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CHAPTER 107: Neonatal and Pediatric Transport 671 TABLE 106-3 Recommended Childhood Immunizations Vaccine* Age DTaP (Tdap >6 y) Hib Hep B Polio Pneumococcal (conjugate) Rotavirus HPV MMR VZV Hep A Meningococcus (conjugate) Influenza † BCG Birth C, U, W W 2 mo C, U, W C, U, W C, U, W C, U, W C, U, W C, U, W 4 mo C, U, W C, U, W C, W C, U, W C, U, W C, U, W 6 mo C, U, W C, U, W C, U, W C, U, W U, W C, U, W C, U, W 12–15 mo U C, U C, U, W C, U, W U, W C, W 15–23 mo C, U, W C C U 2–4 y C C W 4–6 y U C, U U U 10–12 y U C, U, W C, U 13–15 y C 16 y U 17–18 y Abbreviations: BCG = bacillus Calmette-Guérin; C = Canada (Public Health Agency of Canada); DTaP = diphtheria, tetanus, acellular pertussis; Hep A = hepatitis A; Hep B = hepatitis B; Hib = Haemophilus influenzae type b conjugate; HPV = human papilloma virus; MMR = measles, mumps, rubella; U = United States (Centers for Disease Control and Prevention); W = World Health Organization. *The exact sequence varies according to manufactured brand of vaccine, and many combination vaccines and conjugate vaccines with variable serotypes exist. Schedule is approximate. World Health Organization (W) guidelines recommend additional vaccination of high-risk patients for the following: Japanese encephalitis, yellow fever, tick-borne encephalitis, typhoid, cholera, and rabies. See http://www.who.int/immunization/ documents/positionpapers for more information. †Given annually beginning as early as 6 months of life; requires two-vaccine series for children under 9 years of age; avoid live vaccine in children <2 years of age and those with asthma or who are immunocompromised. Neonatal and Pediatric Transport Daniel G. Ostermayer INTRODUCTION Regionalization, the organization of a coordinated system of care across a geographic area, combines all necessary components of care to optimize patient outcomes. Regionalized intensive care for neonatology and pediatric care 1 focuses expensive, high-technology, labor-intensive therapies to a few regional centers. This model of care originated from trauma center regionalization demonstrating reduction of morbidity and mortality for trauma patients at designated trauma centers. 2,3 Because patients in need of specialized services often present to other hospitals, interfacility transport is an important complement to regionalized intensive care. Specialized pediatric transport services improve safety, decrease unplanned adverse events (especially airway events), and lower mortal ity. 4-6 This chapter reviews the general and pediatric considerations for the interfacility transport of critically ill neonates and children. THE TRANSPORT TEAM The American Academy of Pediatrics has published transport guide lines based on expert consensus.7 Caring for critically ill children is best accomplished with at least two patient care providers on each team in addition to the driver or pilot. One of the patient care members should be a registered nurse with a minimum of 5 years of experience, typically CHAPTER is most commonly secondary to respiratory failure in children, rather than primary as in adults. Try to include parents and caretakers in the room during pediatric resuscitation. Children require special medication dosage calculations based on weight or body surface area due to age-dependent metabolic pathways and differing body composition, volumes of drug distribution, and organ development.

rimary as in adults. Try to include parents and caretakers in the room during pediatric resuscitation. Children require special medication dosage calculations based on weight or body surface area due to age-dependent metabolic pathways and differing body composition, volumes of drug distribution, and organ development. Most prescription medications have not been for mally tested in children and do not have specific U.S. Food and Drug Administration approval for use in children due to the ethical and practical difficulties of performing drug trials in children. Common medications can have adverse effects in children, such as dental staining from tetracycline antibiotics and life-threatening complications from antimotility drugs commonly used for adult diarrheal disease. Children generally do not understand the transient nature of painful procedures or of their relative risks and benefits. Such comprehension allows adults to consent to and cooperate with common emergency procedures. Chapter 115, “Pain Management and Procedural Sedation in Infants and Children, ” discusses the pharmacologic and nonpharmacologic approach to this important topic. Caretakers make legal decisions on behalf of their children. Consent for treatment and procedures must be obtained from legal guardians for all minors except in cases of emergency medical necessity. A variable exception is the confidential provision of care to adolescents with regard to their reproductive and mental health. DISPOSITION AND FOLLOW-UP Disposition decisions in children require consideration of caretaker abilities and indications for transfer to another institution. Discharge to reliable caretakers is an important part of practice guidelines for many common pediatric conditions, including minor head injury (see Chapter 138, “Seizures in Infants and Children”) and fever without source in the infant (see Chapter 119, “Fever and Serious Bacterial Illness in Infants and Children”). Children requiring hospitalization may require transfer to a tertiary-care pediatric hospital. The emergency physician has responsibility for determining the need, risks, and benefits of transfer, and the mode of transporting children to a higher level of care. Ultimately, the disposition requires close communication with receiving facilities and with the child’s family. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Tintinalli_Sec12_p0669-0996.indd 671 8/2/19 7:49 PM

ansfer, and the mode of transporting children to a higher level of care. Ultimately, the disposition requires close communication with receiving facilities and with the child’s family. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Tintinalli_Sec12_p0669-0996.indd 671 8/2/19 7:49 PM 672 SECTION 12: Pediatrics pediatric and neonatal patients with sepsis, seizure disorder, shock, or severe neurologic and metabolic conditions can quickly overwhelm the clinical staff at a small hospital. Current expert consensus for transport of sick or injured children recommends physicians understand sending and receiving resources before deciding to transfer (Table 107-2). DECISION TO TRANSPORT Children require transfer to a regional center if the current or anticipated medical care needs of the patient exceed the resources of the local hos pital. Arranging transfer to the regional center can occur simultaneously with assessment, resuscitation, and stabilization at the local hospital. Discussion with the receiving hospital and specialists can aid in deci sions regarding the mode of transport and composition of the transport team. Preestablished transfer protocols should provide information about each regional center to which a patient might be referred, including (1) special services available; (2) criteria for referral; (3) telephone numbers for consultation, referral, and transport; (4) distance and usual response time; (5) type of transport personnel and their capabilities; (6) type of transport vehicles; and (7) protocols for preparation of patients. Establish formal agreements with regional centers that outline the circumstances under which patients can be transported without prior administrative approval. As with adults, proper assessment of the patient’s injury pattern must factor into transport mode. Aeromedical transports have become increasingly more frequent with increased hospital emergency depart ment closure and regionalization of pediatric specialty care facilities, especially for surgical services, trauma, and burns. 15,16 MODE OF TRANSPORT In many areas, physicians have a choice between air and ground transportation. This decision should be made collaboratively between the referring and accepting physicians. 17,18 The risks and benefits of air transport are discussed in Chapter 3, “ Air Medical Transport. ” Time, distance, traffic, weather, geographic constraints, and availability all factor into the decision regarding mode of transport. The most important factor determining the type of transport will be team availability and skill level. The most capable care team may not be available for a ground transport, making flight a TABLE 107-1 Pediatric Conditions at Risk for Deterioration During Transport •  Pneumonia •  Recurrent  brief resolved unexplained event •  Foreign  body aspirations •  Airway  obstructions •  Epilepsy •  Poisoning  or overdose •  Multisystem  or severe intracranial trauma •  Tracheitis •  Severe  asthma •  Metabolic  derangements •  Severe  sepsis TABLE 107-2 Pediatric Conditions Commonly Requiring Interfacility Transports •  Intracranial  trauma •  Severe  trauma •  Airway  (upper or lower) airway disorders •  Sepsis/septic  shock •  Seizures •  Developmental  or neurologic condition •  Poisoning  or overdose •  Intracranial  trauma •  Multisystem  trauma at least 3 years of neonatal or pediatric critical care or ED training. 4 Additional member(s) may include a respiratory therapist, physician, or paramedic. The condition of the child and local resources determine the exact composition of the specialized transport team. For helicopter EMS transports, the most common care arrangement involves a paramedic and neonatal or pediatric care nurse in addition to the pilot.

include a respiratory therapist, physician, or paramedic. The condition of the child and local resources determine the exact composition of the specialized transport team. For helicopter EMS transports, the most common care arrangement involves a paramedic and neonatal or pediatric care nurse in addition to the pilot. Similar arrangements of one paramedic and a critical care nurse or two critical care nurses with neonatal and pediatric expertise are frequently used for ground transports. Accreditation agencies and professional associations will guide local and regional team compositions. TRANSPORT ENVIRONMENT Transporting critically ill patients adds to the risks of the illness or injury because of the hazards associated with the transport environment, par ticularly for neonates and children.8 The features of transport that distinguish the transport environment from the ED setting and the effects of these features on patients and caretakers are outlined in Chapter 3, “ Air Medical Transport. ” All the risks of transport still apply, with the additional need for awareness of the emotional and mental state of the child. Also, since one parent often accompanies the child, additional weight considerations must be accounted for during aeromedical transport.  PRECAUTIONS Suggested guidelines to minimize the impact of the limitations inherent in a transport environment are: 1. Prepare the transport vehicle. Transport vehicles should be prepared to meet the special needs of children (e.g., accessory lighting, con trolled thermal environment) and should be stocked with the nec essary equipment. A list of the minimum necessary equipment for ambulances, which can serve as a guide for EMS agencies, has been published by the Emergency Medical Services for Children program. Transport modality–specific risks should also be considered. 2. Stabilize the patient before transport. Unless the immediate needs of the patient can only be met in the receiving hospital (e.g., emergent surgery), ample time should be devoted to stabilizing the patient in the referring hospital. Time spent undertaking goal-directed inten sive care interventions early in the course of the patient illness at the referring hospital does not worsen patient outcomes. 3. Monitor as many physiologic parameters as possible electronically . Because physical examination is difficult during transport and because children often are transported during dynamic changes in their physiologic condition, electronic monitoring is essential. Children are especially at risk for hypothermia and hypoglycemia. Important monitoring equipment commonly used during transport includes cardiorespiratory monitor (selected based on its size, weight, battery life, and resistance to motion artifact); continuous pulse oximetry with a plethysmographic waveform to assist in identifying motion artifact; temperature monitor (of infants and incubator air temperature); continuous end-tidal carbon dioxide waveform monitoring, which can aid in early identification of unplanned extubation 12; and invasive or noninvasive blood pressure monitoring. Lowering endotracheal cuff pressures during aeromedical transport can help reduce excessive tracheal pressure. 4. Anticipate deterioration. Preparation of the patient should include not only care for the identified problems but also anticipation of problems that may arise during transport. The application of this principle may lead to performance of procedures or therapies before transport such as gastric decompression, placement of a chest tube for pneumothorax, or transfusion (Table 107-1). SITUATIONS REQUIRING TRANSPORT There are severe conditions for which interfacility transports are more common, and neonates require more interfacility transports than older children.

es or therapies before transport such as gastric decompression, placement of a chest tube for pneumothorax, or transfusion (Table 107-1). SITUATIONS REQUIRING TRANSPORT There are severe conditions for which interfacility transports are more common, and neonates require more interfacility transports than older children. Although many community hospitals can care for a preg nant mother and child, premature infants require more resources and often need transfer to a neonatal intensive care unit for care. Likewise, Tintinalli_Sec12_p0669-0996.indd 672 8/2/19 7:49 PM