Transcript In-Flight Patient Care Considerations For - NH-TEMS

In-Flight Patient Care
Considerations For:
O2 utilization
Cardiac
pulmonary
Mechanical Vent
Chest tubes
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
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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
Oxygen Utilization Rate
• Tank Factors
D cylinder = 0.16
E cylinder = 0.28
H cylinder = 3.14
• Calculating Duration of Cylinder Flow
Gauge PSI – safety residual x tank factor
liter flow per minute
Batteries
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2-3 hour life when fully charged
Have manual back-ups
Cigarette light re-chargers
Platform electrical source
Cardiac Considerations
• Preflight assessment
• Diagnosis
 Vital signs, presence of pain, signs of failure,
cardiac rhythm, lung and heart sounds
 Treatment rendered
Cardiac Considerations
• Stresses of flight
Lower partial pressure O2 (hypoxia)
Barometric pressure changes
Thermal changes
Fatigue
Cardiac Considerations
• In-flight care
IV, O2, monitor - maintain POX >95%,
maintain SBP >90, monitor urine output
Pain relief – ASA, Nitrates, Morphine
Elevate head 30-45 degrees
Avoid valsalva – Toynbee maneuver
Cardiac Considerations
• In-flight care
Position patient to minimize temperature
changes, prevent hypo and hyperthermia
Diuretics for failure
Altitude restriction under 6,000 ft cabin
altitude
Cardiac Arrest Considerations
• Limited ACLS drugs, space confinements
• Prior to use of defibrillator – notify pilot
• Defibrillation – Follow ACLS guidelines –
be aware of motion induced interruptions.
Extra precautions in “all clear”.
• Transcutaneous pacing – electromagnetic
interference
Pulmonary Considerations
• Airway and ventilation management is the
first priority of patient care.
• Altitude Hypoxia affects all patients
transported by air.
• Common mistake is to fail to anticipate the
need for a secure airway in patients at high
risk
Pulmonary Considerations
• Six general indications for securing an airway
 Apnea
 Upper airway obstruction
 Airway protection
 Elevated intracranial pressure requiring tight pCo2
control
 Respiratory insufficiency
 Impending or potential airway compromise
(prophylactic intubation)
Altitude Restrictions
• At 7,000ft cabin altitude normal person’s
PaO2=60 mm Hg and POX=90%
• Most commercial aircraft pressurized
between 5,000-8,000 ft. Military 8,500 ft.
• Patients with a PaO2 below 60 mm Hg or
sat 90% will develop hypoxic hypoxia at
altitudes between 2,000-4,000ft.
Altitude Restrictions
• Altitude Restrictions Required
Free air in any cavity – GI tract, lung, skull,
middle ear, sinuses, and teeth
Cardiac with angina, MI, effusion
Eye Injuries
Hgb < 7
Pulmonary Considerations
• Preflight Assessment
Diagnosis and treatment to date
Airway assessment
Baseline vital signs, ABGs, ventilator
settings, POX
Hgb, fluids
Physical assessment, PMH
Pulmonary Considerations
• Stresses of Flight
Lowered partial pressure of oxygen
Decrease humidity
Barometric pressure changes
Thermal changes
Noise, positive G-forces
Pulmonary Considerations
• In-flight care
Elevate head
Treat or avoid hypo/hyperthermia
Judicious administration of IV fluids if
hypovolemia absent
Oxygen administration to maintain baseline
POX
Oxygen Conversion Table
CABIN
ALTITUDE
10,000
CONVERSION TABLE FOR INFLIGHT 02 ADMINISTRATION
30
36
44
51
58
65
73
80
87
94
100
9,000
29
35
42
49
56
63
70
77
84
91
98
100
8,000
28
34
40
46
54
61
67
74
81
87
93
100
7,000
27
32
39
45
52
58
65
71
78
84
91
97
100
6,000
26
31
37
44
50
56
62
69
76
81
87
94
100
5,000
25
30
36
42
48
54
60
66
72
78
84
90
96
100
4,000
24
29
35
42
48
52
57
64
70
75
81
87
93
97
100
3,000
23
28
33
39
48
50
56
61
67
73
78
84
89
95
100
2,000
23
27
32
38
43
48
54
59
64
70
75
81
86
91
97
100
1,000
22
26
31
38
41
47
52
57
62
67
73
78
83
88
93
98
100
21
25
30
36
40
45
50
55
60
65
70
75
80
85
90
95
100
Mechanical Ventilation
• Dalton’s Law
Effects ALL gases – pCo2 will be affected
also – important to monitor ETCO2 maintain ETCO2 range 30-40
• Boyle’s Law
Effects air in ET and trach tubes – replace
with NS prior to flight
Mechanical Ventilation
• Boyle’s Law
Closely monitor Tidal Volumes and delivery
pressures
Sufficient amounts of NMBA and
sedative/analgesic medications
Familiarity with RSI/intubation techniques,
Mechanical Ventilation
• Effects of decreased humidity
 Can lead to airway plugs from desiccation
of mucous – monitor airway pressures
Trach patients not requiring oxygenation,
still require warmed humidification
Mechanical Ventilation
• Logistic considerations
Position ventilator on litter below patient,
secure but ensure access and visibility
Ensure tubing secured to avoid drag and
possible extubation
Ensure B-V-M, manual suction
Pulmonary Emergencies
• Even minor, occult pneumothorax (PTX)
will expand at altitude
• Emphysematous blebs risk for rupture in
non-ventilated patients
• MV patients suspect PTX with acute
desaturations, increasing airway pressures
• Have needle thoracostomy equipment and
be prepared to use it
Chest Tubes
• Chest Drainage Units
Even arid units have H2O in the water seal
Check water seal chamber after descent
Collection chamber must be marked hourly
and after each descent
Check water levels after ascent
Decreased humidity leads to evaporation in
suction control chamber, check frequently
Chest Tubes
• Heimlich Valve – due to distinct
characteristics of flight necessary to ensure
safe transport
• Emergency egress
• Prevents lung collapse from loss of water
seal during descent (fixed wing)
Chest Tubes
• Heimlich Valve
Connected between the chest tube and
drainage unit
Ends secured with tape
Assess frequently for proper function
Always carry an extra valve
Break Time/Questions???