Chapter 107: Neonatal and Pediatric Transport

Regionalized intensive care for neonatology and pediatric care¹ focuses expensive, high-technology, labor-intensive therapies to a few regional centers. This model is based on the reduction of morbidity and mortality for trauma patients at designated trauma centers.^2,3 Because patients in need of specialized services often present to other hospitals, interfacility transport is an important complement to regionalized intensive care.⁴ Specialized pediatric transport services improve safety, decrease unplanned adverse events (especially airway events), and lower mortality.^4,5,6 This chapter reviews the general and pediatric considerations for the interfacility transport of critically ill neonates and children.

Caring for critically ill children is best accomplished with at least two patient care providers on each team in addition to the driver or pilot. One of the patient care members should be a registered nurse with a minimum of 5 years of experience, typically at least 3 years of neonatal or pediatric critical care or ED training.⁴ Additional member(s) may include a respiratory therapist, physician, or paramedic. The condition of the child and local resources determine the exact composition of the specialized transport team.

Transporting critically ill patients adds to the risks of the illness or injury because of the hazards associated with the transport environment, particularly for neonates and children.⁷ The features of transport that distinguish the transport environment from the ED setting and the effects of these features on patients and caretakers are outlined in Table 107-1.

PRECAUTIONS

Suggested guidelines to minimize the impact of the limitations inherent in a transport environment are

1. Prepare the transport vehicle. Transport vehicles should be prepared to meet the special needs of children (e.g., accessory lighting, controlled thermal environment) and should be stocked with the necessary equipment. A list of the minimum necessary equipment for ambulances, which can serve as a guide for EMS agencies, has been published by the Emergency Medical Services for Children program.¹⁰

2. Stabilize the patient before transport. Unless the immediate needs of the patient can only be met in the receiving hospital (e.g., emergent surgery), ample time should be devoted to stabilizing the patient in the referring hospital. Time spent undertaking goal-directed intensive care interventions early in the course of the patient illness at the referring hospital does not worsen patient outcomes.¹¹

3. Monitor as many physiologic parameters as possible electronically. Because physical examination is difficult during transport, and because children often are transported during dynamic changes in their physiologic condition, electronic monitoring is essential. Important monitoring equipment commonly used during transport includes cardiorespiratory monitor (selected based on its size, weight, battery life, and resistance to motion artifact); continuous pulse oximetry with a plethysmographic waveform to assist in identifying motion artifact; temperature monitor (of infants and incubator air temperature); carbon dioxide monitor using continuous inline infrared analysis (or transcutaneous carbon dioxide monitoring or arterial blood analysis), which can aid in early identification of unplanned extubation¹²; invasive or noninvasive blood pressure monitoring; and portable blood gas analyzer.

4. Anticipate deterioration. Preparation of the patient should include not only care for the identified problems but also anticipation of problems that may arise during transport. The application of this principle may lead to performance of procedures or therapies before transport such as gastric decompression, placement of a chest tube for pneumothorax, or transfusion.

DECISION TO TRANSPORT

Children require transfer to a regional center if the current or anticipated medical care needs of the patient exceed the resources of the local hospital. Arranging transfer to the regional center can occur simultaneously with assessment, resuscitation, and stabilization at the local hospital. Discussion with the receiving hospital and specialists can aid in decisions regarding the mode of transport and composition of the transport team.

ASSESSMENT

Proper assessment is the cornerstone of neonatal and pediatric critical care, as management cannot begin until the critical patient is correctly identified. An important tool in pediatric assessment is the Pediatric Assessment Triangle (Figure 107-1). Each face of the triangle represents a critical feature in neonatal and pediatric assessment: Appearance, Work of Breathing, and Circulation. This method can be applied quickly to reliably and accurately assess a potentially critically ill patient and determine the need for life-saving interventions.

BASIC ASSESSMENT

Stabilization is the responsibility of the referring hospital personnel, to the limits of their abilities and resources. Because dealing with a sick neonate is an infrequent occurrence for people working outside of neonatal intensive care units, the Sugar/Safe care, Temperature, Airway, Blood pressure, Lab evaluation, Emotional support (STABLE) mnemonic was created by the developers of the S.T.A.B.L.E.^® course (http://www.stableprogram.org) to aid recall of the steps for managing infants prior to transport.¹³ The principles of STABLE include maintaining blood glucose at 50 milligrams/dL for transport; sustaining a neutral thermal environment with a core temperature range for a neonate of 36.5°C to 37.5°C (97.7°F to 99.5°F); assuring airway patency and respiratory support necessary for optimal ventilation and oxygenation; maintaining adequate blood pressure to provide oxygen delivery to the tissues (normal blood pressure for preterm infants is 45 to 60/25 to 35 mm Hg); laboratory evaluation directed by the underlying condition; and emotional support for the family in crisis.

AIRWAY MANAGEMENT

Intubation and mechanical ventilation are performed to (1) protect the airway from obstruction, (2) ensure adequate ventilation, or (3) provide adequate oxygenation. While this principle applies to both inpatients and those being prepared for transport, the threshold for intervention is lowered for patients requiring transport.¹⁴ For example, an infant with an elevated partial pressure of arterial carbon dioxide level might be observed without ventilatory support in the inpatient setting but may need to be intubated and ventilated in preparation for transport. In addition, children without respiratory failure but in whom deterioration is anticipated should be intubated in preparation for transport. This more aggressive approach to airway management is justified because the ability to identify respiratory failure and to intubate is impaired during transport.

Principles of infant and pediatric airway management including appropriate airway equipment and sizes are reviewed in chapter 111, "Intubation and Ventilation in Infants and Children."

Some airway problems specific to transport are worthy of mention. Even if the child is already intubated at the transferring institution, or if intubated by the transport team confirm or reconfirm tube placement by several methods: direct visualization, auscultation, end-tidal carbon dioxide detection, or chest radiograph for positioning.¹⁵ Make sure the endotracheal tube is well secured, and stabilize the tube by hand when moving the child to make sure movement doesn't dislodge the tube from the trachea into the esophagus. Right mainstem intubation is common in neonates. Prolonged right mainstem intubation increases the likelihood of pneumothorax and is particularly hazardous in premature infants, many of whom will later receive surfactant through the endotracheal tube. Before departure, and soon after the initiation of mechanical ventilation, obtain an arterial blood gas analysis to ensure appropriate oxygenation and ventilation.

Ventilators for transport should accommodate the needs of all pediatric age groups. Neonates are most often ventilated with time-cycled, pressure-limited ventilators using intermittent mandatory ventilation. Older infants and children typically require volume-assisted ventilation using synchronized intermittent mandatory ventilation. Causes of acute decompensation in the mechanically ventilated patient can be remembered using the DOPE mnemonic: (1) dislodgement or obstruction of the endotracheal tube; (2) faulty oxygen source; (3) pneumothorax; and (4) equipment failure.

Initial Ventilator Settings

Neonates are most often ventilated with time-cycled, pressure-limited ventilators using intermittent mandatory ventilation. The goals of mechanical ventilation are to maintain adequate tissue oxygenation while minimizing pressure-induced trauma to the lungs. This is best achieved utilizing a strategy of effective lung recruitment with positive end-expiratory pressure combined with permissive hypercapnia.¹⁶

Preset peak inspiratory pressure, a positive end-expiratory pressure, and an inspiratory time determine the volume of each breath. Suggested initial peak inspiratory pressure for term neonates is 20 to 25 cm of water depending on the severity of respiratory disease, while positive end-expiratory pressure is usually set at 5 cm of water, with an inspiratory time of 0.3 to 0.35 seconds and a rate of 20 to 40 breaths per minute.

Older infants and children typically require volume-assisted ventilations using synchronized intermittent mandatory ventilation, with a volume of 8 to 10 mL/kg, positive end-expiratory pressure of 5 cm of water, pressure support of 10 cm of water, fraction of inspired oxygen >60%, and variable rate depending on normal rate for age and underlying disease process. Obtain an arterial blood gas after initiation of mechanical ventilation to guide future changes. Increases in oxygenation can be achieved by increasing positive end-expiratory pressure and fraction of inspired oxygen, whereas increases in ventilation can be achieved by increasing rate and pressure support.

Ventilator Troubleshooting

Causes of acute decompensation in the mechanically ventilated patient can be remembered using the DOPE mnemonic, discussed earlier: (1) dislodgement or obstruction of the endotracheal tube; (2) faulty oxygen source; (3) pneumothorax; and (4) equipment failure.

The Difficult Airway

Success rates for pediatric direct laryngoscopic intubation are lower than those for adults, and providers must be familiar with advanced airway techniques (see chapter 111, "Intubation and Ventilation in Infants and Children").¹⁷ Supraglottic devices like the laryngeal mask airway and esophageal-tracheal combination tubes can serve as potential rescue devices, and video-assisted laryngoscopy devices may help indirectly visualize the difficult airway.

VASCULAR ACCESS

Nearly all patients should have intravascular access during transport. Critically ill children should have at least two lines of vascular access in case one becomes dislodged or several medications need to be administered simultaneously. For newborns, consider using umbilical vessels for vascular access. Intraosseous cannulation is an alternative technique for fluid and drug administration when intravascular lines cannot be placed or the severity of illness demands immediate access (see chapter 112, Intravenous and Intraosseous Access in Infants and Children).

In small children, IV lines should be infused with the use of pumps. Open "drips" should not be used, even with volumetric drip chambers, because of the risk of fluid overload from inadvertent administration of large boluses. The amount of fluid administered before and during transport should be monitored and carefully recorded.

A small subset of children may do better without IV placement, because IV placement can agitate the child and further compromise the airway. This is particularly true for children with a partial airway obstruction from croup, a foreign body, or epiglottitis. The best measure in the situation of partial airway obstruction may be to keep the child as calm as possible, allow the child to sit in the caregiver's lap during transport, and refrain from IV placement.

Pre-established transfer protocols should provide information about each regional center to which a patient might be referred, including (1) special services available; (2) criteria for referral; (3) telephone numbers for consultation, referral, and transport; (4) distance and usual response time; (5) type of transport personnel and their capabilities; (6) type of transport vehicles; and (7) protocols for preparation of patients. Establish formal agreements with regional centers that outline the circumstances under which patients can be transported without prior administrative approval. Clinical approval of transfers is always physician to physician.

Once the decision has been made to transport a child, the referring hospital has certain legal obligations to the patient in addition to provision of medical care.¹⁸ In the United States, the referring physician is responsible for arranging an appropriate mode of transport to a hospital capable of providing the services needed by the patient and stabilizing the patient as best as possible before transport. The referring physician should inform caregivers of the need for transfer and the risks and benefits, and discuss the transport modality. Written consent for transport should be obtained from a parent or other legal guardian. Important documentation to provide for the receiving facility and care team includes a copy of the current medical record, laboratory data, radiographs, and old medical records, if available.

Clear communication between the referring and receiving physicians is essential. Standardized techniques can help mitigate communication errors, such as the ISBARQ (introduction, situation, background, assessment, recommendation, questions) model developed by Children's Hospital of Philadelphia: During the introduction, the referring physician and patient are identified; the situation is conveyed by the working diagnosis and current medical condition; background includes what is known about the patient, such as past medical history and past tests or treatments; assessment communicates what is happening at the time of transport (current findings, patient needs, treatments, new test results); recommendations are made by receiving physicians regarding further stabilization of the patient, sometimes at the request of the referring doctor (although referring physicians are not obligated to follow these recommendations if they are considered to be medically inappropriate or beyond the capabilities of the referring hospital); and the process concludes with mutual questions that allow for further clarification.^18,19

For most critically ill children, ideal care is provided when the ED of the referring hospital devotes its energy to providing emergent short-term medical care, and the responsibility for transport is left to a regional center. This is particularly true for neonates because of the special equipment and expertise required for transport. When transport services are not provided by the regional center or when time is critical, the only option may be for the referring hospital to provide transport. In these circumstances, it is the responsibility of the referring center to ensure the adequacy of care, as best as possible given available resources and personnel, during transport.

In many areas, physicians have a choice between air and ground transportation. This decision should be made collaboratively between the referring and accepting physicians.²⁰ The risks and benefits of air transport are discussed in chapter 3, Air Medical Transport. Time, distance, traffic, weather, geographic constraints, and availability all factor into the decision regarding mode of transport. When the transport team arrives, the referring physician and local ED staff should be available to coordinate the transition of care and communicate the patient history, recent events, and the care already provided.

Referring providers should provide the family members with written directions to the receiving institution when they are not able to accompany their child in the transport vehicle. Additional helpful information includes parking information, nearby accommodations, and visiting policies of the receiving institution, if known. Allowing a family member to accompany the child during ground transport is valued by the patient and family and does not interfere with the delivery of care.^21,22 Clear communication with family members about the medical needs of the patient, appropriate parental behavior, and logistics involved may help alleviate disruptions during transport. Ultimately, if it is anticipated that family member involvement will diminish the quality of care, it will be necessary to encourage them to meet their child at the receiving institution.

Critically ill neonates depend on extrinsic factors to maintain homeostasis. This is particularly true when birth occurs before term; the complexity of care is often inversely related to birth weight and gestational age. Aspects of clinical care that deserve special consideration when preparing neonates for transport can be remembered using the STABLE mnemonic described earlier.¹³ Common neonatal emergencies are discussed in chapter 114, Neonatal Emergencies and Common Neonatal Problems, and specific considerations for transport are summarized in the following.

HYPOGLYCEMIA

The most common metabolic abnormality in newborns is hypoglycemia, which is discussed in detail in chapter 144, Metabolic Emergencies in Infants and Children. At birth, blood glucose in the neonate is approximately 60% to 70% of the maternal level and falls to approximately 40 milligrams/dL (2.22 mmol/L) within 1 to 2 hours. This decline may be accentuated in premature or small-for-gestational-age infants, acutely ill infants with increased glucose utilization, and certain other high-risk infants (e.g., infants of diabetic mothers, large-for-gestational-age infants). Because of the risk of hypoglycemia, all neonates should receive glucose-containing fluids in preparation for and during transport. An initial glucose infusion rate of 4 to 6 milligrams/kg/min should be targeted, and this can be achieved with 10% dextrose in water infused at a rate of 80 mL/kg/d. Sometimes a bolus of dextrose may be necessary, which can be achieved with 4 to 5 mL/kg of 10% dextrose solution. Repeat measurement of blood sugar at 15- to 30-minute intervals, with a goal to maintain serum glucose at 50 milligrams/dL (2.7 mmol/L).

HYPOTHERMIA

The normal core temperature range for a neonate is 36.5°C to 37.5°C (97.7°F to 99.5°F). A neutral thermal environment is provided when the infant's body temperature is normal and there is a minimal gradient between the core and the skin temperature.

Newborns attempt to conserve heat by several mechanisms: (1) peripheral vasoconstriction, (2) increasing voluntary muscle activity, (3) flexion to conserve exposed surface area, and (4) nonshivering thermogenesis. All of these mechanisms, except nonshivering thermogenesis, are less effective in the neonate than in older infants and children. Unintentional hypothermia in the neonate and young infant can lead to apnea, multisystem organ failure, inability to resuscitate, or intracranial hemorrhages in those most susceptible. The transport vehicle should be equipped with a closed heated incubator with an automatic temperature regulator. If the transport vehicle does not have a closed incubator, an overhead radiant heat source and increasing the heat inside the transport vehicle are other options. During transport, it is necessary to monitor the patient's body temperature frequently to avoid hyper- or hypothermia.

INDUCED HYPOTHERMIA

Therapeutic hypothermia is now a standard of care for neonates with perinatal asphyxia. Guidelines from the International Liaison Committee on Resuscitation recommend therapeutic hypothermia for term or near-term infants with evolving moderate to severe hypoxic-ischemic encephalopathy. Hypothermia lowers mortality rates and improves neurodevelopmental outcomes (number needed to treat = 9).²³ Initiate cooling to a temperature of 33.5°C within the first 6 hours of life using the whole-body method or selective head cooling, and continue cooling throughout transport.

HYPOXEMIA

Recommendations from the 2010 international consensus on neonatal resuscitation²³ state that resuscitation of term babies should begin with room air rather than 100% oxygen and that administration of supplemental oxygen should be regulated by blending oxygen and room air, to a concentration guided by pulse oximetry. A normal newborn would not be expected to achieve normal oxygen saturation during the first 10 minutes. Begin resuscitation of neonates <32 weeks of gestation with 30% to 90% oxygen and titrate according to pulse oximetry (Table 107-2); if blended oxygen and air is not available, use room air (see chapter 108, Resuscitation of Neonates).

For mechanically ventilated patients, arterial blood gas is the gold standard for assessing the efficacy of ventilation and oxygenation and modifying ventilator settings; however, capillary or venous blood is acceptable for measurement of the partial pressure of carbon dioxide and pH in the absence of access to arterial blood. The target ranges for oxygenation and ventilation of neonates differ according to the disease process and gestational age (Table 107-2). No clear relationship has been established between specific partial pressure of arterial oxygen values and adequate tissue oxygenation. It is acceptable to use pulse oximetry alone to guide fraction of inspired oxygen. The overall goal during transport should be to deliver the minimum required fraction of inspired oxygen to maintain adequate tissue oxygenation. The blending of oxygen and air to deliver the minimum fraction of inspired oxygen required to achieve adequate oxygenation is essential in premature infants because of the known retinal and pulmonary toxicities of oxygen.^24,25

RESPIRATORY DISTRESS SYNDROME

Premature infants with respiratory distress syndrome present with progressively worsening retractions, tachypnea, and oxygen requirements because their lungs are too immature to synthesize surfactant. This disease has a characteristic radiographic pattern that includes "ground glass" opacities in the lung parenchyma and prominent air bronchograms (Figure 107-2). Initial therapy for respiratory distress syndrome involves continuous positive airway pressure to stent open airways, thereby reducing collapse of alveoli and limiting further damage. Continuous positive airway pressure can be administered during transport through specially designed nasal cannula–type devices (with a continuous pressure of 4 to 6 cm of water) in the nonintubated patient with mild respiratory distress. A similar strategy should be used in the intubated patient by adjusting the ventilator to provide a positive end-expiratory pressure of 4 or 5 cm of water such that there is never a period of negative pressure during passive exhalation. For intubated infants with respiratory distress syndrome, administer surfactant through the endotracheal tube. This procedure can result in rapid changes in pulmonary compliance, can cause transient airway obstruction, and can be associated with pulmonary hemorrhage. For these reasons, only experienced personnel should administer surfactant. When an infant needs surfactant but the referring institution is unable to administer it, transport personnel to administer surfactant as soon as they arrive on site, thereby minimizing further treatment delay.

PERSISTENT PULMONARY HYPERTENSION

Pulmonary circulation is attenuated in the fetus by high intrinsic vascular resistance in the pulmonary arterioles and bypass shunting around the lungs via the ductus arteriosus. The rapid transition from fetal to newborn circulation includes a precipitous drop in pulmonary vascular resistance concomitant with lung expansion, followed by increased pulmonary blood flow in the first minutes of life and a gradual closing of the ductus arteriosus over the next 48 hours. Unfortunately, there are several common conditions that can disrupt this progression, including meconium aspiration, hypothermia, sepsis, and birth depression. Early diagnosis of persistent pulmonary hypertension is essential to prevent patient morbidity.

Infants with persistent pulmonary hypertension demonstrate labile oxygenation despite adequate ventilation due to right-to-left shunting of blood through the ductus arteriosus (Figure 107-3) or patent foramen ovale. This usually can be detected by placing a pulse oximetry probe on the right hand (preductal) and a second probe on a foot (postductal). Shunting is suggested by a preductal saturation greater than postductal by >10% in a newborn. With shunting exclusively at the atrial level, saturations are low, but the preductal to postductal saturation difference will not be observed.

Initial management of severe persistent pulmonary hypertension includes intubation, administration of 100% oxygen (a pulmonary vasodilator), optimization of ventilation to promote lung recruitment (Table 107-2), correction of acidosis, maintenance of high-normal blood pressures (with fluid boluses and inotropic agents if necessary), maintenance of a normal hematocrit, correction of metabolic abnormalities (hypocalcemia, hypoglycemia), sedation, and sometimes paralysis (to minimize intrathoracic pressure). These therapies may transiently stabilize critically ill infants with persistent pulmonary hypertension but are damaging in the long term. Inhaled nitric oxide is a potent pulmonary vasodilator that can be used after conventional therapies are optimized. Some neonatal transport teams carry portable inhaled nitric oxide tanks. When possible, transport of a neonate with persistent pulmonary hypertension should be performed by a team that can administer inhaled nitric oxide, thus minimizing the time to treatment. Infants who do not respond to conventional therapy or inhaled nitric oxide are likely to require extracorporeal membrane oxygenation for survival. For this reason, infants with severe persistent pulmonary hypertension should be transported preferentially to extracorporeal membrane oxygenation centers.

CONGENITAL HEART DISEASE

Because fetal oxygenation occurs through the placenta, cyanotic heart lesions usually are asymptomatic in the fetus, and a number of cyanotic heart lesions dependent on the ductus arteriosus for pulmonary blood flow at birth remain clinically silent until the time of ductal closure. This sequence of events can result in delayed diagnosis of cyanotic heart disease and a subsequent need for emergency management. The presentation and management of congenital heart disease is discussed in chapter 126, Congenital and Acquired Pediatric Heart Disease, and includes (1) supportive interim management and (2) reopening and maintaining ductus arteriosus patency with a prostaglandin E₁ infusion. Prostaglandin E₁ typically is started by the transport team at 0.05 microgram/kg/min and titrated according to oxygen saturation up to 0.1 microgram/kg/min when trying to reopen the ductus in a severely ill patient. Patients with previously undiagnosed cyanotic heart lesions should be transferred to a tertiary facility that can perform pediatric cardiovascular surgery.

HYPOTENSION

Neonatal hypotension is defined as a systolic blood pressure less than 60 mm Hg. In newborns, hypotension occurs secondary to hypovolemia (intrapartum or postpartum hemorrhage), cardiogenic failure, sepsis, or a combination of these conditions. Physical examination findings of hypotension include weak peripheral pulses, cyanosis, poor perfusion (represented as a capillary refill time >3 seconds), pallor, and cool and mottled skin. Treatment for neonates with hypovolemic shock relies on volume resuscitation initially with normal saline at 10 mL/kg, as larger volumes may be associated with increased risk for intraventricular hemorrhage. In the presence of hypovolemic shock and anemia, administer cross-matched packed red blood cells. Treat cardiogenic failure with inotropic agents (dopamine at 2.5 micrograms/kg/min titrated to desired blood pressure up to 20 micrograms/kg/min).¹⁶ In septic shock, capillary leak and the ongoing third space losses will require volume replacement, and the cardiac effects will require inotropic support. Requiring large amounts of volume replacement is not uncommon for infants in septic shock.

To provide volume and inotropes, peripheral venous access must be obtained, and this may be technically challenging. Consider emergent cannulation of the umbilical vessels or use of intraosseous lines (see chapter 112, Intravenous and Intraosseous Access in Infants and Children).

INFECTION

Signs and symptoms of infection in a neonate are often nonspecific and may be indistinguishable from those associated with other diseases. See chapter 116, Fever and Serious Bacterial Illness in Infants and Children, for details on the evaluation and management of neonates and infants with fever, and consider empiric administration of broad-spectrum antibiotics including meningitic dosages of ampicillin (50 milligrams/kg) and gentamicin (2.5 milligrams/kg).²⁶ A third-generation cephalosporin should be added or substituted for gentamicin when gram-negative meningitis is suspected or confirmed on a cerebrospinal fluid gram stain.²⁷ Sick neonates require stabilization and rapid administration of empiric antibiotics, which should not wait for diagnostic studies such as lumbar puncture.

INBORN ERRORS OF METABOLISM

Inborn errors of metabolism encompass a complicated set of diseases involved with the metabolism of carbohydrates, fats, or proteins and are discussed in detail in chapter 144, Metabolic Emergencies in Infants and Children. Regardless of which defect is involved, the end result is depletion of ATP stores and the accumulation of toxic metabolites. Common presentation includes nonspecific symptoms such as vomiting, lethargy, and poor feeding. Fortunately, the principles of management for all emergent presentations of metabolic disease are the same: stop feedings, provide dextrose, and facilitate removal of the toxic metabolites. Stabilization therapy is 10% dextrose in normal saline at 5 mL/kg/h. Additional therapies are discussed in chapter 144, Hypoglycemia and Metabolic Emergencies in Infants and Children.

VIABILITY

Delivery of premature infants who are at the limits of viability is not an uncommon occurrence in the ED. The first priority of the physician caring for the infant is to determine whether resuscitation is justified. In the United States, an infant born at a gestational age of <23 weeks, weighing <400 grams, and with gelatinous/translucent skin generally should not be resuscitated or transported. According to the 2010 guidelines,²³ when congenital anomalies are associated with almost certain death or an unacceptable high morbidity is likely among survivors, resuscitation is not indicated. Infants born after 23 weeks of completed gestation and without a congenital anomaly associated with a high rate of mortality or unacceptable morbidity are capable of relatively good outcomes and should be supported aggressively after birth. The decision to initiate support must be made immediately because any delay can have a deleterious effect on the infant's prognosis. If the decision is not clear or there is a condition associated with borderline survival and a high rate of morbidity, medical control should be contacted for further directions. The parents' views on resuscitation should be sought and supported. In a newly born baby with no detectable heart rate after 10 minutes of resuscitation, it is acceptable and appropriate to consider stopping resuscitation at that point.²³

The death of a newborn judged to be nonviable often does not occur rapidly, even in the absence of spontaneous respiration. After a decision has been made to withhold interventional care, it is important that the staff remain supportive and available to the parents. Additional support, such as family members, friends, or members of the clergy, should be identified and contacted. If the parents desire, the child can be held in a quiet place with a physician checking periodically to determine the time of death. This period, around the time of death, may be emotionally difficult for the staff as well as for the family. Futile efforts at resuscitation or interfacility transport should not be a substitute for compassionate support without medical intervention.

CONSENT FOR TRANSPORT

In most of the United States, the legal age of majority is 18 years old. However, in most states, mothers of younger ages have authority to consent for medical therapies for their children unless specifically prohibited by court order. Likewise, in many states, medical care for minors can be given without parental consent when it is emergent or involves reproductive health. Thus, the definition of the age of majority is situational and must be addressed on an individual basis within the confines of both federal and state law. In situations in which transport of a minor patient is advisable and a parent or guardian is not available (often the case with pediatric traumas), the minor patient can be transported under the principle of beneficence. In these cases, legal authorization for interfacility transport requires documentation from the referring physician stating that failure to transport would endanger the patient's well-being.

ANXIOLYSIS, ANALGESIA, AND SEDATION

Pediatric pain management is often overlooked but important, especially in anticipation of prolonged interfacility transport. In addition to comfort, adequate sedation may increase transport safety and help to prevent complications such as labile oxygenation and accidental extubation. Chapter 113, Pain Management and Procedural Sedation in Infants and Children, details the approach to assessment and treatment of pediatric anxiety, pain, and sedation.

SURGICAL ABDOMEN

Pediatric patients with surgical abdominal processes often require transfer to a pediatric center for definitive care. Common surgical conditions in the neonate and child are discussed in chapter 130, Acute Abdominal Pain in Infants and Children. Pretransport stabilization of these patients includes correction of hypovolemia, provision of adequate analgesia, decompression of the stomach with nasogastric or orogastric tubes (particularly for patients with obstruction who require unpressurized air transport), and maintenance of nothing by mouth status.