Transcript Document
In Flight Patient Care Considerations for: Gastrointestinal/Genitourinary Orthopedic EENT Objective • Apply knowledge of flight physiology and aviation environmental stressors in the planning and delivery of pre-flight and inflight care of patients with cardiopulmonary, gastrointestinal, genitourinary, neurological, ophthalmologic, otorhinolaryngologic, orthopedic, and burn injuries and conditions General Considerations • Preflight Mode of transport Patient Assessment Supplies Equipment General Considerations • • • • • • IV flow rates without pump O2 conversion table – sea level equivalent Securing patient and equipment Securing self Reliance on low tech physical assessment Hearing protection for patient and ERC personnel Gastrointestinal/Genitourinary Conditions • GI system encompasses 26 feet of liquid and gas-producing viscus • Average GI tract has approximately 1liter of gas present at any one time • Unrelieved GI gas expansion at altitude may produce pain, respiratory difficulty, lead to vasovagal reaction resulting in hypotension, tachycardia, syncope Gastrointestinal/Genitourinary Conditions • Preflight Assessment Diagnosis and treatment to date Assess bowel sounds Check NG for placement and patency Check urinary/suprapubic catheters for patency and output Assess vital signs, surgical sites, supplies and patency of other access lines Gastrointestinal/Genitourinary Conditions • Stresses of flight Decreased partial pressure of oxygen Decreased humidity Barometric pressure changes GI/GU Conditions • In-flight considerations Transport after abdominal surgery delayed 24-48 hours – air pockets may remain in abdominal cavity post-op can lead to emboli Movement within first 24 hours of abdominal surgery or GI trauma from Primary Blast Injury requires altitude restriction GI/GU Conditions • In-flight considerations Hypothermia and coagulopathy continuing problem – continue to provide warmed fluids in flight, keep patient warm Treat hypotension with judicious fluid bolus (4ml/KG) usually 250-500ml at a time Monitor urine output – minimum 30ml/hr GI/GU Conditions • In-flight considerations NG/OG to gravity or suction – never clamp, do not inject air –expands at altitude Pain meds, antibiotics Head elevated 30 degrees GI/GU Conditions • Surgical stabilization for liver, spleen, pancreas, intestinal trauma complicated by sepsis, wound infection, abscess formation Administer antibiotics Check surgical drains Wound vacuums Bogota bags Reinforce dressings – contaminated environment Orthopedic Conditions • Preflight Assessment Diagnosis and treatment to date Neurovascular checks – proximal and distal to injury, compare to non-injured extremity Vital signs, POX, Hgb, IVF, urine output Antibiotics, pin sites, fasciotomies Pain control Orthopedic Conditions • Stresses of flight Barometric pressure changes Vibration G-forces Decreased partial pressure oxygen Orthopedic Conditions • General Care Position on aircraft so that injured extremity is not against bulkhead/frame Elevate injured limb, keep immobilized Neurovascular checks Administer pain meds and antibiotics Check dressings, fasciotomies –drainage Orthopedic Conditions • General Care Monitor urine output – crush injuries maintain output >50ml/hr, assess for need for alkalinizing urine prior to transport Supply supplemental oxygen for Hgb <8.5 Possible altitude restriction for crush injuries, compartment syndromes, major bleeds s/p pelvic fracture Orthopedic Conditions • General Care Casts/Splints – bivalve plaster casts, no air splints Orthopedic Injuries • Fat Emboli Commonly associated with femur, long bone fractures Clinically manifests at 4hours to 4 days post-trauma –avg time 12-48 hours Cardinal sign – petecchial rash upper trunk, axilla, chest, conjunctiva Orthopedic Injuries • Fat Emboli Accompanied by mental status changes, agitation, acute dyspnea, tachypnea, tachycardia, dysrhythmias, chest pain, ARDS Intubate, ventilate, IV RL, supportive treatment of shock Orthopedic Injuries • Fat Emboli Accompanied by mental status changes, agitation, acute dyspnea, tachypnea, tachycardia, dysrhythmias, chest pain, ARDS Intubate, ventilate with peep, IV RL, supportive treatment of shock EENT Injuries • Eye Injury Preflight Assessment Diagnosis, treatment Vital signs, POX Assessment of associated injuries with focus on airway Establish communication plan EENT Injuries • Stresses of Flight Barometric Pressure changes – air bubble expansion along penetration tract, decreased blood flow leads to increase pain Decreased Partial pressure O2 –hypoxia dilates vessels leading to hemorrhage and increased IOP Decreased humidity – eye dryness EENT Injuries • Stresses of Flight Vibration – pain due to constant vibration leads to motion sickness EENT Injuries • In-flight Considerations Eye Injuries Cabin Altitude Restriction 4000ft and under Shield both eyes O2 administration especially for retinal injuries Elevate head to decrease IOP Artificial tears, pain medications,antibiotics EENT Injuries • In-flight Considerations Eye Injuries Antiemetic, immobilize head to prevent motion sickness Eye injury/ post-op repair should NEVER VALSALVA-Toynbee maneuver Avoid use of succinylcholine for RSI – increases IOP EENT Injuries • Preflight Assessment Ear Injuries Diagnosis, treatment Vital signs, physical assessment History of associated injuries – focus on airway Type of aircraft Length of exposure EENT Injuries • Stresses of flight Ear Injuries Barometric pressure changes – ear blocks Noise Vibration EENT Injuries • In-flight Care Ear Injuries Primary Blast Injury, post-op surgery middle ear – Altitude Restriction 4000 feet or under Hearing protection even if PBI with tympanic rupture Increased sensitivity to motion sickness – pre-medicate EENT Injuries • Preflight Assessment Maxillofacial Injuries Diagnosis, treatment Type of airway and patency Type of jaw immobilization if present Vital signs, POX, IVF, Hgb Presence of NG/OG and patency Medications EENT Injuries • Stresses of flight Maxillofacial Injuries Barometric pressure changes Decreased humidity EENT Injuries • In-flight considerations Maxillofacial Injuries Altitude restriction for sinus involvement and inability to valsalva Wire cutters, quick-release for jaw immobilization Pre-medicate with vasoconstrictor – Afrin Provide humidification, suction as needed EENT Injuries • In-flight considerations Maxillofacial Injuries Evaluate for pain/nausea and medicate Tracheostomy balloon filled with saline Elevate head EENT Injuries • In-flight considerations Posterior Nose Bleed IV fluid boluses to maintain SBP >90 Control bleeding – Foley catheter inserted through nostril to posterior pharynx, inflate balloon and withdraw until bleeding is controlled. Mid-face injuries nasal packing Break Time/Questions???