CCP Fall 2013 - Week 2

• pH < 7.2
• PaCO₂ > 55 mmHg
• PaO₂ < 60 mm Hg

• β2 selective sympathomimetics
• Anticholinergics
• ketamine (Ketalar®)
• MgSO4
• Steroids ** Late phase Rx/Hyper-Responsiveness prophylaxis

• Smokers
• Oral contraceptives
• Sedentary
• Cancer
• Obesity
• Gravid
• Greenfield filter

• Acute respiratory distress
• SPO₂ that doesn't respond to high flow O₂

Localized infection results in the accumulation of consolidated proteins in inflammatory factors

Ventilator delivers a pre-set volume when triggered, regardless of airway pressures. AKA “volume limited”

Ventilator delivers gas when triggered until a preset pressure is reached. AKA “pressure limited"

Pressure & Volume

Ventilator delivers a preset V_t or PIP @ a preset rate. Pt cannot initiate breaths. May lead to pt apprehension & air hunger in awake pt.

• Ventilator delivers a preset Vt or PIP w/every breath. Pt is able to trigger breaths, but a backup rate is set in the event the patient breathes below the set rate.
• May be poorly tolerated in awake pts d/t the asynchrony of pt & machine cycle length
• May be associated w/respiratory alkalosis
• May worsen air trapping in COPD pts

IMV Combines a preset # of breaths w/a preset V_t or PIP w/the capability of intermittent pt generated breaths.

• Ventilator senses the start of a pt breath. The mandatory breath is delivered in synchrony w/the pt’s effort
• Allows for various modes of support from complete support to spontaneous breathing
• Risks: Hyperventilation, Respiratory alkalosis &  air trapping COPD pts

Synchronized IMV (SIMV)

Minute Volume (V_e) = V_t x f

4 - 8 L/min

6 - 10 mL/kg

8 - 20/min

1:2 or 1:3

0.21 - 1.0

< 30

• S – suction
• C – connections
• O – obstructions
• P – pneumothorax
• E – ETT dislodgement or displacement

1 to 2 ventilations

D/C from vent

• PIP Alarms: Think Airway problem
• P_PLAT Alarms: Think Lung problem

• O₂ delivery/supply system
• All connections to pt
• Leaks in vent circuit
• All settings
• Evaluate for ETT dislodgement/extubation
• ↓ ETCO₂ or loss of waveform
• ↓ SPO₂
• Hypovolemia (Δ space available for lung expansion: ↑ Space ⇝ ↑ Volume ⇝ ↓ Pressure in Container [Lungs]) [Requires significant ↓ in circulating volume]

• Consider SaO₂ vs. SpO₂ issues (probe placement)
• Appropriate V_t set?
• Appropriate f (rate)?
• Appropriate inspiratory time?
• ETT placement
• Consider PEEP
• Suctioning
• Pneumo?
• PE?

• “SPO₂ reads low when it’s high & high when it’s low”
• With MetHgb > 40% will direct the SPO₂ to 85%

PaCO₂ > 55 mmHg

4-8 L/min

Ventilatory failure w/retention of CO₂

• Current Airway Patency
• Oxygenation or ventilation failure
• Expected clinical outcome

• LEMON
• L – Look
• E – Evaluate 3-3-2-1
• M – Mallampatti
• O – Obstructions
• N – Neck mobility

• Class I: Full visibility of the Pharyngeal arches, Tonsillar pillars, Soft palate & Uvula
• Class II: Visibility of the Soft palate & Part of the pendent uvula
• Class III: Visibility of the Soft palate & only the base of the uvula
• Class IV: Visibility of only the hard palate
• 

• 3 fingers upright into pts mouth
• 3 fingers fit below chin btn mandible and laryngeal cartilage
• 2 fingers btn larynx & hyoid bone
• 1 finger btn upper & lower jaws after displacing mandible forward
• 

• Etomidate
• ~ 96% of pts retain their respiratory drive when properly dosed
• Short acting
• Risks: Myoclonus – Usually self relieving

• Requires sedation
• Expect to be able to intubate 
• Expect to be able to ventilate

To prevent aspiration

• Preparation - Lemon Soda
• Pre-oxygenation - 5 min vs accelerated, BVM vs mask
• Premedication - Load & wait 3 min
• Paralysis w/Induction - Induction followed immediately by NMBA
• Protection & positioning - Sellick’s & proper alignment
• Placement & proofing of ETT - Tube sizes, 1°
• & 2° verification
• Post-intubation management - Tube restraints, Sedation &/or paralysis

• 1: Is the pt unconscious/unresponsive/near death?
• 2: Is this a Difficult Airway

• 1-1½ mg/kg
• Tight heads & Tight lungs

• 1-3 υ/kg
• Attenuation of stress/autonomic response to noxious stimuli

• 0.5-1.0 mg
• Dry up saliva caused by Ketamine
• Treat bradycardia caused by SUX - esp Peds

0.3 mg/kg

• etomidate
• ketamine

0.5-2.0 mg/kg

• 0.05-0.15 mg/kg
• Profound hypotension

15-75 micrograms/kg

• Adult: 0.5-1.5 mg/kg
• Child: 2 mg/kg
• Infant: 3 mg/kg

• Onset: 30-60 sec
• DOA: 3-4 min (80%), 9-13 min (95%)

• CV: Bradyarrhythmias, VF/VT (problematic w/2nd bolus & K⁺ disorders)
• K⁺ shifts (0.5 mEq/L w/typical ETT dosing), much higher in Ach disorders
• NEURO: ↑ ICP, ↑ IOP & ↑ IGP (Attenuate well w/defasciculating premed)

0.1 mg/kg

2.4 min

44 min

0.6-1.2 mg/kg

60-90 sec

36-73 min

No conversations take place on the flight deck that are not related to the safe operation of the aircraft.

Per FAA during any "Critical Phase of Flight"

All flight phases except straight, level, cruise flight

A POST ACCIDENT INCIDENT POLICY (PAIP) should be implemented 15 minutes after an aircraft fails to give a position report or is overdue to arrive.

• 2 personnel attending to the pt
• at least 1 is EMT-P

• 2 personnel attending to the pt
• Dual medic vs Medic/RN

• 2 personnel attending to the pt
• Specialty Care personnel must be accompanied by at least 1 regularly scheduled Air Medical personnel
• & all personnel must have basic safety orientation

• Didactic & clinical portions specific & appropriate for the mission statement & scope of care of the medical transport service
• Includes Stress Recognition & Managment

2000 hrs rotorcraft hrs w/1000 hrs as PIC & 100 hrs as PIC @ night

• Terrain & Weather
• Orientation to Hospital
• Infection Control
• Pt loading & unloading
• Medical systems on aircraft
• CRM: Crew Resource Management
• EMS/Public Service Agencies
• Instrument Meteorologic Conditions (IMC) Recovery procedures by reference to instruments or IFR currency
• 5 hrs area orientation w/2 hrs @ night as PIC prior to EMS missions

• Protective clothing & dress codes pertinent to mission profile
• Boots or sturdy footwear
• Reflective material at night
• Flame retardant clothing
• How does your flight suit fit?
•    ¼” between your flight suit & you
•    All cotton natural fibers beneath flight suit
• Nomex is not required, retardant quality is
• Environment appropriate
• Hearing protection
• Helmets?

• Refueling Policies
• Oxygen Delivery
• Latex Allergies
• Weather minimums
• Cellular phones
• Night Vision Goggles
• Safety committee
• Minimum medical equipment

• Local:
•     Day 500' Ceiling x 1  mile visibility  
•     Night: 800' Ceiling x 2 miles visibility
• Cross Country   
•     Day 1000' Ceiling x 1 mile visibility   
•     Night 1000' Ceiling x 3 miles visibility

Pushing weather (esp @ night)

Visual Meteorological Conditions: You can visually identify where the sky and the ground meet

Instrument Meteorological Conditions: You cannot visually identify where the sky and the ground meet

Visual Flight Rules: Rules for flight during VMC

Instrument Flight Rules: Rules for flight during IMC

• Lay Patient Flat
• Assure Patient Straps Secure
• Turn Off O₂
• Secure Equipment
• Confirm your belts are secure
• Helmet visor down
• Assume crash positions

• Emergency Transmit Freq 121.5
• ELT activation occurs around 4 g
• If the pilot is incapacitated on termination of movement:   
•     Disengage the throttle
•     Disengage the fuel
•     Disengage the battery
• Don’t exit the aircraft until movement stops
• Exit and meet crew members @ 12o’clock
• Secure shelter, fire, then water & finally food

Communications w/Ground personnel

• Day: 75' x 75'
• Night: 100' x 100'