- •ICU Protocols
- •Preface
- •Acknowledgments
- •Contents
- •Contributors
- •1: Airway Management
- •Suggested Reading
- •2: Acute Respiratory Failure
- •Suggested Reading
- •Suggested Reading
- •Website
- •4: Basic Mechanical Ventilation
- •Suggested Reading
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Websites
- •7: Weaning
- •Suggested Reading
- •8: Massive Hemoptysis
- •Suggested Reading
- •9: Pulmonary Thromboembolism
- •Suggested Reading
- •Suggested Reading
- •Websites
- •11: Ventilator-Associated Pneumonia
- •Suggested Readings
- •12: Pleural Diseases
- •Suggested Reading
- •Websites
- •13: Sleep-Disordered Breathing
- •Suggested Reading
- •Websites
- •14: Oxygen Therapy
- •Suggested Reading
- •15: Pulse Oximetry and Capnography
- •Conclusion
- •Suggested Reading
- •Websites
- •16: Hemodynamic Monitoring
- •Suggested Reading
- •Websites
- •17: Echocardiography
- •Suggested Readings
- •Websites
- •Suggested Reading
- •Websites
- •19: Cardiorespiratory Arrest
- •Suggested Reading
- •Websites
- •20: Cardiogenic Shock
- •Suggested Reading
- •21: Acute Heart Failure
- •Suggested Reading
- •22: Cardiac Arrhythmias
- •Suggested Reading
- •Website
- •23: Acute Coronary Syndromes
- •Suggested Reading
- •Website
- •Suggested Reading
- •25: Aortic Dissection
- •Suggested Reading
- •26: Cerebrovascular Accident
- •Suggested Reading
- •Websites
- •27: Subarachnoid Hemorrhage
- •Suggested Reading
- •Websites
- •28: Status Epilepticus
- •Suggested Reading
- •29: Acute Flaccid Paralysis
- •Suggested Readings
- •30: Coma
- •Suggested Reading
- •Suggested Reading
- •Websites
- •32: Acute Febrile Encephalopathy
- •Suggested Reading
- •33: Sedation and Analgesia
- •Suggested Reading
- •Websites
- •34: Brain Death
- •Suggested Reading
- •Websites
- •35: Upper Gastrointestinal Bleeding
- •Suggested Reading
- •36: Lower Gastrointestinal Bleeding
- •Suggested Reading
- •37: Acute Diarrhea
- •Suggested Reading
- •38: Acute Abdominal Distension
- •Suggested Reading
- •39: Intra-abdominal Hypertension
- •Suggested Reading
- •Website
- •40: Acute Pancreatitis
- •Suggested Reading
- •Website
- •41: Acute Liver Failure
- •Suggested Reading
- •Suggested Reading
- •Websites
- •43: Nutrition Support
- •Suggested Reading
- •44: Acute Renal Failure
- •Suggested Reading
- •Websites
- •45: Renal Replacement Therapy
- •Suggested Reading
- •Website
- •46: Managing a Patient on Dialysis
- •Suggested Reading
- •Websites
- •47: Drug Dosing
- •Suggested Reading
- •Websites
- •48: General Measures of Infection Control
- •Suggested Reading
- •Websites
- •49: Antibiotic Stewardship
- •Suggested Reading
- •Website
- •50: Septic Shock
- •Suggested Reading
- •51: Severe Tropical Infections
- •Suggested Reading
- •Websites
- •52: New-Onset Fever
- •Suggested Reading
- •Websites
- •53: Fungal Infections
- •Suggested Reading
- •Suggested Reading
- •Website
- •55: Hyponatremia
- •Suggested Reading
- •56: Hypernatremia
- •Suggested Reading
- •57: Hypokalemia and Hyperkalemia
- •57.1 Hyperkalemia
- •Suggested Reading
- •Website
- •58: Arterial Blood Gases
- •Suggested Reading
- •Websites
- •59: Diabetic Emergencies
- •59.1 Hyperglycemic Emergencies
- •59.2 Hypoglycemia
- •Suggested Reading
- •60: Glycemic Control in the ICU
- •Suggested Reading
- •61: Transfusion Practices and Complications
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Website
- •63: Onco-emergencies
- •63.1 Hypercalcemia
- •63.2 ECG Changes in Hypercalcemia
- •63.3 Superior Vena Cava Syndrome
- •63.4 Malignant Spinal Cord Compression
- •Suggested Reading
- •64: General Management of Trauma
- •Suggested Reading
- •65: Severe Head and Spinal Cord Injury
- •Suggested Reading
- •Websites
- •66: Torso Trauma
- •Suggested Reading
- •Websites
- •67: Burn Management
- •Suggested Reading
- •68: General Poisoning Management
- •Suggested Reading
- •69: Syndromic Approach to Poisoning
- •Suggested Reading
- •Websites
- •70: Drug Abuse
- •Suggested Reading
- •71: Snakebite
- •Suggested Reading
- •72: Heat Stroke and Hypothermia
- •72.1 Heat Stroke
- •72.2 Hypothermia
- •Suggested Reading
- •73: Jaundice in Pregnancy
- •Suggested Reading
- •Suggested Reading
- •75: Severe Preeclampsia
- •Suggested Reading
- •76: General Issues in Perioperative Care
- •Suggested Reading
- •Web Site
- •77.1 Cardiac Surgery
- •77.2 Thoracic Surgery
- •77.3 Neurosurgery
- •Suggested Reading
- •78: Initial Assessment and Resuscitation
- •Suggested Reading
- •79: Comprehensive ICU Care
- •Suggested Reading
- •Website
- •80: Quality Control
- •Suggested Reading
- •Websites
- •81: Ethical Principles in End-of-Life Care
- •Suggested Reading
- •82: ICU Organization and Training
- •Suggested Reading
- •Website
- •83: Transportation of Critically Ill Patients
- •83.1 Intrahospital Transport
- •83.2 Interhospital Transport
- •Suggested Reading
- •84: Scoring Systems
- •Suggested Reading
- •Websites
- •85: Mechanical Ventilation
- •Suggested Reading
- •86: Acute Severe Asthma
- •Suggested Reading
- •87: Status Epilepticus
- •Suggested Reading
- •88: Severe Sepsis and Septic Shock
- •Suggested Reading
- •89: Acute Intracranial Hypertension
- •Suggested Reading
- •90: Multiorgan Failure
- •90.1 Concurrent Management of Hepatic Dysfunction
- •Suggested Readings
- •91: Central Line Placement
- •Suggested Reading
- •92: Arterial Catheterization
- •Suggested Reading
- •93: Pulmonary Artery Catheterization
- •Suggested Reading
- •Website
- •Suggested Reading
- •95: Temporary Pacemaker Insertion
- •Suggested Reading
- •96: Percutaneous Tracheostomy
- •Suggested Reading
- •97: Thoracentesis
- •Suggested Reading
- •98: Chest Tube Placement
- •Suggested Reading
- •99: Pericardiocentesis
- •Suggested Reading
- •100: Lumbar Puncture
- •Suggested Reading
- •Website
- •101: Intra-aortic Balloon Pump
- •Suggested Reading
- •Appendices
- •Appendix A
- •Appendix B
- •Common ICU Formulae
- •Appendix C
- •Appendix D: Syllabus for ICU Training
- •Index
Transportation of Critically Ill Patients |
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Amit Varma and Sandeep Dewan |
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A 57-year-old male patient was admitted to the emergency department with complaints of abdominal pain and recurrent vomiting. He was found to be in a state of septic shock. After the initial resuscitation, his abdominal examination was remarkable for abdominal distension with absent bowel sounds. The ultrasonography report of the abdomen was inconclusive, and he was shifted to the radiology department for a contrast-enhanced CT scan of the abdomen. He was still on inotropic and vasopressor support.
The ideal way to consider transport of a critically ill patient is as a “mobile ICU environment.” Attention to details during transport ensures patient safety.
83.1Intrahospital Transport
Step 1: Evaluate the need for transfer
•The most important initial step is to evaluate the potential benefit which may be derived by shifting the patient against the risks involved.
•The aim or purpose and the justification to transport should be noted in the case record.
•The potential risks can be minimized by careful planning of the procedure and utilization of available equipment and personnel.
•A multidisciplinary team of the physician, nurses, paramedical staff, and transport coordinator is required to plan and coordinate the process.
A. Varma, M.D. (*)
Critical Care Medicine, Fortis & Escorts Heart Institute and Research Centre, New Delhi, India e-mail: amit.varma@fortishealthcare.com
S. Dewan, DA, D.N.B.
Critical Care Medicine, Fortis Escorts Heart Institute, New Delhi, India
R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach, |
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DOI 10.1007/978-81-322-0535-7_83, © Springer India 2012 |
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•Transport of the patient should not be undertaken in the following circumstances:
–Inability to provide adequate oxygenation and ventilation during transport or at destination, either by the manual resuscitator bag, portable ventilator, or standard intensive care unit ventilator.
–Inability to maintain acceptable hemodynamic parameters during transport or at destination.
–Inability to adequately monitor the patient’s cardiopulmonary status during transport.
–Inability to maintain airway control during transport or at destination.
–All the necessary members of the transport team are not present.
–Receiving team is not ready.
Step 2: Pretransport coordination and communication
•A physician-to-physician and nurse-to-nurse communication is required to plan the transport.
•The team ensures that the receiving location is ready to receive the patient for immediate procedure and testing.
•Documentation in the medical record should be done, which includes the indication of transport and the clinical status of the patient.
Step 3: Accompanying personnel
•Minimum of two people, preferably one of them from the treating ICU team, should accompany a critically ill patient.
•It is strongly recommended that a physician with training in airway management and advance cardiac life support accompanies the unstable patient.
•The transport personnel should remain with the patient until return to the ICU.
Step 4: Equipment requirement
•The equipment to be used during transport should be dedicated and should not be used anywhere else.
–A blood pressure monitor, a pulse oximeter, invasive and noninvasive ventilators, and defibrillators.
–Basic resuscitation drugs including epinephrine, nor epinephrine, antiarrhythmic drugs, vasopressin, muscle relaxants, sedatives, narcotics, analgesics, dextrose ampoule, and appropriate IV fluids.
–Drip medications must accompany the patient.
–All battery-operated equipments must be fully charged and should have adequate battery backup provision.
•In mechanically ventilated patients, endotracheal tube position is noted and secured before and during transport and the adequacy of oxygenation and ventilation is reconfirmed.
•No equipment or drugs should be placed over the patient. Most units will have custom-made shelves, which will fit on the beds or trolleys.
•The monitors and/or ventilators should be properly secured with straps to the bed or shelves so that they do not fall on the patient.
83 Transportation of Critically Ill Patients |
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Step 5: Identifying high-risk patients
Patients in the following categories are at particularly high risk for deterioration during or after transport:
•The mechanically ventilated patients, particularly those with requirement of high
positive end-expiratory pressure and FiO2 more than 0.5. Extra oxygen reserve for patients with high oxygen requirement should be kept.
•Patients with high therapeutic injury severity score
•Head-injured patients
•Hemodynamically unstable patients requiring continuous infusion of dobutamine, or a continuous infusion of norepinephrine or other potent vasoactive agents
Step 6: Monitoring during transport includes the followings
•ECG monitoring
•Pulse oximetry
•Periodic measurement of the blood pressure, pulse rate, and respiratory rate
•Selective patients may benefit from capnography, continuous intra-arterial blood pressure monitoring, and intracranial pressure monitoring if required.
Step 7: Care during transport
•Ideally, the patient should receive the same level of care as in the pretransport area.
•Vital signs should be monitored and recorded at fixed intervals.
•Use of memory-capable monitors should be used. This will allow documentation of data during transport.
•Any adverse events should be noted and immediately acted upon.
•There should be a designated senior physician available for consult in case of an adverse or critical event during transport.
•Ideally, he/she should be available on-site and should be able to arrive at the destination area if required.
•The transport team should be able to communicate with the designated person during transit as well as upon arrival at the destination in case of an emergency.
83.2Interhospital Transport
When a critical care patient requires resources, which are not available in the existing hospital, the patient will be transferred to a facility that has the required resources. Interhospital patient transfer will occur only when the benefits exceed the efforts. If needed, the resuscitation and stabilization of the patient should be carried out before the transport.
Basic requirements are the same for intraor interhospital transport. Interhospital transport requires more planning, more personnel, vehicle availability, consideration of altitude effects in air transport, weather condition, battery life of equipments,
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backup equipment, oxygen supply, power supply, contingency plan in case of breakdown, and more documentation for medicolegal purposes.
Step 1: Take informed consent
•An informed consent for interhospital transport must be taken from a competent patient, guardian, or legally authorized representative, if the patient is incompetent.
•It includes a discussion of the risks and benefits of transfer.
•It should be documented in the medical records before the transfer is done.
•In case of life-threatening emergencies when an informed consent cannot be taken, the indication of transfer and the reason for not obtaining consent must be documented in the medical record.
Step 2: Communicate and coordinate prior to transport
•The referring physician will contact the receiving physician and will explain the clinical condition to him/her.
•The mode of transportation (ground/air) will be determined by the transferring physician based on the medical condition, the time savings, facilities available, and the medical interventions required.
•The transport service will then be contacted to confirm its availability and coordinate the timing. A copy of the medical record including case summary and all relevant laboratory and radiographic data will accompany the patient.
Step 3: Decide on accompanying personnel
•It is recommended that minimum of two people should accompany a critically ill patient.
•The transport team leader should be a treating physician/intensivist/anesthesiologist with additional training in transport medicine.
•It is strongly recommended that a physician with training in airway management and advance cardiac life support accompanies the unstable patient.
•The transport personnel will remain with the patient until reaching the ICU.
•There must be a clear chain of responsibility throughout the transfer. A proper handover from referring physician to transfer physician and then to receiving facility physician is essential.
Step 4: Choose transport equipment and medicines
•When choosing the equipment, the following should be considered: size, weight, battery life, ability to fit to trolley railings, ability to function under condition of vibration, ease of use in poor light, and placement in restricted space.
•Equipments should be adequately restrained and should be easily accessible to the operator.
•Backup equipment may be desirable in some situation.
•The recommended minimum transport equipments and medications are given in Tables 83.1 and 83.2.
Table 83.1 Recommended minimum transport equipments
Adult/pediatric bags—valve systems and oxygen reservoir
Adult and pediatric masks
Flexible adaptors to connect the bag valve system to the endotracheal/tracheostomy tube
End-tidal carbon dioxide monitors (pediatric and adult)
Infant mediumand high-concentration masks with tubing
Laryngoscope with blades with extra batteries
Endotracheal tubes with stylets
Magill forceps
Nasopharyngeal airways
Oral airways
Scalpel with the blade for cricothyroidotomy kit
Needle cricothyroidotomy kit
Water-soluble lubricant
Nasal cannulae
Oxygen tubings
Adhesive tape
Aerosol medication delivery system
Alcohol swabs
Arm boards
Arterial line tubings
Intraoseous needle
Blood pressure cuffs
Butterfly needles
Communications backups
ECG monitor/defibrillator with electrolyte pads and jelly
Flashlights with extra batteries
Heimlich valve
Infusion Pumps
IV fluid administration tubing
Y fluid administration tubing
Extension tubing
Three-way stopcocks
IV catheter (14–24G)
Intravenous solutions (1,000 mL, 500 mL of normal saline)
Irrigating syringe (60 mL), catheter tip
Kelley clamp
Hypodermic needles and syringes, assorted sizes
Normal saline for irrigation
Pressure bags for fluid administration
Pulse oximeter with multiple site adhesive or reusable sensors
Soft restraints for upper and lower extremities
Stethoscope
Suction apparatus and catheters
Surgical dressings and tourniquets
Trauma scissors
The followings are considered as needed: neonatal/pediatric isolette, spinal immobilization device, and transport ventilator
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Table 83.2 Recommended minimum transport medication
Adenosine (6 mg/2 mL)
Amiodarone (150 mg/3 mL)
Atropine (0.6 mg/mL)
Calcium chloride (1 g/10 mL)
Dextrose (25%/50%)
Digoxin (0.5 mg/2 mL)
Diltiazem (25 mg/5 mL)
Diphenhydramine (50 mg/1 mL)
Dopamine (200 mg/5 mL)
Epinephrine (1 mg/10 mL)
Furosemide (100 mg/10 mL)
Glucagon (1 mg vial)
Heparin (1,000 units)
Isoproterenol (1 mg/5 mL)
Labetalol (40 mg/8 mL)
Lidocaine (100 mg/10 mL)
Mannitol (50 g/50 mL)
Magnesium sulfate (1 g/2 mL)
Metroprolol (5 mg/5 mL)
Naloxone (2 mg/2 mL)
Nitroglycerine injection (50 mg/10 mL)
Nitroglycerine tablets (0.4 mg)
Nitroprusside (50 mg/2 mL)
Normal saline (30 mL) for injection Nor epinephrine (2 mL)
Phenobarbital (65 mg/mL or 130 mg/mL)
Potassium chloride (20 mEq/10 mL)
Procainamide (1,000 mg/10 mL)
Sodium bicarbonate (50 mEq/50 mL)
Sterile water (30 mL) for injection
Terbutaline (1 mg/1 mL)
Verapamil (5 mg/2 mL)
The following specialized/controlled medications are added immediately before transport as indicated:
•Narcotic analgesics (e.g., morphine and fentanyl)
•Sedatives/hypnotics (e.g., lorazepam, midazolam, propofol, and ketamine)
•Neuromuscular blocking agents (e.g., succinylcholine, pancuronium, atracurium, and rocuronium)
Additional drugs should be added depending on specific circumstances (antiar-
rhythmic or antibiotics that need to be dosed during transport).