Critical Care Air Transport Team Advanced Course

Center For Sustainment of Trauma And Readiness Skills

(CSTARS)

Cincinnati, Ohio 

 CSTARS official website may be found here.

WEBSITE TIP:
Informaiton on the validation process should be taken from the ERCC AFI: 48-307 V2
Information on the course may be obtained from the Knowledge Exchange Website

HOW TO PREPARE

• Be familiar with the current CPG's.  These may be found on the Joint Trauma System website.
• Know your gear bags.  Take a look at CCAT Book One Chapter Three: Allowance Standard.  This chapter has a line by line inventory of the 887N Allowance Standard Version 2 as well as bag diagrams.
• Know your PMI.  This site has all of the PMI manuals you can take advantage of.  Below is a table with links to these manuals.  Understand that these are full manual packages and are not intended for you to memorize; however, having a copy of them may be useful if you ever find yourself needing to troubleshoot a piece of PMI...trust me it happens.
• The specific tasks that you will be expected to perform with each piece of PMI are listed below...KNOW THEM!!
• Patient packaging and preparation is key to a successful transport.  Below are some patient examples for you to train with at your unit level.  It is recommended that you take these patient samples and utilize them during your training exercises...do exactly what you would do to prepare for the simulations at CSTARS. Also, the mission checklist reference book is an excellent resource to keep on your mobile device as it walks you through the mission execution from alert to recovery.  Download the file here or on the AFP CCATT Page.
  • CCATT.info link to mission checklist:  http://ccatt.info/index.php/main-menu-resources/shaggys-resource-page/ccat-books/file/208-book-one-chapter-one-mission-checklist

WEBSITE TIPS
The following videos are the official PMI training videos created by the CCATT Advanced Course Cadre.  These videos may be streamed by clicking the "play" button or downloaded by clicking the "download" button.  The videos may also be streamed directly from the CCATT Advanced Course group page, or the CCATT Advanced Youtube Page.

CCATT Advanced Course Group Page: 
http://ccatt.info/index.php/community-portal/videos?groupid=6

CCATT Advanced Course YouTube Page:
https://www.youtube.com/channel/UC2ejdIZXzIRahKbSRsB1LOA

PATIENT MOVEMENT ITEMS (PMI) TRAINING
&
TESTING CRITERIA

The PMI Training DVD is a compilation of all of the individual videos that have been created by the CCATT Advanced Course Cadre. This DVD is currently in the process of being updated. To view the individual videos contained on the DVD, navigate to the CSTARS group page, you may use the following link : CSTARS Advanced Course Group Videos

SITUATIONAL AWARENESS

PMI STATION 1 & 2:  ICP / VENTRICULOSTOMY / PROPAQ
TIME LIMIT: 8 MINS

 KEY PERFORMANCE POINTS-SETUP PROPAQ

• Turns on Propaq
• Checks the power level of the Propaq

 KEY PERFORMANCE POINTS-CODMAN ICU

• Sets Codman to standby/zero. Zeros on Propaq correctly
• Sets Codman to 100mmHg, Verifies +/- 2mmHg
• Switch Codman to standby/zero
• Attaches intraparanchymal device to Codman
• Enter/identifies correct reference number
• Switches Codman to transducer

 KEY PERFORMANCE POINTS-CODMAN VENTRICULOSTOMY DRAINAGE

• Locates anatomical reference point for ventriculostomy transducer zero
• Performs transducer zeroing for an OPEN or CLOSED system and zeros on propaq (returns buratrol to prescribed level if closed zeroing)
• Positions stop-cock on ventriculostomy in correct position to TRANSDUCE ICP
• Positions stop-cock on ventriculostomy in correct position to DRAIN ICP and MEASURE CSF output.

PMI STATION 3: IVAC TRIPLE CHANNEL
TIME LIMIT: 8 MINS

 KEY PERFORMANCE POINTS: SETUP

• Powers On
• Attaches cartridge/medications w/correlating channel

 KEY PERFORMANCE POINTS: INPUT SETTINGS

• Sets Channel A to infuse as Primary at given rate
• Sets Channel B (mcg/min)
• Sets Channel C (mcg/kg/min)
• Sets Secondary infusion on Channel A w/Primary
• Sets Vasopressin on Channel A

 EXERCISE ONE

1. NS (or maintenance fluid) at 50 mL/hr
2. Norepinephrine 10 mcg/min
3. Propofol 50 mcg/kg/min
4. Administer Ancef 2 gm in 100 mL NS. Infuse as a secondary over 15 mins
5. Remove maintenance fluid and set up Vasopressin at 0.04 units/min

• CONCENTRATIONS: Norepinephrine 4 mg in 250 mL NS, Propofol 10 mg/mL, Vasopressin 100 units/100 mL NS

 EXERCISE TWO

1. NS (or maintenance fluid) at 125 mL/hr
2. Norepinephrine 3 mcg/min
3. Propofol 30 mcg/kg/min
4. Administer Levaquin 500 mg/100mL D5W. Infuse as a secondary over 30 mins
5. Remove maintenance fluid and set up Vasopressin at 0.04 units/min

• CONCENTRATIONS: Norepinephrine 4mg in 250 mL NS, Propofol 10mg/mL, Vasopressin 100 units/100 mL NS

PMI STATION 4: PROPAQ MD DEFIBRILATOR / ACLS
TIME LIMIT: 8 MINS

KEY PERFORMANCE POINTS: SETUP

• Powers On
• Sets up for cardiac monitoring
• Sets up for 12 lead EKG
• Correctly locates anatomical positions for lead placement

KEY PERFORMANCE POINTS: DYSRHYTHMIA IDENTIFICATION

• Atrial Fibrillation
• Monomorphic V-Tach
• V-Fib
• Unstable Complete Heart Block

KEY PERFORMANCE POINTS: ACLS/TREATMENT

• Institutes ACLS for lethal dysrhythmia (v-fib), demonstrates response algorithm according to current AHA guidelines
• Treat A-Fib (unstable)
• Treat Monomorphic V-Tach (unstable)
• Treat Monomorphic V-Tach (stable)
• Treat V-Fib
• Treat Unstable Complete Heart Block

EXERCISE

1. Identify above cardiac rhythms
2. Demonstrate defibrillation, synchronized cardioversion and pacing
3. Identify appropriate pharmacologic therapy
4. Obtain a 12-lead EKG

PMI STATION 5:  IMPACT 731 VENT
TIME LIMIT: 8 MINS

KEY PERFORMANCE POINTS: SETUP

• Powers On
• Attaches circuit correctly
• Attaches O2 (50psi or low flow)
• Utilizes all accoutrements (HME/EtCO2/SX/Filter)

KEY PERFORMANCE POINTS: INITIAL SETTINGS

• Inputs all settings per orders
• O2 Reservoir on
• Pressure support menu
• Safe alarms

KEY PERFORMANCE POINTS: LUNG PROTECTIVE

• Maintains MV
• Appropriate TV/iTime

KEY PERFORMANCE POINTS: VENT CHANGES PER ABG

• Maintains Delta P when increasing PEEP for PaO2
• Correctly adjusts for PCO2

EXERCISE ONE

• 22 Y/O blast injury, bilat puomonary contusions, bilat AKA, massige transfusion
• 6'3", 100 kg
• ABG: 7.38 / 40 / 75 / 23 / 93%
• Vent settings at FOB
  • Mode-SIMV / PC
  • Set PIP-22
  • RR-12
  • Exh Vt-750
  • Peep-6
  • PS-10
  • iTime-0.9
  • FiO2-low flow
• Calculate Ideal Body Weight
• Input Proper Settings
• ABG 30 minutes after settings change: 7.30 / 45 / 69 / 21 / -4 / 90%
• Make appropriate changes to correct for ABG

EXERCISE TWO

• 22 Y/O blast injury, bilat puomonary contusions, bilat AKA, massige transfusion
• 6'2", 97 kg
• ABG: 7.38 / 40 / 75 / 23 / 93%
• Vent settings at FOB
  • Mode-SIMV / PC
  • Set PIP-20
  • RR-14
  • Exh Vt-650
  • Peep-8
  • PS-5
  • I:E-1:2
  • FiO2-low flow
• Calculate Ideal Body Weight
• Input Proper Settings
• ABG 30 minutes after settings change: 7.31 / 47 / 65 / 21 / -2 / 88%
• Make appropriate changes to correct for ABG

TABLETOP SCENARIOS

As you plan your CCATT training days, include the following tabletop scenarios and discuss them exactly as you would for the SIM exercises at CSTARS.

#1.  24 y/o male USA MVC

-         60% Burn (Time of burn is 3 hours ago)

-         Pelvic Fx

-         R fib/tib Fx

-         In:  3850 crystoids, 1250 Blood

-         Out:  350 ml urine

#2.  54 y/o female contractor

-         DOB w/ Anxiety

-         Advance to MI

#3.  21 y/o Male IED Blast

-         Bilateral BKA

-         Pelvic Fx

-         SDH

-         Open ABD

-         In:  4000 cystoids’, 8 PRBCs, * FFP, Cryo, Plts, (7200 Blood Products)

#4.  31 y/o Female

-         GSW to Head

-         Bilateral Craniotomy

CCATT QUICK DRUG REFERENCE

COMMONLY USED CARDIOVASCULAR DRUGS

Amiodarone (Cordarone): 

• CONCENTRATION:  900mg/500mL (1.8mg/mL)
• CONCENTRATION:  450mg/250mL (1.8mg/mL)
• DOSE:  1mg/min for 1^st 6 hrs, then 0.5mg/min for next 18 hrs

Epinephrine:

• CONCENTRATION:  4mg/250mL (16mcg/mL)
• DOSE: 2-10mcg/min

Esmolol (Brevibloc):

• CONCENTRATION:  2.5g/250mL
• DOSE:  5-200 mcg/kg/min

Diltiazem (Cardizem):

• CONCENTRATION:  125mg/125mL (1mg/mL)
• DOSE:  5-15 mg/hr

Dopamine:

• CONCENTRATION:  400mg/250mL (1600mcg/mL)
• DOSE:  2-20 mcg/kg/min

Dobutamine:

• CONCENTRATION:  500mg/250mL (2000mcg/mL)
• DOSE:  2-20mcg/kg/min

Ketamine:

• CONCENTRATION:  100mg/100mL
• DOSE:  2-10mg/hr

Levophed (Norepinephrine):

• CONCENTRATION:  4mg/250mL (16mcg/mL)
• DOSE:  2-12mcg/min

Neosynephrine (Phenylephrine):

• CONCENTRATION:  20mg/250mL (80mcg/mL)
• CONCENTRATION:  10mg/100mL (100mcg/mL)
• DOSE:  40-200 mcg/min

Nicardipine (Cardene):

• CONCENTRATION:  25mg/250mL (0.1mg/mL or 1mg/10mL)
• DOSE:  5-15 mg/hr

Nipride (Nitroprusside):

• CONCENTRATION:  50mg/250mL (200mcg/mL)
• DOSE:  0.5-5mcg/kg/min; may infuse as high as 8mcg/kg/min for short periods of time

Nitroglycerin (Tridil):

• CONCENTRATION:  50mg/250mL (200mcg/mL)
• DOSE:  5-60mcg/min; Max 200mcg/min

Vasopressin:

• CONCENTRATION:  100units/100mL (1unit/mL)
• DOSE:  0.02units/min=1.2mL/hr

• CONCENTRATION:  20units/100mL (0.2 units/mL)
• DOSE:  0.04units/min=2.4mL/hr

COMMONLY USED ANALGESIA

Fentanyl:

• CONCENTRATION:  5000mcg/mL (50mcg/mL)
• DOSE:  50-300mcg/hr

Morphine:

• CONCENTRATION:  100mg/100mL (1mg/mL)
• DOSE:  1-6mg/hr

COMMONLY USED SEDATION

Ativan (Lorazepam):

• CONCENTRATION:  100mg/100mL (1mg/mL)
• DOSE:  1-10mg/hr

Etomidate (Amidate):

• CONCENTRATION: 
• DOSE:  0.2-0.4mg/kg

Midazolam (Versed):

• CONCENTRATION:  100mg/100mL (1mg/mL)
• DOSE:  1-20mg/hr

Propofol (Diprivan):

• CONCENTRATION:  1000mg/100mL (10mg/mL)
• DOSE:  5-70mcg/kg/min

COMMONLY USED NEUROMUSCULAR BLOCKADES

Succinylcholine:

• CONCENTRATION: 
• DOSE:  0.3-1.5mg/kg

Vecuronium (Norcuron)

• CONCENTRATION:  20mg/100mL (0.2mg/mL)
• IVP DOSE:  80-100mcg/kg
• IV GTT DOSE:  0.8-1.2mcg/kg/min

COMMONLY USED ANTICOAGULANTS

Heparin:

• CONCENTRATION:  25,000units/250mL (100units/mL)
• DOSE:  400units/hr

Integrelin (Eptifibatide):

• CONCENTRATION:  200mg/100mL (2mg/mL)
• DOSE:  180mcg/kg bolus, 2 mcg/kg/min gtt

COMMONLY USED NEUROLOGICAL DRUGS

3% Saline:

• CONCENTRATION:  Standard 500mL Bag
• DOSE:  200mL bolus, then 50mL/hr

23% Saline:

• CONCENTRATION:  30-50mL Syringes
• DOSE:  SLOW IV PUSH

DDAVP:

• CONCENTRATION:  4mcg/mL Vial
• DOSE:  2-4mcg Daily

DRUG CALCULATION FORMULAS

• Mg/mL=mg of med/mL of solution
• Mg/hr= mg of med/ mL of solution X infusion rate (mL/hr)
• Mcg/mL= mg of med X 1000/ mL of solution
• Mcg/hr= mg of med X 1000/ mL of solution X infusion rate (mL/hr)
• Mcg/min=  mg of med X 1000/ mL of solution X infusion rate (mL/hr) divided by 60
• Mcg/kg/min= mg of med X 1000/ mL of solution X infusion rate (mL/hr) divided by 60 divided by weight in kg.

REMEMBER
Propofol and Versed can both infuse w/ Fentanyl to make more room when administering several medications.  Also, if you take a few 3-way stopcocks you can make a manifold to help you organize.
Ketamine can infuse w/ most opiods and benzos w/out complication.  Propofol can also be infused via a y-site.

CCATT ADVANCED COURSE GENERAL INFORMATION
&
VALIDATION PROCESS

NOTE
Informaiton on the validation process should be taken from the ERCC AFI: 48-307 V2