i ZHAPTER 1 Introduction to Critical Care ........................ I Transport 2

.................................... Introduction 4

The History of Critical Care Transport ................ 4

Critical Care Team Composition and Qualifications ...... 8

Modes of Transportation and Their Differences ......... 9 ...................................... Dispatch 10

...................... Transportinq by Ground vs Air 11

................................. Medical Control 12 ........................ Interfacility Transport 13

..................... State and National Standards. 13 .......................... Reimbursement Criteria 13

..................................... Wetl.Being 13 ........................................ Stress 13

.................................... Safety Gear 14

..................... Interpersonal Communication 14 ............. Quality Assurance and Improvement 15

... Summary ............................. 15 ....................................... Prep Kit 18

ZHAPTER 2 Medical-Legal Issues ........ 20

. . . Introduction ....................... - 2 2

The Emergency Medical Treatment ......................... and Active Labor Act 22

................ Legal Practice Constraints for CCTPs 25

............................. The Patient's Rights 26

........................... Transport Preparation 30 ........................ Transport Responsibilities 31

Documentation ........... ................ 33 ...................................... Summary 33

.................................... P r e ~ Kit 35

I :HAPTER 3 Aircraft Fundamentals ....... 38

................................... Introduction 40

The Air Medical Role .......... ............. 40 ................................ Communications 40

Rotor-Wing Transport vs Fixed-Wing Transport ........ 42 ............................. Rotor-Wing Aircraft 43

Fixed-Winq Aircraft .............................. 45

Air Medical Efficacy ............................. 45

............. Triaqe of Air Medical Transport Patients 47

Air Medical Crashes ............................. 49

........... Crew Resource Management ..... 50

.............................. Air Medical Safety 51

The Air Medical Crew ............................ 53

Rotor-Wing Operations ........................... 54

....................... Aircraft Safety and Survival 56 ...... Summary .............. ..... 61

....................................... Prep Kit 64

CHAPTER 4 Flight Physiology ........... 68

................................... Introduction 70 ................................ The Atmosphere 70

...................................... Gas Laws 72

Types of Hypoxia ............................... 75

Four Staqes of Hypoxia as They Relate to Altitude ..... 78

Pressurized and Nonpressurized Aircraft ............ 80

.............. Primary Forces That Act on an Aircraft 81

....................... Primary Stressors of Flight 81

Factors Affecting Tolerance of the Physiologic ............................ Stressors of Flight 89

............... Dysbarism and Evolved Gas Disorders 90

...................................... Summary 91 ..................................... Prep Kit.. 94

.......... CHAPTER 5 Patient Assessment 100

Introduction ........ .................... 102

.............................. Scene Transports 103 ......................... Interfacility Transports 104

SKILL DRILL 5-1 Packaqinq Procedures for ...................... an Interfacility Transport 110

.............. The Critical Care Systems Assessment 110

............... Communication and Documentation 120 ..................................... Summary 120 ................................... Prep Kit 123

CHAPTER 6 Respiratory Emergencies and Airway Management ........... 126

Introduction .................................. 128

Anatomy and Physioloqy of the Respiratory System . . 128

Physioloqy of the Respiratory System .............. 131

Pathophysioloqy: Obstructive and Restrictive Disease States ................. 135

Patient Assessment ............................ 135

ABG Monitoring ................................ 140

Respiratory and Ventilation Abnormalities ........... 141

Basic Airway Management ........................ 141

SKlLL DRlLL 6-1 Suctioninq a Patient With an Endotracheal Tube in Place .................... 143

Advanced Airway Manaqement ................... 145

SKILL DRILL 6-2 Performinq Orotracheal lntubation .... 149

SKILL DRILL 6-3 Performing Nasotracheal lntubation .... 151

SKILL DRILL 6-4 Performinq Diqital lntubation ........ 152

SKILL DRILL 6-5 Performing Retrograde lntubation .... 155

SKILL DRILL 6-6 LMA Insertion ..................... 158

SKILL DRILL 6-7 Insertion of the Combitube .......... 160

SKILL DRILL 6-8 Performinq Needle Cricothyrotomy .... 163

SKILL DRILL 6-9 Performing Surqical Cricothyrotomy ... 165

SKlLL DRlLL 6-10 Performinq Rapid Sequence i lntubation ................................. 168

' . Pharmacoloqic Aqents Used in RSI ................ 168 I .

I Tracheostomy Management ....................... 171

Mechanical Ventilation .......................... 171 I

! SKILL DRILL 6-11 Usinq a Portable Ventilator ........... 177 ; SKlLL DRlLL 6-12 Troubleshooting a Ventilator 1 Low-Pressure Alarm ......................... 179

..................................... i Summary 179

Prep Kit .................... ... 182 I '

CHAPTER 7 Pharmacology .............. 186

Introduction .................................. 188

Pharmacoloqy and Medication Information .......... 188

A Practical Approach to Medication Administration ... 188

Pharmacokinetics ............................. 189

Pharmacodynamics . . . . . . . . . . . . . . . . . . . . . . . . . 190 1 Avoiding Medication Errors 194 I ...................... Medication Management ........................ 194 . Specific Medications Used in Critical Care Transport . . 194 . Medication Infusion Technique .................... 222 ' SKlLL DRlLL 7-1 Administering Medication With

an Infusion Pump ............................ 224

Summary ..................................... 224

Prep Kit ...................................... 227

CHAPTER 8 Laboratory Analysis and Diagnostic Studies ............ 234

Introduction .................................. 236

Principles of Analysis . . . . .................... 236

Specimen Cultures ............... ..... 237

Chemistry Review ................ ..... 237

Biochemistry Review ........................ 239

Lab Profiles ................................... 239

Blood Gases .................................. 246

SKILL DRILL 8-1 Obtaininq an Arterial Blood Sample .... 247

Blood Group Testing ............................ 248

Obtaining a Venous Blood Sample ................. 249

Urine Lab Values .............. ........ 250

Cerebrospinal Fluid ............................. 251

Common Errors in Specimen Collection ............. 252

Diaqnostic Imaging ............................ 252

Summary ..................................... 253

Prep Kit ...................................... 257

CHAPTER 9 Shock. Sepsis. and Multiple Organ Dysfunction Syndrome ....... 262

Introduction .................................. 264

Cellular Respiration ......................... 264

The Microcirculation and the Cell . . . . . . . . . . . . . . . 265

Shock ............................ ..... 268

Multiple Organ Dysfunction Syndrome . . . . . . . . . . . 271

Classification of Shock .......................... 272

Sepsis ....................................... 280

--=?"

Contents

I

1

1 I

I

I

1 Contents

Blood Administration ........................... 289

SKILL DRILL 9-1 Administering Blood Products ........ 293

Flight Considerations ........................... 296

Summary .................................. 296

Prep Kit ............ ....... 299

CHAPTER 10 Trauma ................... 306

Advances in Trauma Care ........................ 308

Overview of Trauma ............................ 308

Trauma Scoring Systems ........................ 314

Trauma Systems ............................... 316

General Trauma Management ..................... 317

Diagnostic Imaging for Trauma ................... 318

Thoracic Trauma ............................... 321

SKILL DRILL 10-1 Managing an Open Pneumothorax ..... 323

SKlLL DRILL 10-2 Needle Decompression (Thoracentesis) of a Tension Pneumothorax ....... 325

SKILL DRILL 10-3 Chest Tube Insertion ............... 328

SKILL DRILL 10-4 Pericardiocentesis . . . . . . . . . . . . . 332

Facial Trauma .............................. 337

Neck Injuries ........................ .... 340

Abdominal Trauma ............................. 342

Hollow vs Solid Organ Injury ..................... 343

Pelvic Trauma ................................ 346

Extremity Trauma .............................. 346

Pharmacologic Management ..................... 352

Trauma to Special Populations .................... 353

Flight Considerations .............. .... 354

........... Summary .................... 354

Prep Kit ...................................... 357

CHAPTER 11 Neurologic Emergencies ..... 364

Introduction .................................. 366

Anatomy and Physiology ........................ 366

Neurologic Examination ......................... 381

Neurologic Diagnostics .......................... 394

Traumatic Brain Injury .......................... 395

lntracranial Pressure ........................... 405

SKILL DRILL 11-1 Performing ICP Monitoring ........... 412

Spinal Cord Injuries ............................ 416

Stroke ....................................... 421

Subarachnoid Hemorrhage ....................... 423

Seizures and Epilepsy ........... ....... 424

Transport Considerations ........... ... 425

Flight Considerations ........................... 426

Summary ..................................... 426

Prep Kit ...................................... 431

CHAPTER 12 Burns ..................... 442

Introduction .................................. 444

Anatomy and Function of the Skin ................. 444

Physiology of Burns ............................ 445

Classification of Burn Injury. ..................... 446

Assessment .................................. 449

.................................. Management 453

Special Situations .............................. 458

SKlLL DRlLL 12-1 Performing an Emergency Escharotomy ............................ 460

Summary ...... ... . . . . . . . . . . 464

Prep Kit ...................................... 467

CHAPTER 13 Electrophysiology. Cardiac Devices. and Transport Management .................... 420

Introduction .................................. 472

Cardiac Anatomy and Physiology .................. 473

Cardiac Monitoring: 12-Lead ECG .................. 480

Axis Determination ............................. 486

Bundle Branch Blocks and Hemiblocks ............. 489

Selected ECG Findings .......................... 496

Cardiac Disease ...... ................ 508

Cardiac Devices ............................... 529

Transport Considerations for Cardiac Electrophysiology Devices . . . . . . . . . . . . . . . . . . 543

Flight Considerations ........ ............. 547

Summary ..................................... 547 Prep Kit .................................. -550

......

........... CHAPTER 14 Hemodynrtmic Monitoring .... 560 SKILL DRILL 16-2 Orogastric Tube Insertion 652

................................. Liver Disease 655 .................................. Introduction 562 ........................ Noninvasive Hemodynamic Monitoring 562 Biliary Tract Obstructions 657 .............

............................. lnvasive Hemodynamic Monitoring 563 Pancreatic Disease 659 ................ ....................... SKILL DRILL 14-1 Inserting a Central Venous Line 566 Urinary System Conditions 661 .......

............................. SKILL DRILL 14-2 Inserting an Arterial Line 571 Maintenance Tubes 667 ........... .... lnvasive Pressure Measurements 576 SKILL DRILL 16-3 Placing a Female Urinary Catheter 669 ..................

...... Obtaining lnvasive Hemodynamic Measurements 583 SKILL DRILL 16-4 Placing a Male Urinary Catheter 669 ..... ........... Recognition of Shock 588 SKILL DRILL 16-5 Emptying an Ostomy Pouch 671 ........................... ......... Flight Considerations 588 SKILL DRILL 16-6 Replacing an Ostomy Pouch 672 ...........................

........... Summary 588 Metabolic Regulation of Acid-Base Status 674 ..................................... ........................... Flight Considerations 679 ...................................... Prep Kit 591

..................................... Summary 680 CHAPTER 15 Intra-aortic Balloon Pump Prep Kit ...................................... 683

..*.,,. . . . 4 . E . . . . Therapy ...,a , 596 ...... Introduction .................................. 598 CHAPTER 17 Endocrine Emergencies 692

.................................. History ...................................... 599 Introduction 694 ........................ Cardiovascular Anatomy and Physiology ............ 599 Anatomy and Physiology 694

............ The Intra-aortic Balloon Pump .................... 602 Diabetes , .................. 696 ............................. Mechanics of IABP Function ...................... 603 Pituitary Disorders 701

.......................... .... IAB Insertion .................. 609 Adrenal Abnormalities 702

.......................... .... IABP Operation During Transport ........ 612 Thyroid Abnormalities 706 ................................ . SKILL DRILL 15-1 Operating the IABP During Lipid Disorders 709

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ........................... Transport 613 Flight Considerations 709

......................... I Emergency Interventions 617 ..................................... Summary 709 i ... i SKILL DRILL 15-2 Manual Inflation/Deflation of an IAB 618 Prep Kit ...................................... 712

.......................... Cardiac-Assist Devices 619 I summary ..................................... 621 CHAPTER 18 Environmental Emergencies . . 116

.................................. Prep Kit ...................................... 624 Introduction 718 ............................. Heat Emergencies 719

i CHAPTER 16 Gastrointestinal and .............................. Cold Emerqencies 725 Genitourinary Emergencies ........ 628

h ..................................... Drowning 727 .................................. Introduction 630 Diving Injuries and Decompression Sickness ......... 728

........................ Anatomy and Physiology 630 ................................ Altitude Illness 730 .......... : Conditions Affectinq the Alimentary Canal 638 Flight Considerations ............................ 731

.......................... . Intestinal Obstructions 648 bI ! Summary ...................................... 731 ,,SKILL DRlLL 16-1 Inserting a Nasoqastric Tube 2. Prep Kit ...................................... 734 ........................ in a Conscious Patient 652

viii 1 Contents I *

:HAPTER 19 Infectious and Communicable ........................ Diseases 138

.................................. Introduction 740

Fundamental Principles of Infectious Disease ........ 740 ......................... Human Immune System 740

................................. Pathogenicity 746

................................. Epidemiology 749 ............................... Selected Diseases 751

.................... Emerging Infectious Diseases 766

Strategies for the Treatment of Infectious Disease ..... 771 .......................... The Post-Antibiotic Era 772

.................................. Bioterrorism 775

Exposure and Protection .... ........... 775 .............. Fliqht Considerations .... 783

Summary ........... ........... 783 ...................................... Prep Kit 786

CHAPTER 20 Toxicologic Emergencies ..... 198

.................................. Introduction 800

.................................. Assessment 800

Toxic Syndromes (Toxidromes) and Medication ......................... Reaction Syndromes 803

........ General Toxicologic Emergency Management 806 .............................. Decontamination 808

................. Specific Toxicologic Emergencies 812

Hazardous Materials (Hazmat) Response . . . . . . . . 828 .......................... Radiation Emergencies 830

........................... Flight Considerations 831 ..................................... Summary 831

..................................... Prep Kit -834

CHAPTER 21 Obstetric and Gynecologic .................... Emergencies 840

.................................. Introduction 842

Anatomy and Physiology of the Female ......................... Reproductive System 842

............. Physiologic Changes During Pregnancy 844

Critical Care Transport of the Pregnant Patient ...... 846

................. Fetal Assessment and Monitoring 847

................... SKILL DRILL 21-1 Fetal Monitoring 849

...................... Complications of Pregnancy 849

. . . . . . . . . . . Medical Conditions During Pregnancy 853

.... Complications During Labor ............ 855 ..................................... Delivery 858

...................... Postdelivery Complications 862

....................... Gynecologic Emergencies 864

........................... Flight Considerations 867 ..................................... Summary 867

.... Prep Kit ... ................ 870

....... CHAPTER 22 Neonatal Emergencies 814

.................................. Introduction 876

............. Anatomy and Physiology of a Neonate 876

............. Neonatal Assessment and Stabilization 879

Determining the Need For and Providing Neonatal .............................. Resuscitation 881

............ SKILL DRILL 22-1 lntubation of a Neonate 885

SKlLL DRlLL 22-2 Inserting an Oroqastric Tube .............................. in the Neonate 886

SKILL DRILL 22-3 Resuscitating a Neonate ........... 887 .......................... Respiratory Conditions 892

....................... Cardiovascular Conditions 896

...................... Gastrointestinal Conditions 902

...................... Infectious Diseases/Sepsis 907

..................... Hyperthermia/Hypothermia 907

................................ Toxic Exposure 908 ........................... TraumaIBirth Injuries 908

....................... Neurologic Conditions 910

........................... Metabolic Conditions 912

............... The Transfer Process for a Neonate 913

............................. Using an Incubator 913

................ SKILL DRILL 22-4 Using an Incubator 913

................ Family Communication and Support 913

........................... Flight Considerations 914

................. .............. Summary 915

Prep Kit ...... ........... 917

Contents

.........

CHAPTER 23 MatPie Ernergendes ....... lnttoduction .................................. 924

Anatomy and Physiology . . . . . . . . 924

Growth and Oewl@pmnt ............ ... 927 ...... Approach to Parents and Caregiven ... 927

.... Approach to Pediatric Assessment ... 927 Transport Considerations ....... ... 939

...... Airway Management Devices ... 941

Respiratory Conditions ........ ... 943 .... Cardiac Conditions ... 949

... Renal Disorders ... 957

...... Meningococcal Infections

Trauma ................. .... Environmental Emergencies

Drowning ................ .... Patients With Special Needs

Flight Considerati~ns ...... Summary ............ Prep Kit . . . . . . . . . . Glossary ....................... 982 Index ........................ 1011 Credits ........................ 1033