Paediatric and Neonatal Critical Care Transport

Paediatric and Neonatal Critical Care Transport Edited by Peter Barry and Andrew Leslie Paediatric and Neonatal Critical Care Transport Paediatric and Neonatal Critical Care Transport Edited by Peter Barry Consultant Paediatric Intensivist, Children’s Intensive Care Service, University Hospitals of Leicester and Honorary Senior Lecturer, University of Leicester Andrew Leslie Neonatal Transport Coordinator/Advanced Neonatal Nurse Practitioner, Nottingham Neonatal Service, City & University Hospitals, Nottingham © BMJ Publishing Group 2003 BMJ Books is an imprint of the BMJ Publishing Group All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, without the prior written permission of the publishers. First published in 2003 by BMJ Books, BMA House, Tavistock Square, London WC1H 9JR British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 0 7279 1770 6 Typeset by SIVA Math Setters, Chennai, India Printed and bound in Spain by Graphycems, Navarra Contents Contributors vii Acknowledgements ix Foreword xi Part 1: Planning for safe and effective transport 1 1. Principles of safe transport 3 2. Transport physiology 14 3. The ambulance environment 19 4. Equipment and monitoring 25 5. Air transport of critically ill children 36 Part 2: Practical transport management 41 6. Neonatal resuscitation and stabilisation 43 7. Paediatric resuscitation and stabilisation 53 8. Management of the airway and breathing 69 9. Management of the circulation 79 10. Trauma 90 11. Special transport interventions 102 12. What to do when it all goes wrong 108 13. Drugs 112 Appendix 1: Typical retrieval forms 123 Appendix 2: Essential equations and aide-mémoires 134 Selected references and bibliography 135 Index 139 Contributors Peter Barry Consultant Paediatric Intensivist, Children’s Intensive Care Service, University Hospitals of Leicester and Honorary Senior Lecturer, University of Leicester Sandie Bohin Consultant Neonatologist, University Hospitals of Leicester David Field Professor of Neonatal Medicine, University of Leicester, Honorary Consultant Neonatologist, University Hospitals of Leicester Julie Hall Neonatal Transport Coordinator, University Hospitals of Leicester Taj Hassan Consultant in Emergency Medicine, The General Infirmary at Leeds, Leeds Teaching Hospitals Trust Carmel Hunt Paediatric Retrieval Coordinator, Children’s Intensive Care Service, University Hospitals of Leicester Andrew Leslie Neonatal Transport Coordinator/Advanced Neonatal Nurse Practitioner, Nottingham Neonatal Service, City and University Hospitals, Nottingham David Luyt Consultant Paediatric Intensivist, Paediatric Intensive Care Service, University Hospitals of Leicester Andrew MacIntyre Consultant Paediatric Intensivist, Royal Hospital for Sick Children, Glasgow Sanjiv Nichani Consultant Paediatric Intensivist, Paediatric Intensive Care Service, University Hospitals of Leicester Giles Peek Honorary Lecturer in Cardiothoracic Surgery and ECMO, University of Leicester Moira Robinson Senior Medical Technician, Paediatric Intensive Care Service, University Hospitals of Leicester David Rowney Consultant in Paediatric Anaesthesia and Intensive Care, Royal Hospital for Sick Children, Edinburgh David Vickery Consultant in Emergency Medicine, Gloucestershire Royal Hospital Acknowledgements Many people offered helpful opinions, advice and Tracy Earley, Jenny Burgess, Mary Merriman, criticism as we wrote this manual. We would like Lynda Raphael, Charlotte Huddy, Ian Buck Barrett, to acknowledge the important contributions made Martin Earley, Amanda Bowman, Colin Read, by all the people, past and present, who have Manjeet Riyat and Ashish Chickermane. taught on the Paediatric and Infant Critical Care The manual was expertly guided to fruition by Transport course in Leicester. The course grew Mary Banks, Christina Karaviotis and the team at with the experience and contributions of those BMJ Books. SIVA Math Setters took our crude people, and this book grew from the course. sketches and turned them into the attractive Paediatric and Neonatal Critical Care Transport illustrations seen in this manual. is now the coursebook for NEOSTAR, a course run Every effort has been made to ensure the accuracy by the Advanced Life Support Group. of the data, particularly drug doses, in this manual, Our thanks go to Jackie Howarth, who currently but it remains the reader’s responsibility to ensure administers the transport course, and to Caroline that these are appropriate for their patients. Clay, for her secretarial help. Finally, our personal thanks to Jo and Jane. Our thanks also to the transport teams in Leicester and Nottingham and to Merran Peter Barry Thomson, David Thomas, Rose Kent, Kate Wilson, Andy Leslie Foreword Around the world, intensive care for all age (90 kilograms) could be safely carried in a groups has developed at different rates. Within standard ambulance. Some systems in use each country, local priorities have governed the exceeded 700 pounds (320 kilograms). way in which services have evolved. In the UK, • Many additional items of equipment were the equity of health care provision afforded by loaded into the ambulance without any the National Health Service meant that intensive reasonable means of restraint. care technology has spread fairly rapidly and • The validity of indemnity arrangements for equitably across the whole country. Given the staff injured in any accident and using small distances between centres of population, such equipment seemed unclear, given that the transport was not a major consideration and situation was known to be unsafe. local enthusiasts have dealt with the issue by • Existing Health and Safety legislation regarding employing a variety of solutions. As a result in the manual handling was regularly breached by country as a whole there are currently hundreds neonatal transport systems. of different transport systems in place. • There were no adequate systems for securing In other countries local circumstances led to a the baby in the incubator during the journey. rather different evolution of the service. For • Arrangements for staff training were patchy. example, in Australia the vast distances between • Use of air transport was associated with many intensive care centres meant that excellent additional hazards which appeared to have transport facilities were a necessity and as a been fully addressed by only one transport consequence expert teams with dedicated equip- service in the UK. ment rapidly emerged. In parts of the USA distance was also an issue. There more flexible Although focused on the newborn, most of the funding arrangements made it attractive for problems highlighted by the TINA report were health care providers to set up first class services shared by all forms of intensive care transport. dedicated to transport. During the last few years a number of new Staffing factors have emerged in the UK which have made existing arrangements largely untenable. The last few years have seen many changes in the working patterns of junior doctors; the high Risk pressure specialities of neonatal and paediatric intensive care have been subject to particularly This was highlighted by a road traffic accident close regulation. These changes have compounded which occurred in Northern Region in 1993 difficulties regarding the staffing of intensive involving an ambulance returning to Newcastle care retrievals. Only a minority of units have with a baby requiring intensive care. In response sufficient specialist medical and nursing cover to to this event, the Medical Devices Agency carried reliably fill this role and supervise the rest of out a review of neonatal and paediatric transfers the service. On the other hand, increased numbers in the UK (the TINA inquiry). The report of junior doctors working shorter hours means highlighted various problems. Some of the more that providing adequate training is even more important were: complicated. • The standard devices used to secure transport Demand incubators in ambulances were totally inadequate to provide restraint in the event of During the last five years, neonatal and paediatric an accident. Indeed, on closer inspection, it intensive care have moved in opposite directions was clear that even if the clamps were able to in this regard. For neonatal intensive care, hold the trolley during an impact, the chassis increased numbers of infants cared for in district of the standard ambulance was not. general hospitals and a falling birth rate have • It was unreasonable to expect that any transport brought a small reduction in the demand for urgent system weighing more than 200 pounds postnatal transfers. This of course compounds xii Paediatric and neonatal critical care transport the difficulty of those carrying out transports to Conclusions develop and maintain skill levels. The same period has seen paediatric intensive The overall situation with regard to intensive care care emerge as a speciality in the UK. Therefore transport is quite unsatisfactory, but there are at a time of financial stringency both the basic some positive developments on the horizon. Parts provision for the country and a transport service of the UK have made a clear decision to provide have had to be established. Since the total number emergency transfers using a specialist, dedicated of paediatric intensive

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