CRITICAL CARE AIR TRANSPORT TEAM (CCATT) CAPABILITIES

Intubated U.S. military patients are routinely transported out of theater by the Critical Care Air Transport Team (CCATT).50–52 From October 2001 to May 2006, these made up 1,265 of 1,995 (63%) of all CCATT patients.53 The decision to transport a patient with ARDS should be made jointly with the theater CCATT Director and the validating flight surgeon, the on-site CCATT physician, and the Role 3 Chief of Trauma and/or ICU Director. Considerations should include the severity of the patient’s respiratory failure, the trajectory of that respiratory failure (improving or worsening), and the experience of the team.22

U.S. Air Force CCATT has both the Impact 731™ (Zoll Medical Corporation., Chelmford, MA) ventilator and the LTV 1000™ (CareFusion., Yorba Linda, California) ventilator for use in transport.54 The Impact 731 operates in volume control, pressure control, SIMV, and CPAP with and without pressure support. Up to 100% O2 can be applied as can PEEP of up to 25 cm H2O. Flow rates range from 0 to 100 L/min at 40 cm H2O. Peak inspiratory pressures range from 10 to 80 cm H2O. Inverse ratio ventilation is not possible with the Impact 731.

ADVANCED CRITICAL CARE EVACUATION TEAM (ACCET) CAPABILITIES

In 2012, SAMMC established an ECLS team and now offers long-range transport of patients with severe ARDS with or without ECLS. The team consists of a medical/pulmonary critical care physician, a surgical intensivist, an ICU nurse, and a respiratory therapist. Advanced therapies used by this team include high frequency percussive ventilator (Percussionaire VDR-4), inhaled prostacyclin (Flolan), and ECLS for the management of patients with moderate to severe ARDS who could not otherwise be safely transported.55–58

Indications for requesting an ACCET for transport to the U.S. include the following:

- PaO2: FiO2 < 100 .
- Inhalation injury.
- FiO2 > 0.7 or pH < 7.25 on lung-protective ventilation.
- PEEP > 15 cm H2O w/ PPLAT > 30 cm H2O.
- Severe brain injury with PaCO2 > 40 mmHg on a transport ventilator.
- Cardiogenic shock refractory to maximal medical therapy.
- Anatomic derangement (e.g., Bronchopleural fistula, pneumonectomy).
- Use of advanced ventilator modes such as APRV.
- Acute Pulmonary Embolism (PE) with cardiac arrest or with persistent hypoxemia.
- Multi-system organ failure (e.g., ARDS + Renal Failure).

ACCET team members are specifically trained in the indications for and the use of these modalities which have all been appropriately vetted through the combat casualty care and transport communities.

- High-frequency percussive ventilation can be helpful in cases of purulent pneumonia or inhalation injury by mobilizing secretions while affording safe gas exchange.59
- ECLS is used for adult respiratory failure with good outcomes as demonstrated in recent series using modern equipment.60-62 Most adult ECLS is Veno-Venous which can be performed through either single site internal jugular (IJ) vein cannulation, combined IJ/femoral vein (FV) or dual-FV cannulation. Systemic heparin should be administered once surgical bleeding has been controlled. This approach has been used safely in trauma patients both in the U.S. and in Germany, including patients with Traumatic Brain Injury (TBI).62–65
- ACCET transports should be initiated by the local Chief of Trauma and/or ICU Director by contacting U.S. Transportation Command (TRANSCOM) through the normal intertheater evacuation procedure. This will facilitate timely activation of the appropriate team. Physician-to-physician consultation can also be obtained by contacting LRMC at DSN 314-486-7141 or SAMMC at DSN 312-429-BURN (2876). Early consultation and ECLS team activation are always encouraged.
- From Nov 2005 – Mar 2007, 524 intubated patients were transported via CCATT. Of these, five were moved by the LRMC ALRT which had been called on a total of 11 patients. Of the five ALRT patients requiring advanced support modes, four survived to hospital discharge.66 Furthermore, of 10 U.S. combat casualties transported on either Pumpless Extracorporeal Lung Assist (PECLA) or ECLS, nine survived to hospital discharge.55 These data underscore the importance of utilizing available resources for transporting these tenuous patients to definitive care.