Partnership


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Partnership

  • Partnership

  • Team work

  • Communication



10%-18% pre-hospital calls pediatric

  • 10%-18% pre-hospital calls pediatric

  • 25-34% emergency room

  • Airlift statistics

      • 20% of flights are children < 21 years
      • Of this, 57% are trauma
  • CSHCN represent 35% to 60% pediatric ALNW TX

      • Often higher than AAP statistics
        • Reflects use of medical home and survival
        • Use of AAP Emergency Sheet?


How important is time?

  • How important is time?

    • Time sensitive conditions: ischemic stroke, ischemic limb
    • Potential to quickly decompensate (ICH, intra-abdominal injuries, chest trauma, etc)
    • Unstable patients
  • Realistic transport time

    • Distance
    • Geography (mountain passes, peninsula, islands)
    • Traffic patterns




Airway management

  • Airway management

    • Space limitations
    • Light limitations
  • IV access

  • Temperature control

  • Pertinent labs:

    • glucose, updated ABG/CBG
  • OG/NG



OR CAN IT WAIT?

  • OR CAN IT WAIT?

  • Will it change therapy?

  • Hospital: CT scan/x-ray: Can it be pushed through in a timely manner or need to be repeated?



Infection/sepsis: antibiotics priority…

  • Infection/sepsis: antibiotics priority…

    • Lactate and recent blood gas
  • Trauma: splinting/BB/Pediboard

    • Changes occurring in who gets boarded
      • Nexus criteria, Canadian C-spine
  • Bronchiolitics: suctioning

  • RESPONSE



Asthma: dexamethasone early. High dosing albuterol

  • Asthma: dexamethasone early. High dosing albuterol

  • Croup: dexamethasone early. Racemic if stridor at rest. Humidity minimal evidence

  • DKA: over fluid resuscitation common issue

    • ≥ 40cc/kg = high risk =PICU admission


CSHCN numbers rising

  • CSHCN numbers rising

    • Multisystem involvement
    • Home equipment?
  • = significant fraction of health care resources

  • More likely to receive advance life support & prehospital procedures

    • Increased focus of care coordination: EIF forms


http://depts.washington.edu/pedtraum/

  • http://depts.washington.edu/pedtraum/

  • Online curriculum in the acute assessment and management of pediatric trauma patients, hosted by Harborview Medical Center (Seattle, WA)

  • EMSC (Emergency medical services for children) National Resource CENTER: www.childrensnational.org/EMSC (search for prehospital)

  • SCOPE: Special Children’s Outreach & prehospital education. The center for prehospital pediatrics at Children’s National Medical Center

  • http://www.childrensnational.org/emsc/pubres/oldtoolboxpages/prehospitaleducation.aspx



Hypoxia

      • Hypoxia
      • Gas expansion
      • Temperature changes
      • Noise
      • Vibration




Bellingham (Airlift 5)

  • Bellingham (Airlift 5)

  • Arlington (Airlift 6)

  • Seattle (Airlift 2)

  • Olympia (Airlift 3)





Turbo Commander

  • Turbo Commander

  • 12 hour based in Yakima

  • Lands on shorter runways

  • Serves smaller airports: Ellensburg, Omak, Tonasket, Chelan, Sunnyside



Two Lear 31 A jets based at Boeing Field

  • Two Lear 31 A jets based at Boeing Field

    • Serves Eastern Washington, Montana, and Southeast Alaska
    • Cruise speed 500 mph, range 1200 miles
  • Lear 31A based in Juneau, Alaska

    • Serves southeast Alaska
    • Cruise speed 500 mph, range 1200 miles


Transport ventilator (Draeger Oxylog 3000)

  • Transport ventilator (Draeger Oxylog 3000)

  • Invasive and non-invasive monitor

  • Cardiac monitor/defibrillator with pacing and 12 lead ECG.

  • Multi-channel infusion pump

  • I-Stat

  • Glide Scope video-laryngoscopy



Two critical care nurses

  • Two critical care nurses

    • Pediatric/Neonatal Intensive Care experienced
    • Adult Critical Care experienced/Adult Certified Emergency Nurse
  • Cross-trained to manage and transport all age patients, ill or injured:

    • Neonates, pediatrics, adults, high-risk obstetrics
  • Trained in altitude & flight physiology, aircraft safety

  • Certifications: ACLS, PALS, NRP, BLS, ATCN

  • Airway management: adjuncts & surgical cric







Accurate ETA….if no fog, no snow etc…..

  • Accurate ETA….if no fog, no snow etc…..

  • Door closed < 10 min (RW), Wheels up < 15

  • AIDET

  • Prioritization for our circumstances

  • Time Management

    • <10 minute field
    • <30 minute interfacility (age specific)
  • Medical control contact

  • Protocol driven



SAMPLE hx. if time or…

  • SAMPLE hx. if time or…

  • D-MIVT report style focus

  • Medical necessity Form

  • Films/chart with face sheet

  • Parental information if ride along: (to Comm.)

    • Complete name
    • Weight
  • Priority meds and/or blood products ready to go









Tools that help clinicians quickly assess pediatric patients

  • Tools that help clinicians quickly assess pediatric patients

    • select medications, doses, and equipment
    • Has the potential to improve pediatric patient outcomes during resuscitation IF USED CORRECTLY
  • Broselow Pediatric Emergency Tape and/or the Broselow Pediatric Emergency Cart.

    • shown to decrease time to mobilize resuscitation equipment, and increase the accurate selection of equipment (Agarwal et.al, 2005).


Update tapes. Replace outdated Broselow tapes with the most recent edition (2011)

  • Update tapes. Replace outdated Broselow tapes with the most recent edition (2011)

    • ADJUSTMENTS FOR WEIGHT CHANGES
  • Standardize concentrations. Provide standard concentrations for resuscitation medications stocked

  • Stock Shortages: communication re what is replaced

  • Organize carts.



Simulation on in-hospital pediatric medical emergencies trial

  • Simulation on in-hospital pediatric medical emergencies trial

    • Significant delays & deviations occur in major components of pediatric resuscitation
    • Median time to airway assessment = 1.3 minutes
    • To administering O2 = 2 minutes
    • To recognize need for IO = 3 minutes
    • To assess circulation = 4 minutes
    • To arrival of physician on to floor = 3 minutes
    • Arrival of first member of actual code team = 6 minutes
    • CPR scenarios: elapsed time to starting compressions = 1.5 minutes


75% of codes deviated from AHA PALS

  • 75% of codes deviated from AHA PALS

  • Communication error: 100% of mock codes

  • DELAYS WERE NORM NOT EXCEPTION …LACK OF TIMELY INITIATION OF RESUSCITATION MANEUVERS

  • Importance of floor staff initiating actions

  • Leadership important component of successful teamwork



Can know the differences between pediatric patients & Adults BUT …

  • Can know the differences between pediatric patients & Adults BUT …

  • IF LACK OF TIMELY & CORRECT INTERVENTION OF RESUSCITATION, IT DOESN’T MATTER…..



Cuffed versus Uncuffed Tubes

  • Cuffed versus Uncuffed Tubes

    • Historically not recommended in children under the age of 8 to 10 years until the mid-1990’s.
    • Pediatric anesthetists & intensivists use: 2000-2001
  • Current evidence demonstrates this recommendation is outdated.



Two recent transports:

  • Two recent transports:

    • Received 4 yr old with 5.5 cuffed ETT
    • Received 2 year old 5 cuffed tube
      • Both had significant stridor on extubation with use of raecemic epi, dexamethasone, heliox
      • The 4 year old needed emergent re-intubation in the OR: severe sub-glottic stenosis: could pass a 4 uncuffed tube only


“Cuffed tracheal tubes are as safe as uncuffed tubes for infants (except newborns) and children if rescuers use the correct tube size and cuff inflation pressure and verify tube position. Under certain circumstances (e.g., poor lung compliance, high airway resistance, and large glottic air leak), cuffed tracheal tubes may be preferable.” The International Liaison Committee on Resuscitation (ILCOR) Consensus on Science with Treatment Recommendations for Pediatric and Neonatal Patients: Pediatric Basic and Advanced Life Support

  • “Cuffed tracheal tubes are as safe as uncuffed tubes for infants (except newborns) and children if rescuers use the correct tube size and cuff inflation pressure and verify tube position. Under certain circumstances (e.g., poor lung compliance, high airway resistance, and large glottic air leak), cuffed tracheal tubes may be preferable.” The International Liaison Committee on Resuscitation (ILCOR) Consensus on Science with Treatment Recommendations for Pediatric and Neonatal Patients: Pediatric Basic and Advanced Life Support



The presence of a leak is not a reliable indicator that there is no undue pressure from the tube on the cricoid mucosa

  • The presence of a leak is not a reliable indicator that there is no undue pressure from the tube on the cricoid mucosa

  • The contours of the airway and of the tube are different.

  • Using a cuffed tube would permit the use of a smaller tube, reducing the dangers of pressure damage at the laryngeal inlet and cricoid.

  • The presence of a cuff may ease tube tip away from anterior tracheal wall reducing the incidence of tube tip damage.

  • Cuffed ETT’s protect better against aspiration than an uncuffed ETT.



For the safe use of the cuffed tracheal tube, the following rules should be respected:

  • For the safe use of the cuffed tracheal tube, the following rules should be respected:

    • On Broselow, ½ size down if cuffed tube**
    • An air leak to be present after intubation at ≤ 20 cm H2O airway pressure with the cuff not inflated.
  • Feeling cuff not adequate method to check inflation

    • Check with a manometer
  • Should use bags with inbuilt manometer AND PEEP



Use of the LMA is included in:

  • Use of the LMA is included in:

    • The guidelines for cardiopulmonary resuscitation – ACLS/PALS
    • NRP
    • Difficult Airway Algorithm


Speed and ease of placement

  • Speed and ease of placement

  • Avoidance of endo-bronchial and/or esophageal intubation

  • Regurgitation and gastric distention is less likely

  • Avoidance of sympathetic response to DL

  • Does not require head/neck/jaw manipulation

  • Minimal training required



Failure to protect from aspiration

  • Failure to protect from aspiration

  • Inability to provide high-pressure seal

  • Unable to ventilate poorly compliant lungs

  • Difficult to suction the airway

  • Cannot reliably administer intra-tracheal medications

  • Additional training and

  • skill maintenance









31% not monitored for Hypotension

  • 31% not monitored for Hypotension

    • Most often occurred during “scene” EMS time
    • In children w/o documented hypotension, those not fully monitored had a Relative Risk of in-hospital death of 4.5 compared to those fully monitored
  • Hypotension documented in 39% of children

    • Least likely to be treated at the scene (only treated 12% of time at scene) & more likely to be treated on arrival to hospital…
  • Children not fully monitored: younger & smaller



  • ABSENCE OF BLOOD PRESSURE MONITORING WAS ASSOCIATED WITH YOUNG AGE, INCREASED SEVERITY OF ILLNESS & POOR OUTCOME



34% of children not monitored for O2 sat or apnea during portion of their early care

  • 34% of children not monitored for O2 sat or apnea during portion of their early care

  • Hypoxia or apnea documented in 44% of children in the study

    • Hypoxia/apnea also occurred most often at scene
  • EMS personnel treated noticed hypoxia or apnea 87%. Air-medical & ED treated 100%



Children with hypoxia were significantly younger & smaller than children without documented hypoxia.

  • Children with hypoxia were significantly younger & smaller than children without documented hypoxia.

  • “I don’t need numbers, I go by the LOC…”

    • Problem….
  • Those not monitored had lower median GCS scores than children who were fully monitored.



Study showed that early hypotension and hypoxia/apnea are common events in pediatric TBI and are strongly associated with worse outcomes

  • Study showed that early hypotension and hypoxia/apnea are common events in pediatric TBI and are strongly associated with worse outcomes

  • QA Opportunity Chart/Systems Reviews

    • BP documented in specified time period
    • If not why not?
    • Saturation documented within specified time period
    • Appropriate Interventions?






Agarwal, Swanson, Murphy, Yaeger, Sharek, & Halamek, (2005). Comparing the utility of a standard pediatric resuscitation cart with a pediatric resuscitation cart based on the Broselow tape: a randomized, controlled, crossover trial involving simulated resuscitation scenarios. Pediatrics. 116 (3): e326-33

  • Agarwal, Swanson, Murphy, Yaeger, Sharek, & Halamek, (2005). Comparing the utility of a standard pediatric resuscitation cart with a pediatric resuscitation cart based on the Broselow tape: a randomized, controlled, crossover trial involving simulated resuscitation scenarios. Pediatrics. 116 (3): e326-33

  • Cox, R.G. (2005). Should cuffed endotracheal tubes be used routinely in children? Canadian Journal of Anesthesia, 52(7), 669-674

  • Felten, M.L., Schmautz, E., Delaporte-Cerceau, S., Orliaguet, G.A., & Carli, P.A. (2003). Endotracheal tube cuff pressure is unpredictable in children. Anesthesia & Analgesia, 97, 1612-1616.

  • Hohenhaus SM, Frush KS. Pediatric patient safety: common problems in the use of resuscitative aids for simplifying pediatric emergency care. J Emerg Nurs 2004; 30:49-51.

  • Hohenhaus S. Assessing competency: the Broselow-Luten resuscitation tape. J Emerg Nurs 2002; 28:70-2.

  • Golden, S. (2005). Cuffed vs. uncuffed endotracheal tubes in children: a review. Society for Pediatric Anesthesia, Winter 2005, 10.



James, I. (2001). Cuffed tubes in children. Paediatric Anaesthesia, 11, 259-263.

  • James, I. (2001). Cuffed tubes in children. Paediatric Anaesthesia, 11, 259-263.

  • Neonatal hypoglycemia: initial and follow-up management. National Guideline Clearinghouse www.guideline.gov

  • Wagner, C., Mazurek, P. (2006). Current Practices in Pediatric Immobilization- An Editorial. Air Medical Journal , 25 (4) 144-148

  • Weeks, D., Molsberry, D. (2008). Pediatric advanced life support re-training by videoconferencing compared to face-to-face instruction: A planned non-inferiority trial. Resuscitation, 79: p 109-117

  • Zebrack, M., Dandoy, C., Hansen, K., Scaife, E., Clay Mann, N., Bratton, S. (2009). Pediatrics, 124: 56-64




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