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Air Vs Ground


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#1 sulynn

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Posted 19 February 2010 - 12:35 AM

I just joined the forum. I need some help in gathering evidenced medicine or best practices or even standard of care for one particular subject.

I work at at rural hospital, have only been here about a year and a half. The 20 years prior to this was at a Level 1 trauma Center but do not know if things have changed since I left.

We are 2 hours by ground to higher level of care in any direction. 2 and a half to 3 hours by ground to the closest Level I trauma center.

We recently had a Subdural and Epidural bleed--(result from a fall from ladder)--we shipped him by fixed wing and had him out of our ER in an amazingly short time frame. We got a letter back from the receiving higher level of care that in the future we should transport patients with similar injuries via ground in order to prevent possible expansion of intracerebral hemorrhage. There was no supporting evidence with the letter. Again, this patient went via pressurized cabin??? And even if rotor, would this be the case????

I am searching for evidenced based studies or best practices to support or deny this to take to the Trauma Committee for a case review on this. I looked on ASTNA but you have to be a member to search thier site, or I did not figure out how to get in. I looked at ATLS and did not really find anything definitive. I looked through some American College of Surgeons and did not find what I am looking for.

thanks for any help that you can offer.
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#2 JLP

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Posted 19 February 2010 - 02:52 AM

I just joined the forum. I need some help in gathering evidenced medicine or best practices or even standard of care for one particular subject.

I work at at rural hospital, have only been here about a year and a half. The 20 years prior to this was at a Level 1 trauma Center but do not know if things have changed since I left.

We are 2 hours by ground to higher level of care in any direction. 2 and a half to 3 hours by ground to the closest Level I trauma center.

We recently had a Subdural and Epidural bleed--(result from a fall from ladder)--we shipped him by fixed wing and had him out of our ER in an amazingly short time frame. We got a letter back from the receiving higher level of care that in the future we should transport patients with similar injuries via ground in order to prevent possible expansion of intracerebral hemorrhage. There was no supporting evidence with the letter. Again, this patient went via pressurized cabin??? And even if rotor, would this be the case????

I am searching for evidenced based studies or best practices to support or deny this to take to the Trauma Committee for a case review on this. I looked on ASTNA but you have to be a member to search thier site, or I did not figure out how to get in. I looked at ATLS and did not really find anything definitive. I looked through some American College of Surgeons and did not find what I am looking for.

thanks for any help that you can offer.


We move patients like this by air all the time.
First, there is zilch evidence I am aware of that supports the idea that atmospheric pressure make any difference to expansion of an intracerebral hematoma. Open head injuries, yes, there is a risk of herniation outward of brain tissue and on descent, of air entering the cerebral circulation due to vaccuum effect. Closed head injuries are not affected much by outward pressure (anyone have data to the contrary? I would be happy to change my mind if there is evidence). Second, you can overpressurize most FW cabins and/or fly low enough that there is no pressure difference anyway. We've had to do this with patients with trapped air in the cranial vault. If it's a rotor trip, go low. Under 1000' the pressure difference is not even detectable. Third, the bigger concern is reduced oxygen delivery due to lower atmospheric pressure. Raise the FiO2 is that's a worry, but it usually isn't a problem in isolated head injury. Fiurth, three hours on the road is not good for head injured patients, especially if the roads are at all bumpy. I think this just reflects a poor awareness of air transport methods.
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#3 Mike Mims

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Posted 19 February 2010 - 02:53 AM

Patients with SDH/EDH are flown by fixed-wing short and long distances all the time, just ask a medical crew member who's in the military.

I'm guessing by the 2 1/2 - 3 hours to the Level 1 it's about 200-250(+) miles??? If so, you're right on the bored-line of RW vs FW.
For RW it's going to depend on multiple factors; e.g, the type of AC, the season, weather, IFR vs VFR etc... but typically once you exceed 250Nm it may be better to send the pt by FW.
As for the altitude concerns, with FW you'll climb as high as you can usually greater than 20,000 ft, with one of the reasons being if you loose an engine you at least want to be able to make the airport as altitude is your friend. Yes, it will be a pressured cabin.

For RW, the furtherset I've gone is ~ 240Nm and we climbed to 8K feet (better winds) and no there aren't any helicopters with pressurized cabins, the closest being the Bell BA609, if you want to call it a helicopter.....
As long as you stay below 10,000 ft than you do not have to worry with the effects of atmospheric pressure changes and the risks of hypoxia.

I believe someone at the receiving hospital is not clear with the types and benefits of Air transport. Ask them for the evidence through a legitimate study, not an opinion based off a formula that supports their reasoning and justification for the extended transport time they WILL have if the patient goes by ground. I bet you won't get much in return.
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Mike Mims

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#4 Macgyver

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Posted 19 February 2010 - 03:10 AM

The only issue with FW transport is if there is substantial acceleration (not likely in your case as jet's not usually used under 400miles. Usually only seen otherwise if you have a short runway - say 3000' - and a high performance turboprop, OR a cowboy pilot) or very steep climb (usually only for noise abatement or military flight restrictions in the immediate area) and only if the patient is loaded head aft.

If loaded head forward like 90% of FW in North America the risk is when descending steeply or landing - but that is usually a much lower G-force than takeoff.
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Ken BHSc, RN, REMT-P

#5 old school

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Posted 19 February 2010 - 10:22 PM

We recently had a Subdural and Epidural bleed--(result from a fall from ladder)--we shipped him by fixed wing and had him out of our ER in an amazingly short time frame. We got a letter back from the receiving higher level of care that in the future we should transport patients with similar injuries via ground in order to prevent possible expansion of intracerebral hemorrhage. There was no supporting evidence with the letter. Again, this patient went via pressurized cabin??? And even if rotor, would this be the case????

I am searching for evidenced based studies or best practices to support or deny this to take to the Trauma Committee for a case review on this. I looked on ASTNA but you have to be a member to search thier site, or I did not figure out how to get in. I looked at ATLS and did not really find anything definitive. I looked through some American College of Surgeons and did not find what I am looking for.

thanks for any help that you can offer.


I'm pretty confident that you will find NO recommendations by ASTNA, ENA, ACS, ACEP, BTF, or anyone else against flying a patient with an IC hemorrhage. Not only is there likely no research to support such a recommendation, but there also exists no physiological explanation that I can think of.


The receiving center is the one who must justify their position...not you guys.
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bring it in for the real thing

#6 sulynn

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Posted 26 February 2010 - 03:02 PM

I'm pretty confident that you will find NO recommendations by ASTNA, ENA, ACS, ACEP, BTF, or anyone else against flying a patient with an IC hemorrhage. Not only is there likely no research to support such a recommendation, but there also exists no physiological explanation that I can think of.


The receiving center is the one who must justify their position...not you guys.


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#7 sulynn

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Posted 26 February 2010 - 03:06 PM

We move patients like this by air all the time.
First, there is zilch evidence I am aware of that supports the idea that atmospheric pressure make any difference to expansion of an intracerebral hematoma. Open head injuries, yes, there is a risk of herniation outward of brain tissue and on descent, of air entering the cerebral circulation due to vaccuum effect. Closed head injuries are not affected much by outward pressure (anyone have data to the contrary? I would be happy to change my mind if there is evidence). Second, you can overpressurize most FW cabins and/or fly low enough that there is no pressure difference anyway. We've had to do this with patients with trapped air in the cranial vault. If it's a rotor trip, go low. Under 1000' the pressure difference is not even detectable. Third, the bigger concern is reduced oxygen delivery due to lower atmospheric pressure. Raise the FiO2 is that's a worry, but it usually isn't a problem in isolated head injury. Fiurth, three hours on the road is not good for head injured patients, especially if the roads are at all bumpy. I think this just reflects a poor awareness of air transport methods.



Thanks so much for the help. I have always flown heads so was quite suprised by the response----and especially to make such a statement of suggesting that we change our protocols to something that is not supported by evidence. I would think they would not do that because of the liability if nothing else. But first and formost that is not what is best for the patient. Crazy. Thanks agains so much for responding.
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#8 sulynn

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Posted 26 February 2010 - 03:09 PM

Thanks so much, I appreciate the response. I did not think things had changed in flying closed heads but wanted to ask those of you who would know. Thanks again,
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#9 sulynn

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Posted 26 February 2010 - 03:17 PM

Thanks to all who responded, This will help coming first hand from those of you who are "IN THE KNOW." I was quite suprised by the response telling us that in the future we should change our protocols but no evidence or references to back that up. If we were not so far away from higher level of care, ground might be an option, but three hours is a LONG time for a bleed, esp. epidural. Thanks again to all who responded. I admire and respect what you do up there in the friendly skies!!
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