Retrieval, transport and interfacility stabilisation — formative SAQs

1. The retrieval principle

The governing principle is stay and stabilise, then move: bring intensive care to the child and then move the child through it. This infant is still on the ascending limb of resuscitation, with rising lactate and poor perfusion despite fluid, so he is not yet stable to transport. I continue resuscitation to a sustained perfusion trend, start vasoactive drugs, and secure the airway and ventilation before departure. A child who departs unstable arrives worse. [1] [4]

2. Pre-transport stabilisation

Airway. I secure the airway by rapid sequence intubation because shock, rising lactate and a likely meningococcal presentation predict respiratory failure; I confirm the tube with capnography and fix it firmly, checking cuff pressure because cuff gas expands at altitude. [1] [10]

Breathing. I set the ventilator to effective tidal volume and oxygenation, confirm an oxygen supply that covers the 90-minute flight plus a reserve margin, drain any pneumothorax before flight, and decompress the stomach. [10] [4]

Circulation. I establish two reliable points of access with at least one that takes rapid fluid, start a vasoactive infusion on a dedicated line, crossmatch blood, and continue aliquots to a sustained perfusion trend rather than a single blood pressure. [4] [8]

Disability and metabolic. I treat any seizure, correct glucose, record the Glasgow Coma Scale and pupils, and check the temperature; I warm the infant actively because a cold cabin will drive hypothermia and worsen shock and coagulopathy. [2] [8]

3. The structured referral

I give a structured referral using a standardised format: the identity, age and a working weight; the working diagnosis and current physiology; the actions taken and the response (40 mL per kilogram given, lactate rising, vasoactive drugs started); the local limit (no paediatric intensive care); what the child needs next (intensive-care retrieval to the paediatric ICU); and the safeguarding and family context. I confirm the receiving bed and the accepting consultant before departure. [6] [1]

4. Contingency for deterioration

I rehearse, with the escort team, who does what if the infant obstructs, desaturates, becomes hypotensive, seizes or loses a line in flight. I carry the drugs, the airway equipment and the fluid and blood to manage each, and I know where the journey can be interrupted if needed. The rehearsed plan turns an in-flight emergency into a managed event rather than a crisis. [2] [4]

1. Altitude physics and its fixes

Gas expands by Boyle's law as ambient pressure falls with altitude. At a typical pressurised cabin altitude of around 6000 to 8000 feet a trapped gas volume expands by up to about a third. A presumed pneumothorax can therefore become a tension pneumothorax in the cabin, so I drain it before flight and carry a plan to decompress in flight if needed. The cuff of the endotracheal tube also expands at altitude and can injure the tracheal mucosa, so I check the cuff pressure before departure and adjust it, with a plan to recheck it in flight. [4] [8]

2. Vibration, noise and cold

Vibration and noise jitter the waveforms, make alarms hard to hear over the engine, and make clinical signs hard to elicit, so I trust continuous monitored data — capnography, pulse oximetry and a credible blood pressure — and secure the child and every line before departure, because reassessment in flight is far less reliable than at the bedside. Cold steals heat quickly from a small body and worsens acidosis, coagulopathy and oxygen consumption, so I pre-warm the cabin, cover and wrap the child, use forced-air or exothermic warming, and monitor temperature throughout. Keeping the child warm is a resuscitation act, not a comfort measure. [2] [8]

3. Mode and escort

Rotary-wing transport is justified for a medium-distance, time-sensitive transfer where the speed gain over road outweighs the limitations of weather, cabin size, vibration and range. I escort the child with a specialist paediatric retrieval team that can manage the foreseeable deterioration — re-intubation, decompression, fluid and blood, vasoactive escalation — because matching the escort's skills to the child's needs is the key safety factor, more than the choice of vehicle. [1] [4]

4. Structured handover

I give a structured ISBAR or ISOBAR handover at the receiving door: identity and working weight; the diagnosis and current physiology; the actions taken and the response, including the units of fluid and blood given; the current ventilator and vasoactive settings; the timed events and any unresolved threat; the family and safeguarding context; and the next contingency with a named owner. I confirm acceptance of care and close the loop. [6] [1]