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In Flight Patient Care Considerations for: Burns Neurological Spinal Cord Objective • Apply knowledge of flight physiology and aviation environmental stressors in the planning and delivery of pre-flight and inflight care of patients with cardiopulmonary, gastrointestinal, genitourinary, neurological, ophthalmologic, otorhinolaryngologic, orthopedic, and burn injuries and conditions General Considerations • Preflight Mode of transport Patient Assessment Supplies Equipment General Considerations • • • • • • IV flow rates without pump O2 conversion table – sea level equivalent Securing patient and equipment Securing self Reliance on low tech physical assessment Hearing protection for patient and ERC personnel Burn Injuries • Preflight Assessment %TBSA burned, location and source Status of airway and patency Vascular access Fluid requirements Patency of foley, NG Vital signs, POX, urine output Burn Injuries • Preflight Assessment Pain medication, sedation Peripheral pulses Present wound management Associated injuries and need for altitude restriction (CXR) Secure vascular access, ET tube with sutures Burn Injuries • Preflight Assessment Assess Hct and transfuse if < 30% prior to flight If MD orders topical cream, apply evenly 1/16 to 1/8 inch thick and cover with absorbent dressing and Kling Burn Injuries • Stresses of flight All stresses of flight will affect the burn victim Thermal Decreased partial pressure of oxygen Decreased barometric pressure Decreased humidity Burn Injuries • In-flight considerations Monitor mental status Administer warmed, humidified oxygen – exception for face, head, neck burns Elevate head Continue with fluid resuscitation- second 24 hours add colloids – 200ml salt poor albumin/800ml LR at 0.5ml/kg/%TBSA Burn Injuries • In-flight considerations Second 24 hours addition of dextrose to meet metabolic demands – D51/4 NS Maintain urine output >50ml/hr(75-100ml for electrical) monitor for myoglobinuria NG to gravity or suction -monitor Hourly evaluation of all peripheral pulses Burn Injuries • In-flight considerations Protect from convection heat losses – shield from drafts and airflow Maintain core body temperature 99-100 Dressings should be occlusive, NEVER change en route Medicate frequently – use small doses Morphine 2-4 mg IVP. Avoid Demerol Neurological Injuries • Preflight Assessment Diagnosis, treatment Airway, Mechanical ventilation settings LOC, GCS Pupil assessment Vital signs Motor, sensory evaluation Neurological Injuries • Preflight Assessment Diagnosis, treatment Airway, Mechanical ventilation settings LOC, GCS Pupil assessment Vital signs Motor, sensory eval Neurological Injuries • Preflight Assessment Seizure activity, medications IVF, NG, Foley and patency Neurological Injuries • Stresses of flight Decreased partial pressure of oxygen Barometric Pressure Changes Decreased Humidity G-Forces Neurological Injuries • In-flight considerations Field-level altitude restriction for all penetrating, PBI induced head injuries Maintain POX>/=95%, tight ETCO2 control between 25-27(pCO2 30-32) Administer paralytics, sedation as needed Avoid succinylcholine use for RSI – IIP Neurological Injuries • In-flight Considerations IVF in absence of causes of hypovolemia at 80ml NS/hr – maintain MAP 65-70 Closely monitor GCS, pupils –for deterioration in GCS or pupil changes evidencing IIP administer 20% Mannitol 1-1.5 g/kg bolus Maintain normothermic – protect from thermal changes Neurological Injuries • In-flight Considerations Elevate head NG/OG to gravity/suction Monitor for seizure activity – administer Dilantin prophylaxis, Valium for seizures Hypertension – administer Metoprolol Hearing protection, eye protection ACCELERATION/DECELERATION FORCES POSITIONING THE LITTER PATIENT DURING TAKE-OFF/ LANDING Spinal Cord Injuries • • • • • • • Preflight Assessment Diagnosis and treatment Level of function Airway secured, mech ventilation settings Vital signs, POX, Foley, NG Medications Spinal Cord Injuries • Preflight Assessment IVF and rate Spinal cord immobilization – goal to preserve current level of function. Avoid logrolling patient Spring loaded traction Spinal Cord Injuries • Stresses of flight ALL! Spinal Cord Injuries • In-flight Consideration Maintain spinal immobilization Maintain POX 95% or >, EtCO2 30-40 unless concomitant head injury then 25-27 Altitude restriction if associated head injury IVF 80ml/hr NS Monitor vital signs – Neosynephrine for neurogenic shock? Dopamine? Spinal Cord Injuries • In-flight Consideration Maintain Methylprednisolone drip if in progress Protect from hypothermia Protect from G forces-loss of vasomotor tone in spinal shock ACCELERATION/DECELERATION FORCES POSITIONING THE LITTER PATIENT DURING TAKE-OFF/ LANDING Questions????