Emergency Medical Transportation Guidelines for Nurses in Primary
Care
Chapter 4 - Primary Care During Transport
Introduction
General Guidelines for All Urgent or Emergency Medevacs
Head and Neck (Face, Eyes, Ears, Nose and Throat)
Respiratory System
Cardiovascular System
Gastrointestinal System
Musculoskeletal System
Neurological System (CNS)
The Skin (Integumentary System)
Psychiatry
Appendix 4--1: Suggested Cabin Altitude Restrictions
Appendix 4--2: Splinting for Transport
Introduction
The following guidelines are limited to information pertinent
to the assessment, monitoring and care, during transport, of clients
with a specific (suspected or confirmed) medical or surgical condition.
If possible, the nurse should review the care of a particular
client with a consulting physician before transport.
For details concerning the clinical presentation, assessment and
pre-transport management of clients with such specific medical
or surgical conditions, see Clinical
Practice Guidelines for Nurses in Primary Care and Pediatric
Clinical Practice Guidelines for Nurses in Primary Care (First
Nations and Inuit Health Branch 2000, 2001).
General Guidelines for All Urgent or Emergency Medevacs
For all seriously ill or injured clients, the following principles
apply:
- Stabilize ABCs before transport begins
- Administer high-flow oxygen through a non-rebreather mask with
reservoir bag
- Establish two secure large-bore IV lines
- For air medevacs, use of pressurized aircraft is recommended
- If air medevac must be by unpressurized aircraft, discuss with
the pilot, before the flight begins, the optimal cabin altitude (see Appendix
4-1, "Suggested Cabin Altitude Restrictions," below,
this chapter)
- Collect the basic supplies that should be carried on all trips;
in addition, bring supplies according to the client's specific
needs (see "Basic
Interfacility Transport Equipment," in chapter 6, "Equipment
and Supplies)
Head and Neck (Face, Eyes, Ears, Nose and Throat)
Maxillofacial Injury
Effects of Air Transport
Facial trauma may result in airway compromise. Tissue swelling
may increase with flight, further compromising the airway. Remember,
mid-face fractures may be associated with pneumo-encephalopathy,
so careful transport is required.
In addition, facial injuries are often associated with cervical
spine injury, so C-spine precautions must be taken.
For clients whose jaws are wired, ensure availability of a means
of quick release in the event of air sickness (e.g., wire cutters).
Management: Considerations for Transport
- Airway should be secured before transport
- If the airway is not secured, insert an oropharyngeal airway,
but be careful not to cause vomiting
- If the client is conscious, do not insert airway
- Give oxygen (humidified if possible), and keep oxygen saturations ≥95%
- Elevate head to 30 degrees (immobilize using C-spine precautions)
- If possible, position client on side, to protect the airway
- Ensure that suction equipment is readily available
- An antiemetic (e.g., dimenhydrinate) may be used
- Monitor ABCs and neurological status frequently during transport,
as these type of injuries may be associated with intracranial
damage
- Because of the nature of the injury, constant care and reassurance
will be required to allay the client's anxiety and prevent panic
- Proper mouth hygiene will contribute to reassurance
- Position client with head toward the nose of the aircraft
- If possible, use pressurized aircraft
- Restrict aircraft cabin altitude to 1000 ft above ground level
(AGL)
Eye Disorders and Eye Trauma
Effects of Air Transport
- Retinal hypoxia
- Gas expansion in globe causes vascular or optic nerve compression
and possible extrusion of the intraocular contents
- Corneal drying
- Tension on optic nerve
- Vomiting increases intraocular pressure
Management: Considerations for Transport
- If possible, consult an ophthalmologist for cases of eye trauma
before flight
- Give humidified oxygen, and keep oxygen saturations ≥95%
- For eye injuries, keep the eye covered with a sterile patch
or an eye shield; apply dressings firmly enough over closed lid
to prevent the eye from opening but lightly enough to avoid pressure
on the globe
- Protect extruded eyes with moist dressings, with a cup or cone
covering
- If an open eye injury is present, do not use eye drops or ointments
- Transport by stretcher; elevate head 3045 degrees
- Do not let client bend over or perform tasks that might increase
intraocular pressure
- An antiemetic (e.g., dimenhydrinate) may be used
- Give analgesia as needed (discuss with a physician beforehand,
if possible); note that morphine can
cause pupillary constriction
- Reduce anxiety by offering reassurance and orienting the client
to the aircraft
- Monitor client closely for new or evolving symptoms and signs
- Consider sedation as indicated
- Position client with head toward the nose of the aircraft
- If possible, use pressurized aircraft
- Restrict aircraft cabin altitude to 2000 ft AGL
Upper Respiratory Tract Infection or Congestion
Effects of Air Transport
Gas expansion causes pressure changes, which result in increased
congestion and pain in the tissues of the upper respiratory tract.
Management: Considerations for Transport
- Request a slow, gradual descent
- Restrict cabin altitude in unpressurized aircraft
- Awaken sleeping clients
- Encourage maneuvers to equalize pressure in the middle ear
and sinuses with that of the atmosphere
- Decongestants (oral or nasal) may be of benefit
Epiglottitis
Effects of Air Transport
- Swelling of epiglottis increases
Management: Considerations for Transport
- Secure airway before transport
- Intubation may be needed; this procedure
is not within the CHN's scope of practice and must be performed
by authorized emergency transport personnel (e.g., physician,
emergency flight nurse or paramedic)
- If the client is not intubated, provide oral airway and ventilatory
assistance with bag-valve mask (BVM) device as required
- Give humidified oxygen, and keep oxygen saturations ≥95%
(monitor with pulse oximetry, if available)
- Start IV therapy with normal saline (unless insertion of an
IV line would worsen anxiety and airway compromise)
- Monitor ABCs and vital signs closely
- Give nothing by mouth (NPO) if unable to swallow saliva
- Position client with head elevated and toward the nose of the
aircraft
- Restrict aircraft cabin altitude to 3000 ft AGL
Respiratory System
Respiratory Insufficiency or Hypoxia
Effects of Air Transport
- Increased hypoxia
- Gas expansion may result in spontaneous pneumothorax (especially
in high-risk clients and those with history of pneumothorax)
- Dehydration
- Vomiting, with potential for aspiration
Management: Considerations for Transport
- Protect airway by inserting an oropharyngeal airway if necessary
- Assist ventilation as required with bag-valve mask (BVM) device
- Give humidified oxygen, and keep oxygen saturations ≥95%
(monitor frequently with pulse oximetry, if available)
- Start IV therapy with normal saline to maintain hydration
- Monitor ABCs and vital signs frequently
- Monitor for evidence of pneumothorax
- An antiemetic (e.g., dimenhydrinate) may be used
- Have appropriate equipment and supplies available (e.g., oral
airways, BVM device, IV supplies, suction, 14- to 18-gauge needles
or angiocatheters to perform needle decompression in the event
of tension pneumothorax; see "Pneumothorax," below)
- Reassure and support client to reduce apprehension
- Position client with head elevated and toward the nose of the
aircraft
- Restrict aircraft cabin altitude to 2000 ft AGL
Pneumothorax
A client with pneumothorax, especially if induced by trauma, is
at significant risk during air transport. All cases of pneumothorax
must be treated before air transport. Treatment may include inserting
a chest tube. Consultation with a physician is essential.
Clients and escorts with a history of spontaneous pneumothorax
require special consideration. Consultation with a physician is
recommended.
Effects of Air Transport
- Increased hypoxia
- Expansion of gas in the pleural space, which may cause an increase
in the size of the pneumothorax and may result in tension pneumothorax
Management: Considerations for Transport
- Protect airway by inserting an oropharyngeal airway if necessary
- Assist ventilation as required with bag-valve mask (BVM) device
- Give high-flow oxygen, and keep oxygen saturations ≥95%
(monitor frequently with pulse oximetry, if available)
- Start IV therapy with normal saline
- Insertion of a chest tube may be required before transport; this
procedure is not within the CHN's scope of practice and must
be performed by authorized emergency transport personnel (physician,
emergency flight nurse or paramedic)
- Monitor ABCs and vital signs frequently
- Observe for development of tension pneumothorax; be prepared
to carry out needle decompression if tension pneumothorax occurs
- Have appropriate equipment and supplies available (e.g., oral
airways, BVM device, IV supplies, suction, needle decompression
kit)
- Needle decompression kit:
- variety of IV cannulas (#14, 2 inch for adults;
#16, 1.52 inch for adolescents and older children;
#18, 1.5 inch for children; #20 1.5 inch for infants)
- skin disinfectant
- gloves
- tape
- stopcock
- small-bore latex tubing (35 inches [7.512.5
cm])
- one-way flutter valve
- dressing material
- Position client with head elevated and toward the nose of
the aircraft
- Restrict aircraft cabin altitude to 2000 ft AGL
Chronic Obstructive Lung Disease (COPD)
Effects of Air Transport
- Increased hypoxia
- Possibly spontaneous pneumothorax
Management: Considerations for Transport
- Protect airway by inserting an oropharyngeal airway if necessary
- Assist ventilation as required with bag-valve mask (BVM) device
- Careful oxygen supplementation to keep oxygen saturations at
90% to 93% (monitor frequently with pulse oximeter, if available)
- Start IV therapy with normal saline to maintain hydration
- Monitor ABCs and vital signs frequently
- Monitor for spontaneous pneumothorax and be prepared to treat
as needed (see "Pneumothorax," above,
this chapter)
- Reassure and support client to reduce apprehension
- Position client with head elevated and toward the nose of the
aircraft
- Restrict aircraft cabin altitude to 20004000 ft AGL
Cardiovascular System
General
Effects of Air Transport
Clients with cardiovascular problems are affected by altitude
and acceleration forces. The effects of increasing altitude include
hypoxia (which may aggravate existing ischemia and cardiac failure),
increase in heart rate, increase in respiratory rate, changes in
systolic blood pressure, changes in cardiac output and increase
in myocardial consumption of oxygen. Gravitational forces may cause
hypotension and tachycardia.
Each client with a cardiovascular disorder should be assessed
individually with respect to age, general state of health, extent
of myocardial compromise and presence of complications.
For clients with myocardial infarction (MI), it is preferable
if personnel with advanced cardiac skills, using a portable cardiac
monitor, evacuate the client, if time and aircraft permit, especially
if the infarction is complicated. In clients suffering from acute
MI, thrombolytic therapy should be considered before transport,
unless contraindicated, but only if ordered by a physician.
Angina, Myocardial Infarction and Congestive Heart Failure
Effects of Air Transport
- Hypoxia may aggravate existing ischemia and cardiac failure
- Gravitational forces may cause hypotension and tachycardia
Management: Considerations for Transport
- Stabilize ABCs before transport, as follows (the
sequence is important):
- If client is in cardiogenic shock, secure the airway,
and ventilate to reduce work of breathing
- Give high-flow oxygen, and keep oxygen saturations ≥95%
(monitor frequently with pulse oximeter, if available)
- Start IV therapy with normal saline to keep vein open
- Be prepared to treat hypotension as required; in these
conditions, hypotension is related to poor cardiac contractility,
consult a physician regarding appropriate treatment (e.g.,medication)
- Treat and stabilize ischemia, MI or CHF appropriately before
transport, with the intention of preventing complications
- Limit oral intake
- Insert a Foley catheter if the client is seriously ill or has
received a diuretic (e.g., furosemide)
- Institute cardiac monitoring (if available); watch for signs
of cardiac arrhythmias
- Monitor ABCs, vital signs, intake and output
- Monitor for signs of complications, such as arrhythmias, pulmonary
edema or hypotension (shock), and treat accordingly; consult
a physician as necessary for advice and medication orders
- Sedate to minimize risk of arrhythmia and for apprehension
as required (discuss with a physician, if possible)
- Be prepared with medications to treat increasing chest pain
or acute pulmonary edema (e.g.,nitroglycerin, morphine, furosemide)
- Be prepared to perform CPR in the event of cardiac arrest
- Have appropriate equipment and supplies available (e.g., cardiac
arrest board, airways, BVM device, IV supplies, suction, air
sickness supplies)
- Position client on stretcher with head elevated
3045 degrees and toward the nose of the aircraft (except
for clients with known right ventricular infarct)
- Restrict aircraft cabin altitude as follows:
2000 ft AGL |
4000 ft AGL |
6000 ft AGL |
Moderate to severe CHF |
Mild CHF |
MI 8--24 weeks previous |
Acute MI (within 8 weeks) |
|
Stable angina |
Cyanosis with right ventricular
failure |
|
|
Unstable angina |
|
|
Note: AGL = above ground level. 1000 ft = 304.8 m.
Hypotension
Effects of Air Transport
- Redistribution of blood flow
- Increased hypoxia
Management: Considerations for Transport
- Stabilize blood pressure as much as possible (with fluid) before
transport
- See "Shock," in
chapter 14, "General Emergencies and Major Trauma," in
the adult clinical guidelines (First Nations and Inuit
Health Branch 2000)
- Give high-flow oxygen, and keep oxygen saturations ≥95%
(monitor frequently with pulse oximeter, if available)
- Monitor ABCs, vital signs, intake and output closely
- Insert Foley catheter
- Have appropriate equipment and supplies available (e.g., cardiac
arrest board, airways, BVM device, IV supplies, suction, air
sickness supplies)
- Position client supine with head flat or in Trendelenberg position
if necessary (but do not use this position if shock is cardiogenic
in nature)
- Position client's head toward the tail of the aircraft if hypovolemia
is present
- Restrict aircraft cabin altitude to 2000 ft AGL
Anemia
Effects of Air Transport
Healthy adult males with normal hemoglobin levels will tolerate
an altitude of approximately 6000 ft (1829 m) without symptoms
or signs of hypoxia; however, oxygen saturation will be about 90%
to 93%.
Various factors will influence an anemic individual's "safe" altitude,
including acute or chronic onset of the condition, compensatory
mechanisms in play, associated underlying lung or heart disease,
oxygen-carrying capacity of the blood and presence of sickle cell
anemia.
Anemic clients (hemoglobin < 90 g/L) have reduced oxygen-carrying
capacity. The body compensates to some extent by increasing cardiac
output and ventilation. These compensatory mechanisms are more
efficient when the anemia is chronic rather than acute.
Management: Considerations for Transport
- Give humidified oxygen, and keep oxygen saturations ≥95%
(monitor with pulse oximeter, if available)
- Start IV therapy with normal saline (run at maintenance rate)
- Monitor client's overall clinical condition closely: ABCs,
vital signs, oxygen saturations
- Position client with head toward the nose of the aircraft
- Restrict aircraft cabin altitude to 3000 ft AGL (2000 feet
AGL for clients with sickle cell anemia)
Gastrointestinal System
Nausea and Vomiting (Motion Sickness)
Effects of Air Transport
- Gravitational forces
- Air turbulence
Symptoms
- Apprehension
- Perspiration of forehead and hands
- Pallor
- Excessive salivation
- Feelings of heat and cold
- Dizziness
- Headache
- Nausea and vomiting
Prevention
- Have client sit upright in the aircraft, if it is safe to do
so
- Keep cabin well ventilated and cool
- Instruct client to focus on distant objects (e.g., the horizon)
- Advise client to avoid unnecessary head motion and to move
slowly
Management: Considerations for Transport
- Protect the airway at all times
- Ensure that suction is available
- Place client in upright position if it is safe to do so
- Advise client to keep head still and eyes closed
- Encourage client to gain sense of position (by looking out
the window)
- Keep cabin temperature cool
- Give oxygen intermittently
- Have emesis cups or bags readily available
- An antiemetic (e.g., dimenhydrinate) may be used
Bowel Obstruction or Paralytic Ileus
Effects of Air Transport
- Gas expansion resulting in increased intra-abdominal distension,
pain and vomiting
Management: Considerations for Transport
- Prepare to protect and support airway should vomiting occur
(e.g., oropharyngeal airway, suction)
- Start IV therapy with normal saline; run at a rate adequate
to maintain hydration, unless the client is being treated for
shock
- Give nothing by mouth (NPO)
- Decompress stomach using a nasogastric tube to straight drainage
or low suction; do not clamp
- Monitor client's clinical status closely: ABCs, vital signs,
pulse oximetry (if available)
- Watch for increasing abdominal distension
- An antiemetic (e.g., dimenhydrinate) may be used
- Give analgesia as needed (discuss with a physician beforehand,
if possible)
- Position client with head elevated and toward the nose of the
aircraft
- Restrict aircraft cabin altitude to 20004000 ft AGL
Abdominal Injuries (Blunt Trauma or Penetrating Wound)
The most prominent signs and symptoms of blunt trauma injury to
the abdominal organs tend to be those related to intra-abdominal
bleeding, namely shock. In addition, when the contents of organs
damaged by blunt trauma enter the abdominal cavity, signs and symptoms
of peritoneal irritation occur (i.e., rebound tenderness, rigidity
of the abdominal musculature, vomiting and abdominal distension).
A penetrating abdominal wound is one in which the abdominal wall
and the peritoneum have been pierced or torn. Signs and symptoms
of shock may also be present, but are usually not as marked as
in severe hemorrhage from a solid intra-abdominal organ.
Effects of Air Transport
- Hypoxia
- Gas expansion resulting in increased intra-abdominal distension,
pain and vomiting
Management: Considerations for Transport
- Administer oxygen as required, especially if the client is
in shock or there are associated chest wounds
- Start IV therapy with normal saline, preferably through two
large-bore needles; run at maintenance rate unless the client
is being treated for shock
- Do not attempt to replace intra-abdominal contents (e.g., bowel)
into the abdominal cavity
- Cover wound with a sterile dressing and keep the dressing wet
with normal saline
- Give nothing by mouth (NPO)
- Insert a nasogastric tube with low suction, as well as a rectal
tube if required
- Insert a Foley catheter, and maintain careful record of intake
and output
- Give IV antibiotics as ordered by physician; consider tetanus
prophylaxis for a penetrating wound
- Give analgesia as needed (see note below about narcotic analgesia)
- Monitor client's clinical status closely: ABCs, vital signs,
pulse oximetry (if available)
- Watch for increasing abdominal distension
- Monitor respiratory status (especially if there are associated
chest wounds)
- Position client with head slightly elevated and toward the
nose of the aircraft and with knees bent to prevent tension on
the abdomen
- Restrict aircraft cabin altitude to 20004000 ft AGL
Acute Surgical Abdomen (Including Appendicitis)
Effects of Air Transport
- Hypoxia
- Gas expansion resulting in increased intra-abdominal distension,
pain and vomiting
Gas-forming bacteria in an inflamed appendix may result in distension
of the appendix. The appendix may rupture if aircraft cabin altitude
is not restricted.
Management: Considerations for Transport
- Administer oxygen as required, especially if the client is
in shock
- Start IV therapy with normal saline, preferably through two
large-bore needles; run at maintenance rate unless the client
is being treated for shock
- Give nothing by mouth (NPO)
- Insert a nasogastric tube with low suction, as well as a rectal
tube if required
- Insert a Foley catheter, and maintain careful record of intake
and output
- Give IV antibiotics as ordered by physician
- Give analgesia as needed (see note below about narcotic analgesia)
- Position client supine with head slightly elevated and toward
the nose of the aircraft and with knees bent to prevent tension
on the abdomen and to keep any peritoneal contamination localized;
avoid sudden movements and jolts
- Restrict aircraft cabin altitude to 20004000 ft AGL
Use of Narcotic Analgesia
Narcotic analgesia may mask the physical
signs of peritoneal irritation and may interfere with the client's
evaluation at a treatment facility. There is some controversy
about the use of pain control in the presence of acute abdomen.
Some recent literature supports the use of narcotics, which may
help to make the client more comfortable and capable of participating
in the examination. The client's condition and comfort level,
as well as the time lapse before transfer can be completed, are
factors to consider in the decision to administer a narcotic.
If possible, consult with a physician before administering narcotics.
Musculoskeletal System
Fractures
Effects of Air Transport
- Increased pain
- Increased swelling
Management: Considerations for Transport
- All fractures should be immobilized with splints (see
illustrations in Appendix 4-2, "Splinting
for Transport," below, this chapter)
- Do not use air splints
- Elevate limb to minimize swelling
- Assess neurovascular function in the affected extremity frequently
- Position client with head toward the nose of the aircraft
- Restrict aircraft cabin altitude to 4000 ft AGL
Neurological System (CNS)
Before transport, the originating facility
must carefully document the sensory and motor functioning of
any client with head, neck or spinal trauma.
Head Trauma
Effects of Air Transport
- Increased hypoxia
- Gas expansion and swelling of brain, leading to increased intracranial
pressure
- Vomiting and potential airway compromise
- Seizure activity through the mechanism of "flicker vertigo" (caused
by photic stimuli such as sunlight, propeller movement or aircraft
strobe lights )
Management: Considerations for Transport
- Stabilize ABCs:
- Secure airway and hyperventilate as indicated
- Immobilize C spine
- Give oxygen, and keep oxygen saturations ≥95%
- Ventilate if required
- Establish two large-bore IV lines with normal saline, to keep
vein open, unless there are other injuries requiring volume replacement
- Keep head of bed (or spine board) elevated, and position the
head in the midline to promote venous drainage
- Limit external stimuli: keep cabin quiet and lighting low,
and protect the client's hearing and vision (cover eyes, use
head sets, close window blinds)
- Manage increased intracranial pressure as indicated (use medication
as directed by physician)
- Monitor client's clinical status closely: ABCs, vital signs,
level of consciousness (using Glasgow Coma Scale)
- Monitor for seizure activity
- Give anticonvulsants (e.g., lorazepam) as necessary to control
seizures
- If the client is unconscious, close the eyes or apply artificial
tears to prevent corneal drying
- Position client with head toward the nose of the aircraft
- Use pressurized aircraft whenever possible
- Restrict aircraft cabin altitude to 2000 ft AGL
(or to sea level if pneumoencephalopathy is a possibility)
Cerebrovascular Accident (Stroke)
Effects of Air Transport
- Increased hypoxia
- Gas expansion and swelling of brain, leading to increased intracranial
pressure
- Vomiting and potential airway compromise
- Seizure activity through the mechanism of "flicker vertigo"(caused
by photic stimuli such as sunlight, propeller movement or aircraft
strobe lights)
Management: Considerations for Transport
- Stabilize ABCs
- Secure airway
- Give oxygen, and keep oxygen saturations ≥95%
- Ventilate if required
- Start IV therapy with normal saline, and run at a maintenance
rate
- Elevate head 30 degrees if the airway is intact
- Limit external stimuli: keep cabin quiet and lighting low,
and protect the client's hearing and vision (cover eyes, use
head sets, close window blinds)
- Monitor client's clinical status closely: ABCs, vital signs,
level of consciousness (using Glasgow Coma Scale)
- Monitor for seizure activity
- Give anticonvulsants as required to control seizures
- An antiemetic (e.g., dimenhydrinate) may be used
- If the client is unconscious, close the eyes or apply artificial
tears to prevent corneal drying
- Position client with head toward the nose of the aircraft
- Restrict aircraft cabin altitude to 2000 ft AGL
Seizure Disorders
Effects of Air Transport
- Hypoxia
- Anxiety
- Seizure activity through the mechanism of "flicker vertigo"(caused
by photic stimuli such as sunlight, propeller movement or aircraft
strobe lights)
Management: Considerations for Transport
- If possible, transport should be delayed until after seizures
are controlled
- Stabilize ABCs
- Secure airway
- Give oxygen, and keep oxygen saturations ≥95%
- Ventilate if required
- Start IV therapy with normal saline to keep vein open, unless
there is another reason for volume resuscitation
- Ensure that suction is available
- Position client to avoid photic stimuli from sunlight, propeller
movement or aircraft strobe lights
- Limit external stimuli: keep cabin quiet and lighting low,
and protect the client's hearing and vision (cover eyes, use
head sets, close window blinds)
- Monitor client's clinical status closely: ABCs, vital signs,
level of consciousness (using Glasgow Coma Scale)
- Monitor for seizure activity
- Protect client from injury if acute seizure activity occurs
- Give anticonvulsants as required to control seizures
- Record details of seizures:
- time of onset and duration
- describe events in chronological order
- note focal onset, aura, loss of consciousness, tonicclonic
movements, incontinence, post-seizure behavior (e.g., deep
sleep) and other complaints (e.g., headache)
- Position client with head toward the nose of the aircraftRestrict
aircraft cabin altitude to 40005000 ft unless a head injury
or other condition is present that dictates a lower altitude
SPINAL CORD INJURY
Effects of Air Transport
- Excessive movement
- Gravitational forces
- Swelling of neurological tissues
Management: Considerations for Transport
- Stabilize ABCs
- Secure airway
- Intubation should be carried out before transport if the airway
is unstable or compromised; this procedure
is not within the CHN's scope of practice and must be performed
by authorized emergency transport personnel (e.g., physician,
emergency flight nurse or paramedic)
- Ensure that the client is totally immobilized on a spine board
before moving him or her
- Immobilization must be effected so as to prevent lateral movement
and sliding downward on the spine board
- Give oxygen as required to keep oxygen saturations ≥95%
- Start IV therapy with normal saline to keep vein open, unless
there is another reason for volume replacement (e.g., concomitant
injuries)
- Insert Foley catheter
- Insert nasogastric tube (paralytic ileus is a common complication)
- Monitor ABCs, vital signs, level of consciousness (using Glasgow
Coma Scale) and neurological status closely
- Give analgesia as needed (discuss with a physician beforehand,
if possible)
- Narcotics must be used with care to prevent respiratory depression
(have naloxone available)
- An antiemetic (e.g., dimenhydrinate) may be used
- Have all necessary equipment and supplies (e.g.,suction, Ambu
bag, airways, oxygen and IV supplies) ready for immediate use
- Reassure and support client as necessary
- Position the client supine with head toward the nose of the
aircraft
- Restrict aircraft cabin altitude to 4000 ft AGL
THE SKIN (INTEGUMENTARY SYSTEM)
BURNS
Effects of Air Transport
- Increased fluid loss
- Increased swelling
- Excessive heat loss
- Potential hypoxia (hypoxic, hypemic and histotoxic hypoxia
are all associated with smoke inhalation)
Management: Considerations for Transport
- Stabilize ABCs
- Secure airway before transport, especially if there is potential
for or evidence of inhalation burns
- Give humidified oxygen and ventilatory support, with airway
or bag-valve mask (BVM) device, as needed
- Start IV therapy with normal saline for volume resuscitation
and to maintain urine output
- Burn formula for volume resuscitation: 24 mL/kg for each
percentage point of body surface area burned; give half the volume
in the first 8 hours after burn injury and the remainder over
the next 16 hours
- Cover burns with sterile or clean dry dressings for transport
- Maintain clean environment to reduce risk of infection
- For electrical burns, adhere to spinal immobilization principles
(because of strong tetanic contractions caused by electrical
current)
- For chemical burns, irrigate copiously before transport
- Monitor ABCs, vital signs, neurovascular status of limbs and
chest movements
Remember that oxygen saturations may not be
accurate in the presence of carbon monoxide toxicity!
- Maintain body heat using warmed IV fluids and a warm cabin
environment
- Monitor temperature
- Position client with head elevated and toward the nose of the
aircraft
- Restrict aircraft cabin altitude to 4000 ft AGL
Psychiatry
Anxiety Psychosis
Effects of Air Transport
- Increased anxiety and fear
- Violent or combative behavior
Management: Considerations for Transport
- Provide reassurance
- Administer chemical or physical restraints only if ordered
by a physician
- Consider additional resources, such as a police escort
Appendix 4--1: Suggested Cabin Altitude Restriction
Head, eyes, ears, nose and throat
Client's
Condition |
Maximum Cabin
Altitude (feet AGL)* |
Maxillofacial injury |
1000 |
Eye disorders or trauma |
2000 |
Barotitis or otitismedia |
4000 |
Respiratory system
Client's Condition |
Maximum Cabin
Altitude (feet AGL)* |
Epiglottis or croup |
3000 |
Respiratory insufficiency
or hypoxemia |
2000 |
Pneumothorax |
2000 |
Chronic obstructive pulmonary
disease |
2000--4000 |
Asthma |
2000--4000 |
Inhalation burns (client not
intubated) |
2000 |
Cardiovascular system
Client's Condition |
Maximum Cabin
Altitude (feet AGL)* |
Stable angina or MI 8--24
weeks ago |
6000 |
Unstable angina, acute MI |
2000 |
Congestive heart failure (mild) |
4000 |
Congestive heart failure (moderate
to severe) |
2000 |
Anemia |
3000 |
Sickle cell anemia |
2000 |
Gastrointestinal system
Client's Condition |
Maximum Cabin
Altitude (feet AGL)* |
Bowel obstruction |
2000--4000 |
Abdominal trauma
|
2000--4000 |
Other GI problems |
4000 |
Musculoskeletal system
Client's Condition |
Maximum Cabin
Altitude (feet AGL)* |
Fractures |
4000 |
Central nervous system
Client's Condition |
Maximum Cabin
Altitude (feet AGL)* |
Head trauma: open skull fracture,
basal skull fracture
(where pneumoencephalus is possible) |
Sea level |
Closed head injury (where
pneumoencephalus is not suspected) |
2000 |
Cerebrovascular accident (stroke) |
2000 |
Intracranial problems (e.g.,
bleeding, infection) |
2000 |
Seizure disorders (unrelated
to head injury) |
4000--5000 |
Spinal cord injury |
4000 |
Skin (integumentary system)
Client's Condition |
Maximum Cabin
Altitude (feet AGL)* |
Burns (not including inhalation injury) |
4000 |
Trauma
Client's Condition |
Maximum Cabin
Altitude (feet AGL)* |
Major trauma with potential for shock or entrapped gas |
2000 |
Miscellaneous
Client's Condition |
Maximum Cabin
Altitude (feet AGL)* |
Anaphylactic shock |
2000 |
Gas gangrene |
2000 |
Decompression illness |
Sea level |
Note: AGL = above ground level.
*1000 ft = 304.8 m.
Appendix 4--2: Splinting for Transport
Fracture or dislocation of the elbow
Fracture of dislocation of the elbow
Fracture of the forearm
Fracture of the forearm
Fracture of the lower leg: board splint
Fracture of the lower leg: board splint
Fracture of the lower leg or ankle: pillow
splint
Improvised splint for fracture of the upper
leg
|