Force Critical Care Air Transport Research Articles

Reliability of Continuous Noninvasive Hemoglobin Monitoring in Healthy Participants During En Route Care Training.

Current standards for hemoglobin monitoring during air transports of U.S. combat wounded are invasive and intermittent. Fielded pulse co-oximeters can noninvasively measure total hemoglobin, but this parameter is not currently utilized. The primary objective of this study was to assess the percentage of vital sign measurements with successful capture of total noninvasive hemoglobin measurement using spectrophotometry-based technology for Hb (SpHb) measurements in healthy participants during training flights. Secondary objectives were to assess the feasibility of a novel electronic data capture mechanism from usual patient movement items and perform a pilot analysis of SpHb changes in healthy participants during transitions from ground to air transport. We conducted a feasibility study enrolling healthy participants who had hemodynamic monitoring during usual U.S. Air Force Critical Care Air Transport (CCAT) flight training exercises from 2022 to 2023. Usual CCAT monitoring equipment and currently used Masimo Rainbow® pulse co-oximeters had the capability to measure SpHb. After each training exercise, the study team wirelessly downloaded case files from patient monitors utilizing the Battlefield Assisted Trauma Distributed Observation Kit (BATDOKTM) Case Downloader application. We then calculated point and precision estimates for the percentage of time for successful SpHb capture during the exercise and compared this to pulse oximetry (SpO2) capture. An a priori precision analysis for percentage of flight-time with successful SpHb data capture and descriptive statistics were performed. This study received Exempt Determination by the 59th Medical Wing IRB. We analyzed 26 records with mean monitoring durations of 94.5 [59.3-119.9] minutes during ground phases and 78.0 [59.9-106.5] minutes during flight phases. SpHb measures were successfully captured for 97.7% (n = 4,620) of possible ground measurements and 97.2% (n = 3,973) of possible in-flight measurements compared to 99.5% ground and 98.2% in-flight capture for SpO2. Mean intervals of missing SpHb data were 2 ± 5 minutes on the ground and 4 ± 6 minutes in-flight. Mean SpHb increased by 0.93 ± 0.96 g/dL during the ground phase, but had minimal changes during ascent, cruising altitude or descent. The BATDOKTM Case downloader completed transfer for all files. Masimo Rainbow® SpHb pulse co-oximeters reliably captured continuous, noninvasive hemoglobin measurements using usual CCAT patient movement items in healthy participants during both ground and flight training. The BATDOKTM Case Downloader successfully imported case files from CCAT patient monitors. Mean SpHb measures had a small increase during the ground phase of monitoring followed by minimal changes when transitioning to flight altitude.

Impact of En Route Critical Care Provider Experience on Lung Protective Ventilation Compliance During Air Transport of Combat Wounded.

The primary objective of this study was to evaluate the association between the U.S. Air Force Critical Care Air Transport (CCAT) provider operational experience with compliance for lung protective ventilation (LPV) volumes recommended by Acute Respiratory Distress Syndrome Clinical Network guidelines. We performed a retrospective cohort study of CCAT providers transporting combat casualties requiring mechanical ventilation from the Middle East to Germany from 2007 to 2012. We reviewed CCAT medical records from 2007 to 2012 for the total number of patient transports by CCAT physicians and respiratory care practitioners (RCPs). Center for Sustainment of Trauma and Readiness Skills Cincinnati process improvement questionnaire data described provider demographics and clinical backgrounds. We linked these data to patient demographics and in-flight ventilation management from a prior CCAT cohort study. Patient inclusion criteria included transport by CCAT from the Middle East to Germany for traumatic injury requiring mechanical ventilation between 2007 and 2012. We excluded patients with no documented height or tidal volume. LPV compliance was defined as tidal volumes ≤8 mL/kg of predicted body weight during en route critical care transport. We performed a logistic regression analysis. This study was reviewed and approved by the 59th Medical Wing institutional review board (IRB). We analyzed 491 patient transports conducted by 71 (RCPs and 84 physicians. Patients had a median age of 25 years (IQR 22-30), 98% were male, median injury severity score was 24 (IQR 17-34), and median preflight PaO2/FiO2 was 285 (IQR 220-365). Median experience was 26 missions (IQR 13-40) for RCPs and 23 missions (IQR 12-38) for physicians. All in-flight tidal volumes were LPV compliant in 58.3% of missions. Unadjusted analysis showed higher LPV compliance for RCPs with in-garrison critical care experience. Multivariate models did not find an association between missions flown and LPV compliance but did demonstrate a positive association with physician specialty of medical intensivist (OR 3.0, 95% CI 1.6-5.7) and a negative association with flights in 2008 (OR 0.4, 95% CI 0.2-0.7) for LPV compliance. No association was found between number of missions flown by CCAT providers and lung protective tidal volume compliance. Linkage of multiple data sources enabled investigation of clinical and operational currency associations with a care quality metric compliance in the combat en route care environment. Future studies should evaluate the impact of ongoing CCAT training and quality improvement interventions on LPV compliance.

A Descriptive Study ofCasualties Evacuated Out ofAfghanistan by Critical Care Air Transport Teams During the Withdrawal ofU.S. Troops.

The War in Afghanistan ended in August 2021. Evacuation from the country was a large effort during the last days of the conflict. During evacuation efforts at Kabul Hamid Karzai International Airport, a suicide bombing occurred necessitating emergent medical care for many injured troops and civilians. The U.S. Air Force Critical Care Air Transport Teams (CCATTs) played a role in the medical care provided during the operations in Afghanistan. We report on in-flight events and interventions that took place during the final days of the Afghanistan withdrawal. We performed a retrospective chart review of patients requiring aeromedical evacuation from the Afghanistan theater of operations by CCATT from July 1 to August 30, 2021. From the CCATT patient care record, data abstractors collected patient characteristics, flight information, vital signs, laboratory values, in-flight interventions, and in-flight events in a study-specific electronic database. We performed descriptive analyses of patient characteristics and in-flight interventions. This study was approved by the San Antonio Institutional Review Board. Nine patients were included in this analysis. Seven out of nine patients were foreign nationals; the remaining two were U.S. Marines. Five patients suffered penetrating injuries from gunshot wounds and four suffered blast injuries. Six received intravenous narcotic analgesia. Four received intravenous sedatives, and four received antibiotics in flight. Two patients required chest tube management. One patient received blood. Three patients were in acute respiratory distress. Severe injuries were sustained during the withdrawal efforts at the end of the War in Afghanistan. Critical Care Air Transport Teams played a role in the care and evacuation of patients out of theater during this unique and unprecedented time. Even given the limitations associated with retrospective studies and a small sample size, information reported in this study can help inform future decisions, and aid in preparatory efforts for future operations, that may require medical care by CCATT.

A Retrospective Cohort Study of Burn Casualties Transported by the US Army Burn Flight Team and US Air Force Critical Care Air Transport Teams.

The US Army Burn Center, the only burn center in the Department of Defense provides comprehensive burn care. The Burn Flight Team (BFT) provides specialized burn care during transcontinental evacuation. During Operations Iraqi and Enduring Freedom, burn injuries accounted for approximately 5% of all injuries in military personnel. To augment BFT capacity, US Air Force Critical Care Air Transport Teams (CCATTs) mobilized to transport burn patients. The purpose of this study was to describe critically ill, burn injured patients transported to the US Army Burn Center by BFT or CCATT, to compare and contrast characteristics, evacuation procedures, in-flight treatments, patient injuries/illnesses, and outcomes between the two groups. We conducted a retrospective cohort study of CCATT and BFT patients, admitted to the burn ICU between January 1, 2001 and September 30, 2018. Patients with total body surface area burned (TBSA) >30% were evacuated by BFT, while CCATT evacuated patients with ≤ 30% TBSA. Ninety-seven patients met inclusion criteria for this study. Of these, 40 (41%) were transported by the BFT and 57 (59%) were transported by CCATTs. Compared with patients transported by CCATTs, patients transferred by the BFT had higher median TBSA and full-thickness burn size, higher prevalence of chest, back and groin burns, and higher prevalence of inhalation injury. BFT patients had increased hospital days (62 vs. 37; P = .08), ICU days (29 vs. 12; P = .003) and ventilator days (14 vs. 6; P < .001). TBSA was the only variable significantly associated with ARDS (aOR = 1.04; 95% CI: 1.01, 1.08; P = 0.04), renal failure (aOR = 1.07; 95% CI: 1.03, 1.11; P = .002), and mortality (aOR = 1.08; 95% CI: 1.03, 1.13; P = .001). Evacuation by the BFT was associated with increased ICU and ventilator days, increased mortality, and a greater risk for developing renal failure. The severity of injury/TBSA likely accounted for most of these differences.

TELE-ECMO FOR A YOUNG, ACTIVE DUTY SERVICEMEMBER IN A DOMESTIC COVID-19 HOTSPOT

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Through the Joint Tele-Critical Care Network (JTCCN), the U.S. military has demonstrated that tele-critical care (TCC) services can facilitate the safe delivery of critical care beyond the consulting provider's level of training. While TCC has been described in a variety of scenarios, virtual health support of adult extracorporeal membrane oxygenation (ECMO) management has not been previously reported. We present a case of a young, active duty servicemember with COVID-19 pneumonia complicated by acute hypoxemic respiratory failure refractory to conventional therapy who was cannulated for veno-venous ECMO and successfully managed for 72 hours with TCC support. CASE PRESENTATION: A 39 year-old male Active Duty Service Member (ADSM) presented to Naval Medical Center San Diego (NMCSD) with hypoxemic respiratory failure five days after a positive SARS-CoV-2 PCR test. He was given supportive oxygen therapy, Remdesivir and dexamethasone. On hospital day nine, he was intubated for refractory hypoxemia and the ratio of arterial pO2 to fraction of inspired oxygen (P/F ratio) one hour later was 74. Neuromuscular blockade and prone positioning were initiated. Three days later, the P/F ratio remained less than 100. A request to transfer the patient to a local partner facility for ECMO was declined due to lack of bed availability.The San Antonio Military Medical Center (SAMMC) ECMO Team was consulted via TCC and the patient was placed on veno-venous ECMO, as personnel at NMCSD had previously undergone cannulation training. The NMCSD critical care team had round-the-clock secure video teleconferencing connection to the perfusionists and physician ECMO specialists at SAMMC during this time. After 72 hours of tele-ECMO management without complications, a U.S. Air Force Critical Care Air Transport Team safely transferred the patient 1,276 miles by fixed-wing aircraft to SAMMC for ongoing care. DISCUSSION: As the only certified ECMO center in the Department of Defense and one of the few centers in the world with global air transport capability, SAMMC has partnered with NMCSD to provide short-term ECMO care with TCC support. Previously, this capability had not been demonstrated over a period longer than a few hours. Because this patient's clinical decompensation occurred during the peak of the COVID-19 surge in Southern California, rapid transfer to a local ECMO center was not possible. In this case, JTCCN enabled the provision of lifesaving advanced cardiopulmonary support to an ADSM until aeromedical evacuation could be arranged. CONCLUSIONS: This case serves as proof-of-concept for a hub and spoke model of tele-ECMO support to global military medical facilities, demonstrating the potential to bring sophisticated lifesaving technology to medically-austere environments anywhere in the world. REFERENCE #1: Davis K, Perry-Moseanko A, Tadlock MD, Henry N, Pamplin J. Successful Implementation of Low-Cost Tele-Critical Care Solution by the U.S. Navy: Initial Experience and Recommendations. Mil Med. 2017 May;182(5):e1702-e1707. doi: 10.7205/MILMED-D-16-00277. PMID: 29087914. REFERENCE #2: Read MD, Nam JJ, Biscotti M, Piper LC, Thomas SB, Sams VG, Elliott BS, Negaard KA, Lantry JH, DellaVolpe JD, Batchinsky A, Cannon JW, Mason PE. Evolution of the United States Military Extracorporeal Membrane Oxygenation Transport Team. Mil Med. 2020 Dec 30;185(11-12):e2055-e2060. doi: 10.1093/milmed/usaa215. PMID: 32885813. REFERENCE #3: Badulak J, Antonini MV, Stead CM, Shekerdemian L, Raman L, Paden ML, Agerstrand C, Bartlett RH, Barrett N, Combes A, Lorusso R, Mueller T, Ogino MT, Peek G, Pellegrino V, Rabie AA, Salazar L, Schmidt M, Shekar K, MacLaren G, Brodie D. ECMO for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization (ELSO). ASAIO J. 2021 Feb 26. doi: 10.1097/MAT.0000000000001422. Epub ahead of print. PMID: 33657573. DISCLOSURES: No relevant relationships by John Hunninghake, source=Web Response No relevant relationships by Phillip Mason, source=Web Res onse No relevant relationships by Jeremy Pamplin, source=Web Response No relevant relationships by Nick Rohrhoff, source=Web Response No relevant relationships by Melissa Rosas, source=Web Response No relevant relationships by Jesse Sherratt, source=Web Response No relevant relationships by Robert Walter, source=Web Response

Descriptive Analysis of Coronavirus Disease 2019 Air Medical Evacuations by Critical Care Air Transport Teams

ObjectivePreserving air medical evacuation capabilities for critically ill patients with coronavirus disease 2019 (COVID-19) required innovation for en route care logistics, training, and equipment. The aim of this study was to describe characteristics and in-flight interventions for patients with suspected COVID-19 requiring air medical evacuation by US Air Force critical care air transport teams (CCATTs). MethodsWe performed a retrospective chart review of patients with suspected COVID-19 requiring air medical evacuation by CCATT from April 2020 to February 2021. We included patients with an available CCATT medical record and transport with COVID-19 infection isolation precautions. CCATT medical records were the data source, and we performed descriptive analyses of patient characteristics and in-flight interventions. ResultsWe reviewed 460 records and identified 16 patients for inclusion. The Transport Isolation System (50%) and Negatively Pressurized Conex (31%) were commonly used portable biocontainment units. The median patient age was 48.5 years, and 94% were male. All patients required oxygen supplementation, with 8 (50%) receiving mechanical ventilation. In-flight interventions among intubated patients (n = 8) included vasopressors (50%), paralytics (25%), and patient-ventilator asynchrony management (63%). ConclusionPatients with COVID-19 requiring CCATT transport were older than prior military en route care cohorts, and in-flight interventions for patient-ventilator asynchrony were commonly required during mechanical ventilation.

Deployment Stressors in United States Air Force Nurses Associated with the Experience of Moral Distress

Deployment stressors among military service members are well-documented in the literature such as those related to the horrific experiences often encountered in a war setting. However, less known are the implications of military healthcare professionals providing clinical care in a deployed setting. Previously conducted research examined the experience of moral distress in U.S. Air Force Critical Care Air Transport (CCAT) nurses. A secondary analysis was completed to identify the deployment stressors which affected the nurses' experiences of moral distress. Utilizing an explanatory narrative qualitative approach, 15 previously transcribed interviews were analyzed to identify and describe stressors associated with moral distress experiences told by CCAT nurses in the earlier research study. While the identified stressors cannot be referred to as moral distress, the situation were precipitated or exacerbated by the deployment stressors. Eight themes, with descriptors, resulted from the analysis of interviews. Mitigating strategies to target deployment stressors related to the experience of moral distress may equip healthcare providers to better manage the encounters that arise in the deployed environment, thereby reducing its negative impact.

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...

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.

The critical care air transport experience

There have been over 8000 documented patients transported by US Air Force critical care air transport teams (CCATT) since the beginning of US military involvement in Iraq and Afghanistan (Ingalls et al. in JAMA 149:807–13, 2014). As part of the joint service, integrated and multi-tiered aeromedical evacuation system (AES), critically ill or injured service members are transported by CCATT on tactical (short range, within a theatre of operations) and strategic (long range, between theatres of operation) missions. Within the AE system, patients move through five echelons of care, beginning with care at the point of injury and culminating at major military medical centers in the United States. Patients with critical injuries sustained during support of Operation Iraqi Freedom (OIF) or Operation Enduring Freedom (OEF) are first transported to Landstuhl Regional Medical Center (LRMC) in Germany where they are further stabilized for transport back to US facilities. Flight times between evacuation hospitals within the theatre of operations and LRMC can be as long as nine hours. During transport, CCATT monitor patients and continue ongoing resuscitation and treatment plans. Teams are equipped and prepared to intervene should emergent care be required. Critical patients transported to LRMC will often undergo further surgery and frequently require ICU level care with CCATT for transport from LRMC back to the USA. During the peak of conflicts in Iraq and Afghanistan, aeromedical evacuation of critical patients from the point of injury back to the US typically took 2–4 days (Dorlac et al. in J Trauma 66:S164–71, 2009). The paradigm of transporting “stabilizing” patients, even those with severe traumatic injuries over transcontinental distances and often just hours after initial damage control surgery, is supported by a 0.02 % en route mortality rate and a 98 % survival rate among individuals wounded in OIF/OEF that are transported back to LRMC (Ingalls et al. in JAMA 149:807–13, 2014). The long-range transport of critical patients in the austere environment of a military aircraft creates unique challenges for the transport team and is a vital part of the evolving globally mobile medical support apparatus. This article describes both the role of Air Force CCATT within the context of the integrated military AES and the CCATT mission experience in the deployed environment. The role of specialized transport teams and the expanding role of CCATT in a variety of noncombat operations will also be discussed.

Reducing secondary insults in traumatic brain injury.

To determine the alterations in intracranial pressure (ICP) during U. S. Air Force Critical Care Air Transport Team transport of critically injured warriors with ICP monitoring by intraventricular catheter (IVC). Patients with an IVC following traumatic brain injury requiring aeromedical evacuation from Bagram to Landstuhl Regional Medical Center were studied A data logger monitored both ICP and arterial blood pressure and was equipped with an integral XYZ accelerometer to monitor movement. Eleven patients were studied with full collection of data from takeoff to landing. The number of instances of ICP>20 mm Hg ranged from 0 to 238 and duration of instances ranged from 0 to 3,281 seconds. The number of instances of ICP±50% of the baseline ICP ranged from 0 to 921 and duration of instances ranged from 0 to 9,054 seconds. Five of the patients did not experience ICP>20 mm Hg throughout their flight, but 10 patients showed instances of ICP±50% of baseline ICP. Patient movement results in changes in ICP both from external stimuli (vibration, noise) and from acceleration and deceleration forces. During transport, Critical Care Air Transport Team crews should prioritize monitoring and correcting ICP including additional sedation and/or venting IVC.

365 En Route Use of Opioids, Ketamine, and Epidural Analgesia to Treat Pain in Awake Patients Transported Out of Combat Zones by US Air Force Critical Care Air Transport Teams

Critical Care Air Transport Teams (CCATT) transport critically injured patients with acute pain. Methods such as epidural and regional anesthetics, and ketamine are used alone or in combination with parenteral opioids. Limited data has been reported about analgesic administration en route, and no study has reported analgesic use and in-flight adverse events for CCATT. Our objective was to describe analgesic use and adverse events on CCATT for non-intubated, awake, critically injured trauma patients during evacuation from a combat setting.

193 In-Flight Blood Administration is not Associated With Pre-Flight Hemoglobin Levels in Patients Evacuated Out of Combat by U.S. Air Force Critical Care Air Transport Teams

193 In-Flight Blood Administration is not Associated With Pre-Flight Hemoglobin Levels in Patients Evacuated Out of Combat by U.S. Air Force Critical Care Air Transport Teams

Short-term Outcomes of US Air Force Critical Care Air Transport Team (CCATT) Patients Evacuated from a Combat Setting

Purpose. The purpose of this study is to describe the short-term outcomes (during air transport) of patients managed by the United States Air Force Critical Care Air Transport Teams (CCATT). Methods. This is a retrospective chart review of patients who were transported by CCATT between March 1, 2007 and June 30, 2008. A standardized abstraction form was used. Patients were classified as medical or trauma. Care given inflight was documented, including mechanical ventilation, vasoactive medication administration, and administration of blood products. Short-term events (during air transport) included death, oxyhemoglobin desaturation, hypotension, decline in neurological status, development of anuria or oliguria, and dislodgement of endotracheal and chest tubes. Results. A total of 656 patient moves met inclusion criteria, of which 425 (64.8%) were trauma and 231 (35.2%) were medical. Mechanical ventilation was required by 318 (49%), 68 (10%) received vasoactive medications, and 43 (7%) required blood products during the flight. There were a total of 75 events documented on 65 patient transports (10%). Of these, 19 were oxyhemoglobin desaturation, 29 were hypotension, 3 were decline in neurological status, and 23 were due to anuria or oliguria. We did not encounter any deaths or loss of airway or chest tubes during transport. Conclusion. CCATTs are a successful platform in transporting critically injured/ill patients with minimal short-term complications. Key Words: Critical Care Air Transport; emergency medical services; prehospital; resuscitation; tactical combat casualty care

Occurrence of Secondary Insults of Traumatic Brain Injury in Patients Transported by Critical Care Air Transport Teams From Iraq/Afghanistan: 2003–2006

Traumatic brain injury patients are susceptible to secondary insults to the injured brain. A retrospective cohort study was conducted to describe the occurrence of secondary insults in 63 combat casualties with severe isolated traumatic brain injury who were transported by the U.S. Air Force Critical Care Air Transport Teams (CCATT) from 2003 through 2006. Data were obtained from the Wartime Critical Care Air Transport Database, which describes the patient's physiological state and care as they are transported across the continuum of care from the area of responsibility (Iraq/Afghanistan) to Germany and the United States. Fifty-three percent of the patients had at least one documented episode of a secondary insult. Hyperthermia was the most common secondary insult and was associated with severity of injury. The hyperthermia rate increased across the continuum, which has implications for en route targeted temperature management. Hypoxia occurred most frequently within the area of responsibility, but was rare during CCATT flights, suggesting that concerns for altitude-induced hypoxia may not be a major factor in the decision when to move a patient. Similar research is needed for polytrauma casualties and analysis of the association between physiological status and care across the continuum and long-term outcomes.

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Introduction: US Air Force Critical Care Air Transport Teams (CCATTs) are a unique component of the military medical evacuation system. An understanding of the epidemiology of contemporary warfare is essential for pre-deployment training and optimal outcomes for critically injured warriors. We performed an epidemiological analysis of military patients transported by CCATTs during a discrete period of time. Hypothesis: The epidemiology of contemporary wartime casualties requiring critical care air transport contrasts with the characteristcs of patients seen in previous conventional conflicts. Methods: The primary source of data was the US Transportation Command (TRANSCOM) Regulating and Command and Control (C2) Evacuation System (TRAC2ES). Secondary sources were reviewed and abstracted to compare injury patterns. Descriptive statistics were used to describe the cohort. Results: Final analysis of 2011 TRAC2ES data included 396 CCATT patient transports, representing 290 patients after duplicate transports were removed. The median age was 25 years (IQR, 22 to 33). The majority of transports were male (97.6 %). The most common ICD-9-CM diagnosis was bilateral lower extremity amputation (40%). Nineteen cases of acute coronary syndromes were reported (6.6%). Nine patients with stroke were transported (3.1%). Forty-six cases of traumatic brain injury were reported (15.9%), although reporting for this injury was inconsistent. Only two patients (0.7%) had a primary diagnosis of burns. 125 subjects were injured as the result of an improvised explosive device (IED) explosion (43%), of which 87 (66%) occurred while patients were dismounted from vehicles. In 2011, more non-battle related injuries and illnesses were reported, as compared to historic data from 2001-06. Conclusions: The epidemiology of patients transported by CCATT has changed with contemporary warfare. Amputations and IED injuries were more prevalent in 2011. A higher prevalence of non-battle related injuries and explosion-related injuries may be expected in similar future conflicts. Studies of CCATT epidemiology will help focus training programs and direct evidence-based practices aimed at improving both survival and morbidity for the most severely injured casualties.

Closing the “Care in the Air” Capability Gap for Severe Lung Injury: The Landstuhl Acute Lung Rescue Team and Extracorporeal Lung Support

The success of US Air Force Critical Care Air Transport Teams (CCATT) in transporting critically ill and injured patients enabled changes in military medical force deployment and casualty care practice. Even so, a subset of casualties remains who exceed even CCATT capabilities for movement. These patients led to the creation of the Landstuhl Acute Lung Rescue Team (ALeRT) to close the "care in the air" capability gap. The ALeRT Registry was queried for the period between November 1, 2005, and June 30, 2010. Additionally, Landstuhl Regional Medical Center critical care patient transfers to host nation medical centers were reviewed for cases using extracorporeal lung support systems. For the review period, US Central Command activated the ALeRT on 40 occasions. The ALeRT successfully evacuated patients on 24 of 27 missions launched (89%). Three patients were too unstable for ALeRT evacuation. Of the 13 remaining activations, four patients died and nine patients improved sufficiently for standard CCATT movement. The ALeRT initiated pumpless extracorporeal lung assistance six times, but only once to facilitate evacuation. Two patients were supported with full extracorporeal membrane oxygenation support after evacuation due to progressive respiratory failure. ALeRT successfully transported 24 casualties from the combat zones to Germany. Without the ALeRT, these patients would have remained in the combat theater as significant consumers of limited deployed medical resources. Pumpless extracorporeal lung assistance is already within the ALeRT armamentarium, but has only been used for one aeromedical evacuation. Modern extracorporeal membrane oxygenation systems hold promise as a feasible capability for aeromedical evacuation.