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Royal Hospital for Sick Children (Edinburgh)
Paediatric Intensive Care-Retrieval
Retrieval Team contact :
RHSC PICU Fellow
0131 536 0000 Bleep 100
RHSC PICU Nursing station
0131 536 0910 (direct line)
Prior to phoning please collect as many of the details below as possible concerning your
patient. These details match our consultation form, which is used for patient management
and auditing.




Name
Age
D.O.B
Weight

Referral Diagnosis

Details of illness
Consultant in charge
 Has he seen patient
 Physiological Data
HR:
BP:
RR:
 If Intubated and ventilated
FIO2
PIP
PEEP
ET Size:
ET Length:

Blood Gases
PH
Arterial
Venous
Capillary
(Time)________
PCO2
PAO2
 Inotropes
Dopamine
Dobutamine
Adrenaline
Noradrenaline
mcg / kg / min
Temp:
Paralysed
Yes / No
ET Position:
 Fluid Resuscitation Colloid given
 Recent Blood Results
U&E
Haematology / Coagulation
BE
SAO2:
CXR
Gastric Tube
Yes / No
Nasal / Oral
HCO3
Lines
Arterial
Central
Peripheral
Blood given
 Medications
 Glasgow Coma Scale

Yes / No
Glasgow Meningococcal Septicaemia Prognostic Score
Crystalloid given