Emergency Medical Transportation Guidelines for Nurses in Primary Care

Chapter 5 - Obstetrics and Care of Infants and Children

Obstetric Care

• Indications for Emergency Medical Evacuations
• Aviation Factors Affecting Reproductive Conditions
• General Considerations in Transport of Obstetric Clients
• Pre-Eclampsia and Eclampsia
• Preterm (Premature) Labor
• Prelabor Rupture of the Membranes
• Antepartum and Postpartum Hemorrhage
• Imminent Delivery
• Emergency Delivery

Neonatal Care

• Transport of the Ill Newborn
• Neonatal Resuscitation

Transport of the Infant with a Surgical

• Effects of Air Transport
• Omphalocele
• Esophageal Atresia (with or without Tracheoesophageal Fistula)
• Diaphragmatic Hernia

Care of Infants and Children

• General Guidelines
• Increased Intracranial Pressure
• Acute Respiratory Distress
• Near-Drowning
• Child with Multiple Injuries

Appendix 5-1: Intraosseous Access

• General
• Sites
• Procedure

Obstetric Care

Generally a woman in her ninth month of pregnancy (or beyond the 240th day) is advised not to fly unless there is an urgent or semi-urgent need to do so.

However, for safety reasons, deliveries are not routinely done in semi-isolated or isolated northern communities. In most regions, women are referred out of the community for the duration of their pregnancy at 36–38 weeks' gestation or sooner if they are at higher risk.

Indications for Emergency Medical Evacuations

Complications of pregnancy:

• Prelabor rupture of the membrane
• Pregnancy-induced hypertension (PIH)
• Antenatal bleeding (abruption, placenta previa or incomplete abortion)
• Preterm labor

Complications of labor and delivery:

• Prolapsed cord
• Abnormal fetal positions and abnormal delivery (e.g., breech - footling, frank or full; face or brow delivery; shoulder dystocia; transverse lie; cephalo-pelvic disproportion)

Labor - imminent delivery:

• Delivery during transport is not safe; it is best to remain in the community facility if delivery is imminent

Complications of postpartum period:

• Postpartum hemorrhage
• Postpartum infection (e.g., endometritis)

Aviation Factors Affecting Reproductive Conditions

• Reduced partial pressure of oxygen
• Reduced atmospheric pressure
• Decreased presence of water vapor (dehydration)
• Gravitational forces

Effects of Air Transport

• Maternal and fetal hypoxia (clients with compromised utero-placental perfusion are at increased risk)
• Uterine contractions may be stimulated as gas expands in the bowels during ascent (according to Boyle's law)
• Decreasing atmospheric pressure with increasing altitude causes the breasts to expand, stimulating release of oxytocin and enhancing labor
• Gravitational forces may enhance labor, pulling the fetus "down," if the client's head is positioned toward the nose of the aircraft
• Acceleration forces may adversely affect utero-placental perfusion

Pre-eclamptic clients have increased pulmonary permeability, which, in association with hypoxia and decreased barometric pressure, can lead to pulmonary edema.

General Considerations in Transport of Obstetric Clients

• Give oxygen, and keep oxygen saturations ≥95%
• Start IV therapy with normal saline; run at a rate adequate to maintain hydration
• Give nothing by mouth (NPO)
• Keep cabin quiet and temperature warm
• An antiemetic (e.g., dimenhydrinate) may be used
• Allow for frequent voiding or insert a Foley catheter if transfer time is long (> 1 hour); chart hourly urinary output
• Monitor maternal and fetal condition (including fetal heart rate by Doppler ultrasonography) every 15 minutes
• Position client in left lateral decubitus position, with head elevated and toward the tail of the aircraft
• Restrict aircraft cabin altitude to 4000 ft above ground level (AGL)
• Be prepared for emergency delivery with delivery kit and warmed isolette (if available)

See also "Imminent Delivery," below, this chapter

Pre-Eclampsia and Eclampsia

Effects of Air Transport

• Maternal and fetal hypoxia
• Expansion of breast or uterine tissue may increase the release of oxytocin, thereby enhancing labor
• Gravitational forces may enhance labor

Management

See "General Considerations in Transport of Obstetric Clients," above, this chapter.

Additional Considerations for Transport

• Monitor closely for seizure activity
• Suction and pharyngeal airway should be immediately available in case seizures occur
• Monitor symptoms, blood pressure, heart rate, respirations, deep tendon reflexes and fetal heart rate every 10–15 minutes during transit; watch for hyper-reflexia, vision defects, headache and pain in right upper quadrant
• Ensure that anticonvulsants (e.g., lorazepam), antihypertensive medications (e.g., hydralazine) and medications to reduce neurological excitement (e.g., magnesium sulphate) are available; discuss specific orders for use of these drugs with a physician before transport

Preterm (Premature) Labor

Effects of Air Transport

• Maternal and fetal hypoxia
• Expansion of breast or uterine tissue may increase the release of oxytocin, thereby enhancing labor
• Gravitational forces may enhance labor

Management

See "General Considerations in Transport of Obstetric Clients," above, this chapter.

Additional Considerations for Transport

• Consider IV therapy (500-mL bolus of D5W or D/NS over 30 minutes) to slow or stop preterm (premature) labor
• Discuss with a physician, before the transport, the use of medications to slow or stop labor (e.g., tocolytics)
• Discuss with a physician the use of medications to mature fetal lungs (steroids)
• Monitor fetal heart rate, uterine activity, and maternal blood pressure and pulse every 10–15 minutes.
• If delivery becomes inevitable, follow the emergency delivery protocol; see "Imminent Delivery," below, this chapter
• Avoid the use of depressant narcotic analgesics

Prelabor Rupture of the Membranes

Effects of Air Transport

• Maternal and fetal hypoxia
• Expansion of breast or uterine tissue may increase the release of oxytocin, thereby enhancing labor

Management

See "General Considerations in Transport of Obstetric Clients," above, this chapter.

Additional Considerations for Transport

• Discuss the use of IV antibiotics with a physician before the transport
• Monitor fetal heart rate, uterine activity, maternal blood pressure and pulse every 10–15 minutes
• If delivery becomes inevitable, follow the emergency delivery protocol; see "Imminent Delivery," below, this chapter
• Avoid the use of depressant narcotic analgesics

Antepartum and Postpartum Hemorrhage

Effects of Air Transport

• Maternal and fetal hypoxia
• Expansion of breast or uterine tissue may increase the release of oxytocin, thereby enhancing labor in an antepartum client
• Gravitational forces may enhance labor in an antepartum client

Management

See "General Considerations in Transport of Obstetric Clients," above, this chapter.

AdditionalL Considerations for Transport

• Stabilize ABCs before transport!
• Establish two large-bore IV lines, and ensure adequate volumeresuscitation with normal saline or Ringer's lactate; bring an ample supply of IV replacement fluids
• If client is in shock, treat accordingly; see "Shock," in chapter 14, "General Emergencies and Major Trauma," in Clinical Practice Guidelines for Nurses in Primary Care (First Nations and Inuit Health Branch 2000)
• Monitor fetal heart rate, uterine activity, and maternal blood pressure, pulse and respiratory rate every 10–15 minutes
• Monitor intake and output and blood losses closely; count pads to assess amount of bleeding, and save any clots or tissue that may be expelled

Imminent Delivery

Optimal treatment is to transfer the mother to hospital before delivery. The most important question is whether the client can be transported to the hospital in time. A decision to transfer depends upon local facilities, travel time and risks associated with traveling. The final decision should be made just before departure on the basis of contractions, parity, descent of the presenting part, cervical dilatation and response to attempted treatment for preterm labor. It is always safer to perform an imminent delivery before moving the client, rather than during transport, especially if the labor is preterm.

In addition to the emergency resuscitation kit, assemble equipment and supplies that may be required in transit, if emergency delivery is required. Suggested items:

• Obstetric pack and instrument pack
• Transport incubator and extra power supply (if available)
• Blankets and thermal insulating plastic body envelope (if available)
• Oxygen masks, including infant size; pediatric and infant oral airways; and bag-valve mask (BVM) device
• Pulse oximeter (if available)
• Blood glucometer
• Spare cylinders of oxygen with appropriate fittings, including flow and pressure gauges
• Monitoring equipment with extra batteries and Doppler device for fetal heart monitoring
• Suction and gavage tubes
• IV sets and extra supply of IV solutions
• Adequate supply of any medications ordered by a physician and medications for resuscitation
• Flashlight with extra batteries
• Antiseptic cleaning agent (e.g., povidone–iodine)
• Bowl or kidney basin
• Sterile gauze
• Infant resuscitation equipment

In the event that resuscitation of the infant is required in flight, the following equipment and supplies should also be available:

• Radiant heaters
• Blood pressure machine with neonatal blood pressure cuffs
• Infant oropharyngeal airways
• Infant bag-valve mask (BVM) device and face mask
• Suction equipment
• Oxygen with oxygen analyzer
• Means of monitoring an infant's temperature
• Glucometer
• Transport incubator and functioning battery

Drugs for resuscitation:

• 10% and 25% dextrose solutions
• normal saline
• sodium bicarbonate
• naloxone
• epinephrine
• atropine
• antibiotics (ampicillin and gentamicin)
• 10% calcium chloride

Emergency Delivery

If delivery in transit appears possible or inevitable, be prepared to take the following actions:

• Reassure the mother-to-be
• Position client comfortably, with buttocks slightly raised off the stretcher
• Place a rubber or plastic sheet under the buttocks, and remove any tight clothing
• Ensure that a functioning IV line with normal saline or Ringer's lactate is in place; a second IV line may be advisable if there is an increased risk of postpartum hemorrhage (e.g., multiparity or previous history of this condition)
• Arrange equipment for immediate use
• Have oxygen ready for use (if not already in use)
• Draw up any medications that may be required (e.g. oxytocin)
• Wash perineal area
• Drape client
• Wear mask and sterile gloves, and possibly a sterile gown
• During delivery, let the natural efforts of the mother deliver the baby

Ordinarily the baby will deliver unassisted, head first. Avoid excessive tearing of the vaginal walls by controlling the delivery of the head - don't let it "pop out," but rather ease it out slowly and allow the tissue to stretch. As soon as the head is delivered, feel around the baby's neck to determine if the cord is wrapped around and constricting the trachea. Deliver one shoulder at a time; the rest of the body will follow naturally. Do not use traction on the baby until delivery of the shoulder, to avoid injury to the neck and brachial plexus.

Once the baby is delivered:

• Position baby on his or her back in a neutral position
• Dry off the baby and discard wet linen
• Suction mouth and then nose
• Place in warm linen or blankets to maintain body temperature
• Stimulate baby (e.g., by rubbing back)
• Establish respirations as soon as possible by use of suction, oxygen and manual stimulation
• After the cord stops pulsating, draw a sample of cord blood, double-clamp the cord at 3 inches (8cm) and 5 inches (12 cm) from the baby's abdomen; check to ensure that the clamps are secure and that no bleeding is evident; cut cord
• Assist with delivery of the placenta, but do so without pulling on the cord
• Wrap the placenta in a plastic bag or blanket and save for examination to ensure it is intact
• Gently massage the mother's fundus to keep it firm and to control bleeding after the placenta is delivered or if the placenta is retained
• In cases where uterine contraction is slow, with continued bleeding, encourage the mother to breast-feed the infant (if the infant is healthy and breast-feeding is the planned method of feeding)
• Administer oxytocin 10 units IM or IV
• Continue to observe the mother for hemorrhage and the baby for respiratory distress
• Reassure and support the client

Neonatal Care

Transport of the Ill Newborn

If an ill newborn must be evacuated to a facility offering a higher level of care, it is usually preferable to await the arrival of an appropriate critical care transfer team, who will stabilize the infant. It is dangerous to expose the infant, particularly if premature, to the Additional stresses of transport, especially aeromedical transport, before adequate stabilization.

The newborn who requires resuscitation is particularly vulnerable. See "Neonatal Resuscitation," below, this chapter.

Management: General Considerations for Transport

• Stabilize ABCss
• Give oxygen, and keep oxygen saturations at 93% to 94%
• Give oxygen according to percent concentration rather than flow rate (liters per minute), as would be the case for adults; have an oxygen analyzer (if available) on board to verify the amount of oxygen being administered
• Minimize oxygen demand by maintaining a neutral thermal environment and by minimizing handling and interventions
• Check frequently for any signs of respiratory distress (e.g., flared nostrils, sternal retractions, abdominal breathing, grunting on expiration or unequal chest expansion)
• Establish IV line for normal saline before transport, if possible
• Ensure that IV site is protected and visible
• If possible, use a pediatric drip set or, better, an IV infusion pump (if available), for better control of IV flow rate
• Monitor serum blood sugar, and treat hypoglycemia with a bolus of 10% glucose and an infusion of D10W
• Maintain accurate record of intake and output
• Avoid oral feeding for a sick, asphyxiated or preterm baby
• Observe infant continuously
• Do not leave infant unattended
• Handle infant gently
• Record vital signs every 15 minutes or more frequently, depending on situation:
  • Heart rate: normally 120–160 beats/minute (use pulse oximetry, if available)
  • Respiratory rate: normally 40–60 breaths/minute (airway can be kept open by slightly extending the position of the head and suctioning as necessary)
  • Axillary temperature: normally 36.5°C to 37°C
  • Blood pressure: difficult to assess in newborns without special equipment; signs of adequate perfusion include good capillary refill, good color, adequate urinary output and normal alertness; determine capillary refill time (to assess skin perfusion) by blanching area with digital pressure (normal refill time is 2–4 seconds)

Maintenance of Oxygenation and Ventilation

Signs of Respiratory Distress

• Periodic breathing
• Tachypnea (respiratory rate > 60 breaths/minute)
• Grunting
• Chest wall retractions
• Nasal flaring

Common Causes of Respiratory Distress in Newborns

• Respiratory distress syndrome
• Aspiration syndrome
• Pneumonia
• Pulmonary air leak

In these situations, consult a physician.

• If there is evidence of respiratory failure, take steps immediately to provide positive pressure ventilation (PPV)
• Keep oxygen saturations in the range of 90% to 95%, measured by pulse oximetry (if available)
• Initiate PPV with infant resuscitation bag at 40–60 respirations/minute and pressure of 20–30 cm H₂O
• Effectiveness of ventilation is judged by infant's clinical response, symmetric chest movement and auscultation of air entry to both lungs
• Major cardiopulmonary failure may be prevented by early intervention with 100% oxygen and PPV

Maintenance of Circulation

Adequate cardiac output is essential to maintain circulation. The best way to maintain circulation is provision of adequate fluids and electrolytes. Babies with unstable conditions are usually given nothing by mouth, and an IV infusion is started.

Conditions Necessitating IV Therapy

• Extreme prematurity
• GI anomalies (e.g., gastroschisis)
• Cardiac anomalies
• Respiratory distress syndrome
• Dehydration
• Shock

Fluid Administration Guidelines for Newborns

• Term infant: 80–100 mL/kg every 24 hours
• Preterm infant: 100–140 mL/kg every 24 hours

Maintenance of Homeostasis

The most common problem is hypoglycemia, which occurs in a variety of situations:

• Prematurity
• Restricted intrauterine growth
• Asphyxia during birth
• Hypothermia
• Diabetic mother

Use a reagent strip or blood glucose monitor to assess blood glucose level every hour. A glucose level ≥2.5mmol/L in a term infant is abnormal.

IV administration of a 10% dextrose solution (approximately 3–4 mL/kg each hour) is indicated if the blood sugar is ≤ 1.5 mmol/L. Discuss with a physician.

Abnormalities such as hypocalcemia, hypomagnesium, hyponatremia and hyperkalemia can complicate homeostasis, especially if resuscitation and stabilization processes are prolonged.

Maintenance of Thermal Environment

Maintenance of an optimal thermal environment is one of the most important aspects of transport of a newborn. Newborn infants have a large surface area relative to their weight, and they have less subcutaneous tissue to insulate against heat loss.

The ambient temperature at which an infant uses the least energy to maintain body temperature depends on the infant's weight, gestational age at birth and postnatal age. Prolonged cold stress results in increased oxygen consumption and abnormal glucose utilization, which can lead to hypoglycemia, hypoxemia and acidosis.

• Line incubator walls on three sides to help reduce heat loss during transport
• Place a small clear plastic shield around any small infant (excluding the head), to limit air movement and thereby prevent loss of heat by convection
• Cover the incubator with plastic sheeting, a "space blanket" or a sleeping bag during any period that the baby spends outside the vehicle (e.g., for loading and unloading) to help maintain body temperature
• Ensure that the portable incubator (if available) is in good working order and that extra batteries are available
• If necessary, check axillary temperature during transport, but the incubator should not be opened needlessly
• It is equally important to avoid hyperthermia, which may lead to increased oxygen requirements

Infection

If sepsis is suspected, obtain swabs from ear canal, umbilicus and tracheal secretions. Obtain blood for culture if possible. IV administration of antibiotics should not be delayed. Discuss with a physician.

Usual antibiotics are ampicillin and gentamicin.

Neonatal Resuscitation

Diagnosis

Try to anticipate situations in which a newborn may need resuscitation. The following situations represent some of the predisposing factors.

History of Maternal Perinatal Complications

• Preterm labor
• Placental abnormalities: placenta previa, abruptio placentae or cord compression
• Amniotic fluid abnormalities: polyhydramnios or oligohydramnios
• Infectious process: maternal fever
• Infectious agents (maternal source): group B Streptococcus, gram-negative bacteria, viruses (e.g., HSV, toxoplasmosis, CMV, HIV)
• Maternal abnormalities: diabetes mellitus, size of pelvic outlet
• Neonatal abnormalities: genetic, anatomic or cardiac
• Maternal drugs: prescription or illicit

Physical Examination and Evaluation

The physical examination may have to be done while resuscitation is performed.

• Airway: Is it patent? Is foreign material (e.g.,meconium) present?
• Breathing effort: Present or absent?
• Circulation: Is pulse present? What is heart rate? What is infant's color?
• Disability: neurological status, floppy tone, absence of reflex and grimace
• Environment: heat loss
• Apgar score: should be assessed 1 and 5 minutes after birth (Table 5-1)

*Sum the scores for each feature. Maximum score = 10, minimum score = 0.

Procedure for Resuscitation

1. Position the airway.

2. Suction the mouth and nasopharynx.

3. Dry the neonate and keep warm with thermal blanket or dry towel. Cover scalp.

4. Stimulate by drying the baby and rubbing his or her back.

5. Clamp and cut the cord.

6. Evaluate respirations.

7. Use blow-by method or simple face mask to deliver 100% oxygen for neonate in mild distress.

For an infant with apnea or severe respiratory depression, begin assisted breathing with bag-valve mask (BVM) and 100% oxygen; ventilate at
40–60breaths/minute.

8. Check heart rate (apical beat) after 15–30 seconds after bagging.

If heart rate < 60 beats/minute:

9. Continue assisted ventilation (20breaths/minute).

10. Begin chest compressions at 100/minute.

11. If no improvement after 30 seconds, continue ventilation and compressions.

12. If no improvement after a further 30 seconds, establish vascular access and give epinephrine solution (1:10 000) (D class drug) at 0.01–0.03 mg/kg IV or IO. Subsequent doses must be ordered by a physician.

13. Reassess heart rate and respirations.

If heart rate 60–80 beats/minute:

9. Continue assisted ventilation.

10. If no improvement after 30 more seconds of ventilation with 100% oxygen, begin chest compressions. Ratio of compressions to ventilations should be 5:1 (100 compressions to 20 ventilations).

11. Reassess heart rate and respirations each minute.

If heart rate 81–100 beats/minute and rising:

9. Give 100% oxygen by mask or blow-by method.

10. Provide tactile stimulation.

11. Reassess heart rate and respirations after 15–30 seconds. If heart rate < 100 beats/minute, begin assisted BVM ventilation with 100% oxygen.

12. Reassess heart rate after 15–30 seconds.

If heart rate > 100 beats/minute:

9. Check skin color. If peripheral cyanosis is present, give oxygen by mask or blow-by method.

10. Reassess heart rate after 1 minute.

Transport of the Infant With a Surgical Emergency

Effects of Air Transport

• Gas expansion resulting in increased distension and perhaps pain and vomiting
• Gravitational forces
• Reduced water vapor (leading to dehydration)

Omphalocele

Omphalocele is a protrusion of the intestine through a large defect in the abdominal wall, covered by a thin transparent membrane. Water and heat is lost from the exposed bowels.

Management: Considerations for Transport

Objectives:

• Preserve sterility of exposed viscera
• Prevent mesenteric vascular obstruction through kinking and friction on the viscera
• Prevent heat loss
• Decompress the intestine

Actions required:

• Ensure airway is secure before transport
• Give oxygen, and keep saturations > 93% to 94%
• Start IV therapy with normal saline (maintenance amounts); D10W is also commonly used for neonates; discuss choice of this IV fluid with a physician
• Do not give the infant a pacifier or oral feeding
• Insert an orogastric tube, attached to straight drainage, to prevent further abdominal distension
• Using sterile technique, cover the bowel with Vaseline gauze or sterile gauze that has been moistened with warm saline
• Next, apply a layer of plastic wrap circumferentially around the infant's abdomen and trunk to prevent water and heat loss; the dressing should support the bowel
• Finally, add a third layer of tin foil to enhance conservation of heat and water
• Monitor temperature and serum blood sugar regularly
• Transport infant supine or on the right side, with head elevated 30 degrees and toward the nose of the aircraft
• Restrict aircraft cabin altitude to 2000 ft above ground level (AGL)

Esophageal Atresia (With or Without Tracheoesophageal Fistula)

Esophageal atresia is the congenital absence or closure of the esophagus. In approximately 85% of cases, there is also a fistula between the trachea and the distal esophagus. Aspiration may occur because of overflow from the blind esophageal pouch or through the fistula. Polyhydramnios may have been present antenatally.

Signs of this diagnosis:

• Excessive salivation or persistent regurgitation
• Obstruction in the upper thoracic esophagus when attempts are made to pass a nasogastric tube (the tube might turn on itself and come out of the mouth)

Management: Considerations for Transport

• Ensure airway is secure before transport
• Suction must be available
• Give oxygen, and keep oxygen saturations at 93% to 94%
• Start IV therapy with normal saline (maintenance amounts); D10W is also commonly used for neonates; discuss choice of this IV fluid with a physician
• Pass a no. 10 French catheter through the mouth and nose into the esophageal pouch and suction frequently (as required)
• Do not give the infant a pacifier or oral feeding
• Monitor temperature and serum blood sugar
• Transport infant supine or on the right side, with head elevated 30 degrees and toward the nose of the aircraft
• Restrict aircraft cabin altitude to 2000 ft AGL

Diaphragmatic Hernia

In this condition incomplete development of the diaphragm allows the intra-abdominal contents to herniate into the chest. Respiratory distress occurs early, with a shifting of heart sounds to the opposite side of the chest and depressed breath sounds on the affected side. The trachea is deviated to the opposite side. Bowel sounds are occasionally heard in the chest, and the abdomen may be scaphoid. The mother may have a history of polyhydramnios.

Management: Considerations for Transport

• Manage airway as soon as possible after birth to minimize entrance of air into the stomach
• Assisted ventilation is usually required; respiratory distress worsens with bagging
• Before transport, infant should be intubated; this procedure is not within the CHN's scope of practice and should be performed by authorized emergency transport personnel (e.g., physician, emergency flight nurse or paramedic)
• Give oxygen, and keep oxygen saturations at 93% to 94%
• Start IV therapy with normal saline (maintenance amounts); D10W is also commonly used for neonates; discuss choice of this IV fluid with a physician
• Insert an orogastric tube to straight drainage, and suction tube frequently with syringe
• Monitor temperature and blood sugar
• Transport infant supine or on the right side, with head elevated 30 degrees and toward the nose of the aircraft
• Restrict aircraft cabin altitude to 2000 feet AGL

Care of Infants and Children

General Guidelines

If possible, have a parent or another family member accompany the infant or child. The escort may be apprehensive about the child, so he or she will also require attention and support throughout the transport. Involve the escort in the care of the child as much as possible.

Because children often cannot verbalize their complaints, and because the status of the condition may change rapidly, undertake a careful pre-transport assessment to establish a baseline for later comparison en route.

Assemble sufficient supplies of appropriate nourishment, clothing, disposable diapers and equipment for any anticipated complications related to the condition.

Provide the infant with either a seat, a seat belt or a bassinet that is properly secured on a stretcher or a seat. The child may be held by an adult during a flight, secured with a stretcher strap but not with the same belt as the adult's. Infants up to the age of 2years (legal limit) may be held in the adult's arms.

Awaken the infant during descent and have him or her nurse, drink from an infant cup or eat some food, unless he or she is being kept NPO for medical reasons. Older children can be given gum or can be encouraged to yawn to prevent barotitis media.

If the reason for air evacuation is respiratory, discuss the infant's needs with the pilot to enable choice of the best altitude that safety will permit.

Increased Intracranial Pressure

Management: Considerations for Transport

• stabilize abcs before transport
• Secure the airway before transport and consider immobilization of cervical spine if head injury is suspected
• Give oxygen, and keep saturations ≥95%
• Assist ventilation with bag-valve mask (BM) device if necessary
• Start IV therapy with normal saline to keep vein open, unless volume resuscitation for other injuries is necessary
• Monitor vital signs, including temperature and neurological status (with Pediatric Glasgow Coma Scale) frequently
• Watch for changes in level of consciousness, pupil reaction, headache, reduction in heart rate (down to 40–60/minute), decreased or intermittent (Cheyne–Stokes) respiration, increase in blood pressure, vomiting, seizures or paralysis; be prepared for intervention as indicated
• Monitor blood sugar and manage hypoglycemia
• Keep cabin quiet and dimly lit to prevent stimulation
• Avoid, to the extent possible, stimuli that might increase intracranial pressure, such as suctioning, coughing, Valsalva maneuver and position changes
• Give medications and fluids as necessary; discuss use of medications with a physician before transport (generally IV and oral fluids are restricted to 60% of maintenance requirements)
• Position the infant or child on a stretcher with head elevated by 30 degrees and toward the nose of the aircraft; avoid neck flexion
• Restrict aircraft cabin altitude to 2000 ft AGL

Acute Respiratory Distress

Rapid diagnosis and treatment are important to avoid cardiorespiratory arrest.

Management: Considerations for Transport

• Stabilize ABCs before transport
• Establish a secure airway before transport; ventilate as necessary
• Give as much oxygen as possible, and keep oxygen saturations ≥95%
• If child is in moderate to severe distress, restrict oral fluids and start IV therapy with normal saline; run at a rate adequate to maintain hydration; remember that a lot of fluid can be lost through the respiratory tract if the child is tachypneic and febrile
• Keep the child in a comfortable position, allowing him or her to assume the position of choice
• Keep stresses to a minimum
• If the child is feverish, attempt to reduce body temperature by administering antipyretics and removing heat sources

Ventilation

If ventilation is to be carried out manually, use enough pressure to observe chest movements. Use chest movement as a guide to the adequacy of ventilation. Table 5-2 presents average ventilation rates at various ages.

Once started, manual ventilation should be continued during transport, even if the child is starting to breathe on his or her own. It may be safer to ventilate than to allow the child to breathe on his or her own without knowing whether ventilation is adequate.

the child is adequately ventilated but is excessively restless, check bladder and other vital signs.

Near-Drowning

Do not attempt to evacuate the child until vital signs have been established.

Management: Considerations for Transport

• Stabilize ABCs before transport
• Establish a secure airway before transport; ventilate as necessary
• Immobilize the cervical spine before transport
• Give as much oxygen as possible, and keep oxygen saturations ≥95%
• Start IV therapy with normal saline; run at a rate sufficient to maintain adequate blood pressure and heart rate
• If unable to establish IV line, consider intraosseous access; for procedure, see Appendix 5-1, "Intraosseous Access," below, this chapter
• Monitor temperature, as well as all vital signs, frequently
• Monitor serum blood sugar, and treat hypoglycemia as necessary
• Suction should be available and used as required
• Position the client supine, with head toward nose of aircraft
• Restrict aircraft cabin altitude to 5000 feet AGL
• If near-drowning occurred in cold water, treat as required for hypothermia

See "Hypothermia," in chapter 14, "General Emergencies and Major Trauma," in Clinical Practice Guidelines for Nurses in Primary Care (First Nations and Inuit Health Branch 2000).

Child with Multiple Injuries

Effects of Air Transport

• Increased hypoxemia
• Gas expansion and tissue swelling may increase intracranial pressure
• Vomiting and potential airway compromise

Management: Considerations for Transport

• Stabilize ABCs before transport
• Treat major respiratory emergencies (e.g.,pneumothorax, hemothorax, flail chest or open chest wound) before transport
• Establish a secure airway, and ensure adequate ventilation
• Immobilize the cervical spine and place child on spine board
• Give high-flow oxygen, and keep oxygen saturations ≥95%
• Establish two large-bore IV lines and initiate volume replacement as required with normal saline or Ringer's lactate
• If unable to establish IV line, consider intraosseous access; for procedure, see Appendix 5-1, "Intraosseous Access," below, this chapter
• Control bleeding, and apply pressure dressings as necessary
• Perform neurological assessment frequently, and treat emerging problems as necessary
• Protect from hypothermia (with warm blankets and warm IV fluids)
• Monitor vital signs, neurological status and bleeding continuously
• Minimize the risk of infection by cleaning or debriding open wounds and administering antibiotics as prescribed by consulting physician
• Consider inserting a nasogastric or orogastric tube to prevent gastric distension
• Consider inserting a urinary catheter (unless contrainidicated because of urethral trauma); maintain accurate record of intake and output
• Anticipate potential problems and be prepared for immediate treatment
• Prevent heat loss and hypothermia
• Position child supine, with head toward the nose of the aircraft
• Restrict aircraft cabin altitude to 2000 feet AGL

Appendix 5-1: Intraosseous Access

General

Purpose

• Used to administer IV fluids and medications when attempts at IV access have failed
• For use in emergency situations only

Indications

Attempt intraosseous access in the following situations in children ≤ 6 years of age, when venous access cannot be achieved within three attempts or 60–90 seconds, whichever comes first:

• Multisystem trauma with associated shock or severe hypovolemia (or both)
• Severe dehydration associated with vascular collapse or loss of consciousness (or both)
• Unresponsive child in need of immediate drug and fluid resuscitation: burns, status asthmaticus, sepsis, near-drowning, cardiac arrest, anaphylaxis

Contraindications

• Pelvic fracture
• Fracture in the extremity proximal to or in the bone chosen for the intraosseous access

Sites

Preferred

• Anterolateral (flat) surface of the proximal tibia, 1–3 cm (one finger's breadth) below and just medial to the tibial tuberosity

Other Possibility

• Distal tibia, 1–3 cm above the medial malleolus on the surface of the tibia near the ankle (believed by some to be the best site in older children because of the greater thickness of the proximal tibia relative to the distal tibia)

Procedure

1. Practice universal precautions against contamination with child's body substances (e.g., gloves, possibly goggles, safe disposal of needle).

2. Assemble necessary equipment.

3. Immobilize the child well, but avoid restraints if at all possible.

4. Place the child in the supine position and externally rotate the leg to display the medial aspect of the extremity.

5. Identify the landmarks for needle insertion.

6. Cleanse the puncture site.

7. If the child is conscious, use local anesthesia.

8. Use an intraosseous needle or, in a small child, an 18-gauge butterfly needle.

9. Angle the needle away from the joint. Insert the needle at a 60° angle, 2 cm below the tibial tuberosity, through the skin and subcutaneous tissue.

10. When the needle reaches the bone, exert firm downward pressure, rotating the needle in a clockwise–anticlockwise manner. Be careful not to bend the needle.

11. When the needle reaches the marrow space, the resistance will drop (indicated by a "pop").

12. Attach a 10-mL syringe, and aspirate some blood and marrow to determine if the needle is correctly positioned (other indicators of correct positioning: the needle will stand upright by itself, IV fluid flows freely, no signs of subcutaneous infiltration are apparent).

13. Secure needle with tape.

14. Use as you would a regular IV line. For example, fluids can be infused quickly for resuscitation of a child who is in shock.