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Objective: To analyze flight crew airway management in four different settings (in flight, at trauma scenes, in ambulance, and in referring hospitals) and in two different aircraft used by the same helicopter EMS (HEMS) service. The null hypothesis was that there was no association between practice setting, or aircraft, and airway practices or success rate., Methods: This retrospective study analyzed all patients in whom advanced airway management was attempted by the HEMS service during the study period October 1991 through October 1997. Data used were from flight records of Boston MedFlight Critical Care Transport Service, which uses a nurse/paramedic crew and had a paralytic-assisted intubation protocol in place. Data were analyzed with chi-square and Fisher's exact testing, risk ratio analysis, and logistic regression., Results: Advanced airway management was attempted in 722 patients, with an airway placed in 705 (97.8%). Intubation success was unrelated to site of airway management (p = 0.14), but patients were more likely to have intubation attempted prior to flight (as opposed to in flight) if the crew were in the AS365N2 Dauphin as compared with the BK-117 (p<0.0001). In addition, patients were 0.77 times as likely (95% confidence interval, 0.68-0.88) to receive paralytic-facilitated intubation if airway management occurred in the hospital setting as compared with other sites., Conclusions: While HEMS crew airway management success rates are equally high in all practice settings, airway management decision making and practice appear to be significantly influenced by practice setting and aircraft type. These data support contentions that nonphysician HEMS crews can effectively manage airways in a variety of circumstances.

Objective: To review the 5.5-year safety record of a protocol guiding fentanyl administration to pediatric trauma patients undergoing aeromedical transport., Methods: Retrospective review of an urban aeromedical program's trauma scene responses from October 1991 to March 1997 identified the study population as all pediatric patients (age <15 years) receiving fentanyl for analgesia during air transport. Patients receiving fentanyl concurrently with other agents, eg, paralytics, were not studied. The air transport team consisted of a flight nurse and flight paramedic who provided protocol-driven patient care with off-line medical control. Study patients' flight records were reviewed to determine vital signs (systolic blood pressure [SBP], heart rate [HR], and oxygen saturation [SAT]) before and after fentanyl administration. Postfentanyl vital signs were reviewed for evidence of hemodynamic or ventilatory compromise. Pre- and postfentanyl vital signs were compared with the paired t test (P < 0.05). Flight records were also analyzed for narrative information, eg, naloxone administration and assisted ventilation, indicative of fentanyl side effects., Results: Fentanyl (0.33-5.0 microg/kg) was administered 211 times to 131 patients who had a median age of 6.2 years (0.1-14 years), median Glasgow coma score (GCS) of 9 (3-15), and a mean pediatric trauma score of 8.3+/-2.4. Seventy-nine (60.3%) patients were intubated; these patients received 139 (65.9 %) of the 211 total fentanyl doses. No adverse effects from fentanyl were noted in flight record narratives. The median interval between fentanyl administration and postfentanyl vital sign assessment was 9.5 minutes (1-35 minutes). Median postfentanyl changes in SBP and HR were -4.7 and -2.9%, respectively. No patient became hypotensive after fentanyl administration. In nonintubated patients, mean postfentanyl SAT (99.2+/-1.3%) was not significantly different (P = 0.70) from prefentanyl SAT (99.1+/-1.3%), and no patient was noted to have clinically significant SAT decrement after fentanyl., Conclusion: Retrospective review of more than five years of prehospital fentanyl administration revealed no untoward events. Although prospective definitive demonstration of fentanyl's field use is pending, it is reasonable to continue discretionary fentanyl administration to injured pediatric children in pain.

Introduction: Use review has become increasingly important in the current atmosphere of cost justification for air medical transport. One criterion for use review is patient discharge from receiving hospitals within 24 hours of transport. The objective of this study was to determine the frequency and characteristics of patients discharged within 24 hours of air transport; the goal was to identify particular patient types likely to be discharged soon after air transport., Methods: Flight records from November 1994 to September 1995 were reviewed. Follow-up identified patients who were discharged within 24 hours of air medical transport; these were designated the "24-hour group." Other patients were designated the "overall group." Comparisons between groups were made using the t test, Wilcoxon rank sum, and chi-square analysis (alpha = 0.05) for the following factors: age, vital signs, Glasgow coma score, percentage of intubated patients, and percentage of trauma and scene transports., Results: Of the 945 flights analyzed, 42 (4.4%) transported patients who were discharged within 24 hours of air transport. Patients in the 24-hour group were younger, less likely to be intubated, and more likely to be scene-trauma transports compared with the overall group., Conclusion: This study demonstrates that air medical transports meet currently accepted criteria for helicopter transport. This study suggests that inappropriate air medical transport is rare, even in patients discharged from receiving hospitals within 24 hours of air transport.