Retrieval medicine - ACEM Fellowship Notes

see: [cameron retrieval](x-devonthink-item://1E3379CE-7F8D-4040-AF41-F2193CDCF298?page=5), [Rosen Air Medical transport](x-devonthink-item://FAE2D34F-332E-4E38-A171-8AE1584587D1), [Dunn - patient preparation for transport](x-devonthink-item://CB287B5A-AD14-4DB1-80DB-010C5C7D5F73), [Cameron Paeds - transport and retrieval](x-devonthink-item://69367524-ED59-48C3-8A4F-B9BDFC38CF08) - [ACEM PHRM Educational resources](https://elearning.acem.org.au/course/view.php?id=876) - [ACEM Pre-hospital and Retrieval Medicine curriculum](x-devonthink-item://D3F76417-CBD6-44B6-A94A-4103D8E7BF58) #tables #pre-hospital **Transport urgency** - Time-critical: imminent threat to life or limb - sepsis with shock, coagulopathy, or high lactate - surgical abdomen - upper airway obstruction - refractive seizures - many more - urgent: no immediate threat to life or limb. (standard scenario for many paeds transports) - symptomatic head injury - ALOC - hypoxia requiring O2 therapy - complex: requiring high degree of planning. eg referral for ECMO, extreme-distance, international - return/elective transport # transport options | platform | advantage | disadvantage | | ------------------------- | ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | rotary wing Helicopter | - rapid retrieval reduced time compared to fixed wing - land on some hospitals / doesn't need an airport; ∴ avoids double-handling of patient - usually fastest/most appropriate for 100-350 km (Dunn says 50 - 200) - response is not traffic dependent | - unable to pressurise cabin to sea level (bad for diving injury or eye trauma) - motion sickness - limited range - weather dependent - small cabin makes medical interventions difficult in-flight - restricted by weather and landing sites - motion sickness | | fixed wing | pressurised cabin highest range and fastest over long distance - less weather dependent | road legs at referring and receiving ends slowest to organise most expensive | | road ambulance | - quick to arrange - less danger to crew | longer duration of transfer, delay to definitive treatment | # Patient preparation for transport | element | tasks | | ----------------------- | ------------------------------------------------------------------------------------------------------------------------------ | | secure | - airway, ventilation, oxygenation - IV lines and drains - consider extra IV line prior to transfer | | sedation / analgesia | - consider ↑ requirement during transfer - ppx antiemetic - ppx anticonvulsant if seizure risk | | communication | - patient - relatives/parents - receiving hospital / unit - transport team (eg ARV, PIPER) | | IV considerations | - IV often slows at altitude and requires frequent flushing of line - aim to correct blood volume deficit prior to transfer | | chest decompression | - insert ICC if PTx present - consider PPx chest decompression if ≥ 2 rib fractures visible | | fractures | - splinted - c-spine immobilised | | thermoregulation | | | neonates | - need transport incubators | | documentation | - pt condition pre-transfer - investigations and notes - consent | **Equipment:** - Monitoring (ECG, oximeter, EtCO2, BP) - Resp - ETT - remove gas from cuff on ascent and instil gas on descent - ensure correct position prior to transport - humidification filter needed b/c humidity ↓ with altitude - ventilator - Drug equipment # Problems anticipated during transport | Problem | Issues | Solution | | ---------------------- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Loading / unloading | - IVs and ICCs can get removed - haemorrhage | - secure all equipment - use light equipment | | altitude effects | - ↓ piO2 usually little effect in normal pts as Hb sat usually > 90% < 2500m. - pts at risk due to hypoxia, anaemia, ↑ O2 requirements, fixed [[Oxygen delivery relation to cardiac output\|cardiac output]] | - cabin pressurisation - may need to fly at sea level cabin altitude for severe pulmonary disorders - keep FiO2 high if needed during ransport | | dysbaria | effect of altitude on trapped gas (Boyles's law); entrapped gas expands at altitude | consider for: - fractured skull with arocoele - recent GUT sutures - bowel obstruction - mediastinal emphysema - pneumothorax - penetrating eye injury - [[Diving injuries and Dysbarism\|Decompression illness]] Also has effect on ETT cuff, IV bags, colostomy bags need: - pnemothoraces w/ heimlich valve - fill ETT cuff with water or take out on ascent and replace in descent - gas in abdo may be diminished by giving pt 100% oxygen - vent other cavities eg NGT | ## Specific considerations | Issue | management | | --------------------------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | | air embolism | - lowest cabin altitude possible - usual measures | | decompression illness / dive < 24 hours | - low or sea level cabin altitudes - helicopter or fixed wing may be used if able ot be flow safely at < 300m - if not, transport in aircraft capable of being pressurised to 1 ATA (eg Learjet, Cessna Citation, or Hercules C-130) - portable decompression chamber for transport if needed/available | | anaemia | - transfuse to Hb > 7.5 if possible prior to flight - supplemental O2 - low cabin altitude | | ACS | - lowest cabin altitude possible - oxygen - cardiac monitoring - unstable angina is relative contraindication | | open eye injuries | - low cabin altitude - PPx antiemetics | | head injuries | - aerocoele is contraindication - CSF rhinorrhoea: reverse leak on descent - be prepared for seizures - must fly at or near sea level cabin pressure in penetrating head injuries | | orthopaedic injuries | - rebleeding at fracture site / ↑ pain | | spinal injuries | - helicopter preferred because of low G forces - NGT suction + anti-emetics |