“Scoop and Run” or “Stay and
Play”?
Approach to pediatric
stabilization and transport
Janis Rusin MSN, RN, CPNP-AC
Pediatric Nurse Practitioner
Children’s Memorial Hospital
Transport Team
Case Study
• 2 month old infant
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found in full cardiac
arrest at home
Paramedics initiated
CPR and continued
CPR for 10 minutes
until arrival in ED
Communication Center Call
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Patient arrived to ED with CPR in progress
Intubated with 3.0 ETT and being bagged
Epinephrine given X 2
Atropine given X 2
Heart rate resumed
Sodium Bicarb given X 2
Current vitals: HR-140 RR-40 BP-52/11 Temp- 90F
Vent settings: FiO2 1.0, Rate 40, PIP 20 PEEP 3
Pupils 3mm and sluggish
Cap refill 5 seconds
ABG 6.93/74.4/259/14.8/-16.9
On Arrival
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Unresponsive
Lungs clear and equal bilaterally
Capillary refill 4 seconds
Color pale/gray with cool extremities
Peripheral pulses palpable
Abdomen full and soft to palpation
Fontanel soft and flat
2 tibial IO’s in place bilaterally and one PIV with
maintanance and dopamine infusing at 5 mcg/kg/min
• Glucose-47, K-7.0 non-hemolyzed
• Succinylcholine given by ED staff but patient with
gasping respiratory effort
The Golden Hour
• Concept originated in 1973 by Cowley et al.
• Referred to Army helicopter use
– Goal for soldiers to be within 35 minutes of definitive
life-saving care
• Reported a 3 fold increase in mortality with
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every 30 minutes away from ‘definitive care’
Resulted in less field intervention in favor of
speed of transport
Interventions on transport in 1973, not
comparable to our capabilities today
Initiation of ‘definitive’ care
• Definitive care begins with the arrival of the transport
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team
Early goal directed treatment improves outcomes
– Needs to begin with the local emergency departments and
continue with the transport team
– Early aggressive interventions to reverse shock can increase
survival by 9 fold if proper interventions are done early!
– Hypotension and poor organ perfusion worsens outcomes
“Further improvement in the outcome of critical illness is likely if
the scoop-and-run mentality is replaced by protocol driven, early
goal-directed therapy in the pretertiary hospital setting”
Stroud et al., (2008)
Initiation of ‘definitive’ care
• Ramnarayan (2009)
– Urgent vital interventions such as CPR, intubation or
central venous access required in the first hour after
arrival in an ICU
– May indicate that inadequate stabilization was
completed during transport
• McPhearson and Graf (2009)
– Attention to small details makes significant difference
in pediatric transport
• Securing ETT
• Early recognition and treatment of shock
• Adequate IV access
Adverse Events
• Orr et al. (2009)
– Sample size 1085 pediatric patients
– 5% had at least one unplanned event
• Airway events-Most common
• Cardiac arrest
• Sustained hypotension
• Loss of IV line needed for inotropic support
• Hypothermia
• Pediatric specialized teams had longer transport times, but
lower incidents of adverse events, major interventions and
deaths
Not so fun facts…
• Primary cardiac arrest in infants and children is rare
• Pediatric cardiac arrest is often preceded by respiratory
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failure and/or shock and it is rarely sudden
Early intervention and continued monitoring can prevent
arrest
The terminal rhythm in children is usually bradycardia
that progresses to PEA and asystole
Septic shock is the most common form of shock in the
pediatric population
80% of children in septic shock will require intubation
and mechanical ventilation within 24 hours of admission
Method to the madness
• Stabilization goals on
transport
– Airway/Breathing
• Respiratory distress and
failure
– Circulation
• Shock identification and
management
– Disability
• ICP management
– Exposure
• Avoid hypothermia
Airway
• The respiratory systems
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continues to develop until 8-10
years of age
The pediatric airway is
considerably smaller than the
adult airway
Poiseuille’s Law: If radius of
airway is reduced by half, the
resistance in increased by 16
fold!
The cricoid cartilage is the
most narrow point of airway
Serves as a natural cuff for
ETT’s
Cuffed ETT’s may be used in
young children but only inflate
cuff to minimize air leak
Respiratory Distress
• A compensated state in
which oxygenation and
ventilation are maintained
– Define oxygenation and
ventilation
– How will the blood gas
look?
• Characterized by any
increased work of
breathing
– Flaring, retractions,
grunting
– What is grunting?
Respiratory Failure
• Compensatory mechanisms are
no longer effective
• Inadequate oxygenation
and/or ventilation resulting in
acidosis
– Abnormal blood gas with
hypercapnia and/or
hypoxia
• Medical emergency! Must
protect airway!
• Strongly consider intubation
Respiratory Failure
• Major events that lead to respiratory failure:
– Hypoventilation
• Decreased LOC
– Diffusion impairment
• Alveolar collapse or obstruction
• Pulmonary edema
• Pneumonia
– Intrapulmonary shunting and V/Q mismatch
• Alveoli are ventilated but not perfused-raising FiO2 may not
improve PaO2
• Lungs perfused but not ventilated
• Asthma, ARDS, pneumonia, PPHN
Endotracheal Tubes
• Size
– Pediatric patient:
16 + age in years
4
– Compare to little finger
– Neonates
• See table
Tube
Size
Weight
(grams)
Gestational
Age
2.5
< 1000
< 28
3.0
10002000
28-34
3.5
20003000
34-38
3.5-4.0
> 3000
> 38
Endotracheal Tubes
• Length of tube
estimated by the
following:
– Children > 1 year of
age:
• 13 plus ½ patient’s age
– Infants < 1 year of
age:
• Estimated 3x ETT size
Respiratory assessment and
management on transport
• Across the room
– As you approach patient
– Alert, pink, restless,
combative?
• Airway
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Assess positioning
Airway noise?
Intubated?
ETT secure and in proper
position
• T2-T4-Above carina
Respiratory assessment and
management on transport
• Tired appearance/decreased or
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altered LOC
Children have thin chest walls
that make it relatively easy to
hear their lung sounds. If you
can’t hear them, something is
wrong!
Anxiety-Air hunger
Cyanosis does not become
clinically apparent until
< 88%
Stridor/snoring respirations
Head bobbing
Prolonged expiration
Respiratory assessment and
management on transport
• 100% oxygen via NRB mask
– Wean O2 as patient stabilizes using face mask or nasal
cannula
• Provide bag valve mask ventilation for children who are
not breathing effectively
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Unable to maintain O2 sats on oxygen
Cyanosis
Unable to protect airway
Bag with enough force to make chest rise
1 breath every 3 seconds
• CE hand position
– Do not occlude airway with your fingers!
Rapid Sequence Intubation
• Goals of RSI
– Induce anesthesia and
paralysis to facilitate rapid
completion of procedure
– Minimize elevations of ICP and
blood pressure
– Prevention of aspiration and
ventilation of stomach
• Sellick Maneuver
– Compression of the cricoid
cartilage
– Compresses esophogus to
prevent aspiration
– Improves visualization of vocal
cords
Rapid Sequence Intubation
• Procedure
– Oxygenate with FiO2 of 1.0
– Administer atropine
• Prevents vagally induced bradycardia
• Minimizes secretions
– Administer an opiate and benzodiazepine
• Sedation
– Administer paralytic
• Relaxes all muscles allowing ease of opening airway and
controlling breathing
– Proceed with intubation
Circulation
• Shock
– An abnormal condition of inadequate blood flow to
the body tissues, with life threatening cellular
dysfunction
– Remember: CO = HR X SV
– Oxygen delivery to the tissues is the product of
cardiac output
– Mortality rate varies from 25-50%
– Earliest symptom is tachycardia
– Tachycardia in a child always has a cause-if you don’t
know why, find out!
Circulation
• Compensated Shock
– The body’s compensatory mechanisms are working
and maintaining the body’s most important functions
– Blood pressure is maintained
– Symptoms of early shock include:
• Mild tachycardia
• Mild tachypnea
• Slightly increased capillary refill time
• Weak peripheral pulses
• Decrease in urine output and bowel sounds
• Cool/mottled extremities
Circulation
• Decompensated Shock
– The compensatory mechanisms are no longer effective
– Blood pressure begins to deteriorate-this is what distinguishes
compensated from decompensated shock!
• Symptoms become more pronounced:
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Tachycardia/tachypnea
Diminished or absent peripheral pulses
Very delayed capillary refill and cold extremities
Pallor
Poor or absent urine output
Fluid shifts causing generalized edema
Petichiae: DIC
Hypothermia
Types of shock
• Hypovolemic Shock
– Occurs from loss of blood or body
fluid volume from the
intravascular space
– Causes can be injury, vomiting or
diarrhea
• Cardiogenic Shock
– Pump Failure
• Inability of the heart to
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maintain adequate cardiac
output
SVT, arrhythmias,
cardiomyopathy, heart block
Support ABC’s
Treat the cause
Types of shock
• Obstructive Shock
– Inadequate cardiac output
due to an obstruction of
the heart or great blood
vessels
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Cardiac tamponade
Tension Pneumothorax
Mediastinal mass
Support ABC’s, but fluids
may not be the best
option. The obstruction
must be relieved
Distributive Shock
• Septic shock
– Systemic infection as
evidenced by a positive
blood culture
– Clinical presumptive
diagnosis important
– Patient in early septic
shock will have bounding
pulses and warm
extremities
– Also known as warm shock
Distributive Shock
• Septic shock:
– Bacterial organisms release toxins, which results in an
inflammatory response and cellular damage
– Bacterial toxins serve as vasodilators resulting in loss of
vascular tone
– Increased capillary permeability
– Fluid shifts to extracellular space
– Hypotension may not respond to fluid resuscitation
– Inotropic support
– Early antibiotics
– 80% of children in septic shock will require intubation and
mechanical ventilation within 24 hours of admission
Distributive Shock
• Neurogenic shock:
– Severe head or spinal
injury
– Decreased sympathetic
output from the CNS
– Decreased vascular tone
• Anaphylactic shock:
– Antibody-antigen reaction
stimulates histamine
release
– Histamine is a powerful
vasodilator
– Loss of vascular tone
Shock Management
• Venous access: Ideally 2 large bore IV’s
• Fluid resuscitation: 20ml/kg bolus of NS or LR
• Reassess patient after each bolus
• Convert to blood bolus if patient is bleeding
• Inotropic support for hypotension that persists
despite fluid resuscitation-Beware of
catecholamine resistant shock!
• Treat hypothermia
• Correct F/E imbalances
• Find the cause and fix it!
Disability and Dextrose
• AVPU scale
– Alert: Patient is A & O X 3
– Verbal: Patient requires
verbal stimulation to wake
and respond
– Pain: Patient requires
painful stimuli to wake and
respond
– Unresponsive: Patient does
not respond to any stimuli
• Dextrose
– Children in distress become
hypoglycemic quickly
– Altered mental status can
be a sign of hypoglycemia
– Check accucheck or i-Stat
– Treat hypoglycemia with
2ml/kg of D10W
– Recheck accucheck q 15-30
minutes
Exposure/Enviornment
• Remember a naked child is a cold child!
– Check child’s temperature
– Warm IV fluids if possible: room temperature fluids
are about 20 degrees colder than normal body
temperature
– Warm blankets for transport
– Portawarmer mattress: Can use more than one for an
older child
– Place under blanket to avoid burns to skin
• Hypothermia exacerbates acidosis!
Family Presence
• On transport, the family is almost always present either at the
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OSH or in the ambulance
The literature shows that most clinicians are concerned that
parents will interfere with care if allowed to be present during
resuscitation
However, this is rarely the case
In fact, some studies show that care is improved when a
parent is present
There is no evidence to suggest that the legal risk increases
with parental presence
What would you want if it were your child?
Dingeman et al. (2007)
X-Ray evaluation
• Systematic approach
– Check patient name
– Check time of film-use most recent
– Air is black and solid structures are white due
to increase density
– Ribs should be same length on both sides
• Asymmetry may indicate rotated position
– Check for ETT placement, line placements and
for immediate life threats
X-Ray evaluation
X-Ray evaluation
X-Ray evaluation
X-Ray evaluation
Back to the case study
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Current vitals: HR-140 RR-40 BP-52/11 Temp- 90F
Vent settings: FiO2 1.0, Rate 40, PIP 20 PEEP 3
Cap refill 5 seconds
ABG 6.93/74.4/259/14.8/-16.9
2 tibial IO’s in place bilaterally and one PIV with
maintanance and dopamine infusing at 5 mcg/kg/min
• Glucose-47, K-7.0 non-hemolyzed
• Succinylcholine given by ED staff but patient with
gasping respiratory effort
Interventions
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Re-tape and pull back ETT 1 cm
Increase PEEP to +5
Sedation with Fentanyl 1-2 mcg/kg
Treat hypoglycemia-2ml/kg of D10W
Provide adequate paralysis with pavulon
Give Calcium Chloride-Why?
Give dextrose to increase accucheck to 100,
then give regular insulin 0.1u/kg-Why?
What happened?
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Patient sedated and paralyzed appropriately
CaCl and bicarb given as ordered
Recheck of accucheck after dextrose =112
Insulin given as ordered
Accucheck dropped to 42 so D10W repeated
One IO was infiltrated so new PIV started
Repeat ABG 6.94/92.1/233/18.8/-13.1
BP dropped after pavulon, so dopamine titrated up-to
20mcg/kg/min
• Pt diagnosed with Influenza A
Summary
• Transporting critically ill
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children requires a
systematic approach
Attention to details will
help to avoid adverse
events
Be prepared before you
move
Minimize major
interventions in
ambulance or helicopter
It’s all about the ABC’s
References
• Ajizian, S.J., Nakagawa, T.A., Interfacility Transport of the Critically
Ill Pediatric Patient. Chest. 2007; 132: 1361-1367
• Cowley, R.A., Hudson, F., Scanlan, E., Gill. W., Lally, R.J., Long, W., et
al. An Economical and Proved Helicopter Program for Transporting
the Emergency Critically Ill and Injured Patient in Maryland. The
Journal of Trauma. 1973; 13(12): 1029-1038
• Dingeman, R.S., Mitchell, E.A., Meyer, E.C., Curley, M.A.Q. Parent
Presence during Complex invasive Procedures and Cardiopulmonary
Resuscitation: A Systematic Review of the Literature. Pediatrics.
2007; 120(4): 842-854
• Horowitz, R., Rozenfeld, R.A., Pediatric Critical Care Interfacility
Transport. Pediatric Emergency Medicine. 2007; 8: 190-202
References
• Kliegman, R.M., Behrman, R.E., Jenson, H.B., Stanton, B.F. (eds.),
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Nelson Textbook of Pediatrics, 18th ed., 2004, Philadelphia, Saunders
Elsevier
McCloskey, K.A.L., Orr, R.A. Pediatric Transport Medicine, 1995, St.
Louis, Mosby
McPherson, M.L., Graf, J.M., Speed isn’t Everything in Pediatric
Medical Transport. Pediatrics. 2009;124(1): 381-383
Orr, R.A., Felmet, K.A., Han, Y., McCloskey, K.A., Drogotta, M.A., Bills,
D.M., et al. Pediatric Specialized Transport Teams are Associated
with Improved Outcomes. Pediatrics. 2009; 124: 40-48
Stroud, M.H., Prodhan, P., Moss, M.M., Anand, K.J.S. Redefining the
Golden Hour in Pediatric Transport. Pediatric Critical Care Medicine.
2008; 9(4): 435-437