Aeromedical Evacuation

The burn patient

Final: 12.09.2021
Framework
• Clinical problem.
• Management on ground and air.
• En-route complications and management.
• Flowchart.
• Talking points(notes)
The clinical problems
• 30% TBSA partial thickness burn.
• Signs of airway injury with oxygen saturation at 88%.
• Hypotension and tachycardia.
• Anxiety and Pain.
• Possible CO, Cyanide poisoning and methemoglobinemia.
The management:
• Remove victim from heat source and bring to the site clinic.
• Start NRB mask oxygen at 12 l/m, if saturation not above 94%, or signs of
inhalation injury, consider intubation.
• Raise leg side by 10 degrees, insert two large iv lines and start Ringer
Lactate as per Parkland formula.
The management continued.
• Remove clothing.
• Cool burn areas with towels soaked with cold water within 30
minutes of event time. Clean wounds and apply antibiotics and dry
sheet.
• Consider lorazepam for anxiety and delirium, and narcotic painkillers.
• Cover with blankets and aluminium blanket to prevent hypothermia.
• Insert urinary catheter, to monitor output.
• Insert nasogastric tube to prevent paralytic ileus.
• Do a arterial blood gas analysis.
The management continued
• Maintain high index of suspicion of poisoning if there is deterioration
in neurologic and cardiovascular functions.
• Consider normobaric 100% oxygen therapy.
• Consider hydroxocobalamin for cyanide poisoning.
• Consider carrying additional supplies of hydroxocobalamin, sodium
thiosulphate, methylene blue, and traditional antidote kits.
Safety considerations
Flight paramedic and nurse checklist before take-off:
• Safe approach to aircraft
• Safe loading and unloading
• Recheck ETT placement and secure it. Cuff inflated using NS.
• Oxygen supply tested for functionality and accessibility.
• Reassess ventilator parameters; Pressure mode cycle preferred.
• Monitors anchored and accessible.
• IV and arterial lines patent and accessible.
• IV bags secured and infusion rates checked.
Continued…
• Suction readily available.
• Receiving facility has been notified and has received all pertinent
information.
• Arrangements for ground transport confirmed.
• Give go ahead to flight crew. Maintain communication with receiving
facility
Fixed Wing AE; Safety considerations
• Follow pilot and flight crew instructions.
• Never approach the aircraft while the engine is running.
• Patient must be restrained before boarding and remain so during the
flight.
• Medical personnel must remain buckled to seat and inform pilot the
need to move for administering care.
• Be familiar with communication equipment and refrain from use
during taxi, ascent, descent, landing.
• Stow and secure all equipment.
Complications and management during AE.
• Hypothermia
Any patient with more than 25% TBSA is prone to hypothermia. The flight crew
should be requested to control ambient temperature. The patient should be
covered with a clean sheet and a wool blanket. Additionally an aluminium rescue
blanket should be used.
• Anxiety and delirium.
All burn patients with signs of anxiety and delirium should be given lorazepam.
Other anxiolytics can also considered.
• Pain
Frequent assessment and use of iv narcotics may be required.
• Hypovolemia
Hemodynamic profile and urinary output should be continuously monitored and
flow rate of iv fluids adjusted. A IABP line placed before flight, can be of help.
En-route management continued…
• Maintain high index of suspicion for any poisoning effect still
persisting.
• Any ECG changes, unexplained deterioration in neurologic and
cardiovascular status, ischaemic chest pain, should alert the medic to
use specific antidotes, preferably in combination, based on suspicion
alone.
• A repeat ABG compared to baseline readings pre-flight can be of help.
• Other minor problems can be otic barotrauma, emesis, etc.
Continued…
A repeat secondary survey to identify any bleeding due to previous
escharotomy may be needed. This is best managed by oversewing the
bleeding vessels using absorbable suture.
• Difficulty in monitoring due to ambient noise.
End tidal capnography, pulse oximeter, and CVP line should be
monitored at frequent intervals. Consider plethysmography, hand held
spirometer.
Communications and co-ordination plan
Site medic(SM) informs field office(FO) and logistics coordinator(LC) of
need for patient transport. Assigns flight medic(FM) and flight
nurse(FN) for transfer.
LC
• completes call sheet with patient information, location and
destination.
• Confirms bed availability at receiving facility. Activates ground
ambulance to airport. Contacts FN with initial information.
• Contacts DIA to activate air ambulance. Discusses special
requirements like altitude restriction, etc
Continued…
• Completes electronic flight booking
• Assist FM and FN for preparation and departure.
FM and FN
• Receive call sheet and complete patient assessment at site clinic.
• Receive complete patient information from site medic.
• Completes electronic booking at tertiary centre website.
• Check for patient preparation for transport
• Receive go ahead from LC
Continued…
Al Khor Airport Aeromedical Evacuation office
• Retrieves patient information on booking database.
• Reviews urgency rating and activates flight plan and aircraft.
• Confirms with LC regarding ability to complete transfer to DIA and
time of departure.
• Arranges for required flight crew.
• Contacts DIA to activate ground ambulance.
Continued…
At site clinic:
FM and FN
Advice HMC emergency department of patient status and tentative
ETA.
At Al khor airport:
Flight crew:
Advice FM, FN, and HMC ED of ETA.
Continued…
After arrival at emergency department of HMC
FM and FN
• Completes handover of patient to the doctor in charge.
• Completes transfer documentation.
• Enters details in electronic database.
• Informs LC regarding successful transfer and requests for return
arrangement.
References
• Branson, R. D., & Rodriquez, D. (2020). Monitoring During Transport. Respiratory Care, 65(6), 882–893.
https://doi.org/10.4187/respcare.07796

• Emergent Management of Thermal Burns: Practice Essentials, Prehospital Treatment, Initial Emergency
Department Treatment. (2021). https://emedicine.medscape.com/article/769193-overview

• Initial Evaluation and Management of the Burn Patient: Overview, Initial Evaluation and Resuscitation, Evaluation
of the Burn Wound. (2021). https://emedicine.medscape.com/article/435402-overview#a2

• Smoke Inhalation Injury Treatment & Management: Approach Considerations, Prehospital Care, Emergency
Department Care. (n.d.). Retrieved 17 September 2021, from https://emedicine.medscape.com/article/771194-
treatment

• https://nasemso.org/wp-content/uploads/National-Model-EMS-Clinical-Guidelines-2017-PDF-Version-2.2.pdf

• https://wellingtonicu.com/Data/Flight/2017%20Flight%20course%20manual.pdf