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A preliminary report of the epidemiologic and clinical findings in a new epidemic area in South America blood pressure 6040 order 40 mg valsartan fast delivery. Studies of the coagulation system and blood pres sure during experimental Bolivian hemorrhagic fever in rhesus monkeys heart attack in spanish purchase valsartan in united states online. Alteration of blood coagulation and complement system in neotropical primates infected with Junin virus arrhythmia powerpoint presentation effective valsartan 40mg. Early markers of blood coagulation and fibrinolysis activation in Argentine hem orrhagic fever heart attack 4 blocked arteries cheap 40mg valsartan mastercard. Kinetic study of platelets and fibrinogen in Lassa virus-infected monkeys and early pathologic events in Mopeia virus-infected monkeys blood pressure cuff amazon buy valsartan without a prescription. Clinical aspects of Ebola virus disease at the Ngaliema Hospital blood pressure pediatric order generic valsartan canada, Kin shasa, Zaire, 1976. Hantavirus pulmonary syndrome in the United States: a pathological de scription of a disease caused by a new agent. Coagulacao intravascular diseminada aguda na febre amarela: dosagem dos factores da coagulacao. Effect of human recombinant interleukin-6 and interleukin-8 on monocyte proco agulant activity. Procoagulant soluble tissue factor is released from en dothelial cells in response to inflammatory cytokines. Reverse genetics demonstrates that proteolytic processing of the Ebola virus glycoprotein is not essential for replication in cell culture. The host response to smallpox: analysis of the gene expression program in peripheral blood cells in a nonhuman primate model. Global suppression of the host antiviral response by Ebola and Marburg viruses: increased antagonism of the type I interferon response is associated with enhanced virulence. Use of betapropiolactone inactivated Ebola, Marburg and Lassa intracellular antigens in immunofluorescent antibody assay. Evaluation of the polymerase chain reaction for diagnosis of Lassa virus infection. MassTag polymerase chain reaction for differential diagnosis of viral hemorrhagic fever. Rapid identification of Ebola virus and related filoviruses in fluid specimens using indirect immunoelectron microscopy. A novel immunohistochemical assay for the detection of Ebola virus in skin: impli cations for diagnosis, spread, and surveillance of Ebola hemorrhagic fever. Plasma and plasma components in the management of disseminated intravascular coagulation. Protective efficacy of a live attenuated vaccine against Argentine hemorrhagic fever. Field evaluation of formalin inactivated Kyasanur forest disease virus tissue culture vaccine in three districts of Karnataka state. Live attenuated recombinant vaccine protects nonhuman primates against Ebola and Marburg viruses. Marburg virus vaccines based upon alphavirus replicons protect guinea pigs and nonhuman primates. Postexposure protection against Marburg hemorrhagic fever with recombinant vesicular stomatitis virus vectors in nonhuman primates: an efficacy assessment. Antiviral drug therapy of filovirus infections: S-adenosylhomocysteine hydrolase inhibitors inhibit Ebola virus in vitro and in a lethal mouse model. Prospects for treatment of viral hemorrhagic fevers with ribavirin, a broad-spectrum antiviral drug. Prospective, double-blind, concurrent, placebo-controlled clinical trial of intravenous ribavirin therapy of hemorrhagic fever with renal syndrome. Efficacy of postexposure treatment of yellow fever with ribavirin in a hamster model of the disease. Experimental study of possible treat ment of Marburg hemorrhagic fever with desferal, ribavirin, and homologous interferon [in Russian]. Evaluation of immune globulin and recombinant interferon-alpha2b for treatment of experimental Ebola virus infections. The use of interferon for emergency prophylaxis of Marburg hemorrhagic fever in monkeys. Recombinant human interferon-gamma modulates Rift Valley fever virus infec tion in the rhesus monkey. Gene-specific countermeasures against Ebola virus based on antisense phosphorodiamidate morpholino oligomers. Importance of dose of neutralizing antibodies in treat ment of Argentine hemorrhagic fever with immune plasma. Treatment of Ebola hemorrhagic fever with blood transfusions from conva lescent patients. On an infectious disease transmitted by Cercopithecus aethiops (Green monkey disease) [in German]. Report of a labora tory-acquired infection treated with plasma from a person recently recovered from the disease. Efficacy of immune plasma in treatment of Argentine hemorrhagic fever and association between treatment and a late neurological syndrome. In vivo enhancement of dengue virus infection in rhesus monkeys by passively transferred antibody. Passive antibody therapy of Lassa fever in cynomolgus monkeys: importance of neutralizing antibody and Lassa virus strain. From a practical standpoint, this observa many similarities among severe diseases caused by tion indicates that a large panel of antibody probes will 4 S aureus and S pyogenes superantigens imply a com be required for proper identification of samples. Furthermore, cross-link t-cell antigen receptors and class ii mhc the cD44 molecule reportedly provides protection 10 molecules, mimicking the cD4 molecule, and hence from liver damage in mice caused by seb exposure stimulate large numbers of t cells. Vaccines of seb and sea with altered critical residues Given the complex pathophysiology of toxic shock, involved in binding class ii mhc molecules were also the understanding of the cellular receptors and signal used successfully to vaccinate mice and monkeys ing pathways used by staphylococcal superantigens, against seb-induced disease. Rabbits, endotoxin-primed mice, and ad 10 minutes in a modified henderson head-only aerosol 40 ditional animal models have been developed. Young and mature adult male and female rhesus consistent with the potent stimulatory effect of seb 314 Staphylococcal Enterotoxin B and Related Toxins on the rhesus monkey immune system, was appar eosinophilic beaded fibrillar strands (fibrin), or with ent. Replicate gastrointestinal signs, the monkeys had a variable microsections stained with Giemsa revealed scarce period of up to 40 hours of clinical improvement. Peribronchovas cular connective tissue spaces were distended by pale, homogeneous, eosinophilic, proteinaceous material (edema), variably accompanied by entrapped, beaded fibrillar strands (fibrin), extravasated erythrocytes, neutrophils, macrophages, and small and large lym phocytes. Perivascular lymphatics were generally b distended by similar eosinophilic material and inflam matory cells. Documentation of an accidental laboratory inhala the headaches ranged from severe to mild, but were tion exposure of nine laboratory workers to seb best usually mild by the second day of hospitalization. Gastrointestinal symptoms occurred in more than eight of the individuals experienced at least one half of the individuals, nausea and anorexia in six, shaking chill that heralded the onset of illness. Five had vidual demonstrated hepatomegaly and bile in the inspiratory rales with dyspnea. During recovery, discoid atelectasis all patients who experienced chest pain had nor was noted. Plasma strains is possible by using polymerase chain reaction concentrations of superantigens were measured in amplification and toxin gene-specific oligonucleotide septic patients of an intensive care unit using an en primers. Diarrhea was not observed sure cases described above seemed to provide adequate in human accidental exposure cases, but deposition care. For nausea, initial symptomatic therapy with cough sup vomiting, and anorexia, symptomatic therapy should pressants containing dextromethorphan or codeine be considered. Prolonged coughing and phenothiazine derivatives (eg, prochlorperazine) unrelieved by codeine might benefit from a semisyn have been used parenterally or as suppositories. Prior exposure to seb by inhala case of tss with elevated tsst-1 and sea levels, tion does not appear to protect against a subsequent complicated by life-threatening multiorgan dysfunc episode. Vaccines produced by site-specific mu consequential t-cell activation,7,9,37,38 without altering tagenesis of the toxins, delivered by intramuscular or the three-dimensional structure of the antigen. Vaccines staphylococcal and streptococcal superantigen toxins, currently under development may afford protection to but the limit of field detection is unknown. Staphylococcal Enterotoxin B Battlefield Challenge Modeling with Medical and Non-Medical Countermeasures. Dissemination of the superantigen encoding genes seel, seem, szel and szem in Streptococcus equi subsp. Zinc binding and dimerization of Streptococcus pyogenes pyrogenic exotoxin c are not essential for t-cell stimulation. Role of cD44 and its v7 isoform in staphylococcal enterotoxin b-induced toxic shock: cD44 deficiency on hepatic mononuclear cells leads to reduced activation-induced apoptosis that results in increased liver damage. Divergence of human and nonhuman primate lymphocyte responses to bacterial su perantigens. Production of enterotoxins and toxic shock syndrome toxin by bovine mammary isolates of Staphylococcus aureus. Production of a toxic shock syndrome toxin variant by Staphylococcus aureus strains associated with sheep, goats, and cows. Role of protein tyrosine phosphorylation in monokine induction by the staphylococcal superantigen toxic shock syndrome toxin-1. Reductions in levels of bacterial superantigens/canna binoids by plasma exchange in a patient with severe toxic shock syndrome. Like abrin (from in the manufacture of lubricants, inks, varnishes, and the seeds of the rosary pea, Abrus precatorius), ricin is a dyes. After oil extraction, the remaining seed cake lectin and a member of a group of ribosome-inactivat may be detoxified by heat treatment and used as an ing proteins that block protein synthesis in eukaryotic animal feed supplement. The castor bean is native to Africa, but it has been the toxicity of castor beans has been known since introduced and cultivated throughout the tropical ancient times, and more than 750 cases of intoxication 2 and subtropical world. Although consid temperature range, it grows best in elevated year erably less potent than botulinum neurotoxins and round temperatures and rapidly succumbs to sub staphylococcal enterotoxins, ricin represents a signifi freezing temperatures. However, it is often grown as cant potential biological weapon because of its stability an ornamental annual in temperate zones. The seeds and worldwide availability as a by-product of castor are commercially cultivated in many regions of the oil production. In addition, it has been associated world, predominantly in Brazil, Ecuador, Ethiopia, with several terrorist actions and therefore may be a Haiti, India, and Thailand. In addition, both the oil and whole with serum proteins, and could be transferred to the seeds have been used in various parts of the world for offspring through milk. During World War I, the excellent est in bacterial toxins, interest in plant toxins waned. These subsidies persisted strated that protein synthesis was strongly inhibited until the 1960s, when synthetic oils replaced castor oil in a cell-free rabbit reticulocyte system, and suggested in the aircraft industry. There is no commercial produc that the effects resulted from inhibited elongation of tion of castor oil in the United States today. They also determined the first toxinology work on ricin was performed by that ricin consisted of two dissimilar polypeptide Hermann Stillmark at the Dorpat University in Estonia subunits and that the A chain was responsible for the for his 1888 thesis. He purified ricin to few years revealed the 60S ribosomal subunit as the a very high degree (although not completely to homo enzymatic target and led to further characterization of 7 geneity) and found that it agglutinated erythrocytes the enzymatic action. The active subunit of ricin is specifically In 1891 Paul Ehrlich studied ricin and abrin in targeted to tumor cells by conjugation to tumor-spe pioneering research that is now recognized as the cific antibodies. Experiments is mediated by a discrete sequence moiety separate 324 Ricin from the region related to protein synthesis inhibi United States, ricin and abrin are both included in the tion. Testing in a mouse model demon that ricin was included in the biological warfare pro strated improved effectiveness, suggesting that ricin grams of the Soviet Union, Iraq, and possibly other immunotoxins may yet have a place in the anticancer nations as well. In recent years, ricin has drawn the interest of ex Because of its potency, worldwide availability, and tremist groups. Several individuals have been arrested involved methods of adhering ricin to shrapnel and under the 1989 Biological Weapons Anti-Terrorism the production of effective aerosol clouds. In the past few years alone, the war ended before the evolution of weaponry based various major news organizations have reported the upon this research. While none of these events resulted in any known In addition to its coverage under the 1975 conven human intoxications, they clearly demonstrate that tion, ricin and one other toxin (saxitoxin) were also ricin is well known, available to and recognized by specifically included under the 1993 Chemical Weap extremist groups, and should be seriously considered ons Convention, ratified by Congress in 1997. The disul up 1% to 5% of the dry weight of the castor bean, fide bond links residue 259 of the A chain with residue although the yield can be highly variable. The crystal structure demonstrates a form is a heterodimer consisting of a 32-kd A chain con putative active cleft in the A chain, which is believed nected to the 32-kd B chain through a single disulfide to be the site of enzymatic action. Recombinant A the B chain, and cellular toxicity is much less; uptake and B chains, as well as specific mutants, have been depends on endocytosis. Both chains are glycoproteins expressed and characterized in several expression containing multiple mannose residues on their surfaces; systems including Escherichia coli. Purification and characterization is not difficult, Toxicity and the crystal structure has been determined to . A lactose disaccharide moiety is considerable variation in potency exists among species. Low potency by the oral route likely reflects poor absorption and possibly partial degradation in Endoplasmic Reticulum the gut. The two-chain structure is key to failure of C G A 4324 cellular internalization and subsequent toxicity. Binding, internalization, and intracellular track to glycoside residues on glycoproteins and glycolip ing of ricin leading to enzymatic action at the 60S ribosome. Trafficking protein disulfide isomerase can subsequent ribosomal of the toxin within the cell from the initial binding inactivation take place in the cytosol.

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In both instances arrhythmia lyrics valsartan 80mg lowest price, the institutional management must provide facilities pre hypertension vs hypertension purchase valsartan overnight, staff heart attack is generic valsartan 40mg mastercard, and established practices that reasonably ensure appropriate levels of environmental quality hypertension lifestyle changes buy generic valsartan, safety blood pressure for athletes safe valsartan 160 mg, security and care for the laboratory animal hypertension united states order cheap valsartan. In the animal room, the activities of the animals themselves can present unique hazards not found in standard microbiological laboratories. The co-application of Biosafety Levels and the Animal Biosafety Levels are determined by a protocol-driven risk assessment. These recommendations presuppose that laboratory animal facilities, operational practices, and quality of animal care meet applicable standards and regulations. The supervisor must ensure that animal care, laboratory and support personnel receive appropriate training regarding their duties, animal husbandry procedures, potential hazards, manipulations of infectious agents, necessary precautions to prevent exposures, and hazard/ exposure evaluation procedures (physical hazards, splashes, aerosolization, etc. An appropriate medical surveillance program is in place, as determined by risk assessment. Security-sensitive agent information should be posted in accordance with the institutional policy. A risk assessment should be performed to identify the appropriate glove for the task and alternatives to latex gloves should be available. Sink traps are flled with water, and/or appropriate liquid to prevent the migration of vermin and gases. Internal facility appurtenances, such as light fxtures, air ducts, and utility pipes, are arranged to minimize horizontal surface areas to facilitate cleaning and minimize the accumulation of debris or fomites. Consideration should be given to specifc biohazards unique to the animal species and protocol in use. The supervisor must ensure that animal care, laboratory, and support personnel receive appropriate training regarding their duties, animal husbandry procedure, potential hazards, manipulations of infectious agents, necessary precautions to prevent hazard or exposures, and hazard/exposure evaluation procedures (physical hazards, splashes, aerosolization, etc. Personnel must receive annual updates or additional training when procedures or policies change. A sign incorporating the universal biohazard symbol must be posted at the entrance to areas where infectious materials and/ or animals are housed or are manipulated when infectious agents are present. Only those persons required for program or support purposes are authorized to enter the animal facility and the areas where infectious materials and/or animals are housed or manipulated. All persons including facility personnel, service workers, and visitors are advised of the potential hazards (physical, naturally occurring, or research pathogens, allergens, etc. Gloves are worn to prevent skin contact with contaminated, infectious and hazardous materials and when handling animals. Gloves and personal protective equipment should be removed in a manner that prevents transfer of infectious materials outside of the areas where infectious materials and/or animals are housed or are manipulated. Food must be stored outside of the laboratory in cabinets or refrigerators designated and used for this purpose. Used, disposable needles must be carefully placed in puncture-resistant containers used for sharps disposal. Animals and plants not associated with the work being performed must not be permitted in the areas where infectious materials and/ or animals are housed or manipulated. Procedures involving a high potential for generating aerosols should be conducted within a biosafety cabinet or other physical containment device. When a procedure cannot be performed within a biosafety cabinet, a combination of personal protective equipment and other containment devices must be used. Restraint devices and practices that reduce the risk of exposure during animal manipulations. Medical evaluation, surveillance, and treatment should be provided as appropriate and records maintained. Gowns, uniforms, laboratory coats and personal protective equipment are worn while in the areas where infectious materials and/or animals are housed or manipulated and removed prior to exiting. Disposable personal protective equipment and other contaminated waste are appropriately contained and decontaminated prior to disposal. If the animal facility has segregated areas where infectious materials and/or animals are housed or manipulated, a sink must also be available for hand washing at the exit from each segregated area. Sink traps are flled with water, and/or appropriate disinfectant to prevent the migration of vermin and gases. Penetrations in foors, walls and ceiling surfaces are sealed, including openings around ducts, doors and doorframes, to facilitate pest control and proper cleaning. Chairs used in animal area must be covered with a non-porous material that can be easily cleaned and decontaminated. External windows are not recommended; if present, windows must be sealed and resistant to breakage. An autoclave should be present in the animal facility to facilitate decontamination of infectious materials and waste. The animal facility director establishes and enforces policies, procedures, and protocols for institutional policies and emergencies. Consideration must be given to specifc biohazards unique to the animal species and protocol in use. Therefore, all personnel and particularly women of childbearing age should be provided information regarding immune competence and conditions that may predispose them to infection. Identifcation of specifc infectious agents is recommended when more than one agent is used within an animal room. Restraint devices and practices are used to reduce the risk of exposure during animal manipulations. Disposable personal protective equipment must be removed when leaving the areas where infectious materials and/or animals are housed or are manipulated. To prevent cross contamination, boots, shoe covers, or other protective footwear, are used where indicated. Penetrations in foors, walls and ceiling surfaces are sealed, including openings around ducts and doorframes, to facilitate pest control, proper cleaning and decontamination. Selection of the appropriate materials and methods used to decontaminate the animal room must be based on the risk assessment. Chairs used in animal areas must be covered with a non-porous material that can be easily cleaned and decontaminated. This system creates directional airfow, which draws air into the animal room from clean areas and toward contaminated areas. Personnel must verify that the direction of the airfow (into the animal areas) is proper. Illumination is adequate for all activities, avoiding refections and glare that could impede vision. Provisions to assure proper safety cabinet performance and air system operation must be verifed. The autoclave is utilized to decontaminate 84 Biosafety in Microbiological and Biomedical Laboratories infectious materials and waste before moving it to the other areas of the facility. Laboratory personnel and support staff must be provided appropriate occupational medical service including medical surveillance and available immunizations for agents handled or potentially present in the laboratory. An essential adjunct to such an occupational medical services system is the availability of a facility for the isolation and medical care of personnel with potential or known laboratory-acquired infections. Facility supervisors should ensure that medical staff are informed of potential occupational hazards within the animal facility including those associated with the research, animal husbandry duties, animal care, and manipulations. Personnel are advised of special hazards, and are required to read and follow instructions on practices and procedures. Use of needles and syringes or other sharp instruments are limited for use in the animal facility is limited to situations where there is no alternative such as parenteral injection, blood collection, or aspiration of fuids from laboratory animals and diaphragm bottles. Identifcation of specifc infectious agents is recommended when more than one agent is being used within an animal room. All personnel entering the laboratory must use laboratory clothing, including undergarments, pants, shirts, jumpsuits, shoes, and gloves. These items must be treated as contaminated materials and decontaminated before laundering or disposal. After the laboratory has been completely decontaminated by validated method, necessary staff may enter and exit the laboratory without following the clothing change and shower requirements described above. The animal facility supervisor is responsible for ensuring that animal personnel: a. Equipment must be decontaminated using an effective and validated method before repair, maintenance, or removal from the animal facility. Training in emergency response procedures must be provided to emergency response personnel according to institutional policies. Safety Equipment (Primary Barriers and Personal Protective Equipment) Cabinet Laboratory 1. Workers must wear protective laboratory clothing such as solid-front or wrap-around gowns, scrub suits, or coveralls when in the laboratory. Eye, face and respiratory protection should be used in rooms containing infected animals as determined by the risk assessment. Infected animals should be housed in a primary containment system (such as open cages placed in ventilated enclosures, solid wall and bottom cages covered with flter bonnets and opened in laminar fow hoods, or other equivalent primary containment systems). Personnel wearing a one-piece positive pressure suit ventilated with a life support system must conduct all procedures. Workers must wear protective laboratory clothing, such as scrub suits, before entering the room used for donning positive pressure suits. Services and plumbing that penetrate the laboratory walls, foors or ceiling, must be installed to ensure that no backfow from the laboratory occurs. Selection of the appropriate materials and methods used for decontamination must be based on the risk assessment of the biological agents in use. A visual monitoring device must be installed near the clean change room so proper differential pressures within the laboratory may be verifed. Positioning the bioseal so that the equipment can be accessed and maintained from outside the laboratory is recommended. Rooms in the facility must be arranged to ensure sequential passage through the chemical shower, inner (dirty) change room, personal shower, and outer (clean) changing area upon exit. A double-door autoclave, dunk tank, or fumigation chamber must be provided at the containment barrier for the passage of materials, supplies, or equipment. Biological safety cabinets can also be connected to the laboratory exhaust system by either a thimble (canopy) connection or directly to the outside through an independent, direct (hard) connection. Biological validation must be performed annually or more often as required by institutional policy. Positioning the bioseal so that the equipment can be accessed and maintained from outside the laboratory is strongly recommended. The size of the autoclave should be suffcient to accommodate the intended usage, equipment size, and potential future increases in cage size. This section describes laboratory biosecurity planning for microbiological laboratories. Security assessments and additional security measures should be considered when select agents, other agents of high public health and agriculture concern, or agents of high commercial value such as patented vaccine candidates, are introduced into the laboratory. In the animal industry, the term biosecurity relates to the protection of an animal colony from microbial contamination. Several of the security measures discussed in this section are embedded in the biosafety levels that serve as the foundation for good laboratory practices throughout the biological laboratory community. While the objectives are different, biosafety and biosecurity measures are usually complementary. Both are based upon risk assessment and management methodology; personnel expertise and responsibility; control and accountability for research materials including microorganisms and culture stocks; access control elements; material transfer documentation; training; emergency planning; and program management. Biosafety and biosecurity program risk assessments are performed to determine the appropriate levels of controls within each program. For biosafety, the shipment of infectious biological materials must adhere to safe packaging, containment and appropriate transport procedures, while biosecurity ensures that transfers are controlled, tracked and Principles of Laboratory Biosecurity 105 documented commensurate with the potential risks. Both programs must engage laboratory personnel in the development of practices and procedures that fulfll the biosafety and biosecurity program objectives but that do not hinder research or clinical/diagnostic activities. Therefore, biosafety and biosecurity considerations must be balanced and proportional to the identifed risks when developing institutional policies. Risk Management Methodology A risk management methodology can be used to identify the need for a biosecurity program. This coordinated approach is critical in ensuring that the biosecurity program provides reasonable, timely and cost-effective solutions addressing the identifed security risks without unduly affecting the scientifc or business enterprise or provision of clinical and/or diagnostic services. The need for a biosecurity program should refect sound risk management practices based on a site-specifc risk assessment. Example Guidance: A Biosecurity Risk Assessment and Management Process Different models exist regarding biosecurity risk assessment. Step 1: Identify and Prioritize Biological Materials Identify the biological materials that exist at the institution, form of the material, location and quantities, including non-replicating materials. Principles of Laboratory Biosecurity 107 At this point, an institution may fnd that none of its biologic materials merit the development and implementation of a separate biosecurity program or the existing security at the facility is adequate. Step 3: Analyze the Risk of Specifc Security Scenarios Develop a list of possible biosecurity scenarios, or undesired events that could occur at the institution (each scenario is a combination of an agent, an adversary, and an action).

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The French instituted the first airplane ambulance service organization with six airplanes that could carry three litter patients each pulse pressure under 25 generic 40mg valsartan with visa. More than 1200 patients were transported from the Atlas moun tain area of Morocco during the Riffian War hypertension 200120 order valsartan cheap. Army on an emergency basis only hypertension 150 70 purchase valsartan 160 mg with visa, despite repeated urging by Ar my Medical Department officers for the routine use of transport airplanes for evacuating casualties in the event of war blood pressure medication for kidney transplant patients buy cheap valsartan 80 mg. Large scale aeromedical evacuation first occurred during the Spanish Civil War (1936-1938) by the Germans arrhythmia when lying down cost of valsartan. Each aircraft was configured to carry ten litter cases and from two to eight ambulatory cases heart attack questions generic valsartan 80mg fast delivery. The route involved flying over the Mediterranean to Northern Italy, then crossing the Alps at altitudes of up to 18,000 msl. The distance traveled varied between 1350 to 1600 miles with an elapsed air time of about ten hours. The extreme cold at altitude was a major difficulty because the airplanes did not have heating systems. Army Air Corps formed medical air evacuation squadrons and established a school in 1942. Patients were transported by troop carrier aircraft within the various overseas theaters. They became the primary medical evacuation aircraft for the movement of casualties from the battlefield to the in itial medical treatment facility. Air Force Military Air Transport Service had transported over two million patients. The Vietnam Conflict from 1965 to 1973 saw a much fuller exploitation of the helicopter for aeromedical evacuation. Marines and Army forces picked up the wounded soon after injury, and quickly transported them to definitive treatment facilities. Helicopter 16-2 Aeromedical Evacuation aeromedical evacuation was considered a significant factor in the decreased mortality from wounds noted in that conflict. The Vietnam conflict demonstrated fatality rates of one percent for casualties arriving at medical treatment facilities. Physiological Factors Affecting Air Transportation Any decision to evacuate a patient by air constitutes a major value judgment and should be made only after a thorough assessment of the medical benefits for the patient as compared to the hazards which might be associated with an evacuation flight. Prerequisites to this decision making process are an in-depth understanding of the significant and unique risks imposed on pa tients during transport by aircraft. These may include recommendation of flight level in an un pressurized aircraft or a specific pressurization profile in a pressurized aircraft in the case of dysbarism. Resuscitation and stabilization of the patient prior to evacuation cannot be overem phasized. On occa sion, it may be prudent to delay evacuation in order to stabilize the patient. The space limitations, light, noise or other en route environmental conditions make routine monitoring and therapeutic procedures extremely difficult. There are specific risks inherent in aeromedical flight which interact with medical status. These are related to physical properties of flight and associated factors which include: reduced at mospheric pressure, decreased oxygen tension, dehydration, motion sickness, fatigue and inac tivity. Reduced Atmospheric Pressure Chapter 1, Physiology of Flight, describes the physiological effects of reduced atmospheric pressure. Although scheduled aeromedical evacuation flights are in pressurized aircraft, transport aboard nonpressurized aircraft and helicopters may be required. If unable to escape, this pressure may rupture the containing walls of the cavity or impair circulation. Decreased Oxygen Tension the decreased oxygen tension associated with reduced atmospheric pressure may have signifi cant adverse effects. Oxygen saturation is decreasd only slightly at cabin altitudes in pressurized aircraft and in flight below 10,000 msl in unpressurized aircraft. However, this reduction can be critical in patients with marginal sea level tissue oxygenation. Patients, at risk, include those with anemia, recent acute blood loss, impaired pulmonary function, cardiac failure, organic heart disease or sickle cell trait. Dehydration the relative humidity at altitude is reduced in both pressurized and unpressurized aircraft. Patients with trachesotomies or those who must breath through their mouths may require humidified air or ox ygen to prevent drying of respiratory secretions. Corneal drying in comatose patients may be averted by holding their eyelids closed with moistened cotton pads under eye shields. Motion Sickness There is a low incidence of motion sickness in large jet aircraft flying at altitude. However, mo tion sickness is more frequently encountered in helicopters and small aircraft operating at lower altitudes. Prior administration of antihistamines (25 to 50 mg of meclizine, 50 mg of cyclizine or 50 mg of dimenhydrinate) or scopodex (0. Fatigue and Inactivity the ambulatory patient is sometimes transported aboard operational aircraft. In troop transport aircraft, the crowded seat configuration may discourage the patient from moving around during the fight. The enforced inactivity together with the anxiety and apprehension 16-4 Aeromedical Evacuation associated with illness may produce more fatigue than would be expected. Medical Conditions Requiring Special Management Cardiovascular Diseases Supplemental oxygen should be available in flight and vasodilating drugs should be provided for those patients with symptomatic angina pectoris. Patients in congestive failure or with a history of any myocardial infarction within eight weeks of the acute episode must be evaluated on a case-by-case basis prior to transportation. The American College of Chest Physicians recommends that a cabin altitude not exceed 2,000 ft msl without supplemental oxygen for such patients. Pulmonary Diseases In patients with artificial, traumatic or spontaneous pneumothorax, movement by air should be deferred until radiographic studies demonstrate gas absorption. However, if the volume of gas remaining is small, restriction of altitude may enhance safe movement. All flight attendants must be instructed in the pro per use and function of the Heimlich valve. Patients should not be airlifted for 72 to 96 hours after chest tube removal and a roentgenogram should be obtained within 24 hours of flight to document full lung expansion. Advise the receiving facility of the importance of a repeat chest X-ray when the flight is completed. Anemia Patients with severe anemia or recent acute blood loss should have a hematocrit of above 30 percent prior to entering the aeromedical evacuation system. The presence of an acute infectious process in those patients experiencing reduced oxygen partial pressure may precipitate a sickling crisis manifested by sicklemia, vomiting, and left upper quadrant pain. Gastrointestinal Diseases Large unreduced hernias, volvulus, intussusception, and ileus are particularly susceptible to trapped gas phenomena. Air transport of these patients should usually be deferred until after definitive therapy and recovery. If transport is mandatory, it can usually be accomplished safely if altitude is restricted. It is conceivable that weakened viscus walls in peptic, amoebic, typhoid, or tuberculous ulcers could rupture from the pressures of gas expansion. Disruption of a surgical incision postoperatively due to intra-abdominal gas expansion is a threat. A 10 to 14-day convalescence period prior to aeromedical evacuation is recommended after abdominal surgery if possible. Colostomy patients evacuated by air require an extra supply of colostomy bags and dressings. Orthopedic Patients Casts should be clearly marked with the date of application and the nature of the fracture or surgical procedure performed. All casts, including the underlying web rolling and padding, should be bivalved to allow for soft tissue swelling at altitude. The air splints commonly used for initial stabilization pose a similar potential problem and must be constantly monitored during flight and adjusted to prevent any tourniquet effect. It is preferable to use wire-ladder splints, wood splints or plaster splints to stabilize fractures and severe sprains. Traction devices using sw inging weights are unsuitable for use in flight from the standpoint of efficiency and safety. The Hare traction device is an extremely effective tension devise for providing traction to the ex tremities. Paraplegic patients are generally moved on a Stryker frame to facilitate care and com fort during the flight. It is important that the entire frame accompany the patient since parts from various frames may not be interchangeable. Eye Injuries and Diseases Perforating damage to the globe is a common cause of aeromedical evacuation. Because the eye is normally liquid filled, it is not affected by barometric pressure changes. In such instances, a lower cabin altitude must be maintained in order to prevent barotrauma reopening the wound or separating the surgical incision. In patients having choroidal or retinal disease or injury, oxygen should be administered at cabin altitudes above 4,000 msl. Ear, Nose, Throat Disease the presence of an incidental upper respiratory infection may complicate aeromedical evacua tions for other injuries or illnesses. The patients may be unable to Valsalva due to medication, or impairment of dexterity or cognition. Scull Fracture Any patient with a skull fracture which extends into a paranasal sinus, external ear canal or middle ear must be carefully evaluated. If air has entered the cranial cavity, aeromedical evacuation must be ac complished at cabin altitudes maintained at as near sea level as possible. Mandibular Fracture Commonly, mandibular fractures are wired to stabilize the jaw. Should the patient become air sick, he may be at risk for massive aspiration of vomitus. An emergency release mechanism must be provided which can be activated by either the patient or the attendant. Urgent Describes an emergency case which must be moved immediately in order to save his life, limb, eyesight, or prevent complication of serious illness. A special mission will be required to pick up the patient and deliver him to his destination medical facility. An aircraft already in the air may be diverted or an alert aircraft may be launched. By definition, psychiatric cases or terminal cases with very short life expectancy are not considered urgent. Such patients should be pick ed up within 24 hours and delivered with the least possible delay. Severe psychiatric litter patients who require restraints, sedation, and close supervision at all times. Intermediate severity psychiatric litter patients who are sedated but not restrain ed. Restraint equipment should be available if needed because patients may react badly to air travel or commit acts likely to endanger themselves or the aircraft safety. Psychiatric walking patients of moderate severity, who are cooperative and pro ved reliable under observation. Immobile litter patients who are unable to move about on their own under any circumstances. Walking patients (other than psychiatric) who require medical treatment, care, assistance, or observation en route. Troop class walking patients (other than psychiatric) who require no medical treat ment or observation during flight. Evacuation Decision Consideration the flight surgeon must account for many factors when making decisions regarding the evacua tion of patients. It is important for the flight surgeon to be actively involved in patient care as early as possible. Requests for aeromedical consultation may be re ceived by message, telephone, or radio from shore facilities, troops in the field, or from other ships.

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