7 Operating Guidelines Medical Patients

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CHAPTER 2 STANDING MEDICAL OPERATING GUIDELINES

Medical Patients

Reviewed 02/03, 01/04, 03/05, 03/07, 02/09 25 GENERAL GUIDELINES FOR CRITICALLY ILL PATIENTS I. The following information should be gathered and documented on all critically ill patients: A. History of present illness B. Past medical history including medications and allergies C. Treatment administered prior to arrival of AirLIFE II. Assessment of all critically ill patients should include the following: A. Primary and secondary assessment B. Cardiac rhythm and oxygen saturation C. Specific assessment dependent on medical diagnosis and/or signs and symptoms D. Review of lab values if available III. Treatment will follow the general guidelines contained in American Heart Association courses such as ACLS and PALS. Specific interventions for all critically ill patients may include: A. Airway 1. Open and maintain airway to include intubation if necessary. 2. Utilize C-spine precautions if any suspicion of trauma. B. Breathing 1. Provide supplemental oxygen to keep SpO2 saturations ≥92%. COPD patients may be placed on oxygen via nasal cannula at 2-4 LPM and oxygen titrated as needed. Consider altitude restrictions. 2. Assess for adequate ventilation. Assist as necessary to maintain an adequate tidal volume. If PIP (peak inspiratory pressure) 40 cmH2O, consider sedation and/or intubation with chemical paralysis. 3. Transport ventilator may be utilized on all intubated patients who require assistance with ventilation during flight. Consider the use of PEEP 2.5 – 5 cmH2O for all mechanically ventilated patients. The use of a ventilator is encouraged for longer flights (e.g. > 15 minutes) to maintain consistency in ventilation parameters. 4. ETCO2 monitoring should be utilized for all intubated patients. Maintain ETCO2 between 35-45 mmHg unless disease process requires else wise. C. Circulation 1. Assess and monitor vital signs and cardiac rhythm.

2. Treat specific dysrhythmias as per guideline. 3. “Combo” Defibrillation / Pacing pads may be placed on all patients with increased potential for rhythm disturbances during flight. 4. Initiate IV access with saline lock or Normal Saline infusion at KVO rate. Adjust rate as necessary. 26 a. Hypoperfusing patient who has or is at risk of CHF or Fluid Overload (i.e. pulmonary contusion, s/p AMI, ARDS, etc.): initial bolus of 250 – 500 mL bolus. Reassess and repeat as necessary up to 30 mL/kg. b. Hypoperfusing patient who is at low risk for fluid overload: Initial bolus of 10 mL/kg. May repeat up to 30 mL/kg. 5. If unable to obtain peripheral IV access, perform IO or central line access as per guidelines. 6. If patient in Cardiac Arrest, consider use of Intrathoracic Impedence Device (i.e. ResQPOD®) during resuscitation efforts. Device should be placed between secured airway (Endotracheal Tube) and Bag-Valve device but may also be used during initial treatment by being placed between Bag-Valve and ventilation mask. D. Deficit 1. Assess Glasgow Coma Score (GCS). 2. Assess pupil size and response to light accommodation. E. Additional Interventions 1. Consider NG/OG tube placement and connect to low, intermittent suction on all unresponsive patients or patients with absent bowel sounds transported by air. Consider an NG/OG tube on patients who continue to have emesis despite the administration of anti-emetics. 2. Pain control as per guidelines. 3. Other interventions as per specific guidelines. 4. Pediatric patients should have a recent temperature obtained and recorded on patient care record. Ensure thermal regulatory support as necessary during flight. 5. Monitor Intake & Output (I&O). If required, Foley catheter may be obtained from hospital and inserted for inter-facility transports. F. Documentation - the Patient Care Record should contain the following: 1. Treatment prior to arrival (PTA) of AirLIFE 2. History of present illness 3. Pertinent past medical history 4. Initial assessment to include ECG rhythm, Vital Signs and GCS 5. Treatment rendered while in care of AirLIFE crew 6. Reassessment and evaluation of treatment 7. Any contact with Medical Control G. Post Resuscitation Hypothermia Induction:

1. Following successful resuscitation from “non-traumatic” cardiac arrest consider implementation of Post Resuscitation Hypothermia Induction. (Pg.153) Reviewed/Revised: 10/98, 4/2001, 01/04, 03/05, 03/07, 02/09