Transport of the Critically Ill Child:
The Essentials
Allan de Caen MD FRCP
Pediatric Critical Care Medicine
Stollery Children's Hospital
Edmonton, Canada
Objectives

Case illustration

Starting the transport process:
 who,

how, what team, and why…
Stabilization pre-transport
Conflict of Interest Statement

Medical Director of Stollery PICU
Transport Team

Co-Chair of CAPHC (National) Pediatric
Interfacility Transport Steering Committee
No Financial COI
A previously well 9 year old presents to a rural
hospital with a 24 hour history of fever, malaise,
myalgias. She has had increased lethargy and
respiratory distress over the last 6 hours.
Upon ER presentation, the child appears mottled, is
acting confused, and has moderately increased work
of breathing.
Her ER vitals are T 39°C, HR 150, BP 70/50, RR 35,
and a RA 02 saturation of 89%. It is apparent to the
referral hospital team that her medical care will
ultimately require tertiary care admission.
Starting resuscitation and calling for help

Identify early whether the patient will require
transfer, and call for help early (time to transport
might be hours…)

1800-282-9911 for RAAPID North
 1800-661-1700 for RAAPID South

Air transport of critically ill children (or those at
risk of being so) is coordinated through local
Children's Hospital PICU (provincial dividing line
at Red Deer)

Pediatric Intensivst can not only facilitate getting
help to the referral hospital (transporting team or
otherwise), but supporting the referral center
while help is en route
Pediatric Transport: Weighing Priorities
Referring Hospital
Accepting Hospital
•limited MD/ RN
resources
•MD/ RN resources
•limited technical skills/
experience
•limited equipment
•abundant technical
skills/ experience
•limitless equipment
Patient Care
•Time to tertiary care
•Transport team composition
•Transport mode
•Disease specific issues
Who should transport the patient?

Referral hospital/ regional team (MD/ RN/ Medic)
 Removing local resources
 Do they have setting specific cognitive and
technical skills/ equipment?

ALS/ adult critical care flight team (eg. STARS)
 Predominantly adult-focused
 Limited (non-trauma) pediatric experience

Pediatric critical care
 Best option for critically ill child ( mortality)
 Limited resource
 Prolonged time to patient bedside (av. 90-120 min)
How is the decision made as to what kind of
team transports?

Patient acuity (acuity scores vs. gut feeling)

Age (<5 years age vs. adolescence)

Distance to tertiary care center

Disease specific
 Expanding intracranial mass
 Traumatic shock (refractory-only)
 <5% ped trauma needs surgical intervention
 Time to tertiary care support more important
than time to trauma center

Team availability
Never accept a step-down in care for your patient
Alberta Air Ambulance Network

~9000 Air Ambulance flights in Alberta annually

~10% (~800-900) provincial air tpts are Pediatric trips

70% provincial flight activity is in Central/ Northern
Alberta

150-200 Stollery PICU Air Ambulance trips

~500 advice/ transport calls to Stollery PICU
intensivists/ year
Before the patient is transported…
Does the airway need to be secured?

General indications:
 altered LOC/ resp distress or
decreased effort/ shock
 its more than just ABG/ 02
saturations

Specific disease states (idiopathic vs.
post-traumatic seizure)
Do I need to
intubate, or
 Patient age/ size
can it wait for
 Does the patient have co-morbidities?
the tertiary
 What is the trend?
care team?
Assessment/ Management In the Transport
Setting
Ability (or not) to clinically assess the patient
 Ambient
lighting: is the patient blue/ pink/
white/ grey?
 Noise:
the stethoscope is useless
 ETT
 Motion
position, pneumothorax
artifact (BP cuff, 02 saturation monitor)
What is the transport distance?
Assessment/ Management In the Transport
Setting
 What
is the mode of
transport?
 It’s
difficult to
intubate in the
cramped space of a
helicopter or plane
A
ground
ambulance can
always pull off to the
side of the road
Intubation Pre-Transport

With oxygenation difficulties, lung
compliance/ inflation is often compromised

A cuffed ETT allows for consistent
application of TV and PEEP


ETT (cuffed) size is 0.5 size smaller than noncuffed choice
Oxygenation and ventilation can be
provided with less toxic Fi02/ airway
pressures
CXR post-intubation

Pneumothorax: small becomes big at
altitude/ with positive pressure ventilation

ETT position post-intubation
 Capnography: intra-airway (still either high
or low…)
 Brazelow tape: length not always = weight
 Clinical assessment is unreliable in small
children

Decompression of the stomach
 Gastric distention at altitude compromises
ventilation, with or without ETT
Ventilating the Small Child Pre-transport

Suction post-ETI
 Small airway and thick secretions
 Humidvent/ humidification

Once the ETT is in, ventilate (sub-physiologic rate)
 3 months:
30 BPM
 2 yrs. age:
20 BPM
 10 yrs. Age:
12 BPM

TV 5-7 cc/ kg or PiP<30/ move the chest

PEEP 5

Titrate Fi02 to 02 sat>94%

Baseline (CBG) and trend (EtC02 30-35mm Hg)
Hemodynamic Stabilization Pre-Transport

IV/ IO X 2


Not just trauma
2nd IV allows for a back-up plan in the transport setting

Shock states, repeated assessment every 10cc/
kg of fluid (NS): liver size, lung fields (creps)

Titrate fluids not just to BP, but reversal of shock
S/S (perfusion/ cap refill, HR,…)

Tendency is to undertreat with fluids; most septic
states require at least 60cc/ kg in first hr. of
resusc’n
Hemodynamic Stabilization Pre-Transport

On-going fluid requirements due to
vasodilation/ capillary leak

If hypotension refractory to 60cc/ kg fluid,
remember BS/ Cai/ inotropes

Reassess, reassess, reassess; fluid/ drug
requirements change over time
Has enough resuscitation fluid been given?
Systolic Wave Variation/ Pulse Pressure Variability:
check your pulse oximetry tracing (audio or visual)
Mixing Inotropes: The Rule of 6’s
vs. Pre-mixed bags of inotropes
Run drugs dilute and titrate to BPs > 70 + (ageX2)
Dopamine

6mg X (pt. weight) in 100cc D5W/ NS

1cc/ hr = 1 mcg/ kg/ min

Start at 10mcg/ kg/ min (10cc/hr)
Epinephrine

0.6mg X (pt. weight) in 100cc D5W/ NS

1cc/ hr = 0.1 mcg/ kg/ min

Start at 0.1 mcg/ kg/ min
Once the ETT is in, keeping it in…

Avoid benzodiazepines/ propofol due to
vasodilatory effects

Serial dosing of analgesic agents
 Fentanyl: 1-2 mcg/ kg q30-60 min
 Ketamine 0.5-1 mg/ kg q1hr
 Morphine 0.05-0.1 mg/ kg q1-2hr

The patient with residual paralysis
 Titrate sedative/ analgesic dosing to jumps in
HR/ BP

Even these agents have vasodilator effects…

Rocuronium 01.mg/ kg q30-60 min with patient
movement
Temperature Management of the Pediatric
Patient on Transport

Small children lose significant heat (radiant/
evaporative/ conductive losses)

Hypothermia increases SVR/ myocardial stress

The importance of temperature (fever) control
is disease specific
 Cardiac arrest: Avoid fever; don’t cool
 TBI: Avoid fever; don’t cool (harmful)

The earlier fever is managed, the better for the
patient (window of dose effect starts early)
ICU transport teams take longer to stabilize…
Significant difference in stabilization times
comparing kinds of transport teams
ALS
0.44+/-0.15 hr
ALS (peds)
0.98+/-0.21 hr
PICU
1.24+/-0.34 hr
McNabb, J Trauma, 1991
Transport stabilization times for neonatal and pediatric
patients prior to interfacility transfer
Whitfield, Children’s Emergency Transport Service, Denver,1993
Pediatric Stabilization Times 1988-1990
All transports (n = 1106)
55 (10-419)
Ventilated (n = 157)
88 (18-419)
Ventilated with Inotropes (n = 13)
156 (55-419)
Summary of PICU tpt data

Sick patients get sicker on transport

Longer transports, sicker patients

Sicker patients take longer to stabilize, and
that is usually OK
Tex Kissoon’s Golden Rules of Transport

Plan ahead

Transports are palliative, not curative

No form of transport is ideal for every
patient

Any hospital is a better hospital than an
airplane or ambulance

If it is possible for a sick person to
become sicker, he probably will

Big problems are simply small problems
you have not anticipated

Nothing lasts forever (eg. Air 02,
battery, etc)
Keeping in touch
Remember:

This is your patient until you hand over to
the transport team

Reassess, reassess, reassess…

Call PICU (through RAPID) if patient
condition deteriorates; we are there to help

No question is a stupid question
Thanks for your attention.
Questions?