I. Stabilization

II. Critical Components of Safe Transport of Extremity Wounds

            A. Cessation of bleeding

            B. Prevention of further injury

                        1. stabilization of fractures

                        2. removal of noxious substances and gross contamination

            C. Monitoring for limb threatening conditions

                        1. further blood loss

                        2. overly compressive dressings/splints

                        3. development of compartment syndrome

            D. Simplicity

                        1. use of external fixators has made transport easier, more comfortable, and safer for extremity injuries

                        2. while possible, transport with skeletal traction or tractions splints not advisable

                                    a. monitoring of position of limbs, traction components, and unpredictable delays or transport times make their use potentially dangerous

                                    b. dark, loud aircraft cargo bay on long transatlantic flight with patient in skeletal traction would be difficult environment to provide constant monitoring or traction

                                    c. undue burden on medical crew when attention may be divided between large number of patients
                        3. soft tissue dressings may include devices
                                    a. newly approved negative pressure bandages may allow exact quantification of drainage
                                    b. require surveillance for mechanical/vacuum failure

III. Aeromedical Evacuation (see Figure 9 and Figure 10)

            A. Introduction

                        1. remains essential component of both combat and humanitarian/disaster trauma operations

                                    a. usually in these environments, local medical assets are insufficient or unavailable due to nature of situation

                                    b. not feasible to bring full compliment of tertiary level medical care directly to scene

                        2. rapid air transport of patients to higher levels of care is important capability to establish early in these scenarios
                        3. often if local ground transportation systems disrupted, aeromedical evacuation becomes essential component to provision of care

            B. Types of patient evacuation

                        1. casualty evacuation (CASEVAC)

                                    a. movement of patients by non-medical personnel

                                    b. usually fastest and most convenient means of transport

                                    c. most risk for patients as en route medical care not provided

                                    d. usually refers to rotary wing aircraft of opportunity

                        2. medical evacuation (MEDEVAC)

                                    a. movement of patients by medical personnel

                                    b. can be fast, but requires coordination to get medical team there

                                    c. medical care can be rendered in-transit

                                    d. usually refers to coordinated rotary wing aircraft (Lifeflight, air ambulance, etc.)

                                    e. may be from point of injury to hospital or from hospital to hospital

                        3. aeromedical evacuation (AE)
                                    a. usually refers to fixed wing aircraft of opportunity

                                    b. tactical evacuation (TACEVAC)

                                                i. within a theater of operations

                                                ii. usually from combat/disaster zone to a medical care facility out of that zone

                                    c. strategic evacuation (STRATEVAC)

                                                i. out of one theater of operations to another

                                                ii. usually from the combat/hostile/disaster region to main treatment support area

            C. Medical evacuation order of precedence

                        1. process for moving patients by air is exercise in systematic validation

                        2. some parts of process may be done simultaneously

                                    a. medically stabilize patient

                                    b. validate need for transport by air

                                    c. determine medical staff needed en route

                                    d. determine equipment/medications/treatments needed en route

                                    e. determine need for specialty care team (peds, burns, critical care air transport team)

                                    f. determine medical order of precedence

                                    g. validate request for air mocement with patient movement requirements center (PMRC)

                                    h. package patient for transport

            D. Medical evacuation categories

                        1. urgent: immediate mission to save life, limb, or eyesight

                                    a. Army, Navy/Marine – within 2 hours

                                    b. Air Force – ASAP

                        2. priority: appropriate care not available and medical condition deteriorating/could deteriorate before routine mission

                                    a. Army, Navy/Marine – within 4 hours

                                    b. Air Force – within 24 hours

                        3. routine: medical condition is not serious and unlikely to deteriorate while awaiting routine aeromedical mission

                                    a. Army, Navy/Marine – within 24 hours

                                    b. Air Force – within 72 hours or next available mission

            E. Medical considerations/requirements for transport

                        1. medical evacuation request includes requirement for surgical equipment and/or providers

                        2. patient is sufficiently stabilized for anticipated mode and duration of travel
                                    a. some general parameters that should guide stabilization efforts before clearance to transport
                                               i. heart rate <120 beats/minute
                                               ii. blood pressure >90 mm Hg
                                               iii. temperature >35º C
                                               iv. hematocrit >24%

                        3. patient’s airway and breathing is adequate for movement

                        4. patient’s IV lines, drainage devices, and tubes are fully secured and patent

                        5. patient at high risk for barotraumas should be considered for prophylactic check tube placement before prolonged aeromedical evacuation

                        6. Heimlich valves on chest tubes are functioning

                        7. Foley catheters and nasogastric tubes are placed and allowed to drain

                        8. patient is securely covered with both a woolen and aluminized blanket for air transport

                        9. 3 litter straps used to secure patient to litter

                        10. personal effects and all medical records accompany patient

 

 

Emergency War Surgery, 3rd U.S. revision, Borden Institute, Walter Reed Army Medical Center, 2004, pp. 4.1-4.9.

Joint Theater Trauma System Clinical Practice Guideline. Intratheater transfer and transport of level II and level III critical care trauma patients. Nov. 2008.