Critical Care Air Transport Teams Research Articles

Enteral Nutrition in the Deployed Critical Care Ground and Air Transport Environment: A Narrative Review.

Early and adequate administration of enteral nutrition (EN) improves outcomes in critical care patients. However, the environment where Critical Care Air Transport teams provide patient care poses particular challenges to achieving the same standard of nutritional support readily administered in civilian intensive care units. Providing the highest standard of nutritional care in austere military environments remains the goal for all patients despite inherent challenges. Enteral nutrition, specifically, is not currently a standard of practice in-flight because of concerns for microaspiration and the associated risk of developing ventilator-associated pneumonia. Clinical concern for aspiration combines with the lack of an EN pump approved for use through Safe-to-Fly testing to further decrease the likelihood of initiating EN in trauma patients. Early EN significantly reduces morbidity and mortality risks; therefore, the lack of nutritional support is contrary to established standards of care in civilian intensive care units. Hence, this literature review proposes to provide a clearer understanding of current EN practices as well as any associated risks within the En Route Care system. A narrative review of literature related to EN in military and civilian flight settings using the PRISMA methodology. A search using the key terms of critical care, air ambulance, EN, nutritional status, and aspiration returned a total of 51,990 articles. A title review followed by a more targeted abstract analysis by the research team generated 39 articles for full-text review. The full-text review then yielded a total of 10 relevant articles for inclusion in the final synthesis table. Overall, the consensus of the literature supports that early evaluation and initiation of standard EN feeding protocols on the ground and during transport improves patient outcomes and enhances injury recovery. However, additional research will determine the current number of patients fed in-flight along with the actual risks and benefits of EN in this population.

Scoring system for activation of critical care air transport team for aeromedical evacuation

BackgroundOur hospital began work on formulating its own critical care air transport team (CCATT) and patient transfer unit (PTU) in 2007. A total of 293 patients have been evacuated by air using the various models of the PTU from April 2008 to February 2017. This study has been undertaken to formulate a protocol for activation of CCATT for aeromedical evacuation that best suits our setup keeping in view the availability of electromedical equipment, manpower and aircrafts. MethodsThe study is a cross-sectional study involving patients who were air evacuated between January 2010 to February 2017. Statistical analysis tests were performed to compare and analyze the two scoring systems to find out the sensitivity and specificity of the two scoring systems and to find out the degree of agreement. ResultsThe data using each scoring system were compared with actual requirement of CCATT based on recommendation of team leader of each CCATT mission and available data of each patient. It was observed that the old scoring system showed poor agreement with kappa coefficient of 0.162. The new scoring system based on modified early warning physiological score showed good agreement with kappa coefficient of 0.895. ConclusionCCATT can be activated by peripheral medical echelons based on objective criteria rather than subjective ones so that optimal use of resources can be carried out not only in peace time but also during mass casualty scenarios such as natural calamities or war.

Patients With Traumatic Brain Injury Transported by Critical Care Air Transport Teams: The Influence of Altitude and Oxygenation during Transport.

Traumatic brain injuries (TBIs) are life-threatening, and air transport of patients with TBI requires additional considerations. To mitigate the risks of complications associated with altitude, some patients fly with a cabin altitude restriction (CAR) to limit the altitude at which an aircraft's cabin is maintained. The goal of this study was to examine the effects of CARs on patients with TBI transported out of theater via Critical Care Air Transport Teams. We conducted a retrospective chart review of patients with moderate-to-severe TBI evacuated out of combat theater to Landstuhl Regional Medical Center via Critical Care Air Transport Teams. We collected demographics, flight and injury information, procedures, oxygenation, and outcomes (discharge disposition and hospital/ICU/ventilator days). We categorized patients as having a CAR if they had a documented CAR or maximum cabin altitude of 5,000feet or lower in their Critical Care Air Transport Teams record. We calculated descriptive statistics and constructed regression models to evaluate the association between CAR and clinical outcomes. We reviewed the charts of 435 patients, 31% of which had a documented CAR. Nineteen percent of the sample had a PaO2 lower than 80mm Hg, and 3% of patients experienced a SpO2 lower than 93% while in flight. When comparing preflight and in-flight events, we found that the percentage of patients who had a SpO2 of 93% or lower increased for the No CAR group, whereas the CAR group did not experience a significant change. However, flying without a CAR was not associated with discharge disposition, mortality, or hospital/ICU/ventilator days. Further, having a CAR was not associated with these outcomes after adjusting for additional flights, injury severity, injury type, or preflight head surgery. Patients with TBI who flew with a CAR did not differ in clinical outcomes from those without a CAR.

365 Incidence of Venous Thromboembolism in Critical Care Air Transport Team-Evacuated Casualties Transported to Landstuhl Regional Medical Center

Critically injured combat casualties are transported to Landstuhl Regional Medical Center (6-9 hour flights) via Critical Care Air Transport Teams (CCATTs). Immobility and prolonged air travel following traumatic injury may increase the risk of venous thromboembolism (VTE), yet studies on the incidence of VTE following traumatic injury and prolonged air transport are limited. Our objective was to determine factors associated with the incidence of VTE in patients evacuated from theater by CCATTs. We performed a retrospective record review of trauma patients evacuated from the combat setting by CCATT between March 2007 and December 2011. From CCATT records and Department of Defense Trauma Registry query we collected demographics, injury description, vital signs, labs, thromboprophylaxis, adverse events, and disposition up to 30 days. Data elements abstracted from theater medical records included VTE diagnostic information and relevant procedures with timestamps as available. Patients with at least one documented incidence of DVT or pulmonary embolism were grouped into VTE and compared to patients with no deep venous thrombosis or PE (No VTE). Continuous data were analyzed and reported as median (Interquartile Range), while categorical data were reported as frequencies and percentages. Regression models were performed to identify factors associated with the development of VTE. Of the 1351 CCATT records reviewed, 205 records had diagnoses of DVT (n=114), PE (n=69), or both (n=22). Thirty-five records had more than one occurrence of VTE documented. Subjects were male (98%) with median age of 24 (21-29) years. Comparing VTE versus No VTE there was no difference in age, sex, or injury severity. The VTE group was more likely to have sustained injuries related to a fall (5% versus 2%, p=0.015) or blast (75% versus 67%, p=0.027) compared to No VTE group. The VTE group was more likely to receive blood products pre-flight (p<0.001), during flight (p<0.001), and post-flight (p<0.001). The VTE and No VTE group received procoagulants, anticoagulants, and thromboprophylaxis pre-flight at similar rates. From regression models, a low pre-flight hemoglobin level (<8 g/dL), a pH of ≥7.4, and the administration of platelets were associated with VTE (p<0.001). Other pre-flight labs were similar between groups. There was no difference in proportion of patients who required ventilator support during transport (70% versus 65%, p=0.120), but after flight, the VTE group was more likely to be intubated (72% versus 65%, p=0.029). The VTE group compared to No VTE group was more likely to have an adverse event (such as aspiration pneumonia or cardiac arrest) post-flight (95% versus 90%, p=0.037). Mortality rates did not differ between groups (3.8% versus 4.1%, p=0.859). Of the survivors, the VTE group had more hospital days (p=0.047). The proportion of patients who continued to receive medical care (2.9% versus 2.8%) at 30 days post injury did not differ. The VTE group was more likely to receive blood products before, during, and after flight. Factors associated with VTE included a low hemoglobin level, pH of 7.4 or greater, and platelet administration in spite of the administration of anticoagulants. Further research is needed to determine whether this is related to low red cell to platelet ratios, continued bleeding, or other dysfunctional physiologic response in the coagulation system.

131 Patients With Traumatic Brain Injury Transported by Critical Care Air Transport Teams: The Influence of Altitude and Oxygenation During Transport

Moderate and severe traumatic brain injuries (TBI) are life-threatening, necessitating prompt evaluation and intervention. The safe air transport of patients with TBI to a higher level of care requires additional considerations. Patients with TBI are susceptible to complications related to altitude, including hypobaria and hypoxia. To mitigate this risk, some patients are transported with a cabin altitude restriction (CAR), which limits the altitude at which an aircraft’s cabin is maintained. The goal of this study was to examine the effects of altitude and oxygenation on patients with TBI transported via critical care air transport teams (CCATT) from a Role III medical treatment facility (MTF) to Landstuhl Regional Medical Center (LRMC). We conducted a retrospective chart review of patients with moderate to severe TBI evacuated out of combat theater via CCATT. Data abstractors collected data on demographics, flight information (including CAR), injury type, injury severity, pre-flight procedures, in-flight oxygenation, in-flight complications, and outcomes (mortality, hospital days, ICU days, and ventilator days). We calculated descriptive statistics and conducted Cox proportional hazards regression analyses to evaluate the association between CAR and clinical outcomes. We reviewed the CCATT charts of 435 patients with TBI transported via CCATT from a Role III MTF to LRMC. Eighty-one patients (19%) had a recorded CAR. About 19% of the sample had a PaO2 lower than 80 mmHg and 5% of patients experienced an in-flight SpO2 of 93% or lower. Flying without a CAR was not significantly associated with increased mortality or more hospital days, ICU days, or ventilator days. Further, having a CAR was not significantly associated with hospital days, ICU days, or ventilator days after adjusting for additional flights, injury severity, and injury type. Patients with moderate or severe TBI who were flown with a recorded CAR did not significantly differ from those who flew without a CAR in mortality rates, hospital days, ICU days, or ventilator days. Funding support: Air Force Medical Service (AFMS) Disclaimer: The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Air Force, Department of the Army, Department of Defense, or US Government.

164 Influence of Time to Transport to a Higher Level Facility on the Clinical Outcomes of US Combat Casualties With Traumatic Brain Injury: A Multicenter 7-Year Study

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide and is associated with mortality rates as high as 30%. Patients with TBI are at high risk for secondary injury and need to be transported to definitive care expeditiously. However, the physiologic effects of aeromedical evacuation are not well understood and may compound these risks. It is unknown if combat TBI patients may benefit from early versus delayed aeromedical evacuation. The aim of this study was to evaluate the impact of transport timing out of theater via CCATT to a higher-level facility on the clinical outcomes of combat casualties with TBI. We performed a retrospective record review of patients with TBI who were evacuated out of theater by Critical Care Air Transport Teams (CCATT) from January 2007 to May 2014. Data abstractors collected flight information, laboratory values, vital signs, procedures, and clinical in-flight assessments. Outcomes were obtained from the Department of Defense Trauma Registry (DoDTR). Time to transport was defined as the time (in days) from injury to CCATT evacuation out of combat theater. We calculated descriptive statistics and constructed multivariable regression models to determine the association between time to transport and clinical outcomes. We examined the records of 438 patients transported via CCATT from a Role III facility to Landstuhl Regional Medical Center (LRMC). For analyses we categorized patients into three groups: those transported in one day or less (n=165, 38% of the sample), two days (n=163, 37%), and three days or more (n=110, 25%). Multivariable logistic regression models indicated that patients with longer time to transport (ie, two days, or three or more days) had 50% lower odds of being discharged on a ventilator and were twice as likely to return to duty or be discharged home, even after adjusting for demographics, injury severity, and injury type. Additionally, patients transported in three or more days were 70% less likely to be ventilated at discharge with a GCS of 8 or lower and had 28% lower odds of mortality when compared to those transported in one day or less. In patients with moderate to severe TBI, a delay in aeromedical evacuation out of the combat theater was associated with lower odds of mortality and ventilation at discharge and a higher likelihood of discharge to home and return to duty dispositions.

Influence of Time to Transport to a Higher Level Facility on the Clinical Outcomes of US Combat Casualties with TBI: A Multicenter 7-Year Study.

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide and is associated with mortality rates as high as 30%. Patients with TBI are at high risk for secondary injury and need to be transported to definitive care expeditiously. However, the physiologic effects of aeromedical evacuation are not well understood and may compound these risks. Combat TBI patients may benefit from delayed aeromedical evacuation. The goal of this study was to evaluate the impact of transport timing out of theater via Critical Care Air Transport Teams (CCATT) to a higher level facility on the clinical outcomes of combat casualties with TBI. We performed a retrospective review of patients with TBI who were evacuated out of theater by CCATT from January 2007 to May 2014. Data abstractors collected flight information, vital signs, procedures, in-flight assessments, and outcomes. Time to transport was defined as the time from injury to CCATT evacuation out of combat theater. We calculated descriptive statistics and constructed regression models to determine the association between time to transport and clinical outcomes. This study was approved by the U.S. Air Force 59th Medical Wing Institutional Review Board. We analyzed the records of 438 patients evacuated out of theater via CCATT and categorized them into three groups: patients who were transported in one day or less (n = 165), two days (n = 163), and three or more days (n = 110). We used logistic regression models to compare outcomes among patients who were evacuated in two days or three or more days to those who were transported within one day while adjusting for demographics, injury severity, and injury type. Patients who were evacuated in two days or three or more days had 50% lower odds of being discharged on a ventilator and were twice as likely to return to duty or be discharged home than those who were evacuated within one day. Additionally, patients transported in three or more days were 70% less likely to be ventilated at discharge with a GCS of 8 or lower and had 30% lower odds of mortality than those transported within one day. In patients with moderate to severe TBI, a delay in aeromedical evacuation out of the combat theater was associated with improved mortality rates and a higher likelihood of discharge to home and return to duty dispositions. This study is correlational in nature and focused on CCATT transports from Role III to Role IV facilities; as such, care must be taken in interpreting our findings and future studies are needed to establish a causal link between delayed evacuation and improved discharge disposition. Our study suggests that delaying aeromedical evacuation of TBI patients when feasible may confer benefit.

Descriptive Analysis of Cardiac Patients Transported by Critical Care Air Transport Teams.

Critical Care Air Transport Teams (CCATTs) transport critically ill patients within and out of theaters of combat operations. Studies of the CCATT population reveal as many as 35% of patients have a non-trauma diagnosis, of which more than half are cardiac.The purpose of this retrospective study was to describe the epidemiology of critically ill patients with cardiac diagnoses evacuated from theater via CCATT. We conducted a retrospective review of 290 medical patients with a primary cardiac diagnosis transported from any theater of operation to Landstuhl Regional Medical Center, Germany from January 2007 to April 2015. The majority of patients were male with an average age of 46 ± 11 years, US contractors (47%, n = 137), followed by US Active Duty (32%, n = 93). Patients had an average BMI of 29 ± 5; 62% of cardiac patients were either overweight or obese. The most common cardiac diagnoses were ST elevation myocardial infarction, Non-ST elevation myocardial infarction, and angina. Pre-flight vital signs indicate overall patients were stable prior to evacuation, with the majority receiving supplemental oxygen and only 5% requiring mechanical ventilation. Eighty-one percent of patients experienced at least one cardiac event during flight, however less than 5% required adjustment to oxygen or ventilator settings. Critically ill cardiac patients make up a significant portion of patients transported out of the combat theater. These patients are older, overweight and have identified risk factors for cardiac morbidity. More strenuous pre-deployment screening for risk factors and prevention strategies could minimize the use of military resources to evacuate these patients from the combat theater.

Critical care air transport team and patient transfer unit: A decade of experience of a zonal hospital

Introduction: The critical care air transport team (CCATT) established in 2007 a vital components of medical evacuations (MEDEVAC) in north-east India. Aim of the Study: The aim of this study was to highlight the importance of obtaining epidemiological data pertaining to the patients transported by CCATT. Method: Cases were analyzed based on the following criteria: age, sex, diagnosis of patient ,spectrum of disease and trauma, ventilation modes, inotropic support, hours of illness/injury before transport, flying time, flight distance, dedicated missions, interventions done aboard the flight and outcomes in the patient within 48 hours. Results: As many as 305 patients were analysed.39.5% patients were surgical patients, 58.5% medical and 1% was pediatric. Among surgical patients 56.8% patients were of poly trauma, 22.8% had traumatic brain injury. 68.8% of the patients transported were non-battle casualties. Dedicated missions constituted 43.4%, while the longest time for CCATT to return to base was 28 hours, shortest been 4 hours.46.8% of the patients required ventilatory support.63.4% of the patients were on inotropic support. 82.6% of the patients survived first 24 hours while 72.6 % of the patient survived 48 hours. Conclusion: Understanding the epidemiology of casualties evacuated by CCATT is an imperative requirement for the developments of effective pre-deployment training to ensure optimal outcomes for critically injured.

Pressure Injury Development in Patients Treated by Critical Care Air Transport Teams: A Case-Control Study.

The US Air Force transports critically ill patients from all over the world, with transport times commonly ranging from 6 to 11 hours. Few outcome measures have been tracked for these patients. Traditional methods to prevent pressure injuries in civilian hospitals are often not feasible in the military transport environment. The incidence rate and risk factors are described of en route-related pressure injuries for patients overseen by the Critical Care Air Transport Team. This retrospective, case-control, medical records review investigated risk factors for pressure injury in patients who developed a pressure injury after their transport flight compared with those with no documented pressure injuries. The pressure injury rate was 4.9%. Between 2008 and 2012, 141 patients in whom pressure injuries developed and who had received care by the team were matched with 141 patients cared for by the team but did not have pressure injury. According to regression analysis, body mass index and 2 or more Critical Care Air Transport Team transports per patient were associated with pressure injury development. Although the pressure injury rate of 4.9% in this cohort of patients is consistent with that reported by civilian critical care units, the rate must be interpreted with caution, because civilian study data frequently represent the entire intensive care unit length of stay. Targeted interventions for patients with increased body mass index and 2 or more critical care air transports per patient may help decrease the development of pressure injury in these patients.

Impact of Critical Care Air Transport Team (CCATT) ventilator management on combat mortality.

Aeromedical evacuation platforms such as Critical Care Air Transport Teams (CCATTs) play a vital role in the transport and care of critically injured and ill patients in the combat theater. Mechanical ventilation is used to support patients with failing respiratory function and patients requiring high levels of sedation. Mechanical ventilation, if not managed appropriately, can worsen or cause lung injury and contribute to increased morbidity. The purpose of this study was to evaluate the impact of ARDSNet protocol compliance during aeromedical evacuation of ventilated combat injured patients. We performed a retrospective chart review of combat injured patients transported by CCATTs from Afghanistan to Landstuhl Regional Medical Center (LRMC) in Germany between January 2007 and January 2012. After univariate analyses, we performed regression analyses to assess compliance and post-flight outcomes. Cox proportional hazard models were used to evaluate associations between the risk factor of non-compliance with increased number of ventilator, ICU, or hospital days. Nominal logistic regression models were performed to evaluate the association between non-compliance and mortality. Sixty-two percent (n = 669) of 1,086 patients required mechanical ventilation during transport. A total of 650 patients required volume-controlled mechanical ventilation and were included in the analysis. Of the 650 subjects, 62% (n = 400) were non-compliant per tidal volume and ARDSNet table recommendations. The groups were similar in all demographic variables, except the Non-compliant group had a higher Injury Severity Score compared to the Compliant group. Subjects in the Compliant group were less likely to have an incidence of acute respiratory distress, acute respiratory failure, and ventilator-associated pneumonia when combing the variables (2% vs. 7%, p < 0.0069). The Non-compliant group had an increased incidence of in-flight respiratory events, required more days on the ventilator and in the ICU, and had a higher mortality rate. Compliance with the ARDSNet guidelines was associated with a decrease in ventilator days, ICU days, and 30-day mortality. Therapeutic/care management, level IV.

Critical Care Air Transport Team Evacuation of Medical Patients Without Traumatic Injury.

Air Force Critical Care Air Transport Teams (CCATTs) provide fixed-wing aeromedical evacuation for combat casualties. Multiple studies have evaluated CCATT trauma patients; however, nearly 50% of patients medically evacuated from combat theaters are for nontraumatic medical illnesses to include stroke, myocardial infarctions, overdose, and pulmonary emboli. Published data are limited regarding illness types, in-flight procedures, and adverse events. The objective of our study was to characterize patients with nontraumatic medical illnesses transferred via CCATT to include a description of in-flight procedures and events. We performed a retrospective review of CCATT medical records of patients with nontraumatic medical illnesses transported via CCATT from theater of operations to Landstuhl Regional Medical Center between January 2007 and April 2015. We abstracted data from CCATT records to include demographics, description of current illness, vital signs, labs, in-flight procedures and medications, and in-flight adverse events. Following descriptive analysis, comparative tests were performed based on service status of patients and primary diagnoses. We reviewed 672 records of critically ill medical patients transported via CCATT, most of whom were male (90%, n = 606). Approximately 56% of the patients were U.S. active duty members; the remainder included U.S. contractors and civilians, and foreign citizens or unknown. The three categories (active duty, contractor/civilian, foreign/unknown) significantly differed from one another in age. Over half of the patients received a primary or secondary cardiac diagnosis. The most common in-flight procedures and medications included supplementary oxygenation, anticoagulant/antiplatelet medications, analgesics, and ventilation. Up to 20% of patients required continuous medication infusions other than analgesics. Patients most frequently experienced in-flight complications related to their primary diagnoses. Fifty-six percent (672) of 1,209 CCATT records that were queried were of patients with medical conditions. The most common primary diagnoses of CCATT medical patients were cardiac, pulmonary, and neurological in etiology. Mechanical ventilation and continuous medication infusions were required in approximately 20% of patients. The data provided by this study may assist in guiding future CCATT training requirements and resource allocation, as well as clinical practice guideline development.

Comparison of five video-assisted intubation devices by novice and expert laryngoscopists for use in the aeromedical evacuation environment

BackgroundThe critically ill or injured patient undergoing military medical evacuation may require emergent intubation. Intubation may be life-saving, but it carries risks. The novice or infrequent laryngoscopist has a distinct disadvantage because experience is critical for the rapid and safe establishment of a secured airway. This challenge is compounded by the austere environment of the back of an aircraft under blackout conditions. This study determined which of five different video-assisted intubation devices (VAIDs) was best suited for in-flight use by U.S. Air Force Critical Care Air Transport Teams by comparing time to successful intubation between novice and expert laryngoscopists under three conditions, Normal Airway Lights on (NAL), Difficult Airway Lights on (DAL) and Difficult Airway Blackout (DAB), using manikins on a standard military transport stanchion and the floor with a minimal amount of setup time and extraneous light emission.MethodsA convenience sample size of 40 participants (24 novices and 16 experts) attempted intubation with each of the 5 different video laryngoscopic devices on high-fidelity airway manikins. Time to tracheal intubation and number of optimization maneuvers used were recorded. Kruskal-Wallis testing determined significant differences between the VAIDs in time to intubation for each particular scenario. Devices with significant differences underwent pair-wise comparison testing using rank-sum analysis to further clarify the difference. Device assembly times, startup times and the amount of light emitted were recorded. Perceived ease of use was surveyed.ResultsNovices were fastest with the Pentax AWS in all difficult airway scenarios. Experts recorded the shortest median times consistently using 3 of the 5 devices. The AWS was superior overall in 4 of the 6 scenarios tested. Experts and novices subjectively judged the GlideScope Ranger as easiest to use. The light emitted by all the devices was less than the USAF-issued headlamp.ConclusionsNovices intubated fastest with the Pentax AWS in all difficult airway scenarios. The GlideScope required the shortest setup time, and participants judged this device as the easiest to use. The GlideScope and AWS exhibited the two fastest total setup times. Both devices are suitable for in-flight use by infrequent and seasoned laryngoscopists.

Critical Care Air Transport Team severe traumatic brain injury short-term outcomes during flight for Operation Iraqi Freedom/Operation Enduring Freedom

IntroductionOur understanding of the expertise and equipment required to air transport injured soldiers with severe traumatic brain injuries (TBIs) continue to evolve.MethodsWe conducted a retrospective chart review of characteristics, interventions...

Post-Traumatic Stress Symptoms in United States Air Force Aeromedical Evacuation Nurses and Technicians.

Critical Care Air Transport Teams (CCATT) are specialized military medical personnel who provide high-acuity care in an aeromedical environment. The rate of post-traumatic stress disorder (PTSD) symptoms was assessed in CCATT personnel and their rates were compared to general aeromedical evacuation (AE) personnel. As part of a computer-based occupational stress survey, 188 crew members (138 AE nurses and technicians, 50 CCATT nurses and respiratory therapists) completed the PTSD Checklist - Military Version. A categorical MEET/DOES NOT MEET CRITERIA variable was created, and a Fisher's exact test was computed to identify differences between groups. Contingency table analyses were used to assess associations between demographic and occupational variables with meeting criteria. χ2 or Fisher's exact test results, relative risks, and 95% confidence intervals were obtained, with 4.35% of AE and 14.00% of CCATT crew members meeting PTSD symptom criteria. The CCATT crew members were 3.22 times (95% confidence interval = 1.14-9.12) more likely to meet symptom criteria than AE, and for CCATT meeting criteria, the most commonly endorsed symptoms were arousal and avoidance. The demographic and occupational factors assessed in this study were not associated with meeting PTSD symptom criteria. Current findings are discussed in relation to current research on post-traumatic stress in ground-based critical care personnel.

A Retrospective Cohort Analysis of Battle Injury Versus Disease, Non-Battle Injury-Two Validating Flight Surgeons' Experience.

Today, military combat medical care is the best it has ever been. Regulated U.S. Air Force aeromedical evacuation (AE) is one important reason. The Theater Validating Flight Surgeon (TVFS) validates that a patient is ready for flight. Two TVFSs' experiences, successively deployed in 2007, are the focus of this study. A unique operational worksheet used to manage the AE queue was used for approximately 5 months. A descriptive analysis of the worksheet's 1,389 patients found the majority male (94%), median age 30 years, and mostly Army enlisted soldiers (63%). U.S. civilians made up 9%. Battle Injury (55%) surpassed Disease, Non-Battle Injury (45%); most frequently seen were extremity injuries (73%) and cardiac illness (31%), respectively. Common to both Battle Injury and Disease, Nonbattle Injury were several TVFS prescriptions including no "remain overnights" (79%), head of bed elevation (78%), cabin altitude restriction (57%), no stops (44%), Critical Care Air Transport Team (27%), and supplemental oxygen (22%). This study is a first look at the TVFS experience and it offers up an initial accounting of the TVFS clinical and prescriptive practices. It is also a jumping point for future TVFS investigations using the available AE databases.

Automated control of endotracheal tube cuff pressure during simulated flight

Successful mechanical ventilation requires that the airway be controlled by an endotracheal tube (ETT) with an inflatable cuff to seal the airway. Aeromedical evacuation represents a unique challenge in which to manage ETT cuffs. We evaluated three methods of automatic ETT cuff pressure adjustment during changes in altitude in an altitude chamber. Size 7.5 and 8.0 mm ETTs that are currently included in the Critical Care Air Transport Team allowance standard were used for the evaluation. Three automatic cuff pressure controllers-Intellicuff, Hamilton Medical; Pyton, ARM Medical; and Cuff Sentry, Outcome Solutions-were used to manage cuff pressures. The fourth group had cuff pressure set at sea level without further adjustment. Each ETT was inserted into a tracheal model and taken to 8,000 feet and then to 16,000 feet at 2,500 ft/min. Baseline cuff pressure at sea level was approximately 25 cm H2O. Mean cuff pressure at both altitudes with both size ETTs was as follows: Control arm, 141 ± 64 cm H2O; Pyton, 25 ± 0.8 cm H2O; Cuff Sentry, 22 ± 0.3 cm H2O; and Intellicuff, 29 ± 6.6 cm H2O. The mean time that cuff pressure was >30 cm H2O using Intellicuff at both altitudes was 2.8 ± 0.8 minutes. Pressure differences from baseline in the control arm and with Intellicuff were statistically significant. Cuff pressure with the Cuff Sentry tended to be lower than indicated on the device. Mean cuff pressures were within the recommended range with all three devices. Intellicuff had difficulty regulating the cuff pressure initially with increases in altitude but was able to reduce the pressure to a safe level during the stabilization period at each altitude. The Pyton and Cuff Sentry allowed the least variation in pressure throughout the evaluation, although the Cuff Sentry set pressure was less than the actual pressure. Therapeutic study, level V.

Measuring Intangibles: Defining Predictors of Non-Technical Skills in Critical Care Air Transport Team Trainees.

Critical Care Air Transport Teams (CCATTs) are integral to the U.S. Air Force aeromedical evacuation paradigm. The current study was conducted to evaluate predictors of nontechnical skills (NOTECHS) in CCATT trainees. Sixteen CCATTs were studied over a 6-month period. Team members completed a biographical survey and teams were videotaped during a simulated CCATT mission. Teams and individuals were assigned a "red flag score" using a validated assessment tool for NOTECHS. Salivary cortisol levels were measured at baseline and pre- and postsimulation exercises. 63% of participants reported regular intensive care unit (ICU) experience and 67% had flown real-world CCATT missions. Sixteen simulated missions were reviewed, with 69 crisis events identified. Task saturation was observed in 42% of crisis events. Average team red flag score correlated with task saturation during the simulated missions (odds ratio = 0.5). Daily ICU experience (p < 0.03) and previous deployment (p < 0.04) correlated with NOTECHS performance. Cortisol levels increased from baseline as the result of the simulation (p < 0.01) but did not correlate with red flag scores or biographical data. Task saturation occurred frequently and correlated with performance of NOTECHS. Previous real-world CCATT experience and daily ICU care correlated with improved performance of NOTECHS.

En Route Use of Analgesics in Nonintubated, Critically Ill Patients Transported by U.S. Air Force Critical Care Air Transport Teams.

U.S. Critical Care Air Transport Teams (CCATTs) evacuate critically ill patients with acute pain in the combat setting. Limited data have been reported on analgesic administration en route, and no study has reported analgesic use by CCATTs. Our objective was to describe analgesics used by CCATTs for nonintubated, critically ill patients during evacuation from a combat setting. We conducted an institutional review board-approved, retrospective review of CCATT records. We included nonintubated, critically ill patients who were administered analgesics in flight and were evacuated out of theater (2007-2012). Demographics, injury description, analgesics and anesthetics, and predefined clinical adverse events were recorded. Data were presented as mean ± standard deviation or percentage (%). Of 1,128 records, we analyzed 381 subjects with the following characteristics: age 26 ± 7.0 years; 98% male; and 97% trauma (70% blast, 17% penetrating, 11% blunt, and 3% burn). The injury severity score was 19 ± 9. Fifty-one percent received morphine, 39% hydromorphone, 15% fentanyl, and 5% ketamine. Routes of delivery were 63% patient-controlled analgesia (PCA), 32% bolus intravenous (IV) administration, 24% epidural delivery, 21% continuous IV infusions, and 9% oral opioids. Patients that were administered local anesthetics (nerve block or epidural delivery) with IV opioids received a lower total dose of opioids than those who received opioids alone. No differences were associated between analgesics and frequency of complications in flight or postflight. About half of nonintubated, critically ill subjects evacuated out of combat by CCATT received morphine and more than half had a PCA. In our study, ketamine was not frequently used and pain scores were rarely recorded. However, we detected an opioid-sparing effect associated with local anesthetics (regional nerve blocks and epidural delivery).

Preflight Variables Are Associated With Increased Ventilator Days and 30-Day Mortality in Trauma Casualties Evacuated by Critical Care Air Transport Teams: An Exploratory Retrospective Study.

There are no tools to predict outcomes in the U.S. Air Force Critical Care Air Transport Team (CCATT) trauma patients. The objective of this study was to identify associations between preflight variables and outcomes that could assist planning of ongoing critical care. This Institutional Review Board approved retrospective study included all patients evacuated from Afghanistan by CCATT between 2007 and 2011. Preflight variables were assessed for associations and examined in logistic regression models. Ventilator time over 72 hours, and 30-day mortality were the primary and secondary outcomes respectively. 1,308 trauma patients (24 years, 98% male) were included; 72% blast. Injury severity score (odds ratio [OR] = 1.04 [1.03-1.06]), preflight packed red blood cell units transfused (OR = 1.05 [1.04-1.07]), and preflight intubated status (OR = 11.9 [8.53-16.89]) were independently associated with increased ventilator days; a composite produced an area under the curve of 0.85 with 86% sensitivity and 56% specificity. Injury severity score (OR = 1.06 [1.03-1.09]), prothrombin time (OR = 2.13 [1.18-4.47]), preflight intubated status (OR = 9.2 [1.88-166.11]), and whole blood (OR = 3.18 [1.38-7.04]) were associated with 30-day mortality; a composite produced an area under the curve of 0.84 with 71% sensitivity and 57% specificity. In our large CCATT study a number of preflight variables were associated with outcomes, which may assist in the future planning of critical care services.