Transcript File - 911 Tactical Medicine

Manage Respiratory Injuries in
Enroute Care
The battlefield of medicine…
TERMINAL LEARNING
OBJECTIVE
• Identify the five key steps for operation of the Impact 754
ventilator and identify critical components of the
implications and management of pulmonary injuries to
deliver optimal enroute care
Enabling Learning Objective A
• Select the required five steps to set up and
correctly operate an Impact 754 ventilator to
deliver optimal enroute respiratory support
Critical Thinking
• A ventilator is a support device…it frees
you…
– Physically
– Psychologically
– Lets you focus on:
• PHYSIOLOGICAL CHANGES
• Tools are great but if they don’t work…
– When the 754 stops, your Ambubag starts!
The Eagle 754 Ventilator
BRIEF HISTORY:
• Developed under Army
contract in the mid 90’s
• First available portable
ventilator with internal
compressor and battery
capable
• Good points
– Simple,rugged,reliable
• Bad points
– High failure rate
Eagle 754 Ventilator
• Simple to set up
• Follow the numbers:
– 1-5 to set the vent
Turn On
• Turn all the way
clockwise to “CAL” and
wait until “OK” appears
• Switch counterclockwise
to ordered mode:
– Assist Control
– Spontaneous
Intermittent
Mechanical Ventilation
– Continuous Positive
Airway Pressure
Set Rate
• Generally rate will be
in the range of 12-18
breaths/minute
• Consult with care
team for settings
• Actual rate is
displayed in the
message center
above the adjusting
knob
Set Inspiratory Time
• Full counterclockwise
automatically adjusts
Inspiratory time to achieve a
I:E ratio of 1:2
• Manually set to Inspiratory
time of 1.0 to 1.5 second
• The longer the Inspiratory
time the lower the peak
pressure
• Display shows set I time and
actual I:E ratio
• Can not violate I:E of 1:2
Set Tidal Volume
• Tidal Volume range of 0 –
1000 cc’s
• Tidal volume will be the sum
of Ventilator flow x
inspiratory time
• Tidal Volume displayed is
calculated ( not measured)
• FOR THE 754:
– Minimum flow = 10 L/min
– Maximum flow = 60 L/min
Set FiO2
• Room air to 100 %
• Displayed
Display
• PEEP
– Generally set at 5
– Push button
– Resets at 20
Display
Power status
Display
Minute Ventilations
Display
Mode
Display
Airway Tracing
Display
Pressure
Graph
Display
Peak & Mean
Airway
Pressure
Alarms
• High Pressure
– Set 5-10 cm above
peak pressure once
patient is established
on ventilator
Other Alarms
• Red light indicates an
alarm condition and
the Alarm Message
center will detail the
condition
• Keep a close eye on
the light – you may
not hear the alarm
Check on learning
• How many settings must be set prior to
using the Impact 754 Ventilator?
– Five
• What are they?
– Power/Mode
– Rate
– Inspiratory Time
– Tidal Volume
– % of O2
Why is this important?
Enabling Learning Objective B
• Select critical clinical findings and management
interventions for enroute care of patients with pulmonary
injuries
Case Study (1 of 6)
• Demographics:
– 23 yo AD male after blast, overpressure, and
significant burn injuries from IED attack and
fragmentary injuries to both lower extremities
– No other medical history
• Surgical Interventions:
– Right lower lobe lobectomy with surgical
placement of chest tubes x 2 for drainage
– Debridement of burns and bilateral lower
extremity injuries with vascular repair
Case Study (2 of 6)
• Current Clinical Management:
– Airway/Breathing:
• Intubated with 8 French ETT @ 23 cm/lip
• Ventilator on Assist Control @ 60/12/750/5
• Requires frequent suctioning for bloody, thick
secretions
– Circulation:
• Peripheral IVs x 2 (Both patent and functioning
well)
• LR @ 75 cc/hr, PRBC’s as needed
• No vasoactive medications currently
Case Study (3 of 6)
• Current Clinical Management:
– Drains and Dressings:
• Chest tubes x 2 to right lower and medial lobes
• Both chest tubes to low/intermittent suction with
minimal bloody drainage (less than 50 cc/hr)
• Patient has full circumferential acticoat and dry
gauze dressings to both lower extremities with
minimal bloody drainage
• Foley to gravity draining >30 cc/hr of amber urine
Case Study (4 of 6)
• Plan:
– Transfer for CCAT
evacuation to Level IV
facility in Germany
(approximately 40
minute flight)
– Chest tubes to water
seal for transport
– NOTE: No blood
available for transport
Case Study (5 of 6)
• The team prepares the patient for
transport and has:
– One impact ventilator
– One PROPAQ monitor
– Emergency equipment and medication bag
– One impact intermittent suction device
Case Study (6 of 6)
• In flight, emergency evasive procedures are taken to
avoid an RPG, within a minute after this event, you
notice rapid and significant output from the lower chest
tube and the following vital signs:
–
–
–
–
•
•
•
•
BP 90/54
HR 134
RR 12 V
02 saturation 92% (down from an initial 02 sat of 96%)
What do you suspect is happening?
(USE THE “B PLAN”: BLEEDING OR BREATHING?)
What are your interventions?
THE RULE IS STOP OR FIX THE “BAD B”
•
•
•
•
APPROACH THE PATIENT IN AN
AEROMEDICAL SETTING
(MTF TO MTF)
ABCs are still paramount
Patient needs to be synched on the vent
prior to transport
Once in flight you lose the sense of
hearing and some tactile sensation
(stethoscopes are useless in environ)
Palpation and visual confirmation remain
as phys evaluation tools
THE “A”
• Evaluation
– Look at all tubes ETT, Chest Tubes, Nasal
– ETCO is a gold standard and should be used
2
• Troubleshooting
– ▼ in SaO look at tube(s) for migration
2
The “B”
• Evaluation
– PALPATE for equal rise and fall of chest!!
• Troubleshooting
– 754 not working effectively, switch to
Ambubag, REMEMBER to administer oxygen
– 754 is too hard to troubleshoot in flight,
recommendation: maintain bagging for the
duration of the flight
The “C”
• Evaluation
– Is the container open anywhere (this may
cause RD)?
– Is the container still closed but internally
hemorrhaging. Check Abdomen / Pelvis /
Bloody Show in Chest Tubes
• Troubleshooting
– CLOSE the container!! Provide conservative
fluid boluses
Reviewing the basics…
• Enroute care is focused on:
– Emergency interventions
– Maintaining homeostasis
– Trauma team concepts (Medic/RN-PA-MD)
• Enroute care is not:
– Definitive
– Glamorous
– Based on standard civilian models
How do you prepare?
PEARLS OF AEROMEDICAL
WISDOM
• “Dance with the one that brung ya”
• Have ample O2 onboard the aircraft
– What is ample?
Total PSI-SR x Conversion Factor
Liter Per Minute
• After movement check ABCs, then M2M (man to
machine approach) check connections
– Tube Migration (all tubes)
• NVG Considerations
Check on learning
• What are three critical concerns for managing
patients with pulmonary injuries while delivering
enroute care?
– Watching for physical or physiological symptoms of
distress
– Monitoring all vital signs with a focus on SA02 or
ETC02
– Having all the equipment with you before you need it
• What emergency devices should you always
have available when delivering enroute care?
– Oxygen and Ambubag
– Suction
– Back-up monitoring
Check on learning
• What do you do when the ventilator stops?
– Start giving manual support with the
ambubag!
– Inspect: M2M: Man to machine
• What are the two B’s that can be causes
for respiratory distress?
– Breathing
– Bleeding
Summary
• There are many critical considerations
when managing the care of a patient with
respiratory injuries enroute:
– Know the ventilator
– Do not be afraid to use the ambubag or make
emergency management decisions
– Stick to the basics: Touch, Tube, Tech
– Have all your tools available
– Be calm and stay focused
QUESTIONS?