Manage Respiratory Injuries in Enroute Care

The battlefield of medicine…

TERMINAL LEARNING OBJECTIVE

• Identify the five key steps for operation of the Impact 754 ventilator and identify critical components of the implications and management of pulmonary injuries to deliver optimal enroute care

Enabling Learning Objective A

• Select the required five steps to set up and correctly operate an Impact 754 ventilator to deliver optimal enroute respiratory support

Critical Thinking

• A ventilator is a support device…it frees you…– Physically– Psychologically– Lets you focus on:

• PHYSIOLOGICAL CHANGES

• Tools are great but if they don’t work…– When the 754 stops, your Ambubag starts!

The Eagle 754 Ventilator

BRIEF HISTORY:• Developed under Army

contract in the mid 90’s• First available portable

ventilator with internal compressor and battery capable

• Good points– Simple,rugged,reliable

• Bad points– High failure rate

Eagle 754 Ventilator• Simple to set up• Follow the numbers:

– 1-5 to set the vent

Turn On

• Turn all the way clockwise to “CAL” and wait until “OK” appears

• Switch counterclockwise to ordered mode:– Assist Control– Spontaneous

Intermittent Mechanical Ventilation

– Continuous Positive Airway Pressure

Set Rate

• Generally rate will be in the range of 12-18 breaths/minute

• Consult with care team for settings

• Actual rate is displayed in the message center above the adjusting knob

Set Inspiratory Time

• Full counterclockwise automatically adjusts Inspiratory time to achieve a I:E ratio of 1:2

• Manually set to Inspiratory time of 1.0 to 1.5 second

• The longer the Inspiratory time the lower the peak pressure

• Display shows set I time and actual I:E ratio

• Can not violate I:E of 1:2

Set Tidal Volume

• Tidal Volume range of 0 – 1000 cc’s

• Tidal volume will be the sum of Ventilator flow x inspiratory time

• Tidal Volume displayed is calculated ( not measured)

• FOR THE 754:– Minimum flow = 10 L/min– Maximum flow = 60 L/min

Set FiO2

• Room air to 100 %• Displayed

Display

• PEEP – Generally set at 5– Push button– Resets at 20

Display

Power status

Display

Minute Ventilations

Display

Mode

Display

Airway Tracing

Display

Pressure Graph

Display

Peak & Mean Airway

Pressure

Alarms

• High Pressure– Set 5-10 cm above

peak pressure once patient is established on ventilator

Other Alarms

• Red light indicates an alarm condition and the Alarm Message center will detail the condition

• Keep a close eye on the light – you may not hear the alarm

Check on learning

• How many settings must be set prior to using the Impact 754 Ventilator?– Five

• What are they?– Power/Mode– Rate– Inspiratory Time– Tidal Volume– % of O2

Why is this important?

Enabling Learning Objective B

• Select critical clinical findings and management interventions for enroute care of patients with pulmonary injuries

Case Study (1 of 6)

• Demographics:– 23 yo AD male after blast, overpressure, and

significant burn injuries from IED attack and fragmentary injuries to both lower extremities

– No other medical history• Surgical Interventions:

– Right lower lobe lobectomy with surgical placement of chest tubes x 2 for drainage

– Debridement of burns and bilateral lower extremity injuries with vascular repair

Case Study (2 of 6)

• Current Clinical Management:– Airway/Breathing:

• Intubated with 8 French ETT @ 23 cm/lip• Ventilator on Assist Control @ 60/12/750/5• Requires frequent suctioning for bloody, thick

secretions– Circulation:

• Peripheral IVs x 2 (Both patent and functioning well)

• LR @ 75 cc/hr, PRBC’s as needed• No vasoactive medications currently

Case Study (3 of 6)

• Current Clinical Management:– Drains and Dressings:

• Chest tubes x 2 to right lower and medial lobes• Both chest tubes to low/intermittent suction with

minimal bloody drainage (less than 50 cc/hr)• Patient has full circumferential acticoat and dry

gauze dressings to both lower extremities with minimal bloody drainage

• Foley to gravity draining >30 cc/hr of amber urine

Case Study (4 of 6)

• Plan:– Transfer for CCAT

evacuation to Level IV facility in Germany (approximately 40 minute flight)

– Chest tubes to water seal for transport

– NOTE: No blood available for transport

Case Study (5 of 6)

• The team prepares the patient for transport and has:– One impact ventilator – One PROPAQ monitor– Emergency equipment and medication bag– One impact intermittent suction device

Case Study (6 of 6)

• In flight, emergency evasive procedures are taken to avoid an RPG, within a minute after this event, you notice rapid and significant output from the lower chest tube and the following vital signs:– BP 90/54 – HR 134– RR 12 V– 02 saturation 92% (down from an initial 02 sat of 96%)

• What do you suspect is happening?• (USE THE “B PLAN”: BLEEDING OR BREATHING?)• What are your interventions? • THE RULE IS STOP OR FIX THE “BAD B”

APPROACH THE PATIENT IN AN AEROMEDICAL SETTING

(MTF TO MTF)• ABCs are still paramount• Patient needs to be synched on the vent

prior to transport• Once in flight you lose the sense of

hearing and some tactile sensation (stethoscopes are useless in environ)

• Palpation and visual confirmation remain as phys evaluation tools

THE “A”

• Evaluation – Look at all tubes ETT, Chest Tubes, Nasal– ETCO2 is a gold standard and should be used

• Troubleshooting– ▼ in SaO2 look at tube(s) for migration

The “B”

• Evaluation– PALPATE for equal rise and fall of chest!!

• Troubleshooting– 754 not working effectively, switch to

Ambubag, REMEMBER to administer oxygen– 754 is too hard to troubleshoot in flight,

recommendation: maintain bagging for the duration of the flight

The “C”

• Evaluation– Is the container open anywhere (this may

cause RD)?– Is the container still closed but internally

hemorrhaging. Check Abdomen / Pelvis / Bloody Show in Chest Tubes

• Troubleshooting– CLOSE the container!! Provide conservative

fluid boluses

Reviewing the basics…

• Enroute care is focused on:– Emergency interventions– Maintaining homeostasis– Trauma team concepts (Medic/RN-PA-MD)

• Enroute care is not:– Definitive– Glamorous– Based on standard civilian models

How do you prepare?

PEARLS OF AEROMEDICAL WISDOM

• “Dance with the one that brung ya”• Have ample O2 onboard the aircraft

– What is ample?

• After movement check ABCs, then M2M (man to machine approach) check connections– Tube Migration (all tubes)

• NVG Considerations

Total PSI-SR x Conversion Factor

Liter Per Minute

Check on learning

• What are three critical concerns for managing patients with pulmonary injuries while delivering enroute care?– Watching for physical or physiological symptoms of

distress– Monitoring all vital signs with a focus on SA02 or

ETC02– Having all the equipment with you before you need it

• What emergency devices should you always have available when delivering enroute care?– Oxygen and Ambubag– Suction– Back-up monitoring

Check on learning

• What do you do when the ventilator stops?– Start giving manual support with the

ambubag!– Inspect: M2M: Man to machine

• What are the two B’s that can be causes for respiratory distress?– Breathing– Bleeding

Summary

• There are many critical considerations when managing the care of a patient with respiratory injuries enroute:– Know the ventilator– Do not be afraid to use the ambubag or make

emergency management decisions– Stick to the basics: Touch, Tube, Tech– Have all your tools available– Be calm and stay focused

QUESTIONS?