ALTITUDE PHYSIOLOGY

GAS LAWS There are 5 gas laws that must be considered and fully understood in relation to varing pressure, temperature, oxyge3n tension, and gas volume changes in the aviation environment. 1) Daltons Law of Partial Pressure of Gases The total pressure of a mixture of gases equals the sum of the partial pressures of each gas in a mixture. Physiological significance relate to hypoxia. ** As altitude increases and barometric pressure decreases, gas expansion causes the available oxygen to decrease as gas molecules move further apart **

2)

Boyles Law of Gas Volume The volume of a gas is inversely proportional to its pressure, so long as the temperature remains constant. This law is significant concern with regards to altitude and trapped gases. (tension pnuemothorax) When dealing with body gases, consideration must be made for the water vapour pressure that is present in all organs of the body, at normal body temperature. The increase in volume of a wet gas is greater than that of a dry gas when both are subject to the same pressure change. As a ballon rises, it expands. At 18,000ft it doubles in size, and at 25,000ft it triples. ** the higher the altitude, the more gas expands. The reverse is true as the aircraft descends **
Note Air in ETT cuffs can expand , this effect can be minimized by placing water in the cuffs.

3)

Charles Law The pressure of a gas will directly increase with temperature as long as its volume remains constant. An increase in temperature will cause a gas to expand and increase the pressure exerted ** oxygen delivered by ventilator is usually 72 degrees F, so the tidal volume increases as the oxygen is heated in the body**

4)

Henrys Law of Gas Solubility The amount of gas that will dissolve in a solution is directly related to the pressure of the gas over the solution As you ascend, the pressure decreases and less gas will remain in the solution which may result in the formation of gas bubbles Relates to decompression sickness (the BENDS)

5)

Grahams Law of Gaseous Diffusion Molecules of a gas move from a region of higher concentration to a region of lower concentration. ** Because of the solubility factor, carbon dioxide is approximately 19 times more diffusible than oxygen **

HYPOXIA Hypoxia is defined as a state of oxygen deficiency in the blood cells or tissues sufficient to cause impairment of body function. It is most frequently encountered in the aviation environment. A misconception is that you can easily recognize hypoxia and take corrective measures. One of the first manifestations of hypoxia is impaired judgement. Any compromise in the bodys ability to ventilate, altering the proper exchange of gases will lead to a level of hypoxia. Types of Hypoxia: In high altitudes, hypoxia can be encountered in four forms. Hypoxic Hypoxia -- due to a reduction of the partial pressure of oxygen in the inspired air. When barometric pressure decreases, so must the partial pressure, therefore there is less oxygen pressure but the percentage remains the same This is where Daltons Law takes effect as you increase in altitude the barometric pressure decreases. Hypemic Hypoxia due to a reduction in the amount of oxygen carried by the blood. The two main cause of this is a decrease in the number of red blood cells, and carbon monoxide poisoning. Red blood cells from donating blood, or blood loss Carbon Monoxide is created by exhaust fumes, cigarette and/or burning materials. 3 cigarettes smoked in 30 minutes creates a physiological altitude of 8,000ft. Carbon Monoxide molecules bind 250 times faster to red blood cells than oxygen Histotoxic Hypoxia the action of a toxic substance at the tissue level. Described as tissue poisoning Caused by alcohol and legal or illegal drug use. Do not medicate yourself and/or consume alcohol 12 hours before you fly. Stagnant Hypoxia due to the restriction in blood flow either generally or locally. Causes a) Posture b) Temperature c) Acceleration d) Reduced circulation due to constrictive clothing

SIGN AND SYMPTOMS OF HYPOXIA Since brain cells have no ability to store oxygen, most of the early signs and symptoms relate to brain function. Sign and Symptoms of hypoxia, are broken down into 2 categories. The most dangerous aspect of hypoxia is, it is slow and subtle in onset. SUBJECTIVE: what you can feel yourself Air Hunger Headache Dizziness Blurred Vision Tunnel Vision Fatigue Numbness Hot/Cold Flashes Tingling Nausea Muscle Tremor Apprehension Euphoria Belligerence OBJECTIVE: what other may observe happening in you Hyperventilation Cyanosis Mental Confusion Muscle Incoordination Poor Judgement Unconsciousness Factors Affecting Tolerance To Hypoxia 1. Altitude the higher you are, the less the partial pressure 2. Rate of Ascent the faster you climb, the less time to acclimatize your body 3. Duration of Exposure the longer you are deprived of oxygen, the worse the effect 4. Physical Fitness being physically fit gives you a higher altitude tolerance 5. Physical Activity performing a straining maneuver in order to increase tolerance to acceleration, increases the bodily demand for oxygen 6. Environmental Temperature an excessive amount of heat increases your metabolic rate and excessive cold also increases metabolic rate as well as constricts peripheral blood flow

7. Self Imposed Stress fatigue, alcohol, self medication and low blood sugar due to improper diet and smoking Treatment for Hypoxia Emergency treatment of hypoxia is 100% oxygen, proving you are lower than 34,000 ft. if you are above 34,000 ft you will require positive pressure ventilation with 100% oxygen

HYPERVENTILATION Hyperventilation, is defined as breathing at a rate or depth in excess of the bodys current bodily demand which results in excessive loss of carbon dioxide. Carbon dioxide is necessary as it triggers the respiratory system. Too must CO2, disrupts the acid-base balance.

Causes of Hyperventilation Mostly due to emotion: fear, apprehension, and anxiety. Can also be caused by: excitement, pain, pressure breathing, hypoxia. Signs and Symptoms of Hyperventilation SUBJECTIVE: Dizziness Nausea Numbness Tingling Coolness Visual Impairment OBJECTIVE Twitching Tremors Pallor Cool Clammy Skin Confusion Decreased Awareness

*** Hypoxia can lead to Hyperventilation, and Hyperventilation can lead to Hypoxia ***
which makes it difficult to distinguish between the two. 6

TRAPPED GASES Trapped gases are those gases that are contained within hollow spaces or organs. Issues arise as an individual ascends to altitudes where barometric pressure is reduced allowing trapped gases to expand, in accordance with Boyles Law. Discomfort and pain due to these gases is the most common complaint of air crew, patients, and companions. Commonly affected areas are the sinuses, middle ear, teeth, abdomen, and the lungs. The Middle Ear The middle ear cavity is normally ventilated through the Eustachian tube which connects to the throat. Ventilating the middle ear equalizes the gas pressure inside with the outside atmospheric pressure acting against the ear drum. When ascending to altitude, the increasing pressure in the middle ear must be vented outward to equalize its pressure with the surrounding atmosphere. Difficulty in clearing the ears is more frequently during descent. Aids in equalizing the middle ear pressure are yawning, swallowing, extending the lower jaw, and the Valsalva maneuver. Difficulty in ventilating the middle ear is increased by upper respiratory infections such as sore throats, or colds because inflammation blocks the Eustachian tube. During sleep, the swallowing reflex is diminished and the middle ear is not ventilated as regularly. An occurrence called ear block would develop. With symptoms of a feeling of fullness, decreased hearing, discomfort and occasional pain. Should equalization not take, and decent continue a torn or ruptured ear drum is likely. For this reason, sleeping patients and companions should be awakened during descent so they can consciously clear their ears. The Sinuses The sinuses are inelastic structures located deep in the bone of the skull. They have ducts communicating to the outside by openings in the nasal passages on either sides. There is no discomfort during ascent or descent if the ducts are open. If the ducts are swollen due to an upper respiratory infection, there may be a blockage of the ducts, resulting in varying degrees of pain. Sinus discomfort can occur during both ascent and descent, although descent usually provides the greatest discomfort. The Stomach and Intestines The GI tract is another area where high altitude may cause gas expansion difficulties. Normally gas pressure in the stomach and intestine is equal to the surrounding atmosphere pressure. On ascent the gases in the GI tract expand, and unless relieved by belching or passing flatus, can reach a degree of expansion which may produce pain and discomfort, making breathing more difficult and possibly to hyperventilation and unconsciousness. Because the body is less capable of tolerating pain at altitude than at ground level. Continued pain from expanding gases may result in collapse and shock. Descent should be initiated if pain cannot be relieved.

The Teeth Carious teeth or a recent filing may be sensitive to pressure and cause pain during ascent. Good oral hygiene and frequent dental checks are preventative measures for avoiding gas expansion problems with the teeth. Most commonly, the aching off several teeth is due to sinus involvement. When tooth pain can be localized to a small area in the mouth it is indicative of a dental diagnosis. A dentist should be consulted as soon as possible, to have the tooth repaired. The Lungs The lungs are the largest air filled organ in the body. They communicate to the ambient environment through a series of airways, the bronchi. If a breath is held, or if there is localized obstruction of the airway by tumor, spasm, or mucus, the expanding air is retained causing over-inflation and over-pressurization. If the over-pressurization is great enough, alveoli in the lung can rupture, resulting in a number of lung disorders leading ultimately to collapse. These disorders are extremely great at altitude.

NOISE AND VIBRATION Noise Can be described as any unwanted, disagreeable sound which interferes with the sounds desired. Sound is transmitted when any structure or device transmits vibrations to and through adjacent air molecules. Characteristics of Noise: 1. Intensity The pressure level of sound or loudness Created by the vibrations of air molecules bumping together to produce pressure fluctuations or sound pressure. Measured in decibels 2. Frequency Sound waves moving through the air at different speeds expressed as cycles per second. Types of Noise o Low Frequency affects lower end of scale 0-500Hz o - propeller and turbo prop aircraft o Pure Zone Most annoying o - interferes with speech and hearing because of its whining, whistling sound. o Broad Band most dangerous o - jet at full power 3. Duration Length of time exposed to a noisy environment. Since continuous exposure to noise causes hearing damage, there are limits on daily noise levels one should be exposed to. Duration determines the degree of damage to the ear.

Effects of Noise 1. Auditory Effects of Noise Psychological Effects Annoyance and /or distraction Physiological Effects Fatigue and deteriorating health Working in a noisy environment for a length of time causes you to concentrate harder, therefore you can become tired and irritated much faster Noise induced fatigue/disturbed sleep means lower efficiency and this may lead to accidents

2. Interference with Auditory Communication Noisy background, radio static, noise from environment and so can drown out/interfere with communication/conversation. 3. Ear Damage: 5 types Tinnitus o Ringing sensation in ears o Most noticeable in a quiet area. o Causes: hair cells are quivering violently due to overexposure o Symptoms: feeling of fullness in ears, ringing sensations, dullness in hearing, can last several hours, can cause permanent damage to inner ear. Temporary Threshold Shift (TTS) o Short term loss of hearing, due to continuous exposure due to excessive noise levels. o Complete recovery take place, but may take several hours or days. Permanent Threshold Shift (PTS) o destruction of hair cells in the cochlea resulting in a hearing loss in certain frequencies. o Cannot be corrected by surgery or medicine Mechanical Damage o caused by exposure to noise or sudden blast o can damage eardrum and ossicles o can heal themselves or may be restored by surgery (but will have some degree of hearing loss) Presbycusis o normal deterioration of hearing with age o noticed by individual or on an annuak audiogram o the hairs, either from overexposure or old age o occurs mainly in higher frequencies

Reducing the Effects of Noise There are many noises associated with flying. Can be due to take-offs and climbs, landing approached, airflow into pressurization/AC systems, avionics/communications systems, ground power units, aircraft run ups. 1. Reduce Exposure Time - sometimes work in high decibel areas cant be avoided. - Reduce the time of exposure - Annual hearing checks 2. Noisy Reduction - eliminate or reduce noisy to an acceptable level

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3. Ear Protection - Ear Plugs inserted in to the ears, different shapes and sizes, rubber/plastic/or foam, can be worn under headsets - Headsets better noisy reduction - Helmets need to be properly fitted - Ear Muffs cups can be foam, fiber, or fluid filled.

VIBRATIONS A fluctuating force that is felt rather than heard by human. Aircraft Aircraft power plant Helicopter main source is blade passing frequency Runways Rough runway can generate small oscillations and they can be amplified by the length of the fuselage. Weather Turbulence engine pinch is changed and can cause vibrations

Effects of Vibrations Can occur anywhere Very low to very high frequency Can produce varies effects on respiratory and cardiovascular system Can cause motion sickness, drowsiness, decreased visual acuity, decreased muscular coordination, difficulty with speech, irritability and fatigue. Symptoms loss of appetite, loss of interest, decrease performance, perspiration, salivation, nausea, vomiting, headache, fatigue, generalized discomfort, pain, stiffness of joints.

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CABIN PRESSURIZATION and DECOMPRESSION In most modern aircraft, problems of hypoxia and decompression sickness are overcome by pressurizing the aircraft. Cabin pressurization below 8,000ft, are comfortable and do not require crew to wear supplemental oxygen. All aircraft are different, and need to be pressurized at different altitudes. Loss of Cabin Pressure Can vary from a slow leak, due to minor mechanical fault to a rapid or even explosive rupture of a cabin wall/window. Rapid decompression is indicated by a loud noisy due to the sudden release of pressure, the compressed air rushes out at a velocity near the speed of sound until the cabin pressure reaches that of the outside environment. As this air leaves the cabin, the remaining gas expands, causing the temperature of the air within the cabin to drop to dew point and water condenses as a mist which can be so dense that it interferes with the occupant vision. With a slow leak, there generally is no dramatic indication. The first sign is usually the cabin pressurization failure warning device.

Procedures After Loss of Cabin Pressure Steps must be taken to immediately prevent hypoxia. Oxygen masks will drop from the ceiling, ensure your mask is on Ensure pilots masks are on Ensure patient/companion oxygen masks are on Ensure all seatbelts are fastened (these should be on at all times). As soon as pilots masks are secure they will begin a rapid decent, to an altitude where supplement oxygen is not required, where they will begin approach to closest airport for emergency landing. Only remove oxygen mask when/if instructed to be the pilots

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STRESS Defined as an effort or demand upon energy, the bodys reaction to a harmful force. Stress can be divided into 3 categories self imposed, personal and operation stresses. Stress affects everyone in different ways, for different situations. Each person must find ways to deal with the stresses that are encountered every day, and the stresses of the flight environment is something above the everyday normal stress. Personal Stress a form that is encountered by everyone, including things like, financial problems, marital problems, family problems etc. These problems can and will interfere with flying, however they need to be addressed, on a professional basis if required. Self Imposed Stress those stressors that we bring on ourselves. These include smoking, use/abuse of caffeine, alcohol, illicit/prescription/over the counter drugs, diet and exercise. Stress can be divided into 2 categories, Acute or Chronic. Acute (short term) Stress is normally caused by things such as fear of failure, physical discomfort, physical harm, increased workload. Normally short in duration (few minutes to a few hours) and is quite intense. Chronic (long term) Stress normally caused by dangerous duties, illness, or physiological environmental. Chronic stress tends to last for days to months, and less intense than acute stress.

Environmental Stressors 1. Climatic Changes -- in long range transport of a patient or flight itself over a long period of time. It is possible to depart a tropical destination, and arrive in an artic climate. This dramatic change can place demand upon the body. 2. Adverse Weather Conditions anything ranging from blinding snowstorms that produce zero visibility, to tropical rains will have a direct effect on the flight and the air crew. 3. Poor Visibility / Lighting Within the Aircraft produces strain on the eyes and in turn produces fatigue as a result of the added effort required to see and concentrate. Both cockpit and cabin crew. 4. Dusk, Dawn, and Night Flying -- humans are created to function primary during daylight hours. During night flying a person does not need to his cone cells for vision and therefore loses his central vision, colour vision, and visual acquity, being only able to use his peripheral vision. Both night flying and dusk/dawn flying will produce stresses on the body, with increased concentration required to operate.

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5. Noise and Vibration -- noise is very stressful and fatigue producing, and requires increased concentration. Vibration can increase heart rate, respiratory rate, motion sickness, and many other stresses on the body. 6. Terrain and Altitude -- aircraft that fly at low altitudes, remain close to sea level will produce or create motion sickness or require intense concentration. Aircraft that fly long duration at high altitudes, will produce boredom and lack of attentiveness. 7. Odours and/or Gases -- the smell of flight fuels, exhust etc. can have effects on the body producing nausea, vomiting or vertigo depending on the person and amount of exposure. Other odours/gases may be in the cabin, possible from the patient.

Mission Oriented Stressors Depending on the operational nature of each flight, one or many of the following stressors may apply. 1. Sleep and Circadian Rhythm Disturbances The entire body revolves around the circadian rhythm and involves more than 100 different bodily functions that operate on a 24 hour clock. The body lets us know when to sleep, eat, exercise, etc. In normal day to day living, the body is adjusted to our normal living, when we get up, eat, go to work. Throughout the day our body has it peak times for mental performance, better altitude performance, better athletic performance. Once the body and local time becomes out of sync, circadian de synchronization occurs. This occurs as a result of shift work, and long distance flying. Each body system that is affected requires a different amount of time to adjust. The sleep pattern requires 1.1 days for every time zone crossed to adjust to the new time zone, the digestive system requires 24 hours, body temperature requires 18 hours, and hormonal regulation requires 12 hours. There are no ways of eliminating the effects of circadian de synchronization, but there are effects that can minimize in a couple of areas. Prior to long distance flight, allow 8 hours of quality sleep. Try to avoid the use of diuretics which will cause dehydration for at least 24 hours prior to flight (coffee, tea, alcohol, caffeine). Post flight, ensure adequate sleep to recover from the flight and to prevent cumulative fatigue. Sleep should be good quality, in an optimal setting. Avoid mental excitement, caffeine, alcohol, nicotine prior to sleep. Artifical sleep induction methods should also be avoided. Proteins which contain amino acids are encouraged, as the induce sleep.

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2. Flight time and Delays Long duration and short duration flights can all be extremely fatiguing. Delays, from weather to mechanical, can occur and make travel longer than planned. 3. Quality and Duration of Crew Rest If a crewmember is use to having 8 hours of rest in a quiet bedroom, they need to be able to obtain the same quality and duration of rest away from home. This is not always possible, it will put a strain on the body. 4. Thermal Comfort of the Cabin As is most aircraft there are only two setting too hot or too cold. This produces a demand on the body to either produce more body heat or to lose body heat through sweating. 5. Nature of the Mission A routine inter-facility transport where the patient is ambulatory and requires little more than observation will not be as physically or mentally challenging as a patient that is acutely ill, on the verge of death. 6. Unforeseen Emergencies A routine flight or transfer can unexpectedly change regarding flight plans, stop over, or even crash landing. There is always the possibility of something unforeseen happening enroute, or even port flight. Any and unforeseen events, depending in their severity will place stress and additional demands on the body. Fatigue Defined as a state following a period of mental or physical activity characterized by a decreased work capacity and performance and accompanied by a feeling of tiredness and the desire to rest. Can come in two forms, acute and chronic, and can have a combined and cumulative effect. Subjective signs and symptoms include, a general irritability and/or depression, low morale, loss of enthusiasm, insomnia, sweating, headaches, compulsive eating or drinking, drug or alcohol abuse, hypertension and ulcers. Objective signs and symptoms can include, trembling and twitching, poor work habits, low frustration level, lack of cooperation with peers and supervisors, slowness to respond, and/or carelessness.

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DEALING WITH HUMAN FACTORS There are several ways to deal with human factors. One way is to improve the design in the aircraft, by eliminating or decreasing noise levels, vibration, lighting, ventilation, temperature control etc. Another way of reducing the stressors of flight is good preventative maintenance which reduces breakdown, and flight delays. Improvement in facilities, lounges, terminals. Good leadership, where all the guesswork is removed from the flight by having all concerned informed and up to date. The last component to dealing with flight stress, as well as other forms of stress is a good personal self management program. Different people deal with stress in different ways, some includes exercise, hobbies, vacations, camping, reading etc. The main thing to remember about operational stress and stress in general is that everyone has their limits. It is vital that all personnel in the aviation environment know their limits, and how to deal with stress and fatigue effectively.

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PATHOPHYSIOLOGY AND PATIENT CARE

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DATA COLLECTION Patient History A good, standard technique is required for obtaining information on and from your patient. This is especially true when you are going to transport a patient by air, because of the potential for unknowns as far as the patient is concerned, and also nay other personnel who may not be familiar with the higher altitude environment. Ways of obtaining information: Subjective Data: information obtained from the patient fear of flying, fear of being separated from family/friends, increase/change in symptoms . Objective Data: information obtained from physical/laboratory test pacemaker, hematology (hemoglobin), cast, ETT, NG, IVs. History of Present Illness Chief Complaint (CC) Is there anything in the aircraft environment that would contribute to increasing the symptoms of the chief complaint ? Is the patient stable enough for transport in the altitude environment? Are there any associated medical problems that could exacerbate the symptoms of the chief complaint ? Is there a communicable disease that will have consideration for the flight crew and aircraft? What treatments are currently being used? Can they be continued on the way to/from the aircraft, and in the aircraft? Past Medical History (PMHx) Relevant past illnesses, allergies? Family history? General Information Patient mobility? Diet? Special Needs? Is the patient continent with bowel and bladder? Indwelling urinary catheter? Should there by? Is the patient energy level sufficient for flight? Tolerance to environmental changes transfer in cold weather, inclement weather, changes in temperature in flight? Patient general mood? Are the alert, oriented, cooperative, paranoid, psychiatric problems? Will the reduced barometric pressure jeopardize the patient condition? Will the exertion and duration of transfer negatively affect the condition, and to what degree? What treatments have been performed prior to transport? IV access, wound care, transfusions, medications, tubes, drains, suctioning, xrays, bloodwork ? 18

Initial Assessment Important with an on-scene response. Imperative that a thorough assessment by done to obtain as mush information as possible.
Scene Survey Environmental hazards Mechanism of Injury Number of patients Additional help/recourses required. Level of Consciousness (LOC) Introduce yourself, and evaluate responsiveness Stabilize C-Spine Airway Is the airway open? Clear? Clear airway with modified jaw thrust. Breathing Look, listen and feel: Breathing present? Rate and Quality? Oxygen required, assist respirations? Circulation Presence, rate and quality of carotid vs radial pulses Look and feel for the skin temperature, colour, conditions, cap refill. Neck Look and feel for deformities, contusions, abrasions, penetrations, burns, lacerations, swelling, JVD, tracheal deviation. Apply C-Collar Chest Look and feel for deformities, contusions, abrasions, penetrations, paradoxical movement, burns, lacerations, swelling. Also feel for tenderness, instability, crepitus Auscultate at 4 sites for air entry, quality, and symmetry Seal penetrating wounds Stabilize instabilities, impaled objects Abdomen Look and feel for deformities, contusions, abrasions, penetrations, burns, lacerations, and swelling. Palpate all 4 quadrants, for tenderness, instability and crepitus Pelvis Look and feel for deformities, contusions, abrasions, penetrations, burns, lacerations, and swelling. Palpate for tenderness, instability, and crepitus (if complaints of hip or pelvic pain do not apply any type of pressure to the iliac crests/symphysis pubis) Extremities Look and feel for deformities, contusions, abrasions, penetrations, burns, lacerations, and swelling. Feel for tenderness, instability and crepitus, as well as pulses, motor functions, and sensation. Gross Bleed Examine visually and by feeling for any bleeding Control with direct pressure Back Roll onto side, and look for deformities, contusions, abrasions, penetrations, burns, lacerations, swelling. Transfer onto backboard

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Decision ---- Critical ? Decreased LOC Respiratory Distress Shock Tender or distended abdomen Unstable pelvis Bilateral femur fractures

Secondary Assessment Is a more detailed and thorough examination of the patient beginning at the head and working down to the feet. Should be performed prior to transport in a stable patient, and during transport in a critical patient. Obtain an AMPLE history Use the AVPU method for alertness Head and Neck Check the C-Spine first, by palpating for deformities, gaps, wounds, pain or other abnormal findings. If there are any abnormal findings, or if the patient is unconscious with a suspected head injury, you must assume a possible neck injury and apply a CCollar. Palpate the skull from back to the top. Applying some pressure, feeling for bleeding, bumps, bruises, and depressions. If the patient is unconscious, watch the face for reaction to pain grimacing etc.
Check the eyes for o Lacerations to the globe or lid o Foreign matter in the eyes o Pupil size, equality and reaction to light o Eye movement o Discolouration of the sclera eg. Jaundice o Vision normal ? Check the orbital area for o Ecchymosis o Deformity o Sensitivity to touch Check the ears and surrounding area for o Discharge CSF, blood, or both o Lacerations, depressions o Battle signs Check the nose for o Discharge o Patency of nostrils o Laceration, fractures, bruising o Flaring of the nostrils Check the mouth for o Airway patency vomit, food, dentures, blood o Edema, bruising, lacerations, redness o Alignment of teeth, symmetry of the mandible

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Check the face for o Lacerations, bruising, deformity o Colour, condition, and temperature Inspect the anterior neck o Retractions at supra sternal notch o Lacerations, bleeding, bruising o Tracheal deviation o Deformity o Pain or tenderness in the gland area o JVD o Auscultate the trachea for air sounds noisy airway is an obstructed one Inspect the anterior, lateral and posterior thorax o Intercostals retractions o Chest symmetry o Subcutaneous emphysema o Lacerations, abrasions, and deformities o Puncture wounds o Palpate for pain or deformities of the clavicals and scapula, sternum, rib cage. o Auscultate for air entry, and note breath sounds Inspect and palpate the abdomen for o Lacerations, abrasions, distention o Organ protrusion o Radiation of pain o Pulsating masses o Distention o Local tenderness, rebound pain or guarding o Rebound tenderness Inspect the pelvis and buttocks for o Lacerations, bruising, and deformities o Tenderness o Incontinence Back o

Palpate all the vertebrae

Extremities o Deformities, swelling, pain, lacerations, bruising o Needle marks, bites o Cyanosis, temperature o Impaired sensation o Impaired movement or strength o Symmetry of limbs, and pulses o Reflexes

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Patient Briefing -- Pre Flight 1. Introduce yourself, and your partner(s) 2. Has the doctor told you, you will be flying to . ? 3. Have you ever flown in a small plane before? Describe the plane you will be flying on. 4. Have you ever had any problem with ears or sinuses, when flying? When driving through the mountains? 5. Are you claustrophobic? 6. Explain the aircraft environment o Noise and Vibration communication is a little more difficult, treatment and procedure may be done a little different than in the hospital. o Hypoxia patient may not be on supplemental oxygen on the ground, but will likely need it in the aircraft. Patient has a cast, will need to be bifurcated, if applied in the last 72 hours. o Decompression Sickness any diving in the last 72 hours? o Temperature Variations aircraft only have two temperatures, heat on and off. Let any of crew know if too hot or cold. o Acceleration and effects of G-forces stretcher patient will be laying down, fell like sliding off stretcher, not. Feel very different when laying that when sitting. o Motion Sickness experience when in car, boat or flying ? Patient Briefing In Flight 1. Keep the patient/companion informed of any altitude changes, flight changes, expected turbulence. 2. Prior to landing, advise the patient they may again feel like they are sliding off the stretcher, ensure that the shoulder belts are correctly positioned and secure. 3. Remind the patient to clear their ears. Patient Briefing Post Flight 1. If you are turning the patient over to the ambulance following landing, ensure the patient/companion is aware of this. 2. Advise the patient to report any changes/concerns immediately. 3. Ensure the new escorts have a detailed report, knowledge of any concerns, all documentation, and transfer medication. 4. Ensure the patient/companion have all belonging they brought on-board.

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CARDIOVASCULAR PATIENT

The care and transport with cardiovascular disease, may occur at various altitudes, in both pressurized and unpressurized cabins. Individual tolerances may vary, generally the patient with cardiovascular disease is at risk for decompensation above 6,000 feet. Decompensation is generally a result of hypoxic hypoxia, defined as an oxygen deficiency in the body tissue sufficient to cause impaired function. The decrease in barometric pressure as altitude increases reduces the available oxygen to the tissues.

Hypoxia, can have any of the following physiological changes. Increased respiratory rate Increased heart rate Increased systolic blood pressure Increased cardiac output Increased myocardial oxygen consumption

Cardiac Reserve Refers to the ability of the heart to increase cardiac output in response to increased demands. In healthy individuals, cardiac reserve allows the body to compensate and meet increased demands by increasing blood flow. In normal individuals, cardiac output may triple due to alterations in heart rate, stroke volume or a combination of both. Cardiovascular disease may limit cardiac reserve. In the cardiovascular compromised patient, normal cardiac output at rest can be achieved only through the use of the entire cardiac reserve. A limited cardiac reserve predisposes the patient to decompensation as altitude increases. Effects of Altitude and Acceleration on Patients with Decreased Cardiac Reserve The increased workload imposed on the heart of the patient with limited cardiac reserve, and subsequent decompensation due to the decreased oxygen tension at high altitudes, may result in. Cardiac Arrhyhmias that alter the cardiac rate and rhythm Longer Perfusion times required to provide adequate endocardial perfusion. Tachycardia not only decreases perfusion time, by also increases myocardial oxygen consumption. Angina Pectoris increased rates shorten diastolic filling, resulting in poor perfusion of the coronary arteries and decrease coronary blood flow. Myocardial Infarction alterations in blood flow cause prolonged ischemia or an increase in the workload on the heart of sufficient duration to cause infarction.

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Congestive Heart Failure with Pulmonary Edema when a decompensated cardiac patient is positioned with head towards the front of the aircraft, initial acceleration at takeoff may shunt blood towards to patients feet, causing venous pooling. This redistribution of blood volume and resultant stagnant hypoxia may have an adverse effect on the already compromised heart. CHF may also result from: ischemia of a duration sufficient to impair the ability of the heart to pump, fluid shifts as a result of deceleration as the aircraft descends, fluid shifts resulting from aircraft altitude, sufficient to impair the ability of the heart to pump.

Assessment and Preparation for Flight This is directed to recognition, prevention, and correction of hypoxia and maintenance of adequate tissue perfusion, and effective cardiac output. Other important considerations are prevention and treatment of arrhythmias, CHF, relief of pain, and decreased anxiety and fatigue. A complete history and physical assessment are essential in evaluating the needs of the patient during transport. Greatest factor for consideration is prevention of hypoxic hypoxia. All patient with compromised or partially compromised airway, must be intubated prior to transport, and placed on 100% oxygen. If intubation is not required, the patient should be placed on high flow oxygen to achieve maximum saturation of the hemoglobin, and maintained on oxygen to keep oxygen saturation greater than 92% during the flight. Continuous pulse oximeter, and observation of in-flight trends. Anxiety Anxiety about flying can perpetuate the ischemic process by increasing the sympathetic nervous system response, elevating serum catecholamine and increasing myocardial oxygen consumption. Consider pre-flight sedations, and explain what the patient can expect during takeoff, in-flight, and landing, including the noise of the aircraft. Fatigue and Stresses of Flight Acceleration, vibration, and thermal changes, along with crowded conditions prevent the cardiac patient from acquiring rest, thus increasing cardiac workload and oxygen consumption. These environmental factors can be minimized by: i. Providing physical comfort and pain relief ii. Providing reassurance and explaining procedures iii. Providing adequate hydration and humidification of oxygen iv. Providing for bowel and bladder elimination v. Placing a nasogastric tube to alleviate distention vi. Maintaining adequate body temperature

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Patient Care Enroute Involves continuation of the cardiac care already initiated and constant re-assessment of the patient cardiovascular status. Efforts to reduce fatigue and promote rest should be continued. Vital signs should be obtained soon after take off, and at frequent intervals. Constant monitoring of ventilatory efficiency is imperative. Observe for ease, rate, and depth of respirations. Monitor colour of the skin, and mucus membranes, as well as LOC. Monitor oxygen saturation for acute changes, and be aware of changes in the ECG. Chest pain should be treated promptly per medical directives with nitrates and/or morphine. Severe pain should be treated with IV narcotics. Anticipate potential complications, and initiate preventative measures. Treat cardiac arrhythmias, hypotension, and pain promptly. Be prepared to provide resuscitative measures if necessary. Cardiovascular and Hemodynamic Monitoring An unrecognized arrhythmia that causes cardiovascular collapse can result in death in a matte of minutes. Monitoring the ECG is an essential component in the care of the cardiovascular patient. At times, artifact from the aircraft vibration can interfere with the monitor tracing. Careful preparation of the skin, and electrodes preclude this problem. Also, careful placement of the monitor in the aircraft may ensure artifact-free monitoring. Defibrillation It is recommended that patient in the aircraft be defibrillated with the hands-off, anterior/posterior device. Space limitation and decreased ability to communicate requires the medical crew to use extreme caution when defibrillating in the aircraft, to avoid contact with the patient and ensure that all other are clear prior to and during defibrillation. i. Avoid placing the patient on a metal backboard or scoop, if defibrillation may be indicated. ii. Keep the patients extremities close to the body, avoid contact with other aircraft surfaces and crewmembers. iii. Use defibrillator pads, instead of gel. Gel is difficult to confine and may cause arcing. Hemodynamic Monitoring Frequent in-flight blood pressure monitoring is important and essential during transport of the critically ill patients. Invasive Hemodynamic Monitoring Individuals using IBP monitoring should be familiar with the calibrations, maintenance, complications and limitations of these devices. It is important to obtain baseline readings, and assess recent trends prior to flight. If inflight monitoring is unavailable. Invasive pressure lines must be prepared for flight. Label all lines clearly, secure all connections, and maintain a flush system.

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Medical crew should be aware of the complications associated with pulmonary artery catheters, such as pulmonary artery rupture, pulmonary thromboembolism, pulmonary infarction, and air embolism. In addition, arrhythmias can occur if the tip of the catheter slips back into the right ventricle and irritates it. Have Swan-Ganz catheters pulled back or removed prior to flight in order to prevent spontaneous wedging of the pulmonary artery.

MEDICAL CONDITIONS Angina Pectoris Described as chest pain resulting from myocardial ischemia. Coronary artery disease is the primary predisposing factor for angina. Intravascular lumen size decreases due to the buidup of atherosclerotic plaques, results in decreased arterial flow. This decrease arterial flow and subsequent decreased ability for the myocardium to receive oxygen, makes the heart vulnerable to any changes in myocardial oxygen demands. (increased rate due to cold, exertion, anxiety, metabolism etc) Angina Pectoris typically manifests with heavy, squeezing, or burning chest discomfort located across the anterior chest and possibly radiating to the neck, jaw, arms, and back. Usually brought on by some precipitating factor, and can be relieved rest, oxygen, and nitro. Often describes as stable, or unstable. Stable, is familiar chest discomfort, that resolves with the same management every time. Unstable, is chest discomfort that is new or familiar, but does not resolve with normal management, indicates change in condition, and possible presence of another condition (MI?). Management i. Thorough Assessment - ABCs, good history/description of pain along with medical history, medications, and vitals. ii. Pain Management Oxygen: increases PaO2 and subsequently decreases myocardial ischemia Nitroglycerine: primary coronary vasodilator, can be administered SL spray or pills. If pain persists NTG, other medications may be used to mange the acute situation --- morphine. iii. Follow-Up Assessment - Is pain relieved? Vital Signs? Any changes to the patient? 12 lead ECG, ABGs, Cardiac Enzymes. iv. Follow-Up Management - Nitro infusion, patch etc.

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Flight Implications The biggest implication of flight on angina is hypoxia. Ascent to altitude and subsequent decrease in PO2 (Daltons Law), leaves little room for myocardial ischemia compensation and the onset of angina is accelerated. Supplemental oxygen is recommended to avoid precipitating any ischemia. Other implications of flight for the angina patient may include cold stress, dehydration, vibration, and acceleration. Flight Management i. Thorough History know the patients condition, what causes their angina?, what relieves it?, how long does it last? Any concerns which may contribute to an attack? ii. Flight Briefing explain the environment and what to expect (noise, accelerations, temperature) emphasize the importance of recognizing chest pain/discomfort, and informing medical crew immediately. iii. Supplemental Oxygen - all cardiac patients should receive prophylactically and increase if pain manifests. iv. Medications Nitro patch. SL pills or spray for acute onset. NTG infusion may be necessary. Nitro infusion bottles should be replaced with infusions in IV bags. v. Intravenous Access there should be at least one patent line/lock in place to administered IV medications if required. vi. Monitoring Heart rate, respirations, blood pressure, and skin monitoring are essential. ECG and Pulse oximetry must be monitored.

Myocardial Infarction Described as a localized area of necrotic myocardium as a result of inadequate oxygenation of the tissue. The common patholophysiology of an MI is a disruption of the coronary artery blood flow which results in ischemia and death of the tissue supplied by that artery. This disruption of blood flow can be the result of severe atherosclerotic narrowing of the coronary arteries, or a blockage from a thrombus, plaque, or severe coronary spasm. Typically, a patient having an MI will present with severe substernal crushing chest pain that radiates into the neck, jaw, shoulder, arm, and/or back. Pain is longer in duration (>20-30 minutes), and not resolved with rest. The patient is usually diaphoretic, weak, anxious, and my experience nausea, vomiting, or shortness of breath. However, in approximately 20% of patient the MI is silent. Vital signs will vary with the locations and severity of the infarct. There are a number of significant complications that may be associated with the MI dysrhythmias, pericarditis, papillary muscle rupture, ventricular septal defect, cardiac rupture, embolism, aneurysm, CHF, hypertension, and port infarction angina.

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Management i. Thorough Assessment - ABCs, good history/desription of pain along with medical history, mediations, vitals etc. ii. Oxygen - Increases PaO2 and decreases myocardial oxygen demands Monitor & Vital Signs ECH, HR, LOC, BP, O2 sat. iii. IV Access - Important for rapid administration of medications/fluids iv. Pain Relief Nitro primary coronary vasodilator, administer SL spray or pills. Morphine analgesic v. Reassessment - Pain relieved? Vitals stable? Any changes in the patient? Flight Implications The biggest implication of flight on angina is hypoxia. Ascent to altitude and subsequent decrease in PO2 (Daltons Law), leaves little room for myocardial ischemia compensation and the potential for further infarction and ischemia is increased. Supplemental oxygen is recommended to avoid precipitating any ischemia. Motion Sickness should always be evaluated with a high index of suspicion in the cardiac patient. Although the dynamics of flight can cause motion sickness, remember, inferior wall MIs often manifest with vagal symptoms like nausea and vomiting. Other implications of flight for the angina patient may include cold stress, dehydration, vibration, and acceleration. All of these stresses may exacerbate the patients diminished cardiac function in addition to increasing the anxiety and discomfort of the flight. Flight Management i. Thorough Assessment know the patients condition, what treatments they have received, other medical conditions they have, any concerns about flight. ii. Flight Briefing explain the environment and what to expect, emphasize to the patient the importance of recognizing chest pain/discomfort, and informing the medical crew immediately. iii. Physical Exam it is important to examine the patient and be aware of their presentation. Depending on the course of treatment, they may have peripheral IVs, central lines, foley catheters, pacemaker leads, invasive pressure wounds, or signs of peripheral edema/cyanosis. iv. Supplemental Oxygen prophylactically and increase if any discomfort or pain begins. v. Medications Depending on the severity of the infarct and subsequent treatment, the patient may have many infusions running . Heparin, nitro, amiodarone, etc. Ensure that you have enough infusion pumps, and adequate power supply and that you are familiar with the operation. vi. Intravenous Access -- should be at least one patent line/lock to administer IV medication. vii. Monitoring -- HR, RR, BP, and skin. Also ECG, and O2 sat. viii. Patient Comfort -- maintain as comfortable temperature as possible.

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Congestive Heart Failure Defined as the hearts inability to meet the needs of the circulatory system. The heart decreased ability to pump results in pulmonary congestion, and in severe conditions pulmonary edema results. The most common signs and symptoms of CHF are: anxiety, fatigue, dyspnea, orthopnea, nocturia, pulmonary edema, wheezes, peripheral edema, and cyanosis. Management i. ABC Assessment - Airway and breathing should be the concern, the CHF patient is at risk for or may already be compromised. If dyspnea is severe and hypoxia escalates, intubation is an important consideration. ii. Administer Oxygen - Monitor saturation with pulse oximetry (>90%) iii. Monitor Vitals - Cardiac monitoring is useful iv. IV Access - At least one patent line/lock for medication administration v. Medications Furosemide (Lasix) decreases preload by causing vasodilation (onset 5-15 minutes) and diuresis (onset 30 minutes) Morphine reduces anxiety and respiratory exertion, reduces preload by vasodilation. Nitrates NTG primarily reduces preload by vasodilation, also improves coronary perfusion. vi. Urinary Catheterization important for keeping track of output in the patient being diuresed. Flight Implications There are a number of flight stressors that will impact upon the patient with CHF. First, is altitude related hypoxia, supplemental oxygen should be administered. Another important concern is positioning of the patient, especially during periods of accelerations (take off), these patients are often positioned dependent for ease of breathing, laying completely supine is not an option. The patient is best positioned sitting or semi/high fowlers. The concern of expanding gases with ascent to altitude (Boyles Law) may apply to the CHF patient, if they are intubated. Gas volume increase in the cuff of the ETT, and will cause increased cuff pressures, therefore the air needs to be replaced with normal saline or sterile water. Flight Management i. Thorough Assessment know the patient conditions, what treatment they have received, other medical conditions, concerns for flight. ii. Flight Briefing explain the environment and what to expect (noise, accelerations, temperature), emphasize the importance of recognizing the any sort of discomfort or increase in difficulty breathing, and reporting to the medical crew immediately. iii. Supplemental Oxygen prophylactically and increase if SOB/discomfort begins.

i.

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iv. Medication May have infusions running, ensure adequate pumps and power supply. v. IV Access should have at least one patent line/lock for medications. vi. Monitoring HR, BP, RR, O2 sat and skin, and ideally ECG monitoring. vii. Patient Comfort Position for comfort and ease of breathing. Maintain a comfortable temperature for the patient.

Cardiac Dysrhythmias There are many different types. Cardiac dysrhythmias can by caused by many factors including hypoxia, electrolyte imbalances, poisoning, disease, electrical shocks and environmental stressors (temperature). If the cause is known, management should be directed at treating the cause. However, management should also be directed towards the patients presentation. Management i. ABC Assessment - Begin with the assessment of the Airway, Breathing, and Circulation. This is crucial in determining the seriousness of the patient condition and the dysrhythmia. Unstable patients must be treated aggressively, with treatment specific to the rhythm, which may include cardioversion, pacing and/or IV medications. ii. Oxygen Administration iii. ECG Monitoring - 12 lead diagnostic in addition to 3 lead monitoring. iv. IV access - For anti-arrhythmic medication / fluid administration iv. Manage Concerns - Pain, hypotension, seizure, and other problems need to be managed early, follow medical directive for specific management. Flight Implications Altitude related hypoxia can precipitate dysrhythmias and ectopy, give supplement oxygen. Temperature, dehydration, motion, and vibration can contribute to increased patient anxiety and cardiac risk. i. Thorough Assessment know the patient condition, treatments they have received, other medical conditions, concerns about the flight. ii. Flight Briefing explain the environment and what to expect, emphasize to the patient the importance of recognizing any changes, pain/discomfort and informing the medical crew immediately. iii. Supplemental Oxygen prophlactically and increase with discomfort/pain or aberrancy. iv. IV Access there should be at least one patent line/lock to administer IV medications. v. Monitoring -- HR, RR, BP, O2 sat, skin monitoring, and ECG. vi. Patient Comfort positioning for comfort, ease of breathing. Maintain temperature as comfortable as possible.

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Post Surgical Considerations Cardiac surgeries, involve invasive monitoring, different types of IV lines, and surgical procedures. All of these pose a concern for the patient being transported by air. Invasive Blood Pressure Monitoring (IBP) A patient may have an arterial line in place. The transducer setup includes a bag of saline (with or without heparin) in a pressure infuser for easy and rapid flush of the line. Crew members need to be familiar with the arterial line, the transducer setup, and the monitoring equipment. With ascent to altitude, the pressure infuser bag must be observed for excessive pressure due to gas expansion (Boyles Law). Chest Tubes May be placed to either drain blood, air, or pus from the thoracic space. Proper placement must be confirmed by xray and examination. Care for the chest tube for the flight is very important. Ensure the tube is secure Determine if the tube needs to be connected to drainage, suction, or can be clamped. Assess breath sounds periodically.

Central Lines Subclavian, IJ, and Femoral IV lines are common in cardiac patients. These lines may have more than one lumen, and can be connected to multiple infusions. Ensure the catheter is patent, and well secured. Identify and label, which lumens are being used for medications, and ensure other lumens are clamped and properly capped.

Dressing and Wounds Wounds from CABG, grafting and removal of chest tubes or central lines should always be examined for infection, drainage, bleeding, subcutaneous air and healing. Clean, dry dressing should cover all wounds.

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RESPIRATORY PATIENT Satisfactory oxygenation of the tissue depends on secure links between the thorax, pleura, airways, alveoli, cardiovascular and neurological systems. Any reduction in alveoli O2 levels, diffusion potential between alveoli and capillary, hemoglobin levels or circulation fails to maintain the delicate balance of O2 and CO2 in arterial blood. Both hypoxia and hypercapnia contribute to a patient on the ground, and as we ascend to altitude the continued reduction of oxyhemoglobin saturation becomes critical. Factors contributing to lower PaO2 are: 1. Altitude increased altitude = decreased partial pressure O2 2. Hypoventilation decreased alveolar ventilation Normal Lungs: CNS disorders, PNS dysfunction, anaphyaxis, aspiration Abnormal Lungs: pneumonia, respiratory depressants, pneumothorax, COPD. The primary clinical manifestations are signs and symptoms of hypoxia and hypercapnia. Hypoxia: Altered LOA, judgement , personality restlessness, seizures, headache Tachycardia, hypertension Dyspnea Hypotension, bradycardia, stupor, coma, dysrhythmias and cyanosis are LATE SIGNS Hypercapnia Headache, vertigo Hypertension, increased CSF Papilloedema Coma, hypotension, and cardiac failure are LATE SIGNS Prompt recognition is essential for effective treatment: 1. assess precipitating causes 2. establish patent airway 3. administer O2 for adequate ventilation 4. reassurance and explanation 5. anticipate further complications

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MEDICAL CONDITIONS Chronic Obstructive Pulmonary Disease (COPD) A mechanical blockage related to blood, pus, or foreign body, which induces limited air flow. Types: Asthma mucous plugging, smooth muscle hypertrophy and/or constriction, edema with limited air flow. Bronchitis diffuse inflammation, with thickening of the tracheal-bronchial submucosa and secretions, with limited air flow. Emphysema decreased or non-existent parenchyma elastic recoil, with limited air flow. Signs and Symptoms Pursed lip respiration Orthopnea Pink frothy sputum Cyanosis/pale Anxiety Tachycardia Tachypnea Treatment Oxygen Bronchodilators Anti-inflammatory/antibiotics Antispasmodics Diuretics

Tuberculosis (TB) An infectious disease caused by an airborne infection that commonly effects the lung, but also the GI tract, joints, nervous system, lymph nodes and skin. May occur in an acute form or in a chronic form, and is not always active. TB causes a decrease in vital capacity, decreased inspiratory capacity. Signs and Symptoms Vague chest pain, pleurisy, weight loss Night sweats, pulmonary hemorrhage Decreased vital capacity, decreased inspiratory capacity

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Treatment Methambutol, rifampin Side Effects: Rash, fever, CNS effects Vertigo, GI upset Blurred or loss of vision

Asthma Effect people of all ages, and is the most common chronic illness for those under 17 years of age. The airway spasm may be caused by allergic reaction, foreign bodies in the upper respiratory tract, infections and left heart failure. Many people are asymptomatic between attacks. During an attack, progressive airway obstruction leads to prolonged expiration, and air becomes trapped in the lungs and increase in residual volume. Types: Intrinsic: unknown cause, may be precipitated by infections, weather changes, exercise, emotion, exposure to bronchial irritants. Extrinsic: allergic or bronchial asthma, caused by known allergic reaction, onset occurs during childhood and attacks related to exposure to specific allergies. Status Asthmatics: reoccurring asthma attacks or continuous asthmatic state, may last for fours or days. Signs and Symptoms: Cyanosis Cough Diaphoresis Indrawing, accessory muscle use Anxiety Wheezing Treatment Oxygen Bronchodilators Monitor temperature changes Exposure to flight environment could put the patient into an asthma attack Vibration can make breathing difficult Status asthmatics land ASAP and seek further medical attention

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Pneumonia Inflammation of the lungs primarily caused by bacteria, there are more than 50 causes. Signs and Symptoms Insidious onset Chills, high fever Pain in the chest Cough purulent and bloddy Restlessness Cyanosis Treatment Oxygen Antibiotics Rest Pneumothorax potential Temperature extremes due to the flight environment would make respiration difficulty, therefore avoid over chilling or over heating. Signs and symptoms could be more dramatic due to the dry air, vibration and decreased partial pressure

Laryngeal/Tracheal Trauma Damage to either of these structures can result in both edema and subcutaneous emphysema. Swelling in the airway as a result of trauma reduces the space through which ambient air must pass to reach the lungs and the tissues. At sea level the patient can experience partial or even total obstruction due to laryngeal swelling and spasm, leading to hypoxia and/or anoxia. The patient exposed to the flight environment is even more susceptible, especially in an unpressurized cabin. Subcutaneous emphysema, the presence of free air in the tissues can result from laceration or fracture to the trachea. The air escaping the damaged structures will collect in the tissue of the face and neck causing swelling and deformity. As the patient gains altitude, the decrease in partial pressure of gases can lead to expansion of the free air in the subcutaneous tissues, with greater edema and deformity, potential compression and pain. Bronchial Trauma Disruption of a main stem bronchus is a serious injurt which can lead to massive hemothorax and/or pneumothorax. Most bronchial injuries are due to blunt trauma, and occur within one inch of the carina. Severe edema and inflammation accompany the injury.

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Several aspects of the flight environment can impact on the patient with bronchial trauma. Expansion of free air in the chest cavity which has leaked from the bronchus can lead to rapid compression of the lung on the affected side, and a shift in the mediastinum to the affected side. G-forces encountered in linear and angular accelerations are of concern to the patient as these forces can cause a shearing effect at the injury site near the carina. Actions such as sudden increase or decrease in power could convert a partial tear of a bronchus into a complete disruption. As with any free air in a body cavity, is subject to sudden expansion, which would result in a tension pneumothorax. Pneumothorax/Hemothorax A collection of free air in the pleural cavity, as a result of either blunt or penetrating trauma. Depending on whether the air can or cannot be evacuated from the chest during respirations, this presents as either a simple or tension pneumothorax. A fractured rib which lacerates the lung will cause collapse of the lung, resulting in that part of the lung not participating in gas exchange. A penetrating chest injury which does not seal its self on expiration will have the same effect. In flight the patient will be subject to hypoxic hypoxia as the collapsed alveoli prevent adequate oxygen uptake at the ventilatory level.

Signs and Symptoms Hyperresonance, decreased breath sounds Subcutaneous emphysema Dyspnea, air hunger Cyanosis, shock Distended neck veins Apprehension, anxiety

Flight Implications For Respiratory Disorders 1. Altitude/Hypoxia - Altitude will gravely affect ventilation of an already compromised respiratory system. It is important to consider the decreased partial pressure on oxygenation potentials and that hypoxia is a real hazard. ABGs prior to transport are helpful. 2. Space - The physical confines and limitations of the aircraft may make satisfactory positioning difficult. 3. Gas Expansion - Are chest tubes required? Is intubation required? 4. Thermal Effects - Temperature extremes could hamper respiration, avoid chilling or overheating 5. Dehydration/Humidity - Dry mucosa could be further dehydrated by drier air at altitude

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6. Noise, vibrations and turbulence - Ensure all tubes are secure. Recognize increased difficulty for auscultating chest sounds and the potential for nausea and vomiting. 7. Lighting - Difficulty to observe patient status and treatments, if lighting is inadequate 8. Disorientation - Potential for hypoxic patients

Patient Care En Route 1. Patients with suspected air embolus, decompression sickness or pneumocephalus should be transported at the lowest possible altitude, or with sea level pressurization in a higher altitude, pressurized cabin. 2. Supplemental, humidified oxygen should be provided by the most appropriate route of administration. The patients oxygenation level should be monitored continuously. ETCO2 monitoring would provide useful information for patients with head injuries, hypotensive, or hypothermic. 3. Cardiac rhythm should be monitored for developing dysrhythmias. 4. If air was used to inflate the endotracheal or tracheostomy tube, it will expand with increasing altitude and place more pressure on the surrounding airway mucosa. If you are not able to monitor cuff pressure with a manometer, fill the cuff with sterile water instead of air. 5. Drainage bags connected to chest tubes must be vented. 6. One way flutter valves and/or underwater seal drainage systems must be observed for proper functioning 7. Drug and blood infusions should be continued in flight when necessary. Oral/Nasogastric tubes may require venting in flight to prevent gastric distention, which can cause vomiting with possible aspiration. 8. Suction should be readily availability for ETT, gastric or chest tubes, or for any patient at risk for vomiting. 9. When the aircraft begins to decent, awaken sleeping patients, encourage patients to yawn/swallow. Remove the patients earplugs. Allow an infant to suck or cry to help equalize the air in the middle ear. 10. When possible, relay an in-flight report to the receiving facility to allow them time to prepare.

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HEMATOLOGICAL DISORDERS Decreased circulating RBCs due to anemia, sickle cell disease or circulating blood volume loss translates as a decreased oxygen carrying capacity. In additions to the implications of these disorders at altitude, it should be remembered that any blood dyscrasia interfering with oxygen transport produces hypemic hypoxia. Oxygen must be immediately available to this type of patient. Severe Anemia A patient with severe anemia requires special consideration during aeromedical transport. Blood studies on such a patient should be done as close to proposed transport time of the fight (not more than 72 hours). The anemic patient has a smaller total capacity and a smaller total oxygen content than the normal patient. They may have the same oxygen saturation of his hemoglobin, but not enough to carry sufficient quantities to satisfy tissue demands. Anemias have a great number of causes. They may be primarily due to disturbances in functioning hematopoietic tissue or secondary, due to disturbances in other parts of the body. Clinical Considerations Palpitations: Angina and CHF can occur easily. The heart adjusts to anemia by increasing its rate and stroke volume. Because of the decreased oxygen, cardiac compensation occurs with increased heart rate, and stoke volume. Neuromuscular Disturbances: Patients experience headaches, dizziness, vertigo, fainting, sensitivity to cold, tinnitus, muscular weakness and fatigue. Alimentary Tract Disturbances: The patient may be anorexic and need encouragement to eat. They are prone to flatulence and should be observed carefully for gas exchange. Many of these patients compensate for their anemia at ground level and symptoms are not demonstrated until moderate altitudes are reached.

Sickle Cell Anemia This disorder is present in about 8% of the general black population. The erythrocytes contain abnormal hemoglobin and are abnormal in shape (sickle shaped). Under certain conditions, such as mild to moderate decrease PO2 encountered in cabin altitudes of 4,000 6,000 feet, sickling and hemolysis can occur. These patients often present symptoms of severe anemia. They are extremely prone to leg ulcers and infection. Some patients are addicted to narcotics, the use of drugs to relieve frequent painful episodes. Few patients live beyond the age of 40, infection, pulmonary embolus or thrombus are frequently the cause of death.

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Splenic infarction is the most common complication of the disease, occurring frequently during exposure to lowered partial pressures of oxygen. The most important features are, vomiting, nausea, slight fever, tachycardia, epigastric pain, LUQ pain radiating to the left shoulder, abdominal rigidity, guarding and tenderness. The majority of paitents will improve on symptomatic treatment consisting of oxygen, IV fluids, and mild sedation (avoiding all types of CNS depressants)

Special Considerations: Oxygen may be necessary for an existing hypoxic state to avoid the complications of decreased PO2, which leads to hypoxic hypoxia at altitude. Altitude Restrictions may be necessary for all anemias. The patient may require a 4,000 feet restriction (with sickle cell anemia, a crisis may be experienced at 4,000 feet). If the patient, at rest, is able to compensate for the anemia on the ground keeping them in stable condition, then administering oxygen at moderate altitude should maintain the current condition. Supplying oxygen at altitude ensures that whatever hemoglobin is present is 100% saturated.

Leukemia A malignant disease of tissues in the bone marrow, spleen, and lymph nodes. It is characterized by uncontrolled proliferation of leukocytes resulting in anemia and increased susceptibility to infection and hemorrhage. Other typical symptoms include fever, pain in the joints, and bones and swelling of the lymph nodes, spleen and liver. Clinical treatment of acute leukemia consist of transfusion antibiotics, steroids, and antineoplastic chemicals. In-flight care of these patients will be mainly supportive. Special emphasis should include observation of hemorrhage, good skin care, prevention of bruising and hemorrhage and possible reverse isolation.

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NEUROLOGICAL DISEASES/DISORDERS These can present a challenge when transporting patient by air. The medical team must be prepared to manage special problems in the aviation environment.

Seizure Disorders There are a variety of conditions that could precipitate seizure activity fever, CNS infections, toxic agents, metabolic disturbances, brain lesions, brain trauma, withdrawal symptoms, epilepsy, and hypoxia. Easy access and the ability to closely observe the patient is important. Pre-Flight Assessment Type of epilepsy, or reason for seizures Previous history of seizures Date and duration of last seizure Recognizable aura Treatment, medications In-Flight Care Close observation throughout the flight, with easy access to airway equipment and medications, and protecting the patient from injury during the seizure.

Head Injuries The most important consideration is the degree of damage to the brain. It is not always advisable to transport patient with head injuries by air, but it may be a life-saving measure. They must be transported with the great care and consideration. No sedatives or narcotics should be given, at least in the early hours/days after the injury. Once these patients are seem and treated by a neurosurgeon, you may see them being given narcotics or sedatives. The stresses of flight may induce complication. It is vital that a thorough pre-flight assessment by completed, so this information can be used to compare in flight observations. Increased Intracranial Pressure (ICP) This condition is a result of expanding lesion in the skull. With the skull being rigid, that cannot expand, any increasing pressure is exerted on the soft structures of the brain and its vital centers.

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Causes may include hemorrhage, edema, and air expansion. Patients espesically prone to developing ICP are those with either cerebral edema, or a space occupying lesion in the intracranial cavity. Cerebral edema should be expected in patients with CVAs, Hypoxia, severe metabolic or electrolyte imbalances, thrombosis, hemorrhage, cranial trauma, malignant hypertension, meningitis, or meningioencephalitis. Signs and Symptoms: Headache Increasing irregular pulse Increasing irregular respirations Progressive decrease in consciousness Marked elevatin in blood pressure Fixed dilation of the pupil on the affected side Vomiting Paralysis Seizures If ICP is due to air within the skull, sign and symptoms will emerge as the aircraft gains altitude. These patients should be grounded until the air reabsorbs, if status is too serious to delay, a neurosurgeon may aspirate intracranial air prior to takeoff. If due to hemorrhage, usually signs and symptoms appear within an hour to a week after injury, and if due to edema, signs and symptom appear within 24 hours. Intracerebral Hemorrhage These can be from the rupture of an arteriosclerotic vessel, congenital aneurysm, other malformation, brain infarct, blood dyscrasias, or other systemic diseases. Unconsciousness is frequently common, and may occur rapidly or gradually. There may be nausea and/or vomiting, delirium, and seizures. Consciousness usually returns and neurologic deficits gradually recede as the blood is reabsorbed. Some degree of impairment usually remains. Blood pressure is always elevated, usually with systolic pressure over 200 mmHg. Therapy involves progressive reduction in blood pressure, to a normal range. Subarachnoid Hemorrhage Commonly caused by trauma, and secondary ICP increase is common and may last for several days or weeks. Signs and Symptoms: Visual deficits Headache severe and acute Possible syncope Dizziness, vomiting, seizures, alterations in pulse and respirations Changes in LOC Neck stiffness Elevated temperature Hemiplegia

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Management: Patent airway Avoid exertion Bed rest Maintain fluid balance and nutrition Maintain body heat

Preparation and Assessment: Proper planning for in flight needs and thorough assessment is necessary. Assessment should begin with thorough report on nature and extent of injury, vital signs, pupil reactions, LOC, level of responses/movement. Equipment should focus on preparing for the unexpected. Include routine equipment, along with oxygen, suction, ETT, and cardiac monitor.

Pre-Flight Evaluation and Planning o Gather history o Perform neuro assessment o Assess respiratory status o Renal / bowel function o Immobilization considerations

Management o Ensure patent airway o Immobilization is injuries real or suspected o Careful handling o Sensory/motor assessments q30-60 minutes o ABCs, ensure adequate respiratory function o NG tube, if required o Foley catheter o Monitor vital signs, continuous monitoring o Monitor intake and output.

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Flight Implications for the Neurological Patient 1. Altitude/Hypoxia increase in altitude produces decrease in barometric pressure producing the potential for hypoxia. Compromised respiratory function due to head or spinal injuries may be further complicated by hypoxic hypoxia produced by altitude. 2. Space limited space in the aircraft hinders placement of drainage bags, traction, immobilization and restraint devices (halos, backboards), further limits access to the patient for monitoring status. 3. Gas Expansion Expanding gases may further compromise respiratory efforts (expanded abdomen), as well as increased physical discomfort from inability to expel flatulence. 4. Thermal Effects Brain and cord trauma may alter thermal regulating systems, therefore observe for unusual heat loss/retention. 5. Noise, Vibration, & Turbulence securing of the patient to facility immobilization of injuries, must limit effects of vibration and turbulence. Using extra straps, and/or blankets/pillows for padding. 6. Disorientation Altered LOC as a direct result of the head injury, may be further complicated by motion, and hypoxia of altitude. 7. Motion Sickness immobilization devices produce a real danger for airway protection, should nausea and vomiting occur.

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GASTROINTESTINAL DISORDERS Gas expansion occurs on ascent to altitude, and compounds existing problems within the GI tract. The major influences of gas expansion are the cabin altitude, quantity of existing gas in the bowel, and the patients ability to eliminate the gas.

Site of Gas: The site of gas pockets in the GI tract, may influence the degree of abdominal pain, and other symptoms. Gas distention in the stomach and duodenum results in nausea and vomiting, because of the vagal and sympathetic stimulation of the vomiting center in the medulla, Gas expansion in the ileum causes severe abdominal pain and hypotension because of the parasympathetic stimulation which increases the activity of the intestine, but decreases the effectiveness of the heart.

Complications from gas expansion: The expansion of gas at even a moderate altitude could rupture a disease visera, especially in cases of ulceration and weakening of the tract walls. Gas expansion can exert enough pressure to rupture thin walls. Patients with conditions, such as incarcerated / strangulated hernias, intestinal obstructions, acute appendicitis, and diverticultis may experience complications at a moderately high altitude. Patients who have undergone recent GI surgery, where the stomach or colon have been sutured, may experience problems with the suture line.

Major Implication when caring for patients who may experience gas expansion problems at altitude: o Colostomy patients generally have more profuse discharge at altitude, additional drainage bags should be available also advisable to puncture a tiny hole (with a needle) to ensure increased gas doesnt cause the bag to pop off the flange. o Rectal and NG tubes, should be in place. o Intestinal tract decompression by proper suctioning must be maintained on patients who have penetrating wounds of the visera, or perforated ulcers. o Diet: Avoid foods whoch produce distention, at least 12-24 hours pre-flight.

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Flight Implications for GI Disorders 1. Altitude/Hypoxia compromised perfusion capability may be further threatened by decreased oxygen levels at altitude. 2. Space limited aircraft space hampers placement of suction and monitors, as well as limits positioning of the patient. 3. Gas Expansion Increased altitude produces gas expansion which will worsen gastric distention and discomfort. 4. Thermal Effects as altitude increases, temperature decreases providing a potential problem for a patient who may already be experiencing blood loss and shock symptoms. 5. Motion Sickness motion produced by the aircraft may increase feelings of nausea and pain already experienced.

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MUSCULOSKELETAL CONDITIONS The types of musculoskeletal conditions that can be managed are varied. Fractures: When there is a history of trauma, and a fracture is suspected or proven, a thorough assessment must be done. Signs and Symptoms: o Local tenderness o Pain o Disability o Swelling o Deformity o Loss of function Splinting reduces pain and prevents further injury. When any splints, including casts, bandages, or other devices are applied to immobilize the facture site. Many possible complications must be considered. If a splint is to tight, the resultant pressure can produce necrosis of the skin over bony prominences, damage nerves lying close beneath the skin and interfere with circulation, with resultant distal ischemia. The site must be adequately padded on all bony prominences, and the splinted area checked frequently for changes in pulse, skin temperature, and appearance. Joints are immobilized in positions of optimum function. Pain, tingling, or numbness signify the need for immediate investigation. Localized pain beneath the cast/splint frequently indicates a developing pressure necrosis area. Pain distal to the cast/splint indicates interference with circulation. Numbness, and tingling distal to the cast/splint could be caused by pressure on a superficial nerve or circulatory interference. Swelling which develops after the cast/splint is applied may cause pressure changes. Swelling should be minimized by elevating the affected extremity. This is particularly important during the first 48 hours. Orthopedic appliances (crutches, walkers, canes) these patients should never be permitted on sloping ramps, ladders, or negotiating steps. Medical team members should provide support for the unsteady patient. CASTS Plaster casts should be dried before flight. They should be bivalved at the originating hospital if there is one of the following . o Any possibility of edema formation o There is vascular impairment o Cast applied less than 72 hours before travel.

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Amputations: These require continual observation and documentation. Monitor the whole patient to determine their status. There may be complications that develop from gas expansion, unrecognized anemia, and emboli. A complication of multiple fracture and/or long bone fractures, is that of a fat embolus. This should be strongly considered for any patient that develops signs of disorientation progressing to unconsciousness, when there was had a head injury or no previous history of unconsciousness. This may occur from 1 5 days following the injury and my be increased by handling or moving the patient. Treatment consists of oxygen, maintaining the airway, and reaching a receiving facility for more definitive treatment. Gas expansion may be a particular problem with any patient who has been receiving analgesic and immobilized. This is especially pertinent to a patient in a hip or body spint. With increasing altitude, the abdomen will become more and more distended, pressing on the diaphragm, and the patient will have respiratory difficulties. A change in position, the use of an NG tube, or decreasing the cabin altitude will contribute to the relief of this condition. Management: o Airway patency o Immobilization o NG tube, as required o Careful handling and positioning Flight Implications for Orthopedic Disorders 1. Altitude/Hypoxia hemorrhage from open or complicated fractures or amputations may result in hypovolemia or anemia, putting the patient at further risk to developing hypoxia at altitude. 2. Space space limitations in conjunction with immobilization devices (casts, splints, traction, external fixators) can greatly complicate the maneuvering and positioning of the patients. 3. Gas Expansion increased altitiude facilities gas expansion within closed spaces. 4. Thermal Effects Positioning an immobilization may hinder circulation and body heat conservation. 5. Noise, Vibration & Turbulence will potentially increase discomfort of the patient as a result of vibrations and turbulence.

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TRANSPORTING PSYCHIATING PATIENTS Transporting the psychiatric patient can pose a variety of problems, and/concerns. With intelligent handling, using a few general principles, the crew should be competent to handle any difficulties these patients during flight.

Pre-Flight Preparations: Patients will be loaded on a stretcher with restraints in place, as required. The team should be briefed on the mental status of the patient and also, if there is anything that triggers the patients behaviors. Patients should have their restraints checked frequently, ensuring proper functioning, and quick release if necessary. Proper identification and securing or personal possessions is essential. Hazardous objects are to be both secured for both the protection of the patient and the crew. Sedation of extremely combative or uncooperative patients may be necessary prior to transport to facilitate management, and crew safety. These patients are to remain on the stretcher during the flight. There is sometimes a temptation to remove restraints from the apparently quiet and cooperative patient, but this can be hazardous, as one cannot relay on the intentions of the patient. The restraints used can create some special problems / difficulties, as the may be unfamiliar to the patient, or may provoke anger at what is considered an aggressive move against them. Prevention is the key to handling disruptive behavior. If you are alert to the early signs, such as restlessness or confusion, most often you can avoid an increase in symptoms with appropriate intervention.

Management: Close observation of patient for behavioral changes Non-threatening, firm, problem solving Reinforce reality, as appropriate Prepared for potential abnormal behavioral responses Safety precautions as to hazardous materials and restraint complications

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A patient that is anxious and restless may easily become combative, this type of patient poses a serious risk to the crew and cabin safety. Within the confines of the aircraft, an uncontrollable patient may strike crew members or equipment and sudden movements can challenge aircraft balance. For these reasons, it is imperative to manage a patient who is combative or at risk for such behavior in advance. There should be no hesitation in applying restraints during the flight to control movement. If necessary, sedation should be administered, with careful assessment and documentation before problems arise. Medications such as valium and ativan are useful. Dont forget to consider drug interactions - gravol for motion sickness can cause sedation. It is important to communicate all your intentions to the patient and impress upon them that these measure are not just for their own safety but the safety of the crew and aircraft.

Flight Implications for Psychiatric Patients 1. Space limited space may limit movement of patient or facilitate a sensation of confinement. 2. Noise, Vibration & Turbulence sensations of flight may facilitate hallucinations 3. Disorientation motion, confinement and noise encountered with flight may only serve to increase disorientation levels of the patient.

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