The decision of when a helicopter should respond to the scene of injury or illness remains an inexact science. The best sources acknowledge that the judgment of the prehospital personnel at the scene is of primary importance, but the decision to use helicopter transport can be bolstered by criteria listed below and in Table 7.4:
1. Mechanism of injury 2. Physiologic variables 3. Anatomic variables 4. Time and logistics.
Space constraints are the major issue in provid- ing care in any aircraft. Both the actual space (cubic feet) and the arrangement of the space (cabin configuration) can have profound effects on the ability of the air medical crew to perform inter- ventions such as intubation. This translates into the need for the air medical crew to sometimes adjust the care provided accordingly. One exam- ple would be intubating patients prior to flight if there is a significant chance of airway deteriora- tion while en route. Crewmembers should be cross-trained to allow either crewmember to pro- vide indicated medical interventions during flight. Some interventions, such as provision of
chest compressions, are extremely difficult to pro- vide effectively in the air medical setting.
Noise is of a sufficient degree to preclude reli- able auscultation and monitoring of aural alarms (e.g., on a ventilator). The flight crew must learn to use other means of patient assessment and equipment monitoring.
Vibration is a theoretical problem for the patient, and high-frequency vibrations have been shown to induce fatigue in caregivers. In general, how- ever, the ride in a helicopter or fixed-wing air- craft can often be much smoother than a ride in a ground ambulance.
Lighting in an aircraft, and to a lesser extent in a ground ambulance, differs from that which is normally available in a well-lit hospital resusci- tation area. Some helicopters, for instance, have patient care cabins which are contiguous with (and not separated from) the pilot seat; in such situations the medical crew must work in red, blue, and/or dimmed lighting at night.
Altitude issues relate to hypoxemia, pressure–
volume changes, temperature, and humidity.
Altitude-related hypoxemia is not usually an issue due to the fact that patients receive oxygen therapy and the altitude is usually not sufficiently high for the crew to require supplemental oxy- gen. Exceptions to this general rule occur, how- ever, with both patients (e.g.,premature neonates with narrow therapeutic windows for oxygen administration) and crew (e.g.,crew in programs based at higher altitudes, who wear oxygen masks for prevention of hypoxemic symptoms).
Boyle’s law describes the inverse relationship between ambient pressure and gas volume. This is a factor with respect to both equipment (e.g., ventilator, intra-aortic balloon pump, Minnesota tubes for upper gastrointestinal hemorrhage tam- ponade) and patients (e.g., need for pre-flight placement of a gastric tube to prevent vomiting in unconscious patients). High altitude is associated with decreased ambient temperature. Especially in colder climates where the patient may be hypothermic before being loaded onto the air- craft, and in aircraft with suboptimal heating systems, hypothermia is a risk of helicopter trans- port. Higher altitude and lower temperature are associated with decreased humidity. This can result in hardening of secretions, such as in the ETT, which the air medical crew should monitor (and suction) as indicated. Helicopters generally transport patients at altitudes of 500–2000 feet above ground level. Therefore, unless transports occur at geographic locations where ground level is significantly elevated, altitude issues are of
Prehospital care and emergency medical services
Prehospital care and emergency medical services
Measure Vital Signs and Level of Consciousness STEP 1
Yes No
• GCS 14 or
• RR 10 or 29 or • Systolic BP 90 or
• RTS 11 or • PTS 9
STEP 2
• Flail chest
• Two or more proximal long-bone fractures
• Amputation proximal to wrist/ankle
• All penetrating trauma to head, neck, torso, and extremities proximal to elbow and knee
• Limb paralysis
• Pelvic fractures
• Combination trauma with burns
STEP 3
STEP 4
• Ejection from auto
• Death in same passenger compartment
• Pedestrian thrown or run over
• High-speed auto crash
• Initial speed 40 mph (64 kph)
• Major auto deformity 20 inches (50 cm) • Intrusion into passenger compartment 12 inches (30 cm)
• Extrication time 20 minutes
• Falls 20 ft (6 m)
• Roll over
• Auto-pedestrian injury with 5 mph (8 kph) impact
• Motorcycle crash 20 mph (32 kph) or with separation of rider and bike
Take to trauma center;
alert trauma team Assess anatomy of injury
FLOWCHART 1 TRIAGE DECISION SCHEME
Yes No
Take to trauma center;
alert trauma team
Evaluate for mechanism of injury and evidence of high-energy impact
Yes No
Contact medical control; consider transport to trauma center; consider trauma team alert
Reevaluate with medical control
When in Doubt, Take to a Trauma Center!
Contact medical control; consider transport to trauma center; consider trauma team alert
Yes
No
• Age 5 or 55 years
• Pregnancy
• Immunosuppressed patients
• Cardiac disease; respiratory disease
• Insulin-dependent diabetes; cirrhosis; morbid obesity; coagulopathy Table 7.2 American College of Surgeons’ (ACS) Field Triage Algorithm
BP: blood pressure; GCS: glasgow coma scale; PTS: pediatric trauma score; RR: respiratory rate; RTS: revised trauma score.
Prehospital care and emergency medical services
Table 7.4 National Association of Emergency Medical Service Physicians guidelines for dispatching a helicopter to an emergency scene
1. Partial thickness burns10% (total body surface area)
2. Burns that involve the face, hands, feet, genitalia, perineum, or major joints 3. Third-degree burns in any age group
4. Electrical burns, including lightning injury 5. Chemical burns
6. Inhalation injury
7. Burn injury in patients with pre-existing medical disorders that could complicate management, prolong recovery, or affect mortality. Burns in any patients with concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of morbidity or mortality. In such cases, if the trauma poses a greater immediate risk than the burns, it may be necessary to stabilize the patient in a trauma center before being transferred to a burn unit.
Physician judgment is necessary in such situations and should be in concert with the regional medical control plan and triage protocols
8. Burns in children being cared for in hospitals without qualified personnel or equipment for the care of children 9. Burn injury in patients who will require special social, emotional, or long-term rehabilitative intervention Table 7.3 Criteria for transport directly to a designated burn center
Clinical 1. General
(a) Trauma victims need to delivered as soon as possible to a regional trauma center
(b) Stable patients who are accessible to ground vehicles probably are best transported by ground 2. Specific
Patients with critical injuries resulting in unstable vital signs require the fastest and most direct route of transport to a regional trauma center in a vehicle staffed with a team capable of offering critical care enroute. Often this is the case in the following situations:
(a) Trauma score12
(b) Glasgow coma scale score10
(c) Penetrating trauma to the abdomen, pelvis, chest, neck, or head
(d) Spinal cord or spinal column injury, or any injury producing paralysis of any extremity if any lateralizing signs
(e) Partial of total amputation of an extremity (excluding digits) (f) Two of more long bone fractures or a major pelvic fracture (g) Crushing injuries to the abdomen, chest, or head
(h) Major burns of the body surface area, or burns involving the face, hands, feet or perineum, or burns with significant respiratory involvement or major electrical or chemical burns
(i) Patients involved in a serious traumatic event who are12 or55 years of age (j) Patients with near-drowning injuries, with or without existing hypothermia (k) Adult trauma patients with any of the following vital sign abnormalities:
(i) systolic blood pressure90 mmHg (ii) respiratory rate10 or35/minute (iii) heart rate60 or120/minute (iv) unresponsive to verbal stimuli
Operational situations in which helicopter use should be considered:
1. Mechanism of injury:
(a) Vehicle roll-over with unbelted passengers (b) Vehicle striking pedestrian at10 miles per hour (c) Falls from15 feet
(d) Motorcycle victim ejected at20 miles per hour (e) Multiple victims
2. Difficult access situations:
(a) Wilderness rescue
(b) Ambulance egress or access impeded at the scene by road conditions, weather, or traffic 3. Time/distance factors:
(a) Transportation time to the trauma center15 minutes by ground ambulance
(b) Transport time to local hospital by ground greater than transport time to trauma center by helicopter (c) Patient extrication time20 minutes
(d) Utilization of local ground ambulance leaves local community without ground ambulance coverage
relatively minor concern for the majority of heli- copter transports. On the other hand, fixed-wing transports occur at much higher altitudes, which brings into play issues of cabin pressurization and risks of sudden decompression.
Safety is the paramount consideration for any air transport service. At any time, in any mission, the pilot or medical crew should be empowered to halt the transport if safety considerations become a concern. Direct comparison between air and ground vehicle safety is difficult, since crashes involving medical helicopters (or less commonly, fixed-wing aircraft) are more reliably tracked and more widely publicized than crashes of ground vehicles. Sometimes, considerable judgment must be exercised in determining whether to perform a critical procedure (e.g., intubation) before or after transport commences. Except in cases where a fixed-wing aircraft is used solely because critical patients cannot be evacuated by air (e.g., fog pre- cludes helicopter operations but a fixed-wing air- craft can safely operate in a remote area), patients transported by airplane typically have lesser acu- ity and greater stability than those transported by ground.
References
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Current practice in clinical cervical spinal clearance: implication for EMS. Prehosp Emerg Care 1999;3:42–46.
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Effect of prehospital advanced life support on outcomes of major trauma patients.
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management. Resuscitation2001;48:5–15.
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12. O’Connor R, Domeier R. Use of the Pneumatic Antishock Garment (PASG).
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Prehospital care and emergency medical services
Pain management
Scope of the problem
Acute pain is the most common complaint of patients presenting to the emergency department (ED), comprising 60% of presenting complaints in one study. Recognition and acknowledgment of a patient’s pain, adequate treatment, and timely reassessment are essential to acute pain manage- ment in the ED. Unfortunately, it has been demon- strated that many physicians fail to treat pain promptly or adequately in both inpatient and outpatient settings.
Pain
Pain is whatever the experiencing person says it is, existing whenever he or she says it does. The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage,” “always subjective,” and “learned through experiences related to injury in early life.” Pain includes behavioral and physical indi- cators, in addition to self-report. Thus, preverbal, nonverbal, or cognitively-impaired individuals who experience pain can benefit from objective pain assessment. Fear and anxiety increase the perception of physical pain – the unfamiliar and frequently unfriendly ED environment does little to ameliorate a patient’s pain.
Acute painis a symptom of injury or illness, which serves the biologic purpose of warning an individual of a problem and limiting activities that might exacerbate it. Acute pain is usually associated with identifiable pathology and causes anxiety. By convention, it is present for less than 6 months.
Chronic, malignant pain is associated with a terminal disease, such as cancer or acquired immune deficiency syndrome (AIDS). These patients are usually under the care of a multidis- ciplinary team that directs their analgesia regimen and comfort care.
Chronic, nonmalignant painis a complex prob- lem, defined as pain being present for greater than 6 months. In general, it is not associated with a readily treatable, or sometimes even identifiable,
cause. It is generally associated with depression rather than anxiety. Patients may have a well- defined cause (e.g., tic douloureux) or no object- ively confirmed cause (e.g., reflex sympathetic dystrophy). These patients frequently arouse ani- mosity amongst ED staff because they can be quite demanding, and at times manipulative. The staff often senses that acute interventions will generally fail to help these patients for any length of time.
There are patients who feign pain to acquire opioids, either for their own use or to sell on the streets. These individuals may be difficult to dis- tinguish from the group previously defined.
Analgesia
Analgesia is the “loss of sensitivity to pain.” In the ED, this means the reduction of pain through therapy. The therapy is not solely pharmacologic in nature – psychologic and social support, as well as physical positioning for maximum com- fort help reduce perceived pain. These interven- tions reassure the patient that the provider is aware of his or her pain and is making attempts to relieve it. Child life therapists, when available, provide psychologic support to children as well as distraction from painful procedures, such as starting an intravenous (IV) line.
Oligoanalgesia
Inadequately or poorly treated acute pain may result in negative physiologic outcomes. Poorly treated acute pain may exacerbate the under- lying pathophysiology of many illnesses and injuries, and may result in the development of chronic pain.
The failure of physicians to treat pain has been documented in the ED as well as in the inpatient setting. Children receive fewer doses of analgesia, in general, and opiates, in particular, than adults with equivalent diagnoses or undergoing equally painful procedures.
Wilson and Pendleton reported in 1989 that in one academic ED, 56% of patients presenting with painful conditions received no analgesics. Further- more, only 14% received any analgesia within the first hour of their ED stay. In this study,