Aviation medicine aspects of Aero Medical Evacuation Dr. A. Khamaki Flight Surgeon

The first Aero Medical Evacuation During the siege of Paris in 1870 a total of 160 patients were removed by means of an observational balloon

HISTORY The history of aero medical transportation is almost as long as the history of powered flight itself. The history of aero medical transportation is almost as long as the history of powered flight itself. The earliest recorded evacuation of wounded casualties by aircraft took place during the first world war (1915) when 12 Serbian patients were carried in French aircraft. The earliest recorded evacuation of wounded casualties by aircraft took place during the first world war (1915) when 12 Serbian patients were carried in French aircraft. The second world war heralded rapid advancement and created military casualty evacuation organizations.In the later years of conflict more tan 90% of allied casualties were evacuated by air from all theatres. The second world war heralded rapid advancement and created military casualty evacuation organizations.In the later years of conflict more tan 90% of allied casualties were evacuated by air from all theatres. The potential value of Helicopters in reducing the mortality rates of battlefield casualties demonstrated in Korean and Vietnam conflict. The potential value of Helicopters in reducing the mortality rates of battlefield casualties demonstrated in Korean and Vietnam conflict.

Aero medical transport is a rapidly developing health care concept which can decrease disability and save lives

Golden time The time saving factor of Aero medical transport is often the crucial element in a patient's progress and recovery.

Aero Medical Evacuation (AME) Many studies have shown that the main cause of preventable death prior to the hospitalization was loss of air way. Many studies have shown that the main cause of preventable death prior to the hospitalization was loss of air way. AME can assist in early resuscitation by: AME can assist in early resuscitation by:  Rapidly getting the patient to medical help  Rapidly getting good care to patient Trained personnel should be transported to the patient, then the patient can be stabilized and transported back to the hospital. Trained personnel should be transported to the patient, then the patient can be stabilized and transported back to the hospital.

Specific considerations There are some specific aspects of transferring patients by air due to the effects of altitude and physical characteristics and limitation of the aircraft environment as well as psychological effects of flight.

Problems of altitude A decrease in air density A decrease in air density A fall in air pressure A fall in air pressure Low temperature Low temperature

Flight stressors Hypoxia Hypoxia Hyperventilation Hyperventilation Barotraumas Barotraumas Low temperature Low temperature Low humidity Low humidity G-forces G-forces Vibration Vibration Noise Noise Fatigue Fatigue Motion sickness Motion sickness Jet lag Jet lag D.V.T D.V.T

Hypoxic hypoxia Hypoxic hypoxia occurs when there is a lack of available oxygen in the atmosphere Hypoxic hypoxia occurs when there is a lack of available oxygen in the atmosphere The most lethal factor of all physiological causes of accidents is Hypoxic hypoxia. The most lethal factor of all physiological causes of accidents is Hypoxic hypoxia.

Cabin mild hypoxia Although mild hypoxia, experienced in a modern airliner is not noticed by the healthy passengers, the sudden exposure to mild hypoxia may be the final step over the threshold into the significant tissue hypoxia.

Conditions susceptible to Hypoxia Cardiovascular disease Cardiovascular disease Respiratory disease Respiratory disease Blood disorders Blood disorders Neurological disorders Neurological disorders

Cardiovascular disease Congestive heart failure Congestive heart failure Recent myocardial infarction Recent myocardial infarction Unstable angina Unstable angina Significant cardiac arrhythmia Significant cardiac arrhythmia

Respiratory disease Chronic bronchitis Chronic bronchitis Emphysema Emphysema Bronchioectasis Bronchioectasis

Blood disorders Severe anemia Severe anemia Hemoglobinopathies Hemoglobinopathies

Neurological disorders CVA CVA Arteriosclerosis Arteriosclerosis Epilepsy Epilepsy Cerebral tumors Cerebral tumors Head injuries Head injuries

Oxygen therapy The problems of hypoxia may be largely overcome by the use of supplementary oxygen in flight. The problems of hypoxia may be largely overcome by the use of supplementary oxygen in flight. Passengers’ own oxygen cylinders are generally unacceptable as they may not comply with safety regulations. Passengers’ own oxygen cylinders are generally unacceptable as they may not comply with safety regulations.

Barotraumas Pressure changes in gas containing cavities

Body gas-filled cavities Semi closed cavities: Semi closed cavities: Lungs Lungs Middle ear Middle ear Para nasal sinuses Closed cavities: Closed cavities: Gastro-intestinal tract Teeth

Conditions susceptible to Barotraumas Otic & sinus barotraumas Otic & sinus barotraumas Gastro-intestinal disorders Gastro-intestinal disorders  Recent GI surgery  Recent intestinal hemorrhage  Recent laparoscopy  Colostomies  Paralytic ileuses/bowel obstruction Pneumothorax Pneumothorax Head injuries Head injuries  Skull fractures  Closed gun-shot wounds  craniotomy Penetrating eye injuries Penetrating eye injuries Plaster of Paris Plaster of Paris

Vibration Vibration can cause a deterioration in the condition of patients with head or spinal injuries. Fractures may be more painful due to movement.

Motion sickness Motion sickness is a physiological response to discordant sensory information. Motion sickness is a physiological response to discordant sensory information. It is characterized primarily by nausea, vomiting, pallor and cold sweating. It is characterized primarily by nausea, vomiting, pallor and cold sweating. Preventive procedures: Preventive procedures:  Prophylactic anti emetics  Placing the patient over the centre of gravity of aircraft  Using nasogastric tube

DVT (Orthostasis) Prolonged immobilization predispose the patient to deep vein thrombosis. Prolonged immobilization predispose the patient to deep vein thrombosis. Prophylaxis with calf movement, TED stockings or subcutaneous heparin should be instituted. Prophylaxis with calf movement, TED stockings or subcutaneous heparin should be instituted.

Low humidity Many aircraft cabins have very low humidity (often less than 15% relative humidity ). Many aircraft cabins have very low humidity (often less than 15% relative humidity ). Care must be taken for: Care must be taken for:  Eye and mouth  Hydration  Heat conservation

Noise Although there is no good evidence that noise directly compromises any patient’s condition, but hearing protection is necessary.

Spinal injuries Fixed traction Fixed traction The Soehngen vacuum mattress The Soehngen vacuum mattress A full length sheepskin A full length sheepskin Core body temperature monitoring Core body temperature monitoring 6-12 L of oxygen by nasal tongs 6-12 L of oxygen by nasal tongs Betamethasone 4mg. 6hourly Betamethasone 4mg. 6hourly

Head injuries Ventilator settings before transport Ventilator settings before transport Intubations of the patient Intubations of the patient Passing a nasogastric tube Passing a nasogastric tube Determining presence of air in the head Determining presence of air in the head Monitoring of BP and PR Monitoring of BP and PR A good IV line A good IV line A urinary catheter A urinary catheter Monitoring of core body temperature Monitoring of core body temperature

Orthopedic injuries Blood loss »» »» IV fluid administration Blood loss »» »» IV fluid administration Fractures »» »» Immobilization with splints or vacuum mattress Fractures »» »» Immobilization with splints or vacuum mattress Pain »» »» Administration of small doses of intravenous narcotics Pain »» »» Administration of small doses of intravenous narcotics

Serious burns Protection of the air way and ventilation Protection of the air way and ventilation Assessment of the degree of thermal damage Assessment of the degree of thermal damage Appropriate intravenous fluid administration Appropriate intravenous fluid administration Pain relief by suitable intravenous infusion Pain relief by suitable intravenous infusion Care of the burnt area Care of the burnt area

Eye injuries The eye is sensitive to hypoxia The eye is sensitive to hypoxia An eye with a perforating injury is at risk of extruding the contents if there is a drop in pressure An eye with a perforating injury is at risk of extruding the contents if there is a drop in pressure

Precaution procedures for transport of Psychiatric patient Well restrained before flight Well restrained before flight Trained medical escort Trained medical escort Sedation Sedation Prevention of barotraumas, DVT & nerve palsy. Prevention of barotraumas, DVT & nerve palsy.

Contraindications to air travel Infectious disease Infectious disease Late pregnancy Late pregnancy The moribund The moribund Offensive conditions Offensive conditions

General principles of AME Stabilize before take-off Stabilize before take-off Don’t be rushed by any one Don’t be rushed by any one Anticipate and prevent: Anticipate and prevent:  Complications  Movement induced changes  Position changes

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