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Transportation and

Stabilitation in
Critically Ill Patient

dr. Akhmad Yun Jufan, M.Sc., Sp.An


Anaesthesia and Intensive Care
RSS – FM GMU
Patients transfer

Intra - Hospital
• ICU
• Ward
• OT
• Radiology
• Etc..

Inter - Hospital
• Regional
• National
• International
CONTRA -
INDICATION INDICATION
•DIAGNOSTIC PURPOSES • POTENTIAL BENEFITS
e.g. CT SCAN , MRI. <POTENTIAL RISKS.
•THERAPEUTIC PURPOSE • UNSTABLE (OR) POTENTIALLY
e.g.:- SURGERY, PACEMAKER
UNSTABLE PATIENT .
•SPECIALIZED CARE e.g. :-
EMERGENCY DEPARTMENT TO
ICU (or) TERITIARY LEVEL
HOSPITAL.
Ground transport…
• Advantages of ground transport over air
transport
– Larger patient compartment
– Lower cost
– Relative immunity to changing weather
– Safer
– Less severe environmental factors
• Oxygen levels
• Acceleration/deceleration forces
• Gas volume changes with altitude
• Cabin pressurization
• Humidity
• Noise
• Vibration
Air Transport
• Advantages
– Faster
– Can accommodate more than one patient
– Allows care providers more room
• Increases workspace
• Holds more crew when patients require
• Disadvantages
– Requires large, sturdy landing site
• May be too heavy or large for some pads
– Expensive
• Original cost
• Maintenance
• Fuel
Ground Vs Air

• The potential for transport delay that


may be associated with the use of ground
transport (e.g., traffic and distance) is
likely to worsen the patient's clinical
condition
ESSENTIAL ELEMENTS

• Communication.
• Personnel.
• Equipment.
• Monitoring.
• Handing over (Documents, Information).
• Medico legal and ethical aspects.
COMMUNICATION

 PHYSICIAN TO  NURSE TO
PHYSICIAN NURSE
INFORMATION

• Reason for transport

• The patient's condition

• Equipment needed.

• Just before leaving notify the receiving


department
Crew

• Strong assessment and critical thinking skills

• Ability to manage patients

• Strong knowledge of communications

• ability to function autonomously in a variety of


settings if immediate communication with a
physician is not possible or if immediate life-
saving actions are required.
Advanced Critical Care Skills
• Include:
– Intra-aortic balloon pump
– Advanced airway
techniques – 12-Lead ECGCentral
• RSI venous catheter
• Surgical airway
maintenance/placement/
interpretation
– Ventilator
management – Intracranial pressure
monitoring
– Pulse oximetry and
capnogram – Venous cutdown
interpretation – Blood/blood product
– Chest tube administration and
placement and monitoring
monitoring – Infusion pumping
– Thoracic – Advanced
escharotomies pharmacological
– Transvenous pacing intervention
ACCOMPANYING
EQUIPMENT

 Airway management equipment

 Medication

 Electronic devices

 Trolley

 Oxygen cylinder

 Appropriate monitoring, resuscitation equipment, and


medications  based upon the anticipated need and
duration of the planned transport.
AIRWAY MANAGEMENT
EQUIPMENT

Resuscitations Kit
Oxygen cylinder
Electronic Devices

ECG Monitor Infusion pump

Pulse Oxymeter
STANDARD RESUSCITATION
DRUGS
TROLLEY
PREPARING PATIENT FOR
TRANSPORT
• Secure intra venous access
• Airway stabilization
• Trauma victims – spinal mobilization
• Naso gastnc tube
• Foley’s catheterization
• Chest tube insertion
• All drains
• -under water seal
• -urinary
• -wound
• Infusion pump & IV drips functioning properly
• Soft wrist and leg restraints
• Vital signs displayed on monitors
• Patient is safely secured on a trolley
Trauma:Initial Stabilization
The Primary Survey

• Airway:
– Establish patency
– Beware C- Spine
– Do not:
• Flex
• Hyperextend
Trauma:Initial Stabilization
Suspected Airway Obstruction

• Stridor
• Cyanosis
• Absence of breath sounds
• Dysphagia, snoring, gurgling
• Altered mental status
• Trauma to head, face, neck
Trauma:Initial Stabilization
Airway Management

• Clear airway
• Jaw thrust/stabilization maneuver
• Oral/nasal airway
• Oxygenate/ventilate
• Intubation
• Cricothyroidotomy
Trauma:Initial Stabilization
C-Spine Immobilization

• Backboard
• Appropriate C-collar
• Snadbags or towel
• Tape
• Torso immobilization
Trauma:Initial Stabilization
Primary Survey: Breathing
• Assess via
– Exposure
– Rate/depth of respiration
– Inspection/palpation
– Quality/symmetry of breath
sounds
NB: An intact airway Does Not assure
adequate ventilation
Trauma:Initial Stabilization
Primary Survey: Breathing

• Oxygen
• Assisted ventilation
• Alleviate life threatening injuries
– Tension pneumothorax
– Hemothorax
– Flail chest
– Cardiac tamponade
Stabilitation
The patient with acute respiratory failure who
requires advanced mechanical ventilatory
support using :
– positive-end expiratory pressure (PEEP)
– pressure-controlled ventilatory modes

• not tolerate even a brief interruption of high-


level mechanical ventilatory support.
• Consistent, uninterrupted ventilation is difficult
to maintain
Trauma:Initial Stabilization
Circulation: Fluid Therapy

• Goal: restore vascular volume


– amount: 20 cc/kg

• Initial bolus given rapidly


• Crystalloids as effective as colloids
• Isotonic, balanced salt solution
preferred
• Reassess response additional
boluses?
Trauma:Initial Stabilization
Circulation:Pediatric Considerations

• Vascular access
– peripheral I.V.
• two large bore catheters

– intraosseous
– central venous line
– venous cutdown
Trauma:Initial Stabilization
Disability

• Rapid, brief neurological assessment


• Level of consciousness
A - Alert
V - responds to Vocal stimuli
P - responds to Painful stimuli
U - Unresponsive
• Assess pupillary size, symmetry, reactivity

• No convulsion
MONITORING
o Pulse

o Oxygen saturation

o BP,RR
IN-TRANSIT PROCEDURE

 A best route

 Lift should be reserved before hand

 Status of patient checked at intervals

 Continuous monitoring
ADVERSE EFFECTS OF
TRANSPORTATION

Hemodynamic instability
Hypertensive crisis
Systemic hypotension
Cardiac arrhythmias
Cardiac arrest
Airway obstruction
POTENTIAL MISHAPS

Accidental extubation.
Ventilator disconnects.
ECG disconnects.
Monitor power failure.
Vaso – active drug interruption.
Intravenous disconnection.
Stabilitation for transportation

• During transport, 20-75% lifethreatening


complications (arytmia, hypertension,
hypoxemia, hypo- or hypercarbia, or
intracranial hypertension)

• Even the simple maneuver of transferring


a patient from one bed to another can
result in significant, protracted, and
occasionally irreversible, cardiopulmonary
dysfunction.
Case

• 39% of transports in diagnostic tests


that led to a change in patient
management within 48 hours.

• Abdominal CT scanning (51 %) and


angiography (57%) tests leading to a
management change.
Case

Head-injured patients requiring in-


hospital transport :

• 51 % : significant arterial hypertension,


arterial hypotension, intracranial
hypertension, or hypoxia during
transport.