An Air Medical Approach to In-Flight Cardiac Arrest Management.

OBJECTIVE: Cardiac arrest during air medical transport is a complex and challenging issue, with unique factors such as limited physical space with restricted access to patients and equipment, small transport teams, limited resources, clinical isolation, effects of altitude, and the need for rapid decision making. The American Heart Association proposed 10 steps to improve outcomes of in-hospital cardiac arrest and serve as the framework for this article. This article aimed to explore these unique challenges and propose a contextual approach that might serve as the basis for improvement projects looking to improve outcomes for affected patients. METHODS: This article represents a narrative review of the subject to consolidate the issue of cardiac arrest in the air medical setting specifically. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses literature search extension was used to guide the search strategy and methodology. The applicable items in the literature were selected through searches of the PubMed and Google Scholar databases. The Medical Subject Headings search terms used included "cardiopulmonary resuscitation" or "heart arrest" and "air ambulance" or "air medical transport,'' yielding 477 results. Screening for relevant results for inclusion was based on the relevance of the title or abstract. Articles not written in English or German or addressing commercial air transport were excluded. The reference lists of the included articles were searched for additional literature not included in the original search. RESULTS: Three distinct phases are arbitrarily identified by the authors, and the results are discussed under the following headings: pre-arrest, intra-arrest, and post-arrest phases. The pre-arrest phase is characterized by a wide array of concepts such as appropriate goals of care, advanced preparation and action, good clinical governance, patient assessment and handover, system design and ergonomics, sterile cockpit management, appropriate alarm management, and contingency planning in the case of failed resuscitation. The intra-arrest phase is characterized by the contextualization of the usual resuscitation approach, and specific recommendations for immediate nonresuscitative actions, history, hazards, help, airway, breathing, circulation, drugs, and reversible causes are suggested. The post-arrest phase highlights the vulnerable nature of the post-cardiac arrest patient in the air medical setting. Specific considerations regarding postresuscitation care and practitioner well-being are highlighted. CONCLUSION: This article outlines a systematic approach to various physical, clinical, mental, and systemic factors that can be used during various phases of the transport journey as well as the individual patient journey. This overview sensitizes individual clinicians or program directors to the factors needing consideration when looking to improve cardiac arrest patient outcomes.

Helicopter Emergency Medical Services Response to a Major Incident.

Major incidents account for a vast number of consequences, whether it be individual morbidity and mortality or economic disruption and expense. Because of the infrequent nature, it poses a variety of unique risks and challenges for individual emergency medical services systems. Air ambulances are usually dispatched based on the clinical presentation of an individual patient who needs emergent critical care intervention. The response to a major incident is unusual and infrequent, but the benefit of tasking air ambulances to such incidents has been described by various authors. Here, such a response is described in a low- to middle-income country that saw the immediate tasking of 2 separate air ambulances to a single, multivehicle collision with multiple injured patients that occurred near a small, rural hospital not capable of treating critically ill patients. The benefits of tasking of the air ambulance in the sense of additional expertise as well as potential other nonclinical benefits are discussed and described here.

A 12-month retrospective descriptive analysis of a single helicopter emergency medical service operator in four South African provinces.

Introduction: Helicopter Emergency Medical Services (HEMS) is integrated into modern emergency medical services because of its suggested mortality benefit in certain patient populations, it is an expensive resource and appropriate use/feasibility in low- to middle income countries (LMIC) is highly debated. To maximise benefit, correct patient selection in HEMS is paramount. To achieve this, current practices first need to be described. The study aims to describe a population of patients utilising HEMS in South Africa, in terms of flight data, patient demographics, provisional diagnosis, as well as clinical characteristics and interventions. Methods: A retrospective flight- and patient-chart review were conducted, extracting clinical and mission data of a single aeromedical operator in South Africa, over a 12-month period (July 2017 - June 2018) in Gauteng, Free State, Mpumalanga and North-West provinces. Results: A total of 916 cases were included (203 primary cases, 713 interfacility transport (IFT) cases). Most patients transported were male (n=548, 59.8%) and suffered blunt trauma (n=379, 41.4%). Medical pathology (n=247, 27%) and neonatal transfers (n=184, 20.1%) follows. Flights occurred mainly in daylight hours (n=729, 79.6%) with median mission times of 1-hour 53 minutes (primary missions), and 3 hours 10 minutes (IFT missions). Median on-scene times were 26 minutes (primary missions) and 55 minutes (IFT missions). Almost half were transported with an endotracheal tube (n=428, 46.7%), with a large number receiving no respiratory support (n=414, 45.2%). No patients received fibrinolysis, defibrillation, cardioversion or cardiac pacing. Intravenous fluid therapy (n=867, 94.7%) was almost universal, with common administration of sedation (n=430, 46.9%) and analgesia (n=329, 35.9%). Conclusion: Apart from the lack of universal call-out criteria and response to the high burden of trauma, HEMS seem to fulfil an important critical care transport role. It seems that cardiac pathologies are under-represented in this study and might have an important implication for crew training requirements.