In-Flight Patient Care Considerations For:

O2 utilizationCardiac

pulmonaryMechanical 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 transportPatient AssessmentSuppliesEquipment

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 soundsTreatment rendered

Cardiac Considerations

• Stresses of flightLower partial pressure O2 (hypoxia)Barometric pressure changesThermal changesFatigue

Cardiac Considerations

• In-flight careIV, O2, monitor - maintain POX >95%,

maintain SBP >90, monitor urine outputPain relief – ASA, Nitrates, MorphineElevate head 30-45 degreesAvoid valsalva – Toynbee maneuver

Cardiac Considerations

• In-flight carePosition patient to minimize temperature

changes, prevent hypo and hyperthermiaDiuretics for failureAltitude 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 airwayApneaUpper airway obstructionAirway protectionElevated intracranial pressure requiring tight pCo2

controlRespiratory 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 teethCardiac with angina, MI, effusionEye InjuriesHgb < 7

Pulmonary Considerations

• Preflight AssessmentDiagnosis and treatment to dateAirway assessmentBaseline vital signs, ABGs, ventilator

settings, POXHgb, fluidsPhysical assessment, PMH

Pulmonary Considerations

• Stresses of FlightLowered partial pressure of oxygenDecrease humidity

Barometric pressure changesThermal changesNoise, positive G-forces

Pulmonary Considerations

• In-flight careElevate headTreat or avoid hypo/hyperthermiaJudicious administration of IV fluids if

hypovolemia absentOxygen administration to maintain baseline

POX

Oxygen Conversion Table

CABIN

ALTITUDE CONVERSION TABLE FOR INFLIGHT 02 ADMINISTRATION 10,000 30 36 44 51 58 65 73 80 87 94 100

9,000 29 35 42 49 56 63 70 77 84 91 98 100

8,000 28 34 40 46 54 61 67 74 81 87 93 100

7,000 27 32 39 45 52 58 65 71 78 84 91 97 100

6,000 26 31 37 44 50 56 62 69 76 81 87 94 100

5,000 25 30 36 42 48 54 60 66 72 78 84 90 96 100

4,000 24 29 35 42 48 52 57 64 70 75 81 87 93 97 100

3,000 23 28 33 39 48 50 56 61 67 73 78 84 89 95 100

2,000 23 27 32 38 43 48 54 59 64 70 75 81 86 91 97 100

1,000 22 26 31 38 41 47 52 57 62 67 73 78 83 88 93 98 100

21 25 30 36 40 45 50 55 60 65 70 75 80 85 90 95 100

Mechanical Ventilation

• Dalton’s LawEffects ALL gases – pCo2 will be affected

also – important to monitor ETCO2 - maintain ETCO2 range 30-40

• Boyle’s LawEffects air in ET and trach tubes – replace

with NS prior to flight

Mechanical Ventilation

• Boyle’s LawClosely monitor Tidal Volumes and

delivery pressuresSufficient amounts of NMBA and

sedative/analgesic medicationsFamiliarity with RSI/intubation techniques,

Mechanical Ventilation

• Effects of decreased humidity Can lead to airway plugs from desiccation

of mucous – monitor airway pressuresTrach patients not requiring oxygenation,

still require warmed humidification

Mechanical Ventilation

• Logistic considerationsPosition ventilator on litter below patient,

secure but ensure access and visibilityEnsure tubing secured to avoid drag and

possible extubationEnsure 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 UnitsEven arid units have H2O in the water sealCheck water seal chamber after descentCollection chamber must be marked hourly

and after each descentCheck water levels after ascentDecreased 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 ValveConnected between the chest tube and

drainage unitEnds secured with tapeAssess frequently for proper functionAlways carry an extra valve

Break Time/Questions???