Complex, high-acuity services cannot be offered at every site
where children receive medical care. These services are expensive
and require personnel resources that are in limited supply. Thus,
it is best to concentrate skilled caretakers and equipment in hospitals
and medical centers that function as local, regional, or national
or international referral centers. In the United States and other
industrialized countries, implementing this principle has resulted
in the development of interhospital referral networks reminiscent
of the hub-and-spoke distribution system used by the airlines. In most
cases, the referral centers, or hubs, have developed highly detailed
protocols for the transfer of patients to their facilities, sometimes
involving complex stabilization efforts at the referring facility
and in transport.
The success of these protocols at a local level has resulted
in the progressive adoption of basic standards and expectations
around the transfer of patients at a more global level. These expectations
invariably start with the clinician, who is first confronted with
an acutely ill child and who must recognize that the problem exceeds the
skills and resources immediately available and who becomes responsible
for the preparations needed before the transport team is available.
The important steps of recognizing the severity of the situation,
establishing a first diagnostic evaluation, and implementing the necessary
stabilization measures have been facilitated enormously by the wide
distribution of the American Heart Association’s pediatric advanced
life support (PALS) guidelines.1 PALS guidelines
are updated frequently and are an invaluable repository of information
and an excellent vehicle for the education of any clinician who
cares for sick infants and children.
The scope of this chapter cannot include every possible scenario
for stabilization and transport. Rather, the chapter details the
most common circumstances and courses of action involved in the
The effort to stabilize an acutely ill or unstable infant or
child for transportation is dependent on both the physiological
derangement and the speed with which the transfer can be carried out.
The latter is obviously influenced by factors such as distance,
available means of transportation, and frequently the weather in
the area, particularly if an aircraft is used. The decision of which
institution to send the patient should ideally be based on the perceived
acuity and the type of illness/injury, and should generally
favor the closest option that is equipped to care for the patient
during the acute period and thereafter. Unfortunately, extraneous
considerations such as the type of insurance the patient has or
the existing patterns of referral often influence the course of
action, not always in the best interest of the child.
Whether initiated in a primary care office, an emergency room,
or a hospital, the preparations for transport always start with
the recognition and summary evaluation of the patient’s
problem. Every clinician should ideally be prepared to recognize,
diagnose, and begin treatment for life-threatening respiratory,
circulatory, and neurological impairments (see Chapters 102, 103, and 104).
Often this ...