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 in-flight 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

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 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

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???