E-PREP emergency procedure education program

The procedural skills accreditation pathway for ED registrars

CRITICAL CARE PATIENT

TRANSPORT

Nick Taylor

Introduction

Transporting a critically ill patient is one of the most

challenging and potentially risky procedures an ED trainee

will undertake

This learning package aims to provide a brief overview of

key issues and safety aspects of performing a transport

A mentored transport is the best way of learning practical

aspects such as equipment placement in the CT

Minimum requirements

Background Knowledge and skills (Mandatory

before being eligible for Transport Assessment)

Intubation Accreditation

Retrieval Pack contents demonstrated

ACLS

Arterial Line Accreditation

Basic Ventilation accreditation

Considerations

Do I need to transport this patient (what are the risks/benefits of my transport?)

Where am I taking the patient?

How long do I anticipate I will be out of the dept for?

What do I need to do before I go?

What will I need to take with me (What is the diagnosis, how stable is my patient, what could possibly go wrong)??

Who will look after my other patients while I am gone?

General principles

Checklist before leaving: ABCDE for all

Airway: secure and patent

Breathing: ventilator, sats and pressures are safe for transport

Circulation: haemodynamic parameters are acceptable, Lines are working and identified

Disability: Check pupils and sedation adequacy and paralysis

E: Limb splints are applied, haemorrhage is contained

Ensure transport rationale is appropriate ;

Eg: a haemodynamically unstable multi trauma should

be transported to theatre not the CT room

Lines and tubes

Place all necessary lines and tubes prior to leaving, but

avoid delays by placing unneccessary devices

Eg

delaying a coning patient to CT to place an IDC is dangerous and

unneccessary

Delaying a GCS 5 patient to place an ETT is appropriate and

necessary

Arterial lines are almost never required for a CT trip and are the

commonest source of delay

Patient preparation

Optimize your patients physiology and pharmacology prior to leaving

Eg

Weaning the Fi02 prior to transport reduces your patients physiological reserve if a problem occurs

Keep the patient paralysed and sedated for the transfer if appropriate

Start the Norad infusion before leaving if the BP is borderline

Anticipation

Run through a mental checklist of all the problems you may encounter and prepare in advance

Eg

If you think the patient’s propofol may need increasing in the CT, bring some metaraminol to counteract the post bolus hypotension

If the N/S is half way through, bring another bag

Equipment

Minimum equipment to bring is mandatory and includes

Assembled & Checked

Retrieval Pack

Self inflating bag and mask

Oxygen (tank full)

Suction

Airway adjuncts

Ventilator Circuit: Assembly,Basic Checks,Settings

Monitor: NIBP, ECG, SaO2, IBP, ETCO2

Infusion Pumps

Batteries / Power

Staff

A nurse and wardsperson are mandatory additional

personnel

Ensure you have briefly handed over your other

patients before leaving

Ask for senior assistance if you patient is very

unwell and you are out of your comfort zone

Specific Pearls for a safe

transport

Untangle all your leads and lines before you

go…optimize everything in the safe environment,

minimize delays in the unsafe place

Position the monitors so you can always see them; a

visible end tidal, sats and ECG tracing are

absolutely critical

Always take personal responsibility for the airway

Use a firm loud and clear voice when leading the transfers

Give advance warning before changing anything: “We are

going to move across on 3”, then “1 2 3”

Stay focused on the patient and monitor, avoid

distractors…drugs, lines, CT images

Moving the patient from bed to bed, bed to CT

Disconnect the ventilator from the ETT for all

transfers UNLESS:

PEEP is a requirement for ventilation (eg ARDS or CCF).

Sudden loss of PEEP can be catastrophic

The patient has respiratory failure and you think the brief

disconnection may be dangerous

There is raised intracranial pressure and you are controlling

CO2 (relative risk)

Moving the patient from bed to bed, bed to CT

Place your ventilator on the rail at the head of the bed whilst moving the patient over (ensures enough tubing length, allows access to patient for all staff)

Move the monitor to the foot of the receiving bed prior to moving the patient (ensures enough line length, allows access to patient for all staff)

Move the patient half way across , check your lines

and tubes, then complete the transfer

Move the IMEDs and A-Line pressure bags across to

a pole on the far side of the head end of the

receiving bed prior to moving the patient

In the CT room

Ask the radiographer to manually move the patient

in the scanner to the far limit required.

Check you have enough tubing length with a safety

margin

Only then can you leave the room

Avoid unneccessary exposure

Keep blankets on, keep fluid warmers going

For raised ICP patients

Keep at 30 degrees head up until just before moving

across

MCQs

1. What is the correct transport decision for an intubated 50

year old male with a blown R pupil from a presumed

subdural haemorrhage.

A. Place an arterial line and IDC prior to CT to ensure appropriate

monitoring

B. Take the patient to CT ASAP with full non invasive monitoring

C. Take the patient to CT ASAP even if non invasive monitoring is not

applied yet.

2. What is the correct transport decision for a 27 M post MVA with Sats of 83% immediately post intubation who the surgeons want an urgent panscan for.

A. Take to CT now on a bag and mask with PEEP valve and 100% O2.

B. Take to CT now on a transport ventilator with PEEP of 10 and 100% O2.

C. Delay in ED until a CXR is seen and the patients saturations are improved.

D. Refuse to transport the patient under any circumstances.

3. What is the correct transport decision for an this 8 year old female?

The treating team have requested a CT chest to look for pleural effusions. She is ventilated for severe ARDS and has FiO2 of 95%, PEEP of 25 , PIP of 50 and P02 of 51? A. Transport to CT with transport ventilator

B. Ask anaesthetics to transport to CT

C. Refuse to transport to CT

D. Arrange urgent transfer to ICU, and liaise with the treating team regarding your decision

4. What is the most appropriate transport decision for a patient who has just been intubated, with Sats of 98% and the post intubation CXR shows a 30% R pneumothorax?

A. Transport the patient to the ICU and handover the CXR findings.

B. Delay the transport to ICU until an ICC can be placed.

C. Delay the transport to ICU until a needle thoracostomy can be placed, and then transport.

5. Where should the ventilator be placed when

transferring a patient from bed to CT table?

A. On the rail at the foot of the bed

B. On the side bed rail

C. On the patient’s chest

D. On the rail at the head of the bed.

6. What are minimum monitoring traces required for

transport of an intubated patient?

A. Sats and CO2

B. Sats, CO2 and cardiac

C. Sats and cardiac

D. CO2 and cardiac