanton, B.F. (eds.), Nelson Textbook of Pediatrics, 18(eds.), Nelson Textbook of Pediatrics, 18thth ed., 2004, ed., 2004, Philadelphia, Saunders ElsevierPhiladelphia, Saunders Elsevier

• McCloskey, K.A.L., Orr, R.A. Pediatric Transport Medicine, McCloskey, K.A.L., Orr, R.A. Pediatric Transport Medicine, 1995, St. Louis, Mosby1995, St. Louis, Mosby

• McPherson, M.L., Graf, J.M., Speed isn’t Everything in McPherson, M.L., Graf, J.M., Speed isn’t Everything in Pediatric Medical Transport. Pediatric Medical Transport. Pediatrics. Pediatrics. 2009;124(1): 381-2009;124(1): 381-383383

• Orr, R.A., Felmet, K.A., Han, Y., McCloskey, K.A., Drogotta, Orr, R.A., Felmet, K.A., Han, Y., McCloskey, K.A., Drogotta, M.A., Bills, D.M., et al. Pediatric Specialized Transport M.A., Bills, D.M., et al. Pediatric Specialized Transport Teams are Associated with Improved Outcomes. Teams are Associated with Improved Outcomes. Pediatrics. Pediatrics. 2009; 124: 40-482009; 124: 40-48

• Stroud, M.H., Prodhan, P., Moss, M.M., Anand, K.J.S. Stroud, M.H., Prodhan, P., Moss, M.M., Anand, K.J.S. Redefining the Golden Hour in Pediatric Transport. Redefining the Golden Hour in Pediatric Transport. Pediatric Pediatric Critical Care Medicine. Critical Care Medicine. 2008; 9(4): 435-4372008; 9(4): 435-437