Medical Transport in Trauma

Ekkit Surakarn,M.D General Surgery

Aviation Medicine Emergency Department

Stabilized patient – Fit to fly

A - Airway secured

B - Breathing with O2 +/- support

Pneumothorax drained

C - Bleeding controlled, Shock treated

D - Deformity immobilized

E - Coverage

Flight factor

Change in altitude

Vibration

Motion

Limited resource

Limited space

BE PREPARED.

Flight factor

Change in altitude

Lower oxygen = Hypoxia

Gas expansion

Pneumothorax

Lung cyst / bleb

Bowel gas

Middle ear

Diving / Decompression sickness

Flight factor

Vibration & Motion

Team : Vertigo, Motion sickness

Patient : Pain / Injury

Equipment : Displaced / Damage

Limited resource

Oxygen / Drugs

Equipment

Space

Flight Doctor or Specialist

Flight Nurse

Airline Staff

Patient and Family

Payor

Teamwork

Equipment

What are possible injury ???

Burn – Burn – Burn

Monitor and Observation

Airway Injury

Risk Prevention Noise - Unable to check breath sound

ET Tube malposition , Pneumothorax Secure airway

Straps + Tape + Marking

Confirm ET Tube Position

End Tidal CO2 Monitoring

Pulse Oximeter

End tidal CO2

Airway Injury

Risk Prevention Movement and Vibration

Close observation

Secure airway

Recheck – After each movement

End Tidal CO2 Monitoring

Pulse Oximeter

Cricothyroidotomy

C spine immobilization ?

C-Spine and ET Tube Fixation

Air Leak – Tension Pneumothorax

Bleeding – Massive Hemothorax

Deformity

Flail Chest / Open Chest Wound

Lung Contusion – ARDS / Pneumonia

Pain – Limited breathing and Cough

Breathing - Chest Injury

Pneumothorax

Pneumothorax

Needle thoracostomy

TENSION to SIMPLE

Large bore needle

2nd intercostal space

Midclavicular line

One-way valve

Under water tube

Needle + One-way Valve + Container

Preflight Plan - Risk Prevention

Drainage

Any pneumothorax … Before

Monitoring

Chest symptoms

Chest movement

V/S SpO2

Breathing - Chest Injury

ICD

Chest Pain

Limited chest movement

Breathing – Inadequate >>> Atelectasis

Cough – Ineffective >>> Secretion

Preflight Plan - Adequate pain control

Epidural block

Analgesic

Breathing - Chest Injury

One-way valve

Hemothorax

Bleeding in pleural cavity

Chest wall / Lung

Great vessels / Heart

Preflight Plan – Stable with Patent ICD

Blood < 100 ml/hr

IVF / Blood products

Breathing - Chest Injury

Chest Surgery

CVT, ICD, Thoracentesis

Preflight Plan

Fly with ICD - Safe

Fly without ICD

No residual air leak – CXR ???

Low risk of leak in flight : 1-2 Week

Prepare for E-Decompression

Breathing - Chest Injury

Bilateral Pneumothoraces

Bilateral Pneumothoraces

Hemopneumothorax

Bilateral Pneumothoraces

Respirator circuit

O2 – Ventilator - Suction

O2 needed, How much?

C - Circulation

Circulation

Preflight Plan - Blood

Secure hemostasis … Before flightBleeding control

Coag. – FFP/ Cryo / Novo 7

Keep Hb > 7 – 8.5 gm%

In trauma > 10 gm%

Occult ongoing blood loss

Cardio / Respiratory Reserve

Preflight Plan - Volume

Euvolemia

Stable = Controlled hypotension is OK.

No dehydration

Urine output 0.5ml/kg/hr

IVF – Crystalloid, Colloid, Blood

Secure venous access

2 good lines – Large / Patenty checked

Circulation

Fit to fly ?

Liver injury

Hemopericardium

Burn at chest wall

Post cardiac arrest

Transfusion Rx

Preflight preparation

POCT

Point of Care Test

Blood sugar

PT & INR

PASG

Application

Standby

Before move

Shock > Inflate

Urine output

Preflight Plan - Perfusion

Inotropes

All types – Mixed component

Vasoconstriction – NO FLOW

Keep warm

IVF/ Blood Products

Blankets

Circulation

On board

Check : venous access sites

Monitor

P, BP, SpO2

Conscious

Cap. Refill – Central / 2 sec

Urine Output

Circulation

Tubes and Lines

Deficit – Brain injury

Check list

A-B-C

Initial assessment – AVPU or GCS

Localizing signs

Associated injury – Face/Neck

C-Spine protection

T-L Spine protection

Monitoring : BP and Neuro signs

Bleeding – Contusion - Swelling

Secondary Injury

CPP = MAP – ICP

Intracranial SOL / Swelling MAP is normal.

ICP is high.

CPP is LOW !!!

Systemic Perfusion – OK.

Brain – Shock ???

Save Body & Brain

A – B – C – D

Airway Control

Breathing & Oxygenation

CPP : keep MAP

Decrease demand

Fever – Fighting – Fit

Pneumocephalus – Tension ???

Pneumocephalus

Requirement : Brain injury

Medical staff - Competency in

Neuro. assessment + Consultation

Basic airway technique

Definite airway procedure

Ventilation support

Monitoring

Spine immobilization

Recheck

• Neck Pain

• Motor Power

• Sensory

• Pulse Rate

• Blood Pressure

Spinal protection

Immobilization

Fx : Femur – T Spine – C Spine

Deformity – Limb injury

Immobilization

Distal perfusion

Compartment syndrome

Cast

Vascular injury

Reperfusion injury

DVT

Immobilization – Traction Splint

Non-constricted immobilizer

Compound fracture Vascular injury and limb ischemia

Pelvic fracture with C-Clamp

Pelvic fracture with Binder

Burn

Burn Problems

A – Airway Swelling

Difficult / Obstruction

B – Breathing

Inhalation Injury & ARDS

Increase Systemic Injury

Carbon monoxide + Gaseous toxicity

Body Eschar – Chest Movement

Burn Problems

C – Burn Shock

20% BSA in Adult

Less in Child/Elderly

Systemic Response

Leak

Depressed Myocardial Fn.

Burn Problems

C – Distal Circulation

Tissue swelling

Circumferential Burn

Compartment Syndrome

Circum. Dressing

Burn or more ???

Associated Injury Burn and fall, car accident, ….

Electrical Injury to …

Muscle, Heart, Neuro - Cord, Lens …..

Bleeding Debridement

Escharotomy

Fasciotomy

Myoglobinuria

Heat loss – Cold IVF

Burn Care – On board

Airway – Swelling

ET Tube ? – Do it on the ground

Breathing – Hypoxia

Ventilator / O2 in flight

Circulation

V/S – Limb swelling : NIBP ?

Urine output

Distal Limb – SwellingCircumferential Wound

Circum. Dressing

Monitor

Distal pulse/Cap. Refill – SpO2

Sensory / Motor

Bleeding

Burn Care – On board

Abdominal Distension

Abdominal

Compartment Syndrome

Rectal Tube

Decompression Tube