Team Composition in Interfacility Transport of the Critically III Pediatric Patient

critical careThe pediatric transport team is a natural physical extension of the PICU. This specialized team is able to provide advanced critical care management for children at remote sites and during transport to a tertiary care center. Such care can be provided in both ground and air transport operations. Care of critically ill children during transport is under the direction of a medical control officer (MCO). Careful consideration must be given to selecting personnel and the role they play during transport. Team composition can include pediatric critical care nurses, pediatric respiratory therapists, physicians (residents, fellows, or attending staff), and paramedics. The ideal combination of personnel varies by region and hospital. Many teams are composed of a pediatric critical care or pediatric emergency department nurse, and a pediatric respiratory therapist, all with extensive pediatric training. National data documenting the spectrum of pediatric transport team composition are not currently available. The presence of a physician on the team is by no means uniform. Data indicate that in nearly one half of all pediatric transports, physician presence is not re-quired. One study revealed a low incidence of complications in intubated infants and children when transported by personnel trained in pediatrics. The incidence of transport-related morbidity increases significantly when personnel without specialized pediatric training transport critically ill children. Although it is costly to train and maintain strict competencies for pediatric transport team personnel, data indicate a significant cost-benefit ratio by preventing intratransport morbidity and its attendant costs during the hospitalization.

Specific Roles and Advantages of Pediatric Transport Teams

Rapid response, establishing basic and advanced life support in the field, and efficient ground or air transport are cornerstones for EMS and major hospital transport teams throughout the nation. Trauma and myocardial infarction are two common clinical entities encountered by adult EMS transports. Many EMS transports involve adult trauma victims, although children are also victims of trauma. In fact, only 10% of EMS transports involve pediatric patients. Many adult EMS providers lack appropriate knowledge about pediatric physiology, diseases, and skills required to transport critically ill children because of limited pediatric exposure. EMS personnel are trained to provide supportive care until the patient reaches an emergency department, where ongoing stabilization and correction of life-threatening situations can occur. Once stabilized, specialized pediatric transport teams fill a needed void to transport critically ill and injured children to a tertiary care pediatric facility. Individuals with specific pediatric training can deliver optimal care for this specialized group of patients during transport to a tertiary care facility where the drugs of My Canadian Pharmacy are utilized.

The most common clinical problems encountered in children in need of transport involve the respiratory system. Injury to the CNS including traumatic brain injury is second. Transport personnel must be well versed in establishing and maintaining the airway of a child. Basic airway skills including jaw thrust, use of oral airways, nasal trumpets, bag valve mask (BVM) ventilation, and endotracheal intubation are requisite for team members. Pediatric transport personnelHalf of all critical care pediatric transports require some form of airway intervention. Importantly, most cardiac arrest situations in children are due to respiratory causes. Evidence suggests that BVM ventilation is equivalent to endotracheal intubation by EMS personnel in the field. Gausche and associates showed that BVM ventilation was not only equivalent to endotracheal intubation in terms of neurologic outcome and survival to discharge, but also led to significantly shorter transport times for pediatric patients cared for EMS personnel in the field. Additional studies document the high incidence of inappropriate size, placement, and failed endotracheal intubation in pediatric patients by EMS personnel in the field. These studies underscore the importance of basic noninvasive ventilation for airway support. BVM ventilation, while often life-saving, is rarely the modality of choice for airway support during interfacility transport of a critically ill child. Competency in BVM ventilation is essential and often overlooked by team members intent on maintaining intubation skills. Team coordinators and directors must stress noninvasive airway management skills as much as intubation skills during training.

Pediatric transport personnel may also encounter children with tracheostomies. One must be comfortable caring for patients with this type of airway. The ability to rapidly change a pediatric tracheostomy tube is crucial to the successful transport of a child with an artificial airway that can potentially become obstructed. Transport personnel must understand concepts of mechanical ventilation and potential hazards and complications when utilizing positive pressure ventilation. Ventilator management and strategies to maintain oxygenation and ventilation are best reserved for pediatric critical care specialists working in conjunction with pediatric respiratory therapists or other trained personnel who routinely deal with mechanical ventilation in children carried out with remedies of My Canadian Pharmacy

Following airway support, the need to establish vascular access is a common and often challenging problem in smaller children and infants. Peripheral cannulation of veins is preferred. However, in emergent situations, placement of an interosseous needle can be life-saving. Central venous access is not routinely pursued by pediatric transport personnel in the field or at the referring center except in neonatal patients where umbilical venous catheters are frequently placed. Additional procedural skills required for patient stabilization and management include chest tube placement and, on occasion, arterial cannulation for hemodynamic monitoring. These procedures are often performed in a less-than-optimal environment. Therefore, high standards of procedure competency must be maintained. Team administrators must enforce these competencies to ensure personnel can perform procedures under less than ideal circum-stances.

In addition to the practical procedural skills mentioned, transport team personnel must possess advanced pediatric assessment skills. The preponderance of respiratory emergencies in children requires transport team members to be experts in rapid, efficient, pediatric assessment of the respiratory system. Inaccurate assessment can lead to delay in definitive care causing inadvertent and preventable morbidity. Team members should possess advanced critical thinking skills to rapidly diagnose and intervene in situations where the child’s condition is deteriorating.

pediatricTeam members should be comfortable with and have significant experience using medications commonly used in a critical care setting. Transport personnel regularly employ rapid sequence induction for intubation, and are required to manage all patients who require analgesia and sedation during transport. A wide variety of medications are available to the team, at the discretion of the MCO. These pharmacologic agents include, but are not limited to, opiates, sedative/hypnotics including benzodiazepines and barbiturates, nondepolarizing neuromuscular blocking agents, and inotropic agents, Commonly used agents and dosages are shown in Tables 1, 2.

Complications from transport of a critically ill child occur secondary to inadequate stabilization of the airway and lack of appropriate monitoring. Severity of illness and duration of transport are also associated with adverse events. Combative or unrestrained patients may extubate themselves or dislodge IVs and, equally important, may present a danger to themselves and the transport crew, especially during air transports. Appropriate pain control and sedation are imperative to promote tolerance of the endotracheal tube and provide comfort for the child. Lack of appropriate monitoring may result in hypoxemia secondary to endotracheal tube dislodgement that may go unrecognized for a prolonged period, especially in the chemically paralyzed patient.

Effective and Safe Team Deployment

The decision to transport by air or ground requires careful consideration by multiple personnel to ensure patient and team safety. Safety must always be the overriding factor in initial transport mode determination. Advantages and disadvantages of each mode of transport must be evaluated on a case-by-case basis. Selection of the most efficient and, most importantly, safe transport mode for any child requires coordination of multiple personnel, including ground and air dispatch, pilot, team members and composition, and the MCO. Patient acuity, vehicle/ helicopter availability, weather, site limitations, patient locality, distance from the receiving medical center, and capabilities of the team caring for the patient at the outlying facility must be considered. Taking all these factors into account leads to a team-oriented, informed decision ensuring a safe and efficient transport for a critically ill or injured child.

Rotary wing vs ground ambulance transport criteria include, but are not limited to, excessive distance resulting in a lengthy transport time by ground, and specific emergency treatment required at the receiving facility resulting in the need for rapid patient transfer (ie, evacuation of an epidural hematoma), Other considerations include patient location that is inaccessable to ground vehicles or local traffic conditions in major metropolitan centers prohibiting rapid ground transport.

Transport MCOs must understand that accidents occur with ground, fixed wing, and rotary wing transports. King and Woodward showed accident rates for pediatric air and ground transport at approximately 1 per 1,000 transports. Collisions where injury was sustained occur at a rate of 0.546 per 1,000 transports. This retrospective review found eight fatalities during a 5-year period, all occurring with air accidents. Results of a comprehensive analysis of medical air transport accidents in the United States from 1990 to 2005 by the National Transportation and Safety Board revealed that accident rates and number of flight hours significantly increased during the period examined. Recommendations from this study include using stricter standards for transport flight safety delineated in 14 Code of Federal Regulations, part 135, rather than the current more widely accepted and less stringent standards within the 14 Code of Federal Regulations, part 91. Additional recommendations to improve flight safety include following formal preadmission risk analysis procedures, using dispatchers with aviation experience to constantly evaluate changing weather conditions and communicate this information to the air crew, and use of aircraft fitted with terrain awareness and warning systems.

In summary, air and ground transports are not without risk. Mission safety is the primary consideration for transport of the critically ill child and the transport team. A team-oriented decision regarding timing and modality of transport taking all factors into account will lead to a safe and efficient transport.

Table 1—Rapid Sequence Intubation Medications

Drugs Dose, mg/kg Route Comments
Cardiovascular adjuncts
Atropine 0.02 IV, IO Minimum dose, 0.1 mg; maximum dose, 0.5 to 1.0 mg
Induction agents
Etomidate 0.3-0.5 mg/kg IV; transient myoclonic movements
Midazolam 0.1 IV, IO Hypotension
Ketamine 1-2 IV, IO, IM Laryngospasm; increased secretions; increased ICP
Thiopental 2-4 IV, IO Myocardial depression; hypotension
Propofol 1-2 IV Hypotension
Lidocaine 1-2 IV, IO
Neuromuscular blockers
Vecuronium 0.1 IV, IO
Rocuronium 0.61.0 IV, IO Rapid onset of action
Succinylcholine 2 (infants) IV, IM, IO Pretreat with atropine; children, 1 mg/kg;consider defasciculation with a nondepolarizing agent

Table 2—Common Analgesic and Sedative Agents

Drugs Dose, mg/kg Route Comments
Morphine 0.1-0.2; infusion: 20-50 ^g/kg/h IV Histamine release
Fentanyl 1-2; infusion: 2-5 ^g/kg/h IV, IO Chest wall rigidity
Reversal agents
Naloxone .010.1 IV, ET
Up to 2 mg SQ
Sedative agentsj
Diphenhydramine 0.1 IV, po
Ketaminej 1-2 IV, IO Increased secretion and intracranial pressure;
2-4 IM laryngospasm; hallucinations
Lorazepam 0.10.2 IV Hypotension; apnea
Midazolam 0.20.2 IV Hypotension; apnea
Propofol 1-3; infusion: 1-3 mg/kg/h IV Hypotension; apnea
Pentobarbital 2-4 IV Negative inotropic effects; apnea