Physiological Events William Buck Dodson III MD MPH

Physiological Events William Buck Dodson III MD MPH FACPM Col, ANG, MC, CFS Aerospace, Occupational, & Undersea Hyperbaric Medicine ANG Assistant to the 711 HPW Commander 711 th Human Performance Wing Wright-Patterson AFB, Ohio “Saving Lives – Our Calling”

Disclosures No Financial COIs Not DOD Policy – My Opinions if Differs Brands May Be Shown Non-FDA Usage may be Mentioned

Overview Physiological Events Reporting Treating Advanced Cardiovascular Life Support (ACLS) 2015 Edition Tactical Combat Casualty Care (TCCC) 2016 Update

Mishap Classification Classes per AFI 91 -204 12 FEB 2014 ; CORRECTIVE ACTIONS APPLIED ON 10 APRIL 2014 “SAFETY INVESTIGATIONS AND REPORTS” inc AFGui. Mem 2016 -02 11 Jan 2016: (Just need 1 Item on the line to be in that class) A: $2 M +, Death, Permanent Total Disability, Aircraft Destroyed B: $500 K-2 M, Permanent Partial Disability, Hospitalization of 3 plus Members C: $50 K-500 K, Permanent Change of Job, Loss of 1 plus Workdays D: $20 K-50 K, Recordable/Reportable Injury or Illness E: “Events”, Situations that do Not Fall into the Above Classes

Lead Resource “AVIATION SAFETY INVESTIGATIONS AND REPORTS” Air Force Manual (AFMAN) 91 -223 16 MAY 2013, incorporating Change 1 dated 8 June 2016

“Events” 1. 3. 2 Class E Events Unless noted, report all of the following events whether intent for flight is established or not. In most cases, events do not require reporting if they occur as described in the aircraft flight manuals and are expected responses to a crew’s actions or flight regime. For example, do not report the loss of pitot-static instrument indications if the loss is the result of crew failure to activate the pitot heat. If the circumstances of an event meet two or more criteria, such as an in-flight fire which results in a physiological episode, report the event using the following hierarchy: Physiological, Propulsion, Flight Control, Instrument, Miscellaneous, High Accident Potential (HAP), Hazardous Air Traffic Report (HATR), Controlled Movement Area (CMA) Violation, Bird/Wildlife Aircraft Strike Hazard (BASH). Note: Although Class E events do not require findings, a finding is required in order to input a recommendation into the Air Force Safety Automated System (AFSAS).

“Physiological Events” 1. 3. 2. 1. Physiological Events Report all flight-related aircrew abnormal physiological conditions not categorized as Class AD mishaps as Class E Physiological events. Reportable events include hypoxia, trapped gas disorders, G-induced loss of consciousness (GLOC), incapacitating hyperventilation, spatial disorientation and/or visual illusions resulting in an unusual aircraft attitude, and toxic smoke/fumes/liquid exposure resulting in aircrew and/or passenger symptoms (report exposures without symptoms as Class E Miscellaneous events), or any condition that a qualified flight surgeon determines to be significant to the health of the aircrew member. Include accurate descriptions of symptoms in the event narrative and ensure applicable human factors codes are selected in AFSAS. (via the Wing Safety Officer)

Decompression Sickness 1. 3. 2. 1. 1. Confirmed aircrew or passenger decompression sickness (DCS) is considered a mishap (usually will be a Class D Mishap), while suspected DCS with symptoms that resolve on descent (with or without oxygen) or within 2 hours at ground level (with or without oxygen) with no recurrent symptoms and no (Other) medical treatment required is considered a Physiological Event. 1. 3. 2. 1. 2. Include lab and/or toxicological test results for involved personnel in the report only when determined necessary by the commander or flight surgeon. Include 72 -hour and 7 -day histories for GLOC events.

Flight Surgeon Duties Unlike Class A - D Mishaps, the documentation requirements are less for Events. FS collects the usual patient care information such as History, Physical, Studies, Treatment that he and any other providers have produced. The Wing Safety Officer will have an account in AFSAS and a portion of that FS collected information will be inputted by him and/or the FS. More documentation, studies, etc may be decided to be obtained by POCs such as the FS or others.

Support If a Safety Officer is not readily available locally: Air Force Safety Center Human Factors Section Kirtland AFB, NM Aerospace Physiology Officers: (505) 853 -1117 DSN 263 (505) 846 -0880 DSN 246 Flight Surgeon: (505) 853 -4868 DSN 263 24/7 Command Post: (505) 846 -3777 DSN 246

DCS Class A-D Mishap: DCS treated w/ Hyperbaric Oxygen (HBO 2) Class E Physiological Event: Possible DCS or DCS resolved w/ 100% O 2 within 2 hrs

Aviation DCS – USAF Approach Type I Aviation DCS: Joint, Skin 100% Oxygen* + Hydration (Improves w/in 60 min? Yes – 2 more hours; No – TT 5) Total Relief YES *100% Oxygen: Aviator’s Mask – 1 st Choice Bi. PAP CPAP Nonrebreather Mask (> 15 L/min) Call USAF UHM (210) 292 -3483 (DSN 554) 24/7: -5990 NO TT 5 Type II Aviation DCS: Neuro, Pulmonary, etc. TT 6 Observe Total Relief w/in 10 min NO Total Relief YES Complete Treatment Table 5 & Observe YES NO Modified treatment regimens Complete TT 6 & Observe

Emergency Evacuation Hyperbaric Stretcher (EEHS) “Hyperlite” Transport Chamber m

Monoplace Chamber

Example of Multiplace Chambers Duke University 8 Chambers Interconnected By Airlocks

Approved HBO 2 Indications – UHMS “Life, Limb, Eyesight – All Saved” 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Air or Gas Embolism “AGE or DCI” (All - should have consultations) Decompression Sickness/Illness “DCS or DCI” (All) Clostridial Myositis/Myonecrosis – “Gas Gangrene” (All) Crush Injury/Compartment Syndrome (Some: esp if Ischemic Hypoxia) Carbon Monoxide (CO) Poisoning (Cardiac or Neuro S/S, or Hi COHb) Arterial Insufficiencies: 1) Cent Retinal Art Occlusion (If O 2 Fails) 2) Problem Wounds (Hypoxic-Diabetes, RA, Etc-Some) Exceptional Blood Loss Anemia (2* Religion-Some) Intracranial Abscess (Some: if Surgery/Abx Failing) Necrotizing Soft Tissue Infections (Some: as #8) Delayed Radiation Injury (Some; All Pre-Dental Proc) Idiopathic Sudden Sensorineural Hearing Loss (Some) Skin Grafts & Flaps (Some: If Failing) Thermal Burns (Some: Face, Hands, Ft, Hi TBSA) Refractory Osteomyelitis (Failed 6 wks Abx+Surg)

Why Mechanisms Simplified: Pressure Effects with Arterial Gas Embolism (AGE), DCS: Makes Bubbles Smaller Oxygen Effects with AGE, DCS: N 2 Leaves Faster Due to Better Gas Gradient with Infection: WBCs are Released + Eat More; Anaerobes Killed with Wounds: Increased Capillary + Tissue Production with CO: Reduces Half-Life of Carboxyhemoglobin

USAF Chamber San Antonio ‘ 06 Wilford Hall => BAMC, SAMMC ‘ 16

USAF San Antonio Multiplace Chamber

Life, Limb, Eyesight – All Saved Questions (FSs to call USAF Hyperbarics STAT re Any Possible Cases) USAF Hyperbarics TX: (210) 292 - (DSN 554) 0700 -1600: x 3483 24/7: x 5990 If Above Not Reachable: Divers Alert Network (DAN) 24/7: 1 (919) 684 -9111

Advanced Cardiovascular Life Support (ACLS) 2015 ACLS q 5 year update recently released in 2015: # Meds Focused Upon Now Down To 4: Epinephrine: VFib, Asystole, Pulseless Electrical Activity (PEA) Amiodarone: VFib Adenosine: Tachycardia Atropine: Bradycardia Electricity if Unstable/Meds Fail: Cardioversion, Defibrillation, Pacing ETs not 1 st Choice for Ventilation unless Provider Current: Mask/Other Airways OK Capnography (CO 2 mm. Hg): Compressions: 10 -20 (if < 10, assess CPR technique) Ventilations: 35 -45 (if < 35, reduce volume or frequency; if > 45, increase)

Tactical Combat Casualty Care (TCCC) T Triple C, TC 3 “~Mil Version” Pre Hospital Trauma Care Courses, Pre Hospital Trauma Life Support Courses CAPT (ret) Frank Butler MD (Ophtho, UHM) Former SEAL, SOCOM SG; Current Chair DOD Committee on TCCC (Not All Interventions may be FDA Approved …or Totally Accepted Yet by All Nations/ All Components Guidance Aimed At Combat Casualties …but May Be Applicable in Other Situations

TCCC Terms Recent Term Definitions: CCFP: Critical Care Flight Paramedics A new advanced level of training in response to # preventable deaths during evac Administer: Blood Products, Place Advanced Airways, Pneumothorax (PNTX) Procedures PFC: Prolonged Field Care No Longer within 4 hrs can majority of casualties in AORs be evac’ed to an OR Medics now getting PFC Training TACEVAC: Tactical Evacuation TACEVAC “= CASEVAC + MEDEVAC” CASEVAC: Any Means w/ Anybody; MEDEVAC: Medical Conveyance and/or Medical Staff (AEROVAC if needed would usually occur after TACEVAC)

TCCC Current Care Initiatives: “A’s A-lways die quickly”: “Over-Triaging into Category A” puts True A’s at More Risk Reduces Staff per Patient and Slows Evac to Definitive Life, Limb, Eyesight–Saving Care Combat Gauze: Combat Gauze = Gauze w/ Quik. Clot Granules - has become more popular than Quik. Clot XStat Injector: Mini-CGs into Deep Wounds; 3 min Direct Pressure after application

TCCC Current Care Initiatives: 1: 1: 1 Transfusions in Trauma: Whole Blood 1 st Choice*; if components: Ratio of 1 U PRBCs : 1 U Plasma : 1 U Platelets* Freeze Dried Plasma becoming popular w/ Medics of many nations (IND in SOCOM) *If collected in AOR, Whole Blood and Apheresis Platelets may not be FDA Compliant (Use FDA Compliant stores 1 st) BP in Trauma: No Longer IVF x 2 Wide Open: at SBP 94 plus, clots may dislodge => increased bleeding Target is SBP 90 or Less: ensure perfusion by assessing clinical parameters

TCCC Current Care Initiatives: Pneumothorax Treatment: Loss of VSs ? reasons ~ Tension PNTX: needle suspected side, other side if no better 14 Gauge preferred, at least 3 ¼ Inch long: 2 nd Intercostal Space slightly lateral to nipple Tranexamic Acid (TXA): Can reduce transfusion volume: Stops clot breakdown, esp in Massive Transfusion (MT*) Give ASAP w/in 3 Hrs: especially if MT; 1 gm over 10 min then 1 gm over 8 hrs *MT definitions: >10 U in 24 h, > 4 U in 1 h, ABC Score> 2 (1 for: P>120, BP<90, FAST +, Penetrating Torso Trauma)