WELCOMEWELCOME

Programme1. Air Evacuation of Casualties Sqn Ldr AVK

Raju

2.Training Video: Casualty Evacuation & Life Support

IAF Presentation

3. Familiarisation: Level I Hospital, IAC II

4. Tea HQ Lawns

3

“When they take care of you like that, you don’t mind fighting”

- Wounded Army soldier on his evacuation by air

4

Air Evacuation of CasualtiesAir Evacuation of Casualties

PlanHistory and evolution of air evacuation

Aim

Aeromedical issues

System specific clinical conditions

Practical problems

Handy tips

Prioritisation

Pre flight – In flight – Post flight considerations6

History of air evacuation…1870: Aeromedical evacuation idea conceived

1910: Siege of Paris: 160 soldiers evacuated in hot air

balloon

1928: Nicaragua, first US military airlift

1929: Established air evacuation officially

1937: International Aeromedical Association- 62 nations

1936-39: Germans air evacuated soldiers

1941: USAF in WW II

1946: Helicopters used for medical air-evacuation 7

Death rate of woundedWorld War I – 8.5%

World War II – 4%

Korean War – 2%

Vietnam War – 1%

[ Aeromedical evacuation/Antibiotics/Advances in Medical Science]

8

Air EvacuationRevolutionised mode of evacuation

HelicoptersQuick access to trauma sitesLand where there are no air strips

Fixed wing aircraftsSpaciousComfortablePressurised

9

AimOvercome adverse terrain

Enable early institution of definitive treatment

Avoidance of infection

Save skilled man power

Keep morale of personnel high

Keeps communication lines free

Economy

Safety

Comfort

10

Circumstances of Casualty Evacuation

Life saving measures

Forward areas to hospitals

In between hospitals

Errands of mercy

11

Disadvantage of Aero-medical evacuation…

12

…lack of controlled environment

Aeromedical Issues in Cas evac1. Hypoxia2. Expansion of gases3. Acceleration4. Vibration5. Noise6. Humidity7. Physical requirements – space, toilets etc

13

HypoxiaDalton’s Law of Partial Pressures

“Hypoxia at altitude”

All patients must be on supplemental Oxygen regardless of their clinical condition

CVS cases/Ischaemic cases – special precautions

14

Expansion of gasesBoyle’s Law

Expansion of gases trapped within the body

Special precautions – Pneumothorax, Penetrating head or eye injury, Bowel obstruction, Ruptured Tympanic Membrane

15

Cardiovascular DiseasesSupplemental Oxygen – “Must”

Lack of Oxygen – Cardiac catastrophe/Arrythmia

AMI – ideally no air evacuation for 06 weeks (?)

CPR board

17

Respiratory SystemSupplemental OxygenObstructive Pulmonary Disease – thorough evaluationUntreated Pneumothorax – air evacuation

contraindicated in presence of respiratory embarrassment

Pulmonary Surgery – air evacuation after proper convalescence

Pneumonia – Supplemental Oxygen !

18

Blood DisordersHaemoglobin - < 7 gm%

Heamoglobin - < 8.5 gm% ‘or’ Sickle Cell Anaemia

19

Neurological ConditionsIncreased intracranial pressure –

supplemental Oxygen

Head Injury – Position of Head at towards the rear

20Acceleration

Neurological ConditionsCSF Leak through nose/ear – air evacuation

contraindicated[Suction of air/bacteria during descent of

aircraft]

Seizures – Hypoxia can trigger seizures

21

Orthopaedic casesSufficient time should have elapsed before air

evacuation

Pressure changes – soft tissue oedema - ? Vascular compromise

Air splint – avoided !

Traction equipment – possible missiles !

22

BurnsPulmonary burns to be ascertained before air

transportation

Air evacuation of patient with pulmonary burns – fatal

Pre flight Chest X-ray – mandatory

Stabilisation of patient – patency of airway, adequate ventilation, Oxygenation and fluid resuscitation

23

Gastro Intestinal CasesRecent Adbominal Surgery cases – extra care

Gas in abdomen – expansion - ? Pain/Bowel circulation compromise/ ? rupture of sutures

24

Neuro Psychiatry CasesAdequate observation prior to air

transportation

Kept adequately sedated

Availability of restraint system

25

PregnancyActive labour – only contraindication

High risk obstetric cases – safe

Placental insufficiency – supplemental Oxygen

Altitude restriction – 5000’ (abdominal gas distension)

26

Prior to any air evacuation….Ponder over the following questions:1.Is the risk to the patient being transferred

less than the risk of not being moved?2.Is the patient adequately stabilised?3.Do the benefits of the move justify the clinical

and fiscal costs?4.Is the move medically necessary or driven by

emotion or family based concern?5.Is the move based on necessity or

convenience?28

Practical problems !1. BP monitoring/checking of pulse difficult2. Auscultation is difficult3. Difficult to establish IV line4. Difficult to pass Naso Gastric tube, catheterise5. Nearly impossible to Intubate6. CPR is difficult7. Motion Sickness – vertigo/vomiting - ? Airway

compromise8. Electro Medical equipment – may interfere

with the flight instruments29

Handy tips...1. Electronic BP and HR monitor2. 2 x wide bore IV canulas in place, syringes

filled with drugs3. If needed, Intubate with ET tube before the

sortie4. NG tube, catheterisation pre flight procedure5. All catheters to be filled with Normal Saline6. For Air Sickness: Tab of Cinnarizine – 30 min

before air evacuation sortie & low flow Oxygen

7. Tab Pseudoephidrine/Vasoconstrictor Nasal Drops – prevents Otitic Barotrauma

8. CPR board9. Humidified Oxygen

30

Relative contraindicationsInfectious diseases

Moribund patient

Offensive patient

Decompression sickness

31

Priorities of evacuationPriority 1. Patient whose transfer by quickest

means is necessary as a life saving measure or to avoid serious permanent disability

Priority 2. Patient whose condition is likely to be adversely affected unless they are speedily evacuated or who need early specialized treatment

Priority 3. Patients whose immediate treatment are with in the powers of local medical units, but whose progress would benefit from movement by air rather than by surface transport

Priority 4. Patients for whom movement by air is a matter of convenience rather than a medical requirement

32

Preflight Procedures‘Understand the case well’

Briefing of pilot & crew1. Height limitations required 2. Intermediate stops3. Precaution in transfer of special cases4.The aircraft for use for Evacuation should

be fitted with proper equipment.5. Communication facilities with departure

intermediate & destination air field6. Captain of aircraft in charge of over all

discipline 33

InflightFluid management

Oxygen/ IV line management

Medicines intake

Brief cabin/ aircrew for any changes from planned

Prevent exacerbation deterioration in clinical condition

Manage emergencies

34

Post flightMake a note of problems encountered

Brief the Hospital who are receiving the patient

Brief the Hospital who have demanded air evacuation

Share your experiences and suggestions on ‘Lotus’

35

Mi - 17

Stretcher Spinal BoardOrtho Scoop stretcher + splints

Resuscitation equipment including

Oxygen Apparatus

Suction Apparatus

Physiological Monitor & Defibrillator

IV Fluids

Doctor’s Bag

Oxygen Mask

Urine/Vomitus/Stool Receptacles can be kept under the seats

Patient being monitored and being rendered medical treatment

Loading of patient from the rear

Mass Casualties: Modification 12 Lying Patients

To summarise…. Special precautions

I. Condition susceptible to pressure change1. CNS

Air in CNS due to surgery or trauma, CSF Rhinorrhoea

2. Eye- Perforating Injury

3. EarASOM/ Mastoiditis/ Eustachian tube stenosis, Sinusitis

4. Respiratory SystemPneumothorax/ Mediastinal Emphysema/ Sucking Wounds/ Open case of TB 40

5. GITHernias/ Gangrenous Appendicitis/ Penetrating Perforating Wounds/ Post Operative Cases/ Colostomies/ Liver Abscess

6. SkinGas Gangrene/ Subcutaneous Emphysema

7. Maxillofacial injuriesTill wires are removed

8. Decompression sickness

41

Cases requiring special attentionII.Condition susceptible to hypoxia1. CNS

Head injury & epilepsy

2. EyeOcular injuries/ Post Surgical Cases/ Glaucomatous Eye

3. RS Reduced vital capacity/ Pulmonary HT/Pul surgery

4. CVSAngina/ MI/ HT/ CCF/ Cardiac arrhythmiaRequire supplemental oxygen

5. BloodAnemia less than 7 gm% 42

Remember......Murphy’s Law: “If anything has to

go wrong, it will go wrong”

“If you are prepared for the worst..the worst seldom happens;

If not prepared….the worst is guaranteed to happen”

43