2012 Air Transport

EM Critical Care
UNDERSTANDING AND CARING FOR

CRITICAL ILLNESS IN EMERGENCY MEDICINE
Air Transport Of The Critically Ill Authors

Volume 2, Number 4
Emergency Department Patient Susan R. Wilcox, MD

Physician, Department of Emergency Medicine, Department of
Anesthesia, Critical Care and Pain Medicine, Massachusetts
General Hospital, Boston, MA
Abstract William W. Tollefsen, MD
Harvard-Affiliated Emergency Medicine, Brigham and Women’s
Hospital, Boston, MA
Critically ill patients often require the specialized care offered only
Peer Reviewers
at tertiary care centers and must frequently be transferred from
referring emergency departments. This transportation often oc- Francis X. Guyette, MD, MS, MPH, FACEP
Assistant Professor of Emergency Medicine, University of
curs by air. Currently, there are no widely accepted or mandated Pittsburgh School of Medicine, Pittsburgh, PA
guidelines regulating critical care transport, and regional medical Carl Laffoon, DNP, APRN, CNP, CFRN, CEN, EMT-P
transport systems have disparate models of performing this service. President, Partners in Health MultiCare Clinic, Tuttle, OK; Medical
It is essential for practicing emergency physicians to be aware of the Manager, Air Methods Corporation, Englewood, CO
current evidence supporting critical care transport as well as federal Michael Lewell, MD, FRCP
Associate Professor of Medicine, Western University; Medical
laws regarding transfer of patients. With the variability in medi- Director, Southwest Ontario Regional Base Hospital; Medical
cal systems, each region has diverse resources and protocols, and Director, Ornge Air Ambulance Service, London, Ontario, Canada
emergency physicians should be aware of these prior to needing to Juan C. Nalagan, MD
Medical Director, MediFlight of Oklahoma; Assistant Professor,
transfer a patient. Select populations should be considered for air Department of Emergency Medicine, University of Oklahoma
transport, and certain patients will require resources beyond typical School of Medicine, Oklahoma City, OK
helicopter transport teams. This review highlights the indications for CME Objectives
helicopter transport of critically ill emergency department patients, Upon completion of this article, you should be able to:
the capabilities of many critical care transport teams, and current 1. Discuss potential capabilities of critical care transport and
controversies in the field. become motivated to explore the capabilities and nuances of
your own local service.
2. Describe how particular patient populations benefit from
Case Presentation critical care transport and recognize those who would benefit
from air transport.
3. Describe techniques for initiation of critical care transport,
A 54-year-old man presents to your community ED complaining of and discuss the current safety concerns within the industry.
abdominal pain and numbness in his right leg. Shortly after arrival to the 4. Recognize contraindications to air transport of the critically ill.
ED, he complains of pain extending to his chest. He describes the pain as a 5. Summarize the current evidence relating to the use of critical
“tearing” sensation that rips through his chest and back between his shoul- care transport.
der blades. The pain is constant, and he has never experienced it before. On Prior to beginning this activity, see “CME Information”
physical exam, his blood pressure is 208/110 mm Hg, and his pulse is 110 on the back page.
Editor-in-Chief Center for Resuscitation Science, Andy Jagoda, MD, FACEP Julie Mayglothling, MD Emanuel P. Rivers, MD, MPH, IOM
Robert T. Arntfield, MD, FRCPC, Philadelphia, PA Professor and Chair, Department Assistant Professor, Department Vice Chairman and Director
FCCP of Emergency Medicine, Mount of Emergency Medicine, of Research, Department of
Assistant Professor, Division Lillian L. Emlet, MD, MS, FACEP Sinai School of Medicine; Medical Department of Surgery, Division Emergency Medicine, Senior
of Critical Care, Division of Assistant Professor, Department of Director, Mount Sinai Hospital, New of Trauma/Critical Care, Virginia Staff Attending, Departments of
Emergency Medicine, Western Critical Care Medicine, Department York, NY Commonwealth University, Emergency Medicine and Surgery
University, London, Ontario, of Emergency Medicine, University Richmond, VA (Surgical Critical Care), Henry
Canada of Pittsburgh Medical Center; William A. Knight, IV, MD Ford Hospital, Clinical Professor,
Program Director, EM-CCM Assistant Professor of Emergency Christopher P. Nickson, MBChB, Department of Emergency
Fellowship of the Multidisciplinary Medicine, Assistant Professor MClinEpid Medicine and Surgery, Wayne State
Associate Editor Critical Care Training Program, of Neurosurgery, Emergency Senior Registrar, Emergency University School of Medicine,
Scott Weingart, MD, FACEP Pittsburgh, PA Medicine Mid-Level Program Department, Alice Springs Detroit, MI
Associate Professor, Department of Medical Director, University of Hospital, Alice Springs, Australia
Emergency Medicine, Mount Sinai Michael A. Gibbs, MD, FACEP Cincinnati College of Medicine, Isaac Tawil, MD
School of Medicine; Director of Professor and Chair, Department Cincinnati, OH Jon Rittenberger, MD, MS Assistant Professor, Department of
Emergency Critical Care, Elmhurst of Emergency Medicine, Carolinas Assistant Professor, Department Surgery, Department of Emergency
Hospital Center, New York, NY Medical Center, University of North Haney Mallemat, MD of Emergency Medicine, Medicine, University of New
Carolina School of Medicine, Assistant Professor, Department University of Pittsburgh School of Mexico Health Science Center,
Chapel Hill, NC of Emergency Medicine, University Medicine; Attending, Emergency Albuquerque, NM
Editorial Board of Maryland School of Medicine, Medicine and Post-Cardiac Arrest
Benjamin S. Abella, MD, MPhil, Robert Green, MD, DABEM, Baltimore, MD Services, UPMC-Presbyterian
FACEP Hospital, Pittsburgh, PA
Research Editor
FRCPC
Assistant Professor, Department Evie Marcolini, MD, FAAEM Amy Sanghvi, MD
Associate Professor, Department
of Emergency Medicine and Department of Emergency
of Anaesthesia, Division of Critical Assistant Professor, Department of
Department of Medicine / Emergency Medicine and Critical Medicine, Mount Sinai School of
Care Medicine, Department of
Section of Pulmonary Allergy Care, Yale School of Medicine, Medicine, New York, NY
Emergency Medicine, Dalhousie
and Critical Care, University of University, Halifax, Nova Scotia, New Haven, CT
Pennsylvania School of Medicine; Canada
Clinical Research Director,
beats per minute. He is diaphoretic with tenderness to fusionist, or physician.3,4 Although scene transfers
palpation in his upper abdomen that is most prominent in are commonly studied, almost 80% of CCT mis-
the epigastrium. The chest and cardiac exams are normal, sions are interfacility transfers.5,6
but he has 4/5 strength and decreased sensation in his left Despite the expertise of CCT teams, the trans-
leg. Lab results are all within normal limits. ECG dem- fer of critically ill patients is not without risk. Even
onstrates sinus tachycardia without ischemic changes. A transportation of critically ill patients within the
CT scan demonstrates a dissection from the aortic root hospital is associated with increased adverse events
to the level of the common iliac arteries. IV esmolol and when patients are not accompanied by appropriate
nitroprusside are started, and bilateral radial arterial staff.7,8 The risk of adverse events is increased when
lines are placed to monitor blood pressures. The diagno- interhospital transport is considered,7 as EMS trans-
sis is obvious, and the correct emergency treatment has port is performed around the clock, at high speeds,
been initiated. This patient needs life-saving surgery, but and with short response times on an unscheduled
cardiothoracic surgical support is not available at your basis. Mitigating this risk by adequately stabilizing a
hospital. You need to transfer this critically ill patient. patient and employing the correct resources is essen-
tial. The potential benefit of emergent transfer must
Introduction outweigh the potential risk.
Unfortunately, there are significant regional
Motor vehicle collisions, myocardial infarctions, disparities in CCT services as there are no uniform
drownings, childbirth, and gunshot wounds are national requirements or mandated skill sets for
all examples of acute presentations that require CCT providers. The Commission on Accreditation of
immediate medical attention. Emergency medical Medical Transport Services (CAMTS) has evolved as
services (EMS) personnel provide vital care while an accrediting body for air CCT; however, CAMTS
they treat and transport the sick or injured to ap- accreditation is not required for organizations pro-
propriate medical facilities.1 EMS providers are also viding air CCT.
accustomed to transferring patients from the emer- It is important for any physician needing to
gency department (ED) of one facility to another transfer a critically ill patient to be aware of avail-
for tertiary or definitive care that is not available at able regional EMS and CCT resources. While occa-
the sending facility. sionally a CCT service medical director or transport
While variability exists from state to state, physician will accept “shared responsibility” for a
many EMS options are available in most areas, patient in transport, the Emergency Medical Treat-
including basic life support (BLS), advanced life ment and Active Labor Act (EMTALA) stipulates
support (ALS), and critical care transport (CCT) that a transferring physician remains responsible
services. BLS ambulances can provide rapid ground for the patient’s care until the patient has arrived
transport, oxygen therapy, and fracture or spinal at the receiving institution.9,10 Familiarization with
immobilization. ALS ambulances can provide regional EMS capabilities and the transfer policies of
additional cardiac monitoring, advanced airway local tertiary care facilities is imperative to provide
management, and intravenous (IV) therapy with patients with the highest level of care.
limited pharmacologic intervention, typically by This issue of EMCC will discuss the advantages
maintaining continuous infusion rates. ALS ser- and disadvantages of air CCT, describe techniques
vices, however, cannot titrate medications, cannot for initiation of CCT, and discuss contraindications
provide invasive monitoring or intervention, and to air CCT.
transport primarily by ground.
CCT teams consist of a small cadre of highly Critical Appraisal Of The Literature
trained EMS professionals who travel by air or
ground and are regularly called upon to transport The data for helicopter transport of the critically ill
critically ill patients. Not only are CCT teams able ED patient have limitations similar to much of the
to travel by air via rotor or fixed-wing aircraft, they EMS literature. Due to the emergent nature of patient
can also provide invasive monitoring, advanced presentations and variability in transport systems,
ventilator support, cardiac pacing, defibrilla- performing high-quality, broadly generalizable stud-
tion, central line access, needle thoracostomy, and ies is challenging. There are no randomized trials of
advanced airway management (including surgical helicopter transport, and, as such, the majority of the
approaches). Additionally, CCT teams typically literature for helicopter transport consists of observa-
have a substantial pharmacy, including vasoactive tional studies, case series, and expert opinion.
agents, volume expanders, sedatives, analgesics, Many studies attempt to control for variability
paralytics, antiarrhythmics, and anticonvulsants.2 in patients by using the Injury Severity Score (ISS) or
A typical CCT team in the United States will consist the Trauma Related Injury Severity Score (TRISS).11 A
of specially trained nurses and paramedics, but commonly noted limitation of these scoring systems
they may also include a respiratory therapist, per- is that they require clinical information that is only
EMCC © 2012 2 www.ebmedicine.net • Volume 2, Number 4

obtained after transport, thereby limiting their use include the need for tertiary care services not avail-
in a prospective manner. These studies are further able at the referring hospital, such as specialist care,
limited by insufficient reporting of transport times, advanced diagnostics, or specialized procedures.
transport distances, and patient data. Studies often Nonclinical reasons for transfer occur in a minority
lack a control group, or, in the case of air versus of cases13 and include lack of a critical care bed or
ground transport, the ground cohort is used as the repatriation to a patient’s local hospital. These trans-
control. Many authors use multiregression analyses ports should be avoided, if possible, as the transfer
to account for differences in the subsets of patients of a critically ill patient for a reason other than medi-
transported by each mode, but these may leave some cal necessity is an undue risk for both the patient
factors unaccounted for, leading to selection bias and and the crew. All practitioners should be aware of
reporting bias. Despite well-designed meta-analyses federal and state laws regarding patient transfers,
of helicopter transport, the diverse patient popula- including EMTALA, which defines the legal respon-
tions, variability of trauma systems, and inconsistent sibilities regarding initiation of patient transfer. EM-
reporting of outcomes in the primary studies pre- TALA was enacted to prevent patient “dumping,”
clude strong evidence-based guidelines. and it states that a hospital must provide a medical
Due to the homogeneity of trauma patients, screening examination and stabilization to the best
studies on helicopter transport are commonly of the hospital’s capability prior to transfer.9,14
centered around these patients. Studies of trauma A discussion of the risks and benefits of transfer
patients benefit from substantial local and national must be held with, and informed consent must be
trauma registries as well as a uniform trauma obtained from, a competent patient or the patient’s
scoring system (ie, TRISS). The majority of these legally authorized representative prior to trans-
studies have evaluated outcomes associated with fer. Documentation of this conversation should be
transporting patients from the scene of the trauma placed in the medical record. In the case of a life-
to a trauma center rather than interfacility transport. threatening emergency, if informed consent is not
Although not directly applicable to the interhospital obtained, the indications for the transfer and the
transport of critically ill ED patients, the best avail- rationale for not obtaining consent must be docu-
able data support the efficacy of CCT for improving mented. The referring physician must write an order
outcomes for trauma patients. for transfer in the medical record.7 Although trans-
Many of the studies and guidelines regarding fers from EDs constitute a significant proportion of
CCT and helicopter transport are from Australia, the interhospital transports, data indicate that there are
United Kingdom, and other areas of Europe. While significant deficiencies in providing adequate equip-
some studies and their outcomes are applicable to ment, patient monitoring, staff training, and docu-
the United States, the differences in healthcare sys- mentation of the transfer.15 In one survey, only 56%
tems (such as hospital design, geography, etc) may of EDs in the United Kingdom had established de-
limit broad application. The Intensive Care Society partmental transfer guidelines.15 Emergency physi-
published guidelines regarding CCT in 2002, 2007, cians should review their institution’s resources and
and 2011. The American College of Critical Care policies prior to encountering a situation in which a
Medicine published guidelines for the interhospital patient requires transport.
and intrahospital transport of critically ill patients in The ultimate decision to transfer rests with the
1993; these guidelines were revised in 2004 but have referring physician. Once the decision is made to
not been updated since. transfer the patient, the referring physician must
find an accepting institution. This can be a difficult
Considerations For Critical Care Transport and time-consuming process unless the physician
has access to a local centralized referral center. An
Decision To Transfer Australian study found that transferring a patient
The decision to transfer a patient from one hospital required an average of 4.7 phone calls per patient
to another is ultimately determined by weighing the and a mean time of 1 hour from the time of the
potential benefits of transport to the patient against decision to transfer until the patient was accepted
the potential risks. There are little data available at a receiving facility.16 Once a receiving institution
about how clinicians make the decision to trans- is found, the referring physician must confirm that
fer patients or how clinicians determine patients’ appropriate higher-level services are available. The
suitability for transport; these decisions have been receiving physician should be given a full report
described as an ad hoc process.12 Transfer should of the patient’s condition, with an opportunity to
only occur if it is likely to improve the patient’s clini- ask questions. While the receiving institution may
cal outcome. Financial considerations should not be provide guidance and medical recommendations,
a factor when considering transferring a patient.7 the patient remains the responsibility of the referring
The indications for interhospital transfer from the hospital until arrival at a receiving institution.7,17
ED should be primarily clinical. Potential indications
www.ebmedicine.net • Volume 2, Number 4 3 EMCC © 2012

Decisions Regarding Mode Of Transport was a predictor of survival.32 Though subject to the
In most instances, the determination of how to limitations of any retrospective database review,
transport the patient — whether by helicopter or this study is the only large, nationwide survey of
ground — is that of the referring physician. Only transport practices in the United States.
in rare circumstances, such as when the transport Patients with moderate injuries (as determined
is to be provided by the receiving institution, does by the ISS) are more likely to benefit from helicopter
the receiving physician make this decision.7 When transport than those with scores at either extreme, as
selecting a mode of transport, the referring physician mildly injured patients will likely do well regardless,33
must consider the patient’s illness, clinical stability, and moribund patients are not likely to benefit from
urgency of transfer, availability of various transport either air or ground transport. A study in 2011 found
modalities, geography, traffic, and weather condi- that while air transport made no difference for patients
tions.7,17,18 The referring physician must also under- with lesser injuries (an ISS < 15), patients with an ISS >
stand the benefits and risks of helicopter transport. 15 did benefit from helicopter transport.31
While some authors assume that the primary A recent systematic review of helicopter trans-
benefit of helicopter-based transport is the decreased port literature demonstrated improved survival with
time to arrival at the receiving hospital,19 this is not the use of air CCT, although the review was limited
necessarily the case. The interval from the time the by inconsistent methodology in many of the stud-
decision is made to transport a patient until the pa- ies. When the 4 reliable studies in the review were
tient arrives at the receiving facility may be extended examined, an overall mortality reduction of 2.7 ad-
due to organizational issues that cause delays in he- ditional lives saved per 100 helicopter deployments
licopter dispatch.20 Many transports also entail long was found.35
ground legs if the helicopter must land at a helipad Although helicopter transport likely confers
remote from either facility.18,21 In addition, the air benefit for a subset of patients, this mode of trans-
CCT team may have to spend more time preparing port may incur additional risks to the patient and
the patient for transport than a ground ALS team.22-24 the crew. A significant increase in the number of air
However, despite the potentially increased total time ambulance crashes in recent years, out of propor-
until arrival at the receiving institution, the helicop- tion to the number of providers, has prompted more
ter offers the advantage of decreasing the time the scrutiny from regulators and media. The rate of EMS
patient spends in transit.20 This may be of particular helicopter crashes has increased over the last de-
benefit in unstable patients, for whom the time in the cade, from a rate of 1.7 per 100,000 in 1997 to 4.8 per
out-of-hospital setting should be minimized. 100,000 in 2004. In 2008, 9 crashes killed 35 people.36
Some authors and guidelines have recom- Crashes with fatalities most commonly occur at
mended that air transport be considered for travel night or in bad weather.37 Individual trauma sys-
distances greater than 50 miles or transfer times tems must develop triage criteria that maximize the
greater than 90 minutes.18,25 A study of scene trauma benefits of helicopter transport while minimizing the
transports found that if the patient was located risks of flying patients who are least likely to benefit
45 miles from the referring hospital, the patient’s from air transport.38
transport was faster by air even with nonsimulta- Once the decision is made to transport a patient
neous dispatch of the ground crew and helicopter by helicopter, the transport team should be contacted
crew.26 Others note, however, that defining a uni- to confirm availability and coordinate the timing of
versal distance beyond which the helicopter is faster the transport.7 Some systems provide a central dis-
is difficult.21 A study from Canada found that even patch center to streamline the referral process by com-
for long distances, due to variability in helipad municating with receiving institutions and arranging
placement, geography, and overall systems, ground an accepting physician if the sending physician has
transport may actually be faster.21 Therefore, deter- not already found one. In one region where multiple
mining when one should choose a helicopter based tertiary care centers are located, a “roster” system has
on distance alone is difficult. Selection will vary de- been established that allows a CCT dispatch center
pending upon aspects of the local healthcare system to activate a transport team and assign a receiving
as well as individual patient factors. hospital on a rotating “next-up” basis. One study
Although flying does not necessarily decrease has shown that this type of system allows for timely
time to arrival at the receiving facility, helicopter transport both to EDs and directly to operating rooms
transport does have benefits.27-34 A review of the and that patients have similar outcomes as those
National Trauma Data Bank, including nearly transported to predesignated facilities.39 Unfortunate-
260,000 patients, about 42,000 of which were ly, this system is not available in all areas.
transported by helicopter, was published in 2010.
While patients undergoing interhospital transport Patient Selection
by helicopter were more severely injured than
patients transported by ground, multiregression Specific populations that should warrant consider-
analysis demonstrated that helicopter transport ation for activation of a CCT team include multi-
trauma and burn patients, cardiac patients, and improve outcomes.44 Since most of the United States
stroke patients. population does not live near a 24-hour PCI center,
transfer to a PCI center is often done by air CCT.43-45
Trauma And Burns Transport of cardiac patients is not without risks.
Most research on the benefit of CCT and air transport One study of STEMI patients requiring transport
has evolved from trauma patients. Patients with mul- demonstrated that 79% of patients required an ALS
tisystem trauma or burns whose injuries exceed the intervention during transport (most commonly anti-
capacity of a referring facility should be transferred to arrhythmic administration).23
a trauma center. Approximately 42 million people in Unfortunately, other studies have identified
the United States live in rural areas without immedi- that the majority of STEMI patients transported by
ate access to specialist care, and 60% of all fatal motor helicopter had a transfer time that exceeded 2 hours
vehicle crashes occur in these rural areas.40 As such, and did not receive thrombolysis.23,46,47 The average
trauma patients are one of the largest patient groups patient transport time in one system was only 15
to undergo interfacility transport.30,41 minutes by air, but the hidden times of CCT trans-
Helicopter transport has been found to improve port are commonly not taken into account when a
outcomes for this population. A recently published sending physician is arranging transport.23
retrospective study of trauma patients transported The time taken to get to the patient’s bedside
from the scene by either air or ground to Level I or and package them for transport is commonly the
Level II trauma centers assessed for an association longest time lag. Incompatibility of pump tubing
between mode of transport and 14-day mortality rates. and monitoring cables and the need for additional
These authors found a 33% reduction in death when patient stabilization prior to lift-off are common rea-
the patients were transported by helicopter, although sons for this delay.46,48 Beyond early activation, one
they noted that patients with normal vital signs had no strategy to streamline care is to eliminate heparin
mortality benefit associated with air transport.33 Other and IIb/IIIa inhibitor infusions after bolus, as these
studies have shown that for patients with an ISS associ- medications have durations of action that exceed the
ated with a 10% or greater risk of dying, there was a average transport time of most CCT agencies. This
25% reduction in mortality among patients transported eliminates the need to transfer pumps and IV tubing
by air versus traditional ground services.31 as well as the need to set up infusions. This single
Time to intervention is one of the most im- change can significantly cut the time needed to pack-
portant factors in the care of hypotensive trauma age the patient for transport.46
patients.42 CCT’s benefit in traumatic hypotension CCT also plays a role in the transport of comatose
may be as much due to advanced medical resuscita- survivors of cardiac arrest. Therapeutic hypothermia to
tion as it is due to timely delivery to definitive surgi- a temperature of 32°C to 34°C (89.6°F-93.2°F) has been
cal therapy. CCT services bring critical care experts shown to improve neurological outcomes and is now
to the patient and offer capabilities that traditional recommended as part of the American Heart Associa-
EMS cannot always provide, including the ability to tion (AHA) guidelines for the care of out-of-hospital
intubate in transport with neuromuscular blockade, cardiac arrest.49 While no current consensus exists on
the ability to obtain intraosseous (IO) access, and the how quickly to initiate postarrest hypothermia, most
ability to provide narcotic analgesia. Furthermore, believe benefit is obtained when it is employed as early
aircraft launched from a base hospital can often as possible. Studies have suggested that infusion of 2 to
bring uncrossmatched blood, an essential nonsurgi- 4 L of normal saline at 4°C can drop core body tem-
cal intervention. perature by 1.5°C to 4°C.50 While this does not result in
maintenance of hypothermia, this technique employed
Cardiac: Time Is Muscle by CCT services is a practical way to initiate therapeu-
As time-sensitive interventions have become the tic hypothermia while transporting such critically ill
standard of care for cardiac patients; the use of CCT patients. (For a more detailed discussion of therapeutic
teams for transport of these patients has increased. hypothermia, see the April 2011 issue of Emergency
Percutaneous coronary intervention (PCI) has Medicine Practice, “Current Evidence In Therapeutic
proven to be superior to fibrinolysis,43 and transfer- Hypothermia For Postcardiac Arrest Care.”)
ring patients to PCI-capable hospitals has become a
major mission of CCT teams. The goal of emergency Neurologic: Time Is Brain
care providers is to obtain emergent revasculariza- Thrombolytic therapy for ischemic stroke has been
tion within 90 minutes of ST-segment elevation used since 1996, and acute stroke is a time-sensitive
myocardial infarction (STEMI) — or, if this not be diagnosis that commonly requires transport to spe-
possible, to initiate thrombolysis within 30 min- cialty centers. CCT services have played an increas-
utes. EMS protocols have been developed for rapid ingly important role in transporting patents to stroke
interfacility transport of STEMI patients to PCI centers for definitive evaluation and thrombolytic
centers; in one study, these protocols were shown to therapy.44,51,52 CCT plays a key role in programs

that allow a specialist, via teleconference, to provide illuminated display of the heart rhythm, blood pres-
expert opinion regarding the initiation of thromboly- sure, oxygen saturation, and (ideally) end-tidal CO2.
sis and subsequent transport of patients to specialty Given significant ambient noise within the aircraft,
centers where services such as intra-arterial throm- alarms should be visible as well as audible.7,18 When
bolysis, endovascular clot retrieval, and post-tissue not deployed, vehicles should be connected to shore-
plasminogen activator (t-PA) care can be obtained.51 power to ensure all equipment is fully charged and
CCT teams can closely monitor a patient’s blood secured. The National Patient Safety Agency (NPSA)
pressure, oxygenation, and evolution of neurological of England and Wales reports that there were 55
status to allow for early intervention to help prevent CCT equipment failures between August 2006 and
secondary brain injury. These critically ill patients February 2007, including loss of battery power for
often require advanced therapies, including ventila- monitors in 6 cases.58
tor and airway management as well as monitoring Additional required equipment includes defi-
of end-tidal CO2. Increased intracranial pressure can brillation and suction capabilities.7,18 A warming
also be monitored and treated accordingly. Tradi- blanket is useful, especially in colder climates.18
tional EMS agencies are not trained or experienced Syringe pumps with a long battery life are required,
enough to provide this level of care.52 as use of gravity drips during helicopter transport is
discouraged due to potential unreliability when fly-
Practical Considerations For Critical ing.7,18 All appropriate medications that the patient
requires or is likely to require en route should be
Care Transport available.7,18
Equipment for establishing and maintaining a
Staffing safe airway is essential. The CCT team should have
A principal concept in helicopter transport of a portable mechanical ventilator that can provide
critically ill patients is that they must continue to multiple modes of ventilation, variable oxygen con-
receive the same level of care they were receiving centrations, respiratory rates, and positive end-expi-
at referring hospitals up to and during transport. ratory pressure. The vehicle should carry sufficient
Studies have reported that standards of care during oxygen to last the duration of the transfer, plus a
transport may be suboptimal, due to lack of moni- reserve of 1 to 2 hours.18
toring and lack of appropriately trained staff.7,17,25
Patients should be accompanied by a minimum of Clinical Course In The ED
2 providers specifically trained in principles of CCT
and emergency medical procedures.7,17 In many Stabilization
countries, 1 provider is always a physician; however,
Prior to transport, patients should be stabilized as
in the United States, specialty trained nurse and
much as possible to minimize the risks of transport.
paramedic teams are the most common crew config-
Patients may not be able to be completely stabilized
uration.7 While many regions have dedicated CCT
without the tertiary care services they are being
teams, their availability is not universal.
transported to receive; in select cases, this may be
Data show that specialist CCT teams provide
acceptable.17 The referring physician must make the
better medical care. A study compared 168 transfers
determination that the benefits of transfer outweigh
performed by specialized transport teams with 91
the risks for such unstable patients. Nonessential
transfers performed by teams comprised of staff
tests or procedures that may delay transport should
from the referring facility. Patients transported by
be avoided.7 Several societies and authors have pub-
the specialist transport team were less likely to be
lished pretransport checklists.7,18 (See Figure 1.)
acidotic and hypotensive on arrival to the receiv-
On arrival at the referring institution, the trans-
ing facility.53 While some studies have shown worse
port team must be given a thorough report regard-
outcomes for head trauma patients intubated in the
ing the patient’s presentation and hospital course.17
field by paramedics, studies specifically examining
The team should perform a physical examination,
intubations performed by CCT teams demonstrate
including an airway assessment, prior to transport.
improved outcomes.54-56 Although some of these
If there is risk of airway deterioration, the airway
studies involved physicians, similar studies in the
must be secured prior to the patient leaving the
United States involving highly trained paramedic-
referring hospital.7,17,59 Though success rates for
based CCT teams have shown comparable results to
CCT intubation are generally excellent, intubation in
physician-led teams.56,57 These findings support the
the helicopter is more challenging than intubation at
notion that focused education and training of CCT
the referring institution. If the patient is intubated,
personnel are associated with improved outcomes.
adequate sedation must be provided. In appropriate
instances, paralytics should be provided to maxi-
Equipment
mize oxygenation and ventilation and to facilitate
Necessary equipment for patient monitoring dur- safe transport.
ing transport includes a portable monitor with an

Figure 1. Pretransport Checklist
Decision to Transfer:
Indication for transfer (specialist services, diagnostics, procedures):___________________________________________________________________
Does the benefit of transport outweigh the risks? n Yes n No
Accepting institution and physician: ____________________________________________________________________________________________
Does the accepting institution have the capability and capacity to care for this patient? n Yes n No
Has informed consent for transfer been obtained from patient or family? n Yes n No
If not, the reason for not obtaining consent:______________________________________________________________________________________
Mode of Transport:
Has the appropriate level of EMS service (BLS, ALS, CCT) been called? n Yes n No
Considering distance, geography, patient factors, need for a CCT team, and other factors, should this patient be transported by air? n Yes n No
Does this patient require specialized services? n IABP n Isolette n Pediatric Team n ECMO n Other: ____________________
Who will accompany the patient? n EMS providers n CCT team n Staff from referring or receiving institution n Other: ____________________
Equipment:
n Portable, lighted monitor
n Portable ventilator
n Oxygen source with 1-2 hours of additional reserves
n Airway equipment, including LMA or other rescue device
n Defibrillator
n Suction
n Syringe pumps
n Additional battery supplies
n All medications the patient is likely to require, including sedatives, paralytics, and vasoactive medications
n All resuscitative fluids the patient may require, including crystalloid and blood products, as indicated
Stabilization Prior to Transport:

Is the patient likely to require airway management en route? n Yes n No
If yes, has the airway been secured? n Yes n No
Does the patient have 2 routes of IV (or IO) access? n Yes n No
Have appropriate vasoactive medications been initiated? n Yes n No
Are trauma patients properly immobilized, with cervical-spine collars, backboards, and splinting of long-bone fractures, as indicated? n Yes n No
Have chest tubes been placed for all pneumothoraces, and has gastric decompression been initiated for all bowel obstructions? n Yes n No
Is the patient being monitored with:
l Continuous cardiac rhythm (ECG) monitoring n Yes n No
l Noninvasive blood pressure n Yes n No
l Oxygen saturation (SaO2) n Yes n No
l End-tidal CO2 (in ventilated patients) n Yes n No
l Temperature n Yes n No
Is the patient as well stabilized as possible? n Yes n No
Do all providers agree that the patient is ready to travel? n Yes n No
Communication:
Has the transport team been given a full report? n Yes n No
Has the receiving facility been updated of any new findings or clinical changes? n Yes n No
Has the referring nurse called the receiving nurse to give a nurse-to-nurse report? n Yes n No
Have copies been made of all clinical documentation? n Yes n No
Have images of radiographic studies been copied, and are they being sent with the patient? n Yes n No
If lab or radiographic data is not available at the time of transport, what is the plan to convey that information to the receiving hospital? ______________
________________________________________________________________________________________________________________________
Abbreviations: ALS, advanced life support; BLS, basic life support; CCT, critical care transport; ECMO, extracorporeal membrane oxygenation; ECG,
electrocardiogram; EMS, emergency medical services; IABP, intra-aortic balloon pump; IO, intraosseous; IV, intravenous; LMA, laryngeal mask airway.

Adequate IV access should be established, ide- Unfortunately, deterioration in transport is not
ally with 2 IVs, a central venous line, or an IO line. uncommon. A recent review of incidents that oc-
The patient’s underlying diagnosis will guide resus- curred in transport of critically ill patients in Aus-
citation goals, such as whether hypotensive resusci- tralia found that 59% of critical incidents (including
tation should be pursued, but the provider should both system-based and human-based errors such
be aware that resources such as blood products or as transport operations, haste, equipment malfunc-
large volumes of crystalloid may not be available in tion, failure to check pressure, etc) resulted in direct
transport unless provided to the transport team in patient harm. This study also found that 91% of the
advance. All appropriate hemodynamic agents for incidents were preventable.61 Additionally, a report
heart rate and blood pressure modification should from the Netherlands showed that 34% of patients
be started prior to transport in order to monitor the had an adverse event during transport, 70% of
patient’s response. which were considered to be avoidable.62 A study
Trauma patients should be maintained in from Canada found that critical events occurred
cervical-spine immobilization, and other fractures in 5.1% of air transports and were independently
should also be immobilized. Orogastric or nasogas- associated with prior hemodynamic instability, as-
tric tubes and Foley catheters should be placed, as sisted ventilation, and female gender.59
indicated.
Published guidelines17 recommend the follow- Special Circumstances
ing as minimum standards of monitoring during
air CCT: Most CCT teams are available 24 hours a day with
• Continuous cardiac rhythm monitoring via elec- a standard crew configuration that is able to handle
trocardiogram most emergencies and calls for service. Clinical situ-
• Noninvasive blood pressure ations may arise when a patient’s needs require ad-
• Oxygen saturation (SaO2) ditional or specialty personnel. When given notice,
• End-tidal CO2 (in ventilated patients) many CCT services can deploy specialty transport
• Temperature teams for specific patient populations. Such teams
include pediatric, neonatal, intra-aortic balloon
Intermittent noninvasive blood pressure cuffs pump (IABP), and extracorporeal membrane oxy-
may be unreliable due to motion artifact. If available, genation (ECMO) transport teams.
indwelling arterial lines are preferable. A central ve-
nous line may be of benefit, as it allows for monitor- Neonates And Pediatric Patients
ing central venous pressures and administration of Very few hospitals are equipped to manage complex
centrally acting medications.17 developmental and metabolic diagnoses or to care
for critically ill children. Neonates require a dispro-
Deterioration portionate number of interfacility transports for this
Critically ill patients tend to become unstable dur- reason.63 These transports often require specialized
ing transport,59 and helicopters are often cramped equipment such as transport isolettes, low-volume
and not conducive to active intervention.17,18 In the ventilators, and medications specific to pediatric
helicopter, if a patient deteriorates, there are few op- and neonatal care (ie, surfactant and prostaglandin).
tions for obtaining additional help. As compared to Given the complexities and cost of this specific equip-
ground transport, where the vehicle may reroute to ment, many regional pediatric centers have their own
a closer hospital if the patient deteriorates, altering CCT vehicles and staff.64 Other CCT services are able
the flight plan en route can be dangerous and is not to modify standard set-ups to provide this service.3
routinely recommended.
In addition to the constrained environment of the Patients With IABPs
helicopter, several factors specific to air transport war- While many 24-hour PCI centers have cardiac surgi-
rant consideration. Close monitoring of a critically ill cal services available, some hospitals that offer this
patient’s oxygenation during transport is essential, as service do not have surgical support. Some unstable
patients may become hypoxemic.17 As the decreased patients may require emergent cardiac surgical inter-
barometric pressure associated with altitude expands vention; IABPs and other ventricular assist devices of-
gas-filled cavities in the patient, untreated pneumo- fer a bridge to augment cardiac output until a surgical
thoraces can cause clinical deterioration.17 Flying is treatment is available. While uncommon, the capac-
associated with a decrease in temperature,60 and criti- ity to transfer IABP-dependent patients is available
cally ill patients may require additional interventions in many areas, and transport IABPs are available.65
to maintain body temperature. Noise and vibration Although not standard equipment on most CCT
can cause nausea, pain, and motion sickness. Anti- vehicles, IABPs can easily be added. Management of
emetic medications should be available for patients, these patients and devices usually requires adding a
and ear protection should be provided.17 perfusionist to the transport team, although studies

have shown that cross-trained critical care paramed- neonatal CCT team should be dispatched for neona-
ics can often perform this transport safely.3,66-68 tal care and transport.
Patients with injuries or conditions that would
Patients Requiring ECMO be made more severe with altitude should not be
Other specialty teams have been developed specifi- transported by CCT aircraft until these conditions are
cally for the transfer of patients requiring ECMO. appropriately stabilized. CCT aircraft typically fly at
Patients requiring ECMO are among the most altitudes less than 5000 feet, and, although this is a
critically ill and the most difficult to transfer. CCT lower altitude than commercial aircraft, most aero-
programs have developed protocols to transport medical helicopter cabins and patient compartments
such patients to ECMO centers.69 In some cases, are not pressurized. This can lead to alterations in
ECMO must be started prior to transport, and a normal physiology via Boyle’s and Dalton’s laws.
surgical team must be transported to the referring Boyle’s law states that at a constant tempera-
facility for cannulation and initiation of ECMO. ture, the volume of a gas varies inversely with
While few programs have developed specific pressure. Therefore, as altitude increases and
protocols or dedicated multidisciplinary healthcare atmospheric pressure decreases, the volume of gas
teams prepared to transport such complex patients, increases. This effect is seen on all gas-containing
transport ECMO circuits have been developed, and compartments of the body, including ears, sinuses,
successful transport has been performed with both and (most importantly) the gastrointestinal tract
veno-arterial and veno-venous circuits.70 Patients and lungs.72 Pneumothoraces or bowel obstructions
receiving ECMO are at increased risk for significant must be managed prior to flight. To prevent devel-
complications during transport, including the risk opment of tension pneumothorax, patients with
of decannulation and membrane lung thrombosis.70 any pneumothorax should have a chest tube(s)
The most common complication for interfacil- placed. Chest tubes should not be clamped during
ity transport of these patients is a loss of power, transport. For patients with bowel obstructions,
resulting in the need for manual hand cranking of nasogastric tube decompression should be per-
the ECMO circuit until power is restored.70 Close formed to minimize the risk of visceral expansion,
medical oversight of transport teams and coordina- worsening bowel ischemia, or perforation.73 The
tion of care is essential for the success of programs endotracheal tube cuff pressure should be moni-
that transfer patients receiving ECMO.70 (For an tored closely in intubated patients. While some
in-depth review of ECMO in the ED, see EMCC’s guidelines suggest that pneumoperitoneum and
research report, Extracorporeal Cardiopulmonary Re- pneumocephalus are relative contraindications to
suscitation In The Emergency Department.) air transport,7,17 these must be considered in the
context of the individual patient’s clinical circum-
Contraindications stances and other transport options available. Soft
tissues may also swell, and plaster casts should be
Not all critically ill patients who require transport to bivalved to prevent compartment syndrome.17 Air
specialty centers are appropriate for helicopter trans- transport is not absolutely contraindicated for other
port, even with a CCT team. Profoundly unstable or gas-containing devices such as esophageal tam-
coding patients are not candidates for transport. A ponade (eg, Blakemore) tubes; however, helicopter
patient in cardiac arrest will receive no benefit from crews must pay close attention to pressures main-
rapid transport during resuscitation, and CCT ser- tained in these devices during flight.
vices do not offer any additional therapy that is not Dalton’s law states that the pressure of a gas
already available at a local ED. Furthermore, while mixture is equal to the sum of the partial pres-
resuscitation does occur when needed in transport sures of all the gases contained in the mixture.
vehicles, choosing to do so in a dimly lit, cramped, Therefore, with increasing altitude and increas-
and moving space is not in the patient’s best interest. ing volume of a gas mixture (Boyle’s law), the
In fact, it is the policy of many EMS agencies to not percentage of an individual gas in the gas mix-
transport patients in cardiac arrest to a local hospital ture does not change. As a gas mixture’s volume
and to simply perform the resuscitation at the scene. increases with altitude, the gas molecules within
Patients are only transported if return of spontane- the mixture spread farther apart. One consequence
ous circulation is obtained.71 of this is that alveolar gas exchange becomes less
Active labor is also a contraindication for CCT. efficient, resulting in lower hemoglobin satura-
Many CCT programs have protocols prohibiting tion and hypoxia.72 During flight, this effect can
transport of women in active labor, as helicopters be mediated with supplemental oxygen and cabin
are not equipped to provide simultaneous maternal pressurization; however, even when passenger
and neonatal resuscitation. It is recommended that compartments are pressurized, it is only to the
delivery or tocolysis be achieved at the sending facil- equivalent of 5000 to 8000 feet — enough to cause
ity prior to transport, and, if needed, an additional hypoxia in patients with poor reserve.73

Controversies preparations should be made for departure. The
equipment should be rechecked, ensuring compat-
While the advanced care of CCT teams has been ibility and sufficient reserves of battery power and
shown to provide benefit in some subsets of patients, oxygen. Adequate supplies of medications, fluids,
the use of this expensive service is not always appro- and blood products, as indicated, should be veri-
priate or feasible, as the evidence reviewed here has fied. If using a pretransport checklist, as is recom-
shown. An increasing number of patients who could mended,18 it should be filled out at this time. Once
be transferred by ground services are being taken the referring physician and the CCT team agree
by air.74 A recent review of hospital-based helicopter that the patient is ready to travel, the CCT team
CCT services led to recommendations that Medicare can depart.
recover overpayments due to inadequate justification The importance of communication cannot be
of medical necessity for air CCT.74 One specific metric over emphasized. Although the CCT team will give
assessed by payers is the proportion of patients dis- a report to the receiving institution on arrival, the
charged within 23 hours of CCT. Some feel that this referring institution is still responsible for ensuring
metric is particularly unreasonable given that defini- that all clinically relevant information is commu-
tive imaging and expert consultations, which are nicated. In addition to the physician-to-physician
available only through transport, may ultimately rule discussion, a nurse-to-nurse report between the 2
out significant disease in an undifferentiated trauma hospitals should also be completed. If the patient
patient, allowing timely discharge. In addition, there has had any clinical change since the initial discus-
are concerns for over-triage of patients with non-life- sion between the 2 physicians, the referring physi-
threatening injuries where the use of the helicopter cian should notify the receiving physician. Copies of
may not make a difference in outcomes.75,76 all medical records, including laboratory values and
The United States has seen a dramatic increase images of radiographic examinations, should be pro-
in the number of aeromedical CCT providers; vided to the CCT team prior to departure. If some
however, there is significant variability of air CCT information is not available at that time, departure
organizations’ qualifications or capabilities. In 2005, should not be deferred; instead, the referring institu-
there were 753 rotor-wing aeromedical units in tion should send the data to the receiving institution
operation; in 1990, there were only 231.74 Along with as soon as possible.
this growth, there has also been a disproportionate
rise in helicopter crashes.36-38 Due to safety concerns Summary
and the increase in competition, groups such as
CAMTS have developed standards for medical care Critically ill patients in the ED often require trans-
and safety for the air medical industry. CAMTS ac- fer to tertiary care centers for specialized care. The
creditation is voluntary but is considered the “gold decision to transfer the patient lies with the referring
standard” for the industry. physician, who must weigh the potential benefits of
Despite generally being more expensive than transport against the risks. All emergency physicians
ground transport, a number of studies have found must be familiar with federal laws regarding the
helicopter transport to be cost effective. However, transfer of ED patients as well as locally available re-
given the variation inherent in the health systems in sources and protocols. The referring physician is re-
which helicopter transports operate, generalization sponsible for selecting the most appropriate method
of such findings across differing health environ- of transporting the patient as well as for the patient’s
ments is problematic.77 The most thorough cost-ben- care until arrival at the receiving institution.
efit study found that helicopter transport resulted Helicopter transport does not always decrease
in a $2500 cost per life-year, compared to a cost per the total time until arrival at the receiving facility,
life-year of $41,000 for zidovudine prophylaxis for but it often decreases the time in the out-of-hospital
HIV exposure.78 Another study found helicopter setting. Helicopter transport is usually performed
transport for thrombolysis in stroke patients to be by CCT teams that specialize in the transport of
associated with a cost of $35,000 per additional good critically ill patients. Patients should be stabilized
outcome and $3700 per quality-adjusted life year.79 A as much as possible, with special attention to the
recent study in the United Kingdom found helicop- airway and hemodynamics. If the patient is not able
ter transport to be well below cost-effectiveness ra- to be stabilized without tertiary care, the referring
tios described as generally acceptable by healthcare physician must carefully weigh the risks and ben-
economists and policy makers.34 efits of transport. Select patients may benefit from
CCT, including severely injured trauma patients,
Disposition cardiac patients, and stroke patients. Additionally,
highly specialized teams are often available to trans-
After the CCT team arrives and completes an port critically ill neonates and children, patients with
assessment, and the patient has been stabilized, IABPs, and patients requiring ECMO.

Patients with pneumothoraces and bowel ob- References
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flying. Furthermore, patients in cardiac arrest should Evidence-based medicine requires a critical appraisal
not be transported. Prior to departure, the equip- of the literature based upon study methodology and
ment and medications should be rechecked, and a number of subjects. Not all references are equally
transport checklist should be completed. The patient robust. The findings of a large, prospective, random-
should not leave until both the CCT team and the ized, and blinded trial should carry more weight than
referring physician agree that the patient is ready for a case report.
transport. To help the reader judge the strength of each
Although flying incurs additional risk, data reference, pertinent information about the study, such
support the use of helicopters to improve outcomes as the type of study and the number of patients in the
in critically ill and injured patients. While expensive, study, will be included in bold type following the ref-
the best available data suggest that helicopter trans- erence, where available. In addition, the most infor-
port provides cost-effective care. mative references cited in this paper, as determined
by the author, will be noted by an asterisk (*) next to
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study of 192 transports of stroke patients, comparing guideline)
interventions in the prethrombotic and thrombotic eras of 69. Dorlac GR, Fang R, Pruitt VM, et al. Air transport of patients
stroke care) with severe lung injury: development and utilization of the
52. Uren B, Lowell MJ, Silbergleit R. Critical care transport of acute lung rescue team. J Trauma. 2009;66(4):S164-171. (Review
patients who have acute neurological emergencies. Emerg of 11 patients)
Med Clin North Am. 2009;27(1):17-26. (Review article) 70. Foley DS, Pranikoff T, Younger JG, et al. A review of 100
53. Bellingan G, Olivier T, Batson S, et al. Comparison of a spe- patients transported on extracorporeal life support. ASAIO J.
cialist retrieval team with current United Kingdom practice 2002;48(6):612-619. (Retrospective review of 100 patients)
for the transport of critically ill patients. Intensive Care Med. 71. Bailey ED, Wydro GC, Cone DC. Termination of resuscitation
2000;26(6):740-744. (Retrospective review of 259 patients) in the prehospital setting for adult patients suffering nontrau-
54. Davis DP, Peay J, Sise MJ, et al. The impact of prehospital matic cardiac arrest. National Association of EMS Physicians
endotracheal intubation on outcome in moderate to severe Standards and Clinical Practice Committee. Prehosp Emerg
traumatic brain injury. J Trauma. 2005;58(5):933–939. (Retro- Care. 2000;4(2):190-195. (Clinical practice guideline)
spective trauma database review of 13,625 patients from 5 72. Woodward GA, Vernon DD. Aviation physiology in pediatric
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55. Newton A, Ratchford A, Khan I. Incidence of adverse events Pediatric and Neonatal Transport Medicine. 2nd ed. Philadelphia,
during prehospital rapid sequence intubation: a review PA: Hanley & Belfus; 2002:43-54. (Book chapter)
of one year on the London helicopter emergency medical 73. American Academy of Pediatrics. Guidelines for Air and
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56. Fakhry SM, Scanlon JM, Robinson L, et al. Prehospital rapid 74. McGinnis KK, Judge T, Nemitz B, et al. Air medical services:
sequence intubation for head trauma: conditions for a suc- future development as an integrated component of the emer-
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57. Harrison T, Thomas SH, Wedel SK. In-flight oral endotrache- State EMS Officials, National Association of EMS Physicians,
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spective study of 302 intubations) 2007;11(4):353-368. (Clinical practice guideline)
58. Thomas AN, Galvin I. Patient safety incidents associated 75. Shatney CH, Homan SJ, Sherck JP, et al. The utility of helicop-
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1197. (Retrospective review of 12,084 incidents with criti- spective review of 947 trauma patients transferred from the
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59. Singh JM, MacDonald RD, Bronskill SE, et al. Incidence 76. Bledsoe BE, Wesley AK, Eckstein M, et al. Helicopter scene
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60. Carchietti E, Cecchi A, Valent F. Influence of helicopter flight 77. Taylor CB, Stevenson M, Jan S, et al. A systematic review
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61. Flabouris A, Runciman WB, Levings B. Incidents during transport)
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reports, documenting 272 incidents in transport) 1997;30(4):500-506. (Cost-effectiveness analysis)
62. Ligtenberg JJ, Arnold LG, Stienstra Y, et al. Quality of 79. Silbergleit R, Scott PA, Lowell MJ, et al. Cost-effectiveness of
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63. Nieman CT, Merlino JI, Kovach B, et al. Intubated pediatric

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Coming Soon In EMCC
Optimizing Initial Antibiotic Cardiocerebral Resuscitation:
Delivery For Adult Patients With An Evidence-Based Review
Severe Sepsis And Septic Shock In
AUTHORS:
The Emergency Department
JON RITTENBERGER, MD, MS
Assistant Professor, Department of Emergency
AUTHORS:
Medicine, University of Pittsburgh School of Medicine;
ROBERT S. GREEN, MD, DABEM, FRCPC Attending, Emergency Medicine and Post-Cardiac
Associate Professor, Department of Anesthesia, Arrest Services, UPMC-Presbyterian Hospital,
Division of Critical Care Medicine, Department Pittsburgh, PA
of Emergency Medicine, Dalhousie University, BENJAMIN S. ABELLA, MD, MPHIL, FACEP
Halifax, NS, Canada Assistant Professor, Department of Emergency
Medicine and Department of Medicine / Section
SEAN K. GORMAN, BSC, PHARMD
of Pulmonary Allergy and Critical Care, University
Clinical Coordinator, Critical Care, Capital District of Pennsylvania School of Medicine; Clinical
Health Authority; Associate Professor, Dalhousie Research Director, Center for Resuscitation Science,
University College of Pharmacy, Halifax, NS, Philadelphia, PA
Canada FRANCIS X. GUYETTE, MD, MS, MPH, FACEP
Severe sepsis and septic shock account for one-fifth Assistant Professor of Emergency Medicine, University
of all admissions to the intensive care unit (ICU) of Pittsburgh School of Medicine, Pittsburgh, PA
and remain the leading cause of death. There are Cardiac arrest is the third most common cause of death
more than 500,000 emergency department (ED) in North America, resulting in approximately 300,000
visits annually in the United States due to suspected deaths per year. Following restoration of pulses, multiple
severe sepsis, and the average length of stay in the organ systems demonstrate varying degrees of injury or
failure. This postarrest syndrome demonstrates features
ED is approximately 5 hours. In addition, many more
of systemic inflammatory response (the postarrest
patients present to the ED with infection-related state has been likened to a “sepsis-like syndrome”)
conditions without signs of tissue hypoperfusion along with diffuse anoxic injury to the brain. Aggressive
and, therefore, may be considered to have sepsis.3 titration of care to optimize cerebral resuscitation has
Approximately 25% of these patients progress to improved outcomes. Multiple strategies are used to
prevent secondary neuronal injury, including therapeutic
severe sepsis or septic shock within 72 hours of
hypothermia, aggressive revascularization, titrated blood
presentation to the ED. Because of the high mortality pressure goals, careful control of ventilator parameters,
associated with severe sepsis and septic shock, early and monitoring for seizure activity. An in-depth review
identification, monitoring, and management of septic of the literature to determine the evidence supporting
patients in the ED are imperative. This issue of EMCC present postarrest guidelines is presented in this issue of
will answer the following questions: EMCC, with a primary focus on treatment of the postarrest
patient to improve survival and neurologic outcomes.
Upon completion of this article, you should be able to:
1. Does the choice of antibiotic matter, as long as it
1. Describe indications and contraindications for
“covers” the suspected bugs?
postresuscitation care.
2. Describe organ system strategies for optimizing
2. Do we have to adjust the first dose of antibiotic postresuscitation care.
for patients with sepsis in the ED? 3. Describe techniques for optimizing organ system
resuscitation during the postresuscitation phase.
3. Does the timing of antibiotic administration 4. Discuss current controversies in postarrest care.
matter in patients with septic shock? 5. Summarize the evidence for postresuscitation care.

Upcoming EMCC Topics CME Information
Date of Original Release: August 1, 2012. Date of most recent review:
• Severe Sepsis And Septic Shock July 1, 2012. Termination date: August 1, 2015.
Accreditation: EB Medicine is accredited by the ACCME to provide
• Massive Gastrointestinal Bleeding continuing medical education for physicians.
Credit Designation: EB Medicine designates this enduring material for a
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• Severe Traumatic Brain Injury activity.
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of this publication; review of morbidity and mortality data from the
CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for
emergency physicians.
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medicine physicians, physician assistants, nurse practitioners, and
Now Available: The Latest residents as well as intensivists and hospitalists.
Goals: Upon completion of this article, you should be able to: (1)
Research On ECMO demonstrate medical decision-making based on the strongest clinical
evidence; (2) cost-effectively diagnose and treat the most critical ED
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Dr. Joe Bellezzo and Dr. Zack Shinar have for each topic covered.
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it — are discussed in detail in their latest article: promote off-label use of any pharmaceutical product.
Extracorporeal Cardiopulmonary Resuscitation In The Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity,
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Send Us Your disclosures of potentially relevant financial interests were made:

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EM Critical Care

UNDERSTANDING AND CARING FOR

Air Transport Of The Critically Ill Authors

Emergency Department Patient Susan R. Wilcox, MD

EMCC © 2012 2 www.ebmedicine.net • Volume 2, Number 4

www.ebmedicine.net • Volume 2, Number 4 3 EMCC © 2012

www.ebmedicine.net • Volume 2, Number 4 5 EMCC © 2012

EMCC © 2012 6 www.ebmedicine.net • Volume 2, Number 4

Stabilization Prior to Transport:

www.ebmedicine.net • Volume 2, Number 4 7 EMCC © 2012

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Take This Test Online!

Current subscribers receive CME credit absolutely

1. The primary benefit of helicopter transport is:

2. One strategy to streamline care of STEMI pa-

EMCC © 2012 14 www.ebmedicine.net • Volume 2, Number 4

www.ebmedicine.net • Volume 2, Number 4 15 EMCC © 2012

Send Us Your disclosures of potentially relevant financial interests were made:

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EB Medicine EMCC Subscription Information:

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