University of Pennsylvania

ScholarlyCommons
Miscellaneous Papers Miscellaneous Papers

1-1-2001

Critical Care Nursing of Infants and Children

Martha A. Q. Curley
University of Pennsylvania, curley@[Link]

Patricia A. Moloney-Harmon
The Children's Hospital at Sinai

Copyright by the author. Reprinted from Critical Care Nursing of Infants and Children, Martha A.Q. Curley and Patricia A. Moloney-Harmon
(Editors), (Philadelphia: W.B. Saunders Co., 2001), 1,128 pages.

NOTE: At the time of publication, the author, Martha Curley was affiliated with the Children's Hospital of Boston. Currently, she is a faculty member
in the School of Nursing at the University of Pennsylvania.

This paper is posted at ScholarlyCommons. [Link]

For more information, please contact repository@[Link].
Please Note: The full version of this book and all of its chapters (below) can be found on ScholarlyCommons (from
the University of Pennsylvania) at [Link]

Information page in ScholarlyCommons

Full book

[Link] - Front Matter, Contributors, Forward, Preface, Acknowledgements, and Contents

Chapter [Link] - The Essence of Pediatric Critical Care Nursing
Chapter [Link] - Caring Practices: Providing Developmentally Supportive Care
Chapter_3.pdf - Caring Practices: The Impact of the Critical Care Experience on the Family
Chapter_4.pdf - Leadership in Pediatric Critical Care
Chapter [Link] - Facilitation of Learning
Chapter_6.pdf - Advocacy and Moral Agency: A Road Map for Navigating Ethical Issues in Pediatric Critical Care
Chapter_7.pdf - Tissue Perfusion
Chapter [Link] - Oxygenation and Ventilation
Chapter_9.pdf - Acid Base Balance
Chapter [Link] - Intracranial Dynamics
Chapter [Link] - Fluid and Electrolyte Regulation
Chapter [Link] - Nutrition Support
Chapter [Link] - Clinical Pharmacology
Chapter_14.pdf - Thermal Regulation
Chapter_15.pdf - Host Defenses
Chapter [Link] - Skin Integrity
Chapter_17.pdf - Caring Practices: Providing Comfort
Chapter [Link] - Cardiovascular Critical Care Problems
Chapter [Link] - Pulmonary Critical Care Problems
Chapter [Link] - Neurologic Critical Care Problems
Chapter [Link] - Renal Critical Care Problems
Chapter [Link] - Gastrointestinal Critical Care Problems
Chapter_23.pdf - Endocrine Critical Care Problems
Chapter_24.pdf - Hematologic Critical Care Problems
Chapter_25.pdf - Oncologic Critical Care Problems
Chapter_26.pdf - Organ Transplantation
Chapter [Link] - Shock
Chapter_28.pdf - Trauma
Chapter_29.pdf - Thermal Injury
Chapter [Link] - Toxic Ingestions
Chapter_31.pdf - Resuscitation and Transport of Infants and Children
[Link] - Appendices and Index
 Resuscitation and Transport
of Infants and Children
Mary Fallon Smith
Aimee Lyons

EPIDEMIOLOGY OF CARDIOPULMONARY ARREST IN CHILDREN of the techniques taught in these courses can greatly
improve the success rate of pediatric resuscitation efforts.
EnoLoGY OF CARDIOPULMONARY ARREST This chapter begins with a discussion of the epidemiol-
RED FLAGS OF IMPENDING CARDIOPULMONARY ARREST ogy of cardiopulmonary arrest in infants and children.
Research that influenced standards of pediatric resuscitation
STRATEGIES FOR PREVENTION OF CARDIOPULMONARY are discussed. The standards for pediatric advanced life
ARREST support are reviewed, emphasizing nursing care issues.
Management and coordination of the transport of critically
COlLABORAnVE MANAGEMENT
ill children are then outlined.
Airway Management and Breathing
Circulation
EPIDEMIOLOGY OF CARDIOPULMONARY
Evaluation of Interventions
ARREST IN CHILDREN
Diagnostic Studies
Family Care Intentional and nonintentional InJunes remain the most
common cause of death in children over I year of age,
Documentation
followed by cancer and congenital anomalies. J Half of all
POSTRESUSCITATION MANAGEMENT infant deaths are caused by one of four diagnoses: congen-
ital anomalies, prematurity or low birth weight, sudden
INTERFAClLlTY TRANSPORT
infant death syndrome (SIOS), and respiratory distress
History syndrome. 2 The data show a much higher incidence of
Transport Process deaths in the infant population (711 per 100,000) than in all
RESUSCITATION PERFORMANCE IMPROVEMENT
other pediatric ages combined (38 per 100,000).
The average age of children requiring cardiopulmonary
SUMMARY resuscitation (CPR) reported from a large urban pediatric
center was 1.98 years of age with a median age of 5
months. 3 Children under the age of I year accounted for

P ediatric resuscitation offers a challenge to the pediatric

critical care nurse. Participating in resuscitation at-
tempts requires specialized knowledge and skills. Consid-
roughly half of all cases reported in a review by Young and
Seidel. 4 The incidence of adolescent CPR was shown to be
intermediate between that of children and adults. These
eration of the potential impact of the child's developmental statistics are helpful in identifying age groups at higher risk
maturity integrated with nursing's humanistic approach to for cardiopulmonary arrest.
supporting families in crises is a vital aspect of care.
Educational programs in advanced pediatric life support
ETIOLOGY OF CARDIOPULMONARY
are now widely available, including the Emergency Nursing
Pediatric Course (ENPC) and Trauma Nursing Core Course
ARREST
(TNCC) from the Emergency Nurses Association and Cardiac arrest resulting from primary cardiac dysfunction is
Pediatric Advanced Life Support (PALS) provider course a rare occurrence in the pediatric population. s Pediatric
from the American Heart Association. These courses pro- cardiac arrests occur after a prolonged disruption in
vide an excellent means of preparing nurses to manage homeostasis produced by the final common pathways of
emergent situations when caring for children. Consistent use respiratory failure or cardiovascular collapse.

1025
1026 Part V Multisystem Problems

respiratory distress, respiratory failure, and then cardiac

TABLE 31·1Survival Rates alTest.
in Pediatric CPR Regardless of the setting, one dramatic finding in
pediatric resuscitation research is that the type of arrest
Survival Rate (%)
significantly influences outcome. Although the causes of
8.4 pediatric cardiac arrest vary across settings, the outcomes
24 are equally dismal. The survival rate and long-term neuro-
~t: Intensive care unit 20 logic outcome for children who suffer pure respiratory arrest
I:
li!!
Drowning
Asystole
26
5
with timely intervention are dramatically better than those
of secondary cardiac arrest, even when intervention is
]!! VTNF 30 rapidly initiated. There was a 25% mortality rate for
~l!.
¥!C Age <1 year 6 children who experienced a respiratory arrest and an 87%
mortality rate when cardiac arrest occurred. 4 An excep-
J;Adapted from Young KD, Seidel JS: Pediatric cardiopulmonary
~ifresuscitalion: a collective review,
AIIII £1/1"8 Med 33: 195-204, 1999.
tion to this is the near-drowning patient. Children who
~;;CPR, Cardiopulmonary resuscitation; VF, ventricular fibrillation: receive rapid early advanced life support have a survival rate
f~'VT. ventricular tachycardia. closer to 35%6
jff.'

RED FLAGS OF IMPENDING

In a secondary cardiac arrest, widespread organ dysfunc-
CARDIOPULMONARY ARREST
tion occurs not only during the arrest but also during the Nurses, by early recognition of the prearrest state, can
period preceding the arrest. Pediatric resuscitation attempts significantly affect patient outcome. This intervention re-
are often very difficult and prolonged because the precipi- quires expertise in recognizing the red flags of impending
tating events, such as a prolonged period of hypoxemia, cardiopulmonary alTest. These include clinical signs of
acidosis, and organ hypoperfusion, must be corrected, and compensation for respiratory distress and cardiovascular
ongoing secondary organ dysfunction must be reversed. collapse that are present in the clinically unstable pediatric
Secondary cardiac arrest also predisposes patients to severe patient. Many believe that "children deteriorate rapidly,"
or irreversible organ damage, for example, poor neurologic but in reality, they are exquisitely capable of compensating
outcome or multiorgan dysfunction syndrome (MODS). until they can no longer support vital organ function. The
Respiratory failure is imminent when the respiratory clinical manifestations of compensation are related to failure
system is unable to fulfill its role in gas exchange. The of oxygen delivery to end organs, such as the skin, brain,
causes of respiratory failure are varied and result from both kidney, and cardiovascular system.
intrinsic and extrinsic factors. Any shock state can contrib- Even if vital signs are within the normal range for the
ute to insufficient tissue perfusion and cardiovascular patient's age, if they are incongruent with the child's clinical
collapse. In contrast, a small segment of the pediatric need, they are considered red flags. Faster heart rates can be
population suffers from significant cardiac disease such as expected when, for example, the patient is active, anxious,
complex congenital heart disease (CHD), posH;ardiac anemic, dehydrated, febrile, or in pain. Faster respiratory
surgery myocardiaUconduction system dysfunction, myo- rates can be expected, for example, in the active, febrile
carditis, and cardiomyopathy. child or when there is significant past medical history of
One of the major features that distinguishes pediatric chronic pulmonary disease. Faster heart and respiratory
patients suffering cardiac arrest from adults is that the rates indicate a need for increased cardiac output or minute
causes in children are di verse. Young and Seidel 4 conducted ventilation. Rates incongruent with need are considered red
a collective review of the current body of knowledge flags.
regarding survival rates and oU!comes in pediatric CPR. The Manifestations of oxygen deprivation to the skin include
review encompassed data from 44 studies over 27 years for circumoral pallor, mottling, grayish color, cyanosis, diapho-
a total of 3094 patients. A summary of their findings, resis, and decreased capillary refill time. Pallor and mot-
outlined in Table 31-1, reflects the diverse characteristics tling are earlier indicators of decreased oxygenation and
regarding pediatric cardiopulmonary arrest. A noteworthy deteriorate to cyanosis once compensatory reserves are
finding was that patients in respiratory arrest who did depleted.
not deteriorate into cardiac arrest had a 75% hospital Red flags of respiratory distress are listed in Box 31-1.
discharge rate. Tachypnea, a salient symptom, occurs as the patient
In a series of pediatric CPR cases occurring in the attempts to maintain minute ventilation when tidal volume
hospital, LUdwig 3 found that the most common diagnoses of is compromised. Retractions become more pronounced
hospitalized patients requiring resuscitation involved the when lung compliance continues to decrease within the
respiratory system. Cardiac and central nervous system highly compliant chest wall of the pediatric patient.
abnormalities occurred at relatively the same rates but half Airway problems often precipitate pediatric arrests be-
as often as respiratory disorders. Other causes included cause pathologic processes that cause airway narrowing
gastrointestinal and multisystem disorders. In their experi- exponentially compromise gas flow within the airway.
ence, 80% of children who arrested followed the pathway of Patients position themselves to maximize their airway; they
 Chapter 31 Resuscitation and Transport of Infants and Children 1027

.
[Link] 31·1 Box 31·2
~ Respiratory Distress: Red Flags ~ Cardiovascular Collapse: Red Flags
Early Signs Early Signs
Tachypnea Tachycardia
Mechanics of breathing Altered perfusion
Retractions Skin
Nasal flaring Prolonged capillary refill
Head bobbing Increased core-to-skin temperature gradient
Grunting on exhalalion Brain
Air entry: stridor or wheezing Altered level of consciousness or activity
Change in breath sounds Decreased response to parents
Prolonged inspiratory time-stridor "Worried" appearance
Prolonged expiratory time-wheezing Kidneys
Decreased urine output
Late Signs Decrease in pulse quality
Skin color changes---dusky or cyanotic
Apnea or irregular respirations Late Signs
Change in level of consciousness or activity Decreased response to pain
Bradycardia Flaccid tone
Hypotension
Bradycardia
sit up, lean forward, and extend their neck. Inspiratory
stridor is present with upper airway disease, whereas
wheezing may be heard on auscultation in lower airway deterioration because increased systemic vascular resistance
disease. Inspiratory times are prolonged in upper airway (SYR) maintains blood pressure when the cardiac output is
disease; the opposite is true in lower airway disease. decreased.
Grunting on expiration occurs as an infant attempts to Hypotension is not evident until approximately 25% of
maintain functional residual capacity (FRC). the intravascular volume is lost. The estimated circulating
Changes in the patient's level of consciousness or activity blood volume in children represents approximately 8% of
depend 011 the patient's primary alteration in gas exchange. the body weight or 80 mIlkg. For example, a 5-kg infant
With hypoxia the patient usually becomes restless, agitated, may be expected to have a circulating blood volume of
and irritable. Hypercapnia usually produces opposite symp- 400 ml; 8% of 5 kg is equal to 400 g or ml (l g = I ml). A
toms; the patient usually becomes sonmolent and lethargic, 25% blood loss in a 5-kg infant is 100 ml.
has decreased muscle tone, loses interest in the environ- Early symptoms of low cardiac output are the signs of
ment, or, even more ominous in a toddler, is less reactive to increased SVR and are best assessed in end-organ perfusion
a parent's departure. of the skin, brain, and kidney. Signs include capillary refill
Late signs of respiratory distress often include apnea and longer than 2 seconds, a mottled or marbleized skin
decreasing level of consciousness or activity, followed by appearance, an increased core-to-skin temperature gradient,
bradycardia. Much energy is expended trying to maintain an altered level of consciousness, a worried appearance, and
oxygenation and ventilation. Infants, especially, tire and decreased urine output (less than I mIlkg in an infant or
exhibit periods of apnea. 0.5 mllkg in a child older than 2 years).
Arterial blood gases (ABGs) that are incongruent with Infants' temperatures drop, and serum glucose and
the patient's clinical presentation serve to quantify the calcium levels fall when infants are stressed. Late symptoms
patient's ominous status. When a patient begins to tire, of cardiovascular collapse include decreased response to
Pac02 levels climb despite tachypnea, and Pa02 falls despite pain, flaccid muscle tone, hypotension, and bradycardia.
increasing F102. Pulse oximeters have facilitated rapid These symptoms are directly related to progressive intracel-
detection and intervention during transient periods of lular acidosis and hypoxia.
arterial desaturation. The end-tidal CO 2 (ETc02 ) increases Severe hypoglycemia may also lead to cardiac compro-
with the Pac02, then precipitously falls as pulmonary mise. The clinical manifestations are similar to cerebral
perfusion becomes compromised. 7 hypoxia. Hypoglycemia may also lead to secondary failure
Red flags of cardiovascular compromise include tachy- of oxygen delivery as a result of hypoperfusion.
cardia and alterations in perfusion to the skin, brain, and
kidneys (Box 31-2). Tachycardia, the first sign of a stressed
cardiac state, serves to maintain cardiac output when stroke
STRATEGIES FOR PREVENTION
volume is compromised by inadequate preload, increased
OF CARDIOPULMONARY ARREST
afterload, or myocardial dysfunction. The smaller the child, Although the outcome for pediatric patients who suffer
the more reliant on heart rate to maintain cardiac output. cardiac arrest is grim, existing research has identified a
Blood pressure is usually not helpful as an early sign of number of factors that may improve outcome. These factors
1028 Part V Multisystem Problems

include prevention, early recognition, and monitoring of patient status, and advocating for changes in collaborative
children in distress 8 management when early signs of distress are evident.
Prevention of a pulseless state is critical. Early applica-
tion of both basic and advanced life support to prevent a
pulseless state has been related to improved outcome. 3.4
COLLABORATIVE MANAGEMENT
This intervention is especially critical in the prehospital The alphabetical approach to resuscitation is the same for
phase of care. Pediatric patients are often brought to the all age groups, but pediatric resuscitation requires an
emergency department with minimal treatment in the field. 9 emphasis on support of ventilation, as well as an awareness
Many emergency medical service (EMS) systems train and of the influence of maturation on respiratory and cardio-
equip their emergency medical technicians (EMTs) primar- vascular system performance. The goal is to restore stability
ily to provide adult life support. This leads to prolonged as soon as possible by reestablishing vital organ perfusion
periods of hypoxia and hypoperfusion in children who are and oxygenation, especially to the brain. Neurologic out-
critically ill during transport. This issue is being addressed come appears to be directly related to the child's response
through emergency medical services for children (EMS-C) to initial resuscitation efforts rather than postresuscitation
programs across the [Link] Advanced training in pre- interventions.
hospital critical care should lead to the prevention of a Very little clinical research on resuscitation of pediatric
significant number of cardiopulmonary arrests in children. patients exists, largely because the overall incidence of
Prevention strategies also apply to the emergency depart- cardiopulmonary arrest in infants and children is low. Much
ment setting. Pediatric resuscitation is challenging for of the data that guide pediatric practice are derived from
emergency department staff because of the diverse range in animal models with ventricular fibrillation (VF) that are not
the age and size of the children who come to the hospital reflective of causes most commonly seen in pediatric
with impending cardiopulmonary arrest. Lanoix and Gol- arrests. 13 As new research becomes available, revisions to
den II recommend enhancing pediatric resuscitation rooms the existing standards can be anticipated.
in emergency departments by color coding all equipment,
displaying a simplified wall chart of pediatric parameters,
and suspending monitoring equipment from the ceiling. A
Airway Management and Breathing
weight-based quick reference for pediatric emergency Positioning is the first step in airway management. Infants
medications and infusion drip rates can be used to expedite should be placed in the "sniffing position" by a head
drug administration. A sample is shown in Fig. 31-1. tilt--<:hin lift or jaw-thrust maneuver that brings the angle of
Implementing any of these recommendations will save time the chin up 90 degrees from the bed (Figs. 31-2 and 31-3).
and anxiety during resuscitation efforts. This maneuver prevents hyperextension of the airway and
The emergency team can also take steps to improve allows maximal ventilation. In contrast to the neutral head
outcomes of patients who come to the hospital with multiple position in the infant, a child's head is positioned slightly
trauma. Data have shown that delays in the provision of farther back. Roth and colleagues 14 found the jaw-thrust
definitive care for children who have been critically injured maneuver to be more effective than the head tilt--<:hin lift
increase mortality and morbidity rates. 12 Implementation of maneuver in maintaining an open airway in unconscious
a formal pediatric trauma team that can be rapidly mobilized children. If any secretions, blood, or vomitus are noted in
expedites treatment and facilitates early involvement of the the posterior pharynx when the airway is positioned, they
necessary specialists. should be immediately suctioned with a rigid tonsil-tip
In all settings, the key factor in preventing the deterio- suction device to clear the child's airway.
ration of respiratory failure or shock to cardiopulmonary Airway adjuncts may be required to maintain a patent
arrest is in being prepared. Nurses playa crucial role in this airway in children who are spontaneously breathing. An
area. Nurses ensure that the emergency equipment of the oropharyngeal airway is indicated for unconscious patients
correct size is available and operating, in case it is needed. to relieve obstruction from the tongue. It is sized by placing
This equipment includes a resuscitation bag and mask, it next to the patient's face with the flange at the corner of
.suction set up with both tonsil tip and endotracheal suction the mouth and the tip at the angle of the jaw. IS The airway
catheters, laryngoscope handle and blade, a stylet and an is placed by using a tongue depressor to displace the tongue
endotracheal tube (EIT) (including one size above and downward. It is then inserted into the mouth following the
below). Resuscitation and intubation drugs can also be natural contour of the tongue.
prepared in case they are needed. A nasopharyngeal airway is indicated for conscious
One major factor influencing outcome in the pediatric patients with intact gag reflexes. It is also useful in children
population that has probably received the least amount of with nasopharyngeal edema. The length should approximate
empiric review is the role nurses play in the recognition of the distance between the nares and the tragus of the ear. Its
the prearrest state. Nurses playa critical role by recognizing diameter should be slightly smaller than that of the nares. It
the red flags of respiratory distress and cardiovascular is inserted by lubricating and gently passing it along the
compromise that are present in the clinically unstable floor of the nostril into the nasopharynx.
pediatric patient. The mark of a true nursing expert is skill Once a patent airway is established. the spontaneously
in assessing these red flags, anticipating deterioration in breathing patient with compromised ventilation or perfusion
 Chapter 31 Resuscitation and Transport of Infants and Children 1029

a
•• High dose epinephrine (1:1,060), to be used for En route and as second
dose I.V, (First ETTdose in newborns should be a standard dose) . . ..
"Per anesthesia requesta!ull10 cc syringe of the abOve thiopental dilution shall be
~ra~~~pdurip~!Ih ~[Link]~e iptubatiop.
~1ll_::jrr:i::,:;::ri.:'l:l;:11"::"_J~Miili'lllt~illfi:1JIJ ,.,.;..
Mix eo mgs. (1.5 cc's

Fig. 31-1 Pediatric emergency medications reference guide sample: 19 kilograms. (Courtesy Children's
Hospital, CPR Committee, 1999.)
1030 Part V Multisystem Problems

Fig.31-2 Opening airway with head tilt-chin lift maneuver, One Fig. 31-4 Cricoid pressure (Sellick maneuver), (From Textbook
hand is used to tilt the head, extending the neck, Index finger of of pediatric advanced life support, Dallas, 1994, American Heart
rescuer's other hand lifts the mandible outward by lifting on the Association.)
chin, Note that the angle of the chin is 90 degrees from the bed,
Head tilt should not be performed if cervical spine injury is
suspected, (From Textbook of pediatric advanced life support, tion with 100% oxygen should be consistently maintained
Dallas, 1994, American Heart Association,) because children do not tolerate even short periods of
hypoxia. When pressures greater than 15 cm H2 0 are
necessary to adequately ventilate the patient, the Sellick
maneuver (pressure over the larynx on the anterolateral
surface of the cricoid cartilage) can be used to collapse the
esophagus against the cervical vertebrae (Fig. 31-4), This
maneuver may prevent aspiration in the un intubated patient.
Healthy lungs of infants and children are normally very
compliant and accept large tidal volumes (V T ) at low
pressures. The delivered VT is the amount needed to provide
normal chest excursion, usually 7 to 10 mllkg. Care is taken
because most pediatric resuscitation bags are capable of
delivering volumes in excess of the individual needs of the
patient. Self-inflating bags deliver volume until the pressure
exceeds that of the pop-off valve, which is usually 30 to
35 cm H20. Self-inflating bags only deliver an FI02 of 0.5 to
0.6 unless a gas reservoir is present. In contrast, anesthesia
Fig. 31-3 Opening airway with jaw-thrust maneuver, Airway is bags refill with fresh gas, thus delivering an Ft02 of 1.0.
opened by lifting the angle of the mandible, Rescuer uses two or
Anesthesia bags are also capable of a wider range of peak
three fingers of each hand to lift the jaw while other fingers guide
the jaw upward and outward, (From Textbook of pediatric inspiratory pressures (PIPs) and positive end-expiratory
advanced life support, Dallas, 1994, American Heart Association,) pressure (PEEP) and thus are useful in patients with poor
lung compliance. Use of excessive pressures places the
patient at risk for barotrauma; therefore anesthesia bags
requires oxygen to be delivered at the highest possible should be operated by experienced personnel, with pressures
concentration, A nonrebreather mask is the preferred method monitored and controlled using an attached pressure gauge
unless the patient requires assisted ventilation, 16 and gas escape val ve.
Patients who are not breathing spontaneously require Children have a greater propensity for air swallowing
manual ventilation with a bag-valve-mask and 100% when distressed. This, along with increased tracheal-
oxygen, The mask should be fitled as close as possible to the esophageal proximity, places the child at risk for gastric
size of the child's face, A properly fitted mask provides an distension during positive pressure bag-valve-mask ventila-
airtight seal and minimizes rebreathing, Effective venti la- tion. In addition to the risk of pulmonary aspiration, gastric
 Chapter 31 Resuscitation and Transport of Infants and Children 1031

Box 31-3 ",' ~ TABLE 31-2 Gilid~lines for

~ Steps in Rapid-Sequence Induction Process 'Rapid-Sequence Intubation.,
I. Organize equipment and personnel (RSI) Medications. '
2. Administer 100% oxygen
RSI Medication
3. Administer premedications
4. Administer sedatives and paralytics A. Pentothal
5. Intubate B. Succinylcholine
6. Confirm endotracheal tube placement C. Atropine (under age 7)
A. Lidocaine
B. Pentothal
distension elevates the diaphragm, compromISIng lung C. Pancuronium om mg/kg
expansion and tidal volume. Gastric decompression, using (defasciculating dose)
the largest nasogastric tube that the nares can accommodate followed by succinylcholine
comfortably, should be accomplished early in the resuscita- OR: Rocuronium 1.2 mglkg
tion effort. D. Atropine
Patients requiring assisted ventilation need to be intu-
A. Ketamine
bated as soon as possible by a provider who is skilled in
B. Succinylcholine
pediatric intubation. Early endotracheal intubation is rec-
C. Atropine
ommended because it secures the airway, facilitates the use
of PEEP, and provides a route for the administration of ,:"ypotension A. Midazolam
select resuscitation drugs when venous access is delayed. c~tJntraindications to A. Pentothal
However, for children who require intubation in out-of- ~Iisuccinylcholine B. Rocuronium
hospital settings, effective bag-valve-mask ventilation may '5f (hyperkalemia, renal C. Atropine
be preferable. Gaushe and colleagues 17 found that scene "jfdisease, muscular
time was prolonged and fatal complications more likely ::,_ disease, bums)
-'l,:
when children were intubated in this setting. They recom- A. Pancuronium
mended that emergency medical systems should focus B. Lorazepam
training on providing effective bag-valve-mask ventilation,
A. Fentanyl
along with prompt transport, and defer endotracheal intuba-
tion until the patient arrives in the emergency department. .: unesy Collaborative Practice Group, Emergency Department,
The safest method for intubating when there is risk of ,L.' dren's Hospital, Boston.
aspiration of gastric contents is by rapid-sequence induction
(RSI). This method is performed following a sequence of
steps involving preparation, preoxygenation, premedication, Stylets are used to provide rigidity and direct the tip of
sedation, and paralysis. Box 31-3 outlines the steps in the the ETT up through the glottic opening. To avoid airway
procedure. Indications for RSI are respiratory arrest, need trauma, caution is taken to ensure that the stylet does not
for airway control, Glasgow coma scale score of less than 8, extend beyond the Murphy's eye or the tip of the ETT
shock, and respiratory failure. The RSI medications are during intubation.
selected based on the child's hemodynamic status, preexist- Confirmation of ETT placement is achieved most accu-
ing conditions, and institution-specific policies. Guidelines rately by exhaled CO 2 detection (Fig. 31-5). Auscultating
for medication selection in RSI are outlined in Table 31-2. breath sounds high along the midaxillary line, the axillas,
Once RSI is accomplished, the patient is intubated. and the stomach further confirms ETT placement. Because
Various methods for determining correct ETT size have of the thin chest wall and subsequent prevalence of referred
been proposed. Appropriate ETT size often approximates breath sounds, slight change in the pitch of the patient's
the diameter of the patient's little, or fifth, finger, but this breath sounds may indicate right mainstem intubation in
method is somewhat inaccurate and does not offer an infants and children. Right mainstem intubation is a
opportunity to anticipate equipment needs before a patient's common problem in the pediatric population because of the
arrival in the emergency department or critical care unit. The standard length of ETTs and the variation in sizes of
following formula also accurately predicts correct ETT size: children. Additional clinical indicators of correct ETT
(Age in years + 16) + 4. placement include the presence of condensation in the ETT
Clearly, the ETT size chosen should be the largest that on expiration and symmetric chest excursion with manual
adequately ventilates the lungs while filling comfortably ventilation. On chest radiographs, the ETT should be 1 to 2
through the glottis and the cricoid cartilage. Smaller sizes cm above the carina or halfway between the carina and
increase airway resistance, result in excessive air leaks, plug clavicles. The carina approximates the level of the fourth
easily with secretions, and by themselves may ultimately rib; therefore the tube should approximate the level of the
cause respiratory failure. The nurse may anticipate anatomic third.
variation by choosing three ETT sizes (one larger and one In rare instances, alternative methods to establish an
smaller than the calculated size). airway may be necessary. Laryngeal mask airways may be
1032 Part V Multisystem Problems

the need for cardiac compressions. This section expands

on the traditional concept of circulation to include mea-
sures focused to improve tissue perfusion: vascular access
and the administration of intravenous fluids, followed by
resuscitation medications.
Cardiac Compressions. Cardiac compressions are
indicated if pulses are absent or the pulse rate is less than
60/min with inadequate perfusion. Compression rates are
recommended based on studies that have demonstrated a
relationship between the faster rates and higher mean
arterial pressures, cardiac index, and cerebral blood flOW. 18
Many studies are investigating the mechanism of
blood flow and techniques to improve blood flow during
CPR. However, controversy continues regarding the precise
mechanism of blood flow during closed chest cardiac
Fig. 31-5 End-tidal CO 2 monitor and endotracheal tube taping compression. Recent studies suggest that open cardiac
technique.
compression produces better coronary and cerebral perfu-
sion pressures. J9 This technique is most commonly reserved
for resuscitation of trauma patients. Interposed abdominal
inserted as an alternative to a tracheal tube. They are compression and active compression-decompression CPR
available in sizes to accommodate infants and children. techniques are currently being evaluated in children. 20
Surgical airways include cricothyrotomy and tracheostomy. Establishing Vascular Access. Establishing vascular
Because of the close proximity ofthe cricoid cartilage to the access to administer fluids and drugs is a priority once
vocal cords, a cricothyrotomy is always considered as a last adequate oxygenation, ventilation, and compressions have
resort, especially in children younger than age 12. Emer- been addressed. Obtaining venous access can be difficult
gency tracheostomy is rarely performed. and frustrating in the hemodynamically stable pediatric
Once intubated, the ETT is held firmly in place, and patient and worse in a patient in an arrest situation. During
markings on the ETT in relation to the nares or lip line are an arrest, the largest and most accessible vein that does not
noted while the tube is taped in place. The most common interrupt resuscitation is the preferred site for vascular
method of securing the ETT involves cutting two pieces of access.
I-inch tape that are tom in half and spiraling one half of Establishment of percutaneous peripheral access is lim-
each piece up the ETT. The other half of each piece is ited to three attempts or 90 seconds, whichever occurs first.
secured to the upper lip (see Fig. 31-5). The head is The team then needs to consider other techniques and routes
positioned at midline or maintained in a neutral position, of administration. Several methods of venous access are
particularly during radiographic determination of place- commonly used in children. The steel needle (butterfly) is
ment. Excessive flexion of the patient's neck may force an adequate for infants whose condition is stable but is not
uncuffed ETT down onto the carina, and extension of the recommended during resuscitation because of the risk of
neck or rotation of the head may dislodge the ETT infiltration, especially when administering caustic medica-
completely. tions and fluids at high rates. Over-the-needle catheters are
Continuous assessment of the adequacy of ventilation is preferred because they can be inserted deep into the vein,
always a priority. The magnitude and duration of hypoxia thereby decreasing the risk of infiltration. Larger sizes that
sustained during a period of respiratory distress or arrest facilitate more rapid infusion rates are recommended.
adversely affect the myocardium, ultimately influencing Central lines provide access for volume replacement,
myocardial response to resuscitation if cardiac arrest devel- rapid medication administration close to effector sites, and
ops. Spontaneous breaths are supported with humidified central venous pressure (CVP) measurement. Complications
oxygen at an FIO Z of 1.0. associated with this access option are reported more often in
Short-term hyperventilation may be advantageous in the the pediatric age group. Therefore this procedure should be
initial management of hypercapnia, and it provides a delegated to the more experienced provider to limit the
compensatory alkalosis in the patient with metabolic acido- iatrogenic complications of hemorrhage, pneumothorax,
sis. However, sustained hyperventilation should be avoided hemothorax, embolism, cardiac injury, or infection. IS
because it may compromise cerebral blood flow and Supradiaphragmatic central lines, the jugular and subcla-
promote cerebral anoxia. vian veins, are preferred, based on the theory that higher and
more rapid peak serum drug concentrations are produced
when medications are administered via this route than via
Circulation more peripheral sites. However, neckline placement often
In case of cardiac arrest, the primary goal in resuscita- interferes with the resuscitation attempt, and data are
tion is restoration of hemodynamic stability. After stabi- insufficient to support improved outcomes. Current recom-
lization of the airway and establishment of adequate mendations still consider long catheters placed above the
ventilation, pulses are immediately assessed to determine diaphragm from the femoral vein to be adequate. IS
 Chapter 31 Resuscitation and Transport of Infants and Children 1033

INTRAOSSalUS
NEEDLE

CEII11W.Y£N~O=US~==::;-::::=~~~
CHAJ*£L-_-

Fig.31-6 Intramedullary venous system demonstrates position of

intraosseous needle in medullary sinusoids. Blood may be aspi-
rated from sinusoids to confirm position of needle. (From Spivey
WH: Intraosseous infusions, J Pediatr III :639-643, 1987.)

The intraosseous route for fluid and drug administration

has regained popularity. An intraosseous infusion is recom-
mended as an alternative means to deliver intravenous fluids
and medications in children when vascular access is
inadequate or unavailable within three attempts or 90
seconds, whichever comes first. 18 The success rate for this
method in older children is lower; however, it is a Fig. 31-7 Recommended sites for intraosseous infusion. (From
reasonable alternative. zoa lntraosseous infusion is accom- Manley L, Haley K, Dick M: Intraosseous infusion: rapid vascular
plished by insertion of a bone marrow needle with stylet into access for critically ill or injured infants and children, J Emerg
the medullary cavity in a direction away from the epiphyseal Nurs 14:63-68, 1988.)
plate (Fig. 31-6). The preferred site is the broad flat portion
of the anteromedial surface of the tibia approximately I to
2 cm below the tibial tuberosity or above the femur's volume lost and presence of ongoing losses. It is not
external condyles (Fig. 31-7). Successful insertion is dem- uncommon for children to require large amounts of fluid for
onstrated by (I) loss of resistance from the bony cortex, resuscitation 21 Several 20 ml/kg fluid boluses are required
(2) aspiration of bone marrow, and (3) free flow of fluid before any improvement in the patient's clinical response is
without extravasation. The intraosseous route is acceptable appreciated. Controversy surrounds the type of fluid that
for volume expansion with blood, plasma, colloids, or should be administered during a resuscitation attempt.
crystalloid. Average gravity flow rates of 100 ml/hr can be Colloids and synthetic colloids, such as 5% albumin and
accomplished in the infant, whereas much higher flow rates hetastarch, are true volume expanders and generally remain
have been reported when a pressure infuser is used. Drug within an intact vascular space after administration. Colloids
levels achieved via the intraosseous route are similar to the are not used in patients with capillary leak syndrome (e.g.,
peripheral venous route. those patients with trauma, sepsis, or burns) because of
Complications associated with intraosseous infusion are the high associated risk of respiratory distress syndrome.
rare. These complications may be prevented by limiting the Approximately 20% to 25% of isotonic crystalloids, such as
amount of time they are in place and by avoiding the use of normal saline and Ringer's lactate, leak from the intravas-
hypertonic solutions. The only absolute contraindication for cular space shortly after administration; therefore volume
the use of intraosseous access is placement within a recently replacement with crystalloid may require 20% to 25% more
fractured bone. than the estimated loss. The advantage of using crystalloids
Fluid Resuscitation. Most children suffering cardio- is that they are relatively inexpensive and readily available.
pulmonary arrest require volume restoration or expansion The routine use of large volumes of high dextrose-
because of excessive losses, venous pooling, vasodilation, containing fluids during fluid resuscitation for hypovolemic
and capillary leaking. Often, because of hesitancy in shock is avoided. This may result in significant hypergly-
administering large volumes of fluid rapidly to small cemia with resultant osmotic diuresis.
children, too little fluid is administered too late. When hemorrhage occurs, the volume of red blood cell
Volume restoration precedes the use of vasoactive drugs administration can be approximated by multiplying 4 mt/kg
in resuscitation. The amount of volume administered by the difference, in grams, between actual and desired
depends on the extent of fluid deficit based on an estimate of hemoglobin. In cases in which the hemoglobin is unknown,
1034 Part V Multisystem Problems

approach to resuscitation that helps to organize intervention

TABlE 31-3 Physiologic Approach priorities. Drugs, compared with airway and breathing, are
to Resuscitation,' . often less essential in resuscitation of infants and children.
Correction of hypoxemia and acidosis and the restoration of
',: Airway
tissue perfusion are primary goals. However, the child's
": 'Breathing (oxygenation + ventilation)
response to resuscitation efforts is poor in the face of
, ~,:, Circulation (perfusion)
uncorrected imbalances, such as pH, glucose, potassium,
Asystole Oxygen and calcium. Hypothermia further contributes to metabolic
Bradycardia Epinephrine (bolus acidosis, which renders the myocardium refractory to
and infusion) electrical and pharmacologic intervention. Vagal stimulation
Atropine may result in refractory bradydysrhythmias. In addition,
AV block Oxygen toxic ingestions may compromise respiratory and cardiac
Atropine or
function, requiring immediate intervention. Successful re-
isoproterenol
suscitation depends on correction of such factors, with
Epinephrine infusion
interventions beyond restoring adequate ventilation.
Pacemaker
PVCs Oxygen A great deal of individual physiologic variation, depend-
Lidocaine ing on system maturity, is present in the pediatric popula-
Procainamide tion. Children and adolescents are able to maintain cardiac
Ventricular Oxygen output when heart rate decreases by increasing stroke
tachycardia Cardioversion at volume. However, sick infants have relatively fixed stroke
0.5·1 J/kg volumes, so cardiac output depends primarily on heart rate
Amiodarone and rhythm. A relatively fixed stroke volume, characteristic
Lidocaine of the infant for the first 6 to 12 months of life, is the result
Magnesium of limited ventricular compliance and contractility. Both
Ventricular Oxygen are less than in the mature heart because of the greater
fibrillation Shocks at 2 J/kg proportion of noncontractile myocardial tissue relative to
May repeat doub· contractile myocardial mass?2 In addition, increased inter-
ling joules ventricular interaction is especially evident in the small
Consider: epinephrine infant; that is, the degree of filling of one chamber affects
Amiodarone the degree of filling of another22 Therefore if a large volume
Lidocaine of fluid loads the right ventricle or if pulmonary hyperten-
Magnesium sion is present, the interventricular septum will bulge toward
Volume restoration the left and compromise left ventricular filling. Knowledge
Decrease excessive intrathoracic pressure that infants lack myocardial function sufficient to respond
Relieve cardiac tamponade to volume loading or overcome excessive afterload is
Correct asynchronous cardiac rhythms important.
Correct hypoxemia, acidosis, hypothermia Sympathetic nervous system immaturity is another factor
Question congenital outflow obstruction that requires consideration in seriously ill infants. Sympa-
Treat sepsis, drug overdose, anaphylaxis thetic innervation of the myocardium is incomplete at birth;
Consider vasodilators if CHF is present therefore infants are less responsive to endogenous and
Correct hypoxemia, hypoglycemia, K+ exogenous stimulation of the sympathetic nervous system. 23
and Ca+ As a result, the use of catecholamines in infant resuscitation
Correct acidosis: ventilation (NaHC0 3 ) does not reliably produce the same effect as in the older
Positive inotropic agents: epinephrine, child. Moreover, predicting the cardiovascular effect of any
dobutamine, dopamine, amrinone dose of any agent is difficult. Infants may require higher
Primary management includes correction doses per kilogram of infused catecholamines, but their use
of hypoxemia, acidosis, hypoglycemia, requires continuous monitoring and titration of individual
potassium and calcium imbalance, hemodynamic affects. Because of sympathetic immaturity,
hypothermia, vagal stimulation, and drug infants are more sensitive to parasympathetic stimulation
toxicity and experience more vagal-induced bradydysrhythmias than
".V, Atrioventricular; CHF, congestive heart failure; older children.
PVCs. premature
. ntricular contractions. In summary, determination of how best to individualize
the use of catecholamines to improve cardiac output is based
on the maturity of the patient. Receptor density and
10 mlIkg of packed red blood cells or 20 mllkg of whole responsiveness, ventricular compliance, and stroke volume
blood is administered to restore blood volume. all improve with age.
Resuscitation Medications. Patients with persistent The primary resuscitation drugs used in pediatric ad-
hypotension and poor perfusion following aggressive fluid vanced life support are outlined in Table 31-4. All dosages
resuscitation may require catecholamine support to restore are based on kilograms of body weight. It is important to
effective cardiac output. Table 31-3 outlines a physiologic closely estimate body weight using a reference chart or a
 Chapter 31 Resuscitation and Transport of Infants and Children 1035

the cerebral circulation and coronary blood flow to the

31-4 Primary Pediatric
TABLE myocardium, which then stimulates spontaneous cardiac
Resuscitation Drugs contractions. Restoration of coronary artery perfusion pres-
sures is essential for the return of spontaneous circulation.
Nursing
This effect is critical in infants and children because most
Dose Implications
arrest rhythms are unstable slow rhythms not related to heart
(VIlO: [Link]/kg Instill 2-3 ml block.
(1: 10,000) normal saline Guidelines for administering an epinephrine infusion are
ET: 0.1 mg/kg following ET outlined in Chapter 27. Side effects of a peripheral
(1:1 ,000) administration epinephrine infusion include compromised skin and extrem-
Repeat doses: 0.1 ity blood flow.
mg/kg (l: I 000) Atropine. Atropine, a parasympathetic nervous sys-
0.02 mg/kg Masks hypoxia tem blocker, produces both positive chronotropic and
(min 0.1 mg) induced brady- dromotropic effects. It is indicated for slow arrest-related
cardia: morutor rhythms, that is, bradycardia and atrioventricular blocks
O 2 saturation resulting from structural heart disease. 18
Causes pupillary Slow rhythms during resuscitation most often occur as a
dilation result of hypoxemia. As a consequence, atropine is unlikely
I mEq/kg Flush with normal to be efficacious in this situation. Atropine also blocks
saline before hypoxemia-induced bradycardia. Therefore careful monitor-
and after admin- ing of oxygen saturation through pulse oximetry is indi-
istration cated, and prolonged attempts at intubation are avoided.
Inadequate atropine doses stimulate vagal nuclei and
20 mg/kg Administer slowly
produce paradoxical bradycardia. This affect is avoided by
using the full vagolytic dose.
<20 kg: 0.1 mg/kg Short duration may Sodium Bicarbonate. During an arrest, poor venti-
>20 kg: 2 mg result in return lation and low-flow states produce mixed respiratory and
of symptoms
metabolic acidosis. Inadequate tissue perfusion results in
0.1-0.2 mg/kg Give rapid IV push anaerobic metabolism and subsequent lactic acid produc-
(max 12 mg) Follow with imme- tion. In addition, the circulation of poorly oxygenated blood
diate normal further contributes to tissue hypoxia and subsequent isch-
saline flush emia. The priority in managing acidosis is restoration of
May cause tran- ventilation and tissue perfusion. An in-depth discussion of
sient bradycardia acid-base imbalance is included in Chapter 9.
5 mg/kg Monitor for hypo- Sodium bicarbonate (NaHC0 3 ) serves as a buffer by
Repeat dose: 5 mg/kg tension combining with the hydrogen ion (H+) to form carbonic acid
Max: 15 mg/kg/day (H 2 C0 3 ), then CO 2 and H2 0. It is not a first-line drug in
I mg/kg Give rapid bolus resuscitation. It is indicated when severe acidosis is

,':
',,,' agnesium 25-50 mg/kg Use for presence
documented related to prolonged cardiopulmonary arrest. It
is also indicated for treatment of hyperkalemia and tricyclic

1
Max' 2 g of torsades
antidepressant overdose.
...:.~- de pomtes
Because CO 2 crosses the blood-brain barrier and cell
membranes more rapidly than HC0 3 , transient increa~es in
CO 2 produced by NaHC0 3 administration can paradoxi-
Broselow tape. The Broselow method bases dosages on cally worsen cerebrospinal fluid and inrracellular acidosis.
patients' length. The tape is placed along the patient's side, In hypoxic states, NaHC0 3 administration decreases myo-
and the appropriate drug dosages for the patient are cardial contractility, cardiac index, and blood pressure and
preprinted on it. Suggested emergency cart medications are may worsen electromechanical dissociation. Because respi-
found in Appendix IV. ratory failure is often the precipitating event in cardiopul-
Epinephrine. During an asystolic arrest, the initial monary arrest among infants and children, this population is
beneficial effect of any catecholamine is mediated through at greater risk of severe intracellular acidosis because of
its alpha effect. 18 Epinephrine is the catecholamine of impaired CO2 elimination.
choice during resuscitation because it is direct acting and Many other physiologic disturbances occur with exces-
provides a perfect balance of alpha and beta stimulation. sive NaHC0 3 adminisrration. Potassium shifts into the
Alpha stimulation causes peripheral vasoconstriction that intracellular space; a 0.1 rise in pH typically results in a 0.5
improves myocardial perfusion pressure generated during mEqlL decrease in serum potassium. Hypernatremia and
closed chest compressions, thus enhancing oxygen delivery hypocalcemia result. Hyperosmolar states may also result
to the heart. Epinephrine dramatically increases myocardial from increased serum sodium produced by NaHC0 3 admin-
blood flow, cerebral blood flow, and subsequent cerebral istration. The intravascular shift of free water that results
oxygen uptake. Its effect redistributes carotid blood flow to from hyperosmolarity may be lethal because it has been
1036 Part V Multisystem Problems

implicated in intracranial hemorrhage in infants. To prevent tachycardia, which are rare events in children. Once the
this, NaHC0 3 is diluted I: I with sterile water in infants bolus doses of lidocaine have been effective, a lidocaine
younger than 3 months unless 4.2% infant NaHC0 3 is infusion is initiated. Guidelines for administration of a
available (0.5 mEq/ml). NaHCO) is not recommended until lidocaine drip are outlined in Chapter 27.
the patient has been adequately oxygenated and ventilated, Lidocaine is metabolized by the liver. Therefore its dose
CPR has been initiated, epinephrine has been administered is modified for children with inadequate liver function or
without success, and a venous pH of 7.0 or less or an arterial decreased perfusion to the liver. Symptoms of lidocaine
pH of 7.2 or less has been documented. 18 toxicity that initially appear are alterations in the central
Calcium. Calcium increases myocardial contractility, nervous system such as nausea, decreased mental status, and
increases ventricular excitability, and increases conduction seizures. Depression of cardiac function may occur later as
velocity through the ventricles. It is indicated in the a result of toxicity.
management of documented total or ionized hypocalcemia Magnesium. Magnesium is a major intracellular cat-
(commonly seen in stressed infants) and in the management ion. It inhibits calcium channels and causes smooth muscle
of the adverse cardiac effects associated with hyperkalemia, relaxation. It is used in the treatment of torsades de pointes
hypermagnesemia, and calcium channel blocker overdose. It or documented hypomagnesemia.
may also be indicated for children who have received blood Routes of Drug Administration. Routes of drug
with citrate-phosphate-dextran used as a preservati ve. administration for resuscitation include central venous,
Glucose. Glucose is indicated to treat documented endotracheal, intraosseous, and intracardiac. Ideally, resus-
hypoglycemia. Infants have limited glycogen reserves and citation drugs are administered close to adrenergic receptor
when stressed, particularly in the presence of sepsis, sites located on the arterial side of the circulation. To ensure
experience acute marked hypoglycemia. Hypoglycemia that a bolus medication is delivered into the central
depresses cardiac contractility and may precipitate seizure circulation rapidly, each medication is followed with a rapid
activity. Symptoms of hypoglycemia, which include de- 2- to 5-ml normal saline flush. Continuous infusions of
creased perfusion, diaphoresis, tachycardia, and hypoten- vasoactive medications can be initiated at 5 to 10 times the
sion, mimic those of hypoxemia. usual rate while heart rate and blood pressure are continu-
Conversely, some evidence shows that hyperglycemia ously monitored. When the desired effect is evident, the
worsens neurologic outcome. 24 Rapid-response blood glu- infusion rate is decreased. Another option is to administer
cose screening methods should be used to guide adminis- the continuous infusion through a Y connector with a
tration of glucose. faster running intravenous line. Care is taken when titrating
Naloxone. Naloxone is an opiate antagonist that either line.
reverses the effects of narcotics, such as respiratory The intraosseous route is acceptable when venous access
depression and hypoperfusion. It is indicated when narcotic is delayed. The intraosseous route, considered similar to a
overdose is suspected to be the cause of cardiopulmonary peripheral venous route, is acceptable for all resuscitation
arrest. It is rapid acting and has a short half-life. For cases drugs.
in which complete reversal is not desired, such as with Although data in humans are limited, several resuscita-
patients on morphine drips, naloxone may be titrated to the tion drugs defined by the acronym LEAN (lidocaine,
desired effect. epinephrine, atropine, and naloxone) may be administered
Adenosine. Adenosine is an endogenous purine nu- by the tracheal route if intravenous access is unavailable.
cleoside. It exerts a strong depressant effect on the sinus and These drugs are rapidly absorbed when given by the tracheal
atrioventricular (AV) nodes. It slows conduction through the route, having a direct cardiac effect. Ten times the standard
AV node and causes interruption of the reentry pathway. It intravenous dose is recommended via the tracheal route
is indicated for the treatment of supraventricular tachycardia (i.e., 0.1 mg/kg of the I: 1000 solution).18 Both epineph-
(SVT). If the cause of the tachyarrhythmia is not a reentry rine and atropine have a prolonged effect after tracheal
mechanism, adenosine will not terminate it but may assist administration; thus less frequent administration may be
with identifying the underlying rhythm by producing a required.
transient AV blockade. The half-life of adenosine is less than All tracheal drugs should be diluted with 2 to 3 ml of
10 seconds with duration of less than 2 minutes. normal saline and injected deeply into the tracheobronchial
Amiodarone. Amiodarone is a lipid-soluble antiar- tree using a needleless syringe and attached suction catheter
rhythmic that may be used for atrial and ventricular or feeding tube. Injection is accomplished after passive
arrhythmias. It produces vasodilatation and AV nodal exhalation, and a resuscitation bag is used to distribute the
suppression. It also inhibits the outward potassium current, drug throughout the lung periphery. Sterile normal saline is
which prolongs the QT interval. Amiodarone also inhibits the only diluent recommended for this procedure, in
sodium channels, which slows ventricular conduction. Its volumes not to exceed 5 ml in infants or 10 ml in
most acute side effect is hypotension. It is a highly complex adolescents.
pharmacologic agent with potential for long-term compli- The intracardiac route for drug administration is a last
cations. Its long-term use should be directed by an expert resort, primarily because the procedure interrupts cardiopul-
such as a pediatric cardiologist. monary resuscitation. Other iatrogenic complications in-
Lidocaine. Lidocaine increases the fibrillation thresh- clude cardiac tamponade, pneumothorax, and coronary
old by reducing the automaticity of ventricular pacemakers. artery laceration. If a drug is inadvertently injected into the
It is indicated for ventricular fibrillation and ventricular myocardium, it may cause intractable VP.
 Chapter 31 Resuscitation and Transport of Infants and Children 1037

Cardiac Dysrhythmia Management. During car- Slow Rhythms. Slow rhythms are the most common
diopulmonary arrest in infants and children, hypoxic and arrest-related rhythm disturbance in infants and children.
acidotic blood circulates through nonnal coronary arteries Because of heart rate dependency, the hemodynamic effect
under extremely low perfusion pressure. As a consequence, of bradydysrhythmias may be significant in an infant or
the majority of pediatric cardiopulmonary arrest-related child. Slow arrest-related dysrhythmias are related to either
dysrhythmias occur as a result of metabolic dysfunction and hypoxic-ischemic insults or structural heart disease. 18 Oc-
not from coronary artery disease. Therefore the emphasis in casionally, primary bradycardic arrests occur in children
pediatric resuscitation is on reestablishing adequate oxygen- with congenital complete heart block or in an infant
ation, ventilation, and tissue perfusion, not on complex during procedures that cause vagal stimulation (e.g., oral-
rhythm analysis and its drug management. pharyngeal stimulation or a Valsalva maneuver related to
Unstable rhythms that require treatment are those that painful procedures).
compromise cardiac output and those that have the potential Slow rhythms associated with hypoxic-ischemic insults
to deteriorate into a lethal rhythm. Extremes in heart rate are are often wide QRS complex without P waves. Slow
of no concern unless the effecti ve cardiac output does not rhythms associated with structural heart disease are often
match the patient's clinical need. The clinical assessment related to heart block or sinus node dysfunction. Priorities
parameters of blood pressure, heart rate, and end-organ for managing bradydysrhythmias start with the resuscita-
perfusion (specifically to the brain, skin, and kidneys) tion ABCs (airway, breathing, and circulation) and then
provide rapid measures of the adequacy of cardiac output progress if severe cardiopulmonary compromise is present
and effectiveness of intervention strategies. (Fig. 31-8).

-BLS Algorithm: assess and support ABCs

as needed
- Provide oxygen
-Attach monitor/defibrillator

!
Is bradycardia causing severe cardio-
No respiratory compromise? Yes
(poor perfusion, hypotension, respiratory
diffiCUlty, altered consciousness)

-Observe During CPR Perform chest compression

-Support ABCs if despite oxygenation and
- Consider transfer or Attempt/verify ventilation:
transport to ALS -Tracheal intubation and vascular -Heart rate <60/min in infant
facility access or child and poor systemic
perfusion
Check
• Electrode position and contact
• Paddle position and contact Epinephrine'
- Pacer position and contact -IV/lO: 0.01 mg/kg
(1:10,000; 0.1 mUkg)
Give •Tracheal tube: 0.1 mglkg
• Epinephrine every 3 to 5 minutes (1:1000; 0.1 mUkg)
and consider alternative medications: - May repeat every
epinephrine and dopamine infusions 3 to 5 minutes
at the same dose
Identify and treat possible causes
• Hypoxemia
• Hypothermia
• Head injury Atropine' 0.02 mg/kg
• Heart block (minimum dose: 0.1 mg)
• Heart transplant - May be repeated once
(special situation)
•Toxins/poisons/drugs

Consider cardiac pacing

~
'Give a tropine first for bradycardia due to suspected
increased vagal tone or primary AV block.
I Ilf pulseless arrest develops, see )1
Pulseless Arrest Algorithm (Fig. 31-10)

Fig.31-8 PALS bradycardia algorithm. ABCs, airway, breathing, circulation: ALS, advanced life support;
IV, intravenous. (From American Heart Association: Guidelines 2000 for cardiovascular care, Circulation
2000, 102(suppl):129 1-1342, 2000.)
1038 Part V Multisystem Problems

In an arrest, cardiac pacing may be helpful in manag- Absent (Collapse) Rhythms. Absent (collapse)
ing patients with slow rhythms resulting from structural rhythms include asystole, VF, and pulseless electrical
heart disease. Pacing can be accomplished by external activity (PEA). These rhythms are considered hemodynam-
(transcutaneous), transvenous, or epicardial electrodes. Pac- ically significant because all three fail to produce cardiac
ing in the hypoxic-ischemic cardiac arrest patient is rarely output.
successful. Even if ventricular capture is accomplished, Asystole, like bradycardia, is a common pediatric arrest
pacing does not improve myocardial contractility and tissue rhythm. The management goal is to improve oxygenation
perfusion. and perfusion (Fig. 31-10).
Fast Rhythms. Fast rhythms are expected in critically VF and pulseless VT, which are managed in a similar
ill pediatric patients. Unstable fast rhythms fall into two manner, are uncommon pediatric rhythms. The overall
main categories: those with narrow QRS complexes and frequency of VF and VT is 10%.4 Immediate shocks at 2
those with wide QRS complexes. The differential for narrow J/kg is the most important determinant of successful
fast rhythms include sinus tachycardia (ST), supraventricu- conversion to NSR. The pulse and cardiac rhythm are
lar tachycardia (SVT), atrial flutter (AF), or atrial fibrillation reevaluated after each shock attempt. If unsuccessful, the
(At). One can easily mistake a rapid ST for SVT. Key joules are doubled, and the patient is defibrillated twice in
diagnostic features of ST include rhythm variability and a rapid succession. With the advent of automated external
heart rate that is congruent with the patient's need for defibrillators (AED), shocks in the field are more readily
increased cardiac output. Key diagnostic features of SVT available. AEDs are recommended for use in children older
include a monotonous rhythm and a heart rate in excess than 8 years old. Their use in the field has shown to be as
of the patient's clinical need. ST is a symptom reflect- effective for children as for adults 25
ing the patient's need for increased cardiac output, whereas Epinephrine may improve coronary artery perfusion
unstable SVT is a primary cardiac rhythm disturbance pressure, increasing the effectiveness of shocks. The epi-
requiring primary intervention. AF and Af are rare car- nephrine dose is increased after the first dose as for asystole
diac rhythms in groups other than pediatric patients with and repeated every 3 to 5 minutes. Lidocaine may be used
complex CHD. to increase the fibrillation threshold but should not delay
The differential for wide-complex fast rhythms is aber- defibrillation. Metabolic problems, such as calcium, potas-
rantly conducted SVT or VT. Distinguishing between the sium, magnesium, or glucose imbalance, and hypothermia
two may be impossible in a patient whose condition is or drug intoxication (e.g., with digitalis or tricyclic antide-
unstable. Because wide-complex SVT is extremely rare in pressants), are continually reassessed and corrected. If VF
the pediatric age group, all wide-complex fast rhythms are reoccurs, the previous successful energy level for shocks
considered to be VT until proven otherwise. are used.
Pediatric groups at risk for ventricular tachydysrhythmia Amiodarone is the next medication of choice for
as a terminal rhythm include children requiring prolonged treating VF. Lidocaine may be used as an alternative.
resuscitation, infants beyond the neonatal period, older Magnesium is indicated for VF with a torsades de pointes
children, and children with CHD. A critical cardiac mass pattern.
along with sympathetic maturity characteristic of infants PEA is characteristic of organized cardiac electrical
beyond 6 to 12 months of age is thought to be necessary for activity without effective cardiac output. PEA is usually a
ventricular tachydysrhythmias to occur. During prolonged slow Wide-complex rhythm, for example, junctional or
resuscitation attempts, many doses of catecholamines, idioventricular rhythm. When PEA is caused by hypovole-
which stimulate the sympathetic nervous system, are often mia, tension pneumothorax, or pericardial tamponade, a
administered. Children with CHD who have arrests more narrow-complex, rapid heart rate may be seen. Causes also
often exhibit bradycardia but are 3 times more likely than include hypoxia and acidosis.
those without CHD to exhibit ventricular tachydysrhyth-
mias. Supporting the critical mass theory, many children
with CHD usually have cardiac enlargement. Metabolic
Evaluation of Interventions
causes of ventricular dysrhythmias include hyperkalemia, Patients require thorough and frequent reassessment of
hypoglycemia, hypothermia, and tricyclic antidepressant their airway, breathing, and circulation throughout the
overdose. resuscitation process. Initial improvement in a patient's
Treatment of all unstable fast rhythms includes synchro- condition may not be sustained because of underly-
nized cardioversion at 0.5 J/kg (Fig. 31-9). If unsuccessful, ing causes. The child's response to the interventions
the joules are doubled, and cardioversion is repeated. must be closely monitored. Reestablishment of end-organ
In VT, lidocaine administration before cardioversion perfusion is a positive indicator of successful patient
may result in a higher conversion rate. Lidocaine is outcome.
administered in a dose of I mg/kg every 10 to 15 min- If the patient does not respond despite aggressive
utes. A continuous lidocaine infusion of 20 to 50 Ilg/kg/min efforts to resuscitate, a decision to terminate the resus-
is useful after conversion to normal sinus rhythm (NSR) citation must be made. This is a very difficult decision and
if the patient has structural heart disease, has multiple is most often made collaboratively by the resuscitation
premature ventricular contractions (PVC), or recurrent team. Several laboratory and clinical findings influence the
VT or VE decision to terminate resuscitation efforts. These include
 Chapter 31 Resuscitation and Transport of Infants and Children 1039

10BLS Algorithm: assess, support ABCs

I oInitiate CPR I to Pulse present? I

oSee pulseless arrest algorithm I No
Yes

1 0Provide oxygen and ventilation as needed

oAttach monitorldefibrillator

QRS duration normal for age QRS duration wide for age
(approximately ';;0.08 sec) I 012-lead ECG if practical (approximately >0.08 sec)
I 0Evaluate QRS duration

I Evaluate the tachycardia l - oProvide

OurIng evaluation
oxygen and ventilation as needed
H Evaluate for tachycardia r--
oSupport ABCs
oConfirm continuous monitorlpacer attached
oConsider expert consultation
oPrepare for cardioversion (consider sedation)

Identify and treat possible causes

oHypoxemia
oHypovolemia
oHyperthermia
oHyper-Ihypokalemia and metabolic disorders
oTamponade
oTension pneumothorax
oToxins/poisons/drugs
oThromboembolism
opain

1
Probable sinus tachycardia Probable supraventricular tachycardia Probable ventricular tachycardia
oHistory compatible oHistory incompatible olmmediate cardioversion
oP waves presenVnormal op waves absenVabnormal 0.5 to 1.0 Jlkg
oHR often varies with activity oHR not variable with activity (consider sedation, do not delay
oVariable RR with constant PR oAbrupt rate changes cardioversion)
olnfants: rate usually <220 bpm °lnfants: rate usually >220 bpm
°Children: rate usually < 180 bpm °Children: rate usually >180 bpm

IConsider vagal maneuvers I

(no delays) I Consider alternative medications
oAmiodarone 5 mglkg IV over
Immediate cardloversion 20 to 60 minutes
oAttempt cardioversion with 0.5 to 1.0 Jlkg (may increase to or
2 Jlkg if initial dose is ineffective) oProcainamide 15 mglkg IV over
oUse sedation if possible 30 to 60 minutes
oSedation must not delay cardioversion (Do not routinely administer
or amiodarone and procainamide
Immediate IVIlO adenosine
oAdenosine: use if IV access is immediafely available
oOose: Adenosine 0.1 mglkg IVIIO (maximum first dose: 6 mg)
- together)
or
oLidocaine 1 mglkg IV bolus
oMay double and repeat dose once (maximum second (wide-complex only)
dose: 12 mg) oConsult pediatric cardiologist
oTechnique: use rapid bolus technique 012-lead ECG

fig.31-9 Algorithm for pediatric tachycardia with poor perfusion. CPR, Cardiopulmonary resuscitation;
NS, nonnal saline; ECG, electrocardiogram; IV, intravenous. (From American Heart Association:
Guidelines 2000 for cardiovascular care, Circulation 2000, I 02(suppl):I29 1-1342, 2000.)
1040 Part V Multisystem Problems

-BLS Algorithm: assess and support ABCs

as needed
- Provide oxygen
-Attach monitor/defibrillator

,..- -----11 Assess rhythm (ECG) )f-----------------------,

NotVFNT
VFNT (Includes PEA and asystole)

Attempt defibrillation During CPR

- Up to 3 times if needed
-Initially 2 J/kg, 2 to 4 J/kg, ANemptlverify
4 J/kg' -Tracheal intubation and vascular
access

Check
- Electrode position and contact
- Paddle position and contact
Epinephrine Give Epinephrine
-IV/IO: 0.01 mglkg -Epinephrine every 3 to 5 minutes -IV/IO: 0.01 mg/kg
(1:10,000; 0.1 mUkg) 1-----+-1 ( 'd h' h d f d (1:10,000; 0.1 mUkg)
_Tracheal tube: 0.1 mglkg conSI er Ig er oses or secon
(1:1000; 0.1 mUkg) and subsequent doses) -Tracheal tube: 0.1 mglkg
(1 :1,000; 0.1 mUkg)
Consider alternative medications
- Vasopressors
_Antiarrhythmics (see box at left)
Attempt defibrillation _Buffers
with 4 Jlkg* within 30 to
60 seconds after each Identify and treat causes
, - Continue CPR I
up to 3 minutes
medication -Hypoxemia
* Pattern should be CPR- - Hypovolemia
drug-shock (repeat) or - Hypothermia
CPR-drug-shock-shock- - Hyper-/hypokalemia and
shock (repeat) metabolic disorders
-Tamponade
-Tension pneumothorax
- Toxinslpoisonsld rugs
- Thromboembolism
Antiarrhythmic
- Amiodarone: 5 mg/kg
bolus IVIIO or
- Lidocaine: 1 mg/kg bolus
IV/IO/PT or
- Magnesium: 25 to 50 mg/kg
IV110 for torsades de pointes
or hypomagnesemia
(maximum: 2 g)

Attempt defibrillation ,Alternative waveforms and higher doses are

with 4 Jlkg* within 30 to
60 seconds after each
I Class indeterminate for children. I
medication
- -Pattern should be CPR-
drug-shock (repeat) or
CPR-drug-shock·shock-
shock (repeat)

Fig.31-10 Algorithm for asystole and pulseless arrest. CPR, Cardiopulmonary resuscitation; IV, intra-
venous; 10, intraosseous. (From American Heart Association: /999 Handbook of emergency cardiovas-
cular care for healthcare providers, Dallas, 1999, AHA.)
 Chapter 31 Resuscitation and Transport of Infants and Children 1041

prolonged acidosis, iatrogenic causes of arrest, and the

Documentation
absence of spontaneous circulation after 30 minutes of Ongoing documentation of resuscitation events is crucial.
resuscitation. 26 Accuracy is enhanced if the person responsible for docu-
mentation has no other role in the resuscitation attempt and
is positioned in close proximity to the code leader and
Diagnostic Studies patient. Fig. 31-11 illustrates an example of a resuscitation
For patients who are responsive to resuscitation interven- flow sheet that facilitates documentation. Effective resusci-
tions, a variety of laboratory and radiologic studies are tation flow records provide precise information about code
indicated during and following successful resuscitation events, include the patient's response to therapy, and
depending on the child's underlying diagnosis. Laboratory minimize the time required for documentation during and
studies may include a complete blood count, serum glucose, after the code.
electrolytes, blood culture, blood typing, and arterial or Postresuscitation documentation has a summary state-
venous blood gases. Other laboratory studies commonly ment that includes the time and duration of the arrest, ETT
completed are urinalysis, urine culture, and cerebrospinal size and markings compared with the lip or nares line,
fluid analysis. catheter sizes and length of insertion, all intravenous fluid
The most common radiographic study indicated is a chest administered, blood work and blood loss, drugs and dosages
radiograph to identify any cardiac or pulmonary problems, administered, and the patient's and family's response to
as well as to identify ETT placement. Other radiographs, therapy.
computed tomography (CT), and magnetic resonance imag-
ing (MRI) may be indicated to identify any other injuries or
pathologic processes that may be suspected.
POSTRESUSCITAliON MANAGEMENT
Patient care goals after cardiopulmonary resuscitation in-
clude further stabilization of oxygenation, ventilation,
Family Care cardiac output, and tissue perfusion. These goals are vital for
Throughout the crisis of resuscitation, parents require neurologic preservation. Two major concerns include the
information and support. Information is best provided potential of iatrogenic trauma from the resuscitation attempt
according to the individual needs of the parents. For and multisystem dysfunction resulting from organ hypoper-
example, some parents may want updates every 5 min- fusion with hypoxic and acidotic blood.
utes, whereas others may want to know only the outcome The ABCs are also useful in organizing postarrest
when resuscitation attempts are over. A critical nursing stabilization measures. Assessment starts with an evaluation
intervention is to keep families accurately informed and of the adequacy of the airway. Assessment parameters
assured that everything possible is being done to assist their include the airway size, presence of an ETT leak, and the
child. security of the ETT. If a cuffed ETT is placed, cuff volume
Providing parents with a pri vate place is essential, both and pressures are checked. This is important in pediatrics
for them and for parents of other critically ill children. A because cuffed ETTs are infrequently used and can poten-
member of the team who has an established relationship tially cause a significant amount of airway damage in a short
with the parents, such as the nurse, member of the clergy, or period. The placement and patency of the nasogastric tube
social worker, ideally stays with the parents, especially if (NGT) is also assessed. After decompressing the stomach
they are alone. with a large-volume syringe, the NGT is connected to
Whether stabilization occurs or attempts to resuscitate intermittent suction. A chest radiograph is usually indicated
are unsuccessful, parents should be given options to see, to evaluate pulmonary disease, assess for iatrogenic injury,
touch. or hold their child as soon as possible. Some parents and check tube placement, that is, ETT, central lines, or
may wish to remain at their child's bedside during the chest tube positioning.
resuscitation attempt. Although this may seem difficult for Serial ABGs are assessed throughout the resuscitation
caregivers, each family is assessed individually. Elements of attempt. Exhaled CO 2 detection is continuously monitored
protocols for parental presence may include educating staff as well. Saturation monitoring resumes when the patient's
in resuscitation methods and in providing options for pulse pressure is adequate. Once the airway is stable,
parents, especially parents of children whose conditions optimal ventilator parameters are identified. Airway pres-
have been deteriorating over time and in whom CPR can be sures sufficient to provide adequate chest excursion and at
expected. When death is imminent, the child is allowed to least 95% saturation are noted during hand ventilation.
die in the presence or in the arms of parents. Keeping the patient's FI02 at 1.0, airway pressures are
A movement is underway fostering parental presence matched with the ventilator. Once the patient is supported
during resuscitation because of nursing's moral imperative on the ventilator, the patient's ABGs are reanalyzed in
to preserve the wholeness, integrity, and dignity of the 20 minutes, and further adjustments in PIPs and PEEPs,
family unit. 27 The Emergency Nurses Association position tidal volume, and FlO2 are made.
statement supports this philosophy?8 It seems reasonable to Vascular access is reassessed for adequacy, patency,
initiate flexible programs to facilitate parental presence and security. Additional vascular access may be indi-
during pediatric CPR, especially with parents of chronically cated and, after fluid resuscitation, can be accomplished in
critically ill patients. a controlled manner. Intraosseous lines are discontinued as
 USE PLATE OR PRINT Children's Hospital
CODE BLUE RECORD Page __ of __
-=
.roo
.....
PT. NAME _
LAST FIRST
+'::1. ~--~,;,:~ ,:;[~;~~ '~';- t!: .'...,. ",""!...:;; 'I" ,.. ~i" I;
;:
DATE DIV. _ ";,:;, ,.:;)~1; ,<-0;<;, ,;~j~··i'j ld~;"'J" ~:i!~:' ~,i:k' _ ~:, ,II!'" :1.' 'F" 1•• ',,!!" ~
~~~-i"",*,'~~..•::0" WelghL """ '.j"" LQca1IQn.•.;"..".."""...--.;.~ ...........,.,.,.........,....;..:......,......:,;,.""'""""..,..,.,..... <
MEDICAl REC. NO. ·.~i~':;· ,.~ ,.:~~ ',';:'."'.:," ~:' !!:',;".:"~::!, :,ri·,r.", ~'''AeMmce Pi~B+r"~, EI NO s:
c:
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TIME
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VITAL SIGNS rEte<d CARDIAC
RHYTHM
ASSESSMENT I INTERVENTIONS
(NOTE BY WHOM) MEDICATIONS
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5 m1nuwa) HR I RR BP I spO.1 T EtCa. LAB RESULTS I X-RAYS 3
...o-0
,.. . ,i,~ I. r:T
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,·1 "" I'- •.,. I,· I",':P ""

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I·' ,L I II " ·1 .~~; "

i!" ',;; .. .,.-" "I~ . 1'"-1' ~ ~">,,

F-~ , j', r~ y-:. tS--"

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...,
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'j-

Time of Arrest / Emergency _ Resuscitation Team: Disposition: 0 Survived

Time Code Team Called RN _ RN _ o Expired
Time Code Team Arrived RN _ RN _
Transfer Location:
CPR initiated at by _ _ MD _ Anesthesia _
ET intubation at by _ _ MD _ COpp _ oOR o Floor
MD _ Security OICU OED
Vascular access at by _ _
First defibrillation at by RT o Other; _

Recorder's Name RN Code Leader's Name MD

Recorder's Signature RN Code Leader's Signature MD
03031 2&PKG ~ 1.t copy - [Link] [Link] 2nd COPY - NUrI. Mlnlger 3rd COPY - CPR Commlrt.. (MtCU Office, F.,.,.y 517)

Fig. 31-11 Code blue record. (Courtesy Children's Hospital, CPR Committee, Boston. 1999.)
 Chapter 31 Resuscitation and Transport of Infants and Children 1043

soon as possible after adequate direct vascular access lines provide a framework for minimum goals for pediatric
has been obtained. The skin surrounding peripheral intra- and neonatal critical care transport programs. Federal
venous sites requires particular attention. The potential guidelines also govern interfacility transports. The Con-
for iatrogenic injury from intravenous infiltration is solidated Omnibus Reconciliation Act of 1985 (COBRA)3o
high. Immediate consultation to plastic surgery may be and the Emergency Medical Treatment and Active Labor
indicated. Act (EMTALA)31 regulations state that interfacility trans-
The initial set of vital signs includes temperature port cannot be used as a method to avoid initial assessment,
assessment. Patient exposure and administration of large stabilization, or intervention, especially with regard to a
quantities of unwarmed intravenous solutions during the patient's ability to pay. All necessary means to stabilize
arrest place the patient at risk for postarrest hypothermia. the patient are attempted before transport. Regionally,
The hypothermic patient benefits from rewarming measures, hospitals should have written interfacility transfer agree-
for example, warm blankets and overhead radiant warmers ments outlining the level of responsibility of both receiving
or lights. and referring facilities throughout the transport process.
As soon as possible after resuscitation, a baseline Thus when a transport occurs, preset agreements are
neurologic examination is performed and documented. The already in place, and compliance with federal guidelines
neurologic examination is placed in context of the pre- is ensured.
arrest neurologic status and drugs used during or immedi-
ately after resuscitation (e.g., atropine, dopamine, and
chemical paralyzing agents). Atropine and dopamine act
Transport Process
synergistically to cause pupillary dilation, the duration Once the healthcare team at the referring institution
of which cannot be accurately determined because rou- recognizes the need for specialty services, a decision to
tine half-life calculations are probably invalid following transport to a tertiary facility is made. Once an interfacility
resuscitation. transport team is activated, the patient is prepared.
In addition to ABGs, initial postresuscitation blood The goal is optimal stabilization of the patient. The pa-
work includes studies to evaluate oxygen-carrying capac- tient's condition and the trajectory of the disease process
ity, fluid balance, system function (especially renal and are considered. The ABCs of stabilization help to ensure that
liver function), and coagulation profiles. Urine output is the patient is physically prepared for transport. Airway
evaluated, and if not already present, a Foley catheter is patency is checked. If any question remains concerning the
placed. ability of the patient to maintain a patent airway, a transport
Patients are usually poorly perfused, acidotic, and team will intubate the patient. Once the airway is stabilized,
hypotensive after a cardiac arrest. The most common reason adequate ventilation and oxygenation are ensured. Circula-
for poor perfusion in this case is cardiogenic shock, the tion is then assessed and stabilized. Obtaining intravenous
result of arrest-related myocardial ischemia. Patients may access is critical. In most instances, at least two patent
benefit from a 10- to 20-ml/kg fluid bolus administered over intravenous lines are preferred during transport. Necessary
several minutes. If ventricular or pulmonary compliance is measures are taken to prevent thermal instability. While
poor, a fluid bolus is administered with caution. Continuous patient stabilization is underway, the patient's medical
infusions of inotropic agents (e.g., epinephrine, dopamine, record, laboratory reports, radiographs, and CT scans are
and dobutamine) can be used to augment contractility and copied. Fig. 31-12 provides the standard approach for each
enhance tissue perfusion. Drug therapy is based on clinical patient requiring transport.
presentation. Management of shock is discussed in depth in Team Composition. Transport programs have vari-
Chapter 27. ous team compositions, which include physicians, nurses,
respiratory therapists, paramedics, and EMTs. All pediatric
teams have members who are experts in the management of
INTERFACILITY TRANSPORT critically ill infants and children. A wide variety of team
Following resuscitation, some patients may require trans- compositions exist, and to date, no single composition is
port to a pediatric facility that can best meet their evolving preferred over the other.
needs. Interfacility transport offers a system to ensure that Patient safety and available medical care during trans-
all patients receive an appropriate level of care. According port are factors to consider in composing the team for a
to the American Academy of Pediatrics (AAP),29 the goal of particular transport. There are multiple team compositions
pediatric interfacility transport is to improve outcomes in to choose from, depending on a hospital's location to the
critically ill or injured neonates, infants, and children who tertiary center. Local basic life support (BLS) and advanced
are not in proximity to a hospital that provides the required life support (ALS) systems offer rapid response times, but
level of care. they are adult oriented and have a limited ability for
advanced pediatric resuscitation techniques. Adult-based
critical care transport services offer both flight and ground
History resources but often have limited expertise in the care of
With the development of critical transport services through- the neonatal and pediatric patient. Specialized pediatric and
out the country, the AAP developed guidelines for air and neonatal transport systems offer experienced nurses, re-
ground transportation of pediatric patients. These guide- spiratory therapists, physicians, and emergency medical
1044 Part V Multisystem Problems

Children's Hospital Transport Program Patient Care Protocols

Standard Approach to the Patient
1. Follow universal precautions. If a contagious disease is suspected or there is potential for exposure to blood or body fluids, take
appropriate measures to protect the transport team members and the patient.
2. Perform a primary survey to identify, and initiate treatment for, life-threatening problems with airway, breathing and circulation.
3. Obtain additional history from health care providers, the patient, and the family.
4. Perform a physical assessment, including vital signs.
5. Initiate patient monitoring, to include:
a. ECG and respiratory rate
b. Pulse oximetry (Sp02)
c. Non-invasive blood pressure (NIBP)
d. Additional monitoring as indicated based on the patient's condition
6. Monitor and maintain the patient's body temperature.
7. Perform appropriate diagnostic tests.
8:Provide treatment to stabilize prior to transport based on the applicable Children's Hospital Transport Program Patient Care Protocol(s)
and/or orders from the medical control physician.
a. Unless otherwise specified, follow the Children's Hospital Intensive Care Unit Nursing Policies and Procedures for nursing care and
medication administration
9. Obtain informed consent from parentIs) or guardian(s) for treatment and transport. If no parent or guardian is available, refer to the
administrative policy.
10. Obtain copies of the medical records and x-rays. For neonatal patients, also obtain copies of the mother's records.
11. Provide psychosocial support for the patient and the family.
12. Contact the medical control physician to discuss patient management and/or disposition.
13. Contact the receiving nursing unit and provide a focused report on the patient's condition.
14. Initiate transport as soon as the patient's condition permits.
15. Apply passenger safety restraints to the patient to the extent that the patient's condition permits.
16. Continuously monitor the patient's condition and provide appropriate treatment during transport. Notify the medical control physician
of any significant changes in the patient's condition.
17. Document pertinent data and events using the transport flow sheet; document adverse events on a Children's Hospital incident report.

Fig.31-12 Sample patient care protocol. (Courtesy Children's Hospital Transport Program, Boston, 1999.)

personnel skilled in the care of critically ill infants and specific aspects of transport management, such as air flight
children. physiology, interpreting radiographs, and providing care in
The patient's severity of illness and the risk for deteriora- a mobile environment. Procedure skill stations for the
tion determine the team composition and their level of ex- development of advanced skills such as bag-mask ventila-
pertise. A child who is currently stable but has a potential to tion; tracheal intubation; intravenous, intraosseous, and
deteriorate during the transport necessitates a team that is central venous line placement; shocks; cardioversion; and
not only capable of caring for this child in a mobile environ- arterial puncture are implemented in many programs.
ment but has the expertise necessary to restabilize the Simulated cases consisting of computer-controlled manne-
patient. quins that imitate crisis situations are often part of the
Regardless of the composition, the transport nurse is education process. Team building and communication
often considered the team leader. The transport nurse's skills are also important components of the education
role is to coordinate the stabilization of the child before program.
transport, provide continuous evaluation and monitoring of Didactic sessions, simulation, and procedure skill sta-
the patient's physiologic status, and provide patient man- tions introduce team members to transport protocols.
agement under guidelines throughout the transport. The Protocols provide the standard of care for the transport team
nurse is responsible for patient and team safety at all times. when working outside of the hospital setting. An example of
The transport nurse maintains awareness of the potential a protocol for management of respiratory distress and failure
risks involved and is able to react accordingly in a mobile can be found in Fig. 31-13. If team members need to deviate
environment. Pediatric or neonatal transport nurses maintain from the established protocols the medical control physician
certifications in pediatric advanced life support (PALS), (Mep) is called for advice.
Neonatal Resuscitative Program (NRP), critical care certi- Team Safety. A major consideration for a transport
fication (CCRN), BLS, and the trauma nurse certification team is the safety of the team members and patient. Team
course (TNCC) or advanced trauma life support (ATLS). orientation to ground and air safety, protective clothing,
Education of Team Members. Education and train- physical fitness, emergency planning, wilderness survival,
ing for transport team members are intense. Didactic and stress management, and debriefing sessions are aspects
interactive skill sessions are part of many training programs. that are imperative to safe team performance. 29 Without
Not only are team members expected to manage multiple safety training, the team can be unaware and unprepared
medical and surgical emergencies, but they are also trained for the potential risks that can occur during transport. For
to perform advanced technical procedures. Didactic sessions example, team members must know how to use the
build on the clinician's knowledge base and introduce emergency exits in the planes and rotor-wing aircraft, avoid
 Chapter 31 Resuscitation and Transport of Infants and Children 1045

Children's Hospital Transport Program

Patient Care Protocols
Pediatric Respiratory
Distress and Failure

Definition: Respiratory distress describes a patient's efforts to increase minute ventilation in order to compensate tor impaired gas
exchange secondary to pUlmonary or other systemic disease. Respiratory failure occurs when compensatory mechanisms fail,
and oxygenation and ventilation become inadequate. Respiratory failure may occur without the presence of respiratory distress.
Clinical presentation:
1. History: Dyspnea, rapid andlor labored breathing, difficUlty speaking or swallowing, diaphoresis, fever, cough, drooling.
2. Physical exam: Tachypnea, grunting, nasal flaring, retractions, tachycardia, anxiety, pallor (respiratory distress); head bobbing,
paradoxical movement of the abdomen and chest, decreased responsiveness, decreased respiratory effort and rate, gasping
respirations, cyanosis (respiratory failure). The exam should include assessment for stridor, wheezing, asymmetry of breath sounds,
rales, and rhonchi.
3. Laboratory data: Arterial blood gas, chest x-ray films, plus lateral and anteroposterior neck films.
Differential diagnosis:
1. Upper airway obstruction: croup, epiglottitis, foreign body obstruction, bacterial tracheitis, smoke inhalation
2. Lower airway obstruction: status asthmaticus, foreign body aspiration, bronchiolitis, bronchiectasis
3. Parenchymal or interstiliallung disease: pneumonia, pulmonary edema, pulmonary hemorrhage, pulmonary contusion
Evaluation and Treatment:
1. Assess the airway, and provide management as indicated according to the Airway Management protocol.
2. Assess breathing, including respiratory rate, effort, air entry, and breath sounds. Provide intervention as follows:
a. Provide supplemental oxygen to any patient with respiratory distress, according to the Oxygen Therapy protocol.
b. Assist ventilations using a bag and mask with F102 = 1.0 for patients with respiratory failure or impending respiratory failure as
evidenced by decreasing level of consciousness, decreasing respiratory rate and/or effort, head bobbing, paradoxical abdominal
movement, deep retractions, and/or cyanosis.
c. Utilize a pressure manometer when delivering positive-pressure ventilations unless using a device with a pop-off valve.
d. Perform endotracheal intubation when indicated according to the Aitway Management protocol.
e. Perform cricothyrotomy when indicated according to the Cricothyrotomy protocol.
3. For patients with signs of upper airway obstruction and suspected airway edema:
a, Administer racemic epinephrine 2,25% solution 0.5 ml in 3 ml 0.9% NaCI by nebulizer.
b. If croup is suspected, administer dexamethasone (Decadron) 0.5 mglkg IV. Dexamethasone may be administered 1M if vascular
access is not available.
c, If epiglottitis is suspected, contact the medical control physician.
4. If anaphylaxis is suspected, administer:
a. Epinephrine 0.01 mglkg (0.01 ml/kg) of 1:1,000 solution SC (maximum dose 0.3 mg [0.3 mil)
b. Diphenhydramine (Benadryl) 1 mglkg IV
c, Methylprednisolone (Solumedrol) 2 mglkg IV
5. For patients with signs of bronchospasm, administer bronchodilator therapy as follows:
a. For acute, severe distress, administer epinephrine 0.01 mglkg (0.01 mllkg) of 1:1,000 solution SC (maximum dose 0.3 mg [0.3 mil).
b, Administer albuterol 2.5-5 mg in 3 ml 0.9% NaCI by nebulizer or two to four "puffs" by MOl, and repeat as needed.
c. Administer ipratroprium bromide (Atrovent) by nebulizer or MOl, up to three doses.
d. If reactive airway disease is suspected, administer methylprednisolone (Solumedrol) 2 mg/kg IV. Do not administer if the patient
has already received steroids at the referring hospital within the past 6 hours, unless a lower dose was administered or the patient
experienced vomiting after administration of oral prednisone.
e, If the patient remains significantly bronchospastic, consult with the medical control physician regarding administration of continuous
albuterol by nebulizer or terbutaline by continuous intravenous infusion.
6. For patients who have chronic respiratory insufficiency and are maintained on noninvasive ventilation, continue CPAP or BiPAP as per
the patient's usual settings, and consult with the medical control physician regarding adjustment of ventilatory support for transport.
7. For patients who are chronically dependent on mechanical ventilation:
a, Consult with the medical control physician regarding use of the patient's portable ventilator for transport and adjustment of settings.
b, If the patient deteriorates, remove the patient from mechanical ventilation and provide manual ventilations using a resuscitation bag.
c. Consider obtaining a blood gas (venous or arterial) prior to transport, if clinical assessment of oxygenation andlor ventilation cannot
be reliably performed.
d. Monitor the patient with continuous pulse oximetry and capnography during transport.
8. For patients who require initiation of ventilatory support via endotracheal tube or tracheostomy on transport:
a. Provide ventilatory support using F102 of 1.0 except as outlined in the Oxygen Therapy protocol, using the following:
1. A resuscitation bag using an inflating pressure to produce adequate chest rise, a PEEP of 3 to 5 cm H20, and a rate that provides
adequate ventilation; OR
2. A transport ventilator using an inflating pressure to produce adequate chest rise, a PEEP of 3 to 5 cm H20, and a rate that provides
adequate ventilation.
3. Consult with the medical control physician if higher levels of PEEP are required.
b. If the patient deteriorates, remove the patient from mechanical ventilation and provide manual ventilations using a resuscitation bag.
c. Consider obtaining a blood gas (venous or arterial) prior to transport, if clinical assessment of oxygenation and/or ventilation cannot
be reliably performed.
d, Monitor the patient with continuous pulse oximetry and capnography during transport.

Fig.31-13 Respiratory distress and failure protocol. (Courtesy Children's Hospital Transport Program,
Boston, 1999.)
1046 Part V Multisystem Problems

a spinning tail rotor, and troubleshoot equipment failures dispatcher or communication specialist who then transfers
in any mode of transport. Many teams do not share patient the call to the MCP (Fig. 31-15).
information with the pilots until acceptance or denial of At the same time the transport team is notified, mobili-
the transport has been determined. Pilots do not need zation begins. Once the MCP has discussed the patient's
patient status information to cloud judgment when making current condition with the referring institution and given any
decisions about the ability to fly safely based on weather medical advice necessary for stabilization, the MCP then
conditions. contacts the transport team to update them on the child's
Mode of Transport. Response time, weather, and status.
team capabilities are factors that are carefully considered Cell phones and long-range alpha pagers are used to
when choosing the mode of transport. Modes available for maintain communication between the transport team and the
transport include ground ambulances, rotor-wing air- MCP when out in the field. Dispatchers can also link the
craft (helicopters), and fixed-wing aircraft (propeller planes team to the MCP by land radio access. The communication
and jets). In some cases, weather may necessitate that a method must be continuous and reliable. A backup com-
ground ambulance be used even if the distance is significant. munication system should be available in case the pri-
Time of day and traffic conditions may necessitate a rotor- mary system malfunctions. Continuous verbal contact be-
wing transport to save time because of traffic delays on the tween the transport team and MCP is essential in case
ground. medical direction is necessary when the team is out on a
Time is another factor that influences the mode of transport.
transport chosen for a parricular patient. A 2-hour ground Communication between the team and referring institu-
transport of a child who is thought to have a rapidly tion is also essential. Many transport teams contact the
expanding intracranial bleed is not appropriate, and the referring institution en route to obtain reports from the
referring hospital team chooses the most rapid means of nurses or physicians who are caring for the child, which
transporting the child safely to the tertiary facility. Another accomplishes two goals. First, the team has an up to-date
factor to keep in mind is the number of transfers required if picture of the patient so that they can adequately prepare
the patient is air transported. The more often a patient is the equipment and medication needed en-route, and, sec-
transferred to and from different vehicles (i.e., emergency ond, critical scene time is decreased when the report has
deparrment to ambulance, ambulance to helicopter, helicop- been given before arrival. When the team arrives, only a
ter to ambulance, ambulance to receiving unit), the higher brief update is necessary, and patient care can begin
the likelihood of adverse effects, accidental extubation, and immediately.
displacement of intravenous lines. Altitude may also in- The transport team is also responsible for communicating
crease the risk of adverse affects. However, the time that patient status and estimated time of arrival to the unit at the
is saved by flying may compensate for the potential accepting facility. This can be done through the dispatcher
risks. or other communication system. Before leaving the referring
Equipment. Each transport program requires special- institution, the team communicates with the MCP about
ized equipment to safely transport the pediatric or neonatal patient status and the plan for transport.
patient. Essential for every team is pediatric-sized airway On arrival to the accepting unit, the team is responsible
and intravascular access supplies (Fig. 31-14). Monitoring for ensuring that the accepting physicians and nurses receive
equipment requires pediatric or neonatal modes. Pediatric- a comprehensive report on the child's condition and care to
or neonatal-size ECG leads, oxygen saturation probes, and date. Once the patient's care has been transferred to the
immobilization equipment such as c-spine collars and back accepting medical team, a follow-up call is made to the
boards are essential for safe and efficient patient transport. referring physician stating the patient's condition on arrival.
Pocket-sized pediatric or neonatal drug cards are helpful for This is the final piece of communication from the team to
quick reference. Transport equipment also includes special- the referring institution.
ized comfort measures for this unique population, including Communication between the transport team and the
pacifiers, stuffed animals, and security objects. Many patient's family is extremely important. The team must fully
pediatric or neonatal transport teams have configured inform the parent or guardian about the risks and benefits of
ambulances to include TVs and VCRs and CD players to transporting their child, the differential diagnosis, and what
create a relaxing and nontraumatic transpOlt environment is to be expected from the transport team. The parent or legal
for the child. guardian must sign or verbally give consent for medical
Communication. Team communication begins with treatment and transport. Transport of a child is traumatic to
the call from the referring hospital, clinic, doctor's office, or many parents, and open communication from the team can
local 911 emergency system. Any referring physician should help parents deal with the process.
have rapid and direct access to a transport team. For many The decision to have a parent ride with the team to the
programs, this point of contact is usually accomplished by a receiving facility is governed by state laws and team
toll-free number, which is answered in the transport policies. If the parent rides with the team, two goals can be
program's dispatch center. Initial information, such as accomplished. The child may be less anxious with the parent
patient name, age, weight, referring physician, referring in the ambulance, and the parent's anxiety level may be
facility, phone number, and diagnosis, is gathered by the decreased. The parent will also be available immediately at
 Chapter 31 Resuscitation and Transport of Infants and Children 1047

BLACK SUPPLEMENTAL PACK-CHILDREN'S HOSPITAL

TRANSPORT TEAM

VENOUS ACCESS: THORACOTOMY/ RESPIRATORY: IV

1 5.5F Arrow CVL kit THORACENTESIS: 1 self inflating SUPPLIES:
1 guide wire 2 each 1OF, 12F chesttubes resuscitation bag with 1 each:
2 intraosseous needles 1 sterile Kelly clamp PEEP vaive 500cc NS
2 each 3.5, 5.0 umbilical 2 thoracentesis kits: 1 each neonatal, 500cc 05 ' /.
catheters 23G butterfly pediatric ventilator 500cc 010W
1 each 3.5, 5.0 dbllumen 19G butterfly circuit 250cc5%
umbilical catheters 3-way stopcock 1 meconium aspirator albumin
1 transport instruments tray 60cc syringe 1 "premie" kit
2 3.0 silk sutures Xeroform gauze 1 Survanta kit blood tubing
2 #11 blades 1 Y-connector pressure bag
2 5-in-1 connectors
2 Hemlich values
1 roll 3" foam tape

RED MEDICATION PACK-CHILDREN'S HOSPITAL

TRANSPORT TEAM

I 1 pediatric emergency medication reference guide 1 calculator I

2 methylprednisolone 62.5 mg/ml-2 ml c:
"<:5 _ .,
1 dexamethasone 10 mg/ml-10 ml
,.,'"
E'>
E
·x- "'I-
0
8°
c: E
s·~ uJ:~CT_
1 phytonadione 2 mg/ml-1 mt
"'0 ~E '" ., E
ZE
1 erythromycin opthalmic 3.5 gm >0 <.)01 o
"'''' ~~
~~ '"
1 ondansetron 2 mg/ml-2 ml
2 xylocaine 20/0-2 ml amps
1
"'E
'"
Iii
'> 0a-
u.,
1 heparin 1000 ll!ml-10 ml
WE 7iiE_
1 naloxone 1 mg/ml-2 ml Zo z",E
~c::ill)
2 phenytoin 50 mg/ml-5 ml "'~

I ., .,-E
.,1 ."c:
E
.S 0,
)( <.)
o E
·Q>o -E
.- -
c: E
0.01
eE_
~l
gE
-l!l 0,_
.<:::~

g-J
.!: 0
0.0
"0 lii~E '" E E
.,~
0
"'~~ ~o ... "'M'" C\I~

8 phenobarbitol 1 diphenhydramine 2 lidocaine 20 mg/ml-5 ml

130 mg/ml 50 mg/ml-1 ml

1 epinephrine 1:100D-30 ml

.,
""I
E-
., E
"'-
o 01_
:; E E
-00
~~~

12 lcc syringes 4 30cc syringes 12 18G needles IV drip labels

12 3cc syringes 4 60cc syringes 4 25G needles 1 glucagon kit

12 lOcc syringes 4 27G needles

12 interlink needles

Fig. 31·14 Transport equipment pack list. (Courtesy Children's Hospital Transport Program,
Boston. 1999.) Collt;lllled
1048 Part V Multisystem Problems

ORANGE TRANSPORT PACK-CHILDREN'S HOSPITAL

TRANSPORT TEAM

rubber bands, tourniquet

black pen
oral airways (1 each): 5, 6, 7, 8, 9
nasal trumpets (1 each): 14, 16, 18,20,22,24,26

1 500cc anesthesia Anesthesia face masks Nebulizer Kit:

bag (1 each): 1 20cc btl ventolin 5 mglcc
1 1L anesthesia bag neonate 1 15cc btl racemic epinephrine
2 02 supply tubings infant 3 single dose Atrovent 0.5 mgl2.5cc
1 manometer with toddler 5 amps terbutaline 1 mglcc
tUbing and adaptor pediatric 4 saline "bullets"
small adult 1 neb setup with mask and ett
large adult adaptor

Syringes (5 each): IV Catheters Interlink: Butterflies:

1cc (4 each): 5 hep lock caps (2 each):
3cc 14G 5 blue connectors 19G
lOcc 16G 3 slip-adaptor 21G
18G T-connectors 23G
2 armboards 20G 24G
6 18G needles 22G Thermometer
6 interlink needles 24G

Tegaderm (5) 10cc vials Blood culture bottle 23-way

4X4 gauze NS (5) lancets stopcocks
alcohol pads 1 each:
betadine pads 1 roll each: large red, green,
1" adhesive tape blue, purple lab
(6 each) 1" silk tape tubes, green/purple
Co-flex microtainers

1 set ECG leads 1 each pedi, adult Easy cap

1 each neo, pedi, adult sat probe EtC02 supplies (1 each):
1 each Critikon BP cuffs: #1, #2, #3, #4, #5 ett adapter, supply tubing,
1 each HP BP cuffs:#1, #2, #3 pedi, adult cannulas

Intubation roll:

1 roll 1· adhesive tape

2 bezoin applicators
1 lOcc syringe
1 each neo, pedi McGill forceps
2 laryngoscope handles
laryngoscope blades (1 each):
Miller 0, 1, 2, 3
W-H 1.5
Macintosh 1, 2, 3, 4
1 each pedi, adult stylets
extra laryngoscope bulbs (small and large)
2 AA batteries
2 C batteries
swivel adapter

Endotracheal tubes (uncuffed up to size 5, cuffed ;"5.5):

2 each: 2.0, 2.5, 3.0, 3.5, 4.0, 4.5, 5.0, 5.5, 6.0, 6.5
1 each: 7.0, 7.5, 8.0

Fig. 31-14, (ont'd For legend see p. 1047.

 Chapter 31 Resuscitation and Transport of Infants and Children 1049

CHILDREN'S HOSPITAL PEDIATRIC/NEONATAL USE PLATE OR PRINT

TELEPHONE CONSULTATIONITRANSFER RECORD PT NAME:
MR#:
DATE: _ / _ / _ TIME(MILITARY): _ _
PERSON PROCESSING CALL: _

PT NAME:----==-=- _ LABS: Diff%:

-++< >-<
p B-
SEX: Do" D9 DOB: _ / _ / _ -
AGE: IF NEONATE, GEST. AGE:_ _ L- M-
PRELIM DIAGNOSIS: _

REFERRING MD: OTHER:

REFERRING HOS"""'P,..,.IT=-A-,--,L-:-------- BLOOD GAS #1 : ADVDCD
DED DPEDS DDR DSCN DOTHER _
CITY, STATE: _ BLOOD GAS #2: ADVDCD
CALL BACK #: _
PCP: PHONE: XRAY RESULTS:
ALLERGIES: ----
EXPOSURES: _

HISTORY/COURSE/INTERVENTIONS: RECOMMENDATIONS:

SIGNATURE: _

D CONSULT, REFERRED TO: _

NOTIFIED: DTEAM DAMBULANCE DCOPP
WGT: __kg T__ HR__ RR__ BP__ DATTENDING DRECEIVING CHARGE RN/MD
02 DELIVERY: 02 SAT:
DETTITRACH SIZE: CUFFED YES/NO TEAM COMPOSITION: DRN/RN DRN/RN/HO D
ACCESS:D PIV X_ SIZE:_ DIO DUAC RN/RN/BACK-UP MD DBMF DCH RN/BMF
DUVc 1 2 LUMEN DCVL 1 23 LUMEN DALINE DREF HOSP TEAM DOTHER _
IVF: TYPE: RATE:
ACCEPTING SERVICE/FIRM: _
TYPE: RATE:
TYPE: RATE: ATTENDING: _
UNIT: D7N DP5 DP6 DEDDOTHER: _
NEURO STATUS:
IF NO TRANSPORT, REASON: _

IF NO CH BED, ALTERNATIVE ARRANGEMENT:

Fig.31-15 Transport intake fonn. (Courtesy Children's Hospital Transport Program, Boston, 1999.)
1050 Part V Multisystem Problems

the receiving hospital to give the child's medical history and evaluation at the referring facility, during transport, and
to sign any consents for treatment. If the parent or parents on arrival at the receiving facility. Treatment efforts
are driving to the receiving facility, the team should supply and the patient's ongoing clinical status are docu-
directions to the facility and advise them not to follow the mented throughout the entire transport process, beginning
ambulance. at the referral facility and continuing to the accepting
According to the Joint Commission on Accredita- facility.
tion of Healthcare Organizations (JCAHO).33 The trans- The line of responsibility to the patient is blurred when a
port medical record serves as a basis for evaluat- transport team is called. 34 There is no clear point in the
ing the patient's condition and treatment. The trans- transport process that separates the responsibilities of care
port medical record should contain the patient's medical among the referring facility, the transport team, and the

Children's Hospital Transport Team Call:

In Patient Tracking Form DCH:
For QUALITY ASSURANCE ARH:
DRH:
ACH:

Database:O

Charges: 0

Date of Transport: _

Time of Transport: _

Referring Physician: _ Transport Team Members:

RN/RN: _
Nurse: _ Resident: -:-:-:- _
MD to "make" team: _
Referral Center: _ Ref Hasp. Req. MD: :-; _
MD per Medical Control: _
Address: _
In-Patient Unit admitted to: _
Phone Number: _ Transferred to:
Date of Transfe-r-:--------~
Preliminary Diagnosis: _

Age/Gestational Age: _ APGARS: -'-3 -'-5

Brief History: _

Significant EventS/Procedure done on transport (by whom/# of attempts): _

En Placement by CXR: Taped at: CXR on arrival: _

Transport Opportunities for Improvement Follow-up _

Initial ABG on Admission to CH

Final Diagnoses and Disposition

Quality Assurance Surveillance Indicators

o Hyperventilation-PaC0 2 <30 OFailure to bring equipment
Olnitial ABG hypoventilation pH <7.25 ORan out of 02 or Air
o Accidental extubation en-route ORight main intub. on arrival CXR
o Loss of IV access OBroken equipment _
o Hypothermia/rectal temp <35SC oDeparture from CH >30 minutes
o Departure from receiving hospital >1 hour OTransfer to ICU within 24 hours

Fig. 31-16 Transport team quality assurance form. (Courtesy Children's Hospital Transport Program,
Boston, 1999.)
 Chapter 31 Resuscitation and Transport of Infants and Children 1051

accepting facility. The amount of responsibility tends to displacement. In addition to being secured, intravenous sites
gradually shift throughout the transport process. The accept- are visible and easily accessible during transport to monitor
ing facility begins to take some responsibility when they for infiltration and to access quickly in emergency situa-
agree to accept the child and give treatment recommenda- tions. Keys to remember in emergency situations (arrest,
tions. The transport team and receiving facility become extubation) are to have emergency equipment easily acces-
more responsible as the team becomes more involved in the sible. Having at least one round of code medications in an
patient care. Once the patient arrives at the receiving facility, easily accessible place like a chest or arm uniform pocket
the responsibility of the referring facility continues to will enhance immediate administration if the child requires
diminish. Transport agreements between referring facilities pharmacologic intervention. Protocols and reference mate-
and transport teams can help clarify some of the haziness of rials must be easily accessible during transport. In addition,
liability. All recommendations, arrangements, and interven- all transport equipment must have a 4-hour battery life in
tions are documented in the medical record throughout the case of power failure.
transport process.
Evaluation. A continuous performance improvement
(PI) program is an important component of any transport
RESUSCITAnON PERFORMANCE
program. A PI program ensures delivery of quality patient
IMPROVEMENT
care and safe team performance. The PI process can identify Nurses with specialty education in pediatric emergency
potential system problems, resolve identified problems and critical care are a valuable asset to pediatric resus-
related to patient care and program operations, and provide citation teams. Their positive impact can be further
ongoing evaluation of strategies implemented to resolve the enhanced through coordinated training programs within
problem (Fig. 31-16). institutions that focus on the code team approach to pe-
Keys to a successful transport, regardless of mode or diatric resuscitation. Monthly interdisciplinary mock codes
team composition, include careful and continuous monitor- in which objective criteria are used to evaluate knowledge
ing of patient status. EITs are well secured before transport acquisition and skill performance are excellent ways to
to decrease the risk of accidental extubation. Continuous assess the program. As part of a system-wide quality
ETco 2 measurements during transport provide ongoing improvement plan, pediatric mock codes help to perfect
information about the child's airway status. Intravenous skills while also helping to consolidate individual and
lines require protection so that turbulence, rough driving team roles. In addition, system deficiencies, such as
conditions, or patient transfers do not cause inadvertent availability of personnel, paging difficulties, impossible

OAlOI VARIABLES: EVENT VARIABLES:

Level of response requested Witnessed Initial Condition
DCode Blue DYes Conscious? DYes DNo
D"STAT" (Specify: _ DNo Breathing? DYes DNo
Were there issues with: Pulse? DYes DNo
D Locating the site of the emergency
Describe: _ Types of monitoring at time of event
D ECG Initial Rhythm
Dldentifying medical leadership
Comments: _ DSp02 DVF
DObtaining emergency equipment D Arterial Pressure DVT
Comments: _ DCVp DPEA
DEquipment function Immediate Cause D Bradycardia
Comments: _ D Dysrhythmia DSVT
DTransfer of patient after resuscitation D Shocklhypolension DAsystole
Comments: _
D Respiratory failure/arrest DNSR
D Family members D Neurologic event DST
Comments: _
D Other DOther _
Comments on any factors which could be improved:

To be completed by nurse recorder

For 01 Purposes only - not to be placed in the medical record

Fig. 31-17 Code blue quality improvement tool. (Courtesy Children's Hospital, CPR Committee.
Boston. 1999.)
1052 Part V Multisystem Problems

drug dilutions, and malfunctioning equipment, can be

SUMMARY
identified in a benign setting. Mock codes also ensure that Three major characteristics distinguish cardiopulmonary
resuscitation team members are familiar with crash cart arrest in infants and children. These are the diverse causes of
contents. Appendix IV (Emergency Cart Contents) contains the arrest, the fact that most cardiopulmonary arrests can be
a list of PICU crash cart contents. It is important that crash prevented in infants and children, and certainty that primary
cart contents reflect the patient population of the unit cardiac arrest is unusual. Research demonstrates significant
because items that may be appropriate for a pediatric differences in overall survival and neurologic outcome in
cardiovascular surgical unit may be inappropriate for a children depending on the type of arrest; survival is belter in
multidisciplinary PICU. However, standardizing in-patient those who experience only respiratory arrest. Therefore
pediatric unit crash carts is essential so that code team early recognition and intervention to prevent a pulseless
members can work rapidly from any crash cart in any state are critical. Survival rates have been shown to be
location. Specialty items, such as cast cutters on an higher when the interval between cardiac arrest and
orthopedic unit, can be accommodated in boxes attached intervention is shorter. Despite these factors, which would
to the· generic crash cart. provide the infant and child an apparent advantage, survival
Every resuscitation attempt requires evaluation as a among pediatric patients experiencing cardiopulmonary
potential opportunity for system-wide improvement. Sur- arrest is poor.
vival rates and patient outcomes should be an integral part Critical care nurses, working collaboratively with other
of the resuscitation team's PI program. Strategies that healthcare professionals, are in a unique position to appre-
proved successful can be highlighted through retrospective ciate the anatomic, physiologic, and maturational factors
review. Fig. 31-17 illustrates an example of a perfonnance that affect the pediatric patient's response to resuscitation
improvement assessment tool used by a CPR committee to efforts. The essence of caring for the critically ill pediatric
evaluate resuscitation events. A child's potential death patient includes the ability to rapidly identify signs of
represents one of the most stressful experiences any staff compensation, intervene, and prevent cardiopulmonary
member can encounter. Team conferences after successful arrest. Nurses are in a key position to make a critical
and unsuccessful resuscitation attempts provide the entire difference in improving the currently dismal pediatric
healthcare team with an opportunity for mutual support. outcomes.

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