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
laws regarding transfer of patients. With the variability in medi-
cal systems, each region has diverse resources and protocols, and
emergency physicians should be aware of these prior to needing to
transfer a patient. Select populations should be considered for air
transport, and certain patients will require resources beyond typical
helicopter transport teams. This review highlights the indications for
helicopter transport of critically ill emergency department patients,
the capabilities of many critical care transport teams, and current
controversies in the field.
Case Presentation
A 54-year-old man presents to your community ED complaining of
abdominal pain and numbness in his right leg. Shortly after arrival to the
ED, he complains of pain extending to his chest. He describes the pain as a
“tearing” sensation that rips through his chest and back between his shoul-
Michael Lewell, MD, FRCP
Associate Professor of Medicine, Western University; Medical
Director, Southwest Ontario Regional Base Hospital; Medical
Director, Ornge Air Ambulance Service, London, Ontario, Canada
Juan C. Nalagan, MD
Medical Director, MediFlight of Oklahoma; Assistant Professor,
Department of Emergency Medicine, University of Oklahoma
School of Medicine, Oklahoma City, OK
CME Objectives
Upon completion of this article, you should be able to:
1. Discuss potential capabilities of critical care transport and
become motivated to explore the capabilities and nuances of
your own local service.
2. Describe how particular patient populations benefit from
critical care transport and recognize those who would benefit
from air transport.
3. Describe techniques for initiation of critical care transport,
and discuss the current safety concerns within the industry.
4. Recognize contraindications to air transport of the critically ill.
5. Summarize the current evidence relating to the use of critical
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
Robert T. Arntfield, MD, FRCPC,
FCCP
Assistant Professor, Division
of Critical Care, Division of
Emergency Medicine, Western
University, London, Ontario,
Canada
Associate Editor
Scott Weingart, MD, FACEP
Associate Professor, Department of
Emergency Medicine, Mount Sinai Michael A. Gibbs, MD, FACEP
School of Medicine; Director of
Emergency Critical Care, Elmhurst
Hospital Center, New York, NY
Editorial Board
Benjamin S. Abella, MD, MPhil,
FACEP
Assistant Professor, Department
of Emergency Medicine and
Department of Medicine /
Section of Pulmonary Allergy
and Critical Care, University of
Pennsylvania School of Medicine;
Clinical Research Director,
Center for Resuscitation Science,
Philadelphia, PA
Lillian L. Emlet, MD, MS, FACEP
Assistant Professor, Department of
Critical Care Medicine, Department
of Emergency Medicine, University
of Pittsburgh Medical Center;
Program Director, EM-CCM
Fellowship of the Multidisciplinary
Critical Care Training Program,
Pittsburgh, PA
Professor and Chair, Department
of Emergency Medicine, Carolinas
Medical Center, University of North Haney Mallemat, MD
Carolina School of Medicine,
Chapel Hill, NC
Robert Green, MD, DABEM,
FRCPC
Associate Professor, Department
of Anaesthesia, Division of Critical Assistant Professor, Department of
Care Medicine, Department of
Emergency Medicine, Dalhousie
University, Halifax, Nova Scotia,
Canada
Andy Jagoda, MD, FACEP
Professor and Chair, Department
of Emergency Medicine, Mount
Sinai School of Medicine; Medical
Director, Mount Sinai Hospital, New
York, NY
William A. Knight, IV, MD
Assistant Professor of Emergency Christopher P. Nickson, MBChB,
Medicine, Assistant Professor
of Neurosurgery, Emergency
Medicine Mid-Level Program
Medical Director, University of
Cincinnati College of Medicine,
Cincinnati, OH
Assistant Professor, Department
of Emergency Medicine, University
of Maryland School of Medicine,
Baltimore, MD
Evie Marcolini, MD, FAAEM
Emergency Medicine and Critical
Care, Yale School of Medicine,
New Haven, CT
Julie Mayglothling, MD
Assistant Professor, Department
of Emergency Medicine,
Department of Surgery, Division
of Trauma/Critical Care, Virginia
Commonwealth University,
Richmond, VA
MClinEpid
Senior Registrar, Emergency
Department, Alice Springs
Hospital, Alice Springs, Australia
Jon Rittenberger, MD, MS
Assistant Professor, Department
of Emergency Medicine,
University of Pittsburgh School of
Medicine; Attending, Emergency
Medicine and Post-Cardiac Arrest
Services, UPMC-Presbyterian
Hospital, Pittsburgh, PA
Emanuel P. Rivers, MD, MPH, IOM
Vice Chairman and Director
of Research, Department of
Emergency Medicine, Senior
Staff Attending, Departments of
Emergency Medicine and Surgery
(Surgical Critical Care), Henry
Ford Hospital, Clinical Professor,
Department of Emergency
Medicine and Surgery, Wayne State
University School of Medicine,
Detroit, MI
Isaac Tawil, MD
Assistant Professor, Department of
Surgery, Department of Emergency
Medicine, University of New
Mexico Health Science Center,
Albuquerque, NM
Research Editor
Amy Sanghvi, MD
Department of Emergency
Medicine, Mount Sinai School of
Medicine, New York, NY
beats per minute. He is diaphoretic with tenderness to
palpation in his upper abdomen that is most prominent in
the epigastrium. The chest and cardiac exams are normal,
but he has 4/5 strength and decreased sensation in his left
leg. Lab results are all within normal limits. ECG dem-
onstrates sinus tachycardia without ischemic changes. A
CT scan demonstrates a dissection from the aortic root
to the level of the common iliac arteries. IV esmolol and
nitroprusside are started, and bilateral radial arterial
lines are placed to monitor blood pressures. The diagno-
sis is obvious, and the correct emergency treatment has
been initiated. This patient needs life-saving surgery, but
cardiothoracic surgical support is not available at your
hospital. You need to transfer this critically ill patient.
Introduction
Motor vehicle collisions, myocardial infarctions,
drownings, childbirth, and gunshot wounds are
all examples of acute presentations that require
immediate medical attention. Emergency medical
services (EMS) personnel provide vital care while
they treat and transport the sick or injured to ap-
propriate medical facilities.1 EMS providers are also
accustomed to transferring patients from the emer-
gency department (ED) of one facility to another
for tertiary or definitive care that is not available at
the sending facility.
While variability exists from state to state,
many EMS options are available in most areas,
including basic life support (BLS), advanced life
support (ALS), and critical care transport (CCT)
services. BLS ambulances can provide rapid ground
transport, oxygen therapy, and fracture or spinal
immobilization. ALS ambulances can provide
additional cardiac monitoring, advanced airway
management, and intravenous (IV) therapy with
limited pharmacologic intervention, typically by
maintaining continuous infusion rates. ALS ser-
vices, however, cannot titrate medications, cannot
provide invasive monitoring or intervention, and
transport primarily by ground.
CCT teams consist of a small cadre of highly
trained EMS professionals who travel by air or
ground and are regularly called upon to transport
critically ill patients. Not only are CCT teams able
to travel by air via rotor or fixed-wing aircraft, they
can also provide invasive monitoring, advanced
ventilator support, cardiac pacing, defibrilla-
tion, central line access, needle thoracostomy, and
advanced airway management (including surgical
approaches). Additionally, CCT teams typically
have a substantial pharmacy, including vasoactive
agents, volume expanders, sedatives, analgesics,
paralytics, antiarrhythmics, and anticonvulsants.2
A typical CCT team in the United States will consist
of specially trained nurses and paramedics, but
they may also include a respiratory therapist, per-
EMCC © 2012 2
fusionist, or physician.3,4 Although scene transfers
are commonly studied, almost 80% of CCT mis-
sions are interfacility transfers.5,6
Despite the expertise of CCT teams, the trans-
fer of critically ill patients is not without risk. Even
transportation of critically ill patients within the
hospital is associated with increased adverse events
when patients are not accompanied by appropriate
staff.7,8 The risk of adverse events is increased when
interhospital transport is considered,7 as EMS trans-
port is performed around the clock, at high speeds,
and with short response times on an unscheduled
basis. Mitigating this risk by adequately stabilizing a
patient and employing the correct resources is essen-
tial. The potential benefit of emergent transfer must
outweigh the potential risk.
Unfortunately, there are significant regional
disparities in CCT services as there are no uniform
national requirements or mandated skill sets for
CCT providers. The Commission on Accreditation of
Medical Transport Services (CAMTS) has evolved as
an accrediting body for air CCT; however, CAMTS
accreditation is not required for organizations pro-
viding air CCT.
It is important for any physician needing to
transfer a critically ill patient to be aware of avail-
able regional EMS and CCT resources. While occa-
sionally a CCT service medical director or transport
physician will accept “shared responsibility” for a
patient in transport, the Emergency Medical Treat-
ment and Active Labor Act (EMTALA) stipulates
that a transferring physician remains responsible
for the patient’s care until the patient has arrived
at the receiving institution.9,10 Familiarization with
regional EMS capabilities and the transfer policies of
local tertiary care facilities is imperative to provide
patients with the highest level of care.
This issue of EMCC will discuss the advantages
and disadvantages of air CCT, describe techniques
for initiation of CCT, and discuss contraindications
to air CCT.
Critical Appraisal Of The Literature
The data for helicopter transport of the critically ill
ED patient have limitations similar to much of the
EMS literature. Due to the emergent nature of patient
presentations and variability in transport systems,
performing high-quality, broadly generalizable stud-
ies is challenging. There are no randomized trials of
helicopter transport, and, as such, the majority of the
literature for helicopter transport consists of observa-
tional studies, case series, and expert opinion.
Many studies attempt to control for variability
in patients by using the Injury Severity Score (ISS) or
the Trauma Related Injury Severity Score (TRISS).11 A
commonly noted limitation of these scoring systems
is that they require clinical information that is only
www.ebmedicine.net • Volume 2, Number 4
obtained after transport, thereby limiting their use
in a prospective manner. These studies are further
limited by insufficient reporting of transport times,
transport distances, and patient data. Studies often
lack a control group, or, in the case of air versus
ground transport, the ground cohort is used as the
control. Many authors use multiregression analyses
to account for differences in the subsets of patients
transported by each mode, but these may leave some
factors unaccounted for, leading to selection bias and
reporting bias. Despite well-designed meta-analyses
of helicopter transport, the diverse patient popula-
tions, variability of trauma systems, and inconsistent
reporting of outcomes in the primary studies pre-
clude strong evidence-based guidelines.
Due to the homogeneity of trauma patients,
studies on helicopter transport are commonly
centered around these patients. Studies of trauma
patients benefit from substantial local and national
trauma registries as well as a uniform trauma
scoring system (ie, TRISS). The majority of these
studies have evaluated outcomes associated with
transporting patients from the scene of the trauma
to a trauma center rather than interfacility transport.
Although not directly applicable to the interhospital
transport of critically ill ED patients, the best avail-
able data support the efficacy of CCT for improving
outcomes for trauma patients.
Many of the studies and guidelines regarding
CCT and helicopter transport are from Australia, the
United Kingdom, and other areas of Europe. While
some studies and their outcomes are applicable to
the United States, the differences in healthcare sys-
tems (such as hospital design, geography, etc) may
limit broad application. The Intensive Care Society
published guidelines regarding CCT in 2002, 2007,
and 2011. The American College of Critical Care
Medicine published guidelines for the interhospital
and intrahospital transport of critically ill patients in
1993; these guidelines were revised in 2004 but have
not been updated since.
Considerations For Critical Care Transport
Decision To Transfer
The decision to transfer a patient from one hospital
to another is ultimately determined by weighing the
potential benefits of transport to the patient against
the potential risks. There are little data available
about how clinicians make the decision to trans-
fer patients or how clinicians determine patients’
suitability for transport; these decisions have been
described as an ad hoc process.12 Transfer should
only occur if it is likely to improve the patient’s clini-
cal outcome. Financial considerations should not be
a factor when considering transferring a patient.7
The indications for interhospital transfer from the
ED should be primarily clinical. Potential indications
www.ebmedicine.net • Volume 2, Number 4
include the need for tertiary care services not avail-
able at the referring hospital, such as specialist care,
advanced diagnostics, or specialized procedures.
Nonclinical reasons for transfer occur in a minority
of cases13 and include lack of a critical care bed or
repatriation to a patient’s local hospital. These trans-
ports should be avoided, if possible, as the transfer
of a critically ill patient for a reason other than medi-
cal necessity is an undue risk for both the patient
and the crew. All practitioners should be aware of
federal and state laws regarding patient transfers,
including EMTALA, which defines the legal respon-
sibilities regarding initiation of patient transfer. EM-
TALA was enacted to prevent patient “dumping,”
and it states that a hospital must provide a medical
screening examination and stabilization to the best
of the hospital’s capability prior to transfer.9,14
A discussion of the risks and benefits of transfer
must be held with, and informed consent must be
obtained from, a competent patient or the patient’s
legally authorized representative prior to trans-
fer. Documentation of this conversation should be
placed in the medical record. In the case of a life-
threatening emergency, if informed consent is not
obtained, the indications for the transfer and the
rationale for not obtaining consent must be docu-
mented. The referring physician must write an order
for transfer in the medical record.7 Although trans-
fers from EDs constitute a significant proportion of
interhospital transports, data indicate that there are
significant deficiencies in providing adequate equip-
ment, patient monitoring, staff training, and docu-
mentation of the transfer.15 In one survey, only 56%
of EDs in the United Kingdom had established de-
partmental transfer guidelines.15 Emergency physi-
cians should review their institution’s resources and
policies prior to encountering a situation in which a
patient requires transport.
The ultimate decision to transfer rests with the
referring physician. Once the decision is made to
transfer the patient, the referring physician must
find an accepting institution. This can be a difficult
and time-consuming process unless the physician
has access to a local centralized referral center. An
Australian study found that transferring a patient
required an average of 4.7 phone calls per patient
and a mean time of 1 hour from the time of the
decision to transfer until the patient was accepted
at a receiving facility.16 Once a receiving institution
is found, the referring physician must confirm that
appropriate higher-level services are available. The
receiving physician should be given a full report
of the patient’s condition, with an opportunity to
ask questions. While the receiving institution may
provide guidance and medical recommendations,
the patient remains the responsibility of the referring
hospital until arrival at a receiving institution.7,17
3 EMCC © 2012
Decisions Regarding Mode Of Transport
In most instances, the determination of how to
transport the patient — whether by helicopter or
ground — is that of the referring physician. Only
in rare circumstances, such as when the transport
is to be provided by the receiving institution, does
the receiving physician make this decision.7 When
selecting a mode of transport, the referring physician
must consider the patient’s illness, clinical stability,
urgency of transfer, availability of various transport
modalities, geography, traffic, and weather condi-
tions.7,17,18 The referring physician must also under-
stand the benefits and risks of helicopter transport.
While some authors assume that the primary
benefit of helicopter-based transport is the decreased
time to arrival at the receiving hospital,19 this is not
necessarily the case. The interval from the time the
decision is made to transport a patient until the pa-
tient arrives at the receiving facility may be extended
due to organizational issues that cause delays in he-
licopter dispatch.20 Many transports also entail long
ground legs if the helicopter must land at a helipad
remote from either facility.18,21 In addition, the air
CCT team may have to spend more time preparing
the patient for transport than a ground ALS team.22-24
However, despite the potentially increased total time
until arrival at the receiving institution, the helicop-
ter offers the advantage of decreasing the time the
patient spends in transit.20 This may be of particular
benefit in unstable patients, for whom the time in the
out-of-hospital setting should be minimized.
Some authors and guidelines have recom-
mended that air transport be considered for travel
distances greater than 50 miles or transfer times
greater than 90 minutes.18,25 A study of scene trauma
transports found that if the patient was located
45 miles from the referring hospital, the patient’s
transport was faster by air even with nonsimulta-
neous dispatch of the ground crew and helicopter
crew.26 Others note, however, that defining a uni-
versal distance beyond which the helicopter is faster
is difficult.21 A study from Canada found that even
for long distances, due to variability in helipad
placement, geography, and overall systems, ground
transport may actually be faster.21 Therefore, deter-
mining when one should choose a helicopter based
on distance alone is difficult. Selection will vary de-
pending upon aspects of the local healthcare system
as well as individual patient factors.
Although flying does not necessarily decrease
time to arrival at the receiving facility, helicopter
transport does have benefits.27-34 A review of the
National Trauma Data Bank, including nearly
260,000 patients, about 42,000 of which were
transported by helicopter, was published in 2010.
While patients undergoing interhospital transport
by helicopter were more severely injured than
patients transported by ground, multiregression
analysis demonstrated that helicopter transport
EMCC © 2012 4
was a predictor of survival.32 Though subject to the
limitations of any retrospective database review,
this study is the only large, nationwide survey of
transport practices in the United States.
Patients with moderate injuries (as determined
by the ISS) are more likely to benefit from helicopter
transport than those with scores at either extreme, as
mildly injured patients will likely do well regardless,33
and moribund patients are not likely to benefit from
either air or ground transport. A study in 2011 found
that while air transport made no difference for patients
with lesser injuries (an ISS < 15), patients with an ISS >
15 did benefit from helicopter transport.31
A recent systematic review of helicopter trans-
port literature demonstrated improved survival with
the use of air CCT, although the review was limited
by inconsistent methodology in many of the stud-
ies. When the 4 reliable studies in the review were
examined, an overall mortality reduction of 2.7 ad-
ditional lives saved per 100 helicopter deployments
was found.35
Although helicopter transport likely confers
benefit for a subset of patients, this mode of trans-
port may incur additional risks to the patient and
the crew. A significant increase in the number of air
ambulance crashes in recent years, out of propor-
tion to the number of providers, has prompted more
scrutiny from regulators and media. The rate of EMS
helicopter crashes has increased over the last de-
cade, from a rate of 1.7 per 100,000 in 1997 to 4.8 per
100,000 in 2004. In 2008, 9 crashes killed 35 people.36
Crashes with fatalities most commonly occur at
night or in bad weather.37 Individual trauma sys-
tems must develop triage criteria that maximize the
benefits of helicopter transport while minimizing the
risks of flying patients who are least likely to benefit
from air transport.38
Once the decision is made to transport a patient
by helicopter, the transport team should be contacted
to confirm availability and coordinate the timing of
the transport.7 Some systems provide a central dis-
patch center to streamline the referral process by com-
municating with receiving institutions and arranging
an accepting physician if the sending physician has
not already found one. In one region where multiple
tertiary care centers are located, a “roster” system has
been established that allows a CCT dispatch center
to activate a transport team and assign a receiving
hospital on a rotating “next-up” basis. One study
has shown that this type of system allows for timely
transport both to EDs and directly to operating rooms
and that patients have similar outcomes as those
transported to predesignated facilities.39 Unfortunate-
ly, this system is not available in all areas.
Patient Selection
Specific populations that should warrant consider-
ation for activation of a CCT team include multi-
www.ebmedicine.net • Volume 2, Number 4
trauma and burn patients, cardiac patients, and
stroke patients.
Trauma And Burns
Most research on the benefit of CCT and air transport
has evolved from trauma patients. Patients with mul-
tisystem trauma or burns whose injuries exceed the
capacity of a referring facility should be transferred to
a trauma center. Approximately 42 million people in
the United States live in rural areas without immedi-
ate access to specialist care, and 60% of all fatal motor
vehicle crashes occur in these rural areas.40 As such,
trauma patients are one of the largest patient groups
to undergo interfacility transport.30,41
Helicopter transport has been found to improve
outcomes for this population. A recently published
retrospective study of trauma patients transported
from the scene by either air or ground to Level I or
Level II trauma centers assessed for an association
between mode of transport and 14-day mortality rates.
These authors found a 33% reduction in death when
the patients were transported by helicopter, although
they noted that patients with normal vital signs had no
mortality benefit associated with air transport.33 Other
studies have shown that for patients with an ISS associ-
ated with a 10% or greater risk of dying, there was a
25% reduction in mortality among patients transported
by air versus traditional ground services.31
Time to intervention is one of the most im-
portant factors in the care of hypotensive trauma
patients.42 CCT’s benefit in traumatic hypotension
may be as much due to advanced medical resuscita-
tion as it is due to timely delivery to definitive surgi-
cal therapy. CCT services bring critical care experts
to the patient and offer capabilities that traditional
EMS cannot always provide, including the ability to
intubate in transport with neuromuscular blockade,
the ability to obtain intraosseous (IO) access, and the
ability to provide narcotic analgesia. Furthermore,
aircraft launched from a base hospital can often
bring uncrossmatched blood, an essential nonsurgi-
cal intervention.
Cardiac: Time Is Muscle
As time-sensitive interventions have become the
standard of care for cardiac patients; the use of CCT
teams for transport of these patients has increased.
Percutaneous coronary intervention (PCI) has
proven to be superior to fibrinolysis,43 and transfer-
ring patients to PCI-capable hospitals has become a
major mission of CCT teams. The goal of emergency
care providers is to obtain emergent revasculariza-
tion within 90 minutes of ST-segment elevation
myocardial infarction (STEMI) — or, if this not be
possible, to initiate thrombolysis within 30 min-
utes. EMS protocols have been developed for rapid
interfacility transport of STEMI patients to PCI
centers; in one study, these protocols were shown to
www.ebmedicine.net • Volume 2, Number 4
improve outcomes.44 Since most of the United States
population does not live near a 24-hour PCI center,
transfer to a PCI center is often done by air CCT.43-45
Transport of cardiac patients is not without risks.
One study of STEMI patients requiring transport
demonstrated that 79% of patients required an ALS
intervention during transport (most commonly anti-
arrhythmic administration).23
Unfortunately, other studies have identified
that the majority of STEMI patients transported by
helicopter had a transfer time that exceeded 2 hours
and did not receive thrombolysis.23,46,47 The average
patient transport time in one system was only 15
minutes by air, but the hidden times of CCT trans-
port are commonly not taken into account when a
sending physician is arranging transport.23
The time taken to get to the patient’s bedside
and package them for transport is commonly the
longest time lag. Incompatibility of pump tubing
and monitoring cables and the need for additional
patient stabilization prior to lift-off are common rea-
sons for this delay.46,48 Beyond early activation, one
strategy to streamline care is to eliminate heparin
and IIb/IIIa inhibitor infusions after bolus, as these
medications have durations of action that exceed the
average transport time of most CCT agencies. This
eliminates the need to transfer pumps and IV tubing
as well as the need to set up infusions. This single
change can significantly cut the time needed to pack-
age the patient for transport.46
CCT also plays a role in the transport of comatose
survivors of cardiac arrest. Therapeutic hypothermia to
a temperature of 32°C to 34°C (89.6°F-93.2°F) has been
shown to improve neurological outcomes and is now
recommended as part of the American Heart Associa-
tion (AHA) guidelines for the care of out-of-hospital
cardiac arrest.49 While no current consensus exists on
how quickly to initiate postarrest hypothermia, most
believe benefit is obtained when it is employed as early
as possible. Studies have suggested that infusion of 2 to
4 L of normal saline at 4°C can drop core body tem-
perature by 1.5°C to 4°C.50 While this does not result in
maintenance of hypothermia, this technique employed
by CCT services is a practical way to initiate therapeu-
tic hypothermia while transporting such critically ill
patients. (For a more detailed discussion of therapeutic
hypothermia, see the April 2011 issue of Emergency
Medicine Practice, “Current Evidence In Therapeutic
Hypothermia For Postcardiac Arrest Care.”)
Neurologic: Time Is Brain
Thrombolytic therapy for ischemic stroke has been
used since 1996, and acute stroke is a time-sensitive
diagnosis that commonly requires transport to spe-
cialty centers. CCT services have played an increas-
ingly important role in transporting patents to stroke
centers for definitive evaluation and thrombolytic
therapy.44,51,52 CCT plays a key role in programs
5 EMCC © 2012
that allow a specialist, via teleconference, to provide
expert opinion regarding the initiation of thromboly-
sis and subsequent transport of patients to specialty
centers where services such as intra-arterial throm-
bolysis, endovascular clot retrieval, and post-tissue
plasminogen activator (t-PA) care can be obtained.51
CCT teams can closely monitor a patient’s blood
pressure, oxygenation, and evolution of neurological
status to allow for early intervention to help prevent
secondary brain injury. These critically ill patients
often require advanced therapies, including ventila-
tor and airway management as well as monitoring
of end-tidal CO2. Increased intracranial pressure can
also be monitored and treated accordingly. Tradi-
tional EMS agencies are not trained or experienced
enough to provide this level of care.52 as use of gravity drips during helicopter transport is
Practical Considerations For Critical
Care Transport
Staffing
A principal concept in helicopter transport of
critically ill patients is that they must continue to
receive the same level of care they were receiving
at referring hospitals up to and during transport.
Studies have reported that standards of care during
transport may be suboptimal, due to lack of moni-
toring and lack of appropriately trained staff.7,17,25
Patients should be accompanied by a minimum of
2 providers specifically trained in principles of CCT
and emergency medical procedures.7,17 In many
countries, 1 provider is always a physician; however,
in the United States, specialty trained nurse and
paramedic teams are the most common crew config-
uration.7 While many regions have dedicated CCT
teams, their availability is not universal.
Data show that specialist CCT teams provide
better medical care. A study compared 168 transfers
performed by specialized transport teams with 91
transfers performed by teams comprised of staff
from the referring facility. Patients transported by
the specialist transport team were less likely to be
acidotic and hypotensive on arrival to the receiv-
ing facility.53 While some studies have shown worse
outcomes for head trauma patients intubated in the
field by paramedics, studies specifically examining
intubations performed by CCT teams demonstrate
improved outcomes.54-56 Although some of these
studies involved physicians, similar studies in the
United States involving highly trained paramedic-
based CCT teams have shown comparable results to
physician-led teams.56,57 These findings support the
notion that focused education and training of CCT
personnel are associated with improved outcomes.
Equipment
Necessary equipment for patient monitoring dur-
ing transport includes a portable monitor with an
EMCC © 2012 6
illuminated display of the heart rhythm, blood pres-
sure, oxygen saturation, and (ideally) end-tidal CO2.
Given significant ambient noise within the aircraft,
alarms should be visible as well as audible.7,18 When
not deployed, vehicles should be connected to shore-
power to ensure all equipment is fully charged and
secured. The National Patient Safety Agency (NPSA)
of England and Wales reports that there were 55
CCT equipment failures between August 2006 and
February 2007, including loss of battery power for
monitors in 6 cases.58
Additional required equipment includes defi-
brillation and suction capabilities.7,18 A warming
blanket is useful, especially in colder climates.18
Syringe pumps with a long battery life are required,
discouraged due to potential unreliability when fly-
ing.7,18 All appropriate medications that the patient
requires or is likely to require en route should be
available.7,18
Equipment for establishing and maintaining a
safe airway is essential. The CCT team should have
a portable mechanical ventilator that can provide
multiple modes of ventilation, variable oxygen con-
centrations, respiratory rates, and positive end-expi-
ratory pressure. The vehicle should carry sufficient
oxygen to last the duration of the transfer, plus a
reserve of 1 to 2 hours.18
Clinical Course In The ED
Stabilization
Prior to transport, patients should be stabilized as
much as possible to minimize the risks of transport.
Patients may not be able to be completely stabilized
without the tertiary care services they are being
transported to receive; in select cases, this may be
acceptable.17 The referring physician must make the
determination that the benefits of transfer outweigh
the risks for such unstable patients. Nonessential
tests or procedures that may delay transport should
be avoided.7 Several societies and authors have pub-
lished pretransport checklists.7,18 (See Figure 1.)
On arrival at the referring institution, the trans-
port team must be given a thorough report regard-
ing the patient’s presentation and hospital course.17
The team should perform a physical examination,
including an airway assessment, prior to transport.
If there is risk of airway deterioration, the airway
must be secured prior to the patient leaving the
referring hospital.7,17,59 Though success rates for
CCT intubation are generally excellent, intubation in
the helicopter is more challenging than intubation at
the referring institution. If the patient is intubated,
adequate sedation must be provided. In appropriate
instances, paralytics should be provided to maxi-
mize oxygenation and ventilation and to facilitate
safe transport.
www.ebmedicine.net • Volume 2, Number 4
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.

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

 Adequate IV access should be established, ide-
ally with 2 IVs, a central venous line, or an IO line.
The patient’s underlying diagnosis will guide resus-
citation goals, such as whether hypotensive resusci-
tation should be pursued, but the provider should
be aware that resources such as blood products or
large volumes of crystalloid may not be available in
transport unless provided to the transport team in
advance. All appropriate hemodynamic agents for
heart rate and blood pressure modification should
be started prior to transport in order to monitor the
patient’s response.
Trauma patients should be maintained in
cervical-spine immobilization, and other fractures
should also be immobilized. Orogastric or nasogas-
tric tubes and Foley catheters should be placed, as
indicated.
Published guidelines17 recommend the follow-
ing as minimum standards of monitoring during
air CCT:
• Continuous cardiac rhythm monitoring via elec-
trocardiogram
• Noninvasive blood pressure
• Oxygen saturation (SaO2)
• End-tidal CO2 (in ventilated patients)
• Temperature
Intermittent noninvasive blood pressure cuffs
may be unreliable due to motion artifact. If available,
indwelling arterial lines are preferable. A central ve-
nous line may be of benefit, as it allows for monitor-
ing central venous pressures and administration of
centrally acting medications.17
Deterioration
Critically ill patients tend to become unstable dur-
ing transport,59 and helicopters are often cramped
and not conducive to active intervention.17,18 In the
helicopter, if a patient deteriorates, there are few op-
tions for obtaining additional help. As compared to
ground transport, where the vehicle may reroute to
a closer hospital if the patient deteriorates, altering
the flight plan en route can be dangerous and is not
routinely recommended.
In addition to the constrained environment of the
helicopter, several factors specific to air transport war-
rant consideration. Close monitoring of a critically ill
patient’s oxygenation during transport is essential, as
patients may become hypoxemic.17 As the decreased
barometric pressure associated with altitude expands
gas-filled cavities in the patient, untreated pneumo-
thoraces can cause clinical deterioration.17 Flying is
associated with a decrease in temperature,60 and criti-
cally ill patients may require additional interventions
to maintain body temperature. Noise and vibration
can cause nausea, pain, and motion sickness. Anti-
emetic medications should be available for patients,
and ear protection should be provided.17
EMCC © 2012 8
Unfortunately, deterioration in transport is not
uncommon. A recent review of incidents that oc-
curred in transport of critically ill patients in Aus-
tralia found that 59% of critical incidents (including
both system-based and human-based errors such
as transport operations, haste, equipment malfunc-
tion, failure to check pressure, etc) resulted in direct
patient harm. This study also found that 91% of the
incidents were preventable.61 Additionally, a report
from the Netherlands showed that 34% of patients
had an adverse event during transport, 70% of
which were considered to be avoidable.62 A study
from Canada found that critical events occurred
in 5.1% of air transports and were independently
associated with prior hemodynamic instability, as-
sisted ventilation, and female gender.59
Special Circumstances
Most CCT teams are available 24 hours a day with
a standard crew configuration that is able to handle
most emergencies and calls for service. Clinical situ-
ations may arise when a patient’s needs require ad-
ditional or specialty personnel. When given notice,
many CCT services can deploy specialty transport
teams for specific patient populations. Such teams
include pediatric, neonatal, intra-aortic balloon
pump (IABP), and extracorporeal membrane oxy-
genation (ECMO) transport teams.
Neonates And Pediatric Patients
Very few hospitals are equipped to manage complex
developmental and metabolic diagnoses or to care
for critically ill children. Neonates require a dispro-
portionate number of interfacility transports for this
reason.63 These transports often require specialized
equipment such as transport isolettes, low-volume
ventilators, and medications specific to pediatric
and neonatal care (ie, surfactant and prostaglandin).
Given the complexities and cost of this specific equip-
ment, many regional pediatric centers have their own
CCT vehicles and staff.64 Other CCT services are able
to modify standard set-ups to provide this service.3
Patients With IABPs
While many 24-hour PCI centers have cardiac surgi-
cal services available, some hospitals that offer this
service do not have surgical support. Some unstable
patients may require emergent cardiac surgical inter-
vention; IABPs and other ventricular assist devices of-
fer a bridge to augment cardiac output until a surgical
treatment is available. While uncommon, the capac-
ity to transfer IABP-dependent patients is available
in many areas, and transport IABPs are available.65
Although not standard equipment on most CCT
vehicles, IABPs can easily be added. Management of
these patients and devices usually requires adding a
perfusionist to the transport team, although studies
www.ebmedicine.net • Volume 2, Number 4
have shown that cross-trained critical care paramed-
ics can often perform this transport safely.3,66-68
Patients Requiring ECMO
Other specialty teams have been developed specifi-
cally for the transfer of patients requiring ECMO.
Patients requiring ECMO are among the most
critically ill and the most difficult to transfer. CCT
programs have developed protocols to transport
such patients to ECMO centers.69 In some cases,
ECMO must be started prior to transport, and a
surgical team must be transported to the referring
facility for cannulation and initiation of ECMO.
While few programs have developed specific
protocols or dedicated multidisciplinary healthcare
teams prepared to transport such complex patients,
transport ECMO circuits have been developed, and
successful transport has been performed with both
veno-arterial and veno-venous circuits.70 Patients
receiving ECMO are at increased risk for significant
complications during transport, including the risk
of decannulation and membrane lung thrombosis.70
The most common complication for interfacil-
ity transport of these patients is a loss of power,
resulting in the need for manual hand cranking of
the ECMO circuit until power is restored.70 Close
medical oversight of transport teams and coordina-
tion of care is essential for the success of programs
that transfer patients receiving ECMO.70 (For an
in-depth review of ECMO in the ED, see EMCC’s
research report, Extracorporeal Cardiopulmonary Re-
suscitation In The Emergency Department.)
Contraindications
Not all critically ill patients who require transport to
specialty centers are appropriate for helicopter trans-
port, even with a CCT team. Profoundly unstable or
coding patients are not candidates for transport. A
patient in cardiac arrest will receive no benefit from
rapid transport during resuscitation, and CCT ser-
vices do not offer any additional therapy that is not
already available at a local ED. Furthermore, while
resuscitation does occur when needed in transport
vehicles, choosing to do so in a dimly lit, cramped,
and moving space is not in the patient’s best interest.
In fact, it is the policy of many EMS agencies to not
transport patients in cardiac arrest to a local hospital
and to simply perform the resuscitation at the scene.
Patients are only transported if return of spontane-
ous circulation is obtained.71
Active labor is also a contraindication for CCT.
Many CCT programs have protocols prohibiting
transport of women in active labor, as helicopters
are not equipped to provide simultaneous maternal
and neonatal resuscitation. It is recommended that
delivery or tocolysis be achieved at the sending facil-
ity prior to transport, and, if needed, an additional
www.ebmedicine.net • Volume 2, Number 4
neonatal CCT team should be dispatched for neona-
tal care and transport.
Patients with injuries or conditions that would
be made more severe with altitude should not be
transported by CCT aircraft until these conditions are
appropriately stabilized. CCT aircraft typically fly at
altitudes less than 5000 feet, and, although this is a
lower altitude than commercial aircraft, most aero-
medical helicopter cabins and patient compartments
are not pressurized. This can lead to alterations in
normal physiology via Boyle’s and Dalton’s laws.
Boyle’s law states that at a constant tempera-
ture, the volume of a gas varies inversely with
pressure. Therefore, as altitude increases and
atmospheric pressure decreases, the volume of gas
increases. This effect is seen on all gas-containing
compartments of the body, including ears, sinuses,
and (most importantly) the gastrointestinal tract
and lungs.72 Pneumothoraces or bowel obstructions
must be managed prior to flight. To prevent devel-
opment of tension pneumothorax, patients with
any pneumothorax should have a chest tube(s)
placed. Chest tubes should not be clamped during
transport. For patients with bowel obstructions,
nasogastric tube decompression should be per-
formed to minimize the risk of visceral expansion,
worsening bowel ischemia, or perforation.73 The
endotracheal tube cuff pressure should be moni-
tored closely in intubated patients. While some
guidelines suggest that pneumoperitoneum and
pneumocephalus are relative contraindications to
air transport,7,17 these must be considered in the
context of the individual patient’s clinical circum-
stances and other transport options available. Soft
tissues may also swell, and plaster casts should be
bivalved to prevent compartment syndrome.17 Air
transport is not absolutely contraindicated for other
gas-containing devices such as esophageal tam-
ponade (eg, Blakemore) tubes; however, helicopter
crews must pay close attention to pressures main-
tained in these devices during flight.
Dalton’s law states that the pressure of a gas
mixture is equal to the sum of the partial pres-
sures of all the gases contained in the mixture.
Therefore, with increasing altitude and increas-
ing volume of a gas mixture (Boyle’s law), the
percentage of an individual gas in the gas mix-
ture does not change. As a gas mixture’s volume
increases with altitude, the gas molecules within
the mixture spread farther apart. One consequence
of this is that alveolar gas exchange becomes less
efficient, resulting in lower hemoglobin satura-
tion and hypoxia.72 During flight, this effect can
be mediated with supplemental oxygen and cabin
pressurization; however, even when passenger
compartments are pressurized, it is only to the
equivalent of 5000 to 8000 feet — enough to cause
hypoxia in patients with poor reserve.73
9 EMCC © 2012
Controversies
While the advanced care of CCT teams has been
shown to provide benefit in some subsets of patients,
the use of this expensive service is not always appro-
priate or feasible, as the evidence reviewed here has
shown. An increasing number of patients who could
be transferred by ground services are being taken
by air.74 A recent review of hospital-based helicopter
CCT services led to recommendations that Medicare
recover overpayments due to inadequate justification
of medical necessity for air CCT.74 One specific metric
assessed by payers is the proportion of patients dis-
charged within 23 hours of CCT. Some feel that this
metric is particularly unreasonable given that defini-
tive imaging and expert consultations, which are
available only through transport, may ultimately rule
out significant disease in an undifferentiated trauma
patient, allowing timely discharge. In addition, there
are concerns for over-triage of patients with non-life-
threatening injuries where the use of the helicopter
may not make a difference in outcomes.75,76
The United States has seen a dramatic increase
in the number of aeromedical CCT providers;
however, there is significant variability of air CCT
organizations’ qualifications or capabilities. In 2005,
there were 753 rotor-wing aeromedical units in
operation; in 1990, there were only 231.74 Along with
this growth, there has also been a disproportionate
rise in helicopter crashes.36-38 Due to safety concerns
and the increase in competition, groups such as
CAMTS have developed standards for medical care
and safety for the air medical industry. CAMTS ac-
creditation is voluntary but is considered the “gold
standard” for the industry.
Despite generally being more expensive than
ground transport, a number of studies have found
helicopter transport to be cost effective. However,
given the variation inherent in the health systems in
which helicopter transports operate, generalization
of such findings across differing health environ-
ments is problematic.77 The most thorough cost-ben-
efit study found that helicopter transport resulted
in a $2500 cost per life-year, compared to a cost per
life-year of $41,000 for zidovudine prophylaxis for
HIV exposure.78 Another study found helicopter
transport for thrombolysis in stroke patients to be
associated with a cost of $35,000 per additional good
outcome and $3700 per quality-adjusted life year.79 A
recent study in the United Kingdom found helicop-
ter transport to be well below cost-effectiveness ra-
tios described as generally acceptable by healthcare
economists and policy makers.34
Disposition
After the CCT team arrives and completes an
assessment, and the patient has been stabilized,
EMCC © 2012 10
preparations should be made for departure. The
equipment should be rechecked, ensuring compat-
ibility and sufficient reserves of battery power and
oxygen. Adequate supplies of medications, fluids,
and blood products, as indicated, should be veri-
fied. If using a pretransport checklist, as is recom-
mended,18 it should be filled out at this time. Once
the referring physician and the CCT team agree
that the patient is ready to travel, the CCT team
can depart.
The importance of communication cannot be
over emphasized. Although the CCT team will give
a report to the receiving institution on arrival, the
referring institution is still responsible for ensuring
that all clinically relevant information is commu-
nicated. In addition to the physician-to-physician
discussion, a nurse-to-nurse report between the 2
hospitals should also be completed. If the patient
has had any clinical change since the initial discus-
sion between the 2 physicians, the referring physi-
cian should notify the receiving physician. Copies of
all medical records, including laboratory values and
images of radiographic examinations, should be pro-
vided to the CCT team prior to departure. If some
information is not available at that time, departure
should not be deferred; instead, the referring institu-
tion should send the data to the receiving institution
as soon as possible.
Summary
Critically ill patients in the ED often require trans-
fer to tertiary care centers for specialized care. The
decision to transfer the patient lies with the referring
physician, who must weigh the potential benefits of
transport against the risks. All emergency physicians
must be familiar with federal laws regarding the
transfer of ED patients as well as locally available re-
sources and protocols. The referring physician is re-
sponsible for selecting the most appropriate method
of transporting the patient as well as for the patient’s
care until arrival at the receiving institution.
Helicopter transport does not always decrease
the total time until arrival at the receiving facility,
but it often decreases the time in the out-of-hospital
setting. Helicopter transport is usually performed
by CCT teams that specialize in the transport of
critically ill patients. Patients should be stabilized
as much as possible, with special attention to the
airway and hemodynamics. If the patient is not able
to be stabilized without tertiary care, the referring
physician must carefully weigh the risks and ben-
efits of transport. Select patients may benefit from
CCT, including severely injured trauma patients,
cardiac patients, and stroke patients. Additionally,
highly specialized teams are often available to trans-
port critically ill neonates and children, patients with
IABPs, and patients requiring ECMO.
www.ebmedicine.net • Volume 2, Number 4
 Patients with pneumothoraces and bowel ob-
structions must have these issues addressed prior to
flying. Furthermore, patients in cardiac arrest should
not be transported. Prior to departure, the equip-
ment and medications should be rechecked, and a
transport checklist should be completed. The patient
should not leave until both the CCT team and the
referring physician agree that the patient is ready for
transport.
Although flying incurs additional risk, data
support the use of helicopters to improve outcomes
in critically ill and injured patients. While expensive,
the best available data suggest that helicopter trans-
port provides cost-effective care.
Case Conclusion
You recognize that your patient is in need of close blood
pressure control and monitoring and will need to be
transferred for emergency surgery. Your regional CCT
service operates a roster system and will facilitate the
designation of a receiving facility. You call their central
dispatcher, who requests that a medical helicopter be
launched as soon as possible. After 2 additional calls, you
are able to connect with the receiving hospital’s vascu-
lar surgeon. Within 40 minutes, the helicopter lands on
your hospital’s helipad. As the CCT crew begins assess-
ing and moving the patient onto the transport stretcher,
he becomes unresponsive and is intubated by the CCT
team. His esmolol drip is titrated as he is placed on a
transport ventilator and moved to the waiting aircraft. A
short flight later, he arrives in the OR where the vascular
surgeon you spoke to is scrubbed and ready, waiting for
the patient.
Must-Do Markers Of Quality ED Critical Care
• Emergency physicians must be familiar with
federal laws as well as local resources and
recognize that the decision to transfer, as well as
the responsibility for the patient, rests with the
referring physician until the patient arrives at
the receiving hospital.
• Communication with the receiving facility is
critical, including adequate physician-to-physi-
cian and nurse-to-nurse reporting. All pertinent
medical records, including imaging studies,
should be copied and provided to the receiving
institution.
• The patient should be stabilized as much as pos-
sible prior to departure, including airway assess-
ment and management. Pneumothoraces must
be treated with chest tubes, and bowel obstruc-
tions should be decompressed with nasogastric
or orogastric tubes. Patients in cardiac arrest
should not be transported.
www.ebmedicine.net • Volume 2, Number 4
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Evidence-based medicine requires a critical appraisal
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11 EMCC © 2012
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EMCC © 2012 12
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34.* Ringburg AN, Polinder S, Meulman TJ, et al. Cost-effective-
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ter emergency medical services. Br J Surg. 2009;96(11):1365-
1370. (Prospective cohort study)
35. Ringburg AN, Thomas SH, Steyerberg EW, et al. Lives saved
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16 studies on helicopter transport published between 1985
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36. Greene J. Rising helicopter crash deaths spur debate over
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17A. (News article)
37. Bledsoe BE. Air medical helicopter accidents in the United
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38. Plevin RE, Evans HL. Helicopter transport: help or hindrance?
Curr Opin Crit Care. 2011;17(6):596-600. (Review article)
39. Shewakramani S, Thomas SH, Harrison TH, et al. Air
transport of patients with unstable aortic aneurysms directly
into operating rooms. Prehosp Emerg Care. 2007;11(3):337-342.
(Retrospective consecutive-case analysis of 29 patients)
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gov/people/injury/airbags/BUASBRuralWeb/index.htm.
Accessed November 24, 2011. (Report from NHTSA dataset,
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tion of a prehospital trauma triage tool: a 10-year perspec-
tive. J Trauma. 2008;65(6):1253-1257. (Retrospective chart
review of 1144 patients)
42. Curry N, Hopewell S, Dorée C, et al. The acute management
of trauma hemorrhage: a systematic review of random-
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review of 35 randomized controlled trials)
43. Essebag V, Halabi AR, Churchill-Smith M, et al. Air medical
transport of cardiac patients. Chest. 2003;124(5):1937-1945.
(Review article)
44. Reiner-Deitemyer V, Teuschl Y, Matz K, et al. Helicopter
transport of stroke patients and its influence on thromboly-
sis rates: data from the Austrian stroke unit registry. Stroke.
2011;42(5):1295-1300. (Prospective analysis of 21,712 isch-
emic stroke patients)
45. Berns KS, Hankins DG, Zietlow SP. Comparison of air and
ground transport of cardiac patients. Air Med J. 2001;20(6):33-
36. (Retrospective chart review of 266 patients)
46. Weisberg S, Fitch J, Towner D, et al. Transporting without
infusions: effect on door-to-needle time for acute coronary
syndrome patients. Prehosp Emerg Care. 2010;14(2):159-163.
(Retrospective review of 154 patients)
47. McMullan JT, Hinckley W, Bentley J, et al. Reperfusion is
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 delayed beyond guideline recommendations in patients
requiring interhospital helicopter transfer for treatment of
ST-segment elevation myocardial infarction. Ann Emerg Med.
2011;57(3):213-220. (Retrospective review of 179 patients)
48. Werman HA, Jaynes C, Blevins G. Impact of a triage tool on
air versus ground transport of cardiac patients to a tertiary
center. Air Med J. 2004;23(3):40-47. (Prospective observa-
tional study of 42 patients)
49. Peberdy MA, Callaway CW, Neumar RW, et al. Cardiopul-
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Part 9: Post Cardiac Arrest Care: 2010 American Heart As-
sociation Guidelines. Circulation 2010;122(18 Suppl 3);S768-
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50. Cabanas JG, Brice JH, De Maio VJ, et al. Field-induced thera-
peutic hypothermia for neuroprotection after out-of hospital
cardiac arrest: a systematic review of the literature. J Emerg
Med. 2011;40(4):400-409. (Review of 800 citations)
51. Thomas SH, Kociszewski C, Schwamm LH, et al. The
evolving role of helicopter emergency medical services in
the transfer of stroke patients to specialized centers. Prehosp
Emerg Care. 2002;6(2):210-214. (Retrospective descriptive
study of 192 transports of stroke patients, comparing
interventions in the prethrombotic and thrombotic eras of
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52. Uren B, Lowell MJ, Silbergleit R. Critical care transport of
patients who have acute neurological emergencies. Emerg
Med Clin North Am. 2009;27(1):17-26. (Review article)
53. Bellingan G, Olivier T, Batson S, et al. Comparison of a spe-
cialist retrieval team with current United Kingdom practice
for the transport of critically ill patients. Intensive Care Med.
2000;26(6):740-744. (Retrospective review of 259 patients)
54. Davis DP, Peay J, Sise MJ, et al. The impact of prehospital
endotracheal intubation on outcome in moderate to severe
traumatic brain injury. J Trauma. 2005;58(5):933–939. (Retro-
spective trauma database review of 13,625 patients from 5
trauma centers)
55. Newton A, Ratchford A, Khan I. Incidence of adverse events
during prehospital rapid sequence intubation: a review
of one year on the London helicopter emergency medical
service. J Trauma. 2008;64(2):487-492. (Retrospective observa-
tional study of 175 patients)
56. Fakhry SM, Scanlon JM, Robinson L, et al. Prehospital rapid
sequence intubation for head trauma: conditions for a suc-
cessful program. J Trauma. 2006;60(5):997-1001. (Retrospec-
tive review of 175 intubations)
57. Harrison T, Thomas SH, Wedel SK. In-flight oral endotrache-
al intubation. Am J Emerg Med. 1997;15(6):558-561. (Retro-
spective study of 302 intubations)
58. Thomas AN, Galvin I. Patient safety incidents associated
with equipment in critical care: a review of reports to the UK
National Patient Safety Agency. Anaesthesia. 2008;63(11):1193-
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cally ill patients submitted to a safety agency)
59. Singh JM, MacDonald RD, Bronskill SE, et al. Incidence
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transport. CMAJ. 2009;181(9):579-584. (Retrospective cohort
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60. Carchietti E, Cecchi A, Valent F. Influence of helicopter flight
on temperature of helicopter EMS crewmembers. Air Med J.
2011;30(6):317-321. (Prospective observational study of 95
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61. Flabouris A, Runciman WB, Levings B. Incidents during
out-of-hospital patient transportation. Anaesth Intensive Care.
2006;34(2):228-236. (Retrospective review of 125 incident
reports, documenting 272 incidents in transport)
62. Ligtenberg JJ, Arnold LG, Stienstra Y, et al. Quality of
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patients requiring transport: a review of patients, indications,
and standards. Air Med J. 2002;21(1):22-25. (Retrospective
review of 732 patients)
64. Lavery RF, Tortella BJ, Griffin CC. The prehospital treatment
of pediatric trauma. Pediatr Emerg Care. 1992;8(1):9-12. (Re-
view of 458 patients)
65. MacDonald RD, Farquhar S. Transfer of intra-aortic balloon
pump-dependent patients by paramedics. Prehosp Emerg Care.
2005;9(4):449-453. (Prospective case series of 29 patients)
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ports)
67. McNamara NS, Wharton TP Jr, La Rochelle T, et al. Use of
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Crit Pathw Cardiol. 2002;1(3):159-179. (Review article)
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with severe lung injury: development and utilization of the
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2002;48(6):612-619. (Retrospective review of 100 patients)
71. Bailey ED, Wydro GC, Cone DC. Termination of resuscitation
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72. Woodward GA, Vernon DD. Aviation physiology in pediatric
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2007;11(4):353-368. (Clinical practice guideline)
75. Shatney CH, Homan SJ, Sherck JP, et al. The utility of helicop-
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spective review of 947 trauma patients transferred from the
scene to a trauma center)
76. Bledsoe BE, Wesley AK, Eckstein M, et al. Helicopter scene
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77. Taylor CB, Stevenson M, Jan S, et al. A systematic review
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of helicopter EMS for trauma patients. Ann Emerg Med.
1997;30(4):500-506. (Cost-effectiveness analysis)
79. Silbergleit R, Scott PA, Lowell MJ, et al. Cost-effectiveness of
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13 EMCC © 2012
 CME Questions

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1. The primary benefit of helicopter transport is:

a. Decreasing the time to arrival at the
accepting hospital
b. Decreasing the time the patient spends in
transit
c. More specialized team of transport
d. Better equipment than land transfers

2. One strategy to streamline care of STEMI pa-

tients is to:
a. Eliminate administration of thrombolytics.
b. Minimally stabilize the patient prior to
transfer.
EMCC Has
c. Eliminate heparin and t-PA therapy from the

treatment algorithm.
d. Eliminate heparin and IIb/IIIa inhibitor
infusions after bolus.
3. If there is a risk of airway deterioration, the
airway should be secured:
a. En route to the accepting hospital by device, and you’ll automatically be directed
the CCT team during the early phase of
transport
b. During transport when the patient requires
a crash airway
c. Prior to air transport by the referring team
d. At any point before or during transport
4. All of the following are recommended as a
minimum standard of monitoring during air
CCT EXCEPT?
a. Continuous cardiac rhythm
(electrocardiogram)
b. Noninvasive blood pressure
c. Capillary blood glucose
d. Oxygen saturation (SaO2)
e. Temperature
5. Contraindications for helicopter transport
include all of the following EXCEPT?
a. Patients in cardiac arrest
b. Women in active labor
c. Patients with chest tubes for pneumothorax
d. Patients with bowel obstruction
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EMCC © 2012 14 www.ebmedicine.net • Volume 2, Number 4

 Coming Soon In EMCC
Optimizing Initial Antibiotic
Delivery For Adult Patients With
Severe Sepsis And Septic Shock In
The Emergency Department
AUTHORS:
ROBERT S. GREEN, MD, DABEM, FRCPC
Associate Professor, Department of Anesthesia,
Division of Critical Care Medicine, Department
of Emergency Medicine, Dalhousie University,
Halifax, NS, Canada
SEAN K. GORMAN, BSC, PHARMD
Clinical Coordinator, Critical Care, Capital District
Health Authority; Associate Professor, Dalhousie
University College of Pharmacy, Halifax, NS,
Canada
Severe sepsis and septic shock account for one-fifth
of all admissions to the intensive care unit (ICU)
and remain the leading cause of death. There are
more than 500,000 emergency department (ED)
visits annually in the United States due to suspected
severe sepsis, and the average length of stay in the
ED is approximately 5 hours. In addition, many more
patients present to the ED with infection-related
conditions without signs of tissue hypoperfusion
and, therefore, may be considered to have sepsis.3
Approximately 25% of these patients progress to
severe sepsis or septic shock within 72 hours of
presentation to the ED. Because of the high mortality
associated with severe sepsis and septic shock, early
identification, monitoring, and management of septic
patients in the ED are imperative. This issue of EMCC
will answer the following questions:
1. Does the choice of antibiotic matter, as long as it
“covers” the suspected bugs?
2. Do we have to adjust the first dose of antibiotic
for patients with sepsis in the ED?
3. Does the timing of antibiotic administration
matter in patients with septic shock?
www.ebmedicine.net • Volume 2, Number 4
Cardiocerebral Resuscitation:
An Evidence-Based Review
AUTHORS:
JON RITTENBERGER, MD, MS
Assistant Professor, Department of Emergency
Medicine, University of Pittsburgh School of Medicine;
Attending, Emergency Medicine and Post-Cardiac
Arrest Services, UPMC-Presbyterian Hospital,
Pittsburgh, PA
BENJAMIN S. ABELLA, MD, MPHIL, FACEP
Assistant Professor, Department of Emergency
Medicine and Department of Medicine / Section
of Pulmonary Allergy and Critical Care, University
of Pennsylvania School of Medicine; Clinical
Research Director, Center for Resuscitation Science,
Philadelphia, PA
FRANCIS X. GUYETTE, MD, MS, MPH, FACEP
Assistant Professor of Emergency Medicine, University
of Pittsburgh School of Medicine, Pittsburgh, PA
Cardiac arrest is the third most common cause of death
in North America, resulting in approximately 300,000
deaths per year. Following restoration of pulses, multiple
organ systems demonstrate varying degrees of injury or
failure. This postarrest syndrome demonstrates features
of systemic inflammatory response (the postarrest
state has been likened to a “sepsis-like syndrome”)
along with diffuse anoxic injury to the brain. Aggressive
titration of care to optimize cerebral resuscitation has
improved outcomes. Multiple strategies are used to
prevent secondary neuronal injury, including therapeutic
hypothermia, aggressive revascularization, titrated blood
pressure goals, careful control of ventilator parameters,
and monitoring for seizure activity. An in-depth review
of the literature to determine the evidence supporting
present postarrest guidelines is presented in this issue of
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. Describe indications and contraindications for
postresuscitation care.
2. Describe organ system strategies for optimizing
postresuscitation care.
3. Describe techniques for optimizing organ system
resuscitation during the postresuscitation phase.
4. Discuss current controversies in postarrest care.
5. Summarize the evidence for postresuscitation care.
15 EMCC © 2012
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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only the credit commensurate with the extent of their participation in the
• Severe Traumatic Brain Injury activity.
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• Burn Support Association Category 2A or 2B credit hours per year.
Needs Assessment: The need for this educational activity was
• High-Risk Scenarios In Penetrating Trauma determined by a survey of medical staff, including the editorial board
of this publication; review of morbidity and mortality data from the
CDC, AHA, NCHS, and ACEP; and evaluation of prior activities for
emergency physicians.
Target Audience: This enduring material is designed for emergency
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
presentations; and (3) describe the most common medicolegal pitfalls
Dr. Joe Bellezzo and Dr. Zack Shinar have for each topic covered.
pioneered an ED ECPR (ECMO) service at Sharp Discussion of Investigational Information: As part of the newsletter,
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Memorial Hospital in San Diego. This ground- pharmaceutical products that is outside Food and Drug Administration-
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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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EMCC © 2012 16 www.ebmedicine.net • Volume 2, Number 4