Basic Preparation

When a critically ill child arrives in the emergency department and the decision is made to transport that child to another institution, extensive preparation of the child should occur. This preparation should be completed by the referring hospital personnel to the limits of their abilities and resources, regardless of whether they or a receiving hospital will perform the transport. Two aspects of care to which referring hospitals should direct immediate attention are airway management and vascular access.

AIRWAY MANAGEMENT The decision to intubate and mechanically ventilate a patient is usually based on objective evidence of respiratory failure. This principle applies to both inpatients and those being prepared for transport. However, the threshold for intervention should be lowered for most patients requiring transport. For example, an infant with an arterial partial pressure of carbon dioxide (Pa co2) of 50 mmHg might be observed without ventilatory support in the inpatient setting but probably should be intubated and ventilated in preparation for transport. In addition, children without respiratory failure but in whom deterioration is anticipated should be intubated in preparation for transport. This more aggressive approach to airway management is justified because the ability to identify respiratory failure and to intubate is often impaired during transport.3

All emergency departments should be supplied with equipment to intubate and ventilate patients of all sizes ( Ia.bie„...4.-..l). All nonneonatal patients should be medicated prior to intubation unless they are unconscious or in extreme distress. Neonatal patients should be premedicated only if they are alert and vigorous. An opiate analgesic (morphine or fentanyl) should be administered intravenously to patients less than approximately 3 months of age. Older children should be intubated following rapid-sequence anesthesia and paralysis.

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TABLE 4-1 Intubation Guide for Pediatric Patients

TABLE 4-1 Intubation Guide for Pediatric Patients

Neonatal intubation may be challenging for personnel not experienced in airway management in this population. 4 Attention to the following problems may increase the likelihood of success:

1. A common mistake made during neonatal intubation is to insert the blade into the esophagus and then fail to withdraw it far enough to visualize the glottis.

2. The glottis is in a more ventral position in infants than in older children; therefore, it is more difficult to visualize. This problem can be minimized by avoiding overextension of the neck and by applying gentle pressure to the cricoid. Too much pressure should be avoided because it can occlude the airway and prevent intubation.

3. Premature infants have very small mouths and upper airways, making insertion of the endotracheal tube difficult. Gentle traction on the infant's right cheek by an assistant can usually provide sufficient opening to allow insertion of the endotracheal tube just to the right of the blade. This maneuver also helps preserve the intubator's field of view.

4. Because the skin of newborns is usually moist, extra care must be taken during taping of the endotracheal tube.

Because the distance between the thoracic inlet and the carina is extremely short in small children, the position of the tip of the endotracheal tube should be confirmed with a chest radiograph as soon after insertion as possible. A radiograph should be obtained even when reassuring signs of a successful intubation are present (condensation on the wall of the tube, symmetrical chest rise and breath sounds, and positive CO 2 detection). Right main-stem intubation is common in neonates. Prolonged right main-stem intubation increases the likelihood of pneumothorax and is particularly hazardous in premature infants. Soon after the initiation of mechanical ventilation, arterial blood gas analysis should be performed to ensure appropriate ventilator settings. Overventilation is a common error that may have serious consequences.

VASCULAR ACCESS All patients should have intravascular access during transport. Critically ill children should have at least two lines in case one becomes dislodged or several drugs must be administered simultaneously. Access should be through a device that includes a nonmetallic intravascular component. The metal butterfly needles often used in pediatric inpatient units are not satisfactory during transport because they frequently perforate the vessel as a result of vibration and movement. Intraosseous cannulation is an alternative technique for fluid and drug administration when intravascular lines cannot be placed and the severity of illness demands immediate access.

In small children, intravenous lines should be infused with the use of pumps. Open "drips" should not be used, even with volumetric drip chambers, because of the risk of fluid intoxication from inadvertent administration of large boluses. The amount of fluid administered should be carefully monitored and recorded.

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