Bmj[1].books.pediatric.and.neonatal.critical.care.transport.e book lib

Edited by Peter Barry and Andrew Leslie

PaediatricandNeonatalCritical CareTransport

Paediatric and Neonatal CriticalCare Transport

Paediatric and Neonatal CriticalCare TransportEdited by

Peter BarryConsultant Paediatric Intensivist, Children’s Intensive Care Service,University Hospitals of Leicester and Honorary Senior Lecturer,University of Leicester

Andrew LeslieNeonatal Transport Coordinator/Advanced Neonatal Nurse Practitioner,Nottingham Neonatal Service, City & University Hospitals, Nottingham

© BMJ Publishing Group 2003BMJ Books is an imprint of the BMJ Publishing Group

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system,or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording

and/or otherwise, without the prior written permission of the publishers.

First published in 2003by BMJ Books, BMA House, Tavistock Square,

London WC1H 9JR

British Library Cataloguing in Publication DataA catalogue record for this book is available from the British Library

ISBN 0 7279 1770 6

Typeset by SIVA Math Setters, Chennai, IndiaPrinted and bound in Spain by Graphycems, Navarra

Contents

Contributors vii

Acknowledgements ix

Foreword xi

Part 1: Planning for safe and effective transport 1

1. Principles of safe transport 3

2. Transport physiology 14

3. The ambulance environment 19

4. Equipment and monitoring 25

5. Air transport of critically ill children 36

Part 2: Practical transport management 41

6. Neonatal resuscitation and stabilisation 43

7. Paediatric resuscitation and stabilisation 53

8. Management of the airway and breathing 69

9. Management of the circulation 79

10. Trauma 90

11. Special transport interventions 102

12. What to do when it all goes wrong 108

13. Drugs 112

Appendix 1: Typical retrieval forms 123

Appendix 2: Essential equations and aide-mémoires 134

Selected references and bibliography 135

Index 139

Contributors

Peter BarryConsultant Paediatric Intensivist, Children’s Intensive Care Service, University Hospitals of Leicesterand Honorary Senior Lecturer, University of Leicester

Sandie BohinConsultant Neonatologist, University Hospitals of Leicester

David FieldProfessor of Neonatal Medicine, University of Leicester, Honorary Consultant Neonatologist, UniversityHospitals of Leicester

Julie HallNeonatal Transport Coordinator, University Hospitals of Leicester

Taj HassanConsultant in Emergency Medicine, The General Infirmary at Leeds, Leeds Teaching Hospitals Trust

Carmel HuntPaediatric Retrieval Coordinator, Children’s Intensive Care Service, University Hospitals of Leicester

Andrew LeslieNeonatal Transport Coordinator/Advanced Neonatal Nurse Practitioner, Nottingham Neonatal Service,City and University Hospitals, Nottingham

David LuytConsultant Paediatric Intensivist, Paediatric Intensive Care Service, University Hospitals of Leicester

Andrew MacIntyreConsultant Paediatric Intensivist, Royal Hospital for Sick Children, Glasgow

Sanjiv NichaniConsultant Paediatric Intensivist, Paediatric Intensive Care Service, University Hospitals of Leicester

Giles PeekHonorary Lecturer in Cardiothoracic Surgery and ECMO, University of Leicester

Moira RobinsonSenior Medical Technician, Paediatric Intensive Care Service, University Hospitals of Leicester

David RowneyConsultant in Paediatric Anaesthesia and Intensive Care, Royal Hospital for Sick Children, Edinburgh

David VickeryConsultant in Emergency Medicine, Gloucestershire Royal Hospital

Many people offered helpful opinions, advice andcriticism as we wrote this manual. We would liketo acknowledge the important contributions madeby all the people, past and present, who havetaught on the Paediatric and Infant Critical CareTransport course in Leicester. The course grewwith the experience and contributions of thosepeople, and this book grew from the course.Paediatric and Neonatal Critical Care Transportis now the coursebook for NEOSTAR, a course runby the Advanced Life Support Group.

Our thanks go to Jackie Howarth, who currentlyadministers the transport course, and to CarolineClay, for her secretarial help.

Our thanks also to the transport teams inLeicester and Nottingham and to MerranThomson, David Thomas, Rose Kent, Kate Wilson,

Tracy Earley, Jenny Burgess, Mary Merriman,Lynda Raphael, Charlotte Huddy, Ian Buck Barrett,Martin Earley, Amanda Bowman, Colin Read,Manjeet Riyat and Ashish Chickermane.

The manual was expertly guided to fruition byMary Banks, Christina Karaviotis and the team atBMJ Books. SIVA Math Setters took our crudesketches and turned them into the attractiveillustrations seen in this manual.

Every effort has been made to ensure the accuracyof the data, particularly drug doses, in this manual,but it remains the reader’s responsibility to ensurethat these are appropriate for their patients.

Finally, our personal thanks to Jo and Jane.

Peter BarryAndy Leslie

Acknowledgements

Around the world, intensive care for all agegroups has developed at different rates. Withineach country, local priorities have governed theway in which services have evolved. In the UK,the equity of health care provision afforded bythe National Health Service meant that intensivecare technology has spread fairly rapidly andequitably across the whole country. Given thesmall distances between centres of population,transport was not a major consideration andlocal enthusiasts have dealt with the issue byemploying a variety of solutions. As a result in thecountry as a whole there are currently hundredsof different transport systems in place.

In other countries local circumstances led to arather different evolution of the service. Forexample, in Australia the vast distances betweenintensive care centres meant that excellenttransport facilities were a necessity and as aconsequence expert teams with dedicated equip-ment rapidly emerged. In parts of the USAdistance was also an issue. There more flexiblefunding arrangements made it attractive forhealth care providers to set up first class servicesdedicated to transport.

During the last few years a number of newfactors have emerged in the UK which have madeexisting arrangements largely untenable.

Risk

This was highlighted by a road traffic accidentwhich occurred in Northern Region in 1993involving an ambulance returning to Newcastlewith a baby requiring intensive care. In responseto this event, the Medical Devices Agency carriedout a review of neonatal and paediatric transfersin the UK (the TINA inquiry). The reporthighlighted various problems. Some of the moreimportant were:

• The standard devices used to secure transportincubators in ambulances were totallyinadequate to provide restraint in the event ofan accident. Indeed, on closer inspection, itwas clear that even if the clamps were able tohold the trolley during an impact, the chassisof the standard ambulance was not.

• It was unreasonable to expect that any transportsystem weighing more than 200 pounds

(90 kilograms) could be safely carried in astandard ambulance. Some systems in useexceeded 700 pounds (320 kilograms).

• Many additional items of equipment wereloaded into the ambulance without anyreasonable means of restraint.

• The validity of indemnity arrangements forstaff injured in any accident and usingsuch equipment seemed unclear, given that thesituation was known to be unsafe.

• Existing Health and Safety legislation regardingmanual handling was regularly breached byneonatal transport systems.

• There were no adequate systems for securingthe baby in the incubator during the journey.

• Arrangements for staff training were patchy. • Use of air transport was associated with many

additional hazards which appeared to havebeen fully addressed by only one transportservice in the UK.

Although focused on the newborn, most of theproblems highlighted by the TINA report wereshared by all forms of intensive care transport.

Staffing

The last few years have seen many changes in theworking patterns of junior doctors; the highpressure specialities of neonatal and paediatricintensive care have been subject to particularlyclose regulation. These changes have compoundeddifficulties regarding the staffing of intensivecare retrievals. Only a minority of units havesufficient specialist medical and nursing cover toreliably fill this role and supervise the rest ofthe service. On the other hand, increased numbersof junior doctors working shorter hours meansthat providing adequate training is even morecomplicated.

Demand

During the last five years, neonatal and paediatricintensive care have moved in opposite directionsin this regard. For neonatal intensive care,increased numbers of infants cared for in districtgeneral hospitals and a falling birth rate havebrought a small reduction in the demand for urgentpostnatal transfers. This of course compounds

Foreword

the difficulty of those carrying out transports todevelop and maintain skill levels.

The same period has seen paediatric intensivecare emerge as a speciality in the UK. Thereforeat a time of financial stringency both the basicprovision for the country and a transport servicehave had to be established. Since the total numberof paediatric intensive care patients is relativelylow appropriate catchment populations have beendifficult to establish.

Vehicles

As clinical staff, we often take for granted that thelocal ambulance service will provide a vehicleas and when required. We forget that asking aservice with a tight budget to provide a frontlinevehicle at random for several hours might poseproblems. Similarly, we have on the whole beenpoor at consulting when we plan to change ourtransport system for one that might not fit thelocal vehicles. Where more than one neonatalservice exists within the boundaries of a singleambulance trust, they may be requested totransport incubator systems of vastly differentconfigurations. As a result it has been necessary,in some parts of the country, to take thecostly step of providing two dedicated vehicles.Conversely, ambulance trusts have, on the whole,not sought the opinion of local intensive caretransport teams before ordering new vehicles of adifferent design. Clearly regular dialogue wouldgo a long way towards helping to resolve theseproblems.

Conclusions

The overall situation with regard to intensive caretransport is quite unsatisfactory, but there aresome positive developments on the horizon. Partsof the UK have made a clear decision to provideemergency transfers using a specialist, dedicatedservice. It is anticipated that transport servicesof this type will form part of the much heraldednew national plan for neonatal intensive care(at the time of writing there has been an officialleak of this document but no formal publication).In 2002 the European Union voted to accept newEuropean Standards for transport incubatorsystems and their carriage in emergency vehicles.Although the UK voted against the new Standardsthey should become European “Law” in duecourse. These regulations will place greaterresponsibilities on those who undertake newborntransfers to ensure that the equipment andprocedures used minimise risk for all concerned.However, the specifics around the situation forolder children remain largely unregulated.

For those involved in emergency transfer it isimportant not to ignore the personal responsibilityto prepare as thoroughly as possible for thetechnical and clinical aspects of the task, in orderto provide the highest quality of service possible.It is hoped that the material in this book goessome way to achieving that aim.

David FieldProfessor of Neonatal Medicine

University of Leicester

Paediatric and neonatal critical care transportxii

Part 1Planning for safe and effectivetransport

Introduction

Services for critically ill infants and childrenare, to a greater or lesser extent, provided inregionalised patterns, which influence theprovision of transport. Many hospitals providefacilities for care of newborn infants of varyinglevels of intensity where the need for transfer isdetermined by a requirement for support ortreatment beyond that available locally. Babieswho are very premature, who require surgery orwho are struggling on conventional intensive careare transferred to centres that can provide thenecessary support. Locally agreed in utero transportpolicies can avoid the need for intensive caretransfer for some of these infants, but a substantialnumber of postnatal transfers will remain. In thefuture these may increase as neonatal care isprovided in managed clinical networks.

It is now well accepted that the outcome ofcritical illness or injury in children is better whenthey are cared for in specialised paediatricintensive care units (PICUs). Such units requirehigh cost equipment and staff and thus cannot belocated in all hospitals dealing with children.They are consequently situated in the largerreferral centres in countries where PICUs areprovided, including the UK. Many hospitals inthe UK with emergency paediatric services willthus not have PICU facilities but can, and will,from time to time be presented with critically illchildren. When critical illness or injury occurs farfrom a PICU, the child will need admission to andstabilisation in the nearest hospital. If, afterstabilisation, the child’s needs exceed thefacilities of the local hospital, he or she will needto be transported to a referral centre providingintensive care, ideally by the transport team fromthe PICU. The goal of this team is to function asan extension of the PICU, delivering the samequality of care during transfer.

This chapter gives an outline of all the topicswith which this book is concerned. Many of theissues are explored in greater depth elsewhere inthe book. The principles of interhospital transferare outlined here under the following headings:

• Team composition• Mode of transport• Setting up a transport programme• Equipment• Communication• Documentation• Safety• Transferring a patient.

Team composition

A transport service has organisational andoperational teams. Intensive care unit (ICU) staffcan be members of either or both. Theorganisational team (Box 1.1) is made up of seniorICU staff and is tasked with the setting up andmanagement of the transport service. Byconvention, the service director is a senior ICUconsultant and the service coordinator a seniorICU nurse.

Box 1.1 Organisational team tasks

Medical director (PICU, NICU, or A&E consultant)Oversee programmeDevelop policies and protocolsReview/approve equipment and medication listsEstablish and implement outreach programmesReview transport casesManage quality improvement programmes

Transport coordinator (senior nurse)Develop policies and protocolsDevelop/approve equipment and medication listsEstablish and implement outreach programmesLocal liaison (for example, ambulance) and localtrainingDaily scheduling of transport team membersReview transport casesCollect transport data (audit)Manage quality improvement programmesBudget management

NICU = neonatal intensive care unit; PICU = paediatricintensive care unit.

The operational team is the medic, nurse,paramedic and driver or pilot out on aninterhospital patient transfer (Box 1.2). If a childrequires only level 1 care it is possible that anurse, without a medic, may fetch him or her.Critically ill patients require a transport team of at

1 Principles of safe transport

ObjectivesThis chapter outlines key topics pertinent toestablishing and running interhospital transferservices for critically ill infants and children.

least two personnel, both adequately experiencedand accompanied by the ambulance, helicopteror airplane staff. The team leader will usually bea doctor, although advanced neonatal nursepractitioners (ANNPs) are increasingly leadingneonatal transports.

Box 1.2 Operational team—qualities and tasks

Transport nursesQualities:

• Experienced in PICU or NICU• Seniority• Postbasic speciality training plus paediatric

and/or neonatal life support• Availability 24 hours a day, 7 days a week• Competences:

management of airwaysoperate transport equipmentunderstand limits of equipmentknow suppliesorganisaton of transport

Tasks:

• Nursing care of patient during transport• Liaison with nurses at referring hospital• Deal sensitively with the family• Inform the family about patient’s destination

and how to get there• Inpatient care after transfer• Check and restock transport equipment• Advise transport physician on transport nursing

issues

Transport physician (or ANNP)Qualities:

• Experienced in paediatric/neonatal emergenciesand PICU/NICU

• Able to determine diagnostic and therapeuticpriorities in critically ill infants and children

• Seniority• Paediatric and/or neonatal life support• Available 24 hours a day, 7 days a week• Competences:

leadership management of airwaysoperate transport equipmentcannulationinsert IC drainscan operate within the constraints of the

transport environment

Tasks:

• Know bed availability• Obtain information about patient from the

referring team• Advise about treatment• Assess need for other specialists, for example,

surgeons• Assess and monitor child’s condition

The seniority or grade of the medic and nurse isnot an absolute—experience and competence arealso considered, as is the patient’s diagnosis andperceived condition. In instances of extremelysevere illness, it might be prudent if possible totake two senior medics.

The ambulance or aircraft personnel are anintegral part of the operational team, and not justdrivers. Experienced vehicle personnel, familiarwith the needs of the transport team, can savevaluable time.

Personnel are the most valuable component of atransport team both in the organisation and theperformance of the service.

Mode of transport

Patient transfers are made both within andbetween hospitals. The principles for the safe andeffective movement of a sick patient, particularlywhere the patient is dependent on support devicessuch as intravenous pumps and ventilators, applyto any transfer out of the intensive care environ-ment irrespective of the distance needed to travel.Hence, even when a patient is being moved foran investigation or to the operating theatre, theteam should adhere to their practised safetyprocedures.

Three options are available for interhospitalpatient transfers. The patient may be:

• Sent via the local emergency services• Sent via the local (referring) emergency medical

services, i.e. via ambulance with the referringphysician and/or nurse

• Fetched by a specialised critical care transportteam.

The first two modes are referred to as one-waytransports and the third as two-way transport. Theonly advantage of sending a patient, or one-waytransport, is time. This form of transport hasmany disadvantages (or two-way transport hasmany advantages) (Box 1.3).

Interhospital patient transfers are either by roador by air in a helicopter or fixed wing aircraft.Individual intensive care transport teams willhave protocols as to which form is used based onvarious deciding factors. These factors or criteriainclude:

• Distance between referring and receivinghospital. If the distance exceeds two hours’

Paediatric and neonatal critical care transport4

travel by road, serious consideration has to begiven to transferring the patient by helicopter

• Traffic density. This can be partially overcomewith the help of the emergency services,including the police who can clear the road. Itshould not be a reason to summon a helicopterfor a short distance

• Buildings in the town or city where thehospitals are located. Transferring a patient to orfrom a big city by air has the added difficulty ofhigh rise buildings affecting transit and landing

• Weather. Safety is the prime concern in anyinterhospital patient transfer. There is nothingto be gained from endangering the lives of ahelicopter crew and the transport team bysending them out into poor unsafe weatherconditions. A timely decision to use anambulance may save precious time whilst youwait for the weather to clear.

Two-way transport (or retrieval) of critically illpatients by trained and experienced staff is the bestand most desirable form of interhospital transport.

Setting up a transportprogramme

A three-pronged approach forms the foundationof success when embarking on an investment ofthis magnitude—investment not only in financialterms but also in time and commitment. Thistriad is described below.

Outreach

Identify hospitals in your catchment area andadvertise to their relevant staff the proposed oroperational service. “Relevant staff” includes the

doctors and nurses in their paediatric department,surgical department, neonatal unit and adultintensive care. A visit to the hospital to talk aboutthe service and deliver laminated posters of theservice with a direct dial telephone number to beprominently displayed is arguably the mosteffective form of this outreach.

Education

Education is necessary at many levels:

• Education programme for the ICU staff whowill be doing transfers on transport medicineand interhospital patient transfers

• Study days for staff in referring hospitals onresuscitation and stabilisation of the criticallyill child and the needs when preparing fortransfer

• Study days for the ambulance staff on therequirements of the service and aboutemergency paediatrics

• Information to the referring centres oncommunication lines.

Hard sell

Selling the need for an expensive service isprobably the hardest limb of the triad. Professionalcolleagues outside the ICU and hospital managersand budget holders in your institute need to beconvinced of the necessity of such a service. TheICU organisational team need to embark on anexercise of winning the hearts and minds of thecolleagues mentioned to ensure that the unit isappropriately staffed and funded. They mustknow, as must the ICU staff, that “retrieval is notan option but a necessity”, that “the ICU can’t beseen to pick and choose when they want to helptheir catchment hospitals”, and that the patients inthe catchment hospitals are potentially our ICUpatients.

Equipment

The operational team must carry all equipment,supplies and drugs necessary for stabilisation andtransfer. The team should not rely on the referringhospital for supplies. Paediatric patients are often“held” in adult facilities waiting for the transportteam to arrive. These may carry limited paediatricsupplies.

The equipment must be regularly checkedand serviced. Supplies and drugs (i.e. contents of

Principles of safe transport 5

Box 1.3 Advantages of two-way interhospitalpatient transfers

Entire team—paramedics, nurses, and physicians—have transport training and experience.Outcomes are better for patients transferred bytrained teams

Equipment, including critical care equipment likeventilators and monitors, is dedicated fortransporting critically ill patients

Equipment and drugs are prepared beforehandTransport team usually from centre where there

is staff back up whilst they are away. May evenbe dedicated transport staff without otherresponsibilities on that shift

medical bags) must be replenished after each use;a contents checklist is essential. Checked andrestocked boxes and bags should then be sealed,rendering them ready for immediate use. Theseshould be stored in an accessible but protectedand restrained space.

There is more in-depth discussion of equipmentin chapter 4. The American Critical Care Societylists the equipment needed in transport. Referenceto this list can form the template or basis of atransport service’s checklist. Essential features ofthe exhaustive list with guideline recommen-dations as comments are shown in Box 1.4.

Box 1.4 Equipment required during transport ofa critically ill child

Patient movement

• Trolley• Incubator for children < 5 kg• Metal pole or shelf system to secure ventilator,

pumps, monitors• Adjustable belts (safety belts) to secure patient

in transfer• Equipment bags: multiple compartments to

allow access to individual items withoutunpacking

• Drug boxes

Airway management

• Equipment to establish and maintain a secureairway

bag-valve device (for example, Ambu bag)with selected mask sizes

endotracheal tubes (all sizes), stylet andMagill forceps

laryngoscope with assorted size blades• Portable mechanical ventilator

small, lightweight with economical gas usagecapable of ventilating infants and children

of all agesdisconnection and high pressure alarms

essentialproviding PEEP, facilities for variable FiO2,

I : E ratio, RR, and TV• Portable oxygen supply

provide high pressure supply with lowpressure metred flow

sufficient to last duration of transfer withreserve, usually 1–2 hours

• Suction—portable, battery powered

Intravenous infusions

• Equipment to establish and maintain venousand arterial access

• Drugsresuscitation drugs

infusions of sedating and paralysing agents(for ventilated patients)

inotropic infusions• Infusion pumps—small, lightweight, long

battery life

Monitoring

• Monitor:portable, battery powered, clear illuminated

displayECG, oximetry, non-invasive blood pressure,

temperature, capnographyinvasive channels (preferably 2) for CVP and

invasive BPalarms must be visible as well as audible

because of extraneous noises

Document folder

• Recording chart, audit form, consent form• Infusion charts and crash drug charts—filled in

prior to transfer• Information for parents, i.e. maps and

telephone numbers

Mobile phoneWarm protective clothing for staff

PEEP = positive end expiratory pressure, RR = respiratoryrate, TV = tidal volume.

Each transport team, when developing protocols,must devise a list of equipment, supplies and drugsas well as an inventory or checklist.

Communication

When does the ICU take responsibility for thetreatment of the critically ill child? The answer tothis question is not clear, but once the referringhospital has made contact their referring team isclearly asking for help; however, the arrival ofthat help will obviously be delayed whilst theoperational team is in transit. Interim joint carewill be facilitated by communication, so theorganisational team must pay particular attentionto ensuring ease of communication. Figure 1.1illustrates some of these issues. Notice that thereceiving unit, who will usually be the unit doingthe transfer as a two-way transport, have someresponsibility for the patient even before they leavebase, including responsibilities for assembling ateam in a timely fashion and for sending competentstaff and appropriate equipment. Notice also thatthe referring team are substantially responsiblefor the patient until they hand over to thetransport team, and that they continue to have


responsibilities for the patient after transfer:responsibility for assisting the transport team andfor notifying the receiving unit of significantlaboratory results, such as positive cultures, in thecoming hours and days.

Communication has many facets.

• Hotline. A direct line (not through the hospitalswitchboard) or “hotline” into the ICU that isdedicated to incoming calls (and hence notcontinuously engaged in a busy ICU) but alsoopen to outgoing national calls will makeconversations between consultants considerablyeasier and more effective. Advertise the numberwidely in the catchment area.

• Essential information. The ICU must informtheir regular referring institutes about theinformation they will need to ensure that thereferring doctor has this essential informationto hand when making the telephone call (seebelow).

• Continuous contact:

• After a referral has been made there willinevitably be a delay before departure fromthe receiving hospital. The transportphysician or consultant on call shouldmaintain continuous contact by regularly(every half hour) telephoning the referringphysician for an update and further advice,if needed. The referring physician shouldof his or her own volition also maintaincontinuous contact with updates on anyprogress, for example child’s conditionchanged making the transfer unnecessary.

• Once the team has been despatched theymust maintain contact with their home

base with a mobile phone throughout thetrip, including a brief report about thepatient’s condition prior to departure forthe return journey, expected treatmentrequirements (for example, ventilator,infusions), and expected time of arrival.

• Inform ambulance crew. The operational teammust inform the ambulance crew about thepatient’s condition and the projected timerequired for stabilisation and hence expectedtime of departure for home. This form ofcommunication is particularly important withhelicopter crews in air retrievals.

• Talk to staff and family:

• The referring hospital has asked for help. It isnot helpful to arrive with an arrogant “ivorytower” attitude as in most instances the localteam will have done a sterling job in difficultcircumstances. The referring team willappreciate confirmation and praise as well asmeasured advice and criticism.

• The family need relevant information andreassurance, without misplaced optimism.Their child is being taken from them in anambulance to a strange city, which theymight never have visited before. A state-ment to the effect that the child is very sickbut stable and that the team undertakesmany transfers successfully every yearwill provide great comfort. Families havereported that they felt that once the childleft it was sure to die. They need to knowthat that risk is present but small.

• Regular follow up to the referring team andpossibly the child’s GP as well. Aim to agree to


Call made toreceiving unit

Incr

easi

ng

resp

on

sib

ility

Referral accepted Handover Team leavesreferring unit

Arrival atreceiving unit

Figure 1.1 Changing levels ofresponsibility for patient care followingreferral for transport. (From BrimhallD.The hospital administrators’ role. In:MacDonald M, Miller M, eds. EmergencyTransport of the Perinatal Patient.Toronto: Little, Brown, 1989.)

return the patient to the referring institute assoon as he or she has had maximal benefit ofthe ICU. This allows convalescence close tothe patient’s family, promotes efficient use ofICU beds, and advances cooperation betweeninstitutes.

• Feedback. The ICU must provide feedback,particularly about stabilisation, as teaching forthe referring institute personnel. A period ofsecondment by nurses from referring institutesto the ICU could also serve this purpose.

Communication, communication, communication

Documentation

A good doctor or nurse is only as good as therecords he or she keeps. A clear and concisewritten clinical record is important with anypatient treatment, but possibly more importantduring interhospital patient transfers as these arepatients who are usually critically ill and who inaddition, for the duration of the transfer, are notmanaged in an optimal environment. Importantfeatures of this transport documentation are:

• It provides the only patient record for theduration of the transfer

• Essential link between the referring facility,transport team, and the receiving facility

• Documentary evidence of the course of patientevaluation, treatment, and changes in condition

• Basis for planning the patient’s care and casereview

• Permanent health record.

Box 1.5 lists the essential elements for inclusionin a transport log. Further examples of transportdocumentation are given in Appendix 1.

A good doctor or nurse is only as good as the recordshe or she keeps.

Safety

The safe return of the operational team is apresumption that is made without daring tocontemplate any other alternative. However,interhospital patient transfers are a high riskactivity, so safety considerations are importantat all times. Safety is not only about the avoidanceof accidents; it also considers the physical

wellbeing of the team and legal and clinicalgovernance aspects in transfers (Box 1.6).

Two points about safety merit further comment.

1. Ambulance speed. If the referring hospital hasthe ability to stabilise a sick patient, which allshould do, and if your patient is stabilised


Box 1.5 Data elements of a transport log

Demographic data

• Patient:namedate of birthsexweight (very important for drug calculations)

• Referring institute:referring physiciancontact telephone number and pager numberreferring hospital and ward or unit where

patient will be located

Operational data

• Staff member receiving call• Times:

of receiving callof embarkationof arrival at referring hospitalof departure from referring hospitalof arrival at ICU at receiving hospital

Clinical data

• Predeparture:brief incident-related history, provisional

diagnosis, reason for transfer requestinitial vital signs and pertinent physical

findingsrelevant laboratory results, for example,

arterial blood gas (ABG)treatment given, for example, ventilator

settings, infusions, antibioticsrecommendations given

• Assessment on arrival at referring hospital:clinical findings by transport team, including

treatment, for example, ventilator settingsrecent laboratory investigations, for example,

ABG, CXR with ETT positioninterventions at referring hospital

• In transit:vital signs (monitoring) during transfermedication administered by transport teamproblems encountered and treatment given

• On return to PICU:vital signsventilator settings

Checklists

• For referring hospital• Predeparture (focuses on equipment needed)• Prereturn (focuses on patient care)

before returning, in most instances there is noadditional benefit to the patient in saving afew minutes’ travel time by travelling underblue light conditions. This is balanced by themany disadvantages of high speed travel, suchas increased movement of the back of theambulance possibly placing an airway at riskand definitely making any intervention moredifficult, increased anxiety of the operationalteam in an already difficult situation, andincreased risk of an accident. Travelling athigh speed and weaving through traffic isalmost never necessary and should bediscouraged.

2. Passenger safety. The physical safety of theoperational team is as important as thepatient. There is no sense in endangeringthe team by travelling fast for the perceivedbenefit of the patient.

Speed kills—even in an ambulance

Box 1.6 Safety considerations during transfers

Organisational

• Clinical protocols• Operational protocols and checklists• Regular team training• Audit• Insurance

Passenger safety

• Patient and all transport team members mustwear safety belts or other restraints

• All equipment must be secured to trolley, forexample, ventilator, oxygen cylinders, pumps

• Loose objects, such as drug and equipment bags,should be strapped in when in the ambulance

• The ambulance should obey the speed limit andtraffic signals unless there are compellingclinical reasons to do otherwise

Patient safety

• Predeparture checklist• Crash chart• Careful monitoring throughout transfer

Transport team safety

• Warm clothing• Travel sickness tablets• Nutrition

the transport team should not miss mealshigh calorie snacks should be available in

transit• Money and credit cards carried for emergencies

Transporting a patient

This section deals with a retrieval step by stepand will thus of necessity repeat principlesoutlined previously. It is not meant to be adidactic description of a transfer but ratherhighlights aspects regarded as important.

Referral

Interhospital patient transfers require excellentcommunication between the referring hospital,the operational team, and their receiving ICU.This communication begins with the initialtelephone call and ends when the patient isadmitted to the receiving ICU. The initial call maybe an actual referral or a request for advice, thelatter a facility or service the ICU must advertiseto its clientele.

In the event of a referral the ICU may or may notbe able to accept the patient. Should the ICU beunable to accept the transfer the consultantshould advise his/her referring colleague what thesituation is and the outlook for a potential bed inthe near future. Alternative arrangements couldbe referral to another ICU or holding the child inthe referring institute’s neonatal or adult ICUuntil a bed is available in the accepting ICU. Inpaediatrics the national bed bureau has a recordof ICU bed availability nationwide that is kept upto date, and there are some similar local schemesin neonatal care. Communication about respec-tive bed occupancy between neighbouring ICUsis thus necessary to be able to give referringhospitals useful information as to who to contact.

When a patient is accepted, from the outsetthe ICU team must assess the equipment andmedication needs of the individual patient. Thiscan only be achieved by obtaining relevantinformation, which must include:

• Brief incident-related history• Current vital signs• Child’s weight• Pertinent physical findings• Relevant laboratory results and• Treatment modalities instituted.

The unit transport log is used to record detailsand will act as the patient’s clinical record untiladmission to the ICU. This standard form willguide the doctor or nurse taking the call to obtainall the important information and later direct theteam as they prepare. As the responsibility of the


receiving hospital begins when the referringinstitute makes the initial contact, it is veryimportant to have accurate documentation of allcommunication, i.e. recommendations of caremust be recorded.

Team composition

The on-call consultant has to make decisionsregarding staffing the transport based on thereported condition of the patient and theexperience of his or her resident staff. It can oftenbe difficult to determine the condition of a patientover the telephone. The referring doctor might beinexperienced and through anxiety exaggerate thepatient’s severity or through inexperienceunderassess how sick the child really is. Thesafest advice is to anticipate a more rather than aless severe scenario.

While a small number of acute transfers may beundertaken by a nurse alone, most will requiretwo people. As discussed above, the team leaderwill usually be a doctor, though in neonates anANNP may assume this role. Whoever leads thetransfer must be able to deal with the worstscenario that can be reasonably projected,including sudden deterioration of the patientduring the journey. Consideration must be givento whether the doctor or ANNP is experiencedenough to undertake the retrieval without thesupport of a consultant and to whether thesituation warrants more than one doctor or nurse.

Stabilisation

Stabilisation by the referring team is focused onmaintenance of airway, breathing, and circulation.Before transport all patients must have a stableairway, adequate ventilation, and vascular access.If any of these is recognised to be deficient at theinitial call, the referring hospital has to have thecapability of intervention: the basics of airwaymaintenance, ventilation, and vascular accessshould be available at all facilities that providecare to children. Other interventions such as drugtherapy (for example, antibiotics, anticonvulsants,sedation) and tube placement (for example,urinary catheter, NG tubes) could be advised.

A stable patient will not only improve outcomebut also quicken turnaround time.

Stabilisation begins at the referring hospital. Aretrieval service is not a resuscitation service.

Stabilise or scoop and run?

It is a general principle of transportation ofcritically ill patients that they should be stabilisedprior to transfer. Adequate control of the airway,breathing, and circulation should be established,and treatment should be optimised to ensure thatthe patient is in the best possible condition fortransfer. Sometimes, however, the patient has atime critical condition where delaying specialisttreatment such as neurosurgery or extracorporeallife support (ECMO) is actually dangerous. Inthese situations a judgement must be madeconcerning the risk of transport against the risk ofdenying the patient specialist treatment. The keyto this decision is the assessment of the patient’scurrent treatment, and whether any treatment thatyou can give can stabilise the patient. A goodexample of a patient who should be transferredquickly is a patient with an expanding intracranialhaematoma that is beyond the skill of localsurgeons, who is already paralysed, ventilatedwith low-normal PaCO2 and has received mannitol.Such a patient needs urgent neurosurgery, notfurther intensive care. The opposite situationcould be a patient with sepsis who has notreceived adequate fluid resuscitation, where a fewhours spent stabilising the patient is likely to leadto improvement and make transport much safer.

Always stabilise the patient before transfer; unless:There is nothing you can do to improve the patient’s

conditionThe benefits of treatment at the base hospital

outweigh the risks of transferThe parents are fully aware of the risks and benefits

and accept them.

Operational team assessment andmanagement

In the transport setting, urgent treatment and themanagement of life-threatening problems are thepriority. Evaluations that are diagnosis specificmay not be necessary until returning to the ICU.Although the whole patient must be assessed,examination in depth should be deferred untilafter the transport; for example, a 2-year-old childwho has ingested tablets need not have an earexamination in transit.

When the transport team arrive, their prioritiesare:

• A rapid assessment of the patient, focusing onA, B, and C


• To receive current information from thereferring team

• To review x ray films and laboratory tests• To secure all lines and tubes before loading the

patient.

Airway and breathing

The airway must be patent and stable for theduration of the entire transfer. If in any doubtabout the need to ventilate or intubate the patientto secure his or her airway, it is preferableto intubate before departure. If the patient is alreadyintubated and ventilating adequately, electivereintubation to, for example, change from anorotracheal to a nasotracheal tube is not necessary.In a well sedated and/or paralysed patient an oraltube can be safely secured and maintained.

• Infants:

• Continuous monitoring with oximetry andtranscutaneous gases are advised.

• Ventilation should, in most instances,aim to maintain PaO2 at 6–10 kPa andPaCO2 at 4·0–6·0 kPa. Use higher oxygenconcentrations and higher ventilator ratesthan the patient would require when not intransit, but avoid hyperoxia and hypocarbia.

• Sedate babies for transfer and use musclerelaxation if sedation is not sufficient tosettle the patient.

• Older children:

• Continuous monitoring with oximetry andcapnometry are advised.

• Ventilation should aim to maintain PaO2

at more than 13 kPa and PaCO2 at lessthan 4·0–4·5 kPa. Use higher oxygenconcentrations and higher ventilator ratesthan the patient would require when not intransit.

• Patients who are intubated should besedated and paralysed for the duration ofthe transfer.

Circulation

• Patients must have one secure vascularaccess at least. This would suffice for a highdependency patient who is self-ventilating. Inventilated patients on continuous infusions ofsedatives and paralysing agents more than onevenous line is necessary.

• Fluid resuscitation can be done en route butmust have been initiated before departure.

• If inotropes are necessary, start infusion beforemoving.

Neurological status

Evaluation of the level of consciousness is anongoing assessment performed at the same timeas A, B, and C. Consider airway protection if thelevel of consciousness is low.

• Infants:

• Assess and record all seizures. • Consider specific treatment for encephal-

opathic babies.

• Older children:

• If the child is responsive, ask the parentswhether the behaviour is appropriate.

• Assess and record all seizures.• ALWAYS check the pupils on arrival and

before departure. Ensure that you corrobo-rate your findings with the referring staff ifthere are concerns, for example unreactivepupils, and that you communicate theseconcerns with the parents before you movethe patient.

• Consider specific treatment if raisedintracranial pressure is suspected.

Temperature control

The smaller the patient, the more likely it is thattemperature control will be a major element ofthe transfer process. A small infant has a highratio of surface area to body mass, whichencourages rapid heat loss. Heat loss increasesoxygen consumption by increasing the metabolicrate. This can lead to lactic acidosis and evenhypoxia. Poor post-transfer temperature is a betterpredictor of death in premature infants thangestation or birthweight.

Monitor the temperature continuously—preferably core temperature in infants, toddlers,and unconscious patients. A high temperaturealso increases metabolic demands. Loss oftemperature can occur:

• With the initial event, i.e. severe illness,knocked down in street

• With exposure for evaluation and management• During procedures


• With movement from one environment toanother.

Standard warming devices should be available atthe referring hospital:

• Infants:

• Incubator for infants weighing less than 5kilograms

• Covering the head• Warming mattress.

• Older children:

• Space blanket.

Head-to-toe examination

A brief head-to-toe examination, particularly in theunconscious patient, may alert the transport teamto problems not already identified. Document anyunusual bruises, rashes, or skin markings. Look forcongenital abnormalities in the newborn.

Miscellaneous interventions

• Place a gastric tube (oral or nasal) if the patientis intubated or if there is abdominal distensionand leave on free drainage.

• A urinary catheter is appropriate in shockedpatients to document urine output.

• Assay the blood sugar—especially in youngchildren.

• Keep the patient nil by mouth—may havemotion sickness.

Talking to the parents

Parents should wait at the referring hospital untilthe transport team arrives. This will allow thetransport team to:

• Obtain further history:

• Obstetric and perinatal • Immunisations• Allergies• Past medical history, including medications• Recent exposure to communicable diseases

• Inform or update the parents about the child’scondition

• Obtain any consents.

Should a parent accompany the child (and theoperational team) in the ambulance? There is noadvice or guidance on this issue, so practices oftransport teams are based on personal biases andexperience as well as practical considerations.

• Is there space? Is there a spare seat?• Does the mother have ongoing obstetric needs

that the transport team are not qualified toattend to?

• Will the presence of a parent impair patientcare?

• Is the parent at risk of travel sickness, giventhat he or she is anxious about his or her childand is travelling in an unfamiliar way, i.e.facing sideways in the back of an ambulance?How will the operational team cope with a sickvomiting parent and the sick child?

• Is the ambulance insured to carry a passengernot a patient?

Predeparture check

Before leaving the transport physician andnurse should go through a predeparture check-list. This list must require them to tick off item byitem and is part of the transport log. An exampleis given in the documentation appendix (seeAppendix 1).

Monitoring

It is almost impossible to examine a patient inthe back of an ambulance or a helicopter. It isconsequently essential that the patient ismonitored, that the monitor is resistant tomovement interference, and that it has a screenvisible in all light conditions. The parametersmonitored will depend on the degree of invasivetreatment (for example, intubated or not) andmonitoring (for example, intra-arterial cannulapresent). Aside from heart rate with a visible ECG,oxygen saturation, temperature, and bloodpressure as standard minimums for all patients,the operational team may also monitor invasiveblood pressure or central venous pressure andend-tidal CO2 where these are available.

End-tidal CO2 is a parameter that is not widelymonitored in children in the ICU, possiblybecause of the relatively high cost of theequipment. It is, however, an extremely usefuland probably essential parameter in interhospitalpatient transfers. It gives the operational team abreath by breath record of the patient’s ventilatorystatus and hence the integrity of the ventilator,tubing, endotracheal tube, and lungs. It is so easyto disconnect a tube with patient movementonto the trolley or into the incubator, or withmovement of the ambulance. This disconnectionmay not be noticed by inspection for chestmovement, as this is extremely difficult in a


moving ambulance, but will instantaneously berecognised by an alarming end-tidal CO2 monitor.

A written record of the patient’s vital signsmust be recorded in a flow sheet in the transportlog. This record should start prior to moving thepatient, continue throughout the journey, anddiscontinue when the patient is attached to themonitor in the receiving ICU. The flow sheetshould also have the facility to record alltreatment en route. This is the only documentaryevidence between hospitals of the patient’scondition, treatment, changes in condition, andadverse events. It can form the basis for planningthe current patient’s care, case review, and audit.Examples are given in Appendix 1.

Postreturn assessment

On arrival in the receiving ICU, the operationalteam must make a brief assessment prior to

admitting the patient to an ICU bed. This isessentially to draw a line between the transfer andthe arrival, in the same manner as the teamensured that they monitored the patient beforedeparting and communicated any concerns withthe referring team. This assessment is recorded onthe transport log (Box 1.7).

SummarySafe transport can be encapsulated in the followingkey points:

• Communication• Planning• Correct team composition• Continuous stabilisation• Careful and continuous assessment• Monitoring and recording throughout• Consideration for staff and parents• Complete, accurate and legible documentation• SAFETY.


Box 1.7 Postreturn assessment

On arrival back in ICU

Observations: HR:_____ BP: ___ / ___ mmHg Cap. refill _____ secs

Temperature: Core:________°C Peripheral:________°C

Ventilation: Rate:_____ PIP:_____ PEEP:_____

FiO2:_____ Ti:_____ Te:_____ I : E:_____

ABG on portable vent: pH:_____ PCO2:_____ PO2:_____

HCO3:_____ BE:_____ SaO2:_____

Glucose:_____

Pupils: Left:_______________ Right:__________________

Urine output during transfer:_________ ml/kg/h

Ti = inspiratory time, Te = expiratory time, I : E = inspiratory : expiratory ratio.

Apart from the hazards of equipment failure andmedical staff having to work in a strangeenvironment, interhospital transfer imposes anumber of other physiological stresses on thepatient. These can have an unpredictable effect onthe cardiovascular system, causing hypo- orhypertension, and may also adversely affect othersystems, such as acutely raising intracerebralpressure during deceleration. These physicalstresses may be dynamic, as in acceleration ordeceleration, or static, relating to the problems ofthe ambulance environment (see chapter 3) orfactors such as noise, vibration, and temperature.

ObjectivesTo understand some of the physiological effects

associated with interhospital transport.To know the strategies that may be employed to

minimise these effects. To understand basic altitude physiology.

Acceleration and deceleration

Rapid acceleration and deceleration can lead topooling of blood, with sudden variations invenous return to the heart and subsequentchanges in cardiac output. The Starling curve,which plots stroke volume against end diastolicvolume, gives an idea of some of the effects thatmay be encountered (Fig. 2.1). The normal curve(curve 1) shows an increase in cardiac output

with increasing filling pressure, up to a pointwhere the myocardium fails, and no furtherincrease, or a reduction is seen. In the failingheart, or the normal heart in hypervolaemia,increases in filling pressure are not accompaniedby an increase in cardiac output (curve 2).

If the patient is lying, as is typical, with thehead towards the front of the ambulance, rapidacceleration will tend to reduce venous return,and hence reduce filling pressure, leading toreduced cardiac output. Conversely, decelerationincreases venous return to the heart and mayincrease cardiac output, or in the failing heart,may cause heart failure and reduced cardiacoutput. In general, the patient will tolerate suddenincreases in venous return better than suddendecreases. Hypovolaemia should be correctedbefore transfer, if possible. After clinicalexamination, volume status is best assessed byobserving the response to small (3–5 ml/kg),rapidly infused (2–3 minutes) boluses ofcrystalloid, such as normal saline 0·9%. In thenormovolaemic patient, a short-lived rise infilling pressure is seen, accompanied by animprovement in cardiac output (Fig. 2.2, curve 2).If hypovolaemia is present, there is little changein filling pressure or cardiac output (Fig. 2.2,curve 1). Hypervolaemia is relatively uncommonin the clinical situations covered in this manual.A sustained rise in filling pressure in responseto a fluid challenge, with no change or adeterioration in cardiac output (Fig. 2.2, curve 3),

2 Transport physiology

Curve 1

Curve 2

Filling pressure

Car

diac

out

put

Figure 2.1 The relationship between stroke volume andend diastolic volume for the normal heart (curve 1) and thefailing heart (curve 2). (Adapted from Lawler PG.Transfer ofcritically ill patients: Part 2—preparation for transfer.Care Crit Ill 2000;16:94–7 with permission.)

Curve 3

Curve 2

Curve 1

Fluid bolus

Time

Filli

ng p

ress

ure

Figure 2.2 The change in filling pressure in response tofluid challenge. (Adapted from Lawler PG.Transfer of criticallyill patients: Part 2—preparation for transfer. Care Crit Ill2000;16:94–7 with permission.)

suggests hypervolaemia or myocardial depression.Treatment may include inotropic and ventilatorysupport and diuresis. It should be emphasisedthat hypervolaemia is much less common, andbetter tolerated, than hypovolaemia in mostclinical situations.

One case in which the emphasis is slightlydifferent is the newborn or preterm infant.Because of the relative stiffness of the ventricularwall, fluid loading is not well tolerated, andincreasing heart rate is relatively more importantas a mechanism for increasing cardiac output.

Normally patients respond to sustained changesin filling pressure by altering heart rate. A suddendecrease in venous pressure leads to tachycardiaand a sudden increase to bradycardia. Criticallyill patients may have poor baroreceptor functionand dysautonomia, which reduce their ability tocompensate in this way.

In practice, acceleration is rarely a problem inan ambulance or aircraft. Even at take off, forcesof less than 0·25 G are experienced duringcommercial flights, and only around 0·5 G onlanding. However, rapid braking in an ambulancecan produce forces equivalent to 7 G, which canhave serious, albeit transient, effects on the patient.This is another reason for ensuring that the returnjourney with the patient is made at normal roadspeed with minimum changes in speed.

Pulmonary blood flow is also affected by motionchanges. In acceleration (assuming the patient tobe lying head first), blood is diverted towards thelung base, and away from the anatomical apex. Indeceleration the reverse is true. This may worsenventilation–perfusion mismatch.

Similar effects happen with sudden side to sidemovements, and if the patient has unilateral lungdisease; for instance, changes in oxygenation thatoccur when turning corners may contribute topatient instability.

Changes caused by movement of largeorgans and the diaphragm

The abdomen and thorax are separated by thediaphragm, and acceleration or decelerationwill displace the abdominal contents and hencemove the diaphragm. Again, depending uponthe orientation of the patient, this will eitherincrease or reduce lung volume, and may lead tounderventilation, hypercapnia, and hypoxia.

Changes in intracranial pressure

Sudden increases in venous pooling in the headwill lead to increases in intracranial pressure,which may be of significance to the head injuredpatient. Also, acute reductions in blood pressurecaused by venous pooling in the legs will reducecerebral perfusion (Fig. 2.3).

Specific considerations apply to transferringpatients in helicopters. Ideally the patient shouldbe positioned across the direction of travel, ortheir position should be changed depending onwhether acceleration or deceleration is likely(Fig. 2.4). In practice, neither of these options ispossible, and the best way to avoid problems withacceleration and deceleration is to travel in acontrolled manner.

Transport physiology 15

Figure 2.3 Fixed wing aircraft fly “nose up”. Patientspositioned in the head first position (shown here) are atrisk—feet first or transverse is safer. (From Lawler PG.Transfer of critically ill patients: Part 2—preparation fortransfer. Care Crit Ill 2000;16:94–7 with permission.)

Figure 2.4 Rotary wing aircraft fly “head down/tail up”.Thepatient is best positioned with the head in the direction oftravel (as shown). (From Lawler PG.Transfer of critically illpatients: Part 2—preparation for transfer. Care Crit Ill2000;16:94–7 with permission.)

Noise and vibration

High noise levels are commonplace in bothaeromedical and road transfers, with noise levelsof 95 dB being recorded inside some helicopters.This can be disconcerting to the patient, increas-ing anxiety and cardiovascular instability. Noiselevels as low as 70 dB have been associatedwith changes in heart rate and peripheral vaso-constriction in preterm infants. Incubators alsohave high levels of ambient noise. Ear protectionshould be routinely used for patients, and isnecessary for staff during noisy retrievals, such asin a helicopter.

Noise will also make audible alarms ineffectiveand therefore these should have a visual com-ponent as well. Auscultation with a stethoscopeis impossible in a noisy environment.

Vibration may also upset the patient, worseningfeelings of nausea and motion sickness. Highlevels of vibration may increase the risk ofintracranial bleeding in preterm infants, althoughthe evidence for this is not good. Greatestvibration is experienced during take off andlanding of aircraft. The use of gel filled mattresseshas been shown to reduce vibration duringtransport in a neonatal model. Whether this hasany effect in improving patient outcome isunknown.

Vibration will also disturb some monitors suchas non-invasive blood pressure monitors andpulse oximeters.

Motion sickness will occur in up to 50% ofthe transport team, and an unknown number oftransported patients. The most overt form ofmotion sickness is characterised by nausea,sweating, and vomiting. The symptoms may besevere enough to incapacitate the team memberand prevent him or her from undertaking theirduties. More subtle are the symptoms of the“sopite syndrome”, which include drowsiness,yawning, decreased mental agility, and adisinclination for work. These symptoms mayoccur in the absence of the more overt form, andmay persist after nausea and vomiting havepassed. Both syndromes of motion sickness areaccompanied by a measurable reduction inperformance. There is huge interindividualvariability in the susceptibility to motionsickness, and those who know that they aresusceptible should consider the use of antiemeticpreparations, with the caveat that these may alsoinduce drowsiness. Biofeedback methods andrelaxation techniques have also been shown to be

effective in the treatment or prevention of motionsickness.

Temperature changes

Problems with thermal regulation are discussedin chapter 6 and are of most relevance to theneonatal patient. However, older children andinfants may also suffer from thermal stress, andfrequent monitoring of temperature is necessary.

Heat is lost from the body by four mechanisms.

1. Convection. Air currents replace warm airnear the body with cold air, which is warmedby convection from the skin, and the bodycools as it loses energy. The chilling power ofthe wind can produce extreme cooling.

2. Conduction is the transfer of heat betweensolids in contact. As the area of contactbetween the patient and the cold environmentis normally small, this is a less importantcause of heat loss.

3. Radiation. The transfer of heat byelectromagnetic energy, such as sunshine, orfrom the patient to a cold surface.

4. Evaporation. Water evaporation uses energy,resulting in heat loss from the skin whensweat evaporates, and from the respiratorytract, where air is warmed and humidified.The low humidity of ambient air during longfixed wing retrievals may increase heat andwater loss.

If a patient needs to produce more heat, they willneed to use more oxygen. The amount of oxygenwill depend on the amount of heat loss. It can beseen that children who are not adequatelywarmed will need to increase their cardiac outputin order to deliver the oxygen required for heatproduction. This is often not a problem inwell children but can severely exacerbate thecondition of children who are already shocked.

Many larger infants will be able to maintaintheir body temperature at the expense of having toincrease their cardiac output. Very small andpremature infants are often unable to producesufficient heat and may become hypothermic.This causes the double insult of exacerbatedshock and hypothermia.

A “thermoneutral” environment is one inwhich additional cardiac output is not requiredto maintain temperature. It is important tounderstand that this will be a higher temperature


Sea level 760 1·0 1·0

1500 630 0·83 1·2(unpressurisedaircraft mayfly at thisaltitude)

2500 560 0·77 1·3(commercial flightspressurised tothis altitude)

5000 380 0·5 2·0

than that required to maintain an infant’s bodytemperature.

The retrieval team should minimise heat loss bywrapping the patient up appropriately, while stillallowing access to the patient for monitoring, etc.The head is a major source of heat loss and shouldbe covered by a hat or blanket.

Chemical warming packs may be used to warmblankets and sheets, but should not be placeddirectly against the patient. Warming withsurgical gloves filled with hot water poses aserious risk of scalding and should not be used.

Atmospheric pressure

Barometric pressure changes on ascent to altitudeare covered in chapter 5. Two problems arise thatare of importance to the retrieval team.

Expansion of gas filled spaces

This can cause a small undrained pneumothoraxto become a large tension pneumothorax.

Pneumothoraces should be drained prior toundertaking an air retrieval.

Air in other body cavities, such as the stomach,will expand and may interfere with ventilation orpredispose to vomiting and aspiration. It should bedrained with a nasogastric tube left on free drainage.A syndrome known (in the USA) as “high altitudeflatus explosion” may also prove problematical.

Blood pressure cuffs and air filled bandages orsplints may be affected and should be loosened.Endotracheal tube cuffs will also expand andshould be deflated or filled with an appropriatevolume of saline instead of air.

On descent eustachian tube dysfunction may bea cause of severe earache and sinus pain may alsooccur.

Reduction in oxygen tension

Oxygen tension falls with altitude, and can becalculated from the alveolar gas equation:

PAO2 = (BP – PH2O) × FiO2 (PCO2 × 1/R)

Transport physiology 17

Table 2.1 The effect of increasing altitude on alveolar PAO2. (Reproduced with permissionfrom Jainovich DG. Handbook of Paediatric and Neonatal Transport Medicine. Hanley andBelfus, 1996)

PAO2 (kPa) (assuming PAO2 (kPa) (assuming FiO2 = 0·21) FiO2 = 1·0)

PaCO2 (kPa) At 760 mmHg At 500 mmHg At 760 mmHg At 500 mmHg

2·5 16·5 10 91·2 66

5·3 13·2 6·5 88 64

8 10 3·3 66 61

Table 2.2 Barometric pressure and approximate gas volumes at different altitudes(Reproduced with permission from Jainovich DG. Handbook of Paediatric and NeonatalTransport Medicine. Hanley and Belfus, 1996)

Altitude (m) Barometric pressure (mmHg) Atmospheres Relative volume

where BP is the barometric pressure, and R therespiratory quotient. Table 2.1 shows the effect ofincreasing altitude on alveolar PO2.

Even in “pressurised” aircraft the inspiredoxygen tension will need to be increased, as thecabin is only pressurised to approximately 2500 m,and an oxygen concentration of 30% is needed tomaintain inspired PO2 at the same level as on theground. Apart from this, the effects of hypobariaare limited by the pressurisation of commercialairliners, and the fact that unpressurised aircraftsuch as helicopters do not normally fly very high.Problems may occur if the patient is alreadyreceiving 100% oxygen at sea level, or if thegeography of an area means that substantial ascentneeds to be made. Table 2.2 gives the barometricpressure and approximate gas volumes at differentaltitudes.


SummaryAcceleration and deceleration in the transport

environment lead to cardiorespiratory instabilityand should be minimised where possible.

The adverse effects of motion are worse in patientswho are hypovolaemic, and hypovolaemia shouldbe actively sought and treated.

Neonates tolerate fluid boluses less well than olderpatients. This does not mean that hypovolaemia isbetter tolerated, just that greater caution is neededwhen fluid challenging the neonatal patient.

Noise and vibration are common in the transportenvironment and may provoke cardiovascularinstability. Noise protection should be routinelyused for patients.

Motion sickness is common and may impair theperformance of the transport team. Subtle symptomsinclude drowsiness and decreased performance.

The physiological problems caused by hypoxia ataltitude and expansion of air spaces and bodyparts should be understood and anticipated.

Introduction

The period of a transfer when the patient is athighest risk is the time spent in transit and this isalso when the attending staff feel the most exposedand vulnerable. This is because ambulances are notintensive care units. If there is a clinical emergencymore expert personnel are not at hand to help. Ifa monitor or ventilator fails there isn’t a storeroom to get another from. Power and gas suppliescan run out. All of this, plus the challenges ofworking in a cramped, moving environment withvariable light and heat, means that ambulancesimpose some serious challenges for transportclinicians.

Nearly all transfers use ambulances. If aero-medical transport is utilised, an ambulance willusually still be required to transport the teamand equipment from the aircraft landing site tothe receiving hospital. An ambulance may alsobe utilised as a back up if aeromedical transferis not possible. Aeromedical teams also need toconsider the compatibility of aircraft trolleysystems with ground ambulances at both ends ofthe journey.

The aim, as outlined in the Paediatric IntensiveCare Society’s “Paediatric Intensive CareStandards”, should be to recreate intensive carefor the child within the ambulance, to “provideintensive care on the move”. Although thischapter discusses issues in the planning anddesign of transport vehicles, it must be bornein mind that these are all only as good as thepersonnel using them. The “Transport of Neonatesin Ambulances (TINA)” report highlighted thisissue, recommending that teams “should ensurethat suitably skilled staff, together with equipmentand vehicles are available to ensure the demandsof neonatal transport are met efficiently”.

Standards and reports

There are several documents that have specificimplications for the way transport ambulances areconfigured, and some of the important features ofthese are outlined here. Not all of these refer to allkinds of ambulance transfer.

Although some European standards are notlaw at present, they will have that status in thefuture. Even though equipment is not available tofully comply with some of these, they represent agoal for future practice that should be workedtowards. Individual centres must each assess therisk of the equipment they use and the vehiclesthey use it in.

European Standard for transportincubator systems (CEN 13976-2, draft)

This draft document from the European UnionStandards Committee has been accepted and willbecome binding in due course.

Key issues are likely to be:

• Maximum incubator system weight, probably140 kg

• Users must purchase complete transportsystems, and not modify them

• Incubator systems should be secured inambulances by two separate devices, eachcapable of restraining the incubator in theevent of a sudden 10 G deceleration. This is,very approximately, equivalent to coming to adead stop from 30 mph (50 kmph).

Equipment is not available from manufacturers atthis time that allows users to completely complywith these regulations and so there is likely to bea derogation period while such equipment isdeveloped. As soon as the document is formallypublished those responsible for producing andoperating transport incubator systems need to beworking towards producing a system that willprovide a safe environment within the ambulance,particularly in the light of the safety and restraintregulations. Restraint is discussed further, below.

Two other standards are relevant. One isconcerned with stretchers used in ambulances(CEN EN 1865) and one covers medical vehicles

3 The ambulance environment

ObjectivesThis chapter is concerned with transfers in groundambulances, both planning for transport and thepracticalities of working in ambulances. It isimportant to appreciate the safety-focused legislativeframeworks that cover ambulance transfers, as wellas understanding the constraints imposed onpractice by the environment.

and their equipment (CEN 1789). Althoughneither is specifically concerned with neonatal orpaediatric transfer, they emphasise security andrestraint as key issues. All the standard stretchertrolleys used in ambulances are regulated by thesestandards. Although some stretchers meet thestandard, such as the Falcon (Ferno, Bradford,UK), any modifications undertaken to convertthem to paediatric intensive care (PIC) trolleyswill not. Thus paediatric transfer trolleys arerelatively unregulated, especially when comparedto the new incubator regulations, but the keymessages about weight limitation and restraint inthe vehicle should not go unheeded.

European legislation will increasingly determinestandards for transport equipment.

Ambulance configuration

The design and layout of the ambulance cabinmay help improve on some of the limitations of thetransport environment. Increasingly, ambulanceservices are finding that their operational needs arebest met by providing dedicated vehicles fortransport teams. These are discussed in moredetail below. For this reason it is worth beingaware of some of the major considerations indesigning such a vehicle. Design is substantiallylimited by space. The typical ambulance hasabout 7 m2 of floor space, compared to therecommended standard of 25 m2 for an intensivecare unit (ICU) bed space.

Trolley and seating positions

Trolleys, either with incubators or without, may bemounted transversely or longitudinally, and thissubstantially determines the seating plan (Figs 3.1,3.2). Both positions have some advantages. Thetransverse position is more stable, as the weightof the trolley is not concentrated on one sideof the vehicle. The personnel are seated facingthe direction of travel, which reduces motionsickness. The transverse position will be thepreferred option for neonatal incubators in theEuropean Standard. The longitudinal positionallows central mounting of the trolley and soaccess to both sides of the patient. In bothconfigurations the numbers and precise orienta-tions of seats may vary.

Seating configurations should allow one personto sit at the head of a child on a trolley to provideconstant clinical monitoring and management ofthe airway, though for neonates a position thatallows observation of the baby in the incubatormay be preferable. The second member of theteam needs to be in a position that will enablehim or her to have continuous viewing of themonitor and easy access to additional equipment.Anyone else, such as a parent, who may bepresent must be properly secured.

Power

Ambulances should be designed with reliablerobust electrical systems for the provision ofpower to lights, heaters, air conditioning and


Incubator/trolley

Figure 3.1 Transverse incubator/trolley mounting. Note thepassengers are facing the direction of travel.

communications systems. It is desirable fortransport teams to utilise ambulance power toconserve the batteries of the transport equipment.As ambulance power supplies are generatedby the movement of the vehicle, this is a goodoption and should be widely used. Ensure whenconnecting to the ambulance power supply thatthe ambulance engine is running, in order toavoid ambulance battery failure.

Transport incubators have traditionally beenconfigured to allow them to take power fromthe vehicle. The problem for other items ofequipment, such as pumps and monitors, hasbeen that they have been designed to take externalpower from only alternating current (AC) sourcesand ambulance power is usually direct current(DC).

There are two possible solutions to thisproblem. Firstly, some equipment is now beingmade that can run on an external DC supply, andsecondly the ambulance may be fitted with apower “inverter” which converts the usual DCsupply to AC. It is to be hoped that the futurestandardisation of transport equipment acrossEurope will resolve these issues so that transportteams do not risk battery failure in essentialequipment.

Heating

Temperature within the ambulance environmentwill be variable and seasonal. There will alsobe temperature changes during transfer ofthe patient from the unit to the ambulance.Additional warmth may be achieved by theambulance temperature control system, incubatortemperature control, or a chemically activatedwarming mattress.

Although the UK climate is mostly miserablynondescript, it is highly desirable for ambulancesto have both effective heating for very coldconditions and air conditioning for very warmdays. The cabin should be secure against rain andwind. Staff also need to wear appropriateclothing, which will also allow them to workcomfortably. Taking several layers allows you tomove comfortably from icy conditions whileloading the vehicle to very hot conditions in thecabin in transit.

Lighting

It should be possible to incrementally and rapidlyadjust cabin lighting from low levels that may beappropriate at night on the transfer of a stableinfant/child to lighting equivalent to the ICU,allowing proper physical assessment of thepatient’s colour and perfusion.

Loading

As transport trolleys of all kinds are very heavy(> 150 kg), lifting transport systems in and outof ambulances should be avoided as this hassubstantial health and safety implications. Thereare two main safe loading options:

• A ramp with an electric winch. The rampshould be secure and long enough to avoid asteep climb

• A lift mounted at the tailgate of the ambulance.

The ambulance environment 21

Incubator/trolley

Figure 3.2 Longitudinal incubator/trolley mounting. It maybe possible to mount the incubator more centrally.

Trolley/incubator interfaceswith vehicle

There are two further areas where the interfacebetween the transport trolley and the vehiclerequires consideration—restraint and gas supply.

Restraint

It is essential for the safety of staff and patientsthat trolleys of all kinds are secured effectively inthe vehicle. As a crash involving a neonataltransport team in the Northern Region in the early1990s illustrated, traditional trolley restraints(“York” type) are inadequate.

For this reason it is essential that transportteams liaise with their vehicle provider to ensurethat the safest restraints possible are provided.Following publication of the European stretcherstandard, discussed above, ambulance serviceshave made great progress in attending to trolleysecurity. A number of devices and options areavailable, including trolley designs that are stablein crashes and additional security from extradevices, such as floor clamps to anchor the trolleyvia strapping to specially strengthened slots in thefloor.

All other devices such as monitors, pumps, andventilators should also be secured. Restrainingbolts and cargo straps are both good options. Donot carry unrestrained “extras”.

All of these devices are only as good as thepeople using them on each transfer, and teamsmust be aware of the standard of restraint that isrequired and not depart on a transfer until this isachieved.

Gas supply

All emergency ambulances will carry an oxygensupply that must be secured within the ambulance.The team need to check the ambulance supply ofoxygen is sufficient for their journey. Oxygensupply from the ambulance should be used duringtransport to conserve the transport incubator ortrolley supply. Transport personnel should befamiliar with vehicle gas supplies, so that they canmonitor cylinder contents and ensure continuity ofsupply.

If a compressed air cylinder supply is neededthis must also be secured and extra cylindersshould not be taken into ambulances that are notsecured. Further gas supply issues are discussedin chapter 4.

Speed and safety

There are two key components to safety: restraintand speed. Restraint is discussed above, but itshould be remembered that restraining deviceswill all fail if challenged by a combination ofheavy equipment and high speed collision. Thisis why the European standard for transportincubator systems limits the weight of theequipment.

Speed, and in particular the use of lights andsirens, needs careful consideration. A study byAuerbach in the USA looked at ambulances thatwere involved in road traffic accidents, andexamined key features of each crash. It found thatwhen ambulances were running with lights andsirens, any accident was more likely to yield aninjured victim. Accidents happened most often atintersections, and so the most common incidentwas a side-on collision. These were not trivialaccidents—two people were killed and another 18sustained injuries classified as moderate orsevere. Seat-belts were found to be protective forpassengers and the authors concluded that to“maximise safety … passenger restraints beworn … speed limits obeyed if at all possible andall traffic signals heeded at intersections”.

Another study, by Hunt, looked at the timesaved by using lights and sirens in an urbansetting. By comparing real emergency runs fromaccident scenes to hospital with journeys over thesame route undertaken at normal traffic speed, theauthor was able to conclude that the time saved,an average of 43 seconds, was “… not clinicallysignificant, except in rare circumstances”. Whilemost neonatal and paediatric transfers in the UKare over substantially longer distances than this,we have no comparable data on the time savingsthat might be expected or the clinical benefits ofthe time saved. An important principle from thisstudy is that if traffic is moving normally use oflights and sirens does not result in substantialtime savings.

The decision to use lights and sirens on atransfer is, therefore, a serious one. The defaultposition should be that the ambulance willproceed at normal traffic speed and any otherdecision should be made by the transport teamwith the help of the ambulance crew, afterconsidering these questions.

• Are the traffic conditions such that lights andsirens will facilitate a substantial improvementin journey time?


• Is the condition of the patient such that thescale of the shortening of the journey will beclinically significant?

These clinical indicators are the only justificationfor lights and sirens.

Other simpler and safer methods may yield moresubstantial time savings, for example by avoidinggetting lost by keeping a set of maps that is up todate and written directions to hospitals visited.Some ambulances have a satellite navigationsystem to help guide them, or they can request thelocal ambulance service to help direct them to theirdestination. This will vary from region to regionand should be negotiated by the ambulancepersonnel.

Patient safety

First and foremost, keep the staff safe so that theycan help the patient.

Restraint for neonatal patients in incubators isan unresolved problem. No system is availablethat will reliably restrain a sick neonate in theevent of a crash. There are substantial designproblems in producing a system that will improvesafety while allowing intensive care to proceedand without stripping the skin. This is an issuewhich clearly needs some clarity and evidence-based practice to ensure that infants are safelysecured during transport.

Children transported on a trolley can be securedwith a child-restraining mattress (Paedimate;Ferno, Bradford, UK). These are suitable for largeinfants and children up to 4 years, and effectivelystrap the child to the trolley using a five-pointharness. Older children may be secured using twolap belts attached to the trolley.

Ambulance crew and liaisonwith the ambulance service

Ambulance crews for transfers

Specialist transport-trained intensive care staffattend most UK paediatric and neonatal transfers.

A highly skilled paramedic ambulance crew istherefore not always necessary. An ambulancecrew that are trained in emergency driving,should this be needed, are essential. The crewneed to be clear about where the team need togo, and how urgently they need to arrive at thedestination. Once the team have assessed theinfant/child at the referring hospital, it wouldbe helpful to give the crew an indication ofhow long the team expect to take stabilising theinfant/child. This may be an opportunity for theambulance crew to refuel for the return journey.

Dedicated vehicles

Dedicated vehicles are ambulances that are not partof the wider A&E fleet and are specially configuredfor interhospital transfer. They may be dedicatedfor use by one unit or hospital, or shared by several.Some units have experimented with operatingthe vehicle themselves, without the ambulanceservice, though this is not common. There are someadvantages and disadvantages of the dedicatedvehicle system compared to one where thetransport team can use any frontline ambulance.

Advantages:The vehicle may be optimally configured for

restraining the transport trolley.Gas supplies can be increased and configured for

team needs.Power supply to transport equipment may be

optimised.Clinical supplies may be stored on the vehicle.The environment can be optimised for providing

mobile intensive care.Where the frontline ambulance service is struggling

to meet response targets, there may be benefits forboth ICU and ambulance service in organisingretrieval services separately.

Disadvantages:If this becomes the only vehicle the team can use,

there will be a problem mounting a transfer whenthe vehicle is being serviced, is broken down, or isbeing used by another team.

Without a dedicated crew, there may be delaysinitiating transfer while a crew from another vehicleis diverted to pick up the dedicated vehicle.

Long term replacement may be an issue when thevehicle becomes old and unreliable.

Planning with the ambulance service

It is helpful to have regular contact with seniorpersonnel at the ambulance service, perhaps at anoccasional meeting to discuss mutually importantissues. Ambulance services are quite rightly

The ambulance environment 23

Safety in transit is promoted by:

• Limiting the weight of trolley/incubator systems• Using restraining devices that are approved for

the purpose• Limiting the use of lights and sirens to situa-

tions where any time saved will be clinicallysignificant.

focused on achieving high standards in their coreactivities relating to 999 calls. A similar commit-ment to interhospital transfers can be achievedwhen both transport teams and ambulance servicesrecognise and respect each other’s workload andpriorities.

Staff comfort

Staff should appreciate the difficulty of performingany operation while the ambulance is moving, dueto acceleration/deceleration and lateral movement.If an intervention is needed, the ambulance shouldbe stopped before it is undertaken.

Riding in the back of an ambulance can causemotion sickness, even to the hardiest traveller.This is exacerbated by the type of suspension theambulance has, by uneven bumpy roads, bytravelling seated sideways, and by the inability tosee out of the ambulance and obtain appropriate

visual fixation. Tiredness, stress, hunger, andanxiety also exacerbate motion sickness. Varioustreatments for motion sickness are available, andtransport staff who are afflicted may try to findone that suits, without causing drowsiness.Retrievals may take many hours to complete. It isadvisable to take along a snack and drink for eachmember of the team.

SummaryAmbulance services and transport teams should

cooperate to provide safe effective vehicles fortransport. Particular attention should be given toplanning for effective restraining devices forequipment and staff.

The ambulance environment is not ideal forintensive care. Remember that supplies of gas,power, and clinical equipment are all limited, soensure they are used effectively.

Lights and sirens should only be used whenclinically indicated.


Introduction

Transport equipment should be complete andadequate for the provision of continuous intensivecare throughout the transport episode. Equipmentmust be specific to transport and maintained bythe transport team. All staff should be trained inthe use of the transport equipment and must befamiliar with its whereabouts for ease of access.Transport staff should regularly check the equip-ment and be able to troubleshoot equipment andmonitoring problems. It is a paediatric intensivecare (PIC) standard, and good practice generally,that the retrieval team has annual updates toinclude equipment training.

Equipment should be sufficient to provide therequired level of intensive care, but should not beso comprehensive as to cause risks with thesheer volume carried. Consideration should begiven to the amount of equipment stored on anambulance as most ambulance chassis have amaximum gross vehicle weight of 3·5–4·6 tonne.

The market for specialist transport equipmentis low volume with a limited number of suppliers.For this reason it tends to be relatively expensiveand slow to evolve.

General features of allequipment

Key characteristics

• Self-contained, lightweight, and portable• Be durable and robust to withstand repeated use• Long battery life and short recharge time• Clear displays• Suitable for all ages transferred• Visible and audible alarms• Data storage and download capability• Secure

The British Paediatric Association, the BritishPaediatric Intensive Care Society, and theAmerican Academy of Pediatrics have drawnup guidelines on transport equipment. Whenselecting equipment one should be sure to meetthese guidelines.

Equipment that is built for transport ispreferable to general intensive care unit (ICU)equipment, which may be less reliable and robust.

Electrical components should run off mainspower, have an internal battery, and be able totake power from the vehicle.

Trolleys

To be conveyed in an ambulance the equipmentneeds to be on a trolley, and a number of optionsare available.

Neonatal transport teams have the advantage ofvery small patients, so there is room on a trolleyfor the infant and all the necessary equipment.Without exception ground transfer neonatalteams use an adapted ambulance trolley forthis purpose, the precise trolley choice beingdetermined by the local ambulance service.

Some paediatric transport teams utilise theambulance’s own stretcher trolley and secureequipment to it once they are in the vehicle. Othershave adapted conventional ambulance trolleys.

Paediatric transfer trolleys need space toaccommodate an older child with adequaterestraining straps, a multichannel monitor, atransport ventilator and oxygen supply, and spacefor six infusion devices. Ideally this equipmentshould be placed below the patient to minimiserisk to the patient, should the vehicle be involvedin a sudden brake or impact.

For all trolleys the key feature is security andrestraint in the vehicle in the event of a crash, andthis is discussed in chapter 3.

Batteries

Most electrical items of transport equipmenthave internal rechargeable batteries. Although intheory these batteries last for several hours, longenough for most transports, in practice they arenot so straightforward.

4 Equipment and monitoring

ObjectivesBe aware of transport-specific equipment.Know limitations of transport equipment.Assess level of monitoring required for transport.Be able to evaluate the utility for transport of items

of equipment.

Rechargeable batteries need routine maintenanceto keep them working effectively. Merely leavingan item of equipment plugged in and “charging”for several weeks is not enough. Rechargeablebatteries need to be regularly completely drainedand then fully recharged in order to remainefficient.

Figure 4.1 illustrates an effective batterymaintenance and use cycle, including plannedbattery discharge. Figure 4.2 illustrates a cycle ofbattery use and charging that results in the batterybecoming less effective.

For this reason it is necessary for batteries to beproperly maintained. Even with good plannedmaintenance procedures, rechargeable batterieswill need replacing occasionally, approximatelyonce a year.

On transport, always use external sources ofpower when these are available. If possible, chooseequipment that is not solely reliant on internalrechargeable batteries. The options are either thatthe device may be run from the ambulance poweror that the batteries are accessible and may bereplaced in the event of failure.

Look after your batteries—do not rely on leavingthem charging all the time and hoping for the best.

Ventilators

A transport ventilator must be portable, light,robust, and easy to operate. Disconnection andhigh pressure alarms are essential. Most transportventilators are gas driven, meaning they need onlya gas supply, not electricity, to work. Ventilatorswith complex electrical systems are unlikely towork properly in transit. Any ventilator whichstops working in the event of a power failure ishighly undesirable for transport.

Gas driven ventilators may consume8·5–20 litres per min, or more, of gas and thisneeds to be remembered when calculating theoxygen requirements for the journey. Someventilators have facilities that reduce compressedgas consumption. A particularly useful one is theability to entrain air from the environment toblend with compressed oxygen.

Positive end expiratory pressure (PEEP) may beadded to continuous flow ventilators without thisfacility by adding a PEEP valve to the circuit.

The delivered oxygen concentration should bemonitored with a fuel cell oxygen analyser andshould be variable from 21 to 100%.

A ventilator appropriate to the size of the childshould be available for all transfers, as well as ahand-bagging system for emergencies. In general,neonatal patients need a pressure limited, timecycled ventilator while paediatric patients willneed a volume control facility. Some paediatrictransport teams carry two ventilators to accommo-date the wide specification required.


Time

a b c d e

Empt

yFu

lly c

harg

ed

Figure 4.1 a = Battery is charged to full. b = Fully dischargedto empty in a planned maintenance episode. c = Fully chargedagain. d = Taken on a transfer and partially drained. e = Fullycharged again. Process continues.

Empt

y

Mem

ory

Battery fails

Fully

cha

rged

Time

Figure 4.2 A less effective charging process. Here thebattery is repeatedly charged to full and then taken ontransfers that partially drain it. Over many such cycles thebattery develops a “memory” of the lowest level it isdischarged to, and “forgets” that it can be dischargedeven further.When the team goes on a longer transfer,the battery fails even though it might have been expectedto last longer.

Gas supply

Compressed gases are very precious transportresources. Most transfers need a compressedoxygen source, and some will also needcompressed air.

The importance of carrying sufficient gas, andbeing careful in its use during transport, cannot bestressed too highly. Ensure the ambulance supplyis compatible with the transport equipment andadequate for the journey time. You should havesufficient gas available for double the expectedlength of the journey to allow for unforeseencircumstances. There should be a sufficientsupply on the incubator/trolley to cover thetransfer to and from the ambulance. Appendix 2gives formulae for calculating how many litres ofgas may be needed on a transfer and how manyminutes of gas supply are in a cylinder.

Printed on the neck of all gas cylinders isimportant information about their contents whenfull. The standard “F” cylinder has a “bull nose”valve type and holds 1360 litres, and an “E”cylinder has a pin index valve and contains680 litres. Cylinders carried in most ambulancestoday are classified “HX” and have a star valve.They contain 2300 litres and there may be two ofthem. The pressure the cylinder has been filled tois displayed on a gauge. Cylinders should alwaysbe full for transfer and checked regularly.

Under no circumstances should additional gascylinders be placed insecurely in ambulances.Great care and respect should be given topressurised gas cylinders, as they are potentiallylethal in an accident.

Oxygen supply

Oxygen is usually delivered from cylinders,but liquid oxygen is used by some specialisedservices. This has the advantage of being arelatively large supply, but it is expensive andtraining is required in its use and maintenance.

Air supply

Air may be delivered from three sources.

1. The atmosphere. Some ventilators can entrainatmospheric air and blend this with acompressed oxygen supply. The compressedoxygen is needed to drive the ventilator, butthe air can be blended with the oxygen toachieve inspired oxygen concentrations (FiO2)

from 0·4 to 1·0. At FiO2 around 0·5, this is avery gas efficient mode.

2. Cylinders, as for oxygen. In general ambu-lances do not carry air cylinders and this canmake air a relatively precious gas. Arrange-ments may be made to install extra secured aircylinders in the vehicle when required.

3. Compressor. Some neonatal transport trolleysystems may be supplied with a compressorwhich provides a compressed air supply tothe ventilator using atmospheric air. Compres-sors have the advantage over cylinders of notrunning out, but the disadvantage that if theysuffer an electrical failure they don’t work.

Gas is precious—conserve it at all times by usingexternal supplies. Monitor cylinder contentsfrequently in transit to avoid unexpected failure.

Humidification

Humidification of inspired gases is importantto reduce the risk of partial or completeendotracheal tube blockage by dried secretions.This is particularly so in infants, who havenarrower endotracheal tubes than adults orolder children, and on long transfers. The use ofpoorly humidified gases also worsens lung injury,promotes sputum retention and may lead toatelectasis. Adequate humidification may beachieved by using disposable heat and moistureexchangers (HMEs) of an appropriate size forthe patient, or by using portable heated waterhumidifiers. HMEs are simple, lightweight and donot require any external power, so are not proneto failure. Although they increase the resistanceand the dead space of the ventilator circuit,this does not appear to be a problem in clinicalpractice, even with very small premature babies.

Heated water humidifiers use considerablepower and are technically difficult to use in amoving environment, due to the water sloshingaround.

Temperature maintenance

Heat loss occurs by four main mechanisms, andeach is accentuated as patient size is reduced.

1. By radiation to cooler surrounding objectssuch as ambulance walls and windows.Ambulances are rarely insulated, and so this

Equipment and monitoring 27

must be reduced by reducing skin exposure orplacing infants in an incubator. Infants mayalso lose heat rapidly when moving from thewarm ward to the ambulance outside thehospital, often with its doors open and a windblowing through it. When you are nearlyready to leave the referring hospital, it issensible to ask one of the ambulance crew togo back to the ambulance, shut the doors andrun the engine with the heating full on towarm the ambulance up prior to loading thechild.

2. By conduction directly from the patient tocold objects placed in contact, such as coldblankets. Transport incubators and blanketsshould be prewarmed before use.

3. By convection when cool air flows across thechild, for instance when incubator portholesare open, or when the ambulance doors areopened.

4. By evaporation either from the skin, especiallyin very premature neonates, or from therespiratory tract.

Infants, especially small preterm infants, areparticularly at risk of excessive heat loss. A largesurface to volume ratio, less adipose insulation,an inability to change posture to reduce heatloss, and smaller amounts of brown fat tissuecompared to more mature infants all mean thatthe infant will react less well to cold stress. Inaddition, brown fat metabolism in response tocold increases oxygen demands and may worsenhypoxia. The neutral thermal environment isthe temperature range within which a minimalamount of energy is used by the babies tomaintain their body temperature.

Incubators

Incubators should be used for transporting small(< 5 kg) or premature infants. The incubatorshould allow good visibility, easy access to thechild, a constant ambient temperature, and stableinspired oxygen concentration.

Access to the patient differs between modelsof incubators. For routine procedures, access viaportholes on both sides of the incubator ishelpful. For emergency procedures, such asintubation, the patient tray should slide out. Atray that slides out of the head end of theincubator is useful in this situation, allowingairway control and intubation without exposingthe whole baby. A heating system that is fan

assisted may also be better at retaining heat in aclinical emergency.

An incubator that supports environmentalhumidity may be preferable for very immaturebabies. Systems that use a water-soaked sponge aresurprisingly effective, yielding 80–90% humidityafter an hour or so of operation, and their simpli-city means there is nothing to go wrong.

Babies receiving complex intensive care needgood access for copious tubes and lines into theincubator.

Incubators have a relatively large powerconsumption and so rely on an additional batterysupply within the unit.

Suggested initial incubator temperature settingsfor neonates. This is just a guide, and the infant’scurrent temperature, current incubator temperatureand size all need to be taken into account.

Weight Initial temperature setting (°C)> 2500 g 331500–2500 g 351000–1500 g 36< 1000 g 39

Incubators allow the infant to be left unclothed toobserve chest movement and skin colour. Ablanket or reflective cover over the incubator willreduce heat loss further, but will also preventobservation of the child.

Other warming equipment

Chemical warming mattresses and blankets, suchas Transwarmer (Advanced Health Technologies,Herts, UK), may be used to help maintain bodytemperature for several hours. They may be usedas an additional warming method for an infantin a transport incubator or for a child on atransport trolley. This method of warming is notcontrollable and care needs to be taken as thesemattresses can get very hot (temperatures of40°C). A sheet should be placed between themattress and the skin, particularly for prematureinfants, and continuous temperature monitoringobserved.

Containers or surgical gloves filled with hotwater should not be used to warm an infant orchild as they may spill or burst, leading to scalds.

This section has concentrated on heat loss, asthis is by far the commonest situation. Hyper-thermia can occur when larger babies are inincubators on rare occasions when the sun isshining brightly through onto the incubator,


which acts like a greenhouse. Avoid brightsunlight on incubators.

Pyrexia should also be controlled by properuse of antipyretic medications and the use ofappropriate clothing or coverings. Take care thatextremities do not get cold, as the child may startto shiver, which will then increase the centraltemperature.

Suction equipment

Portable suction must be provided in transport.Some devices use compressed gas from cylindersto generate suction, utilising the Venturi effect.These are simple and reliable devices, but theyuse lots of gas, particularly if continuous suctionis needed. Care must be taken to account for thiswhen calculating oxygen requirements.

Portable suction units which rely on batterypower have the advantage of not using valuablecompressed gas, but may be prone to batteryfailure unless run off the ambulance power.

Ambulances carry portable suction units, but asthese are not as sophisticated as piped suctionunits available within the hospital environment,suction should be performed before leaving thereferring hospital.

There are also foot pump units available whichmay be difficult to use in transit.

All of these suction devices provide suctionthat is intended for clearing the airway. This isrelatively crude suction, applied for a briefperiod. There are two situations where low levelcontinuous suction would be normal practice,and this is problematical for transport where thesuction devices are much too powerful.

1. Infants with oesophageal atresia with areplogle tube in the oesophageal pouch.Normal practice on the NICU is to leave thetube on continuous low level suction to keepthe pouch drained of secretions and avoidaspiration. Continuous high level suctioncan traumatise the oesophageal pouch andimpede surgical repair. The simplest solutionfor transfer is to suction the tube intermittently,but frequently, either with a syringe or byleaving it attached to the suction deviceand turning it on for a few seconds every5–10 minutes, ensuring the secretions havebeen cleared each time.

2. Some pneumothoraces continually recollect,particularly in ventilated patients, and lowlevel suction is needed on the chest drain to

keep the lung expanded. Continuous high levelsuction can traumatise the lung. In the firstinstance, try the infant without suction. Justbecause the infant needed suction a few hoursago does not mean he or she still does. If theinfant does not tolerate withdrawal of suctionthen it will be necessary to provide continuouslow level suction. This may be achieved byconnecting the chest drain circuit to transportsuction in the normal way, but with a break orhole in the circuit to attenuate the suction. Thisis most elegantly achieved with a Y-connector,but a hole in the tubing suffices.

Be aware that suction may be labelled in variousunits (kPa, bar or mmHg).

Infusion pumps

Gravity driven drips and infusion devices thatmeasure drip rates are affected by movement andtherefore not reliable in transport. For neonataland paediatric transport syringe pump devicesare used. These allow accurate delivery of smallvolumes of fluid/medication to infants andchildren.

Infusion pumps:Should be able to accurately deliver flow rates from

0·1 ml/hShould be able to bolus doseShould have occlusion, excess pressure, infusion

complete, syringe disengaged and low batteryalarms

Should be light, compact, and robustShould be easy to useShould have long battery life.

At least six should be carried on paediatrictransfers, as this is the PIC standard. At least threeare needed on neonatal transfers, with up to sixavailable as required for more complex transfers.

The biggest problem with infusion pumps intransport practice is their short battery life. Somesyringe pumps are powered by standard alkalinebatteries that may be changed by the transport teamif they fail. Another good solution is to designatepumps for transport and change the batteries often.

Defibrillators

A defibrillator is not needed on neonatal transfers,except in rare cases of shockable arrhythmia. A


portable defibrillator should be carried bypaediatric teams, ensuring “intensive care on themove”. Although used rarely in children, staffneed to be familiar with their use.

Paramedic ambulances will have a defibrillatoron board. These may be of the automatic externaldefibrillator (AED) type, as recommended forchildren over 8 years of age. The transport teamneed to be familiar with the type of defibrillatoravailable.

When using a defibrillator, it is the currentflowing across the myocardium that is effective.This is maximised by a number of factors.

• The energy selected. Many defibrillatorsdefault to 200 J as the first energy setting. Thisshould be adjusted to the appropriate energylevel based on the weight of the child.

• The electrode position (Fig. 4.3). Either just tothe right of the upper part of the sternum andin the fifth intercostal space in the midclavi-cular line, or anteroposterior, i.e. over the leftshoulder blade and in the fourth intercostalspace in the midclavicular line. The latterposition is useful in young children andinfants.

• The electrode polarity is not critical, althoughone is normally marked “Sternum” and one“Apex”.

• Paddle size. Should be the largest that willmake contact with the chest, taking care tomake sure that the paddles do not touch.

• The use of gel pads and firm pressure improvethe passage of energy from the paddles to thepatient, and reduce the risks of burns. KY Jellyand wet pads are not adequate and may lead toburns. Alcoholic tinctures may ignite, andoxygen may explode.

Caution. Defibrillators deliver serious amounts ofenergy to the patient and anyone else in electricalcontact with the patient. Before defibrillating, itis your responsibility to make sure that everyoneis clear, including yourself. Merely shouting“Charging to 200” in the style of ER is not enough.

Hands-free paddles are probably safer fortransport use.

Select equipment carefully for transport and befamiliar with the features and limitations of theequipment available.

Monitoring

Monitoring critically ill patients during transportis essential to detect changes in their conditionin an environment where observation andauscultation are much more difficult. The propermonitoring of vital signs will allow detection ofearly signs of patient deterioration and theability to respond to these before they becomecritical. It may be difficult to assess how much orhow little monitoring a patient requires. Verysick or unstable children will require extensivemonitoring, whilst those who are stable mayrequire less. Accurate assessment of the child istherefore important. The possibility of monitoringthe following parameters during transport isessential.


Figure 4.3 Defibrillator paddle positions.

Monitors—features and clinicalapplications

Monitors should meet the general criteria fortransport equipment, given above. They shouldmonitor all the desired parameters. A data storageand download capability may be useful. Atpresent simple two-colour screens are preferableto multicoloured monitors as they have longerbattery life.

Monitoring heart rate

The ECG monitor is used to detect electricalactivity of the cardiac muscles using pregelledelectrodes as sensors, an amplifier, and a deviceto record it (Fig. 4.4).

Movement of the child clearly cannot be avoidedduring transport, and this may cause interferenceand a poor quality ECG trace. Artefacts such asthose caused by movement can be eliminated byoptimising the ECG recording technique.

Avoid artefacts by:Cleaning the skinDrying the skin to ensure good adhesion Storing the pregelled electrodes properly to avoid

them drying outOnly using the electrodes onceEnsuring that the lead clips and any other

connections fit snuglyPlacing the electrodes on bony prominences to

reduce skin and muscle movementPlacing the electrodes in the correct positions, as

shown in Fig. 4.4Filtering the ECGAdjusting the gain to optimise the size of the ECG

complexes Setting the alarms 10–15 beats above and below the

heart rate Keeping the child warm, as shivering will produce

artefacts.

Respiratory monitoring

Generally the size of the respiratory waveformequates to the depth of the child’s respiration.

However, even an obstructed airway can showsome respiratory trace, and therefore clinicalassessment is vital.

It is important to:

• Set appropriate alarm limits for the age of thepatient

• Set the alarms to detect apnoea as well asrespiratory rate

• Clinically assess respiration regularly byobserving chest movement

• Remember that the commonest cause for adrop in heart rate is inadequate ventilation.

Oxygen saturation monitoring

Saturation monitoring is only accurate if thesensor is applied properly:


RedYellow

Green

Figure 4.4 ECG electrode positions.

• Heart rate/ECG• Respiratory rate• Oxygen saturation• 2 × invasive pressure monitoring• Non-invasive blood pressure• 2 × temperature• End tidal CO2 (paediatrics)

• According to the child’s size• On an appropriate application site• So that movement of the sensor is minimised• If dark nail varnish is removed.

Problems with monitors in transport arise due toa poor signal, typically due to:

• Motion of the sensor• Poor peripheral perfusion• Hypotension• Hypothermia• Oedema.

Other problems include:

• Electromagnetic interference (for example,from cellphones)

• Inaccuracy at lower saturations. Pulseoximeters are calibrated against valuesobtained from the blood of healthy individualsmeasured by co-oximetry at saturationsbetween 80% and 100%. It would hardlybe ethical to desaturate someone to below80% merely to calibrate the equipment, andtherefore readings less than this are morespeculative and potentially less accurate. Thisis important when transferring infants withcyanotic congenital heart disease, and inthis situation other methods of assessingoxygenation, such as transcutaneous PO2

monitoring, may be preferred• Probe position—be aware that pre- and

postductal saturations may differ substantiallyin infants with a significant ductal shunt

• Response delay. Many pulse oximeters useaveraging techniques over a number of beats togive a more reliable value. This means that thetechnique gives a relatively late warning ofdesaturation. For this reason there should beseparate ventilation and disconnect alarms inthe transport system

• Equally there may be a delay in recovery of theoxygen saturation after effective ventilation isre-established

• Bright lights can overload the sensor and leadto an inaccurate reading

• Carboxyhaemoglobinaemia makes the oximeteroverread, lulling the attendants into a falsesense of security. Pulse oximetry must not berelied upon in a patient who is at risk of carbonmonoxide poisoning

• Methaemoglobinaemia also affects pulseoximetry, causing the device to underread

• Pulsatile veins may confuse the pulse oximeterand lead to an inaccurate measurement.

Be suspicious of a reading of around 85%,especially with a poor waveform, or where it doesnot correlate with the patient’s condition. Adetected ratio of red : infrared light of one gives asaturation of 85% with many pulse oximeters,and this reading can be obtained by taking theoximeter probe off the patient and waving itrhythmically in the air!

Transcutaneous blood gas monitoring

This technique is widely used in the NICU wherethe relatively thin and immature skin of theneonate improves the reliability of the readings.Both transcutaneous oxygen (TcPO2) and carbondioxide (TcPCO2) may be measured. Thistechnique may also be applied in transport, as themonitors (TINA, Radiometer, Copenhagen,Denmark) are fairly small and have a goodexternal battery facility. A randomised trial, byO’Connor, of using these monitors in transportedventilated neonates found that infants transferredwith TcPCO2 monitoring completed the transferwith significantly better blood gases and had theirventilation settings reduced, compared to infantstransferred without the monitoring.

To set the monitor up on an infant beingtransferred:

• Warm the monitor up while the infant is beingstabilised

• After transfer into the transport incubatorapply the probe to the baby, and allow thereadings to stabilise (5–10 minutes)

• Do a blood gas and follow the procedure forcalibrating the monitor to the gas results. Ifonly capillary blood gas is available, calibratejust the TcPCO2

• Make any adjustments to the treatmentregimen necessary on the basis of the bloodgas, and depart on the transfer.

Use the readings on the transcutaneous monitorto keep blood gases within the desired range. Thisis a generally reliable technique. In transit beaware that bizarre or wildly fluctuating readingsprobably indicate the probe is losing contact withthe skin. In shocked infants with poor skinperfusion the system is less reliable.


End tidal CO2 monitoring

End tidal CO2 monitoring (ETCO2 or capnography)is the graphic record of instantaneous CO2

concentration in the respired gases during arespiratory cycle (Fig. 4.5). It indicates changes inthe elimination of CO2 from the lungs, andindirectly reflects changes in CO2 levels in theblood. However, the exact relationship betweenETCO2 and PaCO2 in critically ill children is notalways clear, as ETCO2 is affected by details ofpulmonary blood flow and alveolar ventilation, aswell as the PaCO2. Nevertheless, capnographyprovides a useful trend, gives information aboutthe pattern of respiration, and acts as an extraventilator disconnect alarm.

ETCO2 monitoring is considered mandatory forpatients intubated and ventilated for anaesthesia,and is frequently used in the PICU. Given thatthe aim of a retrieval service is to providemobile intensive care, ETCO2 monitoring shouldbe undertaken in ventilated children duringtransport.

The technique is not widely used in theNICU, where studies have failed to demonstrateutility. To monitor mainstream ETCO2 requiresintroducing a probe into the ventilator circuit,which may be significant in extending the deadspace of the tubing in the neonate. Its use intransport of neonates may be a topic for furtherinvestigation.

Inspired oxygen concentration monitoring

Oxygen analysers are needed for ambient oxygentherapy as well as in ventilator circuits. Sometransport incubators have an oxygen analyserincorporated within the transport system. Oxygenconcentration alarms may be useful.

Blood gas monitoring

New technology allows portable blood gasmonitoring in transit. These devices have notbeen fully evaluated for paediatric or neonataltransport. They may have a valuable role on long

journeys, but most ventilated patients shouldhave a blood gas analysis prior to leaving thereferring hospital and then be managed on thetransport monitoring for the journey.

Non-invasive blood pressure monitoring

This should be available for all transportedchildren, although it is fraught with difficultiesin practice. Measurement by auscultation is oftenimpossible and measurement by palpation isinaccurate and may be misleading. Automated non-invasive blood pressure monitoring measurementsare affected by vibration and motion. All non-invasive methods tend to overestimate low bloodpressure and underestimate high blood pressure.However, they may give reasonable indication ofblood pressure trend.

Frequent non-invasive blood pressure monitor-ing consumes a lot of power, and will deplete themonitor battery quickly.

Cuffs of different sizes should be carried. Theappropriate size cuff will cover two-thirds of theupper arm, and the balloon should almostencircle the arm. Too small a cuff overestimatesblood pressure.

Invasive pressure monitoring

Invasive blood pressure monitoring is morereliable than non-invasive methods in thehaemodynamically unstable child, and should beconsidered in any child who is shocked, requiringlarge volumes of fluids, or receiving inotropicsupport.

The pressure monitoring system consists of anindwelling catheter, tubing, transducer, andmonitor. The tubing is filled with saline orheparinised saline and attached to a thindiaphragm. This converts changes in pressure andmechanical energy into an electrical signal whichis displayed as a waveform on the monitor.

The system is calibrated to provide accuratemeasurement by opening the stopcock to air,thereby creating a zero baseline. From thisbaseline, positive and negative changes can bedetected. The transducer should be placed at thelevel of the chest, and in the event of sudden,unexplained changes in the measured pressure,the transducer position should be checked toensure that it hasn’t fallen to the floor.

There are advantages and disadvantages ininvasive pressure monitoring.


Figure 4.5 Typical capnograph.

Inadequate damping, overdamping, or movementartefact may affect the measured systolic anddiastolic pressures (Fig. 4.6), and in thesecircumstances the mean pressure will be morereliable.

Temperature monitoring

Continuous monitoring of temperature is essentialto regulate incubator temperature for neonatesand environmental temperature for childrentransported on trolleys. Central and peripheraltemperature should be measured in small infantsand children who are shocked or unstable.

Most transport monitors have the facility tomonitor central and peripheral temperatures.

Central temperature in neonates may bemeasured by lightly securing a probe in the axilla.Position the baby in the transport incubator

slightly turned to one side. Use the lower axilla,ensuring the upper arm is by the side of the baby,keeping the temperature probe snug.

Nasopharyngeal and rectal probes are also used,particularly in older children, and the extrareliability of these may be important in very sickpatients with skin hypoperfusion.

Temperature probes are affected by improperplacement. For example, if they are placed tooclose to a large blood vessel or high flow organsuch as the liver, they may read reassuringlyhigh. Conversely, falsely low readings occur ifthe probe has poor contact with the skin, or inthe presence of vasoconstriction. One of thecommonest reasons for an acute fall in rectaltemperature during transport is that the probe hasfallen out.

Monitoring of core and peripheral temperaturecan be used as an indicator of shock, and shouldbe assessed in conjunction with the other clinicalsigns outlined in this manual.

Blood glucose monitoring

Blood glucose should be routinely measuredduring the stabilisation phase in the referringhospital, and more often if there have beenprevious problems with glucose homoeostasis, indiabetics, newborn infants, patients on restrictedfluids, and if insulin is being given.

A handheld glucometer should be part of thetransport equipment.


s

d

s

d

s

d

Correct

Underdamped Overdamped

Figure 4.6 Damping of thearterial trace. s = systolic pressure,d = diastolic pressure.

AdvantagesAccurateCan be used for blood sampling and blood gasesWaveform may be analysedMay be used to count the heart rate—is less prone to

motion artefact than ECG monitoring

DisadvantagesRisk of haemorrhageMay be affected by motionInvasive catheter placement needed, with consequent

risk of distal hypoperfusion

Inspired nitric oxide concentration monitoring

There are few monitors available for transportuse. The Printernox (Micro Medical) has a shortbattery life but may be adapted to use anadditional battery supply, for example theexternal battery on the incubator transportsystem. It is desirable that NO and NO2 aremeasured during delivery. This needs to bemonitored near to the patient, after ensuring gasmixing.

Finally

Good planning, anticipation and knowing yourequipment will ensure a safe transport; however,you may find yourself in a situation where theequipment fails you. For this reason, alwaysmake sure you can ventilate your patient—a

self-inflating Ambu-bag close at hand is essential.If an infusion pump fails, compromise a less vitalinfusion, one that can be administered by bolus. Ifyour monitor fails try to utilise the ambulanceequipment (some ambulances carry saturationmonitors, as do the RAF Search and Rescuehelicopters). If no monitoring is available utilise astethoscope and basic assessment skills. Theworst that can happen is that the ambulance willbreak down as well.

SummaryPlanning and maintenance are necessary for

transport equipment to be effective.Awareness of the limitations of transport equipment

is important in ensuring safe transport.Well set-up monitoring is an excellent resource for

clinical decision making in transit.Know your kit.


Introduction

The use of aircraft to transport sick childrenbetween hospitals can greatly reduce transporttimes compared to ground transportation. This isessential when large distances are involved, i.e.between countries. It may also prove useful whenchildren are extremely ill and require transferfor specialist treatment such as neurosurgery orextracorporeal membrane oxygenation (ECMO). Inthis context air transport is indicated if theestimated ground transfer time exceeds two hours.

ObjectivesTo understand the advantages and disadvantages of

air transport. To know the important safety aspects of air

transport, particularly rotary wing transport.To highlight physiological problems specific to air

transport and reduced barometric pressure.

Choice of aircraft

Both fixed wing and rotary wing aircraft(helicopters) may be used for aeromedicaltransport. However, once the flying time exceedsthree hours then fixed wing aircraft are preferred.

Helicopters

These aircraft are usually unpressurised andrelatively slow, 100 knots being the usual cruisingspeed for a Sea-King. Helicopters are faster thanfixed wing aircraft for short journeys, becausethey are able to land near or at the hospitals atboth ends. In general most journeys by air withinthe UK are quicker by helicopter because of theirversatility in use of landing grounds. The lackof cabin pressurisation can be a problem whentransporting extremely hypoxic patients as thereduction in oxygen pressure that occurs ataltitude can be clinically significant in the patientwith extreme respiratory failure. This problemcan be circumvented by asking the pilot to fly low.In normal weather conditions military pilots willusually be happy to fly at 150 m which does notexacerbate hypoxia.

Many different aircraft are used to transportpatients, and some have been specially outfittedas air ambulances.

Many of these aircraft are cramped and do notafford full access to the patient, especially theairway. Also many smaller civilian helicopters donot have the more sophisticated navigational,avionics, and night flying capability of militaryaircraft. Although military aircraft do not havecustomised air ambulance facilities this is offsetby the rapid mobilisation, night flying capability,and size of the Sea-King. This allows good patientaccess.

Disadvantages of helicopters include the noiseand vibration and, in winter, extreme cold. Evenmilitary helicopters will be unable to fly indense fog or snow (as the pilot needs to see theground to land). High winds may also precludehelicopter use.

Certain safety precautions are essential whenusing helicopters for aeromedical transport.These start by ensuring that the landing ground isapproved for helicopter use. If an impromptulanding area is being used, i.e. if evacuating acasualty from an accident scene, it is helpfulto station an emergency vehicle (police car/ambulance, etc.) at the windward side of thelanding area. The vehicle should be positionedfacing down wind, and should have itsheadlights and blue lights illuminated. This isespecially important at night. The surroundingarea must be cleared of bystanders and spectators,as the down draft from the helicopter can throwup debris and even blow people over. Thepresence of rubbish in or near the landing groundis an additional hazard that should be avoided.Foreign object damage (FOD) from something asseemingly innocuous as a polythene bag hascaused enough damage to aircraft to precipitatea crash.

The transport team should wait 50–100 m fromthe edge of the landing ground and should staythere until the helicopter has landed. Theloadmaster will usually then leave the aircraft andinstruct the transport team how to proceed.Helicopters should only be approached from thefront in order to avoid the tail rotor. Smallerhelicopters also pose a hazard from the main

5 Air transport of critically ill children

rotor. However, in the Sea-King this is at a heightof about 3 m, and so poses little threat (Fig. 5.1).This feature makes “hot loading” (i.e. with therotors still rotating) relatively safe in the Sea-King. In fact the RAF prefer to hot load as itreduces the risks of engine malfunction attendanton shutting the engines down. It is usual also tohave the fire brigade and ambulance service inattendance. This is obviously essential in theevent of a fire or accident.

If the rotors and engines are to be shut down thehelicopter must not be approached until theblades have come to rest and the loadmaster givespermission to approach. This is because thereis a risk of the helicopter capsising duringshutdown. For the same reason when thehelicopter lands at the hospital from which thepatient is being collected the transport teamshould remain strapped in until the rotors havecome to a complete stop and the loadmaster givespermission to unstrap.

Approaching the helicopterDo not go under the rotors until clearly beckoned (or

thumbs up).Usually the loadmaster (winchman) will come out to

you.The starboard (rear) cabin door is used for stretchers.The port (front) door—which has steps—may be

used for walking passengers.Remember that the pilot is still “flying” the aircraft

while still on the ground (unless the rotor hasstopped).

NEVER go around the back of the helicopter—touching the tail rotor will kill you.

When ready (loadmaster’s decision), with no loosearticles, walk—don’t run—to the door and load.

Fixed wing aircraft

These are used when transferring patients distancesof over approximately 300 miles (500 km). Theyare limited by the need to take off and land atairports, but their greater airspeed and rangemake them preferable for long distance transfers.Fixed wing aircraft usually fly at a higher altitudethan helicopters and cabins may therefore bepressurised. This will ameliorate the reduction inbarometric pressure that occurs at altitude. Acommercial airliner flying at an altitude ofapproximately 11 000 m will have a cabin pressureof around 565 mmHg, equivalent to an altitude ofaround 2500 m. Thus whilst the partial pressure ofoxygen remains the same (21% of the total airpressure), the actual alveolar oxygen pressure isdecreased in proportion with the reduction in totalbarometric pressure, i.e. 21% × 565 mmHg = 119mmHg. This would be equivalent to breathing 16%oxygen at sea level, and obviously necessitates anincrease in FiO2 in the hypoxic patient.

In areas where long distance transfers are moreusual (Australia, Scottish Highlands and Islands)ambulance services will have fixed wing airambulances. However, charter and scheduledcommercial aircraft may also be used. The RAF donot provide a fixed wing transport service as theSearch and Rescue (SAR) squadrons do not havesuitable fixed wing aircraft. The United States AirForce (USAF) have considerable experience oflong distance aeromedical transport.

• Air transport is usually faster if the groundtransfer time exceeds two hours.

• In the UK helicopters are usually the quickesttype of aircraft to use.

• Helicopters should be approached from the frontto keep clear of the tail rotor.

• Instructions from aircrew should be obeyed at alltimes.

• Fixed wing aircraft may be faster for transfersexceeding 300 miles (500 km).

Equipment and supplies

During ground transport it is possible to stop theambulance. This can allow further supplies ofoxygen or drugs to be commandeered from ahospital en route. It also provides a quiet andstable environment for diagnosis and therapeuticintervention. This is rarely possible during airtransport. It is therefore doubly necessary to ensurethat enough equipment is carried to cope withany eventuality. Equipment should be appropriate

Air transport of critically ill children 37

11 o’clockto9 o’clock

2 o’clock

to

4 o’clock

Beware ofthe tail rotor

Figure 5.1 Safe approaches to the Sea-King.

for the age of the child and arranged in easilyaccessible bags. It is often helpful to think of andstore items using an ABC (Airway, Breathing,Circulation) framework.

Another important factor that must be consi-dered during air transport is radiofrequencyinterference (RFI). All electronic devices generateradio waves which can interfere with the functionof other electronic devices nearby. Medical devicescan also produce RFI. The USAF and RAF have astrict protocol for testing devices for RFI beforethey are used in the air. Many devices are certifiedby the US Federal Aviation Authority (FAA) as safefor aeromedical use, and should not produce RFI.It is also theoretically possible that RFI could begenerated by the aircraft’s equipment and cause themedical equipment to malfunction, although weare not aware of any reported instances of this.

Communication with base can be very difficult.Mobile phones cannot be used in the aircraft, butit may be possible to get a message to basehospital via the pilot. Two-way conversations areimpossible, so if advice is needed it is preferableto seek this before take off.

• Take plenty of oxygen.• Ensure electronic equipment does not cause

radiofrequency interference.

General issues

The vibration encountered during helicoptertransport can cause displacement of endotrachealtubes and intravascular lines. These must thereforebe secured before take off. Usually the applicationof additional tape (Sleek) is effective in securingthese devices. It is prudent to establish centralvenous access in all but the most stable patient, asperipheral IV lines often cease functioning atthe most inopportune moment. If the patient isreceiving inotropes, prostaglandin infusions, ormagnesium, then central access is mandatory.

In any patient who is ill enough to warrant airtransport an indwelling arterial line is alsomandatory to allow accurate haemodynamicmonitoring, and sampling for blood glucosemeasurement. It is also sensible to have non-invasive blood pressure monitoring available inthe event of arterial line failure.

Cardiac arrest drugs and volume (i.e. humanalbumin solution 4·5%) appropriate for thepatient’s weight should be drawn up ready foruse. Intravenous infusions, including maintenance

fluids, should have enough volume remaining forat least double the estimated transport time.Double the estimated amount of oxygen shouldbe carried. Oxygen consumption may be furtherincreased when operating at higher airwaypressures (as higher flows may be needed), orwhen hand ventilating. It should also beremembered that suction is oxygen driven onmany transport systems, and that this can wastelarge amounts of oxygen, especially if this is notturned off after use. If one has not broughtsufficient oxygen it can sometimes be obtained onaircraft in cylinders which can be connected intoa Waters circuit to allow hand ventilation.However, this facility should not be relied on.

Many authors prefer nasotracheal intubation forair transport. There is no doubt that it is easier tosecure a nasal tube to the patient’s face but oneshould not be lulled into a false sense of security, asthe tracheal end of the tube can still move severalcentimetres if the head is moved. The head, andindeed the entire patient, should be secured insidethe incubator/transport system so that movement isimpossible. Vacuum mattresses, restraining strapsand tape can be used to secure the patient. Theventilator circuit must be supported and strappedso that it does not move in relation to the patient’shead. Ventilated patients should usually befully sedated and paralysed to reduce the risk ofinadvertent extubation, and in order to optimisetheir ventilation and haemodynamics.

It is impossible to hear anything with a stethos-cope in any kind of aircraft. This makes diagnosisof pneumothorax, endobronchial intubation,inadvertent extubation, or a blocked endotrachealtube more difficult. Observation and palpation forchest movement and tracheal shift are useful inthis regard. Passage of an endotracheal suctioncatheter can unblock a tube.

In addition, the airway pressure measured onthe ventilator can give much useful information.If using pressure control ventilation the airwaypressure will remain constant in the presenceof a blocked tube, endobronchial intubation, orpneumothorax, but will fall in the presence of adisplaced tube, or disconnected ventilator circuit.End tidal CO2 monitoring is very sensitive but notvery specific, but can be a helpful extra safetymonitor.

If a pneumothorax develops during transportthen it must be decompressed urgently. This isbest done by needle thoracocentesis, as it is notpractical to insert an intercostal drain duringflight. However, an intercostal drain should beinserted as soon as the patient arrives at the


hospital. Patients with undrained pneumothoracesshould not be taken into the air until intercostaldrains have been inserted, as such air spacesexpand with altitude as the surrounding baro-metric pressure decreases. For the same reasons anasogastric tube should be inserted to decompressthe stomach. Expansion of a gastric gas bubblecan act to splint the diaphragm and also decreasevenous return, thereby impairing cardiovascularfunction.

If venous access fails in the air then theintraosseous route is the preferred technique tore-establish access to the circulation. Maintenanceof core temperature is vital during transport and itis prudent to have chemically activated warmingpads available in case of incubator battery failure(or expiry). The blood glucose should also bechecked regularly during the flight.

• If it can fall out, it will fall out.• If you have to ask yourself “Is central venous

access needed?”—it is.• Have you got enough oxygen?• Is the baby warm?• Is the blood glucose OK?

Due to the isolated nature and potentialphysiological effects of the aeromedical environ-ment, staff selection is even more important thanusual. Air sickness can be disabling and staffwho are prone to this should not undertake airtransfers if antiemetics do not control theirsymptoms. Staff should be specifically trained inaeromedical transfer, and this training shouldinclude a period of preceptored practice wherethe trainee undertakes a number of transfersaccompanied by a trainer. However, there iscurrently no UK standard for training inaeromedical transfer for physicians or nurses,although a number of courses are available.

High altitude physiology

There are two important principles whichmust be remembered when transporting patientsby air (see chapter 2). The first is that thetotal barometric pressure decreases with altitude,for instance from 760 mmHg at sea level to565 mmHg at 2500 m (the effective altitudeinside the pressurised cabin of an airliner flyingat 11 000 m). This has profound effects onoxygen transport across the alveolar capillarymembrane. Obviously if the patient’s FiO2 at sealevel is, for example, 50% then the same oxygen

pressure in the alveolus can be achieved byincreasing the FiO2. The alveolar–arterial oxygendiffusion gradient is thereby maintained.

• In the example of the patient in 50% oxygen,alveolar oxygen pressure at sea level is760 mmHg × 50% = 380 mmHg.

• If total atmospheric pressure at 2500 m is565 mmHg, then 380 mmHg is equivalent to anFiO2 of (380/565) × 100% = 67%.

In practice it is not necessary to perform thiscalculation; the FiO2 can be increased until theoxygen saturation is well maintained, but theprinciple involved should always be remembered.The reduction in atmospheric pressure becomesmore problematical when a patient is breathing100% O2 at sea level and is already hypoxic. Inthese patients other techniques must be used toimprove oxygenation such as increasing the meanairway pressure, increasing the positive endexpiratory pressure (PEEP), inverse I : E ratios (toincrease mean airway pressure (MAP)) or evenprone ventilation to optimise V : Q matching. Itshould be ensured that patients have an adequatehaematocrit as anaemia may further decreaseoxygen transport to life threatening levels.Patients may need transfusing prior to transport.Arguments that transfused blood is deficient in2,3-DPG and will therefore have less efficientoxygen transport than the patient’s red cellsare entirely correct. It should be remembered,however, that transfused blood still carries muchmore oxygen than plasma, and thus it is still auseful therapeutic manoeuvre in this setting.

The other important principle is that gas filledspaces such as a pneumothorax, endotrachealtube cuff, or stomach will expand as the baro-metric pressure reduces with altitude. It isessential therefore that any such collections areadequately drained prior to take off. Endotrachealtube cuffs may either be filled with saline (whichwill not expand as much), or can have some airremoved during ascent to reduce the pressure andvolume. It should also be ensured that all plastercasts and constricting bandages are split down tothe skin as limbs also tend to expand and canbecome critically ischaemic if strangulated bya cast.

One final physiological point which maybecome important on longer flights is thereduction in ambient humidity at altitude, whichis further reduced by air conditioning. Endo-tracheal secretions may become inspissated, and

Air transport of critically ill children 39

regular endotracheal suctioning may be required.The decreased humidity also leads to greatlyincreased insensible fluid losses during longflights, and maintenance fluids should beadjusted to take account of this.


SummaryAir transport can be used either to move patients

long distances or to reduce transport times whenmoving unstable patients over shorter distances.It is usually faster to use road transport if theestimated transport time is less than two hours.

The ABC approach should be used as an aidto diagnosis, treatment, and equipment provision.

This coupled with a fatalistic attitude (if it cango wrong, it will go wrong) will usually preventcomplications, or ensure that they can beadequately dealt with if they arise.

The physiological problems caused by hypoxia ataltitude and expansion of air spaces and body

parts should be offset by drainage of pneumo-thoraces, insertion of a nasogastric tube, andsplitting of plaster splints to allow expansion oflimbs. Approximately twice as much oxygen as youthink is necessary should be carried.

Safety is very important, and staff should obey theinstructions of aircrew at all times. Helicoptersshould only be approached from the front, afterpermission has been given. Beware of the rotors.

Finally wrap up warm, don’t forget some antiemeticsand a credit card (you may get stranded), and enjoythe ride.

• Oxygen pressure falls with altitude so the FiO2must be increased.

• Gases and tissues expand with altitude.• Do not take a child into the air with an undrained

pneumothorax as it will expand.

Part 2Practical transport management

The principles of effective transport detailedthroughout this manual should be as rigorouslyand thoughtfully applied to neonates as to anyother group. This chapter is concerned withissues which may need additional attention inthe transport of neonatal intensive care (NICU)patients.

Most interhospital transfers of NICU patientsare of well stabilised infants who requirespecialist care beyond that available in thereferring unit. The need for active resuscitationand substantial stabilisation will be unusual. Thegoal of careful pretransfer stabilisation is a babyin a safe condition for the transfer.

Who should go?

• A nurse with transport training and experience.• A doctor at specialist registrar level or above,

or an advanced neonatal nurse practitioner(ANNP), also with transport training andexperience.

Assessment and stabilisationof the sick neonate

On arrival at the referring unit listen carefullyto a handover, and ensure you are aware of allthe necessary information.

Assess and stabilise:

• Airway• Breathing • Circulation• Feeds and fluids• Central nervous system• Temperature.

Assessment of the respiratory system

Assess for tachypnoea, recession (intercostal/subcostal), grunting, and for apnoeas anddesaturations. Assess trends in oxygen requirementand blood gases and review chest x ray films forpathology and positions of tubes and lines.

Transilluminate the chest if pneumothorax is apossibility and no chest x ray film is available. Itis more difficult to detect a pneumothorax usingtransillumination in larger babies and confidentdiagnosis may be improved by taking measures tomake the environment as dark as possible beforetransillumination.

If already intubated, assess chest movement(quantity, equality), breath sounds, and the degreeof synchrony between infant and ventilator. Assessthe endotracheal tube (ETT). It must be correctlypositioned, secure, and patent. Do not reintubate ifthe ETT is secure, correctly positioned, and patent.ETTs must be secured to a high standard to avoidbecoming dislodged during transfer.

Stabilisation of the respiratory system

Have a lower threshold for intubation than on theNICU, to minimise the potential for needing tointervene in transit. In an infant of more than30 weeks’ gestation if the vital signs (pulse, bloodpressure, respiratory rate, temperature) andexamination have been consistently stable inoxygen < 50% and if the PCO2 is normal, it may beacceptable to move the infant without intubation.

If the infant:

• Is unstable• Has a rising oxygen requirement > 50%• Is struggling to breathe (recession, grunting,

head bobbing, tracheal tug)• Has a rising PCO2

• Has recurrent apnoea• Is less than 30 weeks’ gestation

then intubation and respiratory support are highlylikely to be required, at least for the duration ofthe journey.

It may be necessary to change ventilation modefor transfer, as most transport ventilators do not

6 Neonatal resuscitationand stabilisation

ObjectiveThis chapter details issues in the assessment,stabilisation and transfer of neonatal patients.Emphasis is placed on factors that distinguish theneonatal population, in particular maintenance ofbody temperature and transfers of babies withcongenital abnormalities.

have facilities for high frequency oscillation orpatient triggered modes. Stabilise the infant onthe altered mode of ventilation before transferringto the transport system.

Use surfactant if indicated—do not delay untilafter transfer. Give surfactant early in thestabilisation period and manage any consequentshort term instability.

Drain all pneumothoraces of babies on positivepressure ventilation before the journey, as anundrained small pneumothorax can become larger.

All ETTs should be suctioned prior to transferto help minimise the need for intervention intransit.

Use blood gas analysis to review the results ofall alterations to respiratory support. It may benecessary to site a peripheral or umbilical arterialline. Calibrate transcutaneous gas monitoringagainst a blood gas sample for the transfer. This isa useful tool for gauging trends and for makingventilatory adjustments in transit.

Provide adequate opiate sedation for all intubatedinfants. Muscle relaxation is not routinely indicatedfor transfer.

Aim to transfer when:

• pH 7·25–7·4 and stable or improving• PaCO2 4–6 kPa and stable or improving• PaO2 6–10 kPa and stable or improving.

• Have a low index of suspicion of the need forintubation/respiratory support.

• Stabilise the respiratory system thoroughly.

Assessment of the cardiovascular system

Assess both absolute values and trends in heartrate, colour, capillary refill time, and peripheralperfusion. These may all help diagnose impendingshock.

Blood pressure may be satisfactory if the meanBP is greater than gestation in the newborn. It maybe necessary to place an arterial line to assess this.The base deficit may be elevated (> 5) where thereis poor perfusion. Assess the urine output, whichshould be more than 1 ml/kg/h, by placing aurinary catheter if necessary.

Review the haemoglobin level and arrangetransfusion if the level is below 12 g/dl in sickinfants.

Stabilisation of the cardiovascular system

Take a proactive approach, aiming to treat anycurrent problems as well as ensuring thatmonitoring will detect problems in transit.

Place an arterial line for blood pressuremonitoring if you are concerned about cardio-vascular status. Avoid reliance on non-invasiveblood pressure measurements in sick infants, asthese are less accurate and technically challengingin transit.

Treat hypotension with volume expansion(4·5% human albumin solution or normal saline,or blood if the haemoglobin is low) 10–20 ml/kgover 30–60 minutes initially. Start inotropes ifresponse to volume is not adequate and place acentral venous line for administration.

Ensure in all circumstances you have amaternal blood sample for cross-matching afterthe transfer.

• Thoroughly assess cardiovascular values andtrends. Place an arterial line if worried aboutblood pressure.

• Use volume replacement and inotropes early, asindicated. Shock and hypotension are very likelyto worsen in transit.

Assessment of feeds and fluids

Check the blood glucose and recheck often whenthere has been instability or vascular accessproblems. Review serum electrolytes (U&E) andexamine the abdomen for distension, tendernessor discolouration. Review whether and howrecently any enteral feeds have been given.

Stabilisation of feeds and fluids

Stop enteral feeds for journeys. Place and aspiratea nasogastric tube (NGT). Ensure there is reliableIV access and administer maintenance fluidsaccording to local policy and U&E results. Keepthe blood glucose higher than 2·4 mmol/l.

Assessment of central nervous system

Review ante-, peri-, and postnatal histories forevidence of CNS injury. Observe unsedatedinfants for posture, tone, and activity. Where thereis the possibility of CNS injury observe for subtleand/or overt signs of convulsions. Subtle signsmay include sucking and chewing, cyclingmovements of arms and legs, and apnoea. Frankfits, tonic and/or clonic, may also be seen.

Promptly investigate seizures—check the bloodglucose, U&E, calcium and magnesium. Completea septic screen, including lumbar puncture.Collect urine as part of the septic screen—some


should go for culturing as usual, but retain asample for potential later investigations.

Stabilisation of central nervous system

Treat according to the results of investigations,to correct an underlying disorder, such ashypoglycaemia or meningitis. Definitive diagnosisand management may have to wait until aftertransfer. Anticonvulsants may be necessary totreat prolonged seizures (see chapter 13), but maycause respiratory depression mandating ventila-tion for transfer.

Current research is concerned with therapeutichypothermia in the first hours of life for infantssuffering a perinatal hypoxic/ischaemic insult,and this may be a future transport challenge.

Thermoregulation

Very immature and low birthweight babiesare particularly vulnerable to cold. There issubstantial evidence that transported babies areat particular risk of becoming hypothermic, andthat this is associated with poor outcome. Theseinfants represent a unique transport challenge,and every effort must be made to promotenormothermia. The following advice refers inparticular to infants of weights less than < 1·5 kg,but the principles should be generally applied toneonatal transfers.

Before setting off to retrieve a lowbirthweight baby

Obtain information about the current temperatureof the baby, and offer advice to the referring team,if required. Prewarm the transport incubator to39–40°C. It may be necessary to run the transportincubator at its top setting as heat is lost muchmore rapidly to the environment on a transferthan in a well heated NICU.

Some transport incubators may be humidifiedusing a simple wet sponge device—start thisprocess now.

During stabilisation on the referring unit

Ensure the transport incubator is plugged inand warming. Monitor the infant’s temperaturecontinuously with a sensor placed in a coreposition such as under the infant or fixed with aspot plaster in the axilla.

Nurse the infant in a warm, humidifiedincubator. Bubblewrap may help reduce evapora-tive heat loss. Actively warm and humidifyventilator gases. Rewarming may be helped byuse of a chemically activated gel mattress(Advanced Health Technologies, Herts, UK) toprovide an additional source of heat when placedunder the infant.

Refractory hypothermia may respond to placingthe whole baby in a headbox with warmed gasflow via a humidifier, as for headbox oxygen.

Do not transfer to the transport incubator untilthe temperature is normal, or at least improving.The need for rewarming and/or maintainingtemperature should be factored into the timing ofstabilisation procedures. It may be necessary toapply some of the rewarming procedures abovefor some time before placing tubes or lines thatare needed for the transfer.

Transfer to the transport incubator

Time spent in transfer from the hospital isolette tothe transport incubator will exacerbate heat lossdue to time spent in contact with cooler air.This transfer should be completed in a maximumof 15 seconds, timed from opening the doors ofthe static incubator to closing the doors of thetransport incubator.

The infant may be conveyed between incubatorson an activated chemical warming mattress.Complete all subsequent procedures throughportholes.

Humidify ventilator gases for transfer. A simpleheat and moisture exchanger is probably aseffective as active humidification for transfer.

Before leaving for return journey

Minimise the need for any intervention requiringopening portholes during the journey by ensuringall monitoring is properly attached and working,and all tubes and lines are patent before departing.

Return journey

Warm the ambulance cabin. Attempt to completethe journey without opening the incubatorportholes. Monitor temperature continuously andadjust the incubator accordingly.

In the event of deterioration of the clinicalcondition requiring active intervention, balancethe likelihood of profound hypothermia consequenton performing a definitive procedure against thepossibility of performing a limited procedure in

Neonatal resuscitation and stabilisation 45

the vehicle and diverting to a nearby hospital,where treatment may be completed and temperatureprotected.

• Special attention must be paid to thermo-regulation on transfer of preterm and lowbirthweight babies, as this affects outcome.

• Meticulous attention to detail is necessary tokeep small babies warm before and duringtransfer.

• Protecting thermal status should be factored intoall clinical decisions.

Care of the family

The transport team should consider care of theinfant’s family to be a central part of their work.After initial introductions, it is best if the teammembers can each set aside some time with thefamily during the stabilising period. Establishwhat the family already understand about theirbaby’s illness and the need for transfer, and buildon this established knowledge to ensure they areaware of the key current problems, treatments,and transport issues. Written and other informationfor the family is helpful at this stage, and manytransport teams carry pre-prepared materialstailored to the local arrangements.

Discuss the family’s travel arrangements andmake sure you have all the necessary phonenumbers to contact them if necessary.

Acute deterioration andresuscitation of the newborn

The need for cardiopulmonary resuscitation ofneonates by transport teams should be rare. In thesituation where two or more personnel arededicated to the care of one infant most problemsmay be managed before they become a crisis.

Endeavour to keep infants warm throughoutresuscitation. As far as possible perform proce-dures through the incubator portholes. Usebubblewrap and heated chemical gel mattressesearly in the process.

Infants will usually present with a combinationof desaturation and/or bradycardia.

Airway and breathing

In unintubated infants check for breathing.Support respirations with bag-valve-mask

ventilation, checking that chest movement isachieved. If the chest does not move (re-evaluatethis after each step):

• Ensure the head is in the neutral position• Ensure there is a good seal of the mask over the

infant’s mouth and nose• Consider using a Guedel airway or jaw thrust• Intubate.

In intubated infants check for chest movement. If none:

• Check the ventilator is delivering breaths andhas not become disconnected

• Suction down the ETT• Reintubate if concerned the ETT is blocked or

dislodged• Assess for pneumothorax—see below.

If the chest is moving:

• Assess the quality of chest movement—ifreduced, does the baby need higher pressuresor a faster rate? If the baby is fighting theventilator increase the dose of sedation andconsider muscle relaxation. Check the IV linedelivering sedation has not dislodged

• Assess for pneumothorax with transilluminationand chest radiograph. Needle thoracocentesisand/or chest drain placement will be necessaryif pneumothorax is present.

Circulation

In the situation where, despite adequate ventila-tion and good chest movement, the heart rateis less than around 60 beats/min, start chestcompressions.

The most effective method is encircling thechest with both hands and using the thumbsto compress the lower third of the sternum(Fig. 6.1). The thumbs should be just below animaginary line joining the nipples. Aim tocompress the lower third of the sternum by aboutone third the depth of the chest. Current neonatalresuscitation guidelines suggest aiming to achieve90 compressions and 30 breaths per minute, in aratio of three compressions to each breath.

Chest compressions may be sufficient to moveoxygenated blood the short distance from thepulmonary bed to the coronary arteries, and sorestore a normal heart rate. If not, consider usingresuscitation drugs.


The evidence for when and how to useresuscitation drugs in the newborn is poor. Thereis broad agreement of the four drugs that may beused, but not the order in which to use them.Familiarise yourself with local policy and followthat.

Sodium bicarbonate 4·2%

Dose: 1–2 mmol/kg (2–4 ml/kg) Route: UVC or other venous line.

• To improve the intracardiac biochemical milieuto allow the heart to work normally. Followthe dose with a small 0·9% saline flush andcontinue compressions for a brief periodbefore reassessing heart rate.

Epinephrine (adrenaline) 1 : 10 000

Dose: 10 micrograms/kg (0·1 ml/kg 1 : 10 000)Route: UVC, other venous line or via tracheal

tube.

• As adrenaline may not be effective when thepH is low, it may be worth giving a furtherdose of 0·3 ml/kg of 1 : 10 000 solution after adose of bicarbonate if there was no responseto an earlier dose.

• Unlike the other resuscitation drugs, epinephrinemay be safely given down the tracheal tube.The current recommendation is to give thesame dose as the IV route.

Dextrose 10%

Dose: 2·5 ml/kgRoute: UVC or other venous line.

• Supplies a bolus of fuel to the heart whenglycogen stores may have diminished.

Volume (normal saline/4·5% humanalbumin solution/blood)

Dose: 10 ml/kg initiallyRoute: UVC or other venous line.

• Rarely bradycardia will respond to volume.Give 10 ml/kg and assess response.

• Do not give more than 10–20 ml/kg volumeexpansion unless there is evidence of loss offluid from the circulation, for example from adisconnected UVC/UAC, fluid loss into theabdomen from bowel perforation or largeintraventricular haemorrhage.

Resuscitation in transit

First, stop the ambulance. Take immediate stepsto warm the vehicle cabin (close windows, turnthe vehicle heater on full) to improve the baby’sthermal environment if procedures such asintubation are necessary.

At each stage it will be necessary to balance theneed for a definitive procedure, such as chestdrain placement, against the risk of performingthe procedure in a cold environment with limitedhelp. Consider performing a limited procedure,such as needle thoracocentesis, and divertingto the nearest hospital in order to do thedefinitive procedure in a warm and controlledenvironment.

Use the mobile phone if necessary to seek senioradvice, particularly if resuscitation attempts areproving unsuccessful. In the event of unsuccessfulresuscitation it may be best to take the baby towhichever hospital the parents are at.

Congenital abnormalitiesand transfers for neonatalsurgery

This section outlines specific issues, beyondnormal transport practice, that need considerationfor these groups of infants.


Figure 6.1 Chest compressions. (From ResuscitationCouncil, UK. Newborn Life Support Provider Course Manual.London: Resuscitation Council, 2001, with permission.Illustration by Steven Brindley.)

Gastroschisis/exomphalos

Before departing to retrieve an infantwith gastroschisis

Ensure you have an appropriate plastic bag tonurse the baby in, for example Vi-Drape IntestinalBag (Becton Dickinson, Meylon, France), as wellas adequate supplies of volume replacementfluids (for example, human albumin solution4·5%). Infants with gastroschisis may need20–60 ml/kg in the first six hours.

During stabilisation

Inspect the defect. Even if it has been carefully,thoroughly and recently covered with a dressing,this should be removed and not replaced. Nursein a clear plastic bag, secured under the arms.Signs of ischaemia (black, poorly perfused bowel)should be discussed urgently by telephone withthe surgeon at the receiving unit. Anecdotally, itis said to be very occasionally necessary toenlarge the abdominal wall defect to restoreperfusion to the bowel.

Maintain circulating volume now and duringthe journey by estimating fluid losses from thedefect and replacing. Volume status may beassessed by:

• Trends in blood pressure and capillary refill• Aspirating and measuring exudate from the

plastic bag. This needs aspirating regularly tohelp keep baby dry

• Worsening toe/core temperature gap trend.

Position baby and defect carefully to preventstretching or twisting of the mesentery. Largedefects may need supporting.

Infants with a covered exomphalos are muchmore straightforward to transfer.

Congenital diaphragmatic hernia

Infants with congenital diaphragmatic hernia(CDH) are often extremely unwell, and requireprompt, effective and thorough general intensivecare to stabilise for transfer.

Before departing to retrieve an infant with CDH

Consider taking inhaled nitric oxide on thetransfer. Be prepared for a complex transfer, withpotentially many infusions.

During stabilisation

Always ventilate and muscle relax infantswith CDH, including the small group who presentlate with a mild respiratory illness. Ventilationallows muscle relaxation, which prevents airbeing swallowed and further distension of theintrathoracic bowel.

Pass a large bore nasogastric tube (min. 10 FG).Leave on free drainage and aspirate regularly.Position hernia side down.

Oesophageal atresia and/ortracheo-oesophageal fistula

Infants with tracheo-oesophageal fistula (TOF)will usually be straightforward to transfer. Ifthere is an oesophageal atresia, a replogle tube(Sherwood Medical, Tullamore, Rep. Ireland)should be placed in the oesophageal pouch. Thesedouble lumen tubes have a large lumen foraspirating pouch contents and a smaller secondlumen for instilling small amounts of normalsaline regularly to loosen secretions. They aresufficiently rigid not to curl up in the pouch.Position the infant slightly head up, to encouragesecretions to pool in the pouch, from where theymay be aspirated.

Ventilation for transfer should be avoided in thisgroup. Babies with oesophageal atresia (OA) and adistal fistula are a unique ventilation problem.Massive irreducible abdominal distension is likelyto follow from positive pressure ventilation andthis may lead to a vicious cycle of increasingabdominal distension, thoracic compression, andworsening respiratory state. If ventilation hasalready been started, or is unavoidable, transfershould proceed very promptly and the receivingsurgical and anaesthetic teams notified.

Bowel obstruction and othergastrointestinal pathology

Bowel obstruction in the newborn requirestransfer for paediatric surgical assessment andmanagement. In many cases definitive diagnosisis not possible until after transfer and so the workof the transport team is to carefully assess thebaby and offer the support necessary to allowfor a safe journey. Potential diagnoses includebowel atresia, meconium ileus, malrotation/volvulus, Hirschsprung’s disease, and necrotisingenterocolitis (NEC). Some may be complicated byperforation of the bowel.


Considerations for transfer

Is there a need for urgent transfer? Babieswith bowel perforation and/or malrotation needprompt surgical assessment. The time spent onvery thorough stabilisation for transfer should bebalanced against the possibility of life savingsurgery.

Always place a large bore NGT, leave it on freedrainage, and aspirate regularly. If fluid manage-ment has been adequate in the preceding period,then replacement fluids are rarely required intransit. Replacement of NG losses may be necessaryif these have not been replaced prior to arrival ofthe transport team. Normal saline will usually beadequate replacement fluid for transfer.

Assess for serum electrolyte disturbances but,unless transfer will take several hours, do notdelay transfer of a critically ill baby in order tocalculate electrolyte deficits and mix custom fluidbags.

For babies with NEC, and other painful condi-tions, consider administration of opiate analgesia.This may also necessitate ventilation, but this isbetter and safer practice than transferring aninfant who keeps going apnoeic through pain.

Consent

Ensure that arrangements are made for properconsent for surgery to be obtained by the surgeonfrom an eligible person. As valid informedconsent may only be obtained by a senior memberof the surgical team, it is not appropriate for thetransport team to seek consent. Instead, thetransport team should seek to ensure that consentis facilitated. Consider:

• When the infant will go to surgery—infantswith perforated bowel, for example, may needan urgent procedure soon after transfer,whereas many infants with diaphragmatichernia are stabilised for several days

• When a person who is able to give validconsent will be able to come to the surgicalcentre.

Balance these two factors. The best solution is fora parent to meet the surgeon before the surgery.

In the event that emergency surgery will beneeded on completion of transfer and it is notpossible for a consent giver to travel at this time,it may be necessary for the transport team tofacilitate and witness a telephone conversationbetween the surgeon and the consent giver.

Transfer from the labourward and other intrahospitaltransfers

In many hospitals there is a substantial distancebetween labour ward and the NICU, necessitatinga carefully planned approach to this transfer.In addition, infants who need surgery andinvestigations may have to leave the NICU whilecritically ill. The latter group should be preparedfor transfer exactly as for an interhospital transfer.

The approach to transfers from labour ward tothe NICU is determined by the distance involvedand by the presence of significant obstacles, suchas lifts. If the transfer time is routinely more thana minute or two, a transport incubator should beused in preference to the Resuscitaire.

Whatever the distance involved, the principlesdescribed below should be observed.

Keep the baby warm. Where a transport incubatoris to be used, it should be kept warm at all times.As well as conventional warming methods, suchas use of the Resuscitaire, chemical gel mattressesand woolly hats, recent data suggest that puttingnewborn infants in a plastic bag up to the neckimmediately at birth is effective in retaining heat,presumably by reducing evaporative heat loss.The bag is left in place until the infant is settledon the NICU.

Attend thoroughly to airway, breathing, andcirculation, and ensure you have control of thesefor the transfer. If intubation has been necessary,secure the tube. Administer surfactant if indicated.Ensure the baby’s chest is moving. If using thetransport incubator, attach the infant to theventilator so that the incubator portholes can bekept closed.

Neonatal procedures

Umbilical vessel catheterisation

The umbilical vessels provide ready access to thecentral venous and arterial circulations. Electiveumbilical catheterisation should be approachedas a sterile procedure.

Equipment

• Sterile procedure pack (including arteryforceps and vessel probes), gown, gloves

• Cord ligature


• Scalpel and large blade• Syringes and saline flushes• Suitable catheters for vessels:

• Umbilical vein—size 5–10FG single ordouble lumen

• Umbilical artery—size 3·5–5FG singlelumen; some have oxygen measuringelectrodes at the tip

• Three-way taps for catheters, to allowsubsequent sampling

• Blood pressure monitoring circuit forarterial lines.

Procedure

• Using aseptic procedure, clean the cord andperiumbilical skin and drape the area.

• Attach three-way taps to catheters and primecatheter(s) with normal saline.

• Tie an umbilical cord ligature loosely aroundthe base of the cord. This may be pulled tightto control bleeding.

• Cut the umbilical cord 1–2 cm above the skin.Cut cleanly, avoiding a sawing motion.

• Identify the three vessels (Fig. 6.2).• For umbilical vein:

• Use an artery forceps to grip one wall of thevein. The vein may need to be gently dilatedwith a probe, but most often will not.

• Gently insert the catheter. Some resistancemay be felt at the umbilical ring—gentlepressure may be applied to pass thecatheter beyond this point.

• Advance the catheter—it should not bepassed further than the distance from thecord base to the internipple line.

• Draw back on the syringe—if blood isreadily aspirated the catheter is in a largevessel and is probably in an adequateposition for transport. If blood is notaspirated, try withdrawing or advancingthe catheter slightly.

• For umbilical artery:

• Stabilise the cord stump by placing twoartery forceps tangentially to the cord, oneon each side.

• Carefully dilate the lumen of one of thearteries to a depth of 5 mm, using a finepair of forceps to tease open the vessel, or ablunt dilator.

• Insert the catheter tip into the dilatedvessel and advance the catheter. Bloodshould be readily obtained on aspiration.The catheter tip needs to rest at a positionthat avoids the origins of the renal artery,coeliac axis, or inferior mesenteric artery.Obtain an x ray picture to ensure the tip ofthe catheter is either between T8 and T10or L3 and L4.

• Observe the infant for the development ofsigns of distal hypoperfusion—blue orwhite legs, or blue toes. If these occur thecatheter should be promptly removed. Tryagain, either in the other artery or with asmaller catheter.

The umbilical vein may be cannulated on transferwhen central venous access is required, either forinfusion of vasoactive drugs such as inotropes, orwhere other venous access proves difficult, suchas in very poorly perfused infants. Double lumencatheters increase the utility of the vessel,providing two separate vascular access routes.Consider the umbilical vein in babies up to 10–14days of age where there is any dried up umbilicalcord stump remaining adherent. Follow theprocedure above, but expose the vessel in thefollowing manner.

• Grip the umbilical cord stump with toothedforceps and apply gentle traction.

• Use the blade to cut off the dried up cordstump as close to the base as possible withoutcutting skin.

• The vein should be exposed in the superiorposition and may be cannulated as above.


Umbilicalvein

Head Feet

Umbilical arteries

Figure 6.2 Orientation and appearance of umbilical vesselswhen the umbilical cord is cut close to the level of the skin.The arteries are small, thick walled, and may stand proud ofthe cut surface.The vein is large and thin walled. (FromResuscitation Council, UK. Newborn Life Support ProviderCourse Manual. London: Resuscitation Council, 2001, withpermission. Illustration by Steven Brindley.)

• Be prepared to control bleeding from thestump either with direct pressure or, if thebleeding is from the vein, by applying pressureto the abdomen 1–2 cm directly superior tothe cord. A haemostatic dressing (for example,Surgicel) is also occasionally required.

For transfer ensure that the catheter is very secure(Fig. 6.3); a displaced UVC may lead to rapidsubstantial blood loss. Once you have secured thecatheter, verify its security by gently pulling onit—it should not move. Chest and abdominalradiographs are needed to check the position oftips of lines and verify that the desired vesselswere cannulated.

Peripheral arterial cannulation is probablypreferable to placing a UAC for transfer, simply asit’s a quicker procedure that does not require anx ray film afterwards. However, where peripheralarterial cannulation has not been possible andaccurate blood pressure measurement is required,then placing a UAC may be necessary. Theumbilical arteries are not usually accessiblebeyond the first 2–3 days of life.

Do not delay necessary tasks until after thetransfer—if you are wondering whether it needsdoing, it probably does.

Back transfer

Neonatal intensive care is distinctive in theprovision of care right through to hospitaldischarge. Back transfer to a hospital that is localfor the infant’s family should happen as soon as itis safe. The principles of safe back transfer arethe same as for any other transfer, as detailedelsewhere in this chapter. Below are some briefadditional considerations.

Planning back transfer

Back transfer should normally be a plannedactivity. Start this planning from the time ofadmission by discussing it with the infant’sfamily. Ensure they understand that their babywill be returned to a local unit at some point, andexplore any issues that arise from this. All staffshould avoid any discussion which elevates thestatus of tertiary units relative to local units intheir ability to provide care—it is all too easy tomake parents wrongly believe that their local unitis incapable of caring for their baby. Keep incontact with the local unit to ensure they areaware that there is a baby who will be returning tothem at some point.

Local agreements and circumstances determinewhether back transfer is performed by the tertiaryor local hospital. In either case, it is crucial thatthe two units cooperate on a collaborativeapproach to return transfers.

Concrete plans for back transfer should beactively constructed from as soon as the period ofacute illness appears to be ending. The tertiarycentre should contact the local unit to alert themto the impending transfer, and to discuss timing.

For babies who have needed ventilation avoidplans that involve extubation followed byimminent back transfer, especially in prematureinfants. It is better to electively leave the infantintubated for transfer, with a plan for weaningand extubation promptly at the local centre, thanto extubate and transfer soon after. Recentlyextubated infants may find the handling and stressassociated with back transfer excessive, and needreventilating. The alternative is to extubate andleave the baby for a day or two before transferring.

Back transfer should include the transfer of allthe information necessary for the local unit tocontinue the care of the baby. Local agreementsdetermine what this comprises, in terms of letters,copies of notes, x ray films and so on, and theseshould be prepared well ahead of time.


Figure 6.3 Securing umbilical lines.Tie two stitches intothe substance of the umbilical cord and cut the silk about4 cm long. Line these ends up alongside the catheter and thenturn the catheter back on itself and tape all together so thatsilk and catheter are encased in the tape. Use very sticky pinktape (“Sleek”) and avoid tape on skin. (From ResuscitationCouncil, UK. Newborn Life Support Provider Course Manual.London: Resuscitation Council, 2001, with permission.Illustration by Steven Brindley.)

Who should go?

Back transfers without exception need a nursewho is experienced in transport. This is to ensurethat all the safety-in-transit issues are properlyattended to, the transport equipment is usedeffectively, and clinical deteriorations are bothspotted early and attended to safely.

Some back transfers, including those of ventilatedinfants and those in high concentrations of oxygen,require a doctor or ANNP in addition to the nurse.

Practical considerations

Stop continuous NGT feeds one hour before transferand aspirate the tube to empty the stomach. For allbut the shortest transfers infants on continuousfeeds will need an IV glucose solution.

Babies on intermittent feeds may not need IVfluids, depending substantially on how long thejourney is and what the feeding frequency is. Forexample, an infant being fed four hourly who isstable and going on a 30 minute transfer willprobably not need IV fluids.

Check the blood glucose prior to departure andensure all tubes and lines are secure and patent.

Continue to monitor the baby in the same way ason the unit. Add any monitoring that has recentlybeen withdrawn—for example, babies who haverecently come out of oxygen should have oxygensaturation monitoring in transit.

Transport equipment should be used andsecured as for emergency transfer. Car seatscannot be recommended for back transfer, as theirsafety for infants who are recovering from aperiod of intensive care has not been established.Back transfer should be undertaken at normaltraffic speeds.

Welcome parent(s) on back transfers, asambulance seating permits.

SummaryIn common with other groups, neonatal patients

should be thoroughly stabilised for transfer. Additional attention to maintaining body tempera-

ture is required. There are distinctive issues in transferring infants

with prematurity, congenital abnormalities or forneonatal surgery, with which the transport teammust be familiar.


In most retrievals, the patient will have beenresuscitated and stabilised by the referring team.The retrieval centre has an important role inoptimising this phase by giving advice andidentifying specific interventions that can beinitiated by the referring hospital before theretrieval personnel arrive, such as intubatingthe child, getting vascular access, or startinginotropes. The importance of maintaining clearlines of communication between the referringteam and the retrieval personnel at the time ofthe initial referral and during the time spenttravelling to the patient has already beenmentioned and deserves emphasis.

Occasionally, however, the child will not bestable on the retrieval team’s arrival, perhapsbecause specific advice was not given, becausethe referring personnel were unable to initiatethe suggested management plan, or because thechild has deteriorated further. On other occasions,the child will deteriorate during transport,despite your best efforts. For this reason, retrievalpersonnel must have advanced life support skillsand must be highly competent in paediatricresuscitation. This chapter reviews resuscitationguidelines, outlines the critical actions that mustbe taken before leaving the referring hospital, andfinally describes some of the procedures that maybe undertaken.

Much of the information needed is in otherchapters of this manual (especially chapters 8and 9), to which the reader is referred whereappropriate.

Recognition and assessmentof the sick child

First undertake a rapid assessment of the child, todetermine whether any immediate interventionis needed (Box 7.1). Your detailed assessmentshould then follow a systematic approach, asoutlined in the various paediatric life supportmanuals available.

The two facts underlying your approach toresuscitation are:

• Most cardiac arrests in children are due tohypoxia

• The outcome is generally poor once the childarrests.

Therefore you should identify the signs that thechild is at risk of cardiorespiratory collapse beforeit happens and intervene appropriately. It isaxiomatic that you need to know the normal rangeof physiological parameters at different ages.

Assessment of the respiratory system

Noisy breathing

This is normally due to obstruction to the flow ofair, either by secretions at the back of the throat,upper airway obstruction, such as croup, or lowerairway obstruction, as in acute asthma. In general,inspiratory noise (stridor) is due to upper airwayobstruction. The loudness of the noise is not anindicator of severity, which is best assessed bythe degree of recession, and the presence ofpulsus paradoxus. Cyanosis due to upper airwayobstruction indicates severe obstruction, andimpending respiratory collapse. A scheme for theassessment and treatment of the child with croupis given in Table 7.1.

Other causes of upper airway obstruction,such as epiglottitis and foreign body, should beconsidered. If epiglottitis is a possibility, theairway should be secured in the referring hospital

7 Paediatric resuscitationand stabilisation

ObjectivesTo recognise and take appropriate actions in the

event of impending or actual cardiorespiratoryarrest.

To know the observations and interventions thatneed to be considered to stabilise the patientbefore departure.

To have an understanding of the proceduresdescribed, leading to an ability to undertake themwith further practice.

in a controlled environment, with the help ofan experienced anaesthetist and the availabilityof an ENT surgeon to secure a surgical airway ifnecessary.

Expiratory noise generally suggests lowerrespiratory obstruction, such as bronchospasm inasthma.

Grunting is also produced in exhalation, but isthe noise made by breathing out against a partiallyclosed glottis. This manoeuvre is used, typicallyby infants, to generate some end expiratory

pressure, and thus keep the lungs open at the endof expiration.

Beware the silent child with respiratorydistress. They may just be too exhausted to makeany noise.

Rate and pattern of breathing

An increased rate of breathing at rest may bedue to fever, fright, lung or airway disease, ormetabolic acidosis. Accessory muscles may be


Box 7.1 Rapid cardiopulmonary assessment

A. AIRWAY PATENCY

B. BREATHING

Rate: Newborn 1 year 18 years< 40 24 16

( > 60 “always” abnormal)

Air entry: Chest rise, breath sounds, stridor, wheezingMechanics: Retractions, grunting

C. CIRCULATION

Heart rate: Newborn–3 months 3 months–2 years 2–10 years > 10 years140 130 80 75

Abnormal: < 5 years: > 180, < 60 > 5 years: > 160

Peripheral/central pulses: Present/absent, volume

Skin perfusion: Capillary refill < 3 secondsTemperature, colour, mottling

CNS perfusion: Recognises parents, reaction to pain,muscle tone, pupil size

Blood pressure: Newborn 1 year > 1 year

Systolic > 60 > 70 > 70 + (age × 2)

Note: Blood pressure only distinguishes compensated from uncompensated shockASSESS—ACT—REASSESS—REACT

Table 7.1 Assessment of croup

Children in category 3 should have their airway secured prior to transport.Children in category 2 may be given nebulised epinephrine (adrenaline) and their responseassessed. It may still be safer to secure their airway prior to transfer.

Category1 2 3

Stridor Inspiratory Biphasic Silent

Sternal recession Absent Present Severe

Pulsus paradoxus Absent Absent Present

will enable you to define a demarcation betweenwarm and cold skin, and the level of demarcationmay be used to monitor response to interventions.Capillary refill time is also used, but is moresubjective.

Blood pressure is a poor sign of circulatoryfailure, as it is maintained until collapse isimminent. A low diastolic pressure may indicaterelative hypovolaemia. It is important that thecorrect cuff size is used to measure blood pressureby the non-invasive method.

Finally, assess the effect of circulatory failureon end organs. Poor skin perfusion has alreadybeen mentioned. Agitation, aggression and thendrowsiness may be due to poor cerebral perfusion,and poor urine output suggests inadequate renalperfusion.

Assessment of the nervous system

A deteriorating or reduced conscious level ismost commonly due to reduced cerebral oxygendelivery, secondary to hypoxia or shock. Thereforeoptimise the airway, breathing and circulationfirst. Conscious level may be difficult to assessformally, especially in infants, but the AVPUsystem provides a simple and reproduciblemethod of doing so (Box 7.2).

The traditional Glasgow Coma Scale (GCS)is modified to accommodate young children(Table 7.2). Such assessments should be repeatedfrequently, as conscious level may change rapidly,and are a good guide to the effectiveness ofresuscitation. In general, children with a GCS lessthan 8 are unable to protect their airway. If simpleresuscitative measures do not improve theirconscious level, the airway should be secured bymeans of endotracheal intubation.

Raised intracranial pressure (ICP) is suggestedby the following signs, in the appropriate clinicalsetting.

• Pupillary reactions—unilateral or bilateraldilatation suggests raised ICP.

• Posturing (Fig. 7.1)—a painful stimulus maybe needed to elicit abnormal posturing. In

Paediatric resuscitation and stabilisation 55

Box 7.2

A AlertV Responds to VoiceP Responds to PainU Unresponsive

Table 7.2 Modified Glasgow Coma Scale

Response Score

Eye openingSpontaneous 4On command/reacts to speech 3On pain/reacts to pain 2No eye opening 1

Best motor responseSpontaneous or on command 6Localises pain 5Flexion with pain 4Decorticate posturing 3Decerebrate posturing 2No motor response 1

Best verbal responseSmiles, orientated, follows objects

or converses appropriately 5Disorientated, consolable crying

or converses inappropriately 4Inappropriate words, cries only to pain 3Incomprehensible, inconsolable, moans to pain 2No verbal response to pain 1

Total 3–15

used to help expand the chest when the work ofbreathing is increased. Recession is also due to anincreased work of breathing, and is prominent ininfants, who have a more compliant chest wall.In the extreme, this may manifest as ‘see-saw’respirations, where the diaphragm moves downduring inspiration, pushing the abdominal wallout, but rather than expanding, the compliantchest moves in. On expiration, the reversehappens, there is no air movement, and breathingis ineffective.

Effectiveness of breathing

Chest expansion, listening for breath sounds,and oxygen saturation all give indications of theeffectiveness of breathing.

Assessment of the cardiovascular system

Heart rate increases early in shock, to compensatefor a falling stroke volume, and in hyperdynamicstates, because infants have relatively non-compliant ventricles and are therefore less able toincrease stroke volume to improve cardiac output.The peripheral pulse becomes weak and thready,and may be absent. Skin perfusion deteriorates,and a useful sign of impending shock is coldperipheries. Running the hand up the lower leg

decorticate posturing the arms flex and thelegs extend. In decerebrate posturing, botharms and legs extend.

• Reflexes (Table 7.3)—the oculocephalicreflexes involve flexing and rotating the head,and should not be tested in patients who mayhave neck trauma. The eyes should move awayfrom the head movement when the head isrotated to the side. No movement, or randommovement, is abnormal. Similarly, when thehead is flexed, the eyes should deviateupwards. Loss of conjugate upward gaze issuggestive of raised ICP.

Systemic hypertension with sinus bradycardia inthe obtunded patient is suggestive of cerebralherniation, and is a late and ominous sign. If theairway has not been secured, do so, ventilate to anormal CO2 and give mannitol (0·5–1 g/kg IV). Insome situations dexamethasone may be useful.

Critical interventions

The rapid assessment or the more detailedsystematic survey may reveal immediateinterventions that are needed to prevent furtherdeterioration. These should be initiated, theireffects reassessed, and the full assessmentcompleted. It is easy to get side-tracked in solving


Table 7.3 CNS lesions by site and typical clinical observations

OculocephalicCNS level of lesion Pupil reactions reflexes Breathing pattern Posture

Thalamus Small, reactive Variable Cheyne–Stokes Normal (A)

Midbrain Mid position, fixed Absent Hyperventilation Decorticate (B),increased tone

Pons Pinpoint, fixed Absent Rhythmic pauses Decerebrate (C)or flaccid

Medulla Small, reactive Present Irregular Flaccid

(a) (b) (c)

Figure 7.1 (a) Normal flexor responseto pain in an unconscious patient.(b) Abnormal flexion: decorticateposturing seen in upper brainstem injury.(c) Abnormal extension: decerebrateposturing seen in lower midbrain/upperpons injury. (From Glasgow JFT,Graham HK. Management of Injuries inChildren. London: BMJ Books, 1997.)

Learning pointsA rapid cardiopulmonary assessment of the child

should be made, following the traditional ABCapproach.

Most cardiorespiratory arrests in children are due tohypoxia, and early intervention can preventmany of these.

Knowledge of the normal physiological parametersat different ages is essential to identify theabnormal.

one particular problem, and then to miss others.This will be avoided by the use of the systemsapproach suggested below. Certain criticalinterventions may need to be undertakenimmediately.

Establish an adequate airway

The child who is unable to protect his or her airwayshould be intubated and mechanically ventilated.

Support breathing

The child who is hypoventilating, or is at risk ofhypoventilating, or is requiring more than 60%oxygen by face mask for transfer, should generallybe intubated and mechanically ventilated.

Support the circulation

A child with hypotension or in compensatedshock should have intravenous access establishedand be supported with the use of plasmaexpanders and possibly inotropes.

Treat raised intracranial pressure

If there are signs of raised ICP, secure theairway, ventilate to a normal CO2, give mannitol(0·5–1 g/kg IV) and consider dexamethasone.

Don’t ever forget glucose

Check the blood sugar, especially in the smallinfant with low glucose stores.

Resuscitation algorithms

The algorithms shown in Figures 7.2–7.5 arebased on published guidelines. Staff responsiblefor the transfer of critically ill children shouldhave training and expertise in paediatricresuscitation, and should ideally be certifiedpaediatric life support providers.

Asystole/bradycardia (Figs 7.2, 7.3)

Hypoxia, hypotension, and acidosis are thecommon causes of bradycardia in children,which, unless intervention takes place, proceedsto asystole. Clearly the overall condition of thepatient must be taken into account (super fit


Determine pulselessnessand start CPR

Secure airwayAdminister 100% O2

Ensure effective ventilation

Epinephrine (adrenaline)10 micrograms/kg IV or IO

0·1 ml/kg 1 : 10 000

EMD?Identify and treat possible causes

3 minutes (60 cycles) ofCPR

Epinephrine10–100 micrograms/kg

IV or IO 0·1 ml/kg1: 10 000 or 1 : 1000

Consider IV fluids oralkalising agents

Maintain airwayAdminister 100% O2

Assess vital signs

Cardiorespiratorycompromise?

Start CPR if, despite oxygen andassisted ventilation, heart rate less

than 60 and shocked.Obtain IV or IO access.

Give epinephrine (adrenaline)

Consider atropine

See asystole algorithm (Fig. 7.2)

ObserveReassess frequently

Consider causes of vagaloverstimulation

(i.e. ET tube position,recent suctioning)

YesNo

Figure 7.2 Asystole algorithm. (Adapted from AdvancedLife Support Group. Advanced Paediatric Life Support, 3rd edn.London: BMJ Books, 2001.)

Figure 7.3 Bradycardia algorithm. (Adapted from AdvancedLife Support Group. Advanced Paediatric Life Support, 3rd edn.London: BMJ Books, 2001.)

teenage athletes may have low heart rates that arenormal for them), but a heart rate less than 60beats per minute associated with poor perfusionshould be treated in any infant or child.

As in any arrest situation, first optimise theairway, breathing, and circulation. After oxygen,epinephrine (adrenaline) is the first drug, given ata dose of 0·1 ml/kg of the 1 : 10 000 solution, withsubsequent doses of 0·1 ml/kg of the 1 : 10 000solution. Previous advice to give subsequentdoses of 0·1 ml/kg of 1 : 1000 solution is notsupported by evidence of benefit. The higherdose may be useful where cardiac arrest issecondary to cardiovascular collapse (i.e. sepsisor anaphylaxis). Atropine may be useful insituations where vagal stimulation has provokedthe bradycardia, such as endotracheal suctioning.The dose is 0·02 mg/kg, but do not give less than0·1 mg, as paradoxical bradycardia may occur.

The commonest causes of pulseless electricalactivity (previously called electromechanicaldissociation or EMD) in children are hypoxia,hypovolaemia, tension pneumothorax, cardiactamponade, electrolyte disorders, and hypothermia.They should be actively sought and treated.

Ventricular fibrillation (Fig. 7.4)

In contrast to adults, ventricular fibrillation (VF) isan uncommon arrhythmia in children, althoughthe outcome of a VF arrest is considerably betterthan when asystole is the presenting rhythm.Causes to consider include hyperkalaemia,poisoning, hypothermia, or a structurally abnormalheart. The treatment of VF and pulselessventricular tachycardia (VT) is defibrillation, and itis essential that all transport personnel understandand are able to practise safe defibrillation.

Tachycardia (Fig. 7.5)

Sinus tachycardia is caused by sinus nodedischarge at a rate that is higher than normal forage. The common causes are hypoxia, shock, feverand fear, and treatment is aimed at addressingthese causes.

Supraventricular tachycardia (SVT) also usuallyhas narrow QRS complexes, but may be distin-guished from sinus tachycardia by its generallyfaster rate (normally above 220 beats per minute),lack of beat to beat variability, and paroxysmalnature with abrupt onset and cessation. Treatmentdepends upon the condition of the child. If shock

is present, synchronised DC cardioversion shouldbe undertaken. The initial energy level is 0·5 J/kg,increasing to 1 J/kg, and 2 J/kg on the second andthird attempts if necessary.

Adenosine is the initial drug of choice in thetreatment of SVT. It acts by blocking conductionat the AV node and has a very short half life andduration of effect of less than two minutes. For thisreason it should be given rapidly and followedby a rapid saline bolus. The initial dose is50 micrograms/kg, doubled if this does not work(100 micrograms/kg), and doubled again for thethird dose if needed (200 micrograms/kg).

Wide complex tachycardia is most likely due toa ventricular arrhythmia, as SVT is narrowcomplex in 90% of cases. Again, if shock ispresent, synchronised DC cardioversion should beundertaken. The initial energy level is 0·5 J/kg,increasing to 1 J/kg and 2 J/kg on the second andthird attempts if necessary. Amiodarone is thedrug treatment of choice in VT, but treatment


Determine pulselessness andstart CPR

Secure airwayAdminister 100% O2


Evaluate rhythmConfirm VF or pulseless VT

DC shock 2 J /kg

DC shock 4 J /kg

DC shock 4 J /kg

DC shock 4 J /kg

1 minute (20 cycles) of CPR

Identify and treat possible causes

Epinephrine 10–100 micrograms/kgIV or IO 0·1 ml/kg

1 : 10 000 or 1 : 1000

DC shock 2 J /kg

DC shock 4 J /kg

Epinephrine (adrenaline)10 micrograms/kg IV or IO 0·1 ml/kg

1 : 10 000

Figure 7.4 VF/pulseless VT algorithm. (Adapted fromAdvanced Life Support Group. Advanced Paediatric Life Support,3rd edn. London: BMJ Books, 2001.)

should normally be instigated after consultationwith a paediatric cardiologist. The dose is 5 mg/kgover 30–60 minutes IV. It is important not to delaytherapy for longer than necessary in VT, as thismay degenerate to pulseless VT or VF. Lidocaine(lignocaine) has been used in the past. It raisesthe threshold for fibrillation and reducesthe occurrence of postcardioversion ventriculararrhythmia. It may be given in a dose of 1 mg/kg IV,with a subsequent infusion of 20–50 micrograms/kg/min if successful. Cardioversion should not bedelayed while waiting for drugs if shock ispresent.

Ideally, patients will be sedated, intubated andventilated before cardioversion. However, ifshock is present, cardioversion should not bedelayed, and common sense should dictate thecorrect sequence and timing of events.

Treatment of arrhythmias in children iscomplex and should be directed by a paediatriccardiologist. The discussion above merely gives aguide for their management in the emergencysetting.

See chapter 9 for further discussion on themanagement of arrhythmias.

StabilisationThis begins with a full assessment. Immediateresuscitation steps have been undertaken eitherby you or the referring team prior to your arrival.Rather than diving in sorting out lines andinfusions, take time to go through the history withthe senior nursing and medical staff available.This recognises their important role in the care ofthe child, makes sure that details recorded in theinitial referring call are accurate, and brings youup to date with any changes since your lastcontact. Clarify any points that are unclear.

Then examine the patient. Examination willbe adapted for each individual situation, andthe assessment and examination of the patientfollowing trauma are outlined in chapter 10.However, a full examination is appropriate andessential to detect those little problems (like fixedand dilated pupils) that may cause embarrass-ment later (Box 7.3). In an unfamiliar andstressful environment, it is easy to forget parts ofthe examination, and a systems approach, usingthe parameters outlined above in “Recognitionand assessment of the sick child”, is useful. In the


QRS normal

Start CPR See VF/pulseless VTalgorithm (Fig. 7.4)

Rapid heart rate with evidenceof poor perfusion

Assess and maintain airwayAdminister 100% O2


Pulse present?

Evaluate QRS duration

QRS wide

Treat as ventriculartachycardia

Vascular access presentor RAPIDLY available?

Vascular access presentor RAPIDLY available?

Identify and treatpossible causes

AmiodaroneAdenosine

Evaluate rhythm

Probable supraventriculartachycardia

Probable sinus tachycardia

Synchronised DCcardioversion

Yes No No Yes

No Yes

Figure 7.5 Tachycardia algorithm.(Adapted from Advanced LifeSupport Group. Advanced PaediatricLife Support, 3rd edn. London: BMJBooks, 2001.)

child following trauma, treat the cervical spine asif it is damaged until investigations are normaland the child wakes up and tells you that it is not.

Stabilisation of the respiratory system

Patients should be well oxygenated and ventilatingappropriately prior to transfer, and in mechanicallyventilated patients this should be confirmed by anarterial blood gas before departure.

In self-ventilating patients, one of the mostdifficult decisions to make is whether to intubateand ventilate prior to departure. If in doubt, thebest course of action is to perform intubation inthe controlled setting of the referring hospital,rather than being forced to do so during transport.The child can often be extubated on arrival atbase, and although intubation is not without risksand, particularly in upper airways obstructionsuch as croup, may necessitate mechanicalventilation for a couple of days, it is safer thanrisking respiratory arrest on the motorway.

Intubation should be undertaken in a controlledway by the most experienced person available. Inmany cases this will be an anaesthetist from thereferring hospital. There is no shame, and a lot tobe gained, from asking for their support with adifficult airway.

Once intubated, secure the endotracheal tubewell, start mechanical ventilation, and confirm tubeposition both by auscultation, evidence of goodventilation and oxygenation, and by radiograph.Note the size of the tube and length of insertion,and any difficulties with intubation.

Oxygen requirements are often raised duringtransport, possibly because of changes inventilation–perfusion ratios due to accelerationforces. It is therefore often necessary to increase theinspired oxygen concentration a little for transfer.In aeromedical transports, oxygen requirementsincrease due to changes in barometric pressure.However, no assumptions should be made, andpathological causes of an increased oxygenrequirement should be actively sought.

Appropriate drugs will have been given forintubation. Sedation and paralysis shouldnormally be continued during transfer, althoughthis will depend upon the particular clinicalsituation.

In most cases, pneumothoraces should bedrained prior to departure. This is mandatory foraeromedical transports. Underwater seals shouldbe replaced by Heimlich (flutter) valves.

These points are covered further in chapter 8.

Stabilisation of the cardiovascular system

Patients should be as haemodynamically stable asyou can get them before departure from thereferring hospital. Ideally this means having anormal heart rate, good perfusion and urineoutput, normal oxygen saturation and blood gasvalues, and a normal blood pressure.

The first step in stabilisation, after the clinicalexamination and any appropriate resuscitation,is to start monitoring (Box 7.4). Minimum moni-toring requirements are discussed in chapter 4.

Clinical examination and monitoring maysuggest intervention such as fluid administrationor inotropes as the next step. As in the intensivecare unit, a good understanding of the underlyingpathophysiology is essential to guide rationaltherapy.

In general, the physiology of transport meansthat patients with compensated shock willdeteriorate during transfer, as fluid will tend topool in the peripheries due to accelerational


Box 7.3 Systems approach to examination

Respiratory system – adequacy of airwayCardiovascular systemNeurological systemCervical spine and traumaAbdomenSkin

Box 7.4 Cardiovascular monitoring

ECG and heart rateOxygen saturationBlood pressure (invasive or non-invasive using

appropriate equipment)Toe and core temperatureCentral venous pressure where appropriate

Learning pointsConsider the need for mechanical ventilation

carefully.Confirm endotracheal tube placement clinically and

radiographically.Secure the tube well. Obtain satisfactory blood gases while ventilating on

the transport ventilator before leaving.Consider the need for sedation and paralysis.

forces in the ambulance. Many patients thereforerequire infusion of fluid during the preparationphase.

Inotropic support may be needed (see chapter 9),particularly in the shocked patient who does notrespond adequately to a fluid challenge. Althoughdobutamine may be given peripherally, inotropeadministration will normally necessitate theplacement of a central venous line, and the patientrequiring inotropic support should usually haveinvasive arterial blood pressure monitoring as well(Table 7.4).

Patients with surgically correctable haemorr-hage should have this dealt with before transfer.The transfer team may be involved in stabilisingthe child before and after this, prior to transfer.

Ensure that you have at least two good, workingpoints of intravenous access. These should bewell secured, and one should be easily availableduring the transfer for administering bolus drugs,emergency drugs and volume as required.

These points are covered further below and inchapter 9.

Stabilisation of the central nervous system

The most common group of patients with CNSdisease requiring transfer are those with traumatichead injury. This will be covered in chapter 10,

but it is worth emphasising that the priority of thetransfer team is to minimise secondary braininjury due to hypotension and hypoxia. Thus theroad traffic accident victim with a contused brainwill suffer much more cerebral damage if he orshe has a cardiac arrest due to the tensionpneumothorax that you missed in your rush to getto the neurosurgical unit than if you had sortedthis out prior to transfer.

For the patient with prolonged seizures, firstensure the patency of the airway and adequacy ofventilation. Check that there is not a biochemicalcause by measuring the blood sugar andelectrolytes. Follow the suggested therapeuticpathway given in Box 7.5.

Rarely, you will be asked to transfer a child whoapparently has no hope of survival or appears tobe brain dead. This difficult scenario is discussedfurther in chapter 12.

Stabilisation of the gastrointestinal system

Most sick children, and certainly those receivingmechanical ventilation or being transported by


Table 7.4 Effects of inotropic drugs (see also chapter 9)

Heart rate Contractility SVR Route Dose

Dopamine Increases Increases Increases C 2–20

Dobutamine Increases Increases Same or ↓ C/P 2–20

Epinephrine (adrenaline) Increases Increases Small ↑ C 0·05–5·0

Norepinephrine (noradrenaline) Small ↑ Small ↑ Big ↑ C 0·05–5·0

Enoximone Mod ↑ Mod ↑ Same C/P 5–20

SVR = systemic vascular resistance, C = central, P = peripheral. Doses are in micrograms/kg/min.

Box 7.5 Treatment of prolonged seizures (seealso chapter 13)

Establish airway and oxygenationDiazepam 0·5mg/kg PR or lorazepam 0·1 mg/kg IVCommence monitoring and get IV access if not

already startedCheck BM sticks, blood gas, and electrolytesLorazepam 0·1 mg/kg IVParaldehyde 0·4 ml/kg in arachis oil PRPhenytoin 20 mg/kg slow IV, with ECG monitoringParalyse and ventilate, thiopentone infusion, ECG

monitoring

Learning pointsPatients should be as haemodynamically stable as

you can get them before departure from thereferring hospital.

Patients with compensated shock will deteriorateduring transfer, so treat this before departure.

The patient requiring inotropic support shouldusually have invasive arterial blood pressuremonitoring in transit.

Ensure that you have at least two good, workingpoints of intravenous access.

air, should have a nasogastric tube passed and lefton free drainage. Feeds should be stopped and thestomach aspirated for the transfer to minimisethe risk of vomiting and aspiration of stomachcontents into the lungs.

Rarely, for long distance or prolonged transfersof stable children (particularly neonates), it maybe appropriate to continue nasogastric feeds. Inthis case the nasogastric tube should be aspiratedregularly to detect gastric stasis and preventvomiting.

Stabilisation of the renal system

Consider urethral catheterisation in children withshock (to monitor urine output), in children whoare paralysed and sedated (to prevent urinaryretention), and in children who have receiveddiuretics or mannitol (for the above reasons andalso to prevent them urinating all over yourequipment).

Acute hyperkalaemia

This may be due to impaired excretion (renalfailure, adrenal insufficiency), increased adminis-tration (IV fluids, transfusion), and endogenousrelease (burns, rhabdomyolysis, haemolysis). Themain clinical effect of importance to the transferringteam is abnormal cardiac conduction (Box 7.6).

Treatment depends upon the underlying cause,the serum potassium level, and the presence ofECG changes (Table 7.5). If the serum potassium is

7 mmol/l or greater, or there are ECG changes,immediate therapy is necessary.

• Stop further potassium administration. • Antagonise the cardiac conduction effects by

administering calcium.• Encourage renal excretion of potassium with

furosemide (frusemide), where appropriate.• Increase the cellular uptake of potassium by

giving sodium bicarbonate or dextrose andinsulin.

• Remove potassium from the body by usingexchange resins.

• Treat the underlying disease.


Box 7.6 ECG changes in acute hyperkalaemia

Tall, peaked T wavesSmall amplitude R waveSmall amplitude P wave Widened QRSVentricular tachycardiaVentricular fibrillation

Learning pointsIn patients with CNS disease, minimise secondary

brain injury due to hypotension and hypoxia.Treatment of prolonged seizures should commence

with ensuring a patent airway and oxygenation,and follow established therapeutic algorithms.

Consider the placement of a nasogastric tube andurethral catheter prior to leaving the referringhospital.

Drug Dose Onset Duration Comments

Calcium chloride 25 mg/kg minutes 30 min Give slowly IV over 5 minutes.Transient effect on ECG. If repeated doses needed, monitor serum ionised Ca2+

Sodium bicarbonate 2·5 mmol/kg < 30 min few hours Monitor blood pH.Beware sodium overload

Sodium chloride 25 mg/kg Transient effect, useful if patient hyponatraemic

Dextrose + insulin 0·5 g/kg dextrose < 30 min few hours Monitor blood glucose with 0·05unit/kg carefully.Additional insulin glucose may be given if

BM start to fall. Bewarehypoglycaemia

Sodium polysterene 0·5–1 g/kg PO, NG, < 24 h Note: constipation(kayexalate) or PR

Nebulised salbutamol 2·5–10 mg < 30 min

Table 7.5 Treatment of hyperkalaemia

Once the patient is on the transport trolley orincubator and observations are satisfactory, thestabilisation phase finishes with a final reviewand checklist (Box 7.7).

Ensure that all supplies needed are availableand drugs drawn up where appropriate. Talk tothe parents and allow them to see the child.Thank the referring staff. Contact your basehospital advising them of your departure, thecurrent status of the patient, and what drugs andequipment will be needed on arrival at base.

Procedures in resuscitationand stabilisation phase

This section describes some of the technicalprocedures in which the transporting team shouldbe competent. The indications, limitations, andcomplications of each are given.

Endotracheal intubation

This is described in chapter 8.

Needle cricothyroidotomy

Indications

Inability to ventilate or oxygenate the patient byany other means.

Method

• Place the patient in the supine position.• Locate the cricothyroid membrane by feeling

for the thyroid cartilage and locating itsinferior pole in the midline (Fig. 7.6).

• Extend the neck slightly if able (but not if thereis any chance of a cervical spine injury).

• Take a cricothyroidotomy catheter or an 18gauge IV catheter with a 5 ml syringe attached.

• Clean the skin over the cricothyroid membrane. • Hold the trachea steady with one hand.• Pass the catheter through the cricothyroid

membrane at an angle of 45°, aspirating on thesyringe as you go.

• When air is aspirated, the tip of the catheter isin the trachea.

• Change the angle of approach to around 20°.Advance the catheter and withdraw the needleas you would if cannulating a vein.

• Repeated aspiration of air confirms that thecannula is still in the trachea.

• Attach a Y-connector to the cannula, andattach oxygen tubing to the Y-connector.

• Set the oxygen flow rate at 1 litre per year ofage of the child.

• Occlude the open end of the Y-connector for1 second, so that oxygen passes into the trachea.

• Release the open end of the connector to allowpassive exhalation (through the upper airway).

• Arrange definitive airway care.

Limitations

Insufflation of oxygen through a narrow catheterwill not ventilate the patient, merely provide


Box 7.7 Predeparture checklist

1. AirwayIntubation needed?Secure endotracheal tube?Position?Suction available?Oxygen for more than anticipated length of

journey?

2. CirculationAdequately perfused?Blood pressure satisfactory?Ongoing circulatory losses to be considered?

3. TemperatureBlankets/prewarmed incubator available?Ambulance heating on?Working temperature monitor available?

4. ProceduresReliable IV access established (preferably two IV

lines in situ)Nasogastric tube (if bowel obstruction/ileus,

ventilated or air transport)Urethral catheter (unconscious/sedated and

diuretics)

5. MonitoringCheck availability and function of:

ECGPulse oximeter/transcutaneous oxygen monitorBlood pressure monitorTemperature monitorBlood sugar monitoring

6. EquipmentIs all equipment working and are the batteries

charged?Spare batteries where possible

7. Drugs/fluidsMaintenance fluid—appropriate type and rate.Ensure availability of:

Emergency drugsAdequate sedationSpecial drugs which may be needed

oxygenation, but will buy you time to get helpand secure the airway in a more definitivemanner (i.e. a surgical airway).

Expiration does not occur through the catheter,but passively through the upper airway. If this iscompletely blocked, and expiration does not occurat all, reduce the insufflating flow to 1–2 l/min,and get on with a definitive procedure.

When insufflating, start off at the suggested gasflow, but if there is no chest movement, increasethe flow gradually.

Complications

Bleeding, false passage, surgical emphysema,damage to the surrounding tissues.

Needle thoracotomy

Indications

Suspected tension pneumothorax.

Method

• Locate the second intercostal space in themidclavicular line.

• Clean the skin over the selected area. • Select an 18 or 20 gauge cannula or butterfly,

connected to a three-way tap and syringe. • Insert the cannula vertically through the chest,

just above the third rib (to avoid the intercostalvessels and nerves).

• Aspirate as you go. • If air is aspirated, remove the needle leaving

the cannula in place. • Drain the pneumothorax by repeated aspiration

via the three-way tap. • Insert a chest drain.

Complications

• 20% chance of causing a pneumothorax ifthe patient did not have one before (checkwith an x ray film; insert a chest drain anywayif the patient is ventilated).

• Damage to the intercostal vessels and nerves.

Chest drain insertion

Indications

To drain a pneumothorax or pleural effusion.

Method

• Select the chest drain—usually the biggest thatwill fit between the ribs.

• Place the patient on the unaffected side, withthe uppermost arm abducted above the head.

• Locate the fifth intercostal space in themidaxillary line (usual site, others may beused in specific situations).

• Clean the skin over the selected area. • Anaesthetise the skin with local anaesthetic. • Make a 2 cm incision along the line of the ribs,

just above the rib below the space you areaiming for (to avoid the intercostal vessels andnerves).

• Bluntly dissect the subcutaneous tissues andmuscle by inserting closed forceps through theskin and opening them in the tissues.

• Dissect down to the pleura using this method(not the scalpel), and pierce this with theforceps or your finger.

• Insert the chest drain (without the trocar)through the track into the pleural space duringexpiration. Listen for air movement andwatch for fogging inside the drain to confirmplacement in the pleura.


Larynx

Cricothyroidmembrane

Cricoid

Figure 7.6 Cricothyroidotomy.(Adapted from Advanced Life SupportGroup. Advanced Paediatric Life Support,3rd edn. London: BMJ Books, 2001.)

• Normally aim the chest drain anteriorly andtowards the head.

• Connect the drain to a Heimlich valve orunderwater seal.

• Secure the chest drain in place.• Take a check x ray film.

Limitations

The drain may become obstructed by overlyinglung, or may be placed inappropriately to drainthe pneumothorax. Suction applied to the chestdrain may be necessary to keep up with a largeair leak.

Complications

• Damage to the intercostal vessels and nerves. • Damage to the underlying lung or viscera,

including the heart and great vessels or the liver.

Never force the chest drain in with the trocar.Imagine the scene – you push with all your might,suddenly the drain goes through the intercostaltissues, there is no resistance and before youknow what has happened, you have speared theheart. Never force the chest drain in with thetrocar.

Intraosseous needle insertion

Indications

Intraosseous needles provide a rapid alternativeto peripheral cannulae during resuscitation.They are effective in neonates, infants, andyounger children. There is no maximum age butthe technique becomes progressively less usefulwith increasing age. Gaining access throughbone becomes more difficult, the intraosseouscompartment becomes less vascular, and thelimited infusion rates imposed by high resistancemake it harder to deliver useful volumes ofresuscitation fluid.

The main role of intraosseous access will bein the urgent resuscitation of patients to betransferred. Adequate venous access shouldalways be subsequently established. Electing toset out on a transfer relying on intraosseous accessis desperate in the extreme and should not beconsidered unless all other options have beenexcluded. Use of an intraosseous needle to gainaccess during the transfer usually indicatesinsufficient access was gained during stabilisation.

Method

• Select the appropriate site. The proximal tibiais the commonest, medial to and 1 cm belowthe tibial tuberosity. Other sites are shown inFigure 7.7.

• Clean the skin, infiltrate local anaesthetic ifappropriate.

• Hold the leg by placing the fingers and thumbon either side.

• Hold the needle near its tip, and insert it at 90°to the skin, until a sudden loss of resistance isfelt as the needle goes through the cortex of thebone.

• Confirm placement by:

• sudden loss of resistance • aspirating marrow• needle stands proud• no evidence of extravasation.

• Secure the needle• Give a bolus of fluid and drugs.

Limitations

• Specialised needles are available and shouldbe used. Spinal needles tend to bend andordinary needles may get blocked with bone asthey have no trocar.

• A less satisfactory technique in children over6 years (loss of marrow space). Sternum andiliac crest sites are associated with increaseddamage to surrounding tissues.

• Fluids and drugs need to be infused actively,as they will not flow passively by gravity.

• All commonly used resuscitation drugs andfluids can be given via the intraosseous route.

• The intraosseous needle is unstable. A methodfor securing it using tape and artery forceps isshown in Figure 7.8.

Complications

• Extravasation, fracture, osteomyelitis, damageto the growth plate, damage to surroundingstructures.

• Missing the bone and impaling the operator(especially if the leg is not held properly).

• Despite their usefulness in resuscitation,intraosseous needles are not appropriateaccess with which to embark on a transfer.Needles are difficult to stabilise or secure.They are held in place largely by the bone intowhich they are inserted. Over time the track


through the bone is widened by movement ofthe needle and fluids or drugs administeredinto the needle often partially extravasate.

Central venous cannulation

Indications

• Intravenous fluid and drug administration,especially of phlebotoxic and concentrateddrugs and infusions.

• Monitoring of central venous pressure.

Method

Usual sites of insertion include the femoral,internal or external jugular and subclavian veins.Long silastic catheters (“linguine lines”) may alsobe inserted via a peripheral vein, but cannot beused for pressure monitoring.

A degree of psychomotor skill, knowledgeof the anatomy, and an appreciation of therisk–benefit ratio are needed by people attemptingcentral venous cannulation. These operatorcharacteristics are the key to success, along withcorrect positioning of the patient prior tocannulation, strict asepsis, and proper fixation ofthe cannula once it is in.

Candidates should learn the anatomical markersfor central line insertion, the details of the techni-ques, the complications of different approaches,

and then obtain first hand experience in a controlledsituation (i.e. theatre or the catheter laboratory)under supervision.

Seldinger technique (Fig. 7.9)

This is the preferred method for central venouscannulation, in which a small needle is used tolocate the vessel, and a guide wire is passedthrough the needle, which is then removed. Thelarger cannula is then passed over the guide wireinto the vein. The wire is removed, the cannulasecured and its position confirmed by aspiratingvenous blood, transducing the venous pressure,and x ray film.

Femoral venous cannulation has a low rate ofserious complications. The patient is positionedwith the leg externally rotated and the hip slightlyflexed. A roll under the buttocks may be helpful.

Local contraindications include local sepsis andintra-abdominal masses. Complications includesepsis (especially to the hip joint), and trauma tothe femoral artery or nerve. If the artery isinadvertently entered too high, bleeding canoccur into the retroperitoneal space, which maybe impossible to control.


lliac crest

Greater trochanter

Distal femur

Proximal tibia

Distal tibia

Figure 7.7 Possible sites for intraosseous needle insertion.

Figure 7.8 Securing the intraosseous needle.


(a) Select your equipment and prepare the site. Review theanatomy.The vein lies medial to the artery, and should becannulated 1 cm or more below the inguinal ligament.

(b) Apply local anaesthetic if appropriate. Enter the skin at anangle of about 45°, aspirating as you go. Ensure the guide wireis within reach without having to turn or stretch for it.

(c) When the vein is entered (flashback), hold the needle inposition, remove the syringe (blood should flow back), andinsert the wire. This is the most difficult bit. If there is anyresistance to the wire, you are probably not in the vein—withdraw the wire, replace the syringe, and find the veinagain. It is useful to have a spare wire, in case you damage thefirst. Make sure that it is the same length and gauge as theoriginal. Never lose control of the wire.You must keep hold of oneend of it at all times, or risk it being lost in the patient.

(d) Once the wire is in the vein 10–15 cm, withdraw theneedle.Thread the dilator over the wire, through the skin, andinto the vein.There can be some resistance to this, and it maybe necessary to nick the skin with a scalpel to get the dilatorthrough.When advancing the dilator, it is possible to kink theguide wire and follow a false passage. Occasionally move theguide wire backwards and forwards to confirm that it moveseasily and that it is not kinked.

(a)

(c)

(d)

(b)

(e) Leaving the wire in the vein, remove the dilator. Have aswab ready, as the site will bleed. Keep control of the wire atall times.Thread the preflushed catheter over the wire andinto the vein. Remove the wire, aspirate the catheter, andflush with saline. Secure the catheter by suturing it to the skinand place a clear dressing over the site.

Figure 7.9 a–e Example of the Seldinger technique—femoral vein.

(e)

Cannulation of the internal jugular andsubclavian veins are technically more difficultand the complications are potentially moreserious. The last thing that you want to do to achild in respiratory failure on a ventilator is togive him or her a pneumothorax. However, inskilled hands, these techniques provide a usefulapproach to the central veins.

Limitations

Various sizes and lengths of catheter are available.Infants under 10 kg should normally have 4 FGcatheters inserted, older children 5 FG, andteenagers may have up to 7 FG catheters placedpercutaneously.

Single, double and triple lumen catheters areavailable. The lumen labelled “1” is normally the

one at the tip of the catheter. This is the largestlumen, and the guide wire should be passedthrough this lumen during insertion.

SummaryThis chapter has outlined the resuscitation and

stabilisation phases of the transfer.In many cases, this phase will have been completed

by the referring team, possibly following advicefrom the retrieval centre.

Make a full and independent assessment of thechild, including reviewing the history and astructured examination.

Initiate resuscitation where appropriate.Aim to achieve the same level of care that you would

in the paediatric intensive care unit before leavingthe referring hospital.


Introduction

Airway and breathing problems may be theprimary reason for transportation to the paediatricor neonatal intensive care units (PICU or NICU).However, they should never be viewed inisolation, but in the context of the whole clinicalpicture. The management of airway and breathingis technically difficult and is the source of manyadverse events occurring during transportation.Meticulous preparation and stabilisation of the

child before departure minimises risk duringtransportation. A systematic “ABC” approachincluding assessment, optimisation and prepara-tion for transportation of the airway and breathingis recommended. During transportation, airwayand breathing must be regularly reassessed toevaluate the impact of treatment and recognisefurther deterioration, which can be rapid.

Developmental changes inairway and breathing anatomyand physiology

It is important to have an understanding of thechanges in airway and breathing anatomy andphysiology which occur with age. The anatomyof the neonatal and infant airway causes apredisposition to airway obstruction and highairway resistance, and can increase the difficultyof intubation (Table 8.1). The neonate and infantalso have a limited respiratory reserve as a result

8 Management of the airwayand breathing

ObjectivesTo understand that AIRWAY and BREATHING

should not be considered in isolation.To appreciate the need for a low threshold for

intubation and ventilation for transportation, astransportation is often associated with clinicaldeterioration in airway and breathing.

To understand that problems should be anticipatedand prevented, and that stability must beachieved prior to embarking on transportation.

Table 8.1 Neonatal and infant airway and breathing anatomy

Anatomy Effect on airway/breathing

Large occiput* Increases neck flexion and airway obstruction

Small nares Increases airway resistance (nasal breathers ≤ 3 months)

Large tongue* Increases airway resistance

Low pharyngeal muscle tone Airway obstruction by tongue

Floppy epiglottis* Increases airway obstruction

Larynx anterior/cephalad*

Short trachea*

Trachea angled posteriorly*

Cricoid cartilage Narrowest point up to 8 years—uncuffed tracheal tubes

Narrow airways Increases airway resistance

Compliant airways Collapse with increased respiratory effort

Compliant chest wall Indrawing with increased respiratory effort

Barrel shaped chest Horizontal ribs contribute less to breathing

Flattened diaphragm Reduced diaphragmatic movement

Immature respiratory muscles Reduced effectiveness of forced expiration, for example, cough

*Increases difficulty or complications of intubation.

of the higher ratio of minute ventilation tofunctional residual capacity (the volume of gas inthe lung at the end of tidal expiration, which actsas a reservoir of oxygen), higher closing volumes(the volume of gas in the lung at which airways independent areas of the lung begin to close duringexpiration), and higher oxygen consumption(Table 8.2). Therefore, respiratory decompensationin neonates and infants can be rapid.

Assessment of airwayand breathing

Respiratory failure accounts for over 50% ofPICU/NICU transfers. The majority of cases aredue to primary respiratory disorders. However,respiratory failure can be caused by other organsystem dysfunction including CNS, renal andmetabolic conditions, and patients in haemo-dynamic shock who require airway and breathingsupport to decrease the work of breathing.Therefore, airway and breathing should besystematically assessed in the context of the fullclinical picture. Areas to focus on are as follows.

History

• Signs and symptoms, presenting diagnosis• Speed of deterioration• Ongoing treatment • Duration of intubation/previous intubation/

intubation difficulty/tracheal tube changes• Volume of secretions/suction requirement

Examination

• Airway patency

• “See-saw” breathing/stridor/secretions/trauma/swelling

• Tracheal tube—size/length/patency/position/fixation.

• Adequacy of breathing

• Oxygen requirement• Rate (trend)/cyanosis/air entry • Intercostals/accessory muscles• Chest trauma—ribs/pneumothorax/chest

drain

• Level of consciousness

• Hypoxia/hypercarbia/CNS dysfunction

• Degree of exhaustion

• Apparent decrease in distress withdeteriorating ABG.

• Sedation and neuromuscular blockade

Monitoring

• Pulse oximetry/capnography/ECG/airwaypressures/FiO2

Investigations

• ABG• CXR

• Tracheal tube position/lung fields/pneumothorax

Airway and breathing should be reassessedregularly, especially after moving the patient.Immediately after changing the oxygen source of aventilator confirm the presence of chest movement,a capnography trace if available and the pressuremeasured on the ventilator pressure gauge.

It is important with premature neonates to avoidhyperoxia which is associated with retinopathy ofprematurity. If a patent ductus arteriosus is presentbe aware of the difference between preductal O2


Table 8.2 Developmental changes in airway and breathing physiology

Neonate Infant Child

Respiratory rate (per min) 32 25 16

Tidal volume (ml/kg) 7 7 7

Dead space (ml/kg) 2·5 2·5 2·5

Minute volume (ml/kg/min) 224 175 112

Vital capacity (ml/kg) 40 50 60

Functional residual capacity (ml/kg) 25 30 40

O2 consumption (ml/kg/min) 7 5 3

saturation, measured from the right hand or earlobe, and postductal O2 saturation. The formerreflects the saturation of blood delivered to thehead, brain, and eyes, whereas the latter reflects thesaturation of blood flowing to the rest of the body.When there is right to left shunting through the ductthe preductal saturations may be significantlyhigher than the postductal saturations.

Deciding to intubate

Airway and breathing must be reliable beforetransportation. The decision to intubate can bedifficult. There should be a lower threshold forintubation and ventilation for transportation thanin routine PICU/NICU practice, with the aim ofoptimising the clinical condition beforetransportation (Box 8.1). Care should be taken thatintubation to secure the airway or facilitateventilation for transportation should not beperceived by the referring staff or parents asimplying either inadequate prior management ordeterioration in the condition of the patient

per se. Consider the entire clinical picture anddiscuss the decision with the supervisingPICU/NICU consultant.

Intubation

Safe intubation requires an appropriately trainedteam, adequate preparation, and a calm methodicalapproach. A trained assistant is vital to applycricoid pressure correctly, assist with the intubationtechnique, and administer drugs as necessary.The skills are best acquired in the operatingtheatre under the supervision of an experiencedanaesthetist. Points worth emphasising includecorrect head and neck positioning to produce adirect line of sight from the mouth to the larynx.The sniffing position, with the head slightlyextended on the neck and the neck slightly flexedon the trunk, is recommended (Fig. 8.1). Excessiveextension or flexion will impede intubation.Patients with suspected cervical spine injury mustnot be positioned in this manner. The head andneck must be immobilised in the neutral positionby manual in-line stabilisation during intubation.

Management of the airway and breathing 71

Box 8.1 Indications for intubation

This is a “physiological” approach rather than a long list of diagnoses, and is not exhaustive. Due to the markeddifferences between neonates and older children the specific values given for the respiratory andhaemodynamic variables are not absolute and should act as a guide only. Specific neonatal factors areindicated in bold.

Deteriorating airway• Chest wall recession, tracheal tug• “See-saw” breathing• Stridor

Respiratory distress• Rate > 60 min• Chest wall recession, grunting• SaO2 < 94% (<< 90% preterm) or PaO2 < 8 kPa (<< 6·5 kPa preterm)• PaCO2 > 6 or < 3·5 kPa • Recurrent apnoeas• Exhaustion

Shock• HR > 180/min or < 80/min (< 5yr), > 160/min or < 60/min (> 5yr)• Absent peripheral pulses• Cold peripheries• Capillary refill > 2 seconds• Systolic blood pressure < 70 + (age in years × 2) mmHg• Mean blood pressure < (postconceptual age in weeks) mmHg

Less than 30 weeks’ gestation

Deteriorating level of consciousness

Recurrent seizures

Preoxygenation to replace the nitrogen in thefunctional residual capacity of the lungs withoxygen is important to create a reservoir ofoxygen to cover the apnoeic period duringintubation. This is very important for neonatesand infants who quickly desaturate and becomehypoxic following the onset of apnoea because ofhigh oxygen consumption and a small functionalresidual capacity. Bag-valve-mask apparatus isrelatively simple to use, can deliver 100% oxygen(with appropriate oxygen flow and a reservoirbag, refer to the manufacturers’ instructions), andcan function in an emergency without an oxygensupply to ventilate the patient with ambient air.An anaesthetic “T” piece circuit (Mapleson Fsystem) can also deliver 100% oxygen and willprovide a visual clue that there is an adequate sealbetween the face mask and the face of the patientand it will also give information about the chestcompliance and airways’ resistance of the patient.It is ideal for preoxygenation of the spontaneouslybreathing patient, delivering 100% oxygen, ifdesired, with variable CPAP (continuous positiveairway pressure). However, significant expertiseis required for correct use. Both systems can beused with an O2/air mixture to avoid hyperoxia inpremature neonates.

Beyond the neonatal period adequate anaesthesiaand neuromuscular blockade with rapidly acting

drugs are essential to limit the apnoeic period.The choice of anaesthetic agent and doserequires considerable clinical experience and islargely determined by the diagnosis andhaemodynamic status of the patient and theexperience of the clinician. The dose ranges givenin this chapter can act only as a rough guide(Table 8.3). It is uncommon for neonates toundergo a formal rapid sequence induction.Opioid sedation, with or without neuromuscularblockade, is commonly used. Awake intubation,without the use of anaesthesia or sedation, is nolonger recommended except during resuscitation. Itincreases the risk of airway trauma, laryngospasm,and hypoxia, and causes marked tachycardia,hypertension and the possibility of intraventricularhaemorrhage in premature neonates.

Cricoid pressure is a technique which is usedto reduce the risk of passive regurgitation ofgastric contents which may be aspirated, andhelps improve the view of the larynx duringlaryngoscopy in neonates and infants. Pressure isapplied by the assistant with two or three fingersdirectly down onto the cricoid cartilage, which ispushed backwards, occluding the oesophagus onthe vertebral column. Cricoid pressure is appliedfrom induction of anaesthesia and discontinuedafter correct placement of the tracheal tube.Incorrectly applied cricoid pressure is both


Head extendedon neck

Neonate and infant

Neck flexed on trunk

Neck flexed on trunk

Rolled towel

Head extendedon neck

Large occiput

Child

PillowFigure 8.1 Correct head and neckposition for intubation.

ineffective in preventing regurgitation and alsodistorts the larynx, significantly increasing thedifficulty of intubation. If application of cricoidpressure causes excessive flexion of the head onthe neck, a two-handed technique can be usedwith the other hand placed behind the neck of thepatient to counterbalance the force and maintainthe optimal position of the head and neck(Fig. 8.2).

Correct tracheal tube placement must beconfirmed by observing it pass through the vocalcords, inspection and auscultation for bilateralchest movement and air entry, confirmation ofend tidal CO2 by capnography, if available, and

maintenance of adequate oxygenation saturationfollowing intubation. If in doubt about thetracheal tube placement TAKE IT OUT andrecommence bag and mask ventilation.

Laryngoscopy and intubation have a number ofpotential adverse consequences (Box 8.2).

It is debatable whether oral or nasal intubationis preferable for transportation. Oral intubation isquicker to perform, is arguably more simple forinexperienced or infrequent practitioners, andavoids the possibility of nasal trauma andbleeding obscuring the view of the larynx duringintubation. However, nasal tracheal tubes areprobably more easy to secure, are less prone


Table 8.3 Intubation drugs

Drug Dose (mg/kg) Onset (min) Duration (min)

Anaesthetic drugs Ketamine 2 < 1 10–15Thiopentone 3–5 < 1 5–10Propofol 2–4 < 1 3–8

Neuromuscular blockers Suxamethonium 1–2 < 1 3–5Vecuronium 0·1–0·2 1–3 20–40Rocuronium 0·5–1·0 1–1·5 20–40

Sedative drugsMidazolam 0·05–0·2 2–5 30–120Morphine 0·05–0·2 2–5 60–240

Adjunctive drugsFentanyl 0·001–0·005 1–3 20–60

See chapter 13 for details of side effects and contraindications.

Trachea

Oesophagus

Vertebrae

Cricoid cartilage

Figure 8.2 Application of two-handedcricoid pressure.

to movement in the trachea during trachealsuctioning, thus reducing tracheal trauma, andprobably kink less during transport. Whateverroute is chosen, the operator should be familiarwith the technique and on completion thetube should be secure, patent, and correctlypositioned.

It is important to choose the correct size oftracheal tube. A tube which is too small will beinadequate for ventilation in transit and a tubethat is too large will traumatise the larynx andtrachea, leading to swelling and possibly long termcomplications such as subglottic stenosis. Thecorrect size of a tracheal tube can be estimatedfrom the age of the patient (Table 8.4). Additionaltracheal tubes one size smaller and larger shouldbe readily available. In children younger than8 years of age the circular cricoid cartilage isthe narrowest part of the airway, therefore anadequate seal can be achieved for positivepressure ventilation with an uncuffed trachealtube. However, in children over 8 years of age theairway is narrowest at the vocal cords, therefore acuffed tracheal tube is required to make a sealwithin the trachea for ventilation. The trachea ofneonates and infants is relatively short and theposition of the head can significantly alter theposition of the tube in the trachea. Therefore, itis important to estimate the required length ofthe tracheal tube from the age of the patient(Table 8.4) and confirm correct positioning onchest radiograph. The use of tracheal tubes

smaller than 2·5 mm is not recommended as theyare virtually impossible to suction through andtherefore dangerous during transportation.

Effective tracheal tube fixation is essential fortransportation. The tracheal tube may be tied,taped, or fixed with dedicated tube fixators. Thetracheal tube position and length should berechecked after fixation. Intubated childrenshould be given sedative and neuromuscularblocking drugs throughout transportation toreduce the likelihood of accidental extubation.However, premature neonates often only requiresedation for transportation.

Special considerations

The full stomach

An acutely ill or injured child should be assumedto have delayed gastric emptying and a “fullstomach”. If there is a nasogastric tube in situ itshould be aspirated with the patient supineand lying on each side. However, this does notguarantee an empty stomach. In this situation arapid sequence induction (RSI) technique ischosen which provides safe and rapid intubatingconditions, minimising the risk of gastricaspiration (Box 8.3). RSI is rarely used in neonatalpractice.

RSI requires thorough preparation and effectiveteamwork. The aim is to minimise the time fromadministration of the anaesthetic induction agent,which will result in the loss of the protectiveairway reflexes, to correct placement of the


Box 8.2 Complications of intubation

Hypoxia:Prolonged apnoea with inadequate

preoxygenationOesophageal intubationRight main bronchus intubation

Haemodynamic:TachycardiaHypertension Intraventricular haemorrhage Bradycardia

Trauma:Teeth, lips, tongue, pharynx, larynx and trachea

Airway:Laryngospasm BronchospasmAspiration

Box 8.3 Rapid sequence induction algorithm

Preparation:Equipment/drugs (+ emergency)/patientIV accessSkilled assistantMonitoringAspirate nasogastric tubeYankuer suction Tipping bed/cot

PreoxygenationAdminister anaesthetic agentCricoid pressureAdminister suxamethoniumIntubation Position checkTracheal tube fixationPosition check

tracheal tube by using rapidly acting anaestheticdrugs. Other safety measures include cricoidpressure to reduce the risk of passive regurgitationof gastric contents and preoxygenation to preventhypoxia during the apnoeic period. Ketamine,thiopentone or propofol are suitable agents forinduction of anaesthesia (Table 8.3). However,benzodiazepines such as midazolam cannot berecommended in this situation because of aslow onset of action. Suxamethonium is theneuromuscular blocking drug of choice becauseof its rapid onset of action, producing optimalintubating conditions within 30–45 seconds. Anadditional benefit of suxamethonium is its shortduration of action of 3–5 minutes in the majorityof patients. Patients who prove to be un-intubatable hopefully will resume spontaneousbreathing before the preoxygenation reserve in thefunctional residual capacity of the lungs isexhausted and hypoxia develops. This is incontrast to the non-depolarising neuromuscularblockers (for example, rocuronium, atracurium,and vecuronium), which have slower onset timesand considerably longer durations of action.

Airway obstruction

A gas induction should be used when there isdoubt about the ability to intubate or ventilateusing a bag and mask after the onset ofanaesthesia and neuromuscular blockade, theclassic example being epiglottitis. The aim ofgas induction is gradual progression to intubatingconditions, maintaining spontaneous breathingand control of the airway at all times. A gasinduction should only be undertaken by aclinician with specialist anaesthetic training. If

necessary request the help of a local experiencedanaesthetist or intensive care clinician.

The difficult airway

The most common cause of difficulty withintubation for the inexperienced or infrequentpractitioner is poor technique (Box 8.4). Ifintubation is not achieved rapidly, attemptsshould cease and bag and mask ventilation berecommenced. The head and neck positioning isreviewed prior to a possible further attempt beingmade. However, excessive attempts at intubationshould not be undertaken. The primary concernis the maintenance of adequate oxygenation bybag and mask ventilation (Box 8.5). If necessarythe patient should be woken up and a moreexperienced clinician summoned for further


Table 8.4 Tracheal tube sizes

Tracheal tube size Age of infant

Internal diameter (mm)2·5–3·0 Premature neonate3·0 Term neonate3·5 6 months4·0 1 year(Age/4) +4 > 1 year

Length (cm)3 × internal diameter oral, add 3 cm for nasal < 1 year (Age/2) +12 oral, add 3 cm for nasal > 1 year

Note: detailed sizes for oral and nasal neonatal tracheal tubes are given in Appendix 2.

Box 8.4 Common technical reasons for difficultyin intubation

Head and neck position:Overextension of the head on the neck Inadequate flexion of the neck on the trunk

Laryngoscopy:Failure to sweep the tongue to the left side of

the mouth Leverage of the laryngoscope instead of lifting

along the axis of the laryngoscope handle

Obstruction of the view:Tracheal tube or operator's hand in the line of

sightInadequate suctioning of secretions

Inadequate anaesthesia or neuromuscular blockade

attempts at intubation. A difficult airway can alsoresult from a variety of anatomical problems, andthese should be excluded during the initialpatient assessment (Boxes 8.6, 8.7). Careful choiceof tracheal tube size, laryngoscope blade and theavailability of adjuncts (for example, stylets andbougies) are important. If in doubt, summon

experienced help for consideration of gasinduction or fibreoptic intubation. It is vitallyimportant during attempted intubation that thescenario of “can’t intubate, can’t ventilate” isavoided.

Shock

A significant percentage of cardiac output isdelivered to the respiratory muscles of shockedpatients. Positive pressure ventilation reducesthis and diverts blood flow to the vital organs.However, anaesthetic agents used for intubationcan cause a significant drop in cardiac output andblood pressure and must be used cautiously.

Raised intracranial pressure

Patients with raised intracranial pressure requireintubation and controlled hyperventilationfor both airway protection and to decreaseintracranial pressure. Adequate anaesthesia isrequired to prevent an acute rise in intracranialpressure caused by the haemodynamic responseto laryngoscopy and intubation. A dose of opioid(for example, fentanyl) is recommended as anadjunct to the anaesthetic agent to blunt thisunwanted response. Ketamine is specificallycontraindicated as it causes a rise in intracranialpressure.

Key points for intubationOxygenation is always the priority.Never lose control of the airway.Bag-valve-mask ventilation is the default position of

safety.An adequately trained team (intubator and assistant)

is required/ask for help.Adequate patient assessment and equipment

preparation.Plan for a failed intubation.

Mechanical ventilation

A selection of portable, gas driven mechanicalventilators is required to deliver the range of tidalvolumes required for neonates and children of allages. Ideally they should have disconnection andhigh pressure alarms and variable respiratory rate,peak inspiratory pressure, tidal volume, FiO2,I : E ratio, and PEEP (positive end expiratorypressure). A controlled or mandatory ventilationmode, either “pressure control” or “volumecontrol”, is recommended for transportation. The


Box 8.5 Failed intubation drill

Maintenance of oxygenation is the priorityCall for HELPDo not make persistent attempts at intubationDo not give repeated doses of neuromuscular

blocking drugs Maintain a patent airwayBag and mask ventilate to maintain oxygenationContinue cricoid pressure unless it is impeding

ventilationTurn onto left side and place head down unless

this impedes ventilation

Box 8.6 Common anatomical reasons fordifficulty with intubation

Limited access to the oropharynx:Facial trauma

Obstructed view of the larynx:Large tongueLaryngeal tumour/papillomataShort mandible (Pierre Robin)Epiglottitis

Narrow larynx:Croup

Narrow trachea:Subglottic stenosisTracheal web

Box 8.7 Preintubation assessment

History:Current illnessPrevious intubation detailsPredisposing diagnoses, for example Pierre Robin

Examination:Head—shape/sizeMouth—size/openingTeeth—size/integrityMandible—size/recedingTongue—sizeNeck—mobility/cervical spine injury/swelling/

masses

patient’s intrinsic respiratory effort is suppressedby sedation with or without neuromuscularblockade. “Pressure control” is recommended forneonates, infants and young children for severalreasons. Minute ventilation is more predictablewhen using uncuffed tracheal tubes with anobligatory inspiratory leak. The risk of barotraumais reduced if sedation and neuromuscularblockade are inadequate and the patient “fights”the ventilator. In “pressure control” ventilationthe peak inspiratory pressure is set on theventilator and the delivered tidal volume willdepend on the patient’s airway resistance andlung compliance. The tidal volume will bereduced by high airway resistance (for example,asthma) and by low lung compliance (forexample, adult respiratory distress syndrome(ARDS)). In “volume control” the tidal volume isset directly or indirectly by setting the inspiratorytime and inspiratory flow rate and the peakinspiratory pressure is dependent on the lungcompliance. It is ideally used in conjunction witha cuffed tracheal tube with no inspiratory leak,which is usually reserved for children over 8years of age. “Volume control” ventilation isuseful when close control of minute volume andCO2 is required (for example, raised intracranial

pressure). However, there is a risk of barotraumaunless an upper pressure limit is set appro-priately. In practice, the currently available“pressure control” transport ventilators (forexample, babyPAC, SIMS pneuPAC) will copeeasily with neonates and infants up to 10 kg.Bigger children will require to be ventilatedusing a “volume control” ventilator (for example,ventiPAC, SIMS pneuPAC). However, for childrenless than 8 years of age with uncuffed trachealtubes and an obligatory inspiratory leak, the“volume control” ventilator is set up in a fashionto simulate many aspects of “pressure control”ventilation. FiO2, respiratory rate and I : E ratio areset as for “pressure control” (Fig. 8.3). However,the inspiratory flow on the “volume control”ventilator is increased from a low level to achievethe desired chest expansion and peak inspiratorypressure on the ventilator pressure gauge. Withthis technique it is important to set the peakinspiratory pressure limit to just above this levelto protect from barotrauma and to give an earlywarning of changing conditions, for exampletracheal tube blockage or inadequate sedation andneuromuscular blockade. Transport ventilatorsare, by design, less sophisticated than theirintensive care counterparts. Therefore, it can bedifficult to achieve a comparable PaO2 and PaCO2

in transit. It is advisable to establish the patienton the transport ventilator as early as possible toallow adequate time to manipulate the ventilatorsettings, including the use of PEEP to optimise theblood gases before transportation.

Patient packaging

Children intubated with an uncuffed trachealtube require a nasogastric tube to avoid gaseousgastric distension. Pneumothoraces should bedrained before departure because positivepressure ventilation or flying at altitude can causethem to expand, resulting in respiratory andcardiovascular compromise. One-way flutter(Heimlich) valves may be used in preference tobottles with underwater seals for chest drainsduring transportation. The child’s head andtracheal and ventilator tubes should be securelyfixed whilst ensuring easy access for airwaymanagement. Emergency drugs, airway andventilation equipment (including a self-inflatingresuscitation bag, valve and mask system) must beimmediately available. A predeparture checklistprevents accidental omissions in stabilisation.


PIP − PEEP

∆P → minute volume

60/(IT + ET)

RR ×

Volume control

Pressure control

Peak inspiratory pressure varies with lungcompliance and airway resistance

Minute volume varies with lungcompliance and airway resistance

Flow rate × IT

TV → minute volume

60/(IT + ET)

RR ×

Figure 8.3 Ventilator settings. RR = respiratory rate,∆ P = change in airway pressure on inspiration,PIP = peak inspiratory pressure, PEEP = positive endexpiratory pressure, IT = inspiratory time, ET = expiratorytime,TV = tidal volume.

Adverse events in transit

Problems which have been reported in transit withairway and breathing include hypoxia, trachealtube blockage, accidental tracheal extubation,ventilator malfunction, and exhaustion of theoxygen supply. During transportation the childshould be regularly reassessed using a systematicABC approach. The position, patency and fixationof the tracheal tube are confirmed. Capnographyis a sensitive way of monitoring airway securityin the intubated child, especially during periodsof maximal risk such as loading and unloadingfrom vehicles when clinical observation isdifficult. In transit, there is a significant risk oftracheal tube blockage by secretions, which canbe reduced by humidifying the inspired gasusing a heat and moisture exchanging filter(HME) and by regular tracheal suction. Adequacyof ventilation is assessed by observing chestmovement, the airway pressure gauge on theventilator, and the capnograph trace. The ventilatorsettings, connections and oxygen source are

regularly observed. The well known mnemonic,DOPE, is a useful method of troubleshootingclinical deterioration (consider Displacement orObstruction of the tracheal tube, Pneumothoraxand Equipment problems). Intubated patientsrequire sedation and usually neuromuscularblockade for transportation to reduce thepossibility of accidental extubation, decreaseawareness and anxiety, and facilitate controlledventilation with the transport ventilator. Ifreintubation is necessary in transit, transportshould be temporarily halted if possible.

SummaryAIRWAY and BREATHING should not be considered

in isolation.A low threshold for intubation and ventilation for

transportation is needed.Transportation is often associated with clinical

deterioration in airway and breathing.Problems should be anticipated and prevented.Stability must be achieved prior to embarking on

transportation.


Introduction

The circulation is the body’s system for trans-porting oxygen, and other essential substrates, toits tissues and organs. The overall function of thecirculation is dependent on multiple factors withthe heart, the circulating volume of blood, and theintegrity of the blood vessels all contributing.

Maintaining a stable circulation is fundamentalto intensive care and therefore the transfer ofintensive care patients. In the transport environ-ment this can be particularly difficult but noless important. Failure to achieve this stabilityendangers the patient in the short term and canhave profound long term consequences.

Physiology

The principal function of the circulation is todistribute oxygen and other essential supplies to thetissues and organs of the body. Understanding thecirculation in this way makes it easier to understandhow it goes wrong and what to do about it.

Oxygen carriage and delivery

Oxygen in the blood is mainly carried by thehaemoglobin in red blood cells. A small amount

is dissolved in the plasma but this is generally sosmall as to be insignificant. “Oxygen saturation”is the percentage of haemoglobin that is carryingoxygen.

Oxygen content in blood = Hb × oxygensaturation

As excessively high haemoglobin concentrationmakes the blood too viscous to pump, efficientoxygen delivery depends on a normal haemoglobinconcentration and good oxygenation. When thishas been achieved the amount of oxygen deliveredto the tissues will be determined by how muchblood the heart pumps, i.e. the cardiac output.

Oxygen delivery = oxygen content × cardiacoutput

Cardiac output

The amount of blood pumped into the circulationby the heart is the cardiac output. This is adjustedby a variety of control mechanisms to meet thebody’s demand for oxygen and to maintain anadequate blood pressure (Table 9.1). It increases tomeet the demands associated with muscle activity,heat production, or illness. The cardiac output maybe unable to meet the metabolic demands of thebody because the heart’s ability to pump blooddecreases, the need increases, or a combination ofboth. Any situation where the cardiac output isinsufficient for the body’s needs is called “shock”.

Cardiac output is determined by how muchblood is pumped by each contraction (stroke

9 Management of the circulation

ObjectivesDiscussion of the management of the circulationin the transport environment covering: physiology;assessment; monitoring; stabilisation; and congenitalcardiac disease.

Table 9.1 Normal cardiovascular values

30 weeks’ gestationnewborn < 1 year 2–5 years 5–12 years > 12 years

Heart rate maximum/min 170 160 140 120 100

Heart rate minimum/min 120 110 95 80 60

Systolic blood pressure 50 70 80 90 100(lowest normal) mmHg

Mean blood pressure 30 50 55 65 70(lowest normal) mmHg

Notes: O2 demand = 3–7 ml/kg/min, arterial O2 content = ((Hb) × 1·34) + (0·003 × PaO2) ml/dl, intravascular volume =75–80 ml/kg.

volume) and how often the heart contracts(heart rate).

Cardiac output = stroke volume × heart rate

Stroke volume is determined by how well theventricle fills between beats and its ability topump the blood forward when it contracts.

The most important factor in ventricular fillingis the volume of blood in the circulation. As thevolume of blood increases the venous pressurerises and more blood flows into the ventriclesbetween contractions. Stroke volume increases asvenous pressure increases until the ventriclebecomes overdistended. Overdistension of theventricle impairs its ability to contract and thestroke volume decreases again.

Young, and especially premature infants, areless able to vary their stroke volume than olderchildren and adults, and are therefore moredependent on heart rate changes to vary theircardiac output.

Blood pressure

The systolic blood pressure is the maximumpressure generated in the circulation as the heartcontracts. Diastolic blood pressure is the pressuremaintained in the system between heart beats.Mean blood pressure is the average pressurethrough a cycle of systole and diastole.

Even with a low cardiac output the bloodpressure can be kept high by increasing thevascular resistance. The blood flow to each organand tissue will depend on both the cardiac outputand the resistance presented by the arteriessupplying that organ. The blood pressure itselfdoes not indicate how good the flow is.

Blood flow to the heart muscle is different fromthe rest of the body. During contraction (systole)the pressure in the heart muscle is the same as theblood that it is pumping. This means it cannotpump blood to itself during systole. Blood flow tothe heart occurs entirely during diastole and isdependent on diastolic blood pressure. In otherorgans the blood flow is determined by the meanblood pressure.

Blood pressure and the brain

The brain controls the blood flow it receivesthrough a process of “autoregulation”. Thisallows the brain to control its own blood supplyregardless of what is happening to the rest of the

body—a very sensible design feature. Adequateblood flow should be maintained if the bloodpressure is low, excessive flow should beprevented if the blood pressure is high.

This control system functions poorly incritically ill neonates, extremely prematureinfants, and patients who have suffered atraumatic or an ischaemic brain injury. In thesepatients the blood supply to the brain becomesdependent on blood pressure. Variations in bloodpressure cause variations in blood flow to thebrain. Low or variable blood pressure can causebrain ischaemia or haemorrhage.

In older children brain swelling following anytype of brain injury causes a rise in intracranialpressure. This reduces the blood flow to thebrain. Maintaining a high blood pressure can benecessary to provide an adequate blood flow.

Low or unstable blood pressure can result in a poorneurological outcome for:

• Extremely premature infants• Critically ill neonates• Infants and children with hypoxic ischaemic

encephalopathy• Children who have suffered a severe head injury

Changes in the cardiovascularsystem with age

The heart chambers and valves form early in fetallife but the function of the whole cardiovascularsystem continues to develop rapidly in the severalmonths after birth. Development continues moreslowly throughout childhood. During this timethe structure of the heart changes, contractileelements in muscle increase and become moresensitive to catecholamines (for example, epineph-rine). The most dramatic changes occur aroundthe time of birth.

In utero blood is oxygenated in the placentaand the lungs have a high vascular resistancewith consequently little pulmonary blood flow.Blood bypasses the lungs by flowing straightfrom the right to the left atrium through theforamen ovale, or by flowing from the pulmonaryartery into the aorta through the ductus arteriosus(Fig. 9.1).

At birth vascular resistance in the lungs dropsto allow blood to flow through them. Flowthrough the foramen ovale ceases. Flow throughthe ductus arteriosus diminishes as pressure inthe pulmonary artery decreases. The ductusnarrows in response to increased levels of oxygen


in the blood and usually closes within the firstfew days of life. Resistance in the lungs remainsquite high initially then decreases over a period ofmonths (Table 9.2).

Failure to establish adequate blood flow throughthe lungs at birth results in general hypoxia.Congenital structural abnormalities of the heartand major blood vessels can also prevent successfultransition to a functioning cardiovascular systemafter birth. This is discussed below (Table 9.3).

Assessment and monitoring

Accurate assessment of the cardiovascular systemis an essential part of the preparation to transferany unwell child from one location to another.Failure to recognise a problem, or the severityof the problem, will result in inadequatestabilisation and a high chance of deteriorationduring the transfer. Effective intervention will bemore difficult because of the limitations of thetransport environment and because the problemwill be more established and serious.

Inevitably some patients will deteriorate duringtransfer. With motion, noise, distraction, littlespace and a limited view of the patient it is clearthat monitoring at least as comprehensive as in

the intensive care unit is necessary to detectproblems.

Immediate assessment

Any patient requiring transfer should be assessedby the transferring staff as soon as possible. Themost immediate assessment will be of the ABCtype discussed in chapters 6 and 7.

History

Key aspects in the history should be sought whileassessing the cardiovascular system.

In the newborn a history of maternal infection,peripartum haemorrhage, cardiotocograph (CTG)abnormalities, details of cord clamping, andcondition at birth may indicate risk of cardiacdysfunction. The timing of the onset of illness inrelation to birth will help diagnose the diseaseprocess and its likely progress.

The presentation of infants in shock, havingbeen well at birth, within the first few days of lifefrequently indicates the presence of congenitalcardiac disease.

In septicaemic patients a history of rapid onsetand progressive deterioration is likely to indicatea need for escalating support. Stability may bedifficult to achieve before transfer.

The history of the mechanism of injury in traumapatients is crucial to their assessment. In childrenblunt trauma to the trunk is often associatedwith occult damage to viscera and subsequentprogressive blood loss. A history of a forceful blowshould prompt careful attention to haemodynamicmonitoring and venous access in children whoinitially seem to have only minor injuries.

The treatment the patient has received alreadyis an important part of the history. Trends in heartrate, respiratory rate and blood pressure arevaluable in assessment of the cardiovascularsystem. The amount of fluid that has been givenand its effect on observations should be noted.The effect of drugs on the circulation shouldbe noted, especially inotropes, diuretics, andprostaglandins.

Examination

A full clinical examination should always bemade but is often neglected in intensive careenvironments. The orientation and emphasis ofthe examination will depend upon the clinicalcircumstances.

Management of the circulation 81

Upperbody andbrain Lungs

Placenta

FOLA

LV

PA

RV

DA

Ao

GI tract and lower body

RA

Figure 9.1 The fetal circulation. (Dr D Thomas: reproducedwith permission.) PA = pulmonary artery, DA = ductusarteriosus, Ao = aorta, RV = right ventricle, LV = leftventricle, RA = right atrium, LA = left atrium, FO = foramenovale

General

Look for dysmorphic features that may be associatedwith particular cardiac lesions. The presence ofchest scars may suggest previous cardiac surgery.

Heart rate

Tachycardia or any progressive trend in heartrate should always be critically considered, anexplanation found, and treatment adjustedappropriately. Heart rate is often the mostsensitive indicator of response to treatment,especially infusion of fluid. The ECG rhythmshould be carefully assessed.

Pulses

The character of pulses is helpful in assessingthe state of the circulation and the presence orabsence of specific pulses crucial to diagnosis ofsome congenital cardiac disorders. All major limbpulses should be palpated.

Colour and perfusion

This should be assessed in a semiquantitativeway using the capillary refill test or peripheraltemperature assessment. Look for differences incolour between the upper and lower body.


Effect Mechanism

Fall in pulmonary vascular resistance Lung fluid emptiedand hence right ventricular force Air entrained

Ductus arteriosus closes functionally Ductus exposed to increased PaO2then anatomically

Foramen ovale functionally then Right atrial and ventricularanatomically shut pressure below equivalents

on left

Shift of dominance from right Pulmonary and systemic to left ventricle circulations become

separateLeft ventricle solely responsible forsystemic cardiac output

Table 9.2 Physiological changes from fetal to adult circulation

Table 9.3 Features of the newborn myocardium

At birth Consequences Practical considerations

Myocytes short Relatively fixed contractility Beware of volume overload

Paucity of contractile elements Cardiac output rate dependent

Activation immature Myocardium sensitive to afterload Avoid increasing peripheral vascular resistance

Metabolically adapted More robust with changes in to hypoxaemia PaO2 and pH

Parasympathetic innervation Bradycardia more easily elicited Give atropine to block vagus ifcomplete with vagal stimulation stimulation anticipated

Sympathetic innervation incomplete Different response of vasculatureof both heart and vasculature to sepsis

Ventricles of similar shape Failure of contractility leads to Assume biventricular failure inbiventricular failure youngest children

Level of consciousness

Low cardiac output causes first agitation thendrowsiness and confusion.

Respiratory rate

A high respiratory rate is most commonly causedby respiratory disease, but is also an indirectindicator of cardiac output. It can be particularlyuseful when considered as a trend over a periodof time.

Blood pressure

Normal blood pressure gives little indication onits own as to the cardiac output; a low bloodpressure always indicates a serious problem.

Abdomen

The size of the liver is a useful indication ofcentral venous pressure (CVP) in younger childrenand should be reassessed during therapy if CVPmonitoring is not in place.

Monitoring

ECG and saturation monitoring are usually easy toarrange and should be the absolute minimummonitoring provided for intensive care transfers.

Non-invasive blood pressure is useful in thestable patient, but is a poor alternative to invasivemonitoring and should only be used in unstablepatients if there is no alternative.

Invasive pressure monitoring provides constant,accurate measurement as well as a waveformdisplay. CVP monitoring is possible where centralaccess has been gained. Interpretation of valuescan be made more difficult in transit by movementartefact.

End tidal CO2, although generally considered arespiratory monitor, also reflects pulmonaryblood flow.

Investigations

A number of investigations have specific relevanceto the assessment of the cardiovascular system.

1. Blood gas. Provides information on therespiratory status, but is also useful inassessment of the cardiovascular system.

Acid–base balance of arterial blood indicatesthe adequacy of tissue oxygenation. Theseverity of acidosis gives an indirectassessment of the adequacy of cardiac output,as low cardiac output will lead to tissuehypoxia and metabolic acidosis.

2. Full blood count. Anaemia in any patient withshock or heart failure will exacerbate theproblem and should be treated early incritically ill children.

3. The need to treat coagulopathy before transferdepends on the clinical situation. Prematureinfants are vulnerable to intracranialhaemorrhage and should have a significantcoagulopathy treated before or during transfer.Older children without evidence of haemorr-hage may not require immediate treatment.

4. Blood electrolytes can have a significant effecton cardiac function, with blood calcium andpotassium particularly important. Attemptsshould be made to correct abnormal valuesbefore transfer in unstable patients.

5. A chest radiograph can contribute to cardiacas well as respiratory status assessment. Theheart size, pulmonary vascular markings,presence of effusions or pneumothorax, andthe position of central venous lines should allbe assessed.

Stabilisation

Vascular access

Stable venous access is a core requirement for safetransfer of unwell patients. As with all aspects ofstabilisation, the transport environment makes itmore likely that the patient will be unstable, morelikely that access will fall out or fail, and muchmore difficult to replace if it does. It is oftentempting to transfer a patient who has “justenough” venous access rather than to spend timegaining more. The high number of children whoarrive at receiving hospitals in extremis because adrip failed, “tissued” or fell out during thetransfer should be convincing evidence that thetime is well spent.

Reliance on an ability to replace lines duringtransfer is unwise. In most situations it will bevery difficult to achieve the same level of lightand access to the patient as could be achieved inhospital. Even a stationary vehicle will be rockedby every passing car. In aircraft vibration makesperformance of delicate procedures extremely


difficult or impossible and there will be no optionto “pull over” while the task is undertaken.

A good practice is to assume that at least onedrip will fail during the transfer. This means that,at a minimum, there should be at least one moresite of access available than is required at the timeof departure. There should be enough access tocontinue all essential infusions as well as to giveboluses of fluid or drugs. It can be seen that everyunwell or ventilated patient will need two ormore drips to meet this standard.

Peripheral venous access

The normal peripherally sited cannula canprovide acceptable venous access for mostpatients. The skills required are generic andaccess can often be achieved quickly withoutmuch handling of the patient. Even narrow borecannulas are short, allowing volume to be infusedrelatively quickly if sited in an adequate vein.Almost all drugs can be given into peripherallines but may require dilution or special care.

There are some important disadvantages ofreliance on peripheral lines. Each line has onlyone lumen so several may be required to achievea safe transfer. In some patients it will beextremely difficult to gain access and, even if aline can be placed, it may not be possible to gainenough access for the transfer. Irritant substancescause phlebitis and it will be more difficult todetect that the line has tissued during the transferthan in normal circumstances.

Central venous access

Central access has a number of advantages overperipheral lines. Multiple lumens may be placedat one time, lines do not tissue in the shortterm, fixation of the line is often easier, irritantand vasoactive drugs may be given at highconcentration, and venous pressure may bemonitored if required.

Access in the newborn is often achieved via theumbilical vein. This is a generic skill and canusually be achieved quickly even in extremelypremature infants. Securing the line can bedifficult and care should be taken to avoidtraction on the line.

After the newborn period access to the centralveins must be by percutaneous insertion. This isslower and more difficult than umbilical veincannulation, especially in small infants. There isa higher risk of immediate side effects as a needle

must be passed blindly into the target vein.Internal jugular, subclavian or femoral veins maybe used.

The advantages of having central access indicateobtaining it at a low threshold when preparingunwell patients for transport. Clinicians should,however, recognise that alternative strategies areusually available if they do not have sufficientexperience of percutaneous techniques to attemptthis safely.

Inotropes

Inotropes are a useful group of drugs that allincrease either the cardiac output or the bloodpressure.

In situations where cardiac dysfunction islikely to be present inotropes should be usedearly. This includes extremely premature infantsfor whom the importance of establishing anadequate and stable blood pressure has beenmentioned. In the presence of cardiac failurerepeated boluses of fluid can cause increasingcardiac dilatation and deterioration of thepatient’s condition. Particularly in infants with ahistory that is compatible with cardiac disease,clinicians should remain alert to deteriorationassociated with fluid administration and modifytheir treatment appropriately.

The effects of the most commonly usedinotropes are summarised in Table 9.4.

Intravenous fluids and blood products

Increasing the amount and pressure of fluidreturning to the heart is usually the quickest andsimplest way to increase cardiac output. The bestfluid to administer depends on what, if any, fluidhas been lost.

In the short term 0·9% saline is an effective andavailable fluid with which to increase thecirculating volume of blood. Many centres useplasma or albumin solutions in the hope thatthese will remain inside the circulation for longerthan saline, but there is little evidence that this istrue.

Use of dextrose or hypotonic saline (less than0·9%) to increase circulating volume is disastrousas the fluid is immediately lost from thecirculation and contributes only to the formationof oedema and electrolyte disturbance.

The amount of fluid administered must betailored to the clinical situation. During initial


resuscitation seriously shocked or hypotensivepatients who do not have obvious cardiac diseaseshould receive an initial bolus of 20 ml/kg.Monitored patients should receive smaller volumesand the patient’s response noted. This can begiven as quickly or as frequently as required aslong as it is tailored to the patient’s response. Theneed for large volumes of fluid should promptconsideration of inotrope use or the possibility ofhaemorrhage.

Children with cardiac disease may deterioraterapidly during fluid administration. Smallvolumes should be used when cardiac disease is apossible diagnosis and inotropes introduced at anearly stage.

A slow infusion of maintenance fluids may beused to maintain blood glucose and electrolytelevels. Premature and newborn infants willrequire a constant glucose infusion. This maynot be necessary in older children during shortdistance transfers.

Arrhythmias

In paediatric intensive care units infants whohave had recent cardiac surgery are the groupmost likely to suffer cardiac rhythm abnorma-lities. Luckily, this group tends not to requireinterhospital transfer. Other groups who are proneto arrhythmias include children: who have hadcardiac surgery in the past; with a congenitalpredisposition to arrhythmias (e.g. supraventri-cular tachycardia and long QT syndrome); whohave ingested toxic levels of drugs (e.g. tricyclicantidepressants); and those who have myocarditisor a cardiomyopathy.

Ways of preventing arrhythmia

• Effectively treat hypoxia and hypercarbia• Detect and treat hypo- and hyperkalaemia• Detect and treat hypo- and hypercalcaemia• Alkalinisation of child who has taken tricyclics• Ensure continuance of antidysrhythmic

medication• Ensure adequate coronary blood flow and

diastolic BP and observe ST segments.

CLINICAL APPROACHIf a child has an arrhythmia, examine:• the child

then• the child’s ECG

Approach to the ECGAlways feel a pulse before looking at the ECG

Question Answer1. Can you see P waves

regularly associated withnormal QRS complex? Yes Sinus rhythmIs heart rate < 200? (fast or slow)

2. Is the heart rate > 220(relatively fixed P waves may or may not be visible)? Yes SVTNormal narrow QRScomplex?

3. Broad complex tachycardiaRate almost constant(between 120 and 250/min) Yes VTSustained > 3 beats

4. Irregular bizarre complexesof fine or coarse nature Yes VF(ensure adequate gainon monitor)


Table 9.4 Effects of most commonly used inotropes

Drug Cardiac output Vascular resistance Effect

Dopamine ↑ ↑ Increases cardiac output and blood↑↑ (high dose) pressure

Dobutamine ↑ — Increases cardiac output butvariable effect on blood pressure

Epinephrine (adrenaline) ↑ ↑ Increases cardiac output and↑↑↑ (high dose) blood pressure

Norepinephrine (noradrenaline) — ↑↑↑ Increases blood pressure but littledirect effect on cardiac output

Milrinone ↑ ↓ Increases cardiac output but maydecrease blood pressure

Staff preparing to transfer a patient who has hador is at risk of having an arrhythmia shoulddiscuss treatment with a paediatric cardiologist orintensivist. All staff need to be able to recognisethe most common and arrest arrhythmias andshould be able to safely use a defibrillator. Anappropriate defibrillator needs to be immediatelyavailable throughout the transfer. Unstablepatients should have defibrillation pads attachedto avoid use of paddles where this is possible.

Many teams do not carry their own defibrillatoron transfers and depend on equipment carried bythe ambulance service. In this situation it isimportant to check that the defibrillator availableis appropriate for the patient. Some ambulanceservices use semiautomatic defibrillators thatcannot be adjusted for use in children.

How the team will react in the event of thepatient having an arrhythmia should be discussedbefore leaving. It is often better for the ambulancecrew to operate ambulance equipment guidedby transfer team staff than to attempt to useunfamiliar equipment in an emergency.

Congenital cardiac disease

Children with congenital cardiac disease representa high proportion of patients managed in manypaediatric intensive care units. Initial presentation,however, is often to neonatal, accident andemergency or general paediatric departments.Transfer to a cardiology or cardiac intensive careunit will be required.

Cardiac malformations that present in thenewborn period usually do so because they causeeither obstruction of blood flow to the lungsor obstruction of blood flow to the systemiccirculation (the rest of the body).

Narrowing or blockage of the pulmonary arteryor valve or failure of the right ventricle to formwill result in blood flowing from the aorta to thepulmonary artery through the ductus arteriosus.This allows the infant to survive after birth.Oxygen saturations will be lower than normal asthere is mixing of oxygenated and deoxygenatedblood, but the infant may appear well and bedischarged from the maternity unit. When theductus starts to close the infant will quicklybecome hypoxic as blood flow to the lungsdecreases. This will cause deep cyanosis followedby collapse.

Narrowing or obstruction of the aorta, or failureof the left ventricle to form, results in blood

flowing from the pulmonary artery to the aortathrough the ductus. Again, oxygen saturationswill be low as there is mixing of oxygenated anddeoxygenated blood but the infant may appeargenerally well. As the ductus closes blood flowinto the aorta will decrease and the infant willbecome shocked. The oxygen saturation mayactually increase at this stage as most of thecardiac output is being directed to the lungs.

Reopening the duct is essential in both thesegroups of patients. This is done with an infusionof prostaglandin E2 (Prostin). A normal startingdose of Prostin is 10 nanograms (0·01 micrograms)per kilogram per minute. This may be increased ifthere is no initial response and can usually bedecreased in stable patients for use over longerperiods.

Patients diagnosed as having a potentially ductdependent circulation (Box 9.1) while still wellshould be started on Prostin to prevent ductclosure.

• Overall about 80% of infants respond.• The response is usually evident within

15 minutes.• If in doubt start the infusion.• Infants with total anomalous pulmonary venous

drainage (TAPVD) may get worse in whichcase stop the infusion.

One of the important side effects of Prostin is itstendency to cause apnoea and this should betaken into consideration when planning transferof the patient. The risk of apnoea is usuallytransient and most commonly associated withuse of higher doses (doses of more than0·01 micrograms/kg/min (10 nanograms/kg/min)).Elective intubation and ventilation should beconsidered for stable infants who are to betransferred immediately after starting Prostin


Box 9.1 Examples of ductus dependent lesions

Decreased pulmonary flow:Tricuspid atresiaPulmonary atresiaCritical pulmonary stenosisTransposition of great arteries

Decreased systemic flow:Hypoplastic left heartCoarctation of aortaCritical aortic valve stenosisInterrupted aortic arch

therapy. Infants who have not suffered apnoea afterseveral hours of Prostin infusion are unlikely to doso and ventilation is not generally necessary. Otherside effects of Prostin infusion are:

• Vasodilatation• Hypotension (mild)• Jitteriness• Fever.

If jitteriness or fever occur consider halving theinfusion rate.

Practicalities of prostaglandin infusion

Prostaglandin E2 (Prostin E2, dinoprostone) isadministered intravenously in a starting dose of0·003–0·01 micrograms/kg/min (3–10 nanograms/kg/min).

Dilution

1. Take ampoule of PGE2 (1 mg/ml) and draw up1 ml (1 mg) into a syringe—do not remove theneedle.

2. Inject 1 ml (1 mg) of PGE2 from the syringe intoa 500 ml bag of 5% dextrose or 0·9% saline

3. Mix well. This solution now contains2 micrograms/ml of PGE2.

4. Start IV infusion at the rate of 0·3 ml/kg/h.This is 0·01 micrograms/kg/min (10 nanograms/kg/min). Round off the infusion rate to thenearest 0·1 ml; for example, for a 3·5 kg infantthe initial estimated infusion rate is 0·3 ml ×3·5 = 1·05 ml/h—infuse at 1·0 ml/h.

Increase the rate of infusion in multiples of0·1 ml/kg/h to a maximum of 0·6 ml/kg/h(0·02 micrograms/kg/min) depending upon theclinical response. Doses above this may beneeded, particularly in the shocked patient, butadvice should be sought from a paediatriccardiologist. Once a sustained clinical improvementis attained (a rise in PaO2 or improvement in heartfailure), the dose should be reduced in similar stepsto below 0·01 micrograms/kg/min.

Do not use the intra-arterial route, except in anemergency—although it is equally effective, sideeffects are common.

Particular congenital heart lesions(Table 9.5)

The most common cardiac malformations aredefects in the septum between the ventricles or

atria. The most severe have both atrial andventricular defects and may be associated withheart valve abnormalities.

These conditions rarely present at birth,although they may be detected on routineexamination. As pulmonary vascular resistancedrops over the first weeks of life pulmonary bloodflow increases and the patient will present withsigns of heart failure. The oxygen saturationswill be normal until pulmonary oedema causesrespiratory hypoxia. It is unusual for this group ofpatients to collapse suddenly unless they developan intercurrent illness, such as bronchiolitis,which is exacerbated by their underlying cardiaccondition.

The ductus arteriosus may fail to close in somechildren. This allows blood flow from the aortato the pulmonary artery, causing increasedpulmonary blood flow and occasionally heartfailure. This is particularly common in prematureinfants in whom it can exacerbate lung diseaseand may prevent weaning from ventilation.Patients may require transfer to a cardiac unit forligation of the ductus.

Hypoplastic left heart

Infants usually present with severe ventricularfailure and cyanosis.

If active treatment is planned, treatment shouldinclude:

• Ventilation:

• Ketamine and suxamethonium induction• Target PaCO2 5 kPa• Target SaO2 75%• Adequate sedation with opiate

• Prostaglandin in infants less than 14 days old• Inotrope (usually epinephrine (adrenaline))• Furosemide (frusemide) 1 mg/kg IV.

Tetralogy of Fallot—hypercyanotic spells

As the right ventricular outflow tract (RVOT)hypertrophies, a dynamic RVOT obstruction maydevelop, presenting as episodic severe cyanosis—hypercyanotic spells.

Treatment aims to:

• Reduce RVOT obstruction• Increase systemic vascular resistance.

Systemic vascular resistance is increased byinitially encouraging the knee–chest position, then


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consideration of the following drugs, often usedsequentially until effective:

1. Morphine 10 micrograms/kg IV or25 micrograms/kg IM

2. Sodium bicarbonate 1 mmol/kg IV initially3. Infuse 10 ml/kg colloid or crystalloid4. Esmolol 0·25 mg/kg over 1 minute then

50 micrograms/kg/min. If ineffective by5 minutes repeat with 0·5 mg/kg and up to250 micrograms/kg/min

5. Phenylephrine 2–10 micrograms/kg stat, then1–5 micrograms/kg/min.

Be prepared to ventilate.

Conditions palliated with a shunt that has blocked

The following conditions may be palliated byshunting between systemic and pulmonarycirculations:

• Tetralogy of Fallot• Pulmonary atresia• Tricuspid atresia.

Blockage of the shunt is usually characterised bycyanosis:

• Heart failure• Extreme cyanosis• Absence of shunt murmur.

It is important to reach a cardiac centre quicklyhaving initiated:

• Ventilation• Inotropic support (usually epinephrine

(adrenaline))• Diuretic.

Transposition of the great arteries

Although there is no actual obstruction intransposition, the circulation is dependent onboth the ductus arteriosus and the foramen ovaleto allow blood from the pulmonary and systemiccirculations to mix. In addition to starting aProstin infusion it is often necessary to enlargethe foramen ovale. A “septostomy” is performedby a cardiologist using a device threaded into alarge vein under echocardiogram guidance. Thisis rarely possible outside a paediatric cardiologycentre so transfer should not be excessivelydelayed. It will occasionally not be possible tofully stabilise the patient before transfer.

SummaryIn unwell infants and children who require

interhospital transfer, stabilisation of thecirculation is essential to ensure the transfer issafe and to avoid the long term consequences ofinstability.

Stabilisation should be approached as it is withinthe intensive care unit and based on a detailedhistory, careful review of information, and clinicalexamination of the patient.

Sufficient monitoring and vascular access must beestablished before transfer to continue all aspectsof intensive care and to compensate for thedifficulties associated with the transportenvironment. Transferring staff should have a lowthreshold for establishing central venous accessand using inotrope infusions.

Children with congenital cardiac disease requirespecialist care and are therefore often transferredbetween hospitals.

The use of Prostin to open the ductus arteriosus iscentral to the stabilisation of infants withcongenital cardiac disease presenting in thenewborn period.


Introduction

In the UK trauma is the commonest cause of deathin children over the age of one. However, as theoverall incidence of severe injury is relativelysmall, most clinicians dealing with these childrenon an infrequent basis will transfer them to majorcentres for definitive care. The Trauma Audit andResearch Network (TARN) recorded that between1991 and the end of 2001 there were 20 492children (aged less than 16) requiring some formof transfer to another centre in the 103 hospitalscontributing to TARN. Of these, 31% had InjurySeverity Scores exceeding 9, suggestive of severeinjury.

When considering transfer it is essential that:

• All injuries which may compromise safetransfer are recognised. Operative interventionmay be required to stabilise the patient prior totransfer

• The benefits of transferring the patient to thereceiving hospital significantly outweigh therisks of the transfer itself

• The optimal time for transfer is identified andthe transport team has all the capabilitiesrequired to carry it out safely.

Objectives

To understand:

• The mechanics and resulting patterns of injuryin infants and children

• Clinical assessment of the child prior to transfer,using the system of a primary and secondarysurvey, with particular emphasis on the need to:

exclude life or limb threatening pathologyrecognise the potential for acute decompensa-

tion in certain body regions• A review of important injuries within individual

body regions of particular relevance for transfer• Practical procedures relevant to transferring the

injured child• Analgesia issues in the trauma patient• Documentation issues prior to transfer• Pitfalls in transferring the injured child.

The mechanics and resultinginjury patterns

Major traumatic injury produces markedlydifferent physiological and physical effects onchildren as compared to adults.

Children are often prone to injuries as a resultof road traffic accidents (RTAs) and falls. Mostcommonly, a child is involved in an accident witha vehicle as a pedestrian or cyclist, rather than asa car occupant. The inquisitive nature of smallchildren, and their lack of appreciation of danger,also predisposes them to injuries from falls.Multisystem injury may be the result, and it isprudent to base the initial assessment on thisassumption until proven otherwise.

Three factors influencing the resulting injurypatterns are discussed below.

Size

Due to the smaller body mass and relative sizeof children, the patterns of injury are different tothose of an adult for the following reasons.

• Collision with a vehicle imparts a greater forceper unit body area.

• Multiple organs are in close proximity to oneanother.

• The child’s body has less fat, muscle andelastic connective tissue to absorb thetraumatic forces.

For example, a child knocked down by a car is atsignificant risk of pelvic and abdominal injuriesas opposed to lower limb fractures in an adult; achild has a disproportionately large head and is atgreater risk of a severe head injury after a fall.

Surface area

The ratio of a child’s body surface area to volumeis highest at birth and diminishes as the childreaches adolescence. As a result, hypothermiamay develop rapidly and complicate themanagement of the traumatised child. Therefore:

• Exposure of the injured child must be kept to aminimum

• Use warmed blankets and fluids• Children with burns can very rapidly become

hypothermic, especially if wet clothes anddressings are applied.

Skeleton

The child’s skeleton is incompletely calcified andis more pliable. As a result, internal organ damagemay occur without overlying bony injury.

10 Trauma

Trauma 91

• Rib fractures are uncommon but pulmonarycontusion is frequent.

• There is little protection to the liver, spleenand kidneys from the overlying ribs.

• Rib and pelvic fractures are rare, but theirpresence implies massive traumatic forces thatwill have been transmitted to the underlyingthoracic and abdominal contents.

Clinical assessment

The emergency management of the criticallyinjured child relies on the assessment andtreatment of hypoxia and shock, as well as on theidentification of injuries and early access todefinitive care in a timely fashion. This approachis structured into a primary and secondary surveyas set out by the Advanced Trauma Life Support(ATLS) course.

Prior to transfer, a primary and secondaryreview must be performed and the findingsdocumented. This reassessment effectivelyconstitutes a tertiary survey, and is specificallytargeted at identifying any potential or actuallife threatening emergencies. These may havedeveloped, or have been overlooked, during theinitial assessment and resuscitation.

Failure to perform a tertiary survey willcompromise the quality of a stable transfer.This survey, and the appropriate managementof any problems identified, should occur in atimely fashion, as the transfer itself may be forurgent definitive treatment of injuries. Thetertiary transport survey should end with a clearmanagement plan, outlining the needs both ofthe patient and the transfer team.

Primary review

The primary review is divided into five parts. It isused as a rapid and logical method to identify anyimmediate or impending life-threatening pathology.The same system is regularly used to re-evaluatethe patient during the transfer itself.

A.Airway and cervical spine control

Assessment of the airway is critical to a safetransfer. Trauma patients will fall into two broadcategories.

• The alert, conscious patient will have a clearairway and no further interventions will benecessary apart from oxygen therapy.

• The patient with a compromised airway, orone where there is potential for compromise.Prior to transfer, the patient must beanaesthetised and the airway secured byendotracheal intubation.

Common indications for securing the airwayinclude:

• The need to protect the lower airway fromaspiration of blood or vomit. Always assumethe trauma patient to have a full stomach withdelayed gastric emptying

• Impending or potential airway compromise;for example, following facial burns orinhalational injury, facial trauma, or epilepticseizures

• Closed head injury with potential forneurological deterioration

• Inability to maintain adequate oxygenationand gas exchange

• High spinal cord injuries.

Once the child is intubated and sedated, frequentre-evaluation of the airway is vital.

Monitor physiological parameters and checkoxygen supply, ventilator settings, circuit andconnections regularly. Be aware of dislodgement(main bronchus or oesophagus) or blockage of theendotracheal tube. Visualise chest expansion andcheck for pneumothorax.

Cervical spine immobilisation must bemaintained at all times in any patient with apotentially severe injury. Clearance of the child’sspine may occur only after both clinical andradiological assessment by an experiencedclinician.

Learning pointsAny doubt about an airway prior to transfer should

suggest the need to secure it by endotrachealintubation.

In the anaesthetised child, ensure that theendotracheal tube is secured by at least twomethods.

An orogastric or nasogastric tube should be insertedprior to transfer in all anaesthetised children.

B. Breathing

Careful assessment is essential to identify signsof respiratory distress compromising ventilatoryfunction. Examination of the chest must be linkedwith a review of changes in respiratory rate,oxygen saturation, and arterial blood gasanalysis. Chest pathology in the injured child iseasily missed. Important causes include: tension


pneumothorax; simple pneumothorax; haemo-thorax; splinting of the diaphragm due to gastricdilatation; pulmonary contusion or even a flailchest.

Learning pointsTension pneumothorax may manifest at any time,

especially after the child has been anaesthetisedand endotracheally intubated. Consider it in allcases where acute compromise occurs.

Beware of pulmonary contusion. Due to thecompliance of the chest wall, there may be fewsigns of severe chest trauma until manifest ashypoxia and respiratory distress.

C. Circulation

All patients must be cardiovascularly stable priorto transfer. Initial assessment will have beenbased upon the pulse rate and volume, capillaryrefill, conscious state, and respiratory rate.Blood pressure is a poor sign of cardiovascularcompromise.

It is essential to examine the charts and reviewthe impact of fluids given to the patient. Ifmore than 40 ml/kg of fluid has been given toresuscitate the child, a possible source forhaemorrhage must be identified. Review possiblecauses of hidden cavity blood loss and ensure thatan experienced surgeon has assessed the patientprior to transfer.

Learning pointsBlood loss may be obvious (scalp laceration,

fractured long bones) or occult (into the chest,abdomen, retroperitoneum, or pelvis). The patientmay require operative intervention to control thehaemorrhage prior to transfer.

In rare circumstances, once hypovolaemia has beenexcluded, there may be other causes for shock(cardiogenic from myocardial contusion orneurogenic from spinal cord injury).

It is essential to have all vascular lines well securedprior to transfer.

D. Disability assessment

A review of the patient’s neurological state isessential prior to transfer. The assessment of theGlasgow Coma Score at this stage is difficult asmost patients with significant head injuries willhave been anaesthetised and given paralysingagents. It is important, however, to elicit anddocument the pupillary responses.

E. Exposure and environment control

Measures to minimise heat loss should beinstituted prior to, and especially during, thetransfer. A core temperature must be documentedand monitored during transfer.

Secondary review

The secondary review allows the transport teamto:

• Familiarise themselves with the injuries thathave been identified thus far

• Identify other injuries that may influence thetransfer of the patient.

The review should be a thorough head to toeexamination. It is best carried out with the teamthat was initially taking care of the patient. Thisreview may identify the need for further urgentinvestigations or treatment prior to transfer.However, it should also be done in a timelyfashion and take into account the urgency of thesituation.

A clear management plan should be formulatedand documented at this stage. Details of specificpersonnel involved in the referring and receivinghospital as well as the exact destination must alsobe recorded.

The next section concentrates on importantinjuries within each of the individual body regions.

Head injury

Children with head injuries constitute the largestsingle group of transfers due to trauma. Headinjuries account for 15% of all deaths in the1–15 year age group. This is most commonly dueto collisions with vehicles and to falls. In infancy,the most common cause is child abuse. Theoverall outcome in children suffering a severehead injury is better than in adults.

Transfer may be indicated for specialisedintensive care facilities, intracranial pressure(ICP) monitoring, or for neurosurgery.

Intracranial pressure

Children tend to have fewer focal mass lesionsthan adults, but raised ICP due to cerebral oedemais more common.

Trauma 93

Normal ICP in the resting state is 10 mmHg. Intrauma, both cerebral oedema and intracranialhaematoma (ICH) can cause raised ICP, thepresence of which not only indicates intracranialpathology, but also exacerbates it in a vicious cycle.

Monro–Kellie doctrine

This is a simple concept in which the cranialcavity can be considered as a fixed-volume box,so that the total volume of intracranial contentsmust remain constant.

If cerebral oedema or ICH occurs, compensatorymechanisms maintain normal ICP by squeezingan equal volume of CSF and venous blood out ofthe cranial cavity.

Once these mechanisms are exhausted,decompensation occurs and ICP rises in anexponential manner until the stage at whichcerebral herniation occurs.

In children this pathophysiological mechanismapplies only after fusion of the cranial sutures(between 12 and 18 months).

Whilst the sutures are open:

• There is greater allowance for intracranialvolume expansion

• Intracranial haemorrhage and/or oedema mayoccur before neurological symptoms or signsdevelop

• An infant with a bulging fontanelle or suturediastasis should be treated as having a severehead injury.

Raised ICP causes an increased pressure gradientfor the inflow of arterial blood and therefore a fallin cerebral perfusion pressure (CPP).

Cerebral perfusion pressure

Both normal and injured brain tissue must remainadequately perfused to prevent irreversibledamage and to preserve function.

CPP = mean arterial blood pressure – ICP

Blood pressure must be maintained in the headinjured patient, particularly in the presence of:

• Raised ICP• Multiple injuries.

Management priorities

Children are particularly susceptible to the effectsof secondary brain injury. The first priority must

be to prevent this by ensuring adequate cerebralperfusion with well oxygenated blood.

• Assessment and stabilisation of the airway,breathing and circulation is mandatory.

• The airway must be protected with anappropriately sized endotracheal tube and thechild ventilated after administration of musclerelaxants and sedation.

• Correction of hypovolaemia and maintenanceof adequate blood pressure are paramount.

• Early liaison with the regional paediatricneurosurgical centre is vital.

• Raised ICP may be apparent clinically orradiologically; follow neurosurgical adviceregarding treatment.

Focal mass lesions

A CT head scan is required to visualise focal masslesions, but these occur less frequently inchildren.

Prevention of secondary brain injury

• Hypoxia. Ensure adequate oxygenation at alltimes.

• Hyper- or hypocapnia. Maintain PaCO2 at thelower range of normal (4·0 kPa) to preventcerebral vasodilatation. Note that hypocapniawill cause marked vasoconstriction and impaircerebral perfusion.

• Hypovolaemia. Monitor physiological para-meters and capillary refill. Assess responseto fluids and urinary output. Exclude ongoingblood loss. Consider invasive monitoring ofarterial pressure and central venous pressure.

• Seizures. Control early with lorazepam andphenytoin. Suspect seizure activity in theparalysed patient if there is a sharp increase inheart rate and blood pressure with dilatation ofthe pupils.

• Hypoglycaemia.• Anaemia.

Temporary measures to counteract raised ICP

• Nurse in the 30° head up position.• Infusion of IV mannitol (0·5–1·0 g/kg) after

neurosurgical advice.• Maintain the PaCO2 at the lower range of

normal; use of the end tidal CO2 (ETCO2)monitor will help to prevent hyperventilation.


Investigations prior to transfer

Blood tests

Review the results of blood tests and correctabnormalities. Review the indications for cross-matched blood and ensure that it is available fortransfer.

Radiographs

Review the x ray films of the cervical spine, chest,and pelvis, as well as those indicated duringthe secondary survey. Ensure that a decision ismade as to whether the entire spinal column hasbeen cleared, otherwise immobilisation mustcontinue.

CT scans

Consult local guidelines on the indications for aCT head scan which should be performed early.The neurosurgical centre must be contacted withthe clinical details and results of the scan. Often,the CT images can be transmitted simultaneouslyand delays to transfer minimised. If CT scanningis unavailable then the child should betransferred after neurosurgical consultation onthe phone.

Learning pointsA decrease in the level of consciousness may

indicate decreased cerebral perfusion or be due todirect cerebral injury.

An altered level of consciousness indicates a need tore-evaluate the patient’s oxygenation, ventilationand perfusion status.

If hypoxia and hypovolaemia are excluded, changesin the level of consciousness should be consideredto be of a traumatic CNS origin until provenotherwise.

Chest injury

Ten per cent of all injuries from trauma involvethe chest. Always consider thoracic injury inchildren with multiple injuries.

Children have a very pliable chest wall, and intrauma significant kinetic energy transfer mayoccur without external signs of injury. As a resultrib fracture is rare but pulmonary contusion iscommon.

Pulmonary contusion

• Pulmonary contusion may not become apparenteither clinically or radiologically until after thefirst few hours.

• The injury is the result of rupture of pulmonarycapillaries and alveolar haemorrhage.

• The child will become progressively morehypoxic, requiring higher concentrations of FiO2.

• Gas exchange and pulmonary mechanics maysignificantly deteriorate unless recognised andanticipated early.

• Thoracic CT is a sensitive imaging modalityfor pulmonary contusion, especially when theinitial chest radiograph is non-diagnostic.

If the child is shocked the following lifethreatening injuries must be excluded.

• Tension pneumothorax. Air accumulates inthe pleural space, pushing the mediastinumacross the chest and compromising venousreturn to the heart.

• Massive haemothorax. A significant proportionof the child’s blood volume accumulates in thepleural space from parenchymal, pulmonaryand chest wall damage.

• Rare injuries include flail chest, cardiactamponade, open pneumothorax, disruption ofthe major airway and great vessels, anddiaphragmatic rupture.


• Recognise the signs of increased work ofbreathing and hypoxia.

• Provide high concentrations of oxygen andmonitor closely.

• Have a low threshold for intubation andpositive pressure ventilation (IPPV).

• Establish clear indications for an intercostalchest drain.

• Be aware of clinically important complicationsof chest drains.

• If sudden deterioration occurs always considertension pneumothorax.

The risk of a tension pneumothorax is increasedin the following circumstances.

• Occlusion of a chest drain, for example kinkedor clamped.

• Misplacement or inadvertent removal of achest drain.

• The presence of rib fractures and IPPV.• An undrained pneumothorax and IPPV.

Trauma 95

Abdominal injury

The abdomen presents a diagnostic challenge inthe traumatised child; occult haemorrhage needsto be excluded before considering transfer.

If haemodynamic stability has not beenachieved after 40 ml/kg fluid resuscitation, thenthoracic, abdominal or pelvic haemorrhage islikely.

A senior and experienced surgeon must beinvolved early if abdominal trauma has occurred,especially if the child has been shocked.

A combination of factors makes the abdominalcontents of the child very susceptible to injury.

• The abdominal muscles are thin and offer littleprotection.

• The liver and spleen are lower and moreanterior due to a relatively flat diaphragm.

• The compliant lower chest wall offers littleprotection to the underlying organs.

• The full bladder is intra-abdominal rather thanpelvic.

Patterns of injury

• Deceleration injuries. Cause differentialmovement between fixed and mobile organs;for example, falls from a height and RTAsmay cause liver and spleen lacerations anddisruption.

• Shearing forces. Cause a crushing-type injurywhen a restraint device such as a seat-belt(lap-belt or shoulder harness) is incorrectlyworn, causing solid organ disruption andmesenteric injuries.

• Compression or crushing injury. Causescontusion and rupture of solid and holloworgans; for example, a direct blow from a punchor bicycle handlebars may cause duodenal orpancreatic contusion, a punch to the fullbladder may cause rupture.

• Straddling injuries. Cause perineal andurethral injury, for example from a fall orbicycle accident.


The potential for abdominal trauma must becontinually reassessed, if not immediatelyapparent during the primary and secondarysurveys.

• Prior to considering transfer, intra-abdominalinjury must be confidently excluded.

• Any child with blunt traumatic injuriesadjacent to the abdomen must be considered tohave an intra-abdominal injury until it isexcluded.

• If there is any uncertainty, particularly inchildren with head or spinal injuries, then thesenior surgeon must decide whether abdominalultrasound, CT scanning or laparotomy isindicated.

• If haemoperitoneum is identified then non-operative management is not an option for thechild being transferred.

Pelvic fractures

Pelvic fractures are relatively uncommon inchildren but when they occur can cause lifethreatening haemorrhage.

Senior orthopaedic staff must be involved earlyif pelvic fracture is identified. The pelvis may needemergency stabilisation to control haemorrhage(external fixation or a pneumatic anti-shockgarment).

Spinal injury

Spinal injury is relatively rare in children. Thisrelates partly to the anatomical differences. Thereis greater laxity in the interspinous ligaments andjoint capsules. In addition the vertebral bodies arewedged anteriorly and therefore tend to slideforwards with flexion. It is essential, however, tomaintain a high index of suspicion based uponthe mechanism of injury.

Assessment is particularly difficult if thechild is unconscious, frightened, or in pain.Immobilisation techniques are outlined belowunder “Practical procedures”.

Spinal injury is almost always located in thecervical region in children. This relates to the

Learning pointsComplications of IPPV:

Failure to correct hypovolaemia prior toanaesthesia and IPPV may result in profoundhypotension.

Tension pneumothorax may develop after IPPVin thoracic trauma.

Complications of chest drains:Assign a member of the transport team to be

responsible for the chest drain duringmovement of the child, to minimise the risks ofocclusion or withdrawal.


relatively large head and the flexibility ofthe cervical spine in the younger child.Thoracolumbar injuries, when they occur, areusually in children with multiple injuries.

Plain radiology is helpful in detectingpathology but can be compromised by:

• Difficulties in interpreting plain x ray filmsdue to ossification centres, physeal lines,and pseudosubluxation of C2 on C3, and C3on C4

• The presence of spinal cord injury withoutradiological abnormality (SCIWORA). Althoughthis is a rare phenomenon, this probablyrelates to the infrequency of spinal cord injuryitself in children. The incidence in one seriesis reported to be 55% of patients withconfirmed spinal cord injury.

It is important to re-evaluate the clinical signsof spinal cord injury prior to transfer to aspecialist centre and clearly document thesefindings.

High dose steroids may be indicated within thefirst eight hours of spinal cord injury. Discuss thecase with the specialist centre and take advice.Also seek advice on the need to catheterise thechild and the type of catheter to use.

Consider spinal cord injury and neurogenicshock in a patient with hypotension and/or arelative bradycardia, where hypovolaemia hasbeen excluded. This is due to loss of vasomotortone caused by disruption of the descendingsympathetic pathways in the spinal cord.Judicious use of fluid therapy and possiblyvasopressors are required. Seek specialist advice.

Transfer with spinal immobilisation can presentmanagement difficulties. Some ambulance servicesuse ordinary scoop stretchers in preference to thespinal board. An alternative is the vacuummattress which is discussed further below. Theproblems with the spinal board include: inadequatesupport and immobilisation, especially with smallchildren; increased risk of pressure sores; andpain and discomfort in the conscious child.Advanced planning is recommended so that thechild is securely immobilised to prevent anysignificant movement.

Learning pointsThe golden rule is to continue spinal immobilisationuntil clinical examination and relevant investi-gations by experienced personnel can excludeinjury.

Extremity trauma

Limb injuries are common reasons for admittingchildren to hospital following trauma. The initialresuscitation and secondary review will identifythe three main groups of patients.

1. Those with potential life threatening con-sequences, for example multiple limb fractures,crush injuries, traumatic amputation.

a. Follow the ABCs. Prevent furtherhaemorrhage with pressure dressings andtraction splints (see below).

b. Give fluids to achieve cardiovascularstability. Ensure blood is given early.

c. Give broad spectrum antibiotics andcheck tetanus status.

d. Store an amputated limb in theappropriate medium (wrap in moistdressings, place in a sealed plastic bag,and surround the bag with crushed iceand water).

2. Injuries leading to progressive limb or jointthreatening conditions, for example acutecompartment syndrome, vascular compromisedue to joint disruption, or vascular injury itselfdue to a penetrating cause.

a. Positively look for, and exclude, acutecompartment syndrome. This occurs dueto a rise in pressure in any fascialcompartment within the body. Thecommonest and most important signs areacute pain on passively stretching themuscles involved and swelling of theaffected limb. The first may be negatedif the child is unconscious. Sensorydisturbance in the distribution of thenerves running through the affectedcompartment may be present but can bedifficult to elicit and is a poor sign. If indoubt, discuss the case with a seniororthopaedic surgeon. This is a trueorthopaedic emergency.

b. A dislocated joint—commonly the elbowor ankle—is best relocated prior to thetransfer. This may be performed undersedation or general anaesthetic, dependingupon the age of the patient.

c. Acute vascular disruption. Absent orweak distal pulses on clinical examinationor Doppler ultrasound suggest arterialinjury. Angiography is required to identifypathology.

Trauma 97

The severity of these injuries themselvesmay be a reason for transferring the patient, orthey may be of secondary importance to otherlife threatening pathology.

3. Isolated limb fractures that may be open(compound) or closed.

a. These may cause difficulties in intravenousor intraosseous access. Insertion of afemoral line or venous cutdown arealternatives in these circumstances.

b. Remember that blood loss is propor-tionately greater into a fractured long boneor a pelvic fracture than in an adult.

c. Ensure appropriate pain control fortransfer. Limb splintage is discussed below.

Learning pointsCompartment syndrome may be difficult to diagnose

in unconscious or anaesthetised patients.Excessive, abnormal movement of broken limbs may

compromise vessels, exacerbate haemorrhage, andcause pain.

Ensure that all major fractures are appropriatelysplinted and that compound injuries are coveredwith appropriate saline-soaked or Betadinedressings.

Burns

Children suffering burns constitute a significantproportion of children requiring transportation tospecialised centres. All staff should be aware ofthe transfer criteria of their local burns centre.The resuscitation priorities are the same asdescribed above. A number of additional pointsrequire emphasis.

The primary review

It is most important to decide if the child hasany signs that might suggest the potential forairway compromise. Patients at risk includethose with facial burns or singed eyebrows,inhalational steam burns, and those withcarbonaceous sputum. In such circumstances, it isessential to secure the airway by endotrachealintubation prior to transfer.

Consider other causes for respiratory distress.These may be due to mechanical causes as a resultof circumferential burns or chest pathology froma fall.

It is essential to measure carboxyhaemoglobin,to exclude carbon monoxide poisoning, if there

is any suggestion of smoke inhalation fromentrapment in a confined space. Cellular hypoxiamay also be a result of cyanide poisoning.

Circulatory compromise should be treated witha fluid bolus of 20 ml/kg of body weight and theresponse assessed.

Search for any signs of coexisting trauma ifthere is any suggestion of a fall (for example, froma house fire). Spinal immobilisation is then alsonecessary, as well as the exclusion of other lifethreatening pathology.

Assessment of the burn size

Clear documentation must identify the exact timeand extent of the burn, as well as the fluids givensince the time of injury.

The total body surface area (BSA) burnt inchildren is best calculated using the Lund andBrowder charts (Fig. 10.1, Table 10.1). Analternative is to use the palm of the child’s hand(not including the digits), if the area of the burn issmall. This constitutes approximately 1% of thechild’s BSA.

Simple erythema should not be counted in theburn area.

Fluid requirements

The Parkland formula recommends 3–4 ml/kg/%body surface area of the burn. Half of this volumeshould be given in the first eight hours followingthe burn and the remainder over the next 16hours. This fluid is supplemented by the normaldaily requirements of the child.

Additional fluids may be required, based uponindices of end organ perfusion. A urine output ofat least 1 ml/kg/h is a useful guide.

Cardiovascular status, haematocrit andelectrolyte balance will also guide fluidrequirements.

Analgesia and dressings

Pain control should be instituted early. Intravenousmorphine is ideal and should be given in smallaliquots titrated to the pain.

Clingfilm acts as an ideal sterile, non-occlusivedressing which does not need removal to view theburns. Antibiotics, or topical preparations, shouldnot be used unless there is a specific policy withthe burns centre.

Children with burns are particularly susceptibleto hypothermia. Measures to minimise heat loss


must be instituted prior to transfer. Cold soaks areuseful only in the first 20 minutes after a burn,and will exacerbate hypothermia after this time.

Practical procedures

Spinal immobilisation

Indications

The mechanism of injury suggests that injury tothe cervical and/or thoracolumbar spinal columnmay have occurred. Cervical spine injuriesconstitute in excess of 95% of all spinal injuriesin children.

Technique

Cervical spine immobilisation can be carried outby either:

• Manual inline immobilisation (Fig. 10.2) or• Use of a hard collar, sandbags, and tape

(bolsters and straps).

Manual immobilisation is labour intensive andrequires some skill, but is useful when log rollingthe patient and examining the neck. It is alsouseful in the irritable patient who is movingexcessively, by allowing better cervical spineimmobilisation in relation to the trunk.

The hard collar technique has three components,all of which must be present for adequatecervical spine immobilisation. However, thecollar must be properly fitting in order to functionoptimally.

Log rolling the patient

Indications

• Examination of the patient’s occiput, back,thoracolumbar spine, and the back of the legs.

13

1

A

B

C

2

1½

1½ 1½

1¼

1

13

B

C

2

1½

1¼

13/4

A

1¾

Figure 10.1 Calculation of bodysurface area (see Table 10.1 forpercentages of different areas atdifferent ages).

Table 10.1 Calculations of body surface area

Age (years)Area % 0 1 5 10 15

A 9·5 8·5 6·5 5·5 4·5

B 2·75 3·25 4 4·5 4·5

C 2·5 2·5 2·75 3 3·25

Trauma 99

• Also allows removal of debris, broken glass,etc., on which the patient may be lying.

• Safe transfer onto or off the spinal board orvacuum mattress.

Technique (Fig. 10.3)

• Log rolling is a disciplined procedure. Itrequires each member of the team to know hisor her role.

• It is essential, if possible, to explain to thepatient what is going to happen. Give adequateanalgesia prior to the log roll if necessary.

• For a small child (for example, age < 8 years)three persons are required to hold the patientwhile a fourth performs the examination. Allshould be clear about their roles.

Person A: Leads the log roll and holds the headand shoulders. Remember not to cover thechild’s ears—producing deafness will onlyincrease anxiety.

Person B: Places one hand behind the patient’sopposite shoulder and the other just abovethe pelvis.

Person C: Places one hand just below the pelvisand the other just below the opposite knee.

For larger children (for example, age > 8 years),four persons are required to hold the patientwhile a fifth performs the examination.

Person A: Leads the log roll and holds the headand shoulders.

Person B: Places one hand behind the patient’sopposite shoulder and the other just abovethe pelvis.

Person C: Places one hand just below the pelvisand the other just above the opposite knee.

Person D: Places one hand just below theopposite knee and the other below theopposite ankle, maintaining that ankle levelwith the hip so as to minimise any abnormalmovement of the lumbar spine.

Figure 10.2 Manual cervicalstabilisation.

A

B

C

D

Figure 10.3 Log rolling—positionof the team. (Adapted from AdvancedLife Support Group. Advanced PaediatricLife Support, 3rd edn. London: BMJBooks, 2001.)

Confirm that the team are aware of the degreeto which the patient will be tilted (60° or 90°)and what the exact command is to start the roll(for example, “on 3”, “after 3”, “when I say roll”,etc., etc.).

The person holding the head is in charge (teamleader) and coordinates a smooth, slow, inline logroll, ensuring the patient’s nose remains alignedwith the umbilicus. After examination, the teamleader coordinates a smooth log roll back to thesupine position, and replaces hard collar,sandbags, and tape.

Make sure that the examining doctor carefullyinspects the back of the scalp as well. A child canlose a significant proportion of their circulatingvolume from an occipital laceration which ismissed. A rectal examination should not beperformed in children unless strongly indicated.

Use of spinal boards and a vacuummattress

Indications

• A spinal board is primarily of use as anextrication device in helping to removepatients from entrapped vehicles.

• The spinal board should be routinely removedafter the primary survey and resuscitationphases. There are significant problemsassociated with prolonged use.

• The vacuum mattress should be consideredthe preferred spinal immobilisation transfersurface.

Splints

Splints act to control pain and prevent continuinghaemorrhage from fractured long bones.

Indications

• Open or closed fractured limbs.• Postreduction of dislocated joints.

A variety of splints are available.

• Plaster of Paris (POP) can be used toimmobilise limbs not requiring traction.

• A variety of traction splints are available.The two commoner ones that are likely to beused for patient transport are the Hare andSagar splints. Alternatively, skin traction witha Thomas splint may be used.

Analgesia issues

Analgesia is an essential part of safelytransporting the injured child. A number oftechniques are available which can be used eitheralone or in combination.

• Intravenous opiates. Morphine given intra-venously in small aliquots titrated to the painis the best form of analgesia. Antiemetics arenot normally required on a prophylactic basisfor children.

• Femoral nerve blockade is particularly suitablefor femoral shaft fractures. Bupivacaine 0·25%(2 mg/kg) should be used.

• Splinting of injured limbs is essential tominimise pain.

• Entonox (50% nitrous oxide, 50% oxygen)may be given via face mask or mouthpiece fora short time.

• General measures including reassurance anddistraction therapy are extremely important.

Documentation

Ensure that copies of all clinical notes accompanythe child, particularly:

• Prehospital ambulance sheets• All notes made by relevant specialty teams• All blood test results• Details of tetanus toxoid and immunoglobulin• All blood transfusion records• All original x ray films• CT scans and results of other imaging

modalities.

State clearly if specific diagnostic measures havenot been completed, for example:

• Clearance of the spine• Log rolling of the patient• Completion of secondary survey for non-

life threatening injuries to the upper and lowerlimbs.

There should be clear documentation detailingthe senior doctor who has had responsibilityfor the child at the referring hospital as well as acontact name, phone number, and designatedarrival point at the receiving hospital.


Trauma 101

Pitfalls in the transfer of theinjured child

The major principle of trauma management is todo no further harm. Care should consistentlyimprove with each step, from the scene of theincident to the facility which can best provide thepatient with the necessary definitive treatment.

Certain principles are especially important toensure that this occurs.

Decision to transfer

Once the child has been stabilised and the needfor transfer recognised, arrangements should notbe delayed for diagnostic procedures that do notchange the immediate plan.

However, review whether any other emergencytherapeutic procedures need to be performedprior to transfer, for example fasciotomy forcompartment syndrome, splinting of fractures,etc.

Ensure that the relevant specialties at thereferring and receiving hospitals communicatedirectly with each other regarding ongoing traumamanagement.

Inadequate resuscitation

The child must not be transferred untiladequately resuscitated and stabilised, otherwisetransfer can be extremely hazardous with highmorbidity and mortality rates.

Children usually have abundant physiologicalreserve and often demonstrate only subtle signsof hypovolaemia even after severe volumedepletion. When deterioration does occur it isprecipitous and catastrophic.

Evidence of adequate or enhanced end organperfusion provides important evidence ofsatisfactory resuscitation, i.e. capillary refill, CNSstatus, and urinary output.

Monitoring

Ensure that all mandatory monitoring isfunctioning and that alarms are on.

When bradycardia occurs hypoxia must beexcluded.

End tidal carbon dioxide (ETCO2) monitoring ismandatory for all intubated and ventilatedpatients, especially the head injured patient.

Remember that pulse oximetry does notmeasure ventilation or partial pressure of oxygen.

Central venous monitoring is optional. It canprovide an indication of the response to fluidresuscitation, and may be particularly useful inthe child with more than one body system injury.However, central vascular access should only becarried out by those expert in the technique.

Invasive blood pressure monitoring is stronglypreferred.

Hypothermia

Reassess core temperature and minimise exposureof the child. Consider the use of an oesophagealtemperature probe.

Ensure that measures to conserve body heatand rewarm the hypothermic child are enacted;for example, covering all burns, using warmedfluids and humidified oxygen, using warmedblankets.

Consider further active rewarming measures ifindicated.

Summary

Prior to transport, the transport team must ensurethat:The PATIENT has had a primary and secondary

trauma review performed and is clinically stable.All lines and tubes must be well secured

The PERSONNEL involved in the transport possessall the skills to deal with the transfer and those atthe receiving hospital are fully aware of thepatient’s injuries

All PIECES of equipment, drugs and fluids requiredfor the transport are maintained and fullyfunctioning and present

All relevant documentation and PAPERWORK travelwith the patient

The PARENTS or carers of the injured child areaware of the need for the transfer, andarrangements have been made for them to travel tothe receiving hospital.

11 Special transport interventions

Inhaled nitric oxide

Background

Inhaled nitric oxide or iNO is in common use inmany paediatric and neonatal intensive care units.It acts as a selective pulmonary vasodilator, whichcan improve VQ matching in the lung, therebyimproving gas exchange. It also reducespulmonary artery pressure, which can be useful inpatients with congenital heart disease or persistentfetal circulation. NO is made by pulmonaryvascular endothelium (and other tissues) whenL-arginine is cleaved by nitric oxide synthase(NOS), releasing NO and citrulline. It has a half-life in the circulation of around 6 seconds as itimmediately binds to haemoglobin to form met-haemoglobin; this reduced form of haemoglobindoes not carry oxygen. NO stimulates theintracellular production of cyclic GMP.

iNO in clinical practice

In clinical practice iNO is added to the ventilatorgases in a concentration of 5–20 ppm; thisimproves oxygenation and has a moderate effect onpulmonary artery pressure. iNO is proven toreduce the need for extracorporeal membraneoxygenation (ECMO) in term neonates (exceptcongenital diaphragmatic hernia); however, thereare no studies in any patient group whichdemonstrate that iNO can reduce mortality. Whenstarting iNO it is usual to have an improvementin oxygenation within a few minutes. Onlyapproximately 5% of neonates who do notrespond to 20 ppm iNO will have a response to80 ppm. However, doses of around 80 ppm maybe needed if iNO is being used to treat pulmonaryhypertension. NOS is rapidly downregulatedwhen iNO is started, so that the patient’sendogenous NO production is greatly reduced.In many patients this leads to severe rebound

pulmonary hypertension and hypoxia if iNO isinterrupted. Rebound can occur even in patientswho do not respond. It is therefore essential that allpatients who do not respond quickly have theiriNO stopped before downregulation of NOS occurs(usually around 30 minutes). It is this reboundphenomenon which makes mobile iNO necessary,as patients who have received iNO for more than afew hours will usually be unable to tolerate itswithdrawal during transport. In addition iNO is auseful tool to improve the condition of a criticallyhypoxic neonate. When taking the referral of apatient who is receiving iNO it is essential toestablish if mobile iNO will be required. Thetransporting team may ask the referring intensivistto attempt to wean the iNO off and assess thechild’s response. However, it is usually impossibleto withdraw iNO successfully, making retrieval onthe mobile iNO system necessary.

iNO set up for retrieval

The most suitable ventilators for iNO therapy arethose with a constant set gas flow. Ventilatorswith variable flow are acceptable if the gas flow iscontinuous, but those where the flow stops onexhalation are unsuitable without bulky andheavy iNO dosing apparatus.

A simple system (Fig. 11.1) is described below.

Delivery

A small gas cylinder (e.g. BOC’s AZ size) isadequate for around five hours’ use at 20 ppm. Itshould be fitted with a regulator to deliver lowpressure; about 0·5 bar is suitable. This feeds aflowmeter of range approximately 0–500 l/min,from which a line takes the set flow to theventilator circuit, well upstream of the patient toallow good mixing. The required flow of gas canbe found from the formula:

ppm NO required × flow of gas in vent circuit

ppm NO in cylinder

A “ready reckoner” is easy to make up, and handyto decide the required gas flow quickly.

A useful refinement is to have a diverter valveallowing the NO to be used in a bagging circuit.

ObjectivesThe use of special transport modes will be

discussed. This will include the use of inhaled nitric oxide,

nebulised prostacyclin, continuous positiveairways pressure, prone ventilation, highfrequency oscillation, and extracorporealmembrane oxygenation.

Special transport interventions 103

Otherwise the whole line can be moved to a bagfor manual ventilation if required.

Monitoring

Gas should be sampled from near the patientY-piece. A monitor with a pump is preferred,since these have less trouble with water trappingin the line.

Scavenging

Since retrieval episodes are relatively short, andthe air on most roads rich in oxides of nitrogen,scavenging may be regarded as optional. However,NO absorbing filters are available for theexpiratory side of the vent if desired.

Leak monitoring

It is advisable to carry an environmental monitorin case of leaks arising between the cylinder andthe flowmeter. Unlike the breathing gas, leaks of1000 p.p.m. could present a hazard.

Safety requirements

Although a safe treatment when used correctly,iNO therapy has some inherent hazards. It isimportant that the retrieval team are fully trainedand experienced in its use.

Nitrogen dioxide

NO oxidises to toxic NO2 in oxygen. The industrialsafe limit for NO2 inhalation is 5 ppm; the clinicallimit is 2 ppm. To minimise NO2 exposure, it isvery important to purge the NO delivery system

thoroughly by running it at high flow for a coupleof minutes before connecting it to the patientcircuit. Once running, NO2 usually settles at0·2 ppm or below.

Accidental leaks

Should the environmental monitor go off,check all fittings between the cylinder and theflowmeter immediately. But note that thesemonitors give false alarms in the presence ofhydrocarbons, for example, from the ambulanceexhaust, alcohol wipes, etc. NO2 has a distinctiveharsh metallic smell.

Interruption of NO to patient

When a patient has become NO dependent, theirO2 saturation drops rapidly if iNO is removed. Itis important to carry enough gas, and have alllines secure. It is easy to forget that iNO must beswitched over to the hand ventilation circuit inthe heat of resuscitation.

Methaemoglobin

This may rise during iNO therapy, and should bemonitored; however, this is rarely a considerationduring transport.

In-flight use

The Civil Aviation Authority does not allow iNOto be used in civilian aircraft in the UK. However,no such prohibition exists for military aircraft andiNO has been used extensively in RAF Sea-Kinghelicopters. Since the Sea-King is fairly draughtyand has a large side door that can be opened in

NOinN2

Ventilator

ON

GLASSFLOATml/min

STEELFLOATml/min

0

90

100

200

0

140

200

300

OFF

NO/NO2monitor

Figure 11.1 An iNO circuit. Notethe position of the monitoring pointnext to the Y-piece.This may be onthe inspiratory or expiratory limbsnear to the Y-piece—where tomeasure from is largely a matter ofconvenience, using the existing breaksin the circuit. In practice, on ourtransport circuit, we deliver NO to aconnector at the beginning of theinspiratory limb and measure from aport in the Y-piece.


flight, it would be possible to provide goodventilation to the cabin space in the event of acylinder leak. We do not believe that iNO hasbeen used in a fixed wing aircraft in the UK.

Results of mobile iNO use

In a series of 55 paediatric and neonatal patientstransported on iNO over a 1·5 year period, 19were moved by helicopter and 36 by road. ThePaO2 improved from a mean pretransport value of7·23 kPa (SD 5·26) to a mean level of 11·23 kPa(SD 7·32); there were no deaths or criticalincidents.

Nebulised prostacyclin

Background

Prostacyclin or prostaglandin I2 is in routineclinical use as an IV vasodilator and antiplateletagent. It has a half-life of around two minutes andso is usually given as a continuous infusion. It isa non-selective vasodilator and will causepulmonary and systemic vasodilatation if givenIV. In higher doses IV prostacyclin can causemarked systemic hypotension. In common withall IV vasodilators, prostacyclin tends to dilate theperfused segments of lung and can thereforeworsen VQ mismatch. However, administeringthe prostacyclin by nebuliser circumvents theselimitations, as the drug is delivered to theventilated segments, thereby improving VQmatching. Systemic absorption is also reduced,making systemic hypotension less of a problem.

Indications

Nebulised prostacyclin may be helpful in patientswho will not wean from iNO or in criticallyhypoxic patients if mobile iNO is unavailable.

Administration

An inline nebuliser is placed in the inspiratorylimb of the ventilator circuit. Oxygen is connectedto the nebuliser and the flow rate adjustedaccording to the child’s weight and lungcompliance. Obviously the flow must be highenough to cause nebulisation, usually around5 l/min. It may be necessary to reduce the flowrate from the transport ventilator to offset thenebuliser flow. A 50 ml syringe of prostacyclinis prepared according to the manufacturer’sinstruction (500 micrograms in 50 ml of thebuffered diluent) and placed in a syringe driver.A 200 cm manometer line is connected to thesyringe and primed, the manometer line is thenintroduced so that the drug enters the reservoir ofthe nebuliser (Fig. 11.2). The syringe gun is thenset to deliver a dose of 50 nanograms/kg/min (thisis about 10 times the IV dose).

Continuous positive airwayspressure

Continuous positive airways pressure (CPAP) iswidely used in neonatal intensive care. Althoughpredominantly used as a weaning tool, a growingnumber of units are investigating the role ofCPAP in conjunction with a developmentallysupportive care regimen as the primary mode of

O2 in

Standard nebuliser

From ventilatorTo

patient

Airtight seal

200 cm manometer lineProstacyclin

Syringe driverset at

50 nanograms/kg/min

Figure 11.2 Set up for nebulisedprostacyclin.


respiratory support for many infants who mighttraditionally have been intubated and ventilated.Intubation is used to give surfactant if indicated,but with rapid extubation to CPAP. Good resultsappear possible with this approach to neonatalintensive care, which is widely practised inScandinavia. Anecdotally its use is increasing insituations where infants would normally beintubated and ventilated for transfer.

CPAP may be delivered from a conventionalventilator using a short nasal tube or a proprietaryCPAP device (INCA, Ackrad Laboratories, NJ,USA). The EME infant-flow CPAP driver (EME,Brighton, UK) is also available in a battery drivenversion that is suitable for transport, though itsgas consumption is considerable and may beproblematical on long transfers.

More research is needed on the risks andbenefits of using CPAP in transport of acutely illnewborn infants.

Prone ventilation

Background

Prone positioning is in increasing use in adultand paediatric intensive care as a tool to improveVQ matching in patients with adult respiratorydistress syndrome (ARDS) and pneumonia. Thesepatients develop consolidation in the dependentposterior portions of their lungs as they liesupine. Turning them prone can result inimproved VQ matching by redirecting blood flowto the now dependent anterior portions of thelungs. In addition there may be improvedrecruitment in the consolidated posterior area.Many patients experience an improvement inoxygenation when turned prone, but there isas yet no evidence demonstrating improvedoutcome. Better oxygenation and lung mechanicshave also been demonstrated in neonates, both

ventilated and unventilated, when cared for in theprone position.

Indications

Some patients become unstable when they areturned back to the supine position. It may benecessary to transport these patients in the proneposition.

Risks, benefits, and precautions

The prone position makes access to the airwayimpossible and makes external cardiac massagedifficult. It is therefore essential to establishthat the level of instability when the patient isturned supine would preclude transport; in otherwords that the risks of the prone position areoutweighed by the benefits of being able to movethe patient. Extra care must be given to thesecurity of the endotracheal or tracheostomy tubeas well as the central venous and arterial lines.Pillows are arranged transversely on the stretcherto cushion the patient’s head, chest, pelvis, andknees. Gaps are left between the pillows for theendotracheal tube, and to allow diaphragmaticexcursion (Fig. 11.3). In newborn infants thesecurity of umbilical lines must be very thoroughlychecked before transfer in the prone position. If aline fell out, substantial blood loss could gounnoticed. The benefits and risks of proneventilation for transported infants have not beeninvestigated.

High frequency oscillation

Background

High frequency oscillatory ventilation (HFOV)is in widespread use in many neonatal and

Space to allowdiaphragmatic

excursion

Space forendotracheal

tube

Figure 11.3 Position of patientfor transfer during proneventilation.

paediatric ICUs. HFOV reduces acute and chroniclung injury in neonates, and seems to be successfulin older children with isolated respiratory failure,but not those with extrapulmonary disease. It hasalso been used more successfully than conventionalventilation in neonatal ECMO candidates, butseems ineffective in those with higher oxygenationindexes. HFOV is not recommended in prematureinfants outside the settings of a randomisedcontrolled trial. There are no published studiesdemonstrating an improved outcome with HFOV.

HFOV is used in a “high-volume strategy” torecruit collapsed portions of lung, thereby reducingVQ mismatch and improving oxygenation. It iscommon practice to use a higher mean airwaypressure on HFOV than during conventionalventilation, but because the sheer stress iseliminated (as there is no mass gas flow duringHFOV) the amount of ventilator induced lunginjury is reduced. Similar improvements inoxygenation have been achieved in the laboratoryif a sufficiently high mean airway pressure andPEEP is used during conventional ventilation toachieve lung recruitment. Some children who arereceiving HFOV do not tolerate the switch back toconventional ventilation, even when higherairway pressures are used. This may be due tohaemodynamic instability or because of reducedCO2 clearance.

Mobile HFOV

The VDR-3C (Percussionaire, Sandpoint, Idaho,USA) is a hybrid ventilator which can providemobile HFOV. It has been used by a number ofteams in the USA and Canada but is not yetavailable in the UK. Currently therefore there isno solution in the UK to the problem oftransporting a child receiving HFOV who cannotbe stabilised on conventional ventilation andiNO.

Mobile extracorporealmembrane oxygenation

Background

Extracorporeal membrane oxygenation, or ECMO,uses a modified cardiopulmonary bypass circuitto provide prolonged cardiorespiratory support inthe ICU. It may be used for patients of any agefrom 34 weeks’ gestation up to adulthood, with

potentially reversible respiratory or cardiacfailure that is refractory to conventionaltreatment. ECMO is proven to result in improvedoutcome in term babies with severe respiratoryfailure compared to conventional ventilation.Patients who are referred for ECMO are usuallyextremely hypoxic and often haemodynamicallyunstable and as such they pose a considerablechallenge to the retrieval team.

Mobile ECMO

Despite the seeming instability of these patientsthe vast majority can be transported with a goodoutcome—in nearly 750 transports of neonatesand children with severe respiratory and cardiacfailure over a four year period there were no deathsduring transport. However, it remains a concernwhen faced with the prospect of transporting anunstable patient with end stage cardiorespiratoryfailure. In order to address this problem a numberof units have developed the capability to establishthe patient on ECMO at the referring hospital.This facility is only used for the most unstablepatients who are believed to be at greatest risk ofdeath during transport. Despite this the survivalin the group of patients who are retrieved onECMO is usually better than that in patients whoare transported conventionally.

Obviously the provision of mobile ECMO is ahuge logistical exercise involving the participa-tion of a large multidisciplinary team and theextensive use of resources. Mobile ECMO circuitsin current use are very similar to those in hospitaluse, with the exception of the type of pump used.Whilst some systems use a standard servoregulatedroller pump (in both neonates and adults), themajority use centrifugal pumps which are not incommon use in hospitals. Centrifugal pumps arefelt to be superior to roller pumps during mobileECMO, as they are safer in the event of inflow oroutlet obstruction. This means that they are lesssensitive to acceleration and deceleration thanroller pumps. The ability of a centrifugal pump toexert venous suction to improve venous drainageis a definite advantage during retrieval, whenincreasing the height of the bed above the pumpcannot be used to increase the venous siphon.This same property causes haemolysis duringprolonged hospital use of the centrifugal pump ifthe inlet pressure is not regulated. Mobile ECMOis currently under development in the UK andshould be available for clinical use soon.



SummaryThe most important factor in the decision to use

special transport modes is the evaluation of therisk : benefit ratio between not transporting thepatient and taking the risk of transport.

Tolerating a lower PaO2 than normal, whilst ensuringadequate perfusion and a normal haematocrit,may allow you to transfer the patient to a centrefor definitive care.

The use of permissive hypercapnia, often withthe use of buffers, can allow transport with aconventional ventilator.

The ability to use iNO during transport is a greatadvantage but has not been shown to alter outcome.

Prone ventilation is useful in intensive care, but addsto the stress of transport for the operator,particularly in the larger child and adolescent.

Inappropriate referrals

There will be a small minority of referrals wherethe child does not appear to be “sick enough” forthe intensive care unit (ICU). In this case it isimportant to ascertain that you have recorded thehistory accurately.

• Ask what particular features are giving thereferring team concern, as this may help you toidentify abnormal clinical signs or symptomsthat you have missed.

• Is the referring physician of appropriateexperience to assess the child? Referralsshould ideally be made at consultant level.

• What is the workload and skill mix of thereferring hospital? Is the child being referred ona Friday afternoon because staffing levels overthe weekend mean that the hospital cannotmaintain care for a “high dependency” patient.

In all cases it is important to maintain communi-cation with the referring clinicians, whether ornot the child is accepted for intensive care.

Very rarely the ICU will receive calls frompractitioners in the community when an emergencyambulance is needed. First aid and basic lifesupport advice should be given, but this should notdelay a call to the ambulance service being made.

Referrals from a second source—for example, aplastic surgery registrar who accepts a child withburns and who then phones the paediatricintensive care unit (PICU) “for a bed”—should bediscouraged, as there is no opportunity to giveadvice on stabilising the child, and importantdetails may be lost or forgotten. In any case, theclinicians actually caring for the child at the time

of the referral should be contacted for informationdirectly.

Children referred inappropriately for the expertiseof the unit—for example, referral of a head injury toa centre that doesn’t have neurosurgery—should bereferred on to a more appropriate centre. Somecentres that provide retrieval services prefer to dothis themselves, allowing the referring clinicians tospend more time stabilising the child.

Some children will improve before you arrive atthe referring hospital, so that they no longer needintensive care. If there is any doubt, bring themback to the ICU, as the improvement may only betemporary.

Unsalvageable child

Occasionally you will arrive at the referringhospital to find that the patient has deterioratedin the interim and is now clearly not going tosurvive.

• How much intervention do you undertake? • Do you scoop and run back to the intensive

care unit, or do you withdraw intensive care atthe referring centre?

• Should you retrieve patients just to “manage thedeath”? Or should the child stay at the referringcentre who may know the family better?

• Does the amount of intervention given dependon the expectation of the referring team?

These are all very difficult questions that willdepend on the local situation and the seniority ofthe retrieval team. It is impossible to beprescriptive and the following comments will notapply to all situations.

Both the family and the referring hospital willwant to know that everything possible has beendone for the child, and so a full assessment andaggressive treatment of immediately remediableproblems should be undertaken. Therefore ensurethat the airway is patent and that ventilation isadequate. Consider giving volume and inotropes.

Most importantly, discuss the situation withbase, the referring clinicians, and the parents.Their expectations will guide you. An importantaspect of the situation is that the parents may

12 What to do when itall goes wrong

ObjectivesWith adequate preparation and intervention, mostretrievals will pass off without any problems. It hasbeen demonstrated that even the sickest patients canbe transferred safely if the accompanying staff havethe appropriate training and equipment. However,sometimes things do go wrong, and some daysit will seem as if everything is going wrong. Thepurpose of this chapter is to discuss some situationswhere problems may arise, and to suggest strategiesfor dealing with them.

What to do when it all goes wrong 109

need time to “say goodbye”, and to allow otherrelatives to be with the patient before he or shedies. Time to undertake religious ceremoniessuch as baptism may be needed. It is not aninappropriate use of an ICU bed to allow time forthis to happen, either by bringing the child backto base, moving to an adult ICU in the referringhospital, or providing intensive care for a longertime than normal in the child’s current location.

Some practitioners feel that transferringsuch children from a unit where they may knowthe staff to a regional ICU where they do not isunnecessary and unhelpful. Don’t forget thattransferring these children to “manage the death”imposes a significant emotional and psychologi-cal burden on your own staff.

The situation may be different if the child isreferred to a specialist centre, for example, forextracorporeal membrane oxygenation or neuro-surgery, where specialist intervention may be lifesaving.

The potential for organ donation should not beforgotten and should be discussed with the organtransplant team, the referring team and, whereappropriate, with the parents. If organ donation is apossibility, intensive care will need to be continued.

Death in transit

This is fortunately rare, although there are onlyanecdotal data on its incidence. If a child arrests,and resuscitation is unsuccessful, a number ofquestions arise.

How long to continue resuscitation? This willdepend to some extent on the seniority of theescorting team. It can be very lonely in theback of an ambulance, and there will be verylittle peer support to help you decide thatfurther resuscitation is futile. No hard andfast rules can be made. However, the sameguidelines for continuing resuscitation inhospital apply in transit.

What is the diagnosis? In hypothermia andsome poisonings you may continue cardio-pulmonary resuscitation (CPR) for a lotlonger than normal.

Where are you going? If you are transporting thechild to a centre for a particular life savingtherapy, it may be justified to continue forlonger.

How far away are you from base, or analternative hospital? If you are close,continue until you arrive and can get help.

Nurse practitioners cannot certify death. Acollapse during a transfer led by an advancedneonatal nurse practitioner mandates fullresuscitation being continued until the babyis delivered to a medical team.

However long you continue for, remember two rules:If you’re doing CPR, make it good CPR.Any hospital is a better hospital than the back of an

ambulance.

If the child dies in the back of the ambulance, it isbest to go to wherever the parents are. If theparents are already on their way to your ICU, youshould probably continue there to be with theparents. Alternatively you may need to return tothe referring unit. Do not be misled by anecdotalconcerns about place of death and countyboundaries being the determining factors inwhere you should go to.

In general, deaths occurring during retrievalshould be referred to the coroner. Depending onlocal policies, lines and endotracheal tubesshould be left in situ until after discussion withthe coroner.

Morbidity in transit

Previous studies have suggested a high levelof untoward incidents during interhospitaltransport. Most of these related to equipmentfailure (often power related) or failure torecognise poor oxygenation and shock. Suchincidents are reduced by appropriate training ofstaff, forward planning and familiarity withretrieval equipment.

Dealing with parents

It may be your fourth retrieval of the week, but forthe parents and family of the child the situation isa unique, unforeseen crisis of immeasurableproportions. Not only is their son or daughtercritically ill, but they are about to be taken on adangerous journey to a distant hospital bycomplete strangers. The physical appearanceof the child and the dramatic nature of thearrival of the retrieval team only heighten theparents’ feelings that the child is in imminentdanger.

Initially, parents go through a feeling of shockand disbelief, accompanied by helplessness.

Coping mechanisms at this stage may includeaggression, regression, withdrawal, or repression.It is important that the retrieval team respond tothese manifestations to enhance the parent’scoping strategy. Thus verbal expressions of anger,guilt or animosity should be met with reassuranceand acceptance. Emotional outbursts may beexpected, and reassurance that the child is beingappropriately cared for and comforted can reduceparental anxiety.

Parents need information about their child, andthey need to know that the retrieval team care forthe child as an individual in his or her own right.Therefore make time to speak privately to theparents. Make sure that you know the child’sname, and give the parents the opportunity toexpress their fears and ask questions.

The parents will remember little of what is saidto them at this stage. Give the most importantinformation first, and summarise it at the end ofthe discussion. Be realistic and do not be afraid tosay that you do not know the answers to certainquestions. Be careful not to undermine the caregiven by the team at the referring hospital.

Loss of physical control for the wellbeing oftheir child is a major stress for the parents. Thismay be reduced by allowing them access to thechild during the stabilisation phase. Typically,one of the staff from the referring team may beallocated to explain to the parents what is beingdone and why. Other major stresses are seeingthe child in pain or frightened, seeing the childunable to communicate, and not knowing howbest to protect the child.

In most cases, it is not possible for the parentsto travel with the child on the return journey tothe intensive care unit. Separate transport shouldbe arranged, or they need to be given specificdirections to the hospital, information on parking,and directions to get to the intensive care unit.They should be discouraged from trying to followthe ambulance.

Debriefing and staff support

Intensive care is by its very nature stressful, andtransporting very sick children in a strangeand hostile environment, isolated from normalsupport, may lead to a great deal of anxiety in theretrieval team.

Improvements occur following reflectivepractice and structured debriefing that allow theteam to identify aspects of the retrieval that have

gone well, and those that have lead to problems orpotential problems. These debriefings should benon-judgemental and may be best facilitated by apsychologist or appropriately trained counsellor.

Structures exist in both the medical andnursing professions for dealing with concernsabout poor staff performance. Initially theseshould be addressed in private with the personconcerned by their mentor, line manager, or theunit’s retrieval coordinator.

Audit and critical incidentmonitoring

Monitoring the quality and effectiveness of thecare delivered during the retrieval process isfundamental to the delivery of a high qualitytransport service. Information is needed not onlyon utilisation of the service, to enable futureplanning, but also on management aspects ofeach retrieval to identify features that characterisethe optimum retrieval and those which needimprovement or change. Reflection and review ofeach retrieval in a semistructured forum will alsobe educational for staff and trainees. Transportalways happens in isolation, and is often apowerful learning experience for the individualsinvolved. The purpose of these sessions is toallow the whole team access to these experiences,so that the learning is shared.

Accurate information gathering is paramount tothe success of a quality improvement programme.For this reason, data collection should be made aseasy as possible, and should be organised so thatdata collectors not only know the relevance of theforms they are being asked to complete, but alsohave a vested interest in ensuring that they arecompleted accurately. Checks should be built into the system to provide information on the dataaccuracy and feedback to the staff.

Review meetings may be held regularly tofeedback to staff about changes in the retrievalservice, administrative issues, performanceindicators, and also to go through specificretrievals to highlight areas where there have beenproblems.

Critical incident monitoring is essential to therunning of an intensive care service. Mistakeshappen and problems occur primarily becauseof a fault with the system (whether it be intraining, communication, or a specific fault withequipment) rather than a fault with individuals.


What to do when it all goes wrong 111

For this reason, critical incident monitoringshould be anonymous and non-judgemental.

Transport services should have robust incidentreporting procedures to pick up when there hasbeen a serious problem or near miss during ajourney. In most cases these should be used as alearning tool rather than a disciplinary matter. Inparticular, other members of the transport teamshould hear about the problem so that they canlearn from the key features of the incident so thatthey might respond appropriately should thesame thing happen to them.

As far as we are aware, there is no mechanismfor the accreditation and training of intensivecare staff in paediatric and neonatal critical caretransport. In-house training, evaluation andaccreditation is therefore of importance. Coursessuch as the Neonatal Life Support course and theAdvanced Paediatric Life Support course willgive practitioners many of the skills in specificaspects of caring for a patient during interhospitaltransfer.

Severity of illness andscoring systems

Reference has already been made to the GlasgowComa Scale. Other scoring systems are also usefulfor prognostication and for audit. The GlasgowMeningococcal Septicaemia Prognostic Score(GMSPS) is a specific risk of mortality score formeningococcal septicaemia (Table 12.1). In oneseries a score of 9 or more had a specificity of 95%and a positive predictive value for death of 74%.

Other severity of illness scores, such as thePaediatric Risk of Mortality (PRISM) score or thePaediatric Index of Mortality (PIM) score, may beused as audit tools. Both of these scores use thedata collected from the first contact of theintensive care team with the patient, rather thanthe physical admission of the child to the PICU,so it is important to collect accurate data from thetime of arrival at the referring hospital. Theneonatal retrieval forms in Appendix 1 show how

Table 12.1 Glasgow Meningococcal SepticaemiaPrognostic Score

a transport score can be used to easily collectreadily available data at critical points on atransfer.

A number of transport teams use interventionrecords or intervention scores such as theTherapeutic Intervention Scoring System (TISS)to quantify the medical and nursing activityduring transfer. Typically, intervention scoresincrease prior to transfer as the retrieval teamintubate, cannulate and catheterise to ensure asmooth run home.

SummaryWith prior preparation, a sound knowledge of the

equipment used, and good clinical skills, mostretrievals should occur without incident.

Occasionally difficult clinical, administrative andethical problems arise that would tax the skills ofmost of us. Forethought and prior discussionwithin the retrieval team will help you deal withthese, and advice from colleagues at your basehospital during the retrieval is invaluable.

Finally, after the dust has settled, revisit the problemwith your colleagues and determine how to dealwith it next time.

Risk factor Score

Systolic BP (< 75 mmHg age < 4 years, 3< 85 mmHg age > 4 years)

Core/peripheral temperature gap > 3°C 3

Modified Coma Scale < 8, or deterioration 3of ≥ 3 points in 1 hour

Deterioration in clinical condition in the 2hour before scoring

Absence of meningism 2

Extending purpuric rash, or widespread 1ecchymoses

Base deficit ≥ 8·0 (arterial or capillary) 1

Maximum score 15

To be able to practise safely, a sound knowledge ofthe pharmacology of drugs that are commonlyused in intensive care is vital.

ObjectivesTo know the dose, effects and side effects of the

drugs commonly used when transferring criticallyill patients between hospitals.

To understand some of the practical issues in theadministration of those drugs.

To be able to prescribe and administer intravenousfluid therapy appropriately.

To remember that neonates handle drugs differently.

The following are the common groups of drugsthat are relevant to the care of the critically illchild and neonate:

• Analgesics• Sedatives• Muscle relaxants• Vasoactive drugs• Steroids• Anticonvulsants• Antiarrhythmics• Antihypertensives• Neonatal respiratory drugs.

Each group will be discussed, giving the onsetand duration of action, the dose, the main sideeffects and any critical issues involved in theadministration of the particular agent.

As with all textbooks and guidelines, the readerhas the responsibility to ensure that the drugsand dosages given here are appropriate for anyparticular patient. Although we have checkedthese carefully, no responsibility can be taken forany errors that have slipped through. The readershould become familiar with the use of a few keydrugs, many of which are discussed below.

Analgesics

The control of pain is one of the most importantfunctions of the team looking after a critically illchild. The ability of neonates and infants to feelpain has been poorly recognised in the past andhas led to inadequate treatment.

The aim of providing analgesia and sedation isto provide hypnosis and pain relief, and to reduce

the normal sympathetic response to variousnoxious stimuli, as well as leaving the patientwith as little memory of the episode as possible.Sedation and analgesia also help to slow downmetabolism in a sick and agitated child as well aspromote more efficient breathing. Transportedventilated infants and children should routinelyreceive pain relief and sedation.

The most commonly used analgesics are theopiates. Of this group, the two most frequentlyused are morphine and fentanyl.

Morphine

Provides excellent analgesia and sedation.

Onset of action: 5 minutes.

Duration of action: 3–5 hours.

Dose: As a bolus, 0·1–0·2 mg/kg IV. As aninfusion, 5–40 micrograms/kg/h. Infusion forneonates: 5–10 micrograms/kg/h.

Side effects: Respiratory depression.

Neonates are more sensitive to morphine as theimmature blood–brain barrier allows more drug topenetrate into the brain. In addition, it is clearedless predictably and more slowly in the neonate,predisposing to higher drug levels.

It also causes reduced gastric and intestinalmotility, nausea, vomiting, and pruritus. Inaddition, morphine is vagotonic and may causebradycardia.

Critical issues: Equipment to support the airwaymust be on hand while administering opiates tocritically ill patients. If its antagonist naloxone isadministered to combat respiratory depression,the analgesic effect is also reversed and that needsto be addressed.

Morphine is associated with histamine release,which is detrimental to a hypotensive patientor an asthmatic. Use boluses of morphine withcare and have fluid drawn up to administer ifnecessary.

Morphine can be administered IV, IM, or SC.

Fentanyl

Is more potent than morphine but shorter acting.

Onset of action: Almost immediate.

13 Drugs

Drugs 113

Duration of action: 30–60 minutes.

Dose: As a bolus, 1–5 micrograms/kg IV slowly.As an infusion, 1–10 micrograms/kg/h.

Side effects: Like morphine but causes lesshistamine release. Doses above 15 micrograms/kgare associated with chest wall rigidity and will needmuscle relaxants to be administered simultaneously.

Critical issues: As it is associated with lesshistamine release, it is “cardiovascularly” stableand is commonly used for cardiovascularanaesthesia. It can also be used in bronchial asthma.Not widely used in neonatal intensive care, due tothe side effect profile and serious withdrawalsymptoms.

Ketamine

An intravenous anaesthetic agent with powerfulanalgesic properties.

It is one of the most commonly used IVanaesthetics prior to intubation, be it rapidsequence intubation or elective. Its effects on theblood pressure are either to cause no change or tocause an elevation in the blood pressure. It istherefore one of the anaesthetics of choice in thesetting of hypovolaemia and hypertension.



Dose: 1–2 mg/kg as an IV bolus.

Side effects: It can cause an increase intracranialpressure hence is contraindicated in pathologicalstates of raised intracranial pressure. It can alsolower the seizure threshold and should be usedwith caution in status epilepticus.

Critical issues: It can be given intramuscularly ifthere is no IV access.

Also ketamine is associated with post-anaesthetic emergence reactions such as dreams,hallucinations, nightmares. These side effects areminimised by pretreatment with benzodiazepines.

Not widely used in neonatal intensive care.

Thiopentone

Short acting barbiturate which is used as anintravenous anaesthetic and an anticonvulsant.

It is the drug of choice for anaesthetising a patientwith raised intracranial pressure for rapid sequenceintubation. It can also be used as a continuousinfusion in refractory status epilepticus.



Dose: 2–4 mg/kg IV.

Side effects: Rapid IV injection can causehypotension. Higher doses can cause myocardialdepression.

Critical issues: Reduces cerebral metabolism,hence used in raised intracranial pressure. Higherdoses can cause loss of pupillary reactions. Notwidely used in neonatal intensive care.

Sedatives

Critically ill children are usually also veryanxious and frightened. Therefore apart fromproviding analgesia it is equally important toadminister sedatives to provide reduction ofanxiety, sedation, and amnesia, and in manysituations to provide an anticonvulsant effect.

The most commonly used IV sedatives are thebenzodiazepines.

Midazolam

Currently the most commonly used IV sedative.

Onset of action: 1–5 minutes.


Dose: 0·1–0·2 mg/kg IV as a bolus. Doses up to0·5 mg/kg may be used.

Can be used as an intravenous infusion in thedose of 1–10 micrograms/kg/min. In newborns,start at 1 microgram/kg/min. In infants less than33 weeks’ gestation this dose must be halved after24 hours to prevent drug accumulation and thepossibility of encephalopathic illness.

Side effects: Can cause respiratory depression butthat is seen more often when used concomitantlywith opiates. Hypotension especially if adminis-tered rapidly. Withdrawal and dependence.

Treatment of overdose is with flumazenil.

Critical issues: Midazolam is a very goodanticonvulsant and can be used as an infusionin spontaneously breathing patients to providesedation or an anticonvulsant effect. Causes lessrespiratory depression than diazepam.

Diazepam

Currently its main use in the ICU setting is as ananticonvulsant.



Duration of action: May be > 24 hours

Dose: 0·1–0·2 mg/kg IV.

Side effects: Respiratory depression is relativelycommon when given as a rapid IV push. Can becaustic on veins. Hypotension due to reduction inperipheral vascular resistance and venous return.

Critical issues: If the patient becomes apnoeicsupporting the patient with bag-valve-maskventilation for a few minutes is often adequaterather than jumping in and intubating the patient.Rarely used in neonatal intensive care.

Lorazepam

Recent addition to the selection of clinicallyuseful sedatives.


Duration of action: 4–6 hours.

Dose: 0·05–0·1 mg/kg IV as a bolus. 25micrograms/kg/h as an IV infusion.

Side effects: Similar to other benzodiazepines.

Critical issues: Good anticonvulsant and causesless respiratory depression than diazepam.

APLS guidelines suggest using lorazepam as thefirst line anticonvulsant. Rarely used in neonatalintensive care.

Muscle relaxants

Are used more commonly in paediatric intensivecare than in adult or neonatal intensive care.

Broadly, there are three situations for use ofmuscle relaxants.

1. For rapid sequence intubation (RSI) in a childwho is rapidly deteriorating regardless of theunderlying pathology.

2. For semielective intubation in a child withpotential respiratory failure, who is steadilyworsening. In general, suxamethonium is themuscle relaxant of choice in this situation (seebelow).

3. To allow artificial ventilation to proceed in aninfant or child who is “fighting” the ventilator.

For infants and children in whom you wish tomaintain muscle relaxation for transfer, choosean agent such as atracurium that may be given

by infusion. When using muscle relaxants ascontinuous infusions, the team caring for thechild must regularly reassess the indication forthe drug and monitor the depth of paralysis.

It is also of paramount importance to ensurethat while a child is paralysed, he/she has adequatesedation/analgesia. In addition, remember thatalthough a child cannot overtly fit when paralysed,they may still actually be fitting.

Muscle relaxants should never be givenunless it has been demonstrated that it ispossible to support the breathing by bag-valve-mask ventilation.

Suxamethonium

Onset of action: 30–60 seconds.


Dose: 1–3 mg/kg IV.

Side effects: Painful muscle fasciculation(give sedative first). Anaphylaxis. Malignanthyperpyrexia. Cardiac arrhythmias, especiallybradycardia. Myoglobinaemia, myoglobinuria,masseter spasm, and a rise in intragastric andintraocular pressure.

Pretreatment with atropine may reduce theincidence of bradycardia.

Critical issues: Serum potassium levels maybecome dangerously elevated following suxame-thonium administration in children with burns,massive trauma, major neurological disease, andrenal failure. Could lead to hyperkalaemic arrest.Contraindicated in severe liver disease.

Can be given intramuscularly (1–2 mg/kg IM) ifno IV access available, but you need to be verycertain of your competence before paralysing achild without IV access. If necessary, put in anintraosseous needle.

Prolonged paralysis may occur in patientswith low plasma pseudocholinesterase, and withrepeated doses of suxamethonium.

Atracurium

A non-steroid based muscle relaxant. Used inrapid sequence intubation where there is acontraindication to suxamethonium. May begiven as infusion for maintaining musclerelaxation during transfer.



Drugs 115

Dose: 0·3–0·5 mg/kg as a bolus. In RSI, higherdoses up to 1 mg/kg may be used to give aquicker onset of paralysis. 10–40 micrograms/kg/min as a continuous infusion. Neonates start at6–8 micrograms/kg/min.

Side effects: Said to be associated with histaminerelease. May rarely drop blood pressure or worsenbronchospasm. May cause flushing, urticaria, andpruritus.

Critical issues: It is metabolised by the endo-thelial cells by a process of Hoffman degradation.Therefore it is the drug of choice in hepatorenalimpairment.

Atracurium is not the drug of choice for rapidsequence intubation as it might take 2–5 minutesto paralyse the child.

Recently, a stereoisomer of atracurium has beenreleased called cis-atracurium. It is more potentthan atracurium and is associated with lesshistamine release. It is therefore the musclerelaxant of choice in bronchial asthma.

Pancuronium

Steroid based muscle relaxant.



Dose: 0·05–0·1 mg/kg as a bolus and 0·1 mg/kg asrequired.

Side effects: Has gone out of favour recentlybecause of the associated tachycardia.

Vecuronium

Steroid based muscle relaxant. Good cardio-vascular profile.



Dose: 0·1 mg/kg as a bolus. 1–10 micrograms/kg/min as a continuous infusion.

Side effects: As it is a steroid based compound, itslong-term use has been associated with prolongedmuscle weakness. Accumulates in cases ofhepatorenal impairment.

Rocuronium

A recent introduction, without the side effectprofile of suxamethonium.

Onset of action: Less than 60 seconds.


Dose: For rapid onset of action, 1·2 mg/kg as abolus.

Side effects: No long term studies available buthas fewer side effects than suxamethonium.

Critical issues: Can be given intramuscularly aswell. It has a longer duration of action thansuxamethonium.

Vasoactive drugs

Cardiac dysfunction is relatively common in thecritically ill child. After restoring intravascularvolume, attention must be paid to supporting thepump. In various disease states, for examplesepsis, it is common to have circulating moleculesthat act as myocardial depressants.

Vasoactive drugs increase the heart rate when itis inappropriately slow for the clinical conditionand increase the contractility of the heart, therebyincreasing cardiac output. The most commonlyused drugs are sympathomimetic agents thatstimulate adrenergic receptors. Receptor activa-tion is different with each drug and can changewith varying doses to produce diverse cardio-vascular effects.

Vasoactive drugs should be titrated to providemaximal therapeutic effects with minimal side ortoxic effects.

Neonates depend more on their heart rate thanstroke volume for their cardiac output.

Receptors

• Alpha, when stimulated, lead to constrictionof arterioles and veins, thereby increasingafterload.

• Beta1 are associated with an increasedcontractility as well as an increase in heart rateand conduction velocity.

• Beta2 are associated with peripheral vasodila-tation and bronchodilatation.

• Dopaminergic are associated with an increasein renal and splanchnic blood flow.

Dopamine

Is a naturally occurring catecholamine.

Dose: 3–5 micrograms/kg/min: stimulates dopaminereceptors in the renal vessels, increasing renalblood flow and causing an increase in urineoutput.


5–10 micrograms/kg/min: causes stimulation ofbeta-receptors (beta1-receptors) and an increase inmyocardial contractility.

10–20 micrograms/kg/min: beta-receptor stimu-lation persists but alpha-receptor activation startsto appear and increases with increasing doses.The alpha effects will lead to constriction ofblood vessels, leading to hepatic and mesentericischaemia, an increase in the work of the heartand an increase in oxygen consumption.

Side effects: Tachycardia, tachyarrhythmias, andpulmonary vasoconstriction.

Critical issues: Tissue necrosis can occurfollowing extravasation if not administered via acentral line. Dopamine has a very short half-lifeand needs to be administered by a continuousinfusion.

Dobutamine

Is a synthetic catecholamine with different effectson receptors.

Dose: 5–20 micrograms/kg/min: selective betaeffects with an increase in cardiac contractilityand a variable increase in heart rate.

Beta2 effects produce mild peripheralvasodilatation.

No dopaminergic or alpha effects seen.

Side effects: Can cause tachyarrhythmia althoughless common than with dopamine.

Critical issues: Can be given peripherally and cantherefore be used early on in a child with lowcardiac output.

Due to afterload reducing effects, is useful in achild with myocardial failure.

Epinephrine (adrenaline)

Powerful inotrope with both alpha and beta effects.

Dose: 0·05–0·2 micrograms/kg/min beta1 effectspredominate; > 0·5 micrograms/kg/min alphaeffects predominate.

Side effects: The alpha effects can lead to anincrease in myocardial work and oxygenconsumption and constriction of renal andsplanchnic vesssels. Can lead to tachyarrhythmias.

Critical issues: As it is a powerful inotrope,should be considered relatively early in patientswith refractory hypotension.

Should be infused through a central line due toextravasation tissue necrosis.

Other situations in which it is used areanaphylactic shock, asystolic arrest, as a bron-chodilator in asthma and acute bronchiolitis, andnebulised as a mucosal vasoconstrictor in croup.

Norepinephrine (noradrenaline)

Powerful vasoconstrictor.

Dose: 0·1–1 microgram/kg/min. It has morepotent alpha than beta effects.

Side effects: Similar to epinephrine (adrenaline).Main problem is potent alpha effects.

Critical issues: Useful in refractory shock due toprofound vasodilatation.

Renal vasoconstriction can be partly overcomeby concomitant use of dopamine in renal doses.

Isoprenaline

Used in very selected situations, mainly for itschronotropic effect.

Dose: 0·05–1·5 micrograms/kg/min beta1 andbeta2 effects. Significant chronotropy, i.e. increasein heart rate.

Side effects: Will increase myocardial oxygenconsumption and may cause tachyarrhythmias.

Critical issues: Can be used peripherally. Usefulin neonates and infants where heart rate isinappropriately low. Also used to treat heart block.

Enoximone

Non-adrenergic inotrope that leads tophosphodiesterase inhibition and ultimately anincrease in available calcium. This results inimproved cardiac contractility and significantvasodilatation.

Dose: 5–20 micrograms/kg/min.

Side effects: May cause arrhythmias and hypotension,especially if the patient is hypovolaemic.

Critical issues: Has to be administered on its own,but can be administered through one lumen of acentral line. As it is an inodilator, it is commonlyused in children with chronic heart failure ormyocarditis. Have a fluid bolus drawn up andready to administer in case of hypotension.

Steroids

A very controversial issue. Steroids were widelyused in newborns to assist weaning fromventilation and oxygen, but recent evidence oftheir effects on neurodevelopment and growthhas led to a re-examination of this strategy.Steroid use should be strictly limited in theneonatal intensive care unit and they will notnormally be needed on transport.

In septic states steroids act in a number of ways,an important one being by reducing cytokinelevels. The crucial issue is the timing of thesteroid, i.e. it should be administered before thecytokine levels reach a critical amount. Studiesthat have shown steroids to be effectiverecommend that they be given before the firstdose of antibiotic, which would cause cytokineliberation on cell death, and lysis of the cell wall.Are also useful in states of massive inflammationsuch as bronchial asthma, croup.

Dose: Methylprednisolone 10–30 mg/kg/day.Dexamethasone: 0·1–0·5 mg/kg/dose 6 hourly.

Side effects: Hypertension, hyperglycaemia,leucocytosis. Other long term side effects are welldocumented, but not normally relevant to patienttransport.

Critical issues: Studies have shown that highdoses of steroids are associated with increasedmortality. That has not been shown to be thecase for more conventional doses; in fact, recentliterature suggests a possible beneficial effect oflow dose steroids in children with hyperin-flammatory states like sepsis even if given afterthe first dose of antibiotics.

Anticonvulsants

Stabilisation of the airway, breathing andcirculation are the first priority in treatingconvulsions. Pharmacological managementshould be initiated during stabilisation. Apartfrom using anticonvulsants, serum calcium,magnesium and blood sugar must always beroutinely monitored and aggressively corrected ifabnormal.

A sequential approach to seizure managementis preferred.

The benzodiazepines (lorazepam, midazolam,and diazepam) are the drugs most commonly usedfor acute termination of the seizure. Sometimes a

second drug will be required for acute and longterm management of the seizures.

In the newborn, phenobarbitone is mostfrequently used as the first anticonvulsant withparaldehyde and clonazepam used subsequently.

Refer to local policy for details of seizuremanagement in practice.

Since the drugs are associated with respiratorydepression, equipment and personnel capable ofmanaging the airway should be present.

Phenobarbitone

Increases the levels of GABA which is the maininhibitory neurotransmitter in the brain.

Dose: Loading dose of 20 mg/kg at a rate not fasterthan 1 mg/kg/min IV.

Subsequent doses: Newborns: 10 mg/kg 30–60minutes after the loading dose if fitting continues,up to 30–40 mg/kg total dose.

Older children: Can be given in stepwiseprogression up to a maximum of 60 mg/kg.Maintenance dose 5–8 mg/kg/day.

Side effects: Can cause drowsiness. Increasingdoses may result in respiratory depression. Mayalso cause hypotension, especially if givenin combination with diazepam. Neurologicaldepression may last several days.

Critical issues: Be ready to intubate after repeatedboluses of phenobarbitone if the seizures areunremitting.

Phenytoin

Reduces neuronal excitability by acting on thesodium channels.

Onset of action: Peak effect occurs in 15–20minutes.

Dose: Loading dose is 15–20 mg/kg, given at a rateno faster than 0·5 mg/kg/min.

Side effects: Bradycardia, cardiac arrhythmias,and hypotension.

Critical issues: Due to side effects, must begiven under cardiovascular monitoring.Phenytoin precipitates in dextrose solutiontherefore must be given in saline. It is also anantiarrhythmic agent.

Drugs 117

Phenytoin is useful in the head injured patientas it does not cause sedation.

Some neurosurgeons recommend prophylacticphenytoin in paralysed children followingserious head injuries.

Not widely used in neonatal intensive care.

Paraldehyde

Although it is one of the oldest, it is also one of themost effective anticonvulsants. Most commonlygiven per rectally.

Dose: 0·3 ml/kg, plus 0·3 ml/kg arachis oil.

Side effects: Can cause corrosion of rectal mucosa,or a skin rash or hepatitis.

Critical issues: Dissolves PVC, thereforepolypropylene syringes should be used. Use withcaution in patients with respiratory disease as it ismainly excreted by the lungs.

Clonazepam

Increasingly used to control neonatal seizuresresistant to phenobarbitone.

Dose: 50–100 micrograms/kg, maximum 1 mg,as slow IV bolus over 30 minutes once daily,for a maximum of three doses. An infusion of10–30 micrograms/kg/h may be started after thefirst dose if seizure control is difficult.

Side effects: Respiratory depression, hypotonia,and increased upper airway and salivarysecretions. Side effects may be severe, requiringventilation, and may interfere with neurologicalassessment.

Midazolam

Relatively new addition to anticonvulsantregimen. Relatively safe when used as an infusionon its own up to fairly high doses. Minimalrespiratory depression.

Antiarrhythmics

Clinical evidence of compromise should besought before embarking on treatment. Seechapter 9. Consultation with a paediatriccardiologist is recommended if at all possiblebefore giving antiarrhythmics.

Consideration must be given to electricallyconverting abnormal rhythms in appropriateclinical circumstances.

Antiarrhythmic agents are classified based ontheir electrophysiological effects.

Class I: these drugs block sodium channels,thereby reducing the excitability of the heart.

Class II: these drugs act by beta-adrenoceptorantagonism.

Class III: act by prolonging the refractoryperiod of the myocardium, suppressingre-entrant rhythms.

Class IV: these drugs are Ca2+ channelantagonists that impair impulse propagationin nodal areas of the heart.

Supraventricular tachycardia

This can be treated with the drugs describedbelow.

Adenosine

The drug used most commonly if vagalmanoeuvres have not succeeded in stopping thearrhythmia. It slows conduction across the AVnode.

Dose: With continuous cardiovascular monitoring,the drug is given as a rapid intravenous bolus of0·05 mg/kg. If there is no effect, the dose maybe doubled. The maximum dose is 12 mg. Asadenosine has a very short half-life, it should beadministered rapidly and immediately followedwith a bolus of saline.

Side effects: Bradycardia, hypotension, andflushing.

Critical issues: It is very short acting, i.e. 10seconds, and its side effects are transient. Must beadministered as a rapid push, followed by a rapidsaline bolus. It may not work well if the child isacidotic. More effective if given centrally.

Digoxin

Its major drawback in acute supraventriculartachycardia is that conversion takes some time.

Dose: 20–30 micrograms/kg, half of the loadingdose initially followed by a quarter in twodivided doses at 8–12 hour intervals.


Side effects: Bradycardia, AV block, bigeminy,and trigeminy. Nausea and vomiting,hyperkalaemia, and visual disturbances.

Critical issues: Electrolytes must be normal whenon digoxin treatment.

Flecainide

A type l antiarrhythmic agent generally used as asecond line agent in those patients unresponsiveto conventional therapy.

Dose: Starting with 1–2 mg/kg, building up to3–6 mg/kg/day in three divided doses.

Side effects: Can cause bradycardia and heartblock.

Critical issues: Interacts with various drugsincluding digoxin, amiodarone, and beta-blockers.

Amiodarone

Class III antiarrhythmic agent which is used in themanagement of resistant life threatening ventriculararrhythmias or unresponsive supraventriculartachycardias.

Onset of action: Even when given intravenouslycan be a few hours.

Dose: 5 mg/kg over 30–60 minutes. Maintenancedose when used as a continuous infusion is7–15 mg/kg/day.

Side effects: Potentially numerous. Can causebradyarrhythmias, second and third degreeAV block, discolouration of the skin, andhypothyroidism.

Critical issues: Amiodarone is light sensitive andshould be administered via a central line.

Watch for its negative inotropic effect.

Ventricular arrhythmias

These are most commonly treated withamiodarone or cardioversion, but in resistantcases the following may be considered.

Lidocaine (lignocaine)

Class I antiarrhythmic agent useful for ventriculararrhythmias, and clinically significant prematureventricular contractions.

Onset of action: 45–90 seconds.

Dose: Loading dose of 1 mg/kg/dose. Infusion canbe given at 10–50 micrograms/kg/min.

Side effects: Bradycardia, hypotension, and heartblock.

Critical issues: Can be given via the endotrachealtube in the same dose.

Antihypertensives

Beta-adrenergic blockers are antihypertensiveand antiarrhythmic agents. They act by a numberof mechanisms:

• A reduction of renin release from the kidney• A reduction in cardiac output• A reduction of sympathetic activity via a

central action.

Propranolol

A non-selective beta-blocker.


Dose: 0·05–0·1 mg/kg.

Side effects: Bronchoconstriction, hypoglycaemia,and cardiac failure.

Critical issues: Is also used in treating cyanoticspells in tetralogy of Fallot.

Labetalol

Blocks both alpha- and beta-receptors.


Dose: 0·2–1 mg/kg, followed by an IV infusion of0·25–1·5 mg/kg/h.

Side effects: Similar to propanolol.

Critical issues: Useful for hypertensiveemergencies.

Nifedipine

A calcium channel blocker that prevents theinflux of Ca2+ through the cell membrane andtherefore blocks contraction of smooth muscle.The ensuing vasodilatation causes a fall in bloodpressure.

Onset of action: 2–5 minutes when administeredsublingually, 20 minutes when given orally.

Drugs 119

Dose: 0·2–0·5 mg/kg/dose for hypertensiveemergencies. Maximum 1–2 mg/kg/day, oral orsublingual.

Side effects: Hypotension, syncope, anddizziness. Hyperglycaemia and hyperuricaemia.

Hydralazine

Produces a drop in blood pressure by causingvasodilatation of arteries and arterioles.


Dose: 0·1–0·2 mg/kg/dose every 6 hours up to amaximum of 3·5 mg/kg/day.

Side effects: Hypotension, tachycardia.

Critical issues: Hypotension will usually respondto IV fluids or Trendelenburg positioning.

Sodium nitroprusside

Another potent arterial vasodilator. Useful drugfor a hypertensive crisis.

Onset of action: Within 2 minutes.

Dose: 0·5–5 micrograms/kg/min.

Side effects: Hypotension and the possibility ofcyanide toxicity when used for long periods oftime.

Critical issues: Can only be administered as acontinuous infusion.

Should be protected from light. Watch foracidosis as a possible indication of cyanidetoxicity.

Must not be used to treat hypertension relatedto increased intracranial pressure due to loss ofcerebral autoregulation and the risk of furtherincreasing intracranial pressure.

Neonatal respiratory drugs

Surfactant

Reduces the pulmonary problems associatedwith surfactant-deficient respiratory distress inpreterm babies in the first three days of life.Two surfactant preparations are widely used inthe UK—poractant (Curosurf) and beractant(Survanta). Treatment protocols that areprophylactic and rescue oriented are variouslyfollowed. Intubated newborn premature babies

who have an oxygen requirement over 30%and a chest radiograph consistent with hyalinemembrane disease should have surfactant prior totransfer. If a baby needs intubating for transferthen surfactant should be given.

Dose:

Curosurf: 200 mg/kg (2·5 ml/kg) single bolus intotrachea. Two further doses of half this amount canbe given at 12 hourly intervals.

Survanta: 100 mg/kg (4 ml/kg) bolus intotrachea. Two further doses of this amount can begiven at 8–12 hour intervals.

Side effects: Transient episodes of bradycardia,decreased oxygen saturation, reflux of thesurfactant into the endotracheal tube, and airwayobstruction have occurred during dosing withsurfactant. These events require interrupting theadministration of surfactant and taking theappropriate measures to alleviate the condition.After stabilisation, dosing may resume withappropriate monitoring.

Critical issues: Surfactant can produce rapidimprovements in lung compliance andoxygenation that may require immediatereductions in ventilator settings and inspiredoxygen. Administration of surfactant shouldnever be less than 30 minutes prior to departureon transport, and blood gases and ventilatorsettings must be reassessed following surfactantadministration prior to undertaking transfer.

Fluids

Administration of fluids intravenously is usuallyone of the first steps in resuscitating critically illpatients. Crystalloids, plasma, albumin or syntheticcolloids such as gelatin, dextran and hydroxyethylstarches are current options for this purpose.

Intravenous fluid administration is welltolerated if the microvascular integrity ispreserved but the inflammatory response thatoccurs in sepsis, trauma, shock and anaphylaxisresults in increased intravascular permeability.

Significant vascular leakage causes interstitialoedema which may adversely affect organfunction: cerebral oedema causes mental statuschanges, pulmonary oedema impairs gas exchange,myocardial oedema decreases compliance andimpairs myocardial function.

It is still not clear whether crystalloids orcolloids are better for resuscitation. Suffice to say,


whichever (crystalloid or colloid) is readilyavailable in an acute emergency should be used.

For ongoing resuscitation, colloids would be theappropriate solutions to use because althoughthere is no evidence to suggest colloids are betterthan crystalloids, there is some evidence tosupport the view that colloids resuscitate thecirculation more efficiently and cause less oedemadue to leakage from the intravascular space.

Crystalloid

The crystalloids used most commonly are isotonicsaline and Ringer’s lactate. Both are confined to theextracellular space due to the sodium content. Ahigh proportion ends up in the interstitial space,contributing to interstitial oedema.

A possible advantage of Ringer’s lactate is thatit contains lactate which is converted into baseby a functioning liver and may additionallybiochemically help the pH. Studies are underwaylooking at the use of hypertonic saline followinghead injuries and for resuscitation followingmajor trauma.

Colloid

Colloids have an oncotic pressure that is providedby large molecules similar in size to humanalbumin. Albumin (4·5% human albuminsolution) has a molecular weight of 69 000daltons and lasts in the circulation for about 3–4hours. It is derived from pooled human serumand therefore has the potential risk of infectingthe recipient. It is also expensive.

Gelofusine is a gelatine with a molecular weightof 35 000 daltons and lasts in the circulation forabout 2–3 hours, less time than other artificialcolloids.

Pentastarch is a polymerised carbohydrate witha molecular weight of 450 000 daltons and lasts inthe circulation for about 4–6 hours. It is thoughtto have many attractive properties such as areduction of oedema in inflammatory states andan improvement of microcirculatory flow.

How much to administer?

Newborn infants: Start with 10 ml/kg. This grouprarely require more than 20 ml/kg of volumereplacement, unless there is clear evidence ofblood or fluid loss. Anticipate the need forvolume replacement when transferring infantswith gastroschisis or who have a perforated

bowel. Use blood transfusion if blood loss is theproblem or the patient is anaemic.

Older children: In the acutely hypovolaemicchild, it may be necessary to administer 20 ml/kgas a bolus in the first instance. This must then befollowed up by constant evaluation.

This bolus can be repeated if signs ofhypovolaemia persist. Consideration should begiven to monitoring the central venous pressureif the child needs more than 40 ml/kg fluidresuscitation.

A child with hypovolaemic shock may oftenrequire 40–60 ml/kg of fluid in the first hour.Large fluid requirements in septic shock shouldalso make one consider the need to supportventilation.

Depending on the clinical situation, fluidreplacement with blood should be consideredafter about 40 ml/kg of fluid has been given.

Drug prescription andadministration

Transported infants and children should have alldrugs prescribed, checked and administered tothe same high standard that they would receiveon the intensive care unit. The transport recordshould clearly show what drugs were given, inwhat doses, when and who prescribed, checkedand administered them. It is sometimes necessaryon transport for the person prescribing a drug toalso be involved in checking and administering,simply because there are fewer pairs of hands. Tryto avoid this if possible, for example by recruitingthe help of the local team, as there is increasedpotential for prescription errors to be duplicatedin the checking process.

Prescription errors are more likely underpressure or in a crisis. One activity the transportteam can attend to on the way to a retrieval,presuming they are not prone to motion sickness,is precalculation and checking of doses for drugsthat may be needed, based on the weight of theinfant or child given at referral.

In general the transport team should reserveany drugs carried in transport packs, and uselocal unit supplies wherever possible, to avoiddepleting supplies that may be needed on thereturn journey.

Advanced neonatal nurse practitioners(ANNPs) who lead transfers will need toundertake the prescribing-like activity provided

Drugs 121


for under the Patient Group Directives (PGD)framework. Local unit and hospital policy willdetermine the precise structure and contents ofPGDs. Drugs initiated by ANNPs should beregularly and rigorously audited to ensure that

both the letter and spirit of the supportingdocuments are being followed. Nurse prescribingin general is a rapidly evolving area, andfuture developments may more overtly facilitateprescribing for nurses in intensive care.

Samples of transport documentation used bypaediatric and neonatal transport teams arereproduced over the next pages.

Documentation will inevitably be tailored tosuit the operational protocols and characteristicsof individual teams. There are some importantprinciples underpinning these documents whichshould apply to all transport documentation.

A proper record should be made and kept ofevery transfer. This has a number of purposes.Firstly, the receiving team will need a good recordof the care and treatment the patient has received.Secondly, the form may act as an aide-mémoire,reminding you of routine procedures that needattending to. Finally, this is your defence in caseswhere negligence is alleged and where there willotherwise be an undocumented gap in the carerecord. It will not be enough merely to assert thatas there were two people on the transfer with asick child, it stands to reason you must have beenobserving and caring for the child in a competent

manner. Remember that by the time the conductof the transfer is legally challenged all concernedmay well have no memory of it. Thedocumentation should include information thatwill allow reconstruction of the key features ofthe transfer—who attended, times, clinicalfindings and interventions, drugs used, andobservations taken.

During the actual journey, record observationsand fluids more frequently than on the unit—every 15–30 minutes. This recognises theadditional hazards of transfer over unit work. Anentry should be made in the patient’s medicalnotes about both the stabilisation and transfer.

Once a good record has been made, it isimportant that it is kept. Discuss the forms withthe medical records department to ensure theyappreciate their importance, and that they areproperly filed. Duplicate forms are useful, whereone copy goes in the notes and another is held bythe transport office.

Appendix 1:Typical retrieval forms


NOTTINGHAM NEONATAL SERVICE TRANSPORT RECORD (1) DATE A.GIBBS.01/00

NAME

DATE OF BIRTH NAME BANDS E.T.T. SIZE

REFERRAL HOSPITAL TIME OF BIRTH CUT AT

REFERRAL HOSPITAL NO. AGE LAST TUBE CHANGE DATE

MOTHERS TRANSFER PLAN CONTACT NO. GUTHRIE/TSH

Time

P.I.P

P.E.E.P./C.P.A.P.

Ti.Time

Ventilator Rate

Respiratory Rate

FiO2

Saturation

TcPO2

TcPCO2

E.T.T.Washout/Suction

Heart Rate

Bp Mean

Systolic/Diastolic

Baby Temperature

Incubator Temperature

Comments/ActionsLocation

NAME SIGNATURE


NOTTINGHAM NEONATAL SERVICE TRANSPORT RECORD (2) DATE A.GIBBS.01/00

NAME D.O.B. HOSP NO. DRUGS

BIRTH WT. PRESENT WT. Vit K. O/I.M.

fluids

mls/kg

blood NG

Time ml/hr Total site ml/hr Total site ml/hr Total site ml/hr Total site ml/hr Total site ml/hr Total site sugar ASP Urine Bowels

HISTORY

STABILISATION

IN TRANSIT

NAME SIGNATURE


Nottingham Neonatal Emergency Transport Service – Audit Form

Baby:Name: CHN number: Birth weight:

QMC number: Weight at transfer:Date: D.O.B: Gestation at birth: Age at transfer:Baby moved from: Baby moved to:

Unit: Hospital: Unit: Hospital

Journey:1. Referral accepted: 2.Vehicle requested: 3.Vehicle arrived: 4.Vehicle mobile:5.Arrival at referring unit:: 6. Departure: 7.Arrival at destination:Further times:Baby attended by team but not transferred: Baby died in transit:Please explain any delays apparent from the times given:

Personnel/Family/Diagnosis:Transport Nurse: Doctor/ANNP: Grade of doctor:

Learner(s) (Name and type of learner):

Mother seen? Y/N Father seen? Y/N Video seen? Y/N Babyfax given? Y/N

Diagnosis: Reason for transfer:

Appropriate? Y/N

Procedures:Which of these was performed, attempted or initiated by the transport team?1st Intubation: Extubation: Reintubation: Surfactant: UAC:Peripheral art.line: UVC: Chest needled: Blood culture: Antibotics:Sedation: Muscle relaxation: Inotropes: CPR: ETT Suction (n=):Blood gas (n=): X-Ray (n=): Chest drains (n=): IV Cannula (n=):Transport Score:Please complete score one on arrival at the referring unit, before you intervene. If possible, do a second score beforedeparture to reflect how the stabilishing period has gone. Score three should be completed when the baby is settled in astatic incubator at the end of the journey. If only capillary pO2 is available, record the TINA and saturation readings

0 1 21. Blood Glucose < 1·3 1·3–2·2 or > 9·7 2·3–9·72. Systolic Blood Pressure < 30 30–40 > 403. pH < 7·2 or >7·5 7·2–7·29 or 7·46–7·5 7·3–7·454. pO2 < 5·3 5·3–6·5 or > 13 6·6–135.Temperature < 36·1 or >37·6 36·1–36·5 or 37·3–37·6 36·6–37·2

Score one:Actual values:

Score two:Actual values:

Score three:Actual values:

AJL 0100

1/ 2/ 3/ 4/ 5/ TOTAL:1/ 2/ 3/ 4/ 5/

1/ 2/ 3/ 4/ 5/ TOTAL:1/ 2/ 3/ 4/ 5/

1/ 2/ 3/ 4/ 5/ TOTAL:1/ 2/ 3/ 4/ 5/


In Transit

Equipment & monitoring:Tick any of these items used during transfer

ECG: Ventilator: INCA CPAP: Prong CPAP/IMV: Humid-vent:Oxygen: Pulse-oximeter: Arterial BP: Dinamap BP: O2 analyser:Temp. probe: SureTemp: TINA (no ABG cal): TINA (pO2 cal): TINA (pCO2 cal):Vehicle call-code: Graseby pump: System 1 or 2: Nitric Oxide:

I.V. and I.A. fluids and drugs required in transit. Please tick:

Maintenance fluids Other infusions10% Glucose 10% Glucose and 0·18% Saline Heparinised Saline Diamorphine Midazolam Sodium bicarbonate

15% Glucose 4% Glucose and 0·18% Saline 0·9% Saline Dobutamine Morphine Tolazoline

5% Glucose Albumin 4·5% Dopamine Pancuronium

Other: Atracurium Epinephrine 1:10,000 Prostacyclin

Blood Magnesium Sulphate Prostaglandin

Other:

Respiratory support:

Start of journey:

End of journey:

Maximum settings:

Mode: PIP: PEEP/CPAP: BPM: FiO2:



Problems:

Did any equipment fail, or give problems?

Were there any problems with the baby in transit?

Action taken:

Please phone other units for final scores if necessary

IMPORTANT: Check this form is complete before filing – a mark in every box

AJL 0100


PAEDIATRIC INTENSIVE CARE – LEICESTERRETRIEVAL DOCUMENTATION

Important: Fill in this document as completely and legibly as possible!

TELEPHONE CALL

Call received by Name:

Date: / / Time:

Reason for contact: [Transfer] [Advice only]

Referring doctor and grade: Bleep no:

Referring consultant: Aware: [Yes] [No]

Referring hospital:

Date of admission to referring hospital: / / Time:

Location of patient: [A&E][ITU][NNU][PICU][Other ]

Hospital telephone number: Extension:

PATIENT DATA

Name: Sex: [M][F]

D.O.B: Age: Weight: Kg

Provisional diagnosis:

Brief history including premorbid conditions:


CURRENT STATUS AT REFERRING HOSPITAL

Intubated [Yes] [No]

If intubated: Time:

Ventilated: [Yes][No][Handbagged]

Ventilator:

ETT: size length [O][N]

Rate /min TV ml MV L

PIP cmH2O PEEP cmH2O

OI[FiO2(%)xMAP/PaO2(mmHg)]

NO (ppm)

CXR

%SaO2 in FiO2

If not intubated:

Resp rate: /min

Resp distress: [None][Mid]

[Moderate][Severe]

Stridor: [Y][N] Wheeze: [Y][N]

Added sounds:

Air entry: [Normal][Abnormal]

[R=L][R>L][R<L]

CXR:

%SaO2 in FiO2

Pulse: /min BP: / mmHg Capillary refill: seconds

Colour: [Pink] [Pale] [Cyanosed] Temperature: Core: Peripheral: °C

Heart sounds: [Normal] [Abnormal] Gallop: [Yes] [No] Murmur: [Yes] [No]

Liver: cms Spleen: cms Urine output: ml/kg/hour

Level of consciousness:

[Alert] Pupils: Right: mm [Brisk][Sluggish][Fixed]

[Responds to voice] Left: mm [Brisk][Sluggish][Fixed]

[Responds to pain] Fundi:

[Unresponsiveness]

[Paralysed and sedated] Meningism: [Yes] [No]

Rash:

MOST RECENT BLOOD RESULTS

Biochemistry Result Blood Gas ResultGlucose pHSodium PCO2

Potassium pO2/FiO2 /Urea BicarbonateCreatinine Base deficitCalcium HaematologyBilirubin HbAlbumin WCC

PlateletsINRAPTT


TREATMENT ALREADY GIVEN BY REFERRING HOSPITAL

Lines: Peripheral venous lines:

Central venous line: [Yes] [No] [Site ] Arterial lines: [Yes] [No]

Fluids given: Colloid ml/kg FFP ml/kg

Blood ml/kg Other ml/kg

Inotropes/ Name rate mcg/kg/min

Vasodilators Name rate mcg/kg/min

Name rate mcg/kg/min

Maintenance fluid Type rate ml/kg/day = ml/hr

[Normal] [Restrict to %] [Increase to %]

Drugs given (Name, dose, time)

CHECKLIST WITH REFERRING DOCTOR

If accepted for transfer ask for the following to be done before Retrieval Team arrives

[ ] TWO IV lines needed

[ ] Stop oral or NG feeding, insert NGT if intubating

[ ] Notify parents of transfer

[ ] Photocopy A&E, medical and nursing notes/obs and copy/borrow Xrays

Additional requests for ECMO patients:

[ ] Full clotting screen

[ ] Head scan (and heart scan if possible)

[ ] Cross match for blood: 10ml clotted sample from mother (if neonate)

1 adult unit (300ml) of packed cells

TRANSFER TEAM DETAILS

Nurses: 1. 2.

Doctors: 1. 2.

TRANSFER TIMES

Time ambulance booked:

Time of departure from Leicester:

Time of arrival at referring hospital:

Time of departure from referring hospital:

Time of arrival at Leicester:


CONDITION ON ARRIVAL OF RETRIEVAL TEAM(Assessment by Medical Team)

Intubated [Yes] [No]

If intubated: Time:

Ventilated: [Yes][No][Handbagged]

Ventilator:

ETT: size length [O][N]

Rate /min TV ml MV L

PIP cmH2O PEEP cmH2O

OI[FiO2(%)xMAP/PaO2(mmHg)]

NO (ppm)

CXR

%SaO2 in FiO2

If not intubated:

Resp rate: /min

Resp distress: [None][Mid]

[Moderate][Severe]

Stridor: [Y] [N] Wheeze: [Y] [N]

Added sounds:

Air entry: [Normal][Abnormal]

[R=L][R>L][R<L]

CXR:

%SaO2 in FiO2

Pulse: /min BP: mmHg Capillary refill: seconds

Colour: [Pink] [Pale] [Cyanosed] Temperature: Core: Peripheral: °C

Heart sounds: [Normal] [Abnormal] Gallop: [Yes] [No] Murmur: [Yes] [No]

Liver: cms Spleen: cms Urine output: ml/kg/hour

Level of consciousness:

[Alert] Pupils: Right: mm [Brisk][Sluggish][Fixed]

[Responds to voice] Left: mm [Brisk][Sluggish][Fixed]

[Responds to pain] Fundi:

[Unresponsiveness]

[Paralysed and sedated] Meningism: [Yes] [No]

Other findings:

Dactors name: Signature:


ACTIONS TAKEN BY TRANSFER TEAM

Airway: Intubated/Tube changed [Yes][No] Time:

ETT: Size: Length: [Oral] [Nasal]

Drugs used for intubation:

Ventilator FiO2: PIP: PEEP:

settings: Rate: Ti : Te:

Access: Peripheral cannulae exiting: put in by TT:

Central venous line: exiting: put in by TT:

Arterial line: exiting: put in by TT:

Urinary catheter: [Present] [Passed] [Changed] [None]

NG tube: [Present] [Passed] [Changed] [None]

Antibiotics: Time:

Other treatments:

PRE-DEPARTURE CHECKLIST

CLINICAL STATUSAirway Airway secure, ETT securely fixed [ ]

Ventilation Ventilation satisfactory, Blood gases, Chest Xray [ ]

Circulation Adequate fluids/inotropes,Vascular access secure [ ]

Neurology Seizures controlled,Adequately sedated/paralysed [ ]

Renal Urinary catheter in place if required [ ]

GIT NG tube passed if required, blood sugar satisfactory [ ]

Temperature Measured and satisfactory,Adequate warming [ ]

DOCUMENTATION [Notes] [Letter] [Transfer consent] [Xrays]

SUPPLIES [Oxygen] [Fluids] [Power]

COMMUNICATION [Parents][Parent package given]

ON TROLLEY [Mask] [Resus drugs] [Rebreathe bag] [Stethoscope]

BAGS [Drugs box][Fridge drugs] [Red/Green bag]

TELEPHONE [PICU Leicester notified]

ECMO PATIENTS [Blood] [ECMO Consent]


Nursing evaluation and notes during transfer:

Nurses name and grade: Signature:

CONDITION ON ARRIVAL BACK IN LEICESTER

Temperature: Core: °C Peripheral: °C

Ventilation FiO2: PIP: PEEP:

Rate: Ti : Te:

SpO2 etCO2

Haemodynamics: Pulse: BP: Cap refill:

Neurology: GCS: Pupils:

UNTOWARD EVENTS

PATIENT EQUIPMENT

Awake [ ] Desaturation [ ] Ventilator failure [ ] Monitor failure [ ]

Hypotension [ ] Rise in etCO2 [ ] Inf. pump failure [ ] Loss of IV [ ]

Hypertension [ ] Extubation [ ] Failed gas supply [ ] Communication [ ]

Bradycardia [ ] ETT blocked [ ] Ambulance prob [ ]

Tachycardia [ ] Pupil changes [ ] Bag not equipped [ ]

Other [ ] Specify:

Brief details of event:

Incident form completed Yes [ ] No [ ]

Estimating weight

Weight (kg) = (age + 4) × 2

Blood gas unit conversion

To convert mmHg to kPa, multiply by 0·1317. To convert kPa to mmHg, divide by 0·1317.

Respiratory support indices

Oxygenation index (OI) = mean airway pressure× FiO2 (%)/PaO2 in mmHg.

Ventilation index (VI) = PaCO2 × respiratory rate× peak inspiratory pressure/1000

Mean airway pressure = ((PIP × TI) + (PEEP × Te))/(TI + Te)

where PIP = peak inspiratory pressurePEEP = positive end expiratory pressureTI = inspiratory timeTe = expiratory time

Other physiological measures

Oxygen content in blood = 1·36 × Hb × oxygensaturation

Desired systolic blood pressure = 80 + (age × 2)(over 2 years of age)

Anion gap = (Na+ + K+) − (CL−+ HCO3−)

Osmolality (serum) = (2 × Na+) + glucose + urea

Gas requirements for transfer

The oxygen requirements (in litres) of a patientcan be estimated from the formula:

Flow delivered (l/min) × FiO2 × journey time(min) × 2

How long a cylinder supply will last may beestimated from the formula:

Cylinder contents (litres)/gas consumption(litres/min)

(approximate cylinder contents when full areprinted on the cylinder)

Endotracheal tube sizes

Rough guide for infant ETT internal diameter −gestation/10 (also see table below). Older childETT sizes:

Diameter: (age/4) + 4Length (oral ETT): (age/2) + 12Length (nasal ETT): (age/4) + 15

Appendix 2: Essential equationsand aide-mémoires

Oral endotracheal tubes Nasal tubesWeight (g) ETT diameter Cut length Length at lips Length at nares

500 2·5 6·5 6 7·5

1000 2·5 7 6·5 8·5

1500 2·5–3·0 7·5 7 9

2000 3·0 8 7·5 9·5

2500 3·0 8·5 8 10

3000 3·5 9·5 9 10·5

3500 3·5 10·5 10 11·5

GeneralAdvanced Life Support Group. Advanced Paediatric

Life Support. London: BMJ Publishing Group, 1997.Advanced Life Support Group. Safe Transfer and

Retrieval—The Practical Approach. London: BMJPublishing Group, 2002.

Booth P, Madar J, Skeoch C. The Handbook of NeonatalTransport. Aberdeen: Scottish Neonatal Consultants’Group, 1996.

British Paediatric Association. The Care of Critically IllChildren. Report of a Multidisciplinary WorkingParty on Paediatric Intensive Care. London: BritishPaediatric Association, 1993.

Glasgow JFT, Graham HK. Management of Injuries inChildren. London: BMJ Publishing Group, 1997.

Jaimovich DG, Vidyasagar D (eds). Handbook ofPediatric and Neonatal Transport Medicine.Philadelphia: Hanley and Belfus, 1996.

Macnab AJ, Smart P. Lightweight monitoringequipment for pediatric transport. Intens Ther ClinMonit 1990;(May/June):92–6.

Macrae DJ. Paediatric intensive care transport. Arch DisChild 1994;71:175–8.

Morton NS, Pollack MM, Wallace PGM (eds).Stabilisation and Transport of the Critically Ill.Edinburgh: Churchill Livingstone, 1997.

Resuscitation Council (UK). Newborn Life SupportProvider Course Manual. London: ResuscitationCouncil, 2001.

Resuscitation Council (UK). Resuscitation Guidelines2000. London: Resuscitation Council, 2000.

Principles of safe transportAnonymous. Guidelines for the transfer of critically ill

patients. Crit Care Med 1993;21:931–7.Barry PW, Ralston C. Adverse events occurring during

interhospital transfer of the critically ill. Arch DisChild 1994;71:8–11.

Britto J, Nadel S, Levin M, Habibi P. Mobile paediatricintensive care: the ethos of transferring critically illchildren. Care Crit Ill 1995;11:235–8.

Edge WE, Kanter RK, Weigle CGM, Walsh RF.Reduction in morbidity in inter-hospital transport byspecialized pediatric staff. Crit Care Med 1994;22:1186–91.

Intensive Care Society. Guidelines for the Transport ofthe Critically Ill Adult. London: Intensive CareSociety, 1997.

Hunt RC, Brown LH, Cabinum ES, et al. Is ambulancetransport time with lights and sirens faster than thatwithout? Ann Emerg Med 1995;25:507–11.

Leslie A, Bose C. Nurse-led neonatal transport. SeminNeonatol 1999;4:265–71.

Logan S. Evaluation of specialist paediatric retrievalteams. Br Med J 1995;311:839.

Lovell MA, Mudaliar MY, Klineberg PL. Intrahospitaltransport of critically ill patients: complications anddifficulties. Anaesth Intens Care 2001;29:400–5.

Macnab AJ. Optimal escort for inter-hospital transportof pediatric emergencies. J Trauma 1991;31:205–9.

Macrae DJ. Paediatric intensive care transport. Arch DisChild 1994;71:175–8.

Paediatric Intensive Care Society. Standards forPaediatric Intensive Care Including Standards ofPractice for the Transportation of the Critically IllChild. Paediatric Intensive Care Society, 1996:Bishop’s Stortford, UK: Saldatore.

Pon S, Notterman DA. The organisation of a pediatriccritical care transport program. Pediatr Clin NorthAm 1993;40:241–61.

Sharples PM. Avoidable factors contributing to death ofchildren with head injury. Br Med J 1990:300:87–91.

Transport physiologyGajendragadkar G, Boyd JA, Potter DW, Mellen BG,

Hahn GD, Shenai JP. Mechanical vibration inneonatal transport: a randomized study of differentmattresses. J Perinatol 2000;20:307–10.

Lawler PG. Transfer of critically ill patients: Part 1—physiological concepts. Care Crit Ill 2000;16:61–5.

Lawler PG. Transfer of critically ill patients: Part 2—preparation for transfer. Care Crit Ill 2000;16:94–7.

Miller C. The physiologic effects of air transport on theneonate. Neonatal Network 1994;13:7–10.

Sherwood HB, Donze A, Giebe J. Mechanical vibrationin ambulance transport. Clin Studies 1994;23:457–63.

Towers CV, Bonebrake R, Padilla G, Rumney P. Theeffect of transport on the rate of severeintraventricular hemorrhage in very low birth weightinfants. Obstet Gynecol 2000;95:291–5.

Wright MS, Bose CL, Stiles AD. The incidence andeffects of motion sickness among medical attendantsduring transport. J Emerg Med 1995;13:15–20.

The ambulance environmentAuerbach P, Morris J, Phillips J, et al. An analysis of

ambulance accidents in Tennessee. JAMA 1987;258:487–90.

Lacher ME, Bausher JC. Lights and siren in pediatric911 ambulance transports: are they being misused?Ann Emerg Med 1997;29:223–7.

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Little JW. Ambulance transport for the newborn. SeminNeonatol 1999;4:247–51.

Madar RJ, Milligan DWA. Neonatal transport: safetyand security. Arch Dis Child 1994;71:F147–8.

Medical Devices Agency. Transport of Neonates inAmbulances (TINA). London: Department of Health,1995.

Equipment and monitoringBrown L, Gough JE, Bryan-Berg D, Hunt R. Assessment

of breath sounds during ambulance transport. AnnEmerg Med 1997;29:228–31.

Gebremichael M, Borg U, Habashi NM, et al.Interhospital transport of the extremely ill patient:the mobile intensive care unit. Crit Care Med2000;28:79–85.

Palmon SC, Liu M, Moore LE, Kirsch JR. Capnographyfacilitates tight control of ventilation duringtransport. Crit Care Med 1996;24:608–11.

Wilson C, Webber S. Oxygenation saturation duringtransfer. Paediatr Anaesth 2002;12:288.

Air transport of critically illchildrenAoki BY, McCloskey K. Evaluation, Stabilisation and

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Bjerke HS, Barcliff L, Foglia RP. Neonatal survival duringa 2500-mile flight. Hawaii Med J 1992;51:332–5.

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Cook L, Kattwinkel J. A prospective study of nurse-supervised versus physician-supervised neonataltransports. J Obstet Gynecol Neonatal Nurs 1983;12:371–6.

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Leslie A, Stephenson T. Audit of neonatal intensivecare transport—closing the loop. Acta Paediatr1997;86:1253–6.

Leslie A, Stephenson T. Neonatal transfers by advancedneonatal nurse practitioners and paediatric registrars.Arch Dis Child 2003 (in press).

Equipment and monitoringNielson H, Jung A, Atherton S. Evaluation of the Porta-

Warm Mattress as a source of heat for neonataltransport. Pediatrics 1976;58:500–4.

O’Connor T, Grueber R. Transcutaneous measurementof carbon dioxide tension during long-distancetransport of neonates receiving mechanicalventilation. J Perinatol 1998;18:189–92.

Vohra S, Frent G, Campbell V, Abbott M, Whyte R.Effect of polyethylene occlusive skin wrapping onheat loss in VLBW infants at delivery: a randomizedtrial. J Pediatr 1999;134:547–51.

OthersAmerican Academy of Pediatrics. Guidelines for Air

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Booth P, Madar J, Skeoch C. The Handbook of NeonatalTransport—A Practical Approach for Scotland.Aberdeen: Scottish Neonatal Consultants’ Group,1996.

Hellström-Westas L, Hanseus K, Jögi P, Lundström N-R,Svenningsen N. Long-distance transports of newborninfants with congenital heart disease. Pediatr Cardiol2001;22:380–4.

Hermansen M, Hasan S, Hoppin J, et al. A validation ofa scoring system to evaluate the condition oftransported very-low-birth-weight neonates. Am JPerinatol 1988;5:74–8.

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L’Herault J, Petroff L, Jeffrey J. The effectivenessof a thermal mattress in stabilizing and maintainingbody temperature during the transport of verylow-birth weight newborns. Appl Nurs Res 2001;14:210–19.

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Special transportinterventionsAnonymous. Inhaled nitric oxide and hypoxic

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Anonymous. Inhaled nitric oxide in full-term andnearly full-term infants with hypoxic respiratoryfailure. The Neonatal Inhaled Nitric Oxide StudyGroup. New Engl J Med 1997;336:597–604.

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Blythe D. A review of pulmonary vasodilators. AnaesthIntens Care 1998;26:26–39.

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Cornish JD, Carter JM, Gerstmann DR, Null DM Jr.Extracorporeal membrane oxygenation as a means ofstabilizing and transporting high risk neonates.ASAIO Trans 1991;37:564–8.

Faulkner SC, Taylor BJ, Chipman CW, et al. Mobileextracorporeal membrane oxygenation. Ann ThorSurg 1993;55:1244–6.

Gattinoni L, Tognoni G, Pesenti A, et al. Effect ofprone positioning on the survival of patients withacute respiratory failure. New Engl J Med 2001;345:568–73.

Gerstmann DR, Minton SD, Stoddard RA, et al. TheProvo multicenter early high-frequency oscillatoryventilation trial: improved pulmonary and clinicaloutcome in respiratory distress syndrome. Pediatrics1996;98:1044–57.

Heulitt MJ, Taylor BJ, Faulkner SC, et al. Inter-hospitaltransport of neonatal patients on extracorporeal

membrane oxygenation: mobile-ECMO. Pediatrics1995;95:562–6.

Kinsella JP, Griebel J, Schmidt JM, Abman SH. Use ofinhaled nitric oxide during interhospital transport ofnewborns with hypoxemic respiratory failure.Pediatrics 2002;109:158–61.

Peek GJ, Firmin RK. Extracorporeal membraneoxygenation for cardiac support. Coronary Artery Dis1997;8:371–88.

Peek GJ, Firmin RK. Extracorporeal membraneoxygenation, a favourable outcome? Br J Anaesth1997;78:235–7.

Peek GJ, Moore HM, Moore N, Sosnowski AW, FirminRK. Extracorporeal membrane oxygenation for adultrespiratory failure. Chest 1997;112:759–64.

Peek GJ, Sosnowski AW. Extra-corporeal membraneoxygenation for paediatric respiratory failure. Br MedBull 1997;53:745–56.

Ring JC, Stidham GL. Novel therapies for acuterespiratory failure. Pediatr Clin North Am 1994;41:1325–63.

Roberts JD, Polaner DM, Lang P, Zapol WM. Inhalednitric oxide in persistent pulmonary hypertension ofthe newborn. Lancet 1992;340:818–19.

Shapiro M, Anderson H, Pranikoff T, Chapman R,Bartlett RH. Transport of unstable patients onextracorporeal life support. Cardiol Young1995;(suppl 2):27.

Wagaman MJ, Shutack JG, Moomjian AS, Schwartz JG,Shaffer TH, Fox WW. Improved oxygenation andlung compliance with prone positioning of neonates.J Pediatr 1979;94:787–91.

What to do when it allgoes wrongBion JF. Transporting critically ill patients by

ambulance: audit by sickness scoring. Br Med J1988:296:170.

Britto J, Nadel S, Habibi P, Levin M. Pediatric risk ofmortality score underestimates the requirement forintensive care during interhospital transport. CritCare Med 1994;22:2029–30.

Britto J, Nadel S, Maconochie I, Levin M, Habibi P.Morbidity and severity of illness during interhospitaltransfer: impact of specialist paediatric retrievalteam. Br Med J 1995;311:836–9.

Gunnarsson B, Heard CMB, Rotta AT, Heard AMB,Kourkounis BH, Fletcher JE. Use of a physiologicscoring system during interhospital transport ofpediatric patients. Air Med J 2001;20:23–6.

Orr RA, Venkataraman ST, Cinoman MI, Hogue BL,Singleton CA, McCloskey KA. Pretransport pediatricrisk of mortality (PRISM) score underestimates therequirement for intensive care or major interventionsduring interhospital transport. Crit Care Med1994;22:101–7.

Woodward GA, Fleegler EW. Should parentsaccompany pediatric interfacility ground ambulancetransports? Results of a national survey of pediatrictransport team managers. Pediatr Emerg Care2001;17:22–7.

Selected references and bibliography 137

DrugsMildenhall LFJ, Pavuluri NN, Bowman ED. Safety of

synthetic surfactant use before preterm newborntransport. J Pediatr Child Health 1999;35:530–5.

Royal College of Paediatrics and Child Health. Medicinesfor Children. London: RCPCH Publications, 1999.

Shann F. Drug Doses, 11th edn. Melbourne: CollectivePty, 2001.


ABCDE see airway; breathing; circulation; disability;exposure

abdomenexamination 83injury 95

acceleration 14–15accreditation 111AC supply 21adenosine, supraventricular tachycardia 58, 118adrenaline see epinephrineadrenergic receptors (adrenoceptors) 115

drugs blocking 118, 119drugs stimulating 115, 116

advanced neonatal nurse practitioner 4, 10drug prescription/administration 121–2unsuccessful resuscitation and 109

air-filled spaces, expansion at altitude 17air sickness 39air supply 27

compressed air cylinders 22, 27air transport 36–40

acceleration/deceleration 15altitude physiology 17–18, 37, 39–40equipment/supplies 37–8fixed-wing aircraft 37helicopters see helicoptersiNO use 103–4

airway (and its management) 11, 53–5, 57, 60, 69–78 adverse events in transit 78anatomy

causing intubation difficulties 76neonates/infants 69–70

assessment principles 70–1burns patients 97deterioration indicating intubation 71difficult (to intubate) 75–6equipment 6

suctioning 29intubation-related complications 74neonates/infants 11, 43–4

anatomy 69–70physiology 70resuscitation 46

obstruction 53–4, 75intubation difficulties with 75

physiology 17–18developmental changes in anatomy and 69–70

predeparture check 63pressure measurement in aircraft 38trauma patient 91see also respiratory system

albumin 84, 121neonatal 47

alpha adrenoceptors 115drugs blocking 119drugs stimulating 116

alternating current supply 21altitude, physiology 17–18, 37, 39–40alveolar oxygen pressure/tension, reduction at altitude

17–18, 37, 39ambulance 20–4

acceleration/deceleration 14–15configuration 20–1environment 16–18, 20–4speed 8–9, 22–3see also vehicles

ambulance crew 23communication with 7, 23–4

amiodarone 58–9, 119anaesthesia for intubation 72, 73

special considerations 74, 75, 76analgesia (and analgesic drugs) 100, 122–3

burns patient 97–8neonatal 49trauma patient 100

antiarrhythmic drugs 118–19tachycardias 58, 58–9

anticonvulsants 61, 113, 114, 117–18antihypertensives 119–20arrhythmias 57–9, 85–6

defibrillation 29–30, 58, 86drug therapy see antiarrhythmic drugsprevention 85–6see also specific arrhythmias

asystole 57–8atmosphere as air source 27atmospheric pressure and altitude 17–18, 37,

39–40atracurium 114–15atrial defects 87atropine 58audit 110–11

Nottingham Neonatal Emergency Transport ServiceAudit Form 126–7

automated non-invasive blood pressuremonitoring 33

automatic external defibrillator 30AVPU system 55axilla, temperature monitoring 34

back transfer, neonates 51–2bag and mask ventilation 75–6bag-valve-mask for preoxygenation 72barbiturates

as anticonvulsants 117as sedatives 113

barometric pressure and altitude 17–18, 37, 39–40batteries 25–6benzodiazepines 113–14

as anticonvulsants 113, 114, 117as sedatives 117

beractant 120

Index

beta adrenoceptors 115drugs blocking 118, 119drugs stimulating 116

bicarbonate see sodium bicarbonatebleeding see blood lossblood, pooling (venous pooling) due to

acceleration/deceleration 14–15in head 15

blood count, full 83blood flow

heart 80lungs see pulmonary blood flowsystemic, congenital heart disease decreasing 87

blood gases monitoring 33, 83

neonatal 44transcutaneous 32–3see also specific gases

requirements for transfer 134unit conversion 134see also specific gases

blood glucose (sugar) monitoring 34, 57blood loss (bleeding/haemorrhage) 61

trauma patient 92see also haemothorax

blood pressure 33–4, 55, 80, 83 brain and 80monitoring 33–4, 55, 83

invasive 33–4, 83non-invasive 33

normal values 79see also hypertension; hypotension

blood products 84–5blood tests, head injury 94blood volume see hypervolaemia; hypovolaemiabowel obstruction 48–9bradycardia 57–8

sinus, systemic hypertension with 56brain

blood pressure and 80herniation signs 56injury

secondary (and its prevention/minimisation) 61, 93signs 56

see also entries under cerebralbreathing 11

adverse events in transit 78assessment 70–1

of effectiveness 55rapid 54of rate and pattern 54–5, 56trauma patient 91–2

noisy 53–4support see ventilation

burns 97–8

calcium channel blockers 118, 119–20calcium chloride 62cannulation see vascular accesscapnography see carbon dioxide, end-tidal

carbon dioxide end-tidal (capnography) 12–13, 33, 83

trauma patient 101tension (PCO2), transcutaneous, measurement 32see also hypercapnia; hypocapnia

carbon monoxide poisoning 32, 97carboxyhaemoglobin 32, 97cardiovascular system see circulation; heartcardioversion, synchronised 58, 59catheterisation

urethral 62vascular see vascular access

central nervous system see disabilitycentral venous access 84

for monitoring in trauma 101neonates (umbilical vessels) 49–51, 84procedure 66–8, 84

central venous pressure 83cerebral herniation, signs 56cerebral perfusion pressure, head-injured 93cervical spine control/immobilisation 91, 98checks, predeparture 12, 63chest compression, neonatal 46chest drain insertion 64–5chest injury 94chest movement assessment, neonatal 46chest radiograph 83circulation/cardiovascular system (assessment and

management) 11, 55, 60–1, 79–89monitoring 31–4, 60, 83neonates 44

resuscitation 46–7physiology 79–81

age-related changes 80–1altitude 14–15

predeparture check 63rapid assessment 54stabilisation 44, 60–1, 83–6trauma patient 92

cis-atracurium 115clonazepam 117, 118coagulopathy 83colloids 120, 121colour 82coma, Glasgow Coma Scale 55communication (of information) 6–8

aircraft 38ambulance crew 7, 23–4parents 7, 12, 110

compartment syndrome 96, 97compression injury, abdomen 95compressor 27computed tomography, head-injured 94conduction, heat loss by 16, 28congenital abnormalities

heart see hearttransfer for surgery 47–9

consciousness level, assessment 55, 83head-injured 94

consent for surgery 49

Index140

continuous positive airways pressure 104–6convection, heat loss by 16, 28convulsions see seizurescorticosteroids 117cricoid pressure 72–3cricothyroidotomy, needle 63–4critical incident monitoring 110–11croup 53, 54crushing injury, abdomen 95crystalloids 120, 121Curosurf 120cyanosis 53

common causes 88cylinders (gas) 22, 27

calculating duration of supply 134nitric oxide 102

DC supply 21death (mortality)

assessing risk of 111in transit 109

debriefing 110deceleration (by ambulance) 14–15deceleration injury, abdomen 95defibrillation 29–30, 58, 86demand for transfers xi–xiidevelopmental changes (in anatomy and physiology)

airway 69–70cardiovascular system 80–1

dextrose 84insulin and 62neonates 47

diaphragmcongenital diaphragmatic hernia 48movement with acceleration/deceleration 15

diastolic blood pressure 80monitoring 34

diazepam 113–14, 117digoxin 118–19dinoprostone (Prostin E2) infusion 86–7direct current supply 21disability (neurological status including CNS)

assessment 11, 55–6neonates 44–5signs of CNS lesions 56trauma patient 92

blood pressure affecting neurological outcome 80stabilisation 61

dislocated joint 96dobutamine 61, 85, 116doctors 10

referring 10as team leader 4

documentation and records 8data collection 110folder contents 6retrieval forms 123–33trauma 100

dopamine 61, 85, 115–16dopaminergic receptors 115

DOPE mnemonic 78dressings, burns 97drugs 112–22

in hyperkalaemia 62inotropic 61, 84, 85, 105–6intubation 60, 73pain control see analgesiapredeparture check 63prescription and administration 121–2resuscitation, neonates 47seizures 61see also specific (types of) drugs

ductus arteriosusnarrowing/closure 80–1

consequences in congenital heart disease 86failure 87

patent 70–1reopening 86–7

ECG 31, 83, 85education, staff 5electrical systems see power supplyelectrocardiogram (ECG) 31, 83, 85electrodes, defibrillator 30electrolyte disturbances 62, 83electromechanical dissociation 58end diastolic volume and stroke volume,

relationship 14endotracheal intubation see intubationend-tidal carbon dioxide see carbon dioxideenoximone 61, 116–17Entonox 100environment

ambulance 16–18, 20–4trauma patient, control 92

epiglottitis 53–4, 75epinephrine (adrenaline) 61, 85, 116

asystole 58neonates 47

equipment and supplies 5–6, 25–30aircraft 37–8general features of all forms 25monitoring 6, 30–5predeparture check 63restraint 22standards covering 20–1umbilical vessel catheterisation 49–50warming 12, 17, 28–9, 49

esmolol, tetralogy of Fallot 89European Standards 20–1evaporation, heat loss by 16, 28examination

airway/breathing 70cardiovascular system 81–3head-to-toe 12for intubation 76

exomphalos 48exposure, trauma patient 92extracorporeal membrane oxygenation 106extremities see limbs

Index 141

Fallot’s tetralogy 87, 88family see parentsfeed(s)

assessment 44stopping to aspirate stomach 62

feedback from ICU 8femoral nerve blockade 100femoral venous cannulation 66fentanyl 122–3fetal circulation 80, 81

change to postnatal and adult circulation 80–1, 82

fibrillation, ventricular 58filling pressure (ventricular) 14–15fixed-wing aircraft 37flecainide 119flexor responses 56fluid loading with acceleration/deceleration

14–15fluid management (including volume expansion)

84–5, 120–1burns patient 97neonatal 44, 47, 121predeparture check 63

fractures 91limb 97pelvic 90, 91, 95

full blood count 83

gas, blood see blood gasesgas-driven ventilators 26gas-filled spaces, altitude effects 17, 39gas induction 75gas supply 22, 27

see also cylindersgastric contents, prevention of aspiration 62gastrointestinal system

neonatal pathology 48–9stabilisation 61–2

gastroschisis 48Gelofusine 121Glasgow Coma Scale 55Glasgow Meningococcal Septicaemia Prognostic

Score 111glucose, blood, monitoring 34, 57

see also dextrosegrunting 54

haemodynamic complications, intubation 74haemorrhage see blood losshaemothorax, massive 94hazards see safety issueshead

injury 92–4venous pooling 15

head/neck position for intubation 71, 72problems relating to 75

head-to-toe examination 12health professionals see staff; team

heartarrest

unsuccessful resuscitation 109see also asystole; resuscitation

congenital disease 86–9assessment for 81, 82fluid administration in, deterioration following 85specific lesions 87–9

muscle (myocardium)blood flow to 80neonatal, features 82

output 79–80rate 82

monitoring 31normal maximum/minimum 79

rhythm abnormalities see arrhythmiasheating (ambulance) 21heat loss

mechanisms 16, 27–8minimising see temperature controlsee also hypothermia

helicopters 36–7acceleration/deceleration 15iNO use 103–4vibration 38

hernia, congenital diaphragmatic 48high altitude physiology 17–18, 37, 39–40high frequency oscillation 105–6history-taking

airway/breathing 70cardiovascular system 81parents in 12

hotline 7“hot-loading”, helicopters 37humidity/humidification 27

altitude and 39–40incubators 28, 45

hydralazine 120hypercapnia, head injury 93hyperkalaemia 62hypertension

drugs treating 119–20systemic, with sinus bradycardia 56

hyperthermia 28–9hyperventilation, controlled, with raised intracranial

pressure 76hypervolaemia 14hypocapnia, head injury 93hypoplastic left heart 87hypotension, neonatal 44hypothermia

burns patient 97–8neonatal 45

refractory 45trauma patient 90, 101see also heat loss

hypovolaemia 14 head injury 93see also fluid management

Index142

hypoxiahead-injured 93intubated patient 74

incubators (transport in) 22, 28, 45–6gas supply 22power supply 21restraint 22, 23standards 20

infants airway see airwayneurological assessment 11premature see premature infantstemperature control 28

warming devices 12transcutaneous blood gas monitoring 32–3ventilation 11, 43–4, 77see also neonates

information see communication; documentationinfusion pumps 29injury see fractures; traumainotropic drugs 61, 84, 85, 115–16insulin + dextrose 62intestinal tract obstruction 48–9intracranial pressure, raised 15, 92–4

causes 80, 93trauma 92–4

signs 55–6treatment 56, 57, 76, 93–4

intubation 76intraosseous needle insertion 65–6intravascular access see fluid management and

specific routes; vascular accessintubation, tracheal 60, 71–6

aircraft 38complications 74drugs 60, 73indications 71muscle relaxants (neuromuscular blockers) 72, 73,

75, 114neonates 43, 44, 46patient packaging 77procedure 71–4special considerations (incl. difficulties) 74–6tubes

correct placement 73, 74fixation 74types/sizes 74, 134

isoprenaline 116

joint, dislocated 96jugular vein, internal, cannulation 68

ketamine 113

labetalol 119labour ward, transfer from 49laryngoscopy 73

difficulties relating to 75

Leicester, retrieval documentation 128–33lidocaine 59lighting (inside cabin) 21lights (flashing), time saved due to 22–3lignocaine 59limbs (extremities)

lower (legs), venous pooling 15trauma 96–7

loading 21log rolling 98–100lorazepam 114, 117low birthweight babies, thermoregulation 45Lund and Browder (body surface area) chart 97, 98lungs see entries under pulmonary

mannitol 56, 57, 93mattress

child-restraining 23vacuum 96, 100

mechanical ventilation 76–7medical director 3medullary lesions, signs 56meningococcal septicaemia, risk of mortality

score 111methaemoglobin in iNO therapy 103methylprednisolone 117midazolam 113, 117, 118midbrain lesions, signs 56milrinone 85monitoring 12, 30–5

cardiovascular system 31–4, 60, 83equipment 6, 30–5NO inhalation 103predeparture check 63respiratory system 31, 70trauma patient 101

morbidity in transit 109morphine 100, 122

tetralogy of Fallot 89mortality see deathmotion (travel) sickness

aircraft 39parents 12staff 16, 24

movementof organs and diaphragm, acceleration/deceleration

causing 15of patient, equipment 6

muscle relaxants (neuromuscular blockade) 114–15for intubation 72, 73, 75, 114

myocardium see heart, muscle

nasopharyngeal temperature probes 34nasotracheal intubation 73–4

air transport 38needle cricothroidotomy 63–4needle thoracotomy 64neonates and young infants 43–52

assessment and stabilisation 43–5

Index 143

back transfer 51–2cardiovascular history-taking 81central venous access (umbilical vessels) 49–51, 84congenital abnormalities

cardiac, presenting in neonates 86transfer for surgery 47–9

fluid loading with acceleration/deceleration 15fluid management 44, 47, 121incubators see incubatorslabour ward to neonatal ICU transfer 49low birthweight 45premature see premature infantsprocedures 49–51respiratory drugs 120restraint 23resuscitation 46–7retrieval forms, Nottingham 124–7stroke volume 80thermoregulation 45–6see also advanced neonatal nurse practitioner;

developmental changes; infantsneurological status and outcome see disabilityneuromuscular blockade see muscle relaxantsnewborns see neonatesnifedipine 119–20nitric oxide, inspired 102–4

monitoring 35nitrogen dioxide inhalation, danger 103nitroprusside, sodium 120noise 16noisy breathing 53–4norepinephrine (noradrenaline) 61, 85, 116Nottingham, neonatal service transport retrieval forms

124–7nurse

senior, as transport coordinator 3transport 4

nurse practitioner see advanced neonatal nursepractitioner

oculocephalic reflex 56oesophageal atresia 48oesophageal pouch 29oesophago-tracheal fistula 48one-way transport 4operational team see teamopiates/opioids 100, 122–3

for intubation 72neonates 44, 49

organisational team 3orotracheal intubation 73oxygen

carriage (in blood) and delivery 79inspired, concentration, monitoring 33preoxygenation for intubation see preoxygenationrequirements, increased 60saturation 79

monitoring 31–2, 83tension (PO2)

alveolar, reduction at altitude 17–18, 37, 39transcutaneous, measurement 32

see also extracorporeal membrane oxygenationoxygen supply 22, 27

aircraft 38

paddles, defibrillator 30Paediatric Index of Mortality score 111Paediatric Risk of Mortality score 111pain control see analgesiaparaldehyde 117, 118parents and family 12, 109–10

communicating with 7, 12, 110infants’ 46transport 12, 110

Parkland formula 97passenger (incl. patient) safety 9, 23pelvic fractures 90, 91, 95pentastarch 121perfusion 82

cerebral, head-injured 93see also ventilation/perfusion mismatch

peripheral venous access 84personnel see staff; teamphenobarbitone 117phenylephrine, tetralogy of Fallot 89phenytoin 117–18physician see doctorphysiology 14–18

airway see airwaycirculation see circulationdevelopmental changes see developmental

changeshigh altitude 17–18, 37, 39–40indices/measures 134

plasma 84pneumothorax 60

air transport and 17, 38–9neonates 43, 44, 46suctioning 29tension 92, 94

pontine lesions, signs 56positive end expiratory pressure 26positive pressure ventilation (PPV/IPPV) 76

chest injury 94postreturn assessment 13posturing 55–6, 56potassium disturbances 62power supply 20–1, 25

batteries 25–6predeparture checks 12, 63premature/preterm infants

fluid loading with acceleration/deceleration 15stroke volume 80temperature control 28

preoxygenation for intubation 72in rapid sequence induction 74

prescribing drugs 121–2pressure control ventilation 76, 77

Index144

air transport 38preterm infants see premature infantsPrinternox 35prognostication 111prone ventilation 105propranolol 119prostacyclin, nebulised 104prostaglandin E2 infusion 86–7psychological dimensions

parents 109–10staff 110

pulmonary artery malformations 86pulmonary blood flow (blood flow in lungs)

at birth 80–1congenital heart disease decreasing 87motion effects 15

pulmonary contusions 92, 94pulmonary valve malformations 86

pulmonary atresia 88pulmonary venous drainage, anomalous

86, 88pulseless electrical activity 58pulseless ventricular tachycardia 58pulse oximeters 32pulses 82pupillary responses/reactions 11, 55, 56

radiation, heat loss by 16, 27–8radiofrequency interference 38radiograph see x rayrapid sequence induction/intubation 74–5, 114rechargeable batteries 26records see documentationrectal temperature probes 34referral, inappropriate 108referring hospital staff, communication with

7, 9–10reflexes 56relatives see parents and familyrenal system, stabilisation 62–3respiratory arrest see resuscitationrespiratory distress

burns patient 97indicating intubation 71

respiratory drugs, neonatal 120respiratory rate 83respiratory support indices 134

see also ventilationrespiratory system

assessment 53–5neonatal 43

monitoring 31, 70stabilisation 60

neonatal 43–4see also airway and entries under pulmonary

restraintequipment 22patient 23

resuscitation 53, 57–9, 63–8

algorithms 57–9neonatal 46–7trauma patient, inadequate 101unsuccessful 109

retrieval forms 123–33review meetings 110rewarming see warmingrib fractures 91Ringer’s lactate 121risks see safety issuesroad traffic see trafficrocuronium 115

safety issues (risk and hazards) xi, 8–9helicopters 36–7nitric oxide therapy 103passenger/patient 9, 23prone ventilation 105restraint see restraintspeed of ambulance 8–9, 22–3

salbutamol, nebulised 62saline (sodium chloride)

isotonic 84, 121normal/physiological/isotonic/0.9[percent] 84

neonates 47see also sodium chloride

satellite navigation 23scoring systems 111Sea-King helicopter 36, 37

iNO use 103–4seating position 20sedation 113–14

drugs used 113–14for intubation 72, 73neonates 44

seizures/convulsions 61, 62anticonvulsant drugs 61, 113, 114, 117–18head-injured 93

Seldinger technique 66–8senior nurse as transport coordinator 3septicaemia 81severity of illness, assessment 111shearing injury, abdomen 95shock

at birth, indicating cardiac disease 81intubation in 71, 76signs of

cold peripheries 55temperature measurement 34

trauma patient 92shunts, palliative, blockage 89sinus bradycardia, systemic hypertension with 56sinus tachycardia 58sirens 22–3skin colour and perfusion 82sodium bicarbonate

in hyperkalaemia 62neonates 47in tetralogy of Fallot 89

Index 145

sodium channel blockers (class I antiarrhythmics)118, 119

sodium chloride in hyperkalaemia 62 see also saline

sodium nitroprusside 120sodium polystyrene 62“sopite syndrome” 16speed of ambulance 8–9, 22–3spinal board 96, 100spine

control/immobilisation 91, 96, 98injury 95–6

stabilisation 10, 59–63cardiovascular system 44, 60–1, 83–6CNS 61gastrointestinal system 61–2neonatal 43–4, 44, 45renal system 62–3respiratory system see respiratory systemscoop and run v 10specific procedures in 63–8

staff referring hospital, communication with 7,

9–10retrieval/transport service

accreditation and training 111comfort 24debriefing and support 110education 5staffing xi

see also ambulance crew; safety issues; teamstandards 20–1Starling curve 14steroids 117stomach contents, aspiration, prevention 62, 74straddling injury, abdomen 95stretcher standards 20–1stroke volume 80

end diastolic volume and, relationship 14subclavian vein cannulation 68suction equipment 29supraventricular tachycardia 58, 118–19surface area, body

burns and 97, 98hypothermia risk in trauma 90

surfactant 44, 120surgery, congenital abnormalities and transfer for

47–9Survanta 120suxamethonium 75, 114sweating, heat loss by 16sympathomimetic agents 115, 116synchronised cardioversion 58, 59systolic blood pressure 80

monitoring 34normal 79

tachycardia 58sinus 58supraventricular 58, 118–19

ventricular 58–9pulseless 58

team 3–4, 10 operational 3–4

assessment and management by 10–13organisational 3safety 9see also ambulance crew; safety issues; staff

temperature control (thermoregulation) 11–12,27–8 34

continuous monitoring 34neonates 45–6predeparture check 63problems 16–17trauma patients 90see also heat loss; hypothermia

tension pneumothorax 92, 94tetralogy of Fallot 87, 88thalamic lesions, signs 56Therapeutic Intervention Scoring Systems 111thermal control see temperature controlthermal injuries 97–8thiopentone 113thoracotomy, needle 64thorax see chesttracheal intubation see intubationtracheo-oesophageal fistula 48traffic

accidents (children) 90density 5

training 111transcutaneous blood gas monitoring 32–3transport, mode of 4–5transport coordinator 3transport log 8transport programme, setting up 5transposition of great arteries 88, 89trauma 90–101

analgesia 100clinical assessment 91documentation 100mechanism and patterns of injury

81, 90–1pitfalls in transfer 101practical procedures 98–100primary review 91, 91–2secondary review 91, 92specific injuries 92–8tertiary survey 91

travel sickness see motion sicknesstricuspid atresia 88trolleys 22, 25

loading 21position 20restraint 23

two-way transport 4, 5

umbilical vessel catheterisation 49–51, 84unsalvageable child 61, 105–6urethral catheterisation 62

Index146

vacuum mattress 96, 100vascular access (for infusion/monitoring) 61,

65–8, 83–4 air transport and 38equipment 6procedures 65–8see also catheters; infusion pumps

vascular injury 96vasoactive drugs 115–16

as antiarrhythmics 120VDR-3C 106vecuronium 115vehicles

acceleration/deceleration 14–15dedicated 23provision xi–xiistandards covering 20–1see also transport, mode of and specific modes

venous access (for infusion) 61, 83–4central see central venous accessequipment 6failed lines and their replacement 83–4peripheral 84

venous pooling see blood, poolingvenous pressure, central 83ventilation 57, 60, 104–6

air transport 38, 39infants and neonates 11, 43–4, 77mechanical 76–7prone 105see also hyperventilation; respiratory support

indices and specific methods of ventilation

ventilation/perfusion (VQ) mismatch, procedureswith 104, 105, 106

ventilators 26air supply 27

ventriclesarrhythmias 119

fibrillation 58tachycardia see tachycardia

congenital defects 87end diastolic volume 14filling pressure 14–15right outflow tract obstruction 87stroke volume see stroke volume

vibration 16helicopters 38

volume control ventilation 76, 77volume expansion see fluid managementVQ mismatch, procedures with 104, 105, 106

warming (and rewarming)devices 12, 17, 28–9, 49neonates 45, 49

weather 6weight estimation 134

x ray (plain films)chest 83head-injured 94spinal injury 94

Index 147

Health & Medicine

Bmj[1].books.pediatric.and.neonatal.critical.care.transport.e book lib