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

1. In-Flight Patient Care Considerations For:O2 utilizationCardiacpulmonaryMechanical VentChest 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 30-45 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???