REACH Air Medical Services

We will be available and prepared to provide customeroriented, high-quality patient care, in a safe and efficient manner. In every situation, we will do what is right for the patient.

• Describe the significance of gas laws pertinent to the transport environment.
• Describe the stresses of flight and their effects on transport teams and their patients.
• Identify specific interventions to combat the different stressors to the transport team and their patients.
• Identify the signs and symptoms of hypoxia.
• Identify appropriate interventions to mitigate the adverse effects of barometric pressure change in transport.

• Ambient Pressure
– The pressure of existing and adjacent environment
• Physiological Zone
– The area from sea level to 10K feet
• Cabin Altitude
– The altitude measured inside the cabin of an aircraft
• Cruising altitude
– The actual, level-off altitude outside the aircraft above sea level

• Atmosphere
– The gaseous layer around the earth, composed mainly of nitrogen and oxygen
• Altimeter
– An instrument used to measure aircraft altitude
• Barometer
– An instrument used to measure atmospheric pressure
• Barometric Pressure
– The pressure of the air in certain environment, measured by a barometer

• Statement of Law
– At a constant temperature, the volume of a gas is inversely proportional to it’s pressure.
• Example
– Trapped gas in the body

• Statement of Law
– Total pressure of a mixture of gases equals the sum of the partial pressure of each gas in the mixture
• Example
– Hypoxia

• Statement of Law
– Gas dissolved in a liquid is directly proportional to the weight of the gas above the liquid.
• Example
– Soda can
– Decompression sickness

– Statement of Law
• The pressure of gas is directly proportional to its temperature (volume remains constant)
– Example
• Storage of oxygen containers

• Statement of Law
– A gas will diffuse from an area of high concentration (or pressure) to an area of low concentration.
• Example
– Gas exchange at the cellular level

• Hypoxia
• Trapped Air
• Thermal changes
• Decreased Humidity
• Noise
• Vibration
• Fatigue
• Gravitational, acceleration/deceleration forces

An oxygen deficiency sufficient to cause an impairment of function
• Causes
– Inadequate supply of oxygen
– Inadequate oxygen transport capability
– Inability of body to use oxygen

• Indifferent Stage
– Physiologic zone: 0 – 10 K feet
– Increased HR and RR
– Decrease in night vision @ around 5 K

• Compensatory Stage
– 10 K – 15 K feet
– Increased HR, RR, BP, Respiration
Depth
– Drowsiness
– Poor judgement
– Impaired coordination
– Impaired efficiency

• Disturbance Stage
– 15 K – 20 K feet
– Characterized by
• Dizziness, sleepiness, tunnel vision, cyanosis, slowed thinking and decreased muscle coordination.
– Which can cause…
• Impaired flight control
• Impaired handwriting
• Impaired speech
• Decreased coordination

• Critical Stage
– 20 K - 30 K feet
– Mental confusion and incapacitation
– Unconsciousness
– Circulatory failure
– Cardiovascular collapse
– Death

• Hypoxic Hypoxia
• Anemic Hypoxia
• Stagnant Hypoxia
• Histotoxic Hypoxia

• Deficiency in alveolar oxygen exchange.
• Causes
– Reduction of pO
2 in inspired air
– Ineffective gas exchange in an area of the lung
• Result
– Inadequate oxygen supply in arterial blood

Altitude Pressure Oxygen sea level 760mmHg 160mmHg
1000 ft. 732 132
8000 ft. 564 118
18000 ft. 380 80
34000 ft. 187 39
• Reference Protocol:
– Atmospheric Pressure, Limits for Specific Disease
Processes

• Treatment
– Supplemental 02
– Altitude restriction
– BIPAP
– Advanced airway management
– Fix problem

• Reduction of 02 carrying capacity
– Decrease in circulating Hgb
– Reduction of functional / avail Hgb
• Treatment
– Maximize available 02
– Consider transfusion

• 02 deficiency secondary to poor circulation
– Heart failure
– Hypovolemia
– Shock (any source)
• Treatment
– Maximize 02 supply
– Maximize 02 delivery
• Consider volume
• Consider pump

• Inability to utilize 02 at cellular level
– “Poisoned tissue”
• Causes
– Sepsis
– Alcohol
– Cyanide
– Carbon monoxide
• Treatment
– Cause specific

• Expands with increase in altitude and contracts on descent
• Trapped air will expand!
• Air expansion can cause rupture!
• One liter of gas at sea level will expand to the equivalent of three liters of gas at
28,000 ft.
• Even with pressurization of the cabin the body can act like a closed container.

• Cranium
• Sinuses
• Ears
• GI Tract
• Thorax
• Medical
Devices

– Middle ear
• Eustachian tube is far easier to open for expanding gases than it is to open when gas contracts. Therefore rupture is more likely on descent when the eustachian tube is blocked.
– Bowel gas, sinus and pleural space gases
• Causing abdominal pain, increased intracranial pressure and possible pneumothorax

• Pneumothorax
– Vent the chest!
• Bowel Obstruction
– NGT
– Vent to atmosphere or place on suction
• Pneumocranium
– Lowest altitude possible

• Colostomy
– BEWARE!
– Vent to atmosphere
• ETT cuff
– If high altitude for long periods of time replace cuff air with saline or sterile H20
• IV Bags
– Remove all air prior to flight
• Glass Bottles
– Do not use!
• Air Splints / MAST Pants
– Monitor for increased pressure with altitude

Other Barometric Pressure Issues
• Dive Injuries
– Transported altitude < 1000 ft.
– Divers should be discouraged from flying within 24 hours of dives > 66 feet.
• Dental work
– Should not fly within 24 hrs.

• Temperature decreases with altitude
• Consider when “packaging” patient
• Consider flight crew dress

• Decreased humidity with increased altitude
– ETT’s plug more easily
– Corneas will dry out
– Dehydration

• Ear protection
• Cannot auscultate BS during flight
• Cannot auscultate BP during flight
• Creates acceleration of other senses

• Constant low vibration
– Traction devices must not have hanging weights
– Diligent check of equipment settings
– Screws and bolts loosen over time
– Palpation of pulses
– Additional stress and fatigue on crew, patient, and equipment

• Operational stressors
• Personal stressors
– D rugs
– E xhaustion
– A lcohol
– T obacco
– H ypoglycemia

• Helicopter G forces are minimal, fixed wing aircraft may experience increased forces
• Maneuvering
– Visual Disturbances
– Disturbances in consciousness
• Acceleration/Deceleration
• CNS depressants and narcotics are potentiated.

• All patients receive supplemental 02!
• Assess and address all pulmonary needs prior to departure
• Assess and address circulatory deficiencies prior to flight
• Release trapped air
• NGTs should never be clamped
• Hematocrit should be > 21 and HGB should be > 7

• Well rested
• Avoid smoking
• Remain in seat with restraints to avoid vibration
• Avoid gas producing foods ( check on your partner!)
• Avoid chewing gum on ascent
• Avoid flying with cold or ear infection
• Avoid effects of ETOH for 12 hours before flight