Download Inter-facility Transport (IFT)Part 1General

HKCEM College Tutorial
Inter-facility
Transport (IFT)
Part 1
General
AUTHOR
DR. LEUNG YUEN HUNG
OCT., 2013
The scenario
▪ A 40 years old man has acute subarachoid
haemorrhage. He has GCS of 12. There is no
neurosurgical service in your hospital. After
consultation, he needs to be transferred to a
tertiary hospital for further management.
How would you prepare
for the transfer?
Preparation
• Comprehensive plan agreed by the referring and receiving
physicians
– Pre-transport communication
– Pre-transport documentation
– Informed consent
– Preparation for equipment support
– Preparation for necessary pharmacological agents
– Pre-transport assessment
– Management Plan
Equipment preparation in IFT
▪ One of the key elements in lowering incidence of en route adverse
events and management of occurred adverse events
▪ Two components:
▪ Transport kit
▪ On-board equipment
Transport Kit
▪ Aims to enhance the efficiency and effectiveness during IFT
preparation
▪ Several transport kits for serving different clinical category of
patients
(Paediatric, Obstetric, etc.)
▪ Different transport team configuration
(e.g. Doctor-led or Nurse-led team)
Transport Kit
• Contents are organized to facilitate the transport personnel in
management of any en route adverse events.
• Tools and pharmacological agents
• Pre-drawn pharmacological agent
– enhance the efficiency and prevent needle stick injury
• Minimize the weight
– e.g. LED laryngoscope and disposable laryngoscope blade
On board equipment
Inter-facility Transport Form
How would you tackle the potential
complications during transfer in
general?
“REST” Approach in IFT
▪Recognition
▪Evaluation
▪Support
▪Transportation
Recognition
• Initial step in management of any en route adverse event before any
intervention
• Allow early management or prompt reversal of deterioration
• Achieved by revealing deviations or trend of deviations in physiological
parameter measurements – BP, PR, Temp, SaO2, GCS, ECG, uterine
activity
• Most deterioration is subtle initially
• Close monitoring of patient is essential to make early recognition
Evaluation
▪ Attention to patient’s Airway, Breathing and
Circulation
▪ Identify life-threatening conditions and
manage appropriately by general inspection
with targeted examination
▪ Non-invasive patient monitoring
Support
▪ Most patients are appropriately prepared and stabilized before
transport
▪ Only monitoring and basic supportive care is required in most IFT
▪ +/- Pharmacologic support
▪ +/- Advanced level of care and intervention
(if patient needs to be transported despite relatively unstable condition)
Transportation
▪ Represents auxiliary elements linking up the whole
transportation process as a continuum
▪ Timeliness of transportation
▪ Inter-facility communication
▪ Continuous monitoring
▪ Documentation
▪ Equipment operation
What are the potential problems
during transfer in the case?
Neurological deterioration
▪ Spectrum of deterioration
▪ Altered mental state
▪ Development of seizure
▪ Coma
Recognition
▪ Detected by close monitoring of patients’
conscious level during transport
▪ In term of GCS assessment
▪ Decline of GCS during IFT
Evaluation
▪ Initially focus on support of airway and breathing
▪ Evaluate blood pressure and oxygen saturation, establish
intravenous access
▪ Necessary to exclude hypotension and hypoxia since both
can lead to altered mental state due to end organ
hypoperfusion
▪ Having stabilized the patient, assess the clinical status of the patient
through careful inspection and targeted examination with emphasis
on CNS
▪ Pupil size - ?increasing ICP ?impending cloning
▪ Focal neurological deficit
▪ Drug history - ?overdose of pharmacologic agents e.g. narcotic or
sedative
▪ Check patient’s blood glucose level for hypoglycemia
▪ Should optimize dysglycaemia in CVA patient as hyperglycemia
is associated with poor outcome
Support
• If the neurological state of the patient deteriorates during IFT
General
• Resuscitation and airway management
• Supplementary oxygen
• If the airway cannot be maintained, reposition the patient using head tilt,
chin lift and jaw thrust maneuver
• Attempt assisted positive ventilation with BVM if spontaneous breathing
is absent or remain inadequate
• Apply adjunct airway like oropharyngeal and nasopharyngeal airway
▪ Intubation may be difficult in a confined environment, reserved for
situations that if BVM ventilation is unsuccessful
▪ Alternatively, use Combitube or LMA
▪ But we need to sedate or paralyze patient before insertion, due to
gag reflex present in conscious patients
▪ If patient with depressed conscious state develops vomiting in IFT
▪ Risk of aspiration, if not yet intubated
▪ Turn laterally and aspirate the vomitus with the help of suction catheter
▪ If keep on deteriorating, airway needs to be secured by intubation
Transportation
▪ The vital signs of the patient (BP, pulse, SpO2) and the GCS should
be closely monitored during the transport.
▪ The receiving facility should be informed of the deterioration to
prepare for resuscitation and provide definitive care.
If the patient is intubated, what
specific complication would be
anticipated?
Desaturation
Recognition
▪ Detected by close monitoring of patients’ SpO2
▪ Should be cautious for any deteriorating SpO2 <95% in
general patients
Evaluation
▪ Evaluate the ET tube
▪ DOPE
▪ Displacement
▪ Obstruction
▪ Pneumothorax
▪ Equipment failure
DOPE
• Displacement
– Into right main bronchus
– Into esophagus
– Accidentally after significant changes of head position
How to evaluate displacement?
• Compare the tube marking with the previous record
• Auscultate the breath sounds over chest and abdomen to rule out
oesophageal or endobronchial intubation
• Check end tidal CO2
DOPE
• Obstruction by
– Sputum plug
– Kinking and biting of the tube
How to evaluate obstruction?
• Circuit for kinking of tube
• Patient for tube biting
• Check tube patency directly by laryngoscope or indirectly by passage of
suction catheter through the ET tube
• If obstruction is still being suspected, disconnect the patient from
ventilator, ventilate manually and check for lung expansion
DOPE
• Pneumothorax
How to evaluate if there is pneumothorax?
• Look for asymmetrical chest wall movement
• Feel for tracheal deviation
• Listen for air entry asymmetry and decreased vocal resonance
DOPE
▪ Equipment failure
▪ Quickly check malfunction of ventilator (setting and circuit), pulse
oximetry, oxygen source as well as connection of the tubing
Support
• For minor tube displacement, with reference to the previously
documented marking, deflate the cuff and adjust the tube position, then
secure the tube and confirm the position again
• For failure in tube re-positioning or major displacement (oesophageal
intubation or accidental displacement), the in-situ airway needs to be
removed
• Change to assisted positive pressure ventilation via BVM or insertion of
Combitube or LMA
• Re-intubation or not depends on the remaining distance to receiving
facility
• If pneumothorax with rising breathing difficulty, ?Tension PTX
-> Immediate needle decompression
Transportation
• Reassess the patient’s condition, continue vital signs monitoring
and administer medications if necessary
• Communicate with receiving facility so that delay in transport and
change in clinical condition are notified
• Transport process interruption should be avoided
• Formal handover upon arrival
End
THANK YOU