This document discusses the aeromedical transfer of critically ill patients. It covers the composition of the transfer team, necessary equipment including ventilators, monitors, pumps and analysis tools. It then discusses potential issues during flight like changes in altitude, and special considerations for patients with trauma, surgery, or neurological, respiratory or circulatory conditions. The checklist, therapeutic regimens and staffing for transfers are also outlined.

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2. Aeromedical
transfer of the
critically ill patient
Dr.Ebadi
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1-INTRODUCTION
-A model of timescale related to casualty death
-Primary,delayed primary,Secondary

4. 2-TEAM COMPOSITION
-Trained in anesthesia & intensive care
-Based on a full team
-Supplemented by additional personnel
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5. 3-EQUIPMENT
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6. -Testing procedures
-Ventilators
-Monitors
-Pacemakers
-Syringe pumps and volumetric pumps
-Suction apparatus
-Blood analysis
-Peripheral nerve stimulators
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7. -Testing procedures:
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8. -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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10. Univent Model 750 and Univent Eagle Model 754
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11. -Monitors
Blood Pressure:
-palpated systolic BPs taken at the radial or brachial site,
-Automated BP monitors using oscillometric
*Not ascultatory method 11

12. -Doppler and pulse oximetry occlusion techniques
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13. -Invasive BP measurements such as the ProPaq Encore.
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14. ECG monitoring:
ProPaq Encore, provide an extended bandwidth where ST segments may
be accurately displayed and printed.
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15. Oxygen Saturation:
Pulse oximetry in the aeromedical evacuation
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16. 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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17. -Pacemakers
Temporary transvenous
pacemakers
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18. -Syringe pumps and volumetric pumps
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19. -Suction apparatus
Suction 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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20. -Blood analysis
The 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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21. -Peripheral nerve stimulators
The ability to assess neuromuscular junction function is
essential when using neuromuscular junction-blocking drugs.
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22. 4-Cotaindications
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5-Check list

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26. 6-EFFECT OF ALTITUDE
Common Problems
Experienced
in Flight
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28. Special Problems
Experienced in
Flight
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29. *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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30. *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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31. *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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32. *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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33. *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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34. *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, 34

35. *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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36. *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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37. *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
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deranged hepatic function may occur.

38. *Fluid balance&resuscitation:
-replacing losses and restricting fluids
-baseline maintenance requirements and
insensible losses
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39. -The circulation must be optimally filled in
flight .
-Some patients,with major trauma or burns,
may require additional fluids.
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40. -Continued resuscitation by large-bore
cannulae.
-Vasoactive drugs require administration
via the central venous route,
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41. *sympathomimetics:
-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.
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42. -The circulation will also require
optimal filling but may need increases
in support from inotropic or
vasoconstrictive drugs as transfer
begins.
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*SIRS:

43. *myocardial infarction:
-The myocardium may be extremely
irritable and prone to arrhythmias, which
may precipitate cardiac arrest.
-Cardiac failure and cardiogenic shock may
also occur.
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44. *Stomach decompression:
-A nasogastric drainage tube is normally a
requirement for aeromedical transfers of
critically ill patients.
-Feeding should be stopped a number of
hours before transfer, in order to reduce the
likelihood of reflux.
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45. -Nasogastric or orogastric tubes should
be aspirated and then placed on free
drainage, while remaining dependent.
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-prokinetic drugs such as
metoclopramide

46. *Upper GI bleeding:
- H2 -receptor-blocking
drugs,proton-pump inhibitors.
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47. -An intra-abdominal surgery and/or bowel
surgery without sufficient time to allow
anastomoses to heal, then sea-level cabin
altitude should be requested.
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*Intra-abdominal surgery:

48. *Hepatic dysfunction
-In the critically ill patient, changes in blood
flow, the presence of toxins and drugs in
the circulation, and the direct effects of
infective
agents compromise hepatic function.
-Impaired hepatocyte function increases the
potential for coagulopathy and for 48
altered
metabolism of drugs.

49. -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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50. *Renal dysfunction
-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 limited
response available and the patient may
suffer irreversible cardiac dysfunction.
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51. 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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53. -Hypercarbia leads to an increase in
intracranial pressure,which may be
critical for the already injured brain.
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-Hypoxia will also lead to further
neurological injury.
-The airway be maintained and ventilation
is controlled.

54. -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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55. -Injuries to the cervical and upper thoracic
region may lead to cardiovascular
instability due to loss of cardio-accelerator
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nerve.
-Below T5, sympathetic innervation of the
myocardium is preserved.
-Ventilation and bronchomotor tone are
also affected.

56. -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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57. -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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59. -Care must be taken to exclude compartment
syndromes and any required fasciotomies
should 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.
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*limb trauma

60. *Hypothermia
-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
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arrhythmias.
-It also interferes with clotting mechanisms.

61. *Therapeutic regimen
-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.
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62. -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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