Post on 30-Jun-2015
description
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Aeromedical transfer of the
critically ill patientDr.Ebadi
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1-INTRODUCTION
-A model of timescale related to casualty death
-Primary,delayed primary,Secondary
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2-TEAM COMPOSITION
-Trained in anesthesia & intensive care
-Based on a full team
-Supplemented by additional personnel
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3-EQUIPMENT
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-Testing procedures
-Ventilators
-Monitors
-Pacemakers
-Syringe pumps and volumetric pumps
-Suction apparatus
-Blood analysis
-Peripheral nerve stimulators
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-Testing procedures :
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-Ventilators
-Continuous positive airways pressure (CPAP),
-Intermittent positive-pressure ventilation (IPPV),
- Positive end-expiratory pressure (PEEP)
-Alteration of the inspiratory to expiratory ratio
-Low power consumption
-Low oxygen consumption
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Univent Model 750 and Univent Eagle Model 754
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-Monitors
Blood Pressure:-palpated systolic BPs taken at the radial or brachial
site,
-Automated BP monitors using oscillometric
*Not ascultatory method
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-Doppler and pulse oximetry occlusion techniques
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-Invasive BP measurements such as the ProPaq Encore.
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ECG monitoring:
ProPaq Encore, provide an extended bandwidth where ST segments may be accurately displayed and printed.
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Oxygen Saturation: Pulse oximetry in the aeromedical evacuation
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End-tidal CO2(EtCO2) : EtCO 2 monitoring provides information on the adequacy of minute
ventilation and the position of the endotracheal tube.
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-Pacemakers
Temporary transvenous pacemakers
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-Syringe pumps and volumetric pumps
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-Suction apparatusSuction apparatus must be fully portable, have high flow capability and be able to collect fluid waste in a manner that protects staff and be safely disposable.
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-Blood analysisThe ability to perform blood gas, electrolyte, glucose, lactate.
Arterial oxygen, carbon dioxide, bicarbonate ,pH, glucose and potassium should be carried out at least every hour during transfer
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-Peripheral nerve stimulators
The ability to assess neuromuscular junction function is essential when using neuromuscular junction-blocking drugs.
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4-Cotaindications
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5-Check list
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6-EFFECT OF ALTITUDE
Common Problems Experienced
in Flight
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Special Problems
Experienced in Flight
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*Changes in pulmonary blood flow:
-may be due to abnormal responses to hypoxia
-reflection of the general state of the circulation
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*Intubated patient - The endotracheal tube should be
checked and a chest X-ray performed to determine the tube position.
-Endotracheal tube cuff pressures
should be checked and monitored during flight.
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*Tube thoracostomy:-They should be on free drainage, not be
clamped at any stage and remain dependent .
-If possible, systems that do not require fluid to function and have non-return systems should be used.
-The use of the Heimlich-type valve
incorporated in the system or certain types of emergency chest drainage systems, as used in acute trauma, may be problematic.
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*Tracheostomy -It is important to remember that this
is not without risk.-The patient should not be transferred
until the risk of immediate post-procedure haemorrhage has passed (at least 24 hours) and a tract has begun to form.
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*Air in the cerebrospinal fluid (CSF):
-expanding the skull can raise intracranial pressure.
*A sudden increase in volume skull:
-may lead to acute cardiovascular instability
-further neurological damage.
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*Air-containing cavities:-within the lung, bullae, post-surgery
or air leaks from trauma can lead to pneumothorax .
*Expanding air in the pleura or pericardium:
-may lead to the conversion of a simple pneumothorax or pneumopericardium to a tension pneumothorax or pneumopericardium,
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*Patients who are post-trauma, post-surgery:
-impaired gastric motility.
* Delayed gastric emptying: - raised gastric volume and nausea,
vomiting, regurgitation and electrolyte disturbances.
*Passive regurgitation in the unconscious patient:
-pulmonary aspiration and the risk of chemical pneumonitis and pulmonary sepsis
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*Surgery in the peritoneal cavity: -residual air trapped after closure
-In large amounts, it may lead to a rise in intra-abdominal pressure and a degree of intra-abdominal hypertension .
*Air or other gases within the lumen of the bowel:
-rise to pain and discomfort and put anastomotic suture lines at risk .
* Ileus or deranged bowel motility:-may also lead to raised intra-abdominal
pressure
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*Intra-abdominal hypertension :
-respiratory and cardiovascular dysfunction.
-renal function may be
impaired,with a rise in creatinine and urea.
- The liver is also vulnerable, and
deranged hepatic function may occur.
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-replacing losses and restricting fluids
-baseline maintenance requirements and insensible losses
* Fluid balance&resuscitation:
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-The circulation must be optimally filled in flight .
-Some patients,with major trauma or burns, may require additional fluids.
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-Continued resuscitation by large-bore cannulae.
-Vasoactive drugs require
administration via the central venous route ,
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-Inotropic sympathomimetics such as adrenaline (epinephrine), dopexamine, dobutamine and dopamine may already be in use.
-These drugs are life-vital components of care, as any sudden interruption in their administration may result in severe instability or cardiac arrest.
*sympathomimetics:
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-The circulation will also require optimal filling but may need increases in support from inotropic or vasoconstrictive drugs as transfer begins.
*SIRS:
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-The myocardium may be extremely irritable and prone to arrhythmias, which may precipitate cardiac arrest .
-Cardiac failure and cardiogenic shock may also occur.
*myocardial infarction:
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-A nasogastric drainage tube is normally a requirement for aeromedical transfers of critically ill patients .
*Stomach decompression :
-Feeding should be stopped a number of hours before transfer, in order to reduce the likelihood of reflux.
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-Nasogastric or orogastric tubes should be aspirated and then placed on free drainage, while remaining dependent.
-prokinetic drugs such as metoclopramide
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*Upper GI bleeding:
-H2 -receptor-blocking drugs,proton-pump inhibitors.
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-An intra-abdominal surgery and/or bowel surgery without sufficient time to allow anastomoses to heal, then sea-level cabin altitude should be requested.
*Intra-abdominal surgery :
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-In the critically ill patient, changes in blood flow, the presence of toxins and drugs in the circulation, and the direct effects of infectiveagents compromise hepatic function.
-Impaired hepatocyte function increases the potential for coagulopathy and for altered metabolism of drugs.
*Hepatic dysfunction
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-In practice, mildly deranged hepatic function is of little significance during transfer.
-In the case of acute hepatic failure, even
short-distance ground transfer may be extremely hazardous due to the circulatory and neurological effects associated with the condition.
-Transfer by air to enable the patient to receive hepatic transplantation may be justified and the attendant risk accepted.
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-Patients who are treated inadequately may be subject to changes in electrolytes during the flight, which will compromise their safety.
-If this occurs, then there is a limitedresponse available and the patient may suffer irreversible cardiac dysfunction.
*Renal dysfunction
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Urinary catheters need to be checked to ensure that there is free drainage. Urine output should be measured hourly, as in the ICU.
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*CNS problems: -If the level of consciousness is
reduced sufficiently, then it is associated with hypoventilation.
-Hypoventilation will lead initially to hypercarbia and then to hypoxia.
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-Hypercarbia leads to an increase in intracranial pressure,which may be critical for the already injured brain.
-Hypoxia will also lead to further neurological injury.
-The airway be maintained and ventilation is controlled.
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-Patients with a GCS of 8 or less should be intubated and ventilated.
-Vasodilation caused by induction agents may lead to hypotension and cerebral hypoperfusion.
--Conversely,intubation may lead to a marked sympathetic stimulation and a marked increase in intracranial pressure.
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-Injuries to the cervical and upper thoracic region may lead to cardiovascular instability due to loss of cardio-accelerator nerve .
-Below T5, sympathetic innervation of the myocardium is preserved.
-Ventilation and bronchomotor tone are also affected.
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-Ileus, urinary retention, gastric ulceration and haemorrhage may also occur in the early period.
-These patients have a markedly increased risk of deep venous thrombosis .
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-The patients with unopposed vagal influence due to high spinal-cord injury may be prone to profound bradycardia or even asystole when subjected to endobronchial suctioning.
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-Care must be taken to exclude compartment syndromes and any required fasciotomiesshould be undertaken pre-transfer.
-Fractures need to be stabilized adequately, preferably with a rigid fixation device.
-In the case of serious pelvic fracture, where there is risk of further haemorrhage, external fixation is also essential.
*limb trauma
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-Hypothermia interferes with normal metabolic processes, including the metabolism of drugs, and it can delay elimination of drugs.
-Hypothermia affects cardiovascular function; when severe,this leads to life-threatening arrhythmias.
-It also interferes with clotting mechanisms.
*Hypothermia
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-As a general principle, the patients should remain on an established regimen if they are stable and are suitable for transfer.
-This will normally include, at the very basic level, analgesia, sedation and often neuromuscular blockade.
*Therapeutic regimen
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-The critically ill patient requires other therapeutic agents such as antimicrobials, anticoagulants, antiarrhythmics and drugs to aid in the prevention of gastrointestinal haemorrhage.
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*TRANSFER-Short transfers by rotary-wing aircraft
or fixed-wing aircraft can be achieved by the minimum of a critical-care aeromedical physician and a critical-care aeromedical nurse .
-For longer, fixed-wing flights,technical support and additional logistic personnel should be included.
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