Inter-facility Transport (IFT) Part 1 General

1. HKCEM College Tutorial Inter-facility Transport (IFT)Part 1General Author Dr. Leung Yuen Hung Oct., 2013

2. The scenario • A 40 years old man has acute subarachoidhaemorrhage. 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.

3. How would you prepare for the transfer?

4. 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

5. 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

6. 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)

7. Transport Kit

8. 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

9. On board equipment

10. Inter-facility Transport Form

11. How would you tackle the potential complications during transfer in general?

12. “REST” Approach in IFT • Recognition • Evaluation • Support • Transportation

13. 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

14. 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

15. 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)

16. Transportation • Represents auxiliary elements linking up the whole transportation process as a continuum • Timeliness of transportation • Inter-facility communication • Continuous monitoring • Documentation • Equipment operation

17. What are the potential problems during transfer in the case?

18. Neurological deterioration • Spectrum of deterioration • Altered mental state • Development of seizure • Coma

19. Recognition • Detected by close monitoring of patients’ conscious level during transport • In term of GCS assessment • Decline of GCS during IFT

20. 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

21. 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

22. Check patient’s blood glucose level for hypoglycemia • Should optimize dysglycaemia in CVA patient as hyperglycemia is associated with poor outcome

23. 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

24. 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

25. 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

26. 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.

27. If the patient is intubated, what specific complication would be anticipated?

28. Desaturation

29. Recognition • Detected by close monitoring of patients’ SpO2 • Should be cautious for any deteriorating SpO2 <95% in general patients

30. Evaluation • Evaluate the ET tube • DOPE • Displacement • Obstruction • Pneumothorax • Equipment failure

31. 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

32. 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

33. 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

34. DOPE • Equipment failure • Quickly check malfunction of ventilator (setting and circuit), pulse oximetry, oxygen source as well as connection of the tubing

35. 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

36. 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

37. End Thank you