Preparing for transport
- How should the referring hospital staff prepare the child for transport ?
- Analgesia and sedation for transport
- Trauma
- Specific Illnesses
How should the referring hospital staff prepare the child for transport ?
Secure the airway, breathing, and circulation
- Intubate if necessary (nasotracheal tube if appropriate)
- Check ETT position on chest x-ray (tip at medial end of clavicles)
- Secure ETT strapping
- Frequent ETT suction (hourly at least). Instil 0.25 - 0.5 ml sterile normal saline into ETT before each suction.
- Humidify gases (with a condenser humidifier (= "Swedish nose") or a heated water humidifier) for every intubated patient, not just those on a ventilator. Ask RCH PICU for advice if necessary.
- Give oxygen 10 l/min by Hudson mask to any severely ill child and to any child who has suffered significant trauma.
- Adequate plasma expansion. Use boluses of 20 ml/kg normal saline, or 4% albumin, repeated if necessary. Titrate against heart rate, blood pressure and skin perfusion (capillary refill time should be < 2 sec). If more than 60 ml/kg are needed, consider starting an inotropic drug infusion: Use dobutamine 15 mg/kg in 50 ml 5% dextrose via a peripheral IV cannula initially. The starting dose is 1 ml/hour (5 mcg/kg/min), increasing in 1 ml/ hour steps every 5 minutes up to 4 ml/hour if no response. In children with septic shock, you may need to start noradrenaline infusion (add noradrenaline 0.3 mg/kg to 50 ml 5% dextrose) as soon as a central venous cannula is inserted. . Starting dose 1 ml/hour (= 0.1 mcg/kg/min). Increase each 2 minutes in 1 ml/hour steps untilan adequate blood pressure is reached. Contact RCH PICU on 03 9345 7007 if noradrenaline infusion is needed.
-
Inserting a central venous cannula for inotrope administration and CVP measurement if more than 60 ml/kg plasma expansion are needed.
- Check the blood glucose hourly and give IV glucose if necessary
- Stop seizures: use diazepam 0.2 mg/kg IV, repeated if necessary
- Continue ventilating any child after cardiac arrest (including SIDS and near-drowning), even if they appear to be breathing adequately
- Maintain body temperature (except after brain injury: allow to fall to 33o C)
- Urine catheter if necessary
- Check electrolytes if appropriate
- Splint the child's arms
- Doctor's letter to RCH
- Copy of observation chart, any xrays and drug chart if possible.
- Ring RCH ICU if there is a problem before the PETS team arrives.
Analgesia and sedation for transport
Upper respiratory tract obstruction
- Most need no sedation
- Nurse on the mother's lap
- Speak gently to the child
- Splint the arms securely, secure the ETT to the face with adequate strapping and ensure adequate ETT humidification and suction
- As a last resort: sedation with chloral NG or with IV diazepam if all other measures fail to reduce the risk of self-extubation.
- In extreme cases the child may require diazepam or morphine and relaxants + IPPV (this is almost never necessary).
Asthma, bronchiolitis, pneumonia, ARDS
If not ventilated, these children should not be sedated during transfer: sedation suppresses respiratory drive and precipitates respiratory failure with rising PaCO2 and falling PaO2; this may cause the child to need emergency intubation and ventilation during transport when these procedures may be very difficult to perform.
If ventilated (not on CPAP or NCPAP), adequate analgesia and sedation (with NG chloral or IV diazepam) should be given. Muscle relaxant drugs are often used during transport in these circumstances.
Conditions with raised intracranial pressure (Head injury, meningitis, blocked VP shunt, tumour, intracranial haemorrhage)
- Unless they are ventilated, these children should not be sedated. Sedation depresses consciousness, obscuring the principal sign of progression of the intracranial hypertension.
- Sedation also suppresses the respiratory drive, raising the PaCO2 and thus the ICP.
If they are paralysed and ventilated, use morphine infusion or boluses of morphine (0.01-0.05 mg/kg/hour) to prevent increases in ICP caused by pain or distress. Small (0.05 - 0.1 mg/kg) doses of diazepam may be given IV if necessary unless neurological assessment will be needed in the next 2-4 hours.
Trauma
Children without head injury may be given a morphine infusion or small IV boluses of morphine (0.025 mg/kg) repeated as necessary up to 0.15 mg/kg per 4 hours.
Children with a head injury and painful fractures or other painful injuries may require doses of morphine large enough to suppress spontaneous ventilation, and may require IPPV simply in order to give them adequate analgesia without causing secondary brain injury.
Beware using intercostal nerve blocks before travel in aircraft (risk of pneumothorax).
Miscellaneous disorders eg septic shock
If these children are sick enough to need IPPV, they often need little sedation.
Unless the child is clearly in pain or agitated, sedative or analgesic drugs should not be given if they may cause hypotension or impaired cardiac output during transport when observation and monitoring are difficult.
If analgesia is required, consider giving ketamine by infusion (1 mg/kg/hour) or repeated IV boluses (0.5 - 1 mg/kg every 30 minutes). Otherwise, give small intravenous boluses of fentanyl (eg 0.2 mcg/kg) or morphine (0.025 mg/kg) repeated as necessary, allowing at least 2 minutes between doses to assess the effect of the drug on blood pressure and circulation.
Repeated small doses of diazepam (0.02 mg/kg) to a maximum of 0.15 mg/kg may be given, especially if ketamine is used (beware reduction of blood pressure and cardiac output).