Assessment & Safety

Considerations to

Transport Patients by

Air

Presented at: ACEM workshop

By: Sutuspun Kajornboon, MD, Dip.Av.Med

Director, Civil Aeromedical Center BMC

Date: 2011

ASSESSMENT OF GENERAL APPEARANCE

• Apparent health status: (base on med

record)

• - Age apparent/chronological

• - Level Of Consciousness

• - Skin finding: presence/absence of

gross deformity, degree of edema, skin

lesion, fingertips & nail beds,

temperature, Turgor (sternum or

forehead)

• - Position of comfort: whenever

feasible during transfer

CARDIOVASCULAR ASSESSMENT

Inspection: acute or chronic health condition

Morbidly obese? Cachectic?

Skin color: pallor / cyanosis

Edema: differentiate between dependent / nondependent

Assessment done at bedside with nursing staff prior to leaving

A 12 lead ECG: a baseline rhythm copy, arrhythmia? treatment?

Ever required defib/cardioversion? Has pacemaker or implanted

cardiodefibrillator

Jugular venous distention indicator for fluid status

CARDIOVASCULAR ASSESSMENT

Assessing Pulse:

Assessed bilaterally for presence, strength, and pattern

Assessment finding over time more valuable than one time

2 person assessment is best, especially when life and limb is at

risk

Pattern of pulsation: not all electrical beat are perfused, check

heart rate on ECG monitor with rate on pulse oximetry display

CARDIOVASCULAR ASSESSMENT

Auscultation:

Each heart sound: evaluated for pattern, intensity, quality & pitch

Finding a new murmur: a systolic murmur after an MI is more

significant than a diastolic murmur of a patient who had it since

turning 90 yrs.old. (generally diastolic murmur are more concerning

than systolic murmur.

Over major artery: bruit and/or loud, hash sounds(flow thru

narrowed artery)

CARDIOVASCULAR ASSESSMENT

Auscultation:

BP is defined by individual patient

Trends in BP, before transport, should be noted, especially in

response to cardiogenic medications and interventions

BP is reassessed at interval based on patient’s condition (every 5

min for acutely ill, and up to 15 minute for stable critical care

patient)

Orthostatic BP are used to assess the need for fluid resussitation,

but Passive Leg Raising (PLR) give more accurate volume

depletion picture.

CARDIOVASCULAR

Preparing Cardiovascular Patients for Air Transport

Allow time to stabilize the following conditions before flight:

Unstable Angina

Congestive Heart Failure

Cardiogenic Shock

Acute Myocardial Infarction

Cardiac Arrhythmias

Immediate transport of patients with true surgical emergencies:

Dissecting thoracic or abdominal aneurysms

CARDIOVASCULAR

Conditions that can be Affected by

Altitude and Acceleration Exposure

Cardiac arrhythmias

Angina pectoris

Myocardial infarction

Congestive heart failure

CARDIOVASCULAR

Cardiovascular Effects of Hypoxia include:

respiratory rate

heart rate

systolic blood pressure

cardiac output

myocardial oxygen consumption

CARDIOVASCULAR

Considerations for Air Transport

Prevent ground and inflight hypoxia and monitoroxygen saturation (100% O2 & pulse oxymeter)

Prevent and be prepared to treat cardiacarrhythmias. Be prepared to perform CPR

Prevent and/or treat anxiety (explain flight profileand consider sedation during flight)

Inflight stress can be caused by acceleration,vibration, thermal changes and crowded conditions

CARDIOVASCULAR

Considerations for Air Transport

Minimize inflight stress by providing:

Physical comfort and pain relief (nitrates, morphine, narcotics)

Adequate hydration (preferably IV)

Oxygenation and humidification (oxygen mask with humidifier)

Bowel and bladder relief (Foley)

NG tube for gastric distension

Maintain normal body temperature

Decreased venous return

Decreased cardiac output

Increased venous return

Increased cardiac output

RESPIRATORY ASSESSMENT :

Inspection:

Mental status

Skin color & temperature; dry or diaphoretic

Presence of artificial airway

Spontaneous breathing or mechanical ventilation

Equal chest expansion with each breath

Use of accessory muscles

Breathing: labored or unlabored

Presence of chest tubes, central lines, and dressing

Presence of signs of injury

RESPIRATORY ASSESSMENT :

Palpation:

Skin warm & dry or cool & clammy

Skin crackling “snap, crackle, pop” (subcut. emphysema)

Trachea for alignment,

Chest wall for asymmetry (pneumothorax)

Subcutaneous emphysema: useful indicator of disease state

(ruptured bleb); Pt with chest tube (air leak); critically ill Pt on

ventilator during transport (too much tidal volume/+ end-

expiratory pressure); chest tube dislodged during transfer

RESPIRATORY ASSESSMENT :

Auscultation:

Compare directly with the opposite side

Normal breath sounds are only normal when correspond

anatomically

Crackles: air passing over fluid in small airways (atelectasis,

fluid congestion)

Rhonchi: air going thru large airways containing secretions.

Wheezing: inspiratory (upper airway obstruction); expiratory

(asthma attack)

Maintaining airway and adequate ventilation is of highest priority

RESPIRATORY

Effects of Barometric Pressure Changes in the

Thorax

Increased risk factors for pneumothorax:

History of previous spontaneous pneumothorax

Bleb or bullae formation, thoracic injury, asthma, emphysema

* EGTA, **EOA and ***PTL/ventilation with mechanical assist

Bag-valve assisted patient

Failure to vent a pneumothorax can lead to tension

pneumothorax

*EGTA - ethylene glycol tetra-acetic acid (mucin staining for surfactant factor)

**EOA – esophageal obturator airway

***PTL - pharyngeo-tracheal lumen airway

RESPIRATORY

Effects of Barometric Pressure Changes in the

Circulatory System

Air embolism can be caused by over-expansion of the lungs

Symptoms may include hypotension, LOC, cyanosis, tachycardia,

chest pain

Decompression Sickness

SCUBA divers are at increased risk (flying after diving)

Nitrogen leaves body tissues (mainly fat) and enters circulation

Symptoms vary depending upon location of nitrogen bubbles

blocking circulation

RESPIRATORY

Effects of Decreased Partial Pressure of Oxygen

(hypoxia):

Patient may decompensate with increasing cabin altitude

Results in inadequate alveolar ventilation

Severity depends upon:

Cabin altitude, length of exposure, pre-existing fatigue, smoking,

alcohol, drugs, ambient temperature, physical fitness, self-

imposed stress, hypoglycemia, and underlying medical conditions

RESPIRATORY

Underlying Medical Conditions Aggravated by

Hypoxia:

Respiratory Dysfunctions

COPD caused by severe asthma, acute bronchiolitis, emphysema

Chest wall disorders such as flail chest and kyphoscoliosis

Neuro-Muscular Dysfunctions

Diminished breathing volume caused by pneumonia, Guillian Barre

Syndrome, muscular dystrophy, and myasthenia gravis

Insecticide poisoning

RESPIRATORY

Underlying Medical Conditions Aggravated by

Hypoxia:

Central Nervous System Disorders

Impaired breathing caused by CVA, meningitis, encephalitis,

intracraneal hypertension

Secondary to seizures

Resulting vomiting and aspiration affects gas exchange

Pharmacological depressants

Effects of Thermal Stress:

Hypothermia or hyperthermia increase O2

consumption and CO2 production

Hyperthermia causes dehydration

Effects of High Altitude Decreased Humidity:

Dries mucous membranes

Aggravates pre-existing respiratory disorders

Oxygen is drying agent if not humidified

Endotracheal, tracheostomy and cricothyroidostomy

tubes increase patient susceptibility to airway drying

Effects of Noise Exposure:

Auscultation with normal stethoscope is difficult

Difficulty in detecting leaks around endotracheal tube or

tracheostomy cuff

Effects of Vibration Exposure:

Equipment connections should be taped

Water entering oxygen delivery system may reach patient

(fill nebulizer half-way only)

Effects of Turbulence:

May produce sudden and unexpected movement

Equipment could move if not properly restrained

RESPIRATORY

Patient Assessment and Management

Determine and secure airway prior to flight

Assess need and perform invasive airway procedures prior to

flight

Administer oxygen by the most appropriate route

Determine patient position by medical condition, weight and

placement of stretcher in aircraft

Prevent gastric distension by allowing patient relief prior to

flight, placement of a NG or oral tube, avoid gas producing

food and beverages, stop tube feeding 30 min prior to flight

RESPIRATORY

Patient Assessment and Management

Provide humidified oxygen during flights longer than 15 min

and at high altitudes

Warm the oxygen if needed at higher altitudes

Oxygen temperature depends upon cabin temperature,

oxygen flow rate, temperature of humidifier/nebulizer water,

and length of oxygen delivery tubing

Intubated patient must receive warm and moist oxygen

Oxygen can we warmed by placing tubing inside patient’s

blankets or using heat packs around the humidifier

RESPIRATORY

Patient Assessment and Management

Consider disconnecting bag-valve assembly during

patient loading and unloading

Transport patient at lowest cabin altitude if there is

suspected air embolism, decompression sickness or

intracraneal air

Have suction equipment readily available

Assist patient in relieving ear pressure during descent

Glasgow Coma ScoreEye Opening (E) Verbal Response (V) Motor Response (M)

4=Spontaneous

3=To voice

2=To pain

1=None

5=Normal conversation

4=Disoriented conversation

3=Words, but not coherent

2=No words......only sounds

1=None

6=Normal

5=Localizes to pain

4=Withdraws to pain

3=Decorticate posture

2=Decerebrate

1=None

Total = E+V+M

NEUROLOGICAL ASSESSMENT

BEFORE CRITICAL CARE TRASPORT

Established baseline status for comparison

LOC is most important parameter in evaluating CNS injury

Glasgow Coma Scale is a focal point of assessing a critical

care patient

Medication affect GCS: anxiolytics, narcotics, paralytics

Assess when sedated & not sedated

Pupils are assessed for increased ICP

NEUROLOGICAL ASSESSMENT

Pupil 4 common shape

• Round: normal & most common

• Oval: indicative of increase ICP is often seen just before brain

tissue herniation

• Keyhole: seen after iridectomies & usually react sluggishly

• Irregular: occurs most often after orbital truama

NEUROLOGICAL

Neurologic conditions that can be affected by flight:

Increased intracraneal pressure

Open and closed- head injuries

Neurogenic shock

Spinal cord injuries

Intra-cerebral hemorrhage

Seizures

Coma

NEUROLOGICAL

Flight factors that can affect the neurologic patient

• Hypoxia • Prolonged immobility

• Gas expansion • Air Sickness

• Dehydration • Vibration and Noise

• Decreased Temperature • G-Forces and Flicker Vertigo

NEUROLOGICAL

Effects of Barometric Pressure Changes in the Cranium

Air expansion in the skull can lead to increased intracranial

pressure and altered breathing patterns

Recent pneumo-encephalography and open depressed skull

fractures can increase risk of pneumocephalus

NEUROLOGICAL

Suspect spinal injury with:

Multiple trauma

Abnormal head tilting

Facial fractures (especially mandibular)

Spinal edema, tenderness or misalignment on palpation

Paraesthesias of extremities

NEUROLOGICAL

Pre-Transportation Stabilization

Stabilization of the head and neck

Stabilization of the spine

NEUROLOGICAL

Inflight Medical Care

Physical assessment: vital signs, respiratory status,

peripheral pulses, neurologic status, adverse effects of

altitude or stresses of flight

Prevent increases in intracraneal pressure by

controlling: pain, anxiety, combativeness, turbulence,

vibration, patient movement, ambient temperature,

blood pressure, hydration, hyperventilation

GASTROINTESTINAL ASSESSMENT

Inspection: overview of oral mucosa & abdomen

Dry mucous membranes (dehydration)

Large abdomen, hernia/masses,

Bruising over abdominal wall: trauma / bleeding into abdominal

cavity

Stool: color, consistency, foul odor

GASTROINTESTINAL ASSESSMENT

Auscultation:

Do it before palpation or percussion(false-positive bowel sound)

Bowel sound presence in all 4 quadrants

Hypoactive or hyperactive in various disease states

Great variation in bowel sounds with clinical conditions such as

an illeus

GASTROINTESTINAL ASSESSMENT

Percussion:

Useful in establishing size & location of liver and sometime

spleen

Dull sound at lowest left intercostal space (spleen is enlarged)

GASTROINTESTINAL ASSESSMENT

Palpation:

Use for document for tenderness or rebound tenderness

(peritoneal inflammation)

Pelvic is suspected, assessed for stability should not be done

by every caregiver

Murphy’s sign: when severe right upper quadrant pain on deep

palpation, often exacerbated by deep inspiration & associated

with cholecistitis.

GASTROINTESTINAL

Effects of Barometric Pressure Changes in the Abdomen

Discomfort from gas expansion can lead to hyperventilation

GI tract expansion can cause upward displacement of the

diaphragm or rupture

ORTHOPEDICS

Preparing orthopedic patients for air transport:

Assess airway, breathing and circulatory status (ABC)

Determine peripheral neurovascular status of injured

extremity

Mark location of peripheral pulses

Patient position & immobilization equipment

Adjust or replace equipment for air transport

Do not over-inflate air splints (indent ½ inch thumb)

ORTHOPEDICS

Preparing orthopedic patients for air transport:

Pad fixation pins

Bivalve spica casts and secure with ace wrap or tape

Carry wire cutters for fractured jaws that are wired and

use rubber bands

Use anti-emboli stockings for venous stasis

Use modified trendelenburg to prevent hypotension

ORTHOPEDICS

Preparing orthopedic patients for air transport:

Elevate injured extremities with edema, pad injured

areas for comfort and protect pressure points

Secure patient to stretcher using 3 straps: under axilla,

over pelvis, and over lower thighs (not over knees)

Secure stretcher to aircraft

Load patient carefully into aircraft to avoid disruption of

splinting devices

ORTHOPEDICS

Patient care during flight:

Evaluate neurovascular status of injured extremity

Monitor and adjust air volume in pneumatic splints

Reinforce dressings but do not change

Remoisten wet dressings

Maintain modified trendelenburg position

Pad fracture sites for comfort

PSYCHOSOCIAL and EMOTIONAL

ASSESSMENT

ESSENTIAL INFO:

After hospital more than 24 hours: psychosocial, emotional,

cultural assessment completed (useful for receiving facility)

Looks for significant coping needs relating to present illness

Looks for level of anxiety, any manifestation of unsafe behavior

requiring physical or chemical restraint during transport

Significant coping issues or high level of anxiety may interfere

with adequate analgesia and/or require administration of

anxiolytic / benzodiazepines

PSYCHIATRIC

PSYCHOLOGICAL

Combative psychiatric patients can be a serious

threat to the safety of flight personnel

Inflight noise, vibration, hypoxia and confined space

can provoke or increase combative behavior

Combativeness can be caused by psychosis, head

or CNS injuries, hypoxia, alcohol intoxication or

withdrawal

PSYCHIATRIC

PSYCHOLOGICAL

Predictors of violent or combative behavior:

Acute psychotic crisis

Organic brain syndrome

Post-seizure states

Antisocial personalities

Chemical poisoning

Severe claustrophobia

Fear of heights (acrophobia) or flying (avio-phobia)

PSYCHIATRIC

PSYCHOLOGICAL

Indications for physical restraint prior

to transport:

Combativeness history

Patient’s activities interfere with medical care

All unconscious patients

Patients with weapons

Prisoners

PSYCHIATRIC

PSYCHOLOGICAL

Types of physical restraints:

Rayon webbing

Leather restraining straps

Polyethylene cable ties

Handcuffs

Precautions:

Prevent limb injuries

Do not pad restraints

PSYCHIATRIC

PSYCHOLOGICAL

Pharmacological restraints:

Antipsychotics

Tranquilizers (benzodiazepines and narcotics

Neuromuscular blockading agents

General precautions:

Medications can depress respiration

Monitor breathing during flight

PSYCHIATRIC

PSYCHOLOGICAL

Patient care inflight:

Do not load or unload the patient in a hurry

Speak softly to the patient

Cover patient’s ears with a headset or ear plugs

Do not invade patient’s personal space

Land immediately if patient cannot be controlled

Patient Preparation for Air Transport:

Assess/treat only life-threatening conditions at scene

Respiratory/cardiovascular emergencies

Spinal immobilization

Perform enroute procedures in helicopter

IV solutions

Inflation of PASG or MAST

Pay particular attention to air-entrapping injuries

Head and facial (basilar skull fractures)

Pneumocephalus

Transport at lowest possible altitude

Reconsider ground transport if patient deteriorates

Chest and neck injuries

Pneumothorax

Subcutaneous emphysema

Suspected/risk of pneumothorax

Requires advanced aeromedical personnel

Administer supplemental oxygen

Establish definitive airway prior to transport

PASG or MAST prior to transport

Inflate during inflight

Monitor during altitude changes

Monitor air-filled splints and pneumatic infusion pumps

during altitude changes

Prevent hypothermia during air transport

Wrap patient circumferentially, cover patient’s head with

blankets, use warm and humidified oxygen, place hot packs

near groin and axilla, maintain high cabin temperature, avoid

prop or rotor wash, and keep windows closed to avoid air

drafts

Immobilize patients at risk for spinal injury

Patient may become combative (consider hard

restraints)

Start therapeutic measures during prolonged

extrication (if possible)

Monitor for abdominal distension

Monitor NG tube if present

Use intermittent or continuous low suction

Useful on long flights or when altitude is a factor

Monitor patient’s behavioral changes

Question?