e1 References 1 Gausche Hill M, Schmitz C, Lewis RJ Pediatric preparedness of US emergency departments a 2003 survey Pediatrics 2007;120 1229 1237 2 Whitfill T, Auerbach M, Scherzer DJ, Shi J, Xiang H[.]
e1 References Gausche-Hill M, Schmitz C, Lewis RJ Pediatric preparedness of US emergency departments: a 2003 survey Pediatrics 2007;120:12291237 Whitfill T, Auerbach M, Scherzer DJ, Shi J, Xiang H, Stanley RM Emergency care for children in the United States: epidemiology and trends over time J Emerg Med 2018;55:423-434 de Oliveira CF, de Oliveira DS, Gottschald AF, et al ACCM/PALS haemodynamic support guidelines for paediatric septic shock: an outcomes comparison with and without monitoring central venous oxygen saturation Intensive Care Med 2008;34:1065 Kumar A, Roberts D, Wood KE, et al Duration of hypotension prior to initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock Crit Care Med 2006;34:1589 AAP Section on Transport Medicine, Romito J, Insoft RM, Schwartz HP Guidelines for Air and Ground Transport of Neonatal and Pediatric Patients Manual 4th ed Elk Grove Village, IL: American Academy of Pediatrics; 2015 Seidel JS, Hornbein M, Yoshiyama K, et al Emergency medical services and the pediatric patient: are the needs being met? Pediatrics 1984;73:769-772 American College of Surgeons Committee on Trauma, American College of Emergency Physicians, National Association of EMS Physicians, Pediatric Equipment Guidelines Committee-Emergency Medical Services for Children (EMSC) Partnership for Children Stakeholder Group, American Academy of Pediatrics Policy statement—Equipment for ambulances Pediatrics 2009;124: e166-e171 Gausche-Hill M, Ely M, Schmuhl P, et al A national assessment of pediatric readiness of emergency departments JAMA Pediatr 2015;169:527-534 Glaeser PW, Linzer J, Tunik MG, et al Survey of nationally registered emergency medical services providers: pediatric education Ann Emerg Med 2000;36:33-38 10 Drayna PC, Browne LR, Guse CE, et al Prehospital pediatric care: opportunities for training, treatment, and research Prehosp Emerg Care 2015;19:441-447 11 Babl FE, Vinci RJ, Bauchner H, et al Pediatric prehospital advanced life support care in an urban setting Pediatr Emerg Care 2001;17:36-37 12 Su E, Schmidt TA, Mann NC, et al A randomized controlled trial to assess decay in acquired knowledge among paramedics completing a pediatric resuscitation course Acad Emerg Med 2000;7: 779-786 13 Youngquist ST, Henderson DP, Gausche-Hill M, et al Paramedic self-efficacy and skill retention in pediatric airway management Acad Emerg Med 2008;15:1295-1303 14 Aijian P, Tsai A, Knopp R, et al Endotracheal intubation of pediatric patients by paramedics Ann Emerg Med 1989;18:489-494 15 Losek JD, Bonadio WA, Walsh-Kelly C, et al Prehospital endotracheal intubation performance review Pediatr Emerg Care 1989;5:1 16 Mishark KJ, Vukov LF, Gudgell SF Airway management and air medical transport J Air Med Transp 1992;11:7-9 17 Boswell WC, McElveen N, Sharp M, et al Analysis of prehospital pediatric and adult intubation Air Med J 1995;14:125-127 18 Doran JV, Tortella BJ, Drivet WJ, et al Factors influencing successful intubation in the prehospital setting Prehosp Disaster Med 1995;10:259-264 19 Bankole S, Asuncion A, Ross S, et al First responder performance in pediatric trauma: a comparison with an adult cohort Pediatr Crit Care Med 2011;12:e166-e170 20 Carcillo JA, Kuch BA, Han YY, et al Mortality and functional morbidity after use of PALS/APLS by community physicians Pediatrics 2009;124:500-508 21 Davis AL, Carcillo JA, Aneja RK, et al American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock Crit Care Med 2017;45:1061-1093 22 Han YY, Carcillo JA, Dragotta MA, et al Early reversal of pediatricneonatal septic shock by community physicians is associated with improved outcome Pediatrics 2003;12:793-799 23 Chance GW, Matthew JD, Gash J, et al Neonatal transport: a controlled study of skilled assistance J Pediatr 1978;93:662-666 24 Patel SC, Murphy S, Penfil S, Romeo D, Hertzog JH Impact of interfacility transport method and specialty teams on outcomes of pediatric trauma patients Pediatr Emerg Care 2018;34:467-472 25 Bellingan G, Olivier T, Batson S, et al Comparison of a specialist retrieval team with current United Kingdom practice for the transport of critically ill patients Intensive Care Med 2000;26:740-744 26 Macnab AJ Optimal escort for interhospital transport of pediatric emergencies J Trauma 1991;31:205-209 27 Edge WE, Kanter RK, Weigle CG, et al Reduction of morbidity in interhospital transport by specialized pediatric staff Crit Care Med 1994;22:1186-1191 28 Orr R, Venkataraman S, Seidberg N, et al Pediatric specialty care teams are associated with reduced morbidity during pediatric interfacility transport Crit Care Med 1999;27:A30 29 Macnab AJ, Wensley DF, Sun C Cost-benefit of trained transport teams: estimates for head-injured children Prehosp Emerg Care 2001;5:1-5 30 Orr RA, Felmet KA, Han Y, et al Pediatric specialized transport teams are associated with improved outcomes Pediatrics 2009;124:40-48 31 Ramnarayan P, Thiru K, Parslow R, et al Effect of specialist retrieval teams on outcomes in children admitted to paediatric intensive care units in England and Wales: a retrospective cohort study Lancet 2010;376:698-704 32 Lampariello S, Clement M, Aralihond AP, et al Stabilisation of critically ill children at the district general hospital prior to intensive care retrieval: a snapshot of current practice Arch Dis Child 2010;95:681-685 33 Stroud MH, Sanders Jr RC, Moss MM, et al Goal-directed resuscitative interventions during pediatric interfacility transport Crit Care Med 2015;43:1692-1698 34 Stroud MH, Prodhan P, Moss M, et al Enhanced monitoring improves pediatric transport outcomes: a randomized controlled trial Pediatrics 2011;127:42-48 35 Ehrenwerth J, Hackel A Air-to-ground communication: a valuable aid in the transport of critically ill patients Crit Care Med 1986;14:543-547 36 Accreditation standards of the Commission on Accreditation of Air Medical Services 5th ed Anderson, SC: Commission on Accreditation of Air Medical Services; 2001 37 Tanem J, Triscari D, Chan M, Meyer MT Workforce survey of pediatric interfacility transport systems in the United States Pediatr Emerg Care 2016;32:364-370 38 DeVita MA, Schaefer J, Lutz J, et al Improving medical emergency team (MET) performance using a novel curriculum and a computerized human patient simulator Qual Saf Health Care 2005;14:326331 39 Campbell DM, Dadiz R Simulation in neonatal transport medicine Semin Perinatol 2016;40(7):430-437 40 Burns B, Hansen ML, Valenzuela S, et al Unnecessary use of red lights and sirens in pediatric transport Prehosp Emerg Care 2016;20:354-361 41 Commission on Accreditation of Medical Transport Systems CAMTS https://www.camts.org/ 42 Schwartz HP, Bigham MT, Schoettker PJ, et al Quality Metrics in Neonatal and Pediatric Critical Care Transport: A National Delphi Project Pediatr Crit Care Med 2015;16:711-717 43 Aspiotes CR, Gothard MQ, Gothard MD, Parrish R, Schwartz HP, Bigham MT Setting the benchmark for the ground and air medical quality in Transport International Quality Improvement Collaborative Air Med J 2018;37:244-248 e2 4 Ground and Air Medical Quality in Transport http://gamutqi.org/ 45 Cheema B, Welzel T, Rossouw B Noninvasive ventilation during pediatric and neonatal critical care transport: a systematic review Pediatr Crit Care Med 2019;20:9-18 46 Holt PL, Hodge AB, Ratliff T, Frazier WJ, Ohnesorge D, Gee SW Pediatric extracorporeal membrane oxygenation transport by EC145 with a custom-built sled Air Med J 2016;35:171-175 47 Lindén V, Palmer K, Reinhard J, et al Inter-hospital transportation of patients with severe acute respiratory failure on extracorporeal membrane oxygenation—national and international experience Intensive Care Med 2001;27:1643-1648 48 Wilson BJ, Heiman HS, Butler TJ, Negaard KA, DiGeronimo R A 16-year neonatal/pediatric extracorporeal membrane oxygenation transport experience Pediatrics 2002;109:189-193 49 Martin T, Glanfield M The physiological effects of altitude In: Martin T, ed Aeromedical Transportation: A Clinical Guide 2nd ed Aldershot, Hampshire, England: Ashgate Publishing; 2006:39-54 50 Orsborn J, Graham J, Moss M, Melguizo M, Nick T, Stroud M Pediatric endotracheal tube cuff pressures during aeromedical transport Pediatr Emerg Care 2016;32:20-22 51 Long MT, Cvijanovich NZ, McCalla GP, Flori HR Changes in pediatric-sized endotracheal tube cuff pressure with elevation gain: observations in ex vivo simulations and in vivo air medical transport Pediatr Emerg Care 2018;34:570-573 52 Rodriquez Jr D, Branson RD, Dorlac W, et al Effects of simulated altitude on ventilator performance J Trauma 2009;66(suppl4):S172S177 53 Flynn JG, Singh B The performance of Dräger Oxylog ventilators at simulated altitude Anaesth Intensive Care 2008;36:549-552 54 Fell MJ The Emergency Medical Treatment and Active Labor Act of 1986: providing protection from discrimination in access to emergency medical care Spec Law Dig Health Care Law 1996;9-42 55 Omnibus Budget Reconciliation Act of 1989, sec 6018 42 USC 1395cc (West Supp 1990) e3 Abstract: Pediatric subspecialty and critical care medicine is largely regionalized, resulting in need for interfacility transport of patients with a range of severity of illness The goal during transport should be to minimize the risk of deterioration while advancing the care initiated at the referring facility Use of specialized pediatric transport teams has been shown to improve patient outcomes These specialized teams represent a vital part of a continuum of critical care providing tertiary care to patients who present to nontertiary care facilities and providers Intentional implementation, administration, oversight, education, and ongoing quality assurance are essential to a successful transport process Key Words: Transport, flight physiology, team composition, medical control physician, interfacility 14 Pediatric Vascular Access and Centeses LAUREN R EDWARDS, MATTHEW P MALONE, PARTHAK PRODHAN, AND STEPHEN M SCHEXNAYDER • Intraosseous infusion is an essential emergency vascular access, with several mechanical devices available Vigilant observation of the needle insertion site is essential to recognize extravasation and prevent serious complications Pericardiocentesis may be required for both diagnostic and therapeutic purposes Except in life-threatening tamponade, ultrasound imaging should be used to improve success and reduce complications Umbilical arterial and venous access may be useful in neonates up to weeks of age in the pediatric intensive care unit Vascular Intraosseous Infusion Venous access can be one of the most challenging aspects of caring for critically ill infants and children Peripheral veins can be difficult to cannulate, particularly in the setting of shock, where there is shunting of blood away from the periphery and collapse of small veins Because of these challenges, intraosseous (IO) infusion has become widely accepted as a quick, reliable means to establish short-term emergency venous access in critically ill children.1,2 The marrow space provides a noncollapsible access point to the vascular system Marrow sinusoids drain into medullary venous channels that empty into the systemic circulatory system This allows IO infusions of fluids and medications to be rapidly distributed Indications IO infusion is indicated for conditions requiring the rapid acquisition of intravenous (IV) access, where the establishment of conventional peripheral access is difficult or impossible: cardiopulmonary arrest, shock, burns, and status epilepticus In these situations, limited attempts at standard peripheral access are usually made prior to placing an IO needle In addition to its use in the hospital, IO access has been used successfully in the prehospital setting as well as in critical care transport.3–5 The success rate for acquiring IO access is high—greater than 95% with experienced practitioners.6 Similar success rates and equivalent pharmacokinetics have been demonstrated when mechanical IO devices are used.7,8 Most fluids and medications that 94 • • • PEARLS access is paramount for the effective management of critically ill and injured children Pediatric critical care providers must be expert at obtaining access using a number of different techniques and approaches Because fluid accumulation in serosal cavities can be part of disease processes as well as a response to fluid resuscitation, fluid removal by centesis is frequently needed for both diagnostic and therapeutic purposes can be given through a conventional IV line can be administered as an IO infusion with comparable results In the setting of cardiac arrest or severe shock, IO access is as effective as peripheral venous access in providing volume resuscitation and antibiotics to the central circulation However, three antibiotics—chloramphenicol, vancomycin, and tobramycin—achieve subtherapeutic levels when administered via an IO line at standard IV doses.9 Additional details regarding laboratory studies obtained from IO versus IV samples are discussed on ExpertConsult.com Contraindications IO infusion has few absolute contraindications A fractured or previously punctured bone should not be used, as infusing fluid will extravasate and potentially cause compartment syndrome Therefore, if an IO needle penetrates the cortex but is nonfunctional, alternative bone sites must be used for subsequent attempts Bone diseases such as osteogenesis imperfecta and osteopetrosis have been suggested as contraindications to IO infusion.16 Placing the needle into an area of cellulitis or burn risks seeding infection and causing osteomyelitis This is a relative contraindication, as limited sites may be available, making these less desirable locations acceptable for use Supplies and Equipment The bone marrow space is accessed with the use of one of several different types of needles Conventional bone marrow needles (e.g., the Jamshidi needle, Becton Dickinson) and IO infusion 94.e1 Comparison of Laboratory Studies Obtained From Intraosseous Versus Intravenous Samples IO access can be used for certain clinical laboratory studies Specimens should be collected promptly after access is established— ideally, after aspirating to mL of waste blood and prior to any medications being given Bicarbonate, partial pressure of carbon dioxide (Pco2), and partial pressure of oxygen (Po2) can differ significantly between IO and venous specimens, whereas pH and base excess correlate well,10 as well as lactic acid 11 Ionized calcium levels may correlate, but the data are inconsistent 10,12 No significant differences were found with glucose, blood urea nitrogen, creatinine, hemoglobin, and hematocrit when comparing IO specimens and venous blood samples.10–12 IO sodium concentrations are lower; however, the difference does not appear clinically relevant.11 IO potassium levels are significantly higher than venous specimens and are invalid; treating these levels poses the risk of inducing iatrogenic hypokalemia.10,11 Leukocytes and platelet counts are unreliable from IO specimens.12 In general, when comparing IO and venous or arterial sources, there are correlations and clinical similarities in laboratory values However, caution should be exercised with their interpretation, as the evidence is relatively weak.13 In contrast, a marrow specimen can be cultured in lieu of a blood culture and can be used for blood type and crossmatching.14,15 ... sinusoids drain into medullary venous channels that empty into the systemic circulatory system This allows IO infusions of fluids and medications to be rapidly distributed Indications IO infusion... the needle into an area of cellulitis or burn risks seeding infection and causing osteomyelitis This is a relative contraindication, as limited sites may be available, making these less desirable