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 30–45 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, 1.5–2 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 (3–5 inches [7.5–12.5 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 2000–4000 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
30–45 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

Hypoxia

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 2000–4000 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 2000–4000 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 2000–4000 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, tonic–clonic 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 4000–5000 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: 2–4 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 lower leg: board splint

Fracture of the lower leg or ankle: pillow splint

$Improvised splint for fracture of the upper leg$

Improvised splint for fracture of the upper leg

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	Last Updated: 2005-03-17		Important Notices