Transcript No Slide Title

Pre-Hospital Transport of the
Critically Ill Pediatric Patient
Adapted for Oklahoma EMS Use by the
EMSC Resource Center
Originally Developed by:
Lynne W. Coule, MD
Pediatric Critical Care Medicine
Medical College of Georgia
Issues of Concern for Education
• Limited Experience with Pediatrics
– 6% of All Ambulance Runs
• Training in Pediatrics is Limited
• Diseases Unique to Children
• Absence of a Direct History
• Wide Ranges of Patient Ages and Sizes
• Need to Tailor Therapy to Size
What Am I Going to See?
• Most Common Critical Pediatric Problems
– Respiratory and Neurologic (55 %)
• Primary Cardiovascular Problems Rare
• Cardiac Arrest Most Often from Respiratory
Arrest
• Infants (<1 year) Most Common Age Group
Urgency of Stabilization
• Compensation is Extreme but Short-Lived.
• To Reverse Focus on Recognition of Pre-Arrest
• 80% of Pediatric death from injury
– Do NOT Survive to Reach Hospital
– 90% Attended by Pre-Hospital Providers
Intervention
• Oxygen Deficiency
– Primary Life-Threatening Problem
• Oxygen Delivery to Cells
– Rapidly Restore and Maintain
• Oxygen Supply MUST be
– Greater than Demand
• Use Measures to Reduce Oxygen Needs
Oxygen Delivery
• Achieved Through the Function of the:
– Respiratory System
– Cardiovascular System
– Hematologic System
Oxygen Delivery
Oxygen Delivery
Hgb-bound Oxygen
1.34 X Hgb X O2 sat
Dissolved Oxygen
PO2 X 0.003
Cardiac Output
Respiratory System
Child vs. Adult
Larynx is More Cephalad
 Epiglottis is Less Stiff
 Narrowest Portion is Cricoid Ring

Examination - Airway
Air Entry
 Noises Made

Stridor
– Wheezing
– Any Air Movement
–
Examination - Breathing
• Respiratory Rate
• Work of Breathing / Position
• Color
• Mental Status
Therapy for Respiratory Distress
• Oxygen
• Maintain Airway
• Position Upright if Needed
• Despite Oxygen Begin PPV for
– Apnea
– Gasping
– Cyanosis
Methods of Administering Oxygen
• Oxy-Hood - 80-90%
• High Flow Face Mask - 100%
• Face Shield - 40%
• Nasal Cannula
– Varies with Age
• Mechanical Ventilation
– Up to 100%
Bag-Valve-Mask Technique
• Bag Method
– “Squeeze / Release / Release”
• Minimize Leak Around Mask
• DO NOT Obstruct Airway with your Fingers
Airway Management
JAMA February 2000 :
No difference in outcome overall when BVM
compared to ET intubation in pediatric
patients Pre-Hospital care. Improved outcome
in the BVM groups for foreign body
aspiration, child maltreatment, and respiratory
arrest.
Endotracheal tube
• Size: 16 + age (yrs)
4
• Uncuffed in children less than 7 years
• Lip to tip distance is 3 times the ETT size
Broselow Tape
Guidelines for Ventilator Settings
• FiO2: 1.0 (100%)
• Rate:
– Infants 30
– Toddler 20-30
– School age 16-20
• Tidal Volume: 10 - 15cc/kg
• Inspiratory Time:0.6 - 1 second
• Peak Inspiratory Pressure: 20 to 30 cm H2O
• PEEP: 4 to 5 cm H2O
Airway Maintenance
• Secure ETT
• NG/OG Tube
• Sedation
• Relaxants
• Suction ETT
Cardiovascular Interaction
Blood Pressure
Oxygen Delivery
Hgb-bound Oxygen
1.34 X Hgb X O2 sat
Dissolved Oxygen
PO2 X 0.003
Cardiac Output
Heart Rate
Preload
SVR
Stroke Volume
Contractility
Afterload
Examination - Circulation
• Heart Rate
• Perfusion
–
–
–
–
Pulses - Presence and Quality
Skin Perfusion
Level of Consciousness
Urine Output
• Blood Pressure
• Skin perfusion
– Temperature of Extremities
– Capillary Refill
– Color
Signs of Early Shock
• Tachycardia
• Cool Extremities
• Decreased Capillary Refill
• Diminished Distal Pulses
• Irritability
• Mild Oliguria
Causes of Shock
• Hypovolemic
• Cardiogenic
• Distributive
– Septic
– Neurogenic
– Anaphylactic
Treatment of Shock
• Increase Preload
• Improve Contractility
• Affect Afterload
Preload
• Palpate Liver Edge
• 20 mL/kg of NS or LR IV Push within 20
Minutes
• Reassess
• Repeat Fluid Bolus
• Better Outcome if Hypovolemic Shock
Patients Receive 60cc/kg the First Hour of Tx
Interosseous Access
• Don’t Be Afraid of It!
• Most Useful with
– Severe Dehydration
– Nontraumatic Arrest
Inotropy
• May Need To Be Used When >80 mL/kg Used
With Minimal Response
• May Be Needed to Improve Contractility or
Adjust Afterload
Resuscitation Drugs
• Epinephrine
– Used for Asystole, PEA, or Bradycardia
– Dosage: 0.1 mL/kg IV/IO 1:10,000 1st Dose,
1:1000 2nd Dose
• Atropine
– Used for Bradycardia
– Dosage: 0.02 mg/kg IV/IO
– Minimum 0.1 mg
Central Nervous System
• Diagnostic and Therapeutic Interventions May
Have Limited Availability
• Critical Decisions Must Be Made Within The
Limits Afforded
• Basic Needs: Oxygen and Glucose
• Primary and Secondary Injury
• Brain’s Response to Injury
Brain’s Response to Injury
• Altered Mental Status
• Seizures
• Altered Respiratory Function
• Loss of Autoregulation of Blood Flow
• Cerebral Edema
• SIADH
Assessment of CNS
• Neurologic Examination with Pupillary
Response
• Levels of Responsiveness: AVPU
• GCS
• Signs of Increased ICP
Glasgow Coma Scale
Increased ICP - Early Signs
• Headache
• Vomiting
• Altered Mental Status
Prevention of
Secondary Brain Injury
• Maintain Oxygen Delivery
• Maintain Glucose
– Avoid Hyperglycemia
• Correct Circulation
– Then Limit Fluids
• Treat Seizures
• Decrease Metabolic Demands
Transport of Critically Ill Patients
Goals
• Maximize Oxygen Delivery
• Support Respiratory System as Needed
• Correct Shock
• Follow Neurological Exam
• DO NOT PANIC!