What are the key considerations for transporting a critically ill child with spontaneous cerebellar intraparenchymal hemorrhage, pulmonary hemorrhage, massive hemothorax, severe coagulation disorder, sepsis, and sedative-opioid withdrawal symptoms?

Critical Transport Considerations for a 1-Year-Old with Cerebellar Hemorrhage, PARDS, Hemothorax, and Coagulopathy

Neurological Management: Cerebral Perfusion is Non-Negotiable

Your primary goal is maintaining mean arterial pressure (MAP) of 55-85 mmHg throughout the 9-hour flight—this is at least 10 mmHg above the normal range for a 1-year-old to account for increased intracranial pressure (ICP). 1

ICP Management During Flight

• Position the child at 20-30° head-up tilt throughout transport to minimize ICP rises, ensuring the stretcher allows this positioning while maintaining secure restraints. 2
• Have hypertonic saline (2.7-3%, 20-30 mL for this 10 kg child) and mannitol 20% immediately accessible for acute neurological deterioration or signs of raised ICP during flight. 1
• Monitor the EVD carefully during takeoff, landing, and the stopover—altitude changes and aircraft movement can affect drainage dynamics and ICP. 1
• Avoid any procedures during active flight phases; if EVD manipulation or interventions are needed, the aircraft must be brought to a complete halt. 2

Sedation Strategy

• Maintain deep continuous sedation with infusions (not boluses) to prevent coughing, straining, or agitation that could catastrophically increase ICP in the setting of posterior fossa crowding. 2, 3
• Continue neuromuscular blockade throughout transport—any movement or endotracheal tube discomfort can spike blood pressure and ICP. 2
• For any required re-sedation, use ketamine 1-2 mg/kg given this child's history of hemodynamic instability; blood pressure maintenance outweighs theoretical ICP concerns. 3

---

Respiratory Management: Strict Ventilation Targets

Maintain PaO₂ ≥13 kPa (≥98 mmHg), PaCO₂ 4.5-5.0 kPa (34-38 mmHg), and avoid both hypercarbia (which increases ICP) and hypocarbia (which causes cerebral vasoconstriction and worsens outcomes). 2

Ventilator Settings and Monitoring

• Continuous end-tidal CO₂ monitoring is mandatory—validate with arterial blood gas at departure, mid-flight (during stopover), and before landing. 1, 2
• Current settings (PRVC, TV 90 mL, PEEP 6, FiO₂ 0.4) are appropriate, but be prepared to increase PEEP to 8-10 cmH₂O if oxygenation deteriorates during altitude changes. 2
• The 4.5 mm ETT is small—have suction immediately available and suction frequently to prevent tube obstruction, but do so gently to avoid ICP spikes. 1

PARDS-Specific Concerns

• Lung-protective ventilation is critical—tidal volume of 9 mL/kg is acceptable but do not exceed 10 mL/kg to prevent volutrauma. 4
• Monitor for recurrent pulmonary hemorrhage: any new blood in ETT secretions requires immediate assessment of coagulation status and Factor VIII levels. 1

---

Hemothorax and Chest Drain Management

The right intercostal drain is your lifeline—secure it meticulously with multiple points of fixation and padding to prevent dislodgement during turbulence. 1

Monitoring During Flight

• Document chest drain output hourly—any sudden increase (>2-3 mL/kg/hour) suggests re-bleeding and requires immediate coagulation support. 1
• Altitude changes can cause pneumothorax expansion—monitor for sudden respiratory deterioration, decreased breath sounds, or cardiovascular compromise during ascent/descent. 2
• Have equipment for emergency chest drain insertion available, though any procedure must wait until the aircraft is completely stationary. 2

---

Coagulation Management: Prevent Catastrophic Re-Bleeding

This child's von Willebrand disease type 3 with Factor VIII deficiency makes him exquisitely vulnerable to re-bleeding in any compartment (brain, lung, pleural space) during a 9-hour flight. 1

Factor Replacement Strategy

• Ensure adequate Factor VIII concentrate supply for the entire journey plus 50% extra—calculate based on 40-50 IU/kg every 8-12 hours to maintain levels >50%. 5
• Continue tranexamic acid infusion throughout transport to prevent fibrinolysis. 5
• Vitamin K should already be on board; if not documented, give 1 mg IV/IM before departure. 5
• Have fresh frozen plasma, cryoprecipitate, and platelets available in transport coolers—this child may need emergency transfusion if re-bleeding occurs. 1

Monitoring

• Check coagulation parameters (PT, aPTT, Factor VIII level) before departure and at the stopover—do not depart if Factor VIII level is <50% or if there are signs of active bleeding. 1

---

Hemodynamic Management: Blood Pressure is Everything

Hypotension will worsen both cerebral perfusion and coagulopathy—maintain systolic BP 90-120 mmHg (current range) with MAP 55-85 mmHg. 1

Monitoring and Access

• Arterial line transducer must be positioned at the level of the tragus (not the phlebostatic axis) when the child is head-up. 2
• Have two secure IV lines—one for continuous infusions, one for emergency medications and blood products. 1
• Prepare vasopressors (metaraminol or norepinephrine) for immediate use if blood pressure drops during flight. 1, 2

SVT History

• This child has a history of supraventricular tachycardia—have adenosine (0.1 mg/kg, max 6 mg) immediately available and be prepared for synchronized cardioversion if SVT recurs. 1
• Avoid hypovolemia and maintain adequate sedation, as both can trigger arrhythmias. 1

---

Sepsis and Infection Control

Continue meropenem and vancomycin on schedule during transport—intermittent fever suggests ongoing infection despite negative cultures. 1

• Monitor temperature hourly—both fever (which increases metabolic demand and ICP) and inadvertent hypothermia (from aircraft temperature) must be prevented. 1, 2
• Maintain normothermia (36.5-37.5°C) using active warming or cooling as needed. 1

---

Withdrawal Management

Sedative-opioid withdrawal can cause agitation, hypertension, and tachycardia—all catastrophic in a brain-injured child. 1

• Do not reduce sedation during transport—maintain current regimen and have additional doses prepared. 1
• Clonidine or dexmedetomidine may be useful if withdrawal symptoms emerge despite adequate opioid dosing. 6

---

Equipment and Supplies Checklist

Age-appropriate equipment for a 10 kg child must be immediately accessible in a dedicated pediatric transport bag. 1

Essential Items

• Osmotherapy: Hypertonic saline 3% (30 mL) and mannitol 20% (50 mL) 1
• Emergency airway: ETT sizes 4.0,4.5.0; laryngoscope with size 1 and 2 blades 1
• Coagulation products: Factor VIII concentrate (minimum 1000 IU), FFP, cryoprecipitate 5
• Vasopressors: Metaraminol, norepinephrine, epinephrine (all weight-based doses pre-calculated) 1
• Antiarrhythmics: Adenosine 1 mg (0.1 mg/kg dose) 1
• Glucose: D10W for hypoglycemia (young children are prone to rapid hypoglycemia) 1
• Chest drain supplies: Heimlich valve, additional chest tube, sterile insertion kit 1

---

Stopover Management

The stopover is your opportunity to reassess and stabilize—do not rush this phase. 1

• Perform arterial blood gas, check Factor VIII level, and assess coagulation parameters. 1
• Examine the child completely: neurological status (GCS), chest drain output, ETT position, all line security. 1
• Communicate with the receiving PICU—update them on any changes and confirm they are prepared for arrival. 1

---

Critical Pitfalls to Avoid

• Never allow hypotension to persist—stabilization takes precedence over departure time. 1, 2
• Never hyperventilate—PaCO₂ <4.0 kPa causes cerebral vasoconstriction and worsens outcomes. 1, 2
• Never perform procedures during active flight—bring the aircraft to a complete halt first. 2
• Never assume the EVD is functioning properly—altitude changes can affect drainage; monitor neurological status continuously. 1
• Never allow Factor VIII levels to drop below 50%—re-bleeding in any compartment could be fatal. 5
• Never use hypotonic fluids—only isotonic saline (0.9%) with glucose added if needed for hypoglycemia. 1, 2