|
Criteria for Emergency Air Medical Transport Utilization
POSITION PAPER ON THE APPROPRIATE USE OF EMERGENCY AIR MEDICAL SERVICES
By the Association of Air Medical Services
This section lists the general criteria and patient identifiers that may be used to customize service-specific air medical guidelines. They are not intended to be all inclusive nor rigidly applied in place of medical judgment.
These criteria concern patients who are at hospital facilities or non-hospital locations where appropriate or urgent medical treatment is not available. In the case of interfacility transfers, such transfers may require clearance from the off-line medical direction with concurrent input from the transferring and receiving physicians. Scene responses may be governed by the protocols and standing orders. All transport decisions will be made in the best interest of the patient.
In the case of trauma patients where speed is important, air medical transport should be used if it decreases the amount of time required to deliver the critically injured patient to a trauma center or appropriate facility. If the injury is such that it is not time dependent and a delay will not increase morbiditv or mortality, other modes of transportation may be considered.
In the case of the critical patient, air medical services may provide advanced life support treatment during transport which may not otherwise be available.
General Criteria
1. The patient requires critical care life support (monitoring, personnel, medications, or specific equipment) during transport that is not available from the local ground ambulance service.
2. The patient's clinical condition requires that the time spent out of the hospital environment (in transport mode) be as short as possible.
3. The potential for delays which may be associated with ground transport, including road obstacles and traffic, is likely to worsen the patient's clinical status.
4. The patient is located in an area which is inaccessible to regular ground traffic.
5. The patient requires specific or timely treatment, not available at the referring hospital or facility.
6. The patient's clinical condition requires that care be given by physician(s) at the receiving hospital who are intimately familiar with the patient's history, including previously begun chemotherapy regimens and extensive prior invasive procedures.
7. The use of a local ground transport team would leave the local area without adequate EMS coverage.
Trauma Patients
1. Lengthy extrication of the patient from the accident site and the severity of the patient's injury requires delivery of a critical care team to the accident site.
2. One or more of the following mechanisms of injury with a motor vehicle accident is present:
- there had been structural intrusion into the patient's space in the vehicle
- the patient was ejected from the vehicle
- another person in the same vehicle died
- the patient was a pedestrian struck by a vehicle traveling more than 20 mph
- the patient was not wearing a seat belt in a car which overturned
- the patient was thrown from a motorcycle traveling more than 20 mph
- the front bumper of the vehicle was displaced to the rear by more than 30 inches or the front axle was displaced to the rear
3. The patient fell from a height of greater than 20 feet.
4. The patient experienced a penetrating injury anywhere on the body between the mid-thigh and the head.
5. The patient experienced an amputation or near amputation and required timely evaluation for possible reimplantation.
6. The patient experienced a scalping or degloving injury.
7. The patient experienced a severe hemorrhage. Included are those patients with a systolic blood pressure of less than 90 mmhg after initial volume resuscitation and those requiring ongoing blood transfusions to maintain a stable blood pressure.
8. The patient experienced burns of the skin greater than 15% of the body surface, or major burns of the face, hands, feet or perineum, or associated with an airway or inhalation injury.
9. The patient experienced, or had great potential to experience, injury to the spinal cord, spinal column, or neurologic deficit.
10. The patient suffered injuries to the face or neck which might result in an unstable or potentially unstable airway and might require invasive procedures (such as endotracheal or nasotracheal intubation, tracheotomy, or cricothyroidotomy) to stabilize the airway.
11. The patient had a score from an objective ranking system for trauma (such as the Champion Trauma Score, Revised Trauma Score, CRAMS, Glasgow Coma Scale, etc.) at the scene of the accident or at the referring hospital's emergency department which indicated a severe injury.
12. The patient is a child less than five years of age with multiple traumatic injuries.
13. The patient is greater than 55 years of age and has multiple traumatic injuries, whether with or without preexistent illness, such as diabetes mellitus, coronary artery disease, chronic obstructive lung disease, or chronic renal failure.
14. The patient is an adult with a respiratory rate of less than 10 or greater than 30 breaths per minute, or a heart rate of less than 60 or greater than 120 beats per minute.8
MORE INFORMATION on both Clinical and Operational Criteria for use of the helicopter
Adult Medical / Surgical Patients
1. The patient experienced a respiratory or cardiac arrest within the past 12 hours or is experiencing acute respiratory failure not responsive to initial therapy,
2. The patient requires continuous intravenous vasoactive medications or mechanical ventricular assist to maintain a stable cardiac output.
3. The patient requires continuous, intravenous anti‑dysrhythmia medications or a cardiac pacemaker to maintain a stable cardiac rhythm.
4. The patient requires mechanical ventilator support or is at risk of having an unstable airway.
5. The patient experiences an acute deterioration in mental status.
6. The patient requires immediate invasive therapy for hypothermia.
7. The patient has an indwelling pulmonary artery catheter, intra‑aortic balloon pump, arterial line or intracranial pressure monitor.
8. The patient has a respiratory rate of less than 10 or greater than 30, or a heart rate of less than 50 or greater than 150, or a systolic blood pressure of less than 90 mmhg or greater than 200 mmhg.
9. The patient has evidence of significant acidosis (such as arterial pH<7.2) not responsive to initial therapy.
10. The patient requires immediate transport in a critical care environment to a medical center that can perform organ transplantation or procurement.
11. The patient is experiencing an acute myocardial infarction, a dissecting or leaking aneurysm, or an acute cerebrovascular accident in evolution and requires therapy or diagnostic procedures not available at the referring institution.
12. The patient is experiencing seizures which cannot be controlled at the referring institution.
13. The patient is pregnant with a high‑risk obstetrical condition (including placenta previa, abruptio placenta, eclampsia, pre‑eclampsia, or premature labor with or without rupture of the membranes) and requires urgent transport to a perinatal center.
Pediatric Patients
1. The patient is experiencing or has a high risk of developing cardiac dysrhythmias or cardiac Pump failure that requires interventions not available at the referring hospital.
2. The patient is experiencing or has a high risk of developing acute respiratory failure or respiratory arrest and is not responsive to initial therapy.
3. The patient requires invasive airway procedures (including endotracheal or nasotracheal intubation, tracheotomy, or cricothyroidotomy) and assisted ventilations.
4. The patient is experiencing any of the following unstable vital signs:
• respiratory rate <10 or>60 breaths per minute
• systolic blood pressure <60 mmHg in a neonate
• systolic blood pressure <65 mmHg in an infant <2 years of age
• systolic blood pressure <70 mmHg in a child 2‑5 years old or systolic blood pressure <80 mmhg in a child 6‑12 years
5. The patient is experiencing any of the following clinical conditions:
• near‑drowning with signs of hypoxia or altered mental status
• status epilepticus
• acute bacterial meningitis
• acute renal failure
• unstable toxicologic syndrome
• Reye's syndrome
• hypothermia
• multiple trauma
Position Summary
A. Proper Use of Service: Air medical services can significantly reduce the time to deliver critical or high-risk patients to definitive care and may provide a higher level of care than is otherwise available.
B. Appropriate Facility: A facility's appropriateness is not based solely on geographic proximity.
C. Patient Qualifications: Descripters may assist in the decision for determining appropriateness of air medical patients but should not replace decisions based on medical judgment.
D. Medical Direction: Medical direction is preeminent in defining which patients will benefit from air medical transport.
Acknowledgements
This composition was taken from the September 1990 issue of the Journal of Air Medical Transport.
The authors would like to thank Dr. Henry Bock, who Put together the initial draft of this paper; the contributors who shared input during the intermediate drafts; and the Medical Advisory Committee members‑Drs. Nicholas Benson, Ira Blumen, William Rutherford, Richard Slevinski and Wendy Witt‑who shaped the final draft.
References
Baxt. Moody: the impact of a rotorcraft aero medical emergency care service on trauma rnortality.111~4 1983; 249(22):3047‑5l.
Baxt. Moodv. Cleveland, et al.: Hospital based rotorcraft aeromedical emergency care service, and trauma mortality: A multicenter study.Ann emer med. 1985:1400:859‑64.
Kaplan. Walsh. Burney: Emergency aeromedical transport of patients with acute myocardial infarction. Ann Emerg Med 1987:160(1):55‑7.
AAMS Rotorcraft and Fixed Wing Standards.
Cowley. R: A state of shock‑ ‑and trauma in Man utilizing the resource, of a clinical shock trauma unit. Maryland State Med Jour 1967; 16:63‑5.
Elliott. O'Keefe, Freeman: Helicopter transportation of patient‑‑, with obstetric emergencies in an urban area. Amer J Obstet Gynecol 1982; 143(2):157‑62.
Black. Mayer. Walker. et al.: Special Report:.Air transport of pediatric emergency cases. NEng1j.11rd 1982; 307(23):1465‑8.
American College of Surgeons Committee on Trauma: Resources for optimal care of the injured patient, 1990.
The Journal of Air Medical Transport ‑ September 1990
|
