1. In Flight Patient Care Considerations for: Burns Neurological Spinal Cord

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. Burn Injuries Preflight Assessment %TBSA burned, location and source Status of airway and patency Vascular access Fluid requirements Patency of foley, NG Vital signs, POX, urine output

6. Burn Injuries Preflight Assessment Pain medication, sedation Peripheral pulses Present wound management Associated injuries and need for altitude restriction (CXR) Secure vascular access, ET tube with sutures

7. Burn Injuries Preflight Assessment Assess Hct and transfuse if < 30% prior to flight If MD orders topical cream, apply evenly 1/16 to 1/8 inch thick and cover with absorbent dressing and Kling

8. Burn Injuries Stresses of flight All stresses of flight will affect the burn victim Thermal Decreased partial pressure of oxygen Decreased barometric pressure Decreased humidity

9. Burn Injuries In-flight considerations Monitor mental status Administer warmed, humidified oxygen – exception for face, head, neck burns Elevate head Continue with fluid resuscitation- second 24 hours add colloids – 200ml salt poor albumin/800ml LR at 0.5ml/kg/%TBSA

10. Burn Injuries In-flight considerations Second 24 hours addition of dextrose to meet metabolic demands – D51/4 NS Maintain urine output >50ml/hr(75-100ml for electrical) monitor for myoglobinuria NG to gravity or suction -monitor Hourly evaluation of all peripheral pulses

11. Burn Injuries In-flight considerations Protect from convection heat losses – shield from drafts and airflow Maintain core body temperature 99-100 Dressings should be occlusive, NEVER change en route Medicate frequently – use small doses Morphine 2-4 mg IVP. Avoid Demerol

12. Neurological Injuries Preflight Assessment Diagnosis, treatment Airway, Mechanical ventilation settings LOC, GCS Pupil assessment Vital signs Motor, sensory evaluation

13. Neurological Injuries Preflight Assessment Diagnosis, treatment Airway, Mechanical ventilation settings LOC, GCS Pupil assessment Vital signs Motor, sensory eval

14. Neurological Injuries Preflight Assessment Seizure activity, medications IVF, NG, Foley and patency

15. Neurological Injuries Stresses of flight Decreased partial pressure of oxygen Barometric Pressure Changes Decreased Humidity G-Forces

16. Neurological Injuries In-flight considerations Field-level altitude restriction for all penetrating, PBI induced head injuries Maintain POX>/=95%, tight ETCO2 control between 25-27(pCO2 30-32) Administer paralytics, sedation as needed Avoid succinylcholine use for RSI – IIP

17. Neurological Injuries In-flight Considerations IVF in absence of causes of hypovolemia at 80ml NS/hr – maintain MAP 65-70 Closely monitor GCS, pupils –for deterioration in GCS or pupil changes evidencing IIP administer 20% Mannitol 1-1.5 g/kg bolus Maintain normothermic – protect from thermal changes

18. Neurological Injuries In-flight Considerations Elevate head NG/OG to gravity/suction Monitor for seizure activity – administer Dilantin prophylaxis, Valium for seizures Hypertension – administer Metoprolol Hearing protection, eye protection

19. ACCELERATION/DECELERATION FORCES POSITIONING THE LITTER PATIENT DURING TAKE-OFF/ LANDING

20. Spinal Cord Injuries Preflight Assessment Diagnosis and treatment Level of function Airway secured, mech ventilation settings Vital signs, POX, Foley, NG Medications

21. Spinal Cord Injuries Preflight Assessment IVF and rate Spinal cord immobilization – goal to preserve current level of function. Avoid logrolling patient Spring loaded traction

22. Spinal Cord Injuries Stresses of flight ALL!

23. Spinal Cord Injuries In-flight Consideration Maintain spinal immobilization Maintain POX 95% or >, EtCO2 30-40 unless concomitant head injury then 25-27 Altitude restriction if associated head injury IVF 80ml/hr NS Monitor vital signs – Neosynephrine for neurogenic shock? Dopamine?

24. Spinal Cord Injuries In-flight Consideration Maintain Methylprednisolone drip if in progress Protect from hypothermia Protect from G forces-loss of vasomotor tone in spinal shock

25. ACCELERATION/DECELERATION FORCES POSITIONING THE LITTER PATIENT DURING TAKE-OFF/ LANDING

26. Questions????