1. In-Flight Patient Care Considerations For: O2 utilization Cardiac pulmonary Mechanical Vent Chest tubes

2. 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

3. General Considerations
Preflight
Mode of transport
Patient Assessment
Supplies
Equipment

4. 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

5. 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

6. Batteries 2-3 hour life when fully charged Have manual back-ups
Cigarette light re-chargers
Platform electrical source

7. Cardiac Considerations
Preflight assessment
Diagnosis
Vital signs, presence of pain, signs of failure, cardiac rhythm, lung and heart sounds
Treatment rendered

8. Cardiac Considerations
Stresses of flight
Lower partial pressure O2 (hypoxia)
Barometric pressure changes
Thermal changes
Fatigue

9. Cardiac Considerations
In-flight care
IV, O2, monitor - maintain POX >95%, maintain SBP >90, monitor urine output
Pain relief – ASA, Nitrates, Morphine
Elevate head degrees
Avoid valsalva – Toynbee maneuver

10. 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

11. 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

12. 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

13. 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)

14. 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.

15. 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

16. Pulmonary Considerations
Preflight Assessment
Diagnosis and treatment to date
Airway assessment
Baseline vital signs, ABGs, ventilator settings, POX
Hgb, fluids
Physical assessment, PMH

17. Pulmonary Considerations
Stresses of Flight
Lowered partial pressure of oxygen
Decrease humidity
Barometric pressure changes
Thermal changes
Noise, positive G-forces

18. 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

19. Oxygen Conversion Table

20. 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

21. 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,

22. 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

23. 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

24. 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

25. 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

26. 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)

27. 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

28. Break Time/Questions???