What are the transport guidelines for a pediatric patient with an intracranial hemorrhage?

From the Guidelines

Transporting a pediatric patient with an intracranial hemorrhage requires a pre-determined pathway for referral and transfer, developed in agreement by the regional transport service, regional trauma network, and the regional neurosciences network, to ensure timely and safe transfer to a neurosurgical centre or PICU. The transport team should ideally include an anaesthetist with regular paediatric elective lists or previous paediatric training, skills, competencies, and experience of brain injury transfer, as well as a paediatric trained nurse 1.

Key Considerations for Transport

• The patient should be secured to the ambulance stretcher with multi-point age/body weight appropriate harness restraints to prevent movement and further injury.
• Age-appropriate equipment, such as ventilators and monitoring devices, should be available and used during transport, particularly for children weighing 2-10 kg.
• Mean arterial blood pressure targets should be maintained at least 10 mmHg above the normal MAP range for age to ensure cerebral perfusion pressure, with specific targets outlined in Table 5 of the guidelines 1.
• Children may have traumatic brain injury with intracranial hemorrhage without an appropriate history, and non-accidental injury should always be considered in a child with neurological presentation.

Management During Transport

• Before induction of anaesthesia, consideration should be given to the use of a bolus of hypertonic saline (2.7–3%, 2–3 ml.kg−1) to avoid an associated rise in ICP during predictable PCO2 rise while performing laryngoscopy 1.
• Osmotherapy, preferably hypertonic saline boluses or mannitol 20%, should be available and accompany the child and team during transfer, with indications for osmotherapy summarized in the transfer checklist 1.
• Blood glucose should be measured, recorded, and managed in the normal range using isotonic saline solution with added glucose (either 5% or 10% depending on the clinical need) as maintenance fluid during transfer.
• In cases of obstructive hydrocephalus with signs of raised ICP, discussion should be held with the neurosurgical team regarding sterile aspiration of the VP shunt reservoir before transfer 1.

Monitoring and Communication

• Continuous monitoring of vital signs, neurological status, and pupillary responses is mandatory during transport.
• Communication with the receiving facility should occur early to prepare for immediate neurosurgical evaluation upon arrival, ensuring that appropriate pathways are triggered at the receiving hospital 1.

From the Research

Transport Guidelines for Pediatric Patients with Intracranial Hemorrhage

The transport of pediatric patients with intracranial hemorrhage requires careful consideration of several factors to ensure the best possible outcomes. Some key points to consider include:

• The skills and expertise of the transport team members, including the ability to perform endotracheal intubation and assisted ventilation, insertion of peripheral, central venous, and arterial catheters, and provision of fluid and electrolyte therapy 2
• The use of telemedicine during interhospital transport to facilitate the transfer of information and imaging, and to reduce time to definitive care 3
• The importance of sufficient communication, gaps in clinical practice, and lack of interhospital transfer structure as impediments to safe, high-quality neurocritical care transitions 4

Team Composition and Skills

The composition of the transport team is crucial in ensuring the safe transport of pediatric patients with intracranial hemorrhage. The team should include:

• A pediatrician or pediatric resident
• A pediatric emergency department nurse
• A pediatric respiratory therapist 5
• Members with skills required for pediatric critical care diagnosis and management, including endotracheal intubation and assisted ventilation, and insertion of peripheral, central venous, and arterial catheters 2

Use of Telemedicine

Telemedicine can play a crucial role in expediting definitive care for children with intracranial hemorrhage requiring emergent neurosurgical intervention. The use of telemedicine during interhospital transport can:

• Reduce time to surgery
• Decrease rates of repeat preoperative neuroimaging
• Shorten median times from trauma bay arrival to surgery and from diagnosis to surgery
• Improve patient outcomes 3

Challenges and Impediments

Despite the importance of safe and high-quality neurocritical care transitions, several challenges and impediments exist, including:

• Insufficient communication
• Gaps in clinical practice
• Lack of interhospital transfer structure 4 These challenges highlight the need for quality improvement initiatives to ensure the best possible outcomes for pediatric patients with intracranial hemorrhage.