Transportatio

n and
Stabilitation
in Critically Ill
Patient
dr. Akhmad Yun Jufan, M.Sc., Sp.An
Anaesthesia and Intensive Care
RSS FM GMU

BACKGROUND
Increased number
Standards and guidelines
Qualifications of medical personnel
The skill and training of personnel
Advancing technologies and sophisticated
equipment

Background
The basic reason for moving : the need for
additional care, either technology and/or
specialists, not available at the patients current
location.

Critical care transport have become a necessary

extension of hospital emergency and critical
care services.

Crew
Strong assessment and critical thinking skills
Ability to manage patients
Strong knowledge of communications
Safety in the out-of-hospital setting.
ability to function autonomously in a variety of
settings if immediate communication with a
physician is not possible or if immediate lifesaving actions are required.

Advanced Critical Care

Skills

Include:

Advanced airway
techniques

RSI
Surgical airway

Ventilator
management
Pulse oximetry and
capnogram
interpretation
Chest tube
placement and
monitoring
Thoracic
escharotomies
Transvenous pacing

Intra-aortic balloon pump

12-Lead ECGCentral
venous catheter
maintenance/placement/
interpretation
Intracranial pressure
monitoring
Venous cutdown
Blood/blood product
administration and
monitoring
Infusion pumping
Advanced
pharmacological
intervention

Patients transfer
Intra - Hospital

ICU
Ward
OT
Radiology
Etc..

Inter - Hospital
Regional
National
International

Patients transfer

v.s

History of Ambulance
Transport
1790s
First Coalition of Napoleonic First EMS
War
1864

Geneva Convention

Established EMS as neutral

186165

Civil War

First U.S. ambulances

1865,
1869

Hospital-based EMS
(Cincinnati, OH, and New
York, NY)

First hospital EMS

1899

Hospital-based EMS
(Chicago, IL)

First motorized ambulance

1950s

Belfast, Ireland, ALS

ambulances

First physician-staffed MICU

1970

Miami FD ALS ambulances

First nonphysician ALS in United

States

1790s
Earliest documented EMS
French transported wounded from
battlefield to hospitals for care
Used horse-drawn carriages
Provided no care on battlefield

1864 (Geneva
Convention)
Established rules for treating injured on
battlefield
Deemed hospitals, ambulances, and their
staff neutral
Rendered immune from attack
Marked with national flag and red cross

Ground transport
Could transport in adverse weather
Cost less than air transport
Were sometimes faster
Had safety benefits
St. Vincent/Medical University/
St. Ritas Critical Care Transport, Toledo, OH

 Advantages of ground transport over air

transport

Larger patient compartment

Lower cost
Relative immunity to changing weather
Safer
Less severe environmental factors

Oxygen levels
Acceleration/deceleration forces
Gas volume changes with altitude
Cabin pressurization
Humidity
Noise
Vibration

System Design

2005 Scott Metcalfe LLC. All rights reserved.

2005 Scott Metcalfe LLC. All rights reserved.

Ambulance Types
Three types
Type I

Modular box compartment on truck chassis

Type II

Van style

Type III

Modular box on van chassis

Type II or Type III typically used for critical

care transport

Type I Ambulance

Jeff Forster

Type II Ambulance

Jeff Forster

Type III Ambulance

Jeff Forster

History of Air Medical

Transport
1870

Prussian siege of Paris

First air transport of

wounded soldiers

1917

World War I

Airplane ambulances

1950s

Korean War

Helicopter ambulances

1960s
and
1970s

Vietnam War

1 million helicopter
transports

1969

Samaritan Air Evac

(Phoenix, AZ)

First civilian helicopter used

in EMS

1970

Maryland State Police

First police/EMS helicopter

1972

St. Anthony Hospital

(Denver, CO)

First dedicated air

ambulance

1950s (Korean War)

Helicopters first used for medical
transport
Injured provided first aid at scene and
moved to Mobile Army Surgical Hospital
(MASH) units
Over 20,000
patients
transported
during war
Mortality rate
declined
Bledsoe/Benner, Critical Care Paramedic
Corbis

2006 by Pearson Education, Inc. Upper Saddle River, NJ

1960s and 1970s (Vietnam

War)
Followed Korean War model
Medical corps staff provided emergency
care in field
Over 1 million
wounded moved
by helicopter
during war
Mortality rate
declined

Dust off 2000, Joe Kline Aviation Art

Bledsoe/Benner, Critical Care Paramedic

2006 by Pearson Education, Inc. Upper Saddle River, NJ

Air

Transport

Advantages

Faster
Can accommodate more than one patient
Allows care providers more room
Increases workspace
Holds more crew when patients require

Disadvantages

Requires large, sturdy landing site

May be too heavy or large for some pads

Expensive

Original cost
Maintenance
Fuel

Ground Vs Air
The potential for transport delay that
may be associated with the use of ground
transport (e.g., traffic and distance) is
likely to worsen the patient's clinical
condition

Ground Vs Air
Beyond 100 miles, a ground may become
inefficient, costly to operate, and time
consuming
Helicopter is used for up to 150 mile
radius
Fixed wing greater than 150

IN-HOSPITAL TRANSPORT
Transport from the intensive care unit (ICU) to
the operating room, radiology suite, or other
patient care area for either diagnostic testing
or therapeutic interventions
a period of potential cardiopulmonary instability
The ability to both continuously monitor and
provide appropriate uninterrupted patient care
during such transports is essential.

Monitoring :
Include but not limited to:
Invasive monitors Swan Ganz, Arterial lines, CVP,
ICP needle
Cardiac Assist Devices Pacemakers, Intra-aortic
balloon pump, extra- corporeal support (ECMO), 12
lead monitoring, interpretation and intervention
Specialty Drug Delivery epidural catheters,
Intra-osseous lines
Respiratory equipment ventilators, artificial
airways, chest tubes, capnography

Stabilitation for
transportation
During transport, 20-75% lifethreatening
complications such as new cardiac arrhythmias,
systemic hypo or hypertension, hypoxemia, hypo- or
hypercarbia, or intracranial hypertension
increased risk for myocardial or cerebral ischemia
and even death.
Even the simple maneuver of transferring a patient
from one bed to another can result in significant,
protracted, and occasionally irreversible,
cardiopulmonary dysfunction.

Stabilitation
intubated patients are ventilated using a
manual resuscitation bag (Ambubag) due
to their simplicity, portability, and
reliability.

Consistent, uninterrupted ventilation is

difficult to maintain

Stabilitation

The patient with acute respiratory failure who

requires advanced mechanical ventilatory
support using :
positive-end expiratory pressure (PEEP)
pressure-controlled ventilatory modes
inverse-ratio ventilation
Advanced pressure, flow, or volume delivery
techniques
not tolerate even a brief interruption of highlevel mechanical ventilatory support.

 Careful coordination with the patients

destination prevent delays and
prolonged transport times.

Appropriate monitoring, resuscitation

equipment, and medications based upon
the anticipated need and duration of the
planned transport.

Case
39% of transports in diagnostic tests
that led to a change in patient
management within 48 hours.
Abdominal CT scanning (51 %) and
angiography (57%) tests leading to a
management change.

Case
Head-injured patients requiring inhospital transport :
51 % : significant arterial hypertension,
arterial hypotension, intracranial
hypertension, or hypoxia during
transport.

Vascular events and

surgical conditions

Acute ischemic stroke

Expanding epidural hematoma
Acute myocardial infarction
Acute aortic dissection
Acute gastrointestinal hemorrhage
Rupturing aneurysm
Acute intra-abdominal hemorrhage from trauma
Amputation with planned reattachment
Ischemia of arm or leg
Necrotizing fasciitis

Neurologic
Acute ischemic stroke
Malignant hypertension (Hypertensive
emergency)
Intracranial hemorrhage
Epidural hematoma
Subarachnoid hemorrhage (SAH)
Subdural hematoma
Status epilepticus

Cardiac
Acute myocardial infarction
Coronary artery disease on intra-aortic balloon
pump (IABP) or ventricular assist device (VAD)
Intermediate coronary syndrome (unstable angina)
Cardiogenic shock on continuous infusion
pharmacotherapy
Dysrhythmia on continuous infusion
antidysrhythmic therapy
Cardiac tamponade
Valvular insufficiency
Post-cardiac arrest

Trauma

Intra-abdominal hemorrhage
Amputation with planned reattachment
Head injury with deteriorating mental status
Spinal cord injury with hypotension and/or neurological deficits
Flail chest
Cardiac injury
Pelvic fracture with hypotension
Multiple long bone fractures with hypotension
Open fractures
Major burn criteria
Inhalational injury
Burns with associated trauma
Electrical burns

Critically-Ill Medical
Conditions

Gastrointestinal hemorrhage
Near-drowning
Emergency hemodialysis
Hyperbaric oxygen therapy
(HBO)
Severe poisoning or
overdose
Airway with potential for
obstruction
Acute respiratory distress
syndrome (ARDS)
Angioedema
Epiglottitis

Retropharyngeal abscess
Specialized ventilation
Intubated and ventilated
Bronchopulmonary
dysplasia
Congenital heart defect
CHF
Persistent hypoglycemia
Temperature instability
Sepsis or meningitis
Seizures
Inverse ratio ventilation
DIC

Obstetric Condition
Premature labor with neonatal weight < 2000g
Hydrops fetalis
Neonatal cardiac disease Medical emergency
Pre-eclampsia or eclampsia
Poisoning or overdose
Surgical emergency
Abruption with hemorrhage

Critically-ill surgical
Aortic dissection
Rupturing aneurysm
Paediatric Conditions
Necrotizing enterocolitis
Abdominal wall defect
Diaphragm hernia
Transplant (heart, renal)
Donor
Recipient

THANK YOU