Clinical features of patients intubated by a flight team

INTRODUCTION: Little information exists about the clinical features of patients intubated by a flight program and the relationships of those factors with flight team intervention. METHODS: Prospective analysis was conducted of consecutive patients intubated by a helicopter flight team. RESULTS: The flight team intubated 11.1% of patients transported. Scene origin and trauma diagnosis were associated with flight team intubation (P <.01). The diagnosis distribution differed between scene and interfacility groups (P <.01), with a trauma diagnosis more common in scene patients and a medical diagnosis more common on interfacility flights. The most common clinical indicator for intubation on both scene and interfacility flights was mental status change. The distribution of indicators, however, also varied with patient origin (P <.01). CONCLUSION: The flight team most commonly intubated patients who originated at the scene, suffered traumatic injury, and had altered mental status. Both the diagnosis distribution and primary clinical indicator for intubation varied with patient origin.     

Characteristics of patients transported by an aeromedical service for acute toxicologic emergencies: a 5-year experience

INTRODUCTION: Aeromedical services are used routinely in the prehospital and interhospital transfer of patients with trauma, neurosurgical, cardiac, and other conditions requiring specialized care. The use of aeromedical transport in patients with acute toxicologic emergencies is not well described. We sought to investigate and describe the characteristics of patients transported by our aeromedical service. SETTING: The study was performed at an urban critical care transport service operating both ground and aeromedical units and transporting an average of 3,362 patients per year during the study period. METHODS: Charts from the 5-year period of 2000 to 2004 for which a toxicologic emergency was coded as the primary diagnosis were identified and reviewed by the authors. Data abstracted included age, sex, toxin(s) involved, treatment rendered at the scene/bedside and en route by the transport team, and additional data (electrocardiogram [ECG] findings, serum levels) when appropriate. RESULTS: One hundred thirty-three patients were transported (for a total of 135 transports). Most (82%) were transported by air. Carbon monoxide was the most common toxic exposure, accounting for 16% of all transports. Fifty-seven percent of the patients were intubated, with 11% intubated by the flight crew. Antidotes were administered in 40 patients, with naloxone and bicarbonate being the most common. CONCLUSION: Acute toxicologic emergencies accounted for a small percentage of total transports. The most common additional intervention by flight crews was endotracheal intubation. Identification of common poisonings encountered by flight crews may assist services in developing education and quality assurance programs.     

Changes in pCO2 during air medical transport of children with closed head injuries.

OBJECTIVES: Because low partial pressure of carbon dioxide (pCO2) can be associated with posttraumatic cerebral ischemia, we conducted a study to determine whether the pCO2 level in ventilated children with closed head injuries transported by a trained team to tertiary care was optimally maintained during transport and determine whether hand-bagging or mechanical ventilation resulted in more optimal pCO2 levels after transport. METHODS: We reviewed the hospital charts and transport records of all infants and children who had sustained a head injury and were transported by a specialized pediatric transport paramedic team to a single tertiary care facility during a 12-month period. All children were intubated and ventilated either mechanically or manually. Outcome measures were final pCO2 before transport and first pCO2 on arrival in the PICU. RESULTS: Twenty-nine children (age 0.6 to 16 years, mean 7.3, median 6) met the criteria. Fourteen patients were hand-bagged (HB), and 15 were mechanically ventilated (MV). Eleven patients (5 HB and 6 MV) started in the target pCO2 range of 35 to 40 mmHg. After transport, nine patients (all MV) had pCO2 within the target range (P < 0.01). Duration of transport (mean 63 minutes, range 15-200 minutes) did not contribute to the final pCO2 level. CONCLUSION: MV improves management of pCO2 during interfacility transport. HB significantly increases the incidence of suboptimal pCO2 and hence the risk of suboptimal cerebral blood flow. MV appears mandatory, and monitoring CO2 in transit (end-tidal or preferably point-of-care testing) should further reduce the likelihood of secondary complications from cerebral ischemia.     

Sidestream end-tidal carbon dioxide monitoring during helicopter transport

INTRODUCTION: End-tidal carbon dioxide (EtCO(2)) monitoring is standard of care for intubated patients. Sidestream technology also allows EtCO(2) monitoring in non-intubated patients. This is the first study to evaluate the feasibility of monitoring sidestream EtCO(2) on intubated and non-intubated patients during helicopter transport. SETTING: An air medical transport program serving two level 1 trauma centers. METHODS: In this prospective observational study, sidestream EtCO2 was monitored in 100 consecutive patients transported by helicopter. Flight nurses rated the difficulty posed by various factors of sidestream monitoring. An experienced flight nurse and a clinical engineer evaluated waveforms and EtCO(2) values. RESULTS: Only 1 of the 100 transported patients required a change from sidestream to mainstream EtCO(2) monitoring. Moisture was noted in the tubing of two patients, and one was changed to mainstream. Eleven patients had occluded nares but were not changed to mainstream monitoring. On a 5-point Likert scale, responses to statements regarding difficulty with length of tubing, patient tolerance, and interference with patient care produced mean scores of 0.5 (range, 0-3). Responses regarding difficulty securing the cannula yielded a mean score of 0.7 (range, 0-3). Of 1,685 (99%) recorded EtCO(2) values, 1,668 met pre-established criteria for "consistent." Alveolar plateaus were identified in 81 of 94 (86%) patient waveforms by the flight nurse and 73 of 94 (78%) patient waveforms by the clinical engineer. CONCLUSION: Sidestream EtCO(2) monitoring is feasible during air medical transport of both intubated and non-intubated patients. The mechanism was easy to use, and consistent numeric values and waveforms with alveolar plateaus were obtained in a large majority of readings.     

Changes in pCO2 during Air Medical Transport of Children with Closed Head Injuries

Objectives: Because low partial pressure of carbon dioxide (pCO₂) can be associated with posttraumatic cerebral ischemia, we conducted a study to determine whether the pCO₂ level in ventilated children with closed head injuries transported by a trained team to tertiary care was optimally maintained during transport and determine whether hand-bagging or mechanical ventilation resulted in more optimal pCO₂ levels after transport. Methods: We reviewed the hospital charts and transport records of all infants and children who had sustained a head injury and were transported by a specialized pediatric transport paramedic team to a single tertiary care facility during a 12-month period. All children were intubated and ventilated either mechanically or manually. Outcome measures were final pCO₂ before transport and first pCO² on arrival in the PICU. Results: Twenty-nine children (age 0.6 to 16 years, mean 7.3, median 6) met the criteria. Fourteen patients were hand-bagged (HB), and 15 were mechanically ventilated (MV). Eleven patients (5 HB and 6 MV) started in the target pCO₂ range of 35 to 40 mmHg. After transport, nine patients (all MV) had pCO₂ within the target range (P < 0.01). Duration of transport (mean 63 minutes, range 15-200 minutes) did not contribute to the final pCO₂ level. Conclusion: MV improves management of pCO₂ during interfacility transport. HB significantly increases the incidence of suboptimal pCO₂ and hence the risk of suboptimal cerebral blood flow. MV appears mandatory, and monitoring CO₂ in transit (end-tidal or preferably point-of-care testing) should further reduce the likelihood of secondary complications from cerebral ischemia.     

Outcomes of pediatric trauma patients transported from rural and urban scenes

OBJECTIVES: Mortality differences exist between victims of urban and rural trauma. It is unknown if these differences persist in those patients who survive to HEMS transport. This study examined the in-hospital mortality, hospital LOS, and discharge status of pediatric blunt trauma victims transported by HEMS from rural and urban scenes. METHODS: Retrospective review of pediatric (< 17) transports between 1997 and 2001. 130 rural and 419 urban pediatric patients transported to area trauma centers were identified from HEMS and registry records. RESULTS: Total mileage, flight times, and scene times were significantly longer for rural flights (P < 0.05). There were no significant differences between the groups with regard to age, gender, vitals, hospital/ICU days, and mortality. After controlling for ISS and mechanism of injury, urban patients were 9 times more likely to die compared to rural patients. CONCLUSIONS: Pediatric patients injured in urban areas had shorter total flight and scene times than pediatric patients flown from rural scenes. Higher adjusted in-hospital mortality rates in the urban group were likely a result of faster EMS response and transport times, which minimized out-of-hospital deaths. Factors prior to HEMS arrival may have more impact on the increased mortality rates of rural blunt trauma victims documented nationally.     

Prehospital blood transfusion versus crystalloid alone in the air medical transport of trauma patients

Introduction: Differences in prehospital resuscitation measures and outcomes of trauma patients transported by two air medical programs were assessed comparing the prehospital administration of crystalloid only (Group A) with the administration of 2 liters of crystalloid followed by blood (Group B).

Methods: A 1-year retrospective review of flight and hospital records of patients taken to Level I trauma centers by two separate air medical programs was completed. Physiologic variables, total fluids infused, and flight times were compared.

Results: Thirty-one patients (Group A) received crystalloids in flight, and 17 patients received in-flight blood (Group B). No statistical differences were found between the two groups when comparing age, ISS, PS, RTS, GCS, survival, and total fluid volume. Group B had statistically greater mean flight times compared with Group A (P < .05). A difference was demonstrated between groups A and B in pH and HCO₃ measurements (P < .05), with Group B presenting in a more acidotic state on admission to the hospital.

Conclusion: Patients with lengthy flight times, despite the administration of blood products, presented to the trauma center more acidotic than trauma patients receiving only crystalloid. The true impact of blood products on outcome could not be demonstrated because of statistical differences in flight times between the groups. A multicenter study matching flight times, head injury status, and flight type to assess benefit of prehospital utilization of blood products is warranted.     

Interfacility transport of patients admitted to the ICU: perceived needs of family members

INTRODUCTION: Limited research has been published regarding the needs of immediate family members with respect to the transport of critically ill loved ones. Furthermore, very little information exists on transport teams members' perception of the needs of the family members. METHODS: During a 9-month period, a 25-item questionnaire was given to family members of adult patients who were transported by air or ground. All patients were admitted into an adult intensive care unit at a major university teaching hospital. Family members were asked to rank the relative importance of each item with regard to informational or situational needs. The identical questionnaire was given to the critical care transport teams employed by the hospital. The team members were asked to indicate what they thought the family members ranked as important. RESULTS: Forty-two of 100 family members (42%) returned the questionnaire by mail. All 13 (100%) critical care transport team members completed surveys as well. Statistical comparisons indicated that family members and team members differed significantly on 13 of 25 items. Team members generally underestimated the importance of these items to family members. CONCLUSION: These findings suggest that, in this sample, transporting crew members often misperceived family members informational and situational needs.     

Safety of fentanyl for analgesia in adults undergoing air medical transport from trauma scenes

Introduction: Although proper analgesia provision for patients in the in hospital acute setting has received recent attention, little discussion has been done of prehospital pain relief. This study was conducted to evaluate the safety of fentanyl administration during air medical transport of adult trauma patients.Setting: Urban air medical transport program using a flight nurse/paramedic crew operating with patient care protocols and off-line medical control.Methods: Flight records for trauma patients transported directly from the scene receiving fentanyl were analyzed retrospectively. Study parameters were obtained for the times just preceding and after fentanyl administration. A t test (α = 0.05) comparison between before and after fentanyl administration was performed for the following study parameters: systolic blood pressure, heart rate, oxygen saturation, respiratory rate, and Glasgow coma score in non-intubated patients. Flight records were also reviewed for any administration of naloxone or subjective notation of complications possibly attributable to fentanyl.Results: Fentanyl was administered 154 times to 99 patients. No patient received in-flight naloxone, and no fentanyl-related complications were noted on flight record review.Conclusion: Administration of fentanyl for in-flight trauma analgesia in adults seems safe. Further study should investigate efficacy of in-flight fentanyl administration and determine whether prehospital opiate administration impairs emergency department evaluation of trauma patients.     

Disagreement between transport team and ED staff regarding the prehospital assessment of air medically evacuated scene patients

STUDY OBJECTIVE: To determine the rate of disagreement in assessment of significant illness or injury between air medical transport team assessment and emergency department (ED) diagnosis in patients transferred from the scene of an incident to the ED. METHODS: Retrospective analysis was performed on 84 patients transported by medical flight teams from an accident scene to an ED. RESULTS: Results show transport team assessment concurred with ED diagnosis 96.7% of the time; most of the differences in assessment were overassessments by the transport team. Assessment differences occurred most often for abdominal injuries and least often for head injuries. Underassessment occurred most often for spinal cord injuries. CONCLUSIONS: Despite the numerous difficulties involved in patient assessment, data show that the transport teams accurately evaluated patients in most instances. Disagreements in assessment of injury/illness most often were overassessments.     

Comparison of air and ground transport of cardiac patients

Purpose: To investigate the outcome of cardiac patients transported by helicopter versus ground ambulance Setting: A hospital-based helicopter program in southeastern Minnesota Methods: Retrospective chart review assessing an 18-month period (January 1998 to June 1999). Charts were reviewed for type of cardiac diagnosis, level of pain, treatments en route, time to intervention, and length of stay (LOS). Two-hundred-sixty-six cardiac patients came by helicopter. Of the 86 turndowns, 50 came by ground ambulance; 28 records were recovered in this group. These patients composed the comparison ground group. Results: Prehospital time was less for patients transported by air than ground transports (P < .001). The amount of time from the call for transport until arrival at our hospital was less for helicopter transports (P = .002). Air transports had more patients with reduced chest pain on arrival. Difference in CCU LOS was not significant (P = .94). Air patients spent an average of 2 fewer days in the hospital than did ground patients (P = .036). Discussion: Helicopter transport benefits the cardiac patient with decreased chest pain as a result of more treatments en route; decreased time from the call until arrival, resulting in decreased time to intervention; and shorter prehospital time and hospital stays. Conclusion: All of these improved variables relate to salvaged cardiac muscle.     

Impact of a triage tool on air versus ground transport of cardiac patients to a tertiary center

INTRODUCTION: The optimum method of transport for acute cardiac patients remains controversial. We proposed a physician-developed triage scheme for appropriate use of air versus mobile intensive care unit (ICU) in the transfer of cardiac patients and sought to determine the impact on the distribution of transport mode for cardiac patients in areas of personal characteristics and clinical factors and whether the triage scheme would be a valuable decision-making tool for physicians referring cardiac patients to tertiary centers. METHODS: This was a prospective, observational study of transport mode for cardiac patients transported to a tertiary care facility. A comparison was conducted with historical controls. The intervention studied was an educational program designed to teach a triage decision tool developed by a receiving cardiologist with input from the critical care transport team. Short-distance (less than 30 minutes) and long-distance transports were examined. A follow-up survey of referring hospitals was conducted. RESULTS: Short-distance transports enjoyed excellent compliance with 41 of 42 patients being transported by mobile ICU. Long-distance transports by mobile ICU increased from 55% to 65% during the study period. However, a third of the mobile ICU patients actually met air transport criteria. Long-distance patients transported by air had significantly higher transport costs, total hospital charges, and direct admission to the catheterization lab. Five of the 10 surveyed emergency department directors found the triage instrument useful in making transport decisions. CONCLUSIONS: A physician-developed triage instrument to select an appropriate mode of transport for acute cardiac transfers was effectively used. Further studies must validate the cardiac triage criteria against clinical outcomes, and more effective dissemination of the triage instrument must be sought. Furthermore, this information must be perceived as useful by referring physicians to gain wider acceptance.     

Introducing glycoprotein IIb/IIIa inhibitor therapy to air medical practice

Introduction: In patients with myocardial infarction, platelet aggregation inhibition with glycoprotein IIb/IIIa antagonists helps restore and maintain coronary blood flow when administered alone, with fibrinolytics, or with angioplasty. This article evaluates whether an adequate number of patients transported by an air medical program could benefit from flight team administration of these agents and describes the implementation issues surrounding a treatment protocol. Methods: A retrospective chart review and a discussion of the program's implementation experience Results: Seven percent of the patients transported by the air medical program met clinical and electrocardiographic criteria for administration of glycoprotein IIb/IIIa inhibitors. The program identified systemic, budgetary, and logistical issues with protocol implementation that require ongoing consideration.     

Air medical transport of the injured patient: scene versus referring hospital

Introduction: In a rural service area, does the outcome of air medical patients transferred from the scene of injury differ from that of patients transferred from a primary receiving hospital?

Methods: Retrospective review of all injured patients transported by air to a single trauma center during calendar year 1996. Data collected include basic patient demographics, time of injury, revised trauma score (RTS), injury severity score (ISS), probability of survival (PS), hospital length of stay (LOS), complications, disposition, and mortality.

Results: Concerning trauma admissions, 594 of 1461 (40.7%) were transported by air: 363 from the scene (24.9%) and 231 from referring hospitals (15.8%). These two groups were similar in demographics, injury severity, hospital LOS, and crude mortality: RTS, 6.61 versus 6.68 (P> 0.05); ISS, 16.0 versus 16.0 (P> 0.05); LOS = 6.9 days versus 7.3 days (P> 0.05); MORTALITY = 11.8% versus 10.8% (P> 0.05). The groups differed significantly, however, in time from injury to definitive care (34.2 minutes versus 196.2 minutes, P < 0.001), overall complication rate (39.1% versus 57.6%, P = 0.009), and potentially preventable deaths (PS> 0.5, 11.6% versus 44%, P = 0.02).

Conclusion: Patient groups were similar, suggesting similar triage criteria. Patients transferred from a referring hospital took almost six times longer to reach definitive care and may have suffered an increased morbidity and mortality on this basis.     

Oxygenation/ventilation of transported intubated adult patients: a national survey of organizational practices

INTRODUCTION: Transporting intubated patients is common among ground and air crews, and providing adequate oxygenation/ventilation through transport ventilators (TV) or manual ventilation (MV) is clinically challenging. However, very little data chronicle service or practice patterns of oxygenation/ventilation within the industry. METHODS: During February 1998, a national sample of 250 air transport agencies was surveyed regarding activities and services surrounding this population of transported patients. One-hundred-ninety-three surveys (77%) were returned. RESULTS: Approximately 40% of responding agencies use rotor-wing transportation only. Various combinations of rotor-, fixed-wing, and critical care ground transport were reported among the sample. Crew configuration consisted primarily of RN/EMT-P (75%). For pre-hospital intubated patients, MV alone (37.3%), TV alone (10.9%), or a combination of MV and TV (43.5%) was used, depending on transport circumstances. Programs not involved in pre-hospital transports accounted for 8.3% of returned surveys. Interfacility transports used MV (6.8%), TV (39.4%), and a combination (53.4%). One respondent did not answer the question, accounting for 0.4% of the returned surveys. More than 75% of programs monitored oxygenation/ventilation during transport. Usually some combination of pulse oximetry and CO2 monitoring was used. More than half (59%) of reporting agencies transport more than 80 intubated adults each year. CONCLUSION: Considerable variation exists in practices involving the transport of intubated patients.     

Reduced emergency department stabilization time before cranial computed tomography in patients undergoing air medical transport

INTRODUCTION: Advanced patient stabilization skills provided by air medical providers were hypothesized to result in streamlined emergency department (ED) stabilization of patients with head injuries requiring urgent cranial computed tomography (CCT). The goal of this study was to compare initial ED stabilization times between air- and ground-transported patients requiring urgent CCT and emergency neurosurgical hematoma evacuation. SETTING: Academic Level trauma center (annual ED census 60,000) receiving patients from ground EMS and a nurse/paramedic air medical transport team. METHODS: This retrospective study identified, from a database of 15 months of ED visits, consecutive group of adults who had CCT performed within 60 minutes of ED arrival and underwent emergent craniotomy for intracranial hematoma. Demographics, hemodynamic status, patient acuity, and time intervals between ED and CCT suite arrivals were compared between air and ground patients using chi-square, Fisher's exact, and t-tests (p = 0.05). RESULTS: Eleven air- and 39 ground-transported patients were eligible. All patient acuity data were similar between groups. Air patients were more likely to be intubated (100% versus 71.8%, p = .04) and had shorter mean ED stabilization times (29 versus 40 minutes, p = .02) than the ground. CONCLUSION: This study suggests that advanced patient stabilization offered by air medical transport may result in reduced ED stabilization time for patients requiring urgent craniotomy.     

8.5 French peripheral intravenous access during air medical transport of the injured patient

Introduction: This study describes a simple approach to peripheral large-bore intravenous (IV) access for the injured patient.Method: Retrospective chart review of patients identified by concurrent transport registry who received peripheral 8.5 F IV access during air medical transport for injury. The transport program consists of four remote-based BK-117 helicopters staffed by a nurse/paramedic crew. A peripheral 8.5 F IV access was obtained by protocol using guidewire technique over an existing peripheral IV. Crew education consisted of a combination of didactic and hands-on experience updated periodically on an ongoing basis.Results: From July 1991 through March 1995, 23 injured patients transported to a single Level I trauma center received a peripheral 8.5 F introducer. The patients averaged 30.9 years of age and were primarily male (78.3%) with blunt injuries (87%). Initial trauma score averaged 9.8; injury severity score averaged 24.6. All patients had at least one additional IV line; 21 of 23 patients were endotracheally intubated. Ground times averaged 19 minutes, flight time averaged 22.1 minutes, and in-flight fluids averaged 2239 ml or 101 ml per minute of flight. Complications associated with prehospital IV access did not occur.Conclusion: Peripheral 8.5 F access through a guidewire technique of an existing IV provides a rapid, simple approach to large-bore IV access in the injured patient transported by air.