Commercial in-flight medical emergencies: Difference between revisions

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==Background==
==Background==
*1 per 604 flights
*Incidence of in-flight emergencies: 1 per 604 flights<ref name="peterson">Peterson DC, et al. "Outcomes of Medical Emergencies on Commercial Airline Flights" N Engl J Med 2013;368:2075-83. DOI: 10.1056/NEJMoa1212052</ref> (0.3% of cases died)
**0.3% of cases died
**For reference, there are ~29,000 commercial flights per day in the US alone<ref>NOAA. Air Traffic. http://sos.noaa.gov/Datasets/dataset.php?id=44 Accessed 03/08/2016</ref>
*As the population ages and people travel longer distances, this number is likely to increase<ref>Goodwin T. In-flight medical emergencies: an overview. BMJ : British Medical Journal. 2000;321(7272):1338-1341.</ref>


===Epidemiology<ref>Peterson DC, et al. "Outcomes of Medical Emergencies on Commercial Airline Flights" N Engl J Med 2013;368:2075-83. DOI: 10.1056/NEJMoa1212052</ref>===
===Epidemiology<ref name="peterson"/>===
*syncope or presyncope (37.4%)
*[[Syncope]] or presyncope (37.4%)
*respiratory symptoms (12.1%)
*[[SOB|Respiratory symptoms]] (12.1%)
*nausea or vomiting (9.5%)
*[[nausea/vomiting|Nausea or vomiting]] (9.5%)
*Cardiac symptoms (7.7%)  
*[[chest pain|Cardiac symptoms]] (7.7%)  
*Seizures (5.8%)  
*[[Seizures]] (5.8%)  
*Abdominal pain (4.1%)  
*[[Abdominal pain]] (4.1%)  
*Infectious disease (2.8%)  
*[[infection|Infectious disease]] (2.8%)  
*Agitation or psychiatric symptoms (2.4%)
*[[Agitation]] or psychiatric symptoms (2.4%)
*Allergic reaction (2.2%)  
*[[Allergic reaction]] (2.2%)  
*Possible stroke (2.0%)  
*Possible [[stroke]] (2.0%)  
*Trauma, not otherwise specified (1.8%)  
*[[Trauma]], not otherwise specified (1.8%)  
*Diabetic complication (1.6%)  
*[[DM|Diabetic complication]] (1.6%)  
*Headache (1.0%)  
*[[Headache]] (1.0%)  
*Arm or leg pain or injury (1.0%)  
*Arm or leg pain or injury (1.0%)  
*Obstetrical or gynecologic symptoms(0.5%)  
*Obstetrical or gynecologic symptoms(0.5%)  
Ear pain (0.4%)  
*[[earache|Ear pain]] (0.4%)  
*Cardiac arrest (0.3%)  
*[[Cardiac arrest]] (0.3%)  
*Laceration (0.3%)  
*[[Laceration]] (0.3%)
 
==Emergency Medical Kit==
*The FAA requires all aircraft with >30 passengers to carry an Emergency Medical Kit and an AED<ref name="Bukowski">Bukowski JH, Richards JR. Commercial Airline In-Flight Emergency: Medical Student Response and Review of Medicolegal Issues. J Emerg Med. 2016 Jan;50(1):74-8.</ref>
**This requirement is the "minimum acceptable", but some airlines carry more extensive kits
 
{{EMK}}


==Management==
==Management==
===General Approach===  
===General Approach===
*Identify yourself and level of medical training
*Flight crew is responsible for responding to medical emergencies in flight - your role is to offer assistance, not to take control<ref name="Gendreau">Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med. 2002 Apr 4;346(14):1067-73.</ref>
*Ask a flight attendant to obtain the emergency medical kit (EMK) and administer oxygen as needed
*Identify yourself and level of medical training to the crew
*Patient assessment:
*Ask a flight attendant to obtain the emergency medical kit (EMK)
**Identify chief complaint and HPI
 
**Obtain vital signs (pulse and blood pressure)
===Patient Assessment===
***If you are unable to assess blood pressure by means of auscultation, assess it by palpating the radial pulse
*Identify chief complaint and perform HPI and appropriate focused physical exam
**Assess mental status and if there are focal neurologic deficits
*Obtain vital signs - emergency medical kit will have sphygomomanometer
*If the patient is in cardiac arrest, obtain and apply an automated external defibrillator (AED)
**Measuring BP by palpation may be easier than auscultation in flight
**For patients with a pulse but a suspected cardiac problem, consider using an AED if it has monitoring capabilities
*If the patient is unresponsive or in cardiac arrest, obtain and apply an automated external defibrillator (AED)
***The airline may require contact with a ground-based consultant before use
 
*Initiate consultation with the ground-based consultant if not already initiated by the flight crew
===Management Options===
*Consider discussing administration of medications or intravenous fluids with ground-based consultant
*Goal is to keep patient stable until the flight lands<ref name="Gendreau" />
*Aircraft diversion, ground-based medical assistance, or both should be coordinated with ground-based consultation
*Management should be based on your assessment and evidence-based best practices, but within the confines of the resources available on board
*Document the clinical presentation and care rendered
**e.g. angina/chest pain may be given [[aspirin]] (± [[nitroglycerin|NTG]]), hypoglycemic episodes may be given PO or IV [[dextrose]], vasovagal syncope may be given PO fluids or placed in leg-elevated position, etc.
**Provide to medical personnel on arrival at the destination with transfer of care
*Be aware of available options
**Emergency medical kit, oxygen, and AED
**May ask crew to lower altitude of plane (increases cabin pressure)<ref name="Gendreau" />
**May request to speak with ground-based physician consult service
**May request diversion of flight to closer airport (ultimate decision rests with captain)


===Management of Syncope or Presyncope===
==Medicolegal Issues==
*Confirm breathing and pulse
*Responding to a request for assistance creates a "doctor-patient" relationship<ref name="Nable">Nable JV, Tupe CL, Gehle BD, Brady WJ. In-Flight Medical Emergencies during Commercial Travel. N Engl J Med. 2015 Sep 3;373(10):939-45.</ref>
*Move the patient to an aisle or galley, place the patient in a supine position with legs raised, and provide oxygen
*Duty to respond<ref name="Bukowski"/>
*Check vital signs
**There is no legal duty for a physician to respond to an in-flight emergency in the USA, Canada, and the UK (in the absence of a pre-existing doctor-patient relationship)
**Most patients will be hypotensive immediately after the episode
**In Australia and many European countries, there is a legal duty to respond
*If the patient has diabetes, a glucometer from the patient or a fellow passenger may be used for glucose assessment
*Legal jurisdiction is usually determined by the country in which the aircraft is registered, but the location of the incident may apply as well<ref name="Nable"/>
**A device may also be available in enhanced EMKs
*Most patients will recover spontaneously within minutes. Give oral fluids when possible
*Consider intravenous fluids only if the patient is persistently hypotensive and cannot take oral fluids or has another indication


===Management of Chest Pain or Palpitations===
===United States===
*Check vital signs
*The Aviation Medical Assistance Act (AMAA) of 1998 provides liability coverage for "medically qualified individuals" who provide medical care aboard an aircraft and imposes a standard of "gross negligence or willful misconduct"
*Provide oxygen
**Covers a wide range of medically trained passengers, including physicians, nurses, PAs, paramedics, EMTs, etc.
*If chest pain may be cardiac in origin, administe aspirin
**Provider is not prohibited from accepting compensation in order to receive liability protection under the AMAA<ref name="Nable"/>
*If systolic blood pressure is more than 100 mm Hg, consider administering sublingual nitroglycerin every 5 minutes
<center>________</center>
**Check blood pressure after each dose
{{quote|text="An individual shall not be liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct."|sign=Aviation Medical Assistance Act of 1998|source=Public Law 105–170—April. 24, 1998[http://www.medaire.com/docs/default-document-library/aviation-medical-assistance-act-of-1998-.pdf?sfvrsn=0 .pdf]}}
*If the AED has monitoring capabilities, consider its use to evaluate the cardiac rhythm and evidence of ST-segment
changes in the limb leads
*If symptoms resolve with the above measures, aircraft diversion is not typically required. Ground-based consultation
can assist with diversion decisions


==Source==
==See Also==
*Peterson DC, et al. "Outcomes of Medical Emergencies on Commercial Airline Flights" N Engl J Med 2013;368:2075-83. DOI: 10.1056/NEJMoa1212052
*[[High altitude medicine]]


==References==
<references/>
<references/>


[[Category:Environ]]
[[Category:EMS]]
[[Category:Environmental]]

Latest revision as of 17:23, 28 September 2019

Background

  • Incidence of in-flight emergencies: 1 per 604 flights[1] (0.3% of cases died)
    • For reference, there are ~29,000 commercial flights per day in the US alone[2]
  • As the population ages and people travel longer distances, this number is likely to increase[3]

Epidemiology[1]

Emergency Medical Kit

  • The FAA requires all aircraft with >30 passengers to carry an Emergency Medical Kit and an AED[4]
    • This requirement is the "minimum acceptable", but some airlines carry more extensive kits

Common Airline Emergency Medical Kit Contents[5]

Medications Equipment
Epinephrine 1:1000 Stethoscope
Antihistamine, inj Sphygmomanometer
Dextrose 50%, inj. 50 ml Airways, oropharyngeal (appropriate range of sizes)
Nitroglycerin tablets or spray Syringes (appropriate range of sizes)
Major analgesic, inj. or oral Needles (appropriate range of sizes)
Sedative anticonvulsant, inj. IV Catheters (appropriate range of sizes)
Antiemetic, inj. Antiseptic wipes
Bronchodilator inhaler Disposable gloves
Atropine, inj. Sharps box
Adrenocortical steroid, inj. Urinary catheter
Diuretic, inj. System for delivering intravenous fluid
Medication for postpartum bleeding Venous tourniquet
Sodium chloride 0.9% (minimum 250 ml) Sponge gauze
Acetyl Salicylic Acid for oral use Tape adhesive
Oral beta blocker Surgical mask
Flashlight and batteries
Thermometer (non-mercury)
Umbilical cord clamp
Basic Life Support cards
List of equipment
Advanced Life Support Guides

Management

General Approach

  • Flight crew is responsible for responding to medical emergencies in flight - your role is to offer assistance, not to take control[6]
  • Identify yourself and level of medical training to the crew
  • Ask a flight attendant to obtain the emergency medical kit (EMK)

Patient Assessment

  • Identify chief complaint and perform HPI and appropriate focused physical exam
  • Obtain vital signs - emergency medical kit will have sphygomomanometer
    • Measuring BP by palpation may be easier than auscultation in flight
  • If the patient is unresponsive or in cardiac arrest, obtain and apply an automated external defibrillator (AED)

Management Options

  • Goal is to keep patient stable until the flight lands[6]
  • Management should be based on your assessment and evidence-based best practices, but within the confines of the resources available on board
    • e.g. angina/chest pain may be given aspirin (± NTG), hypoglycemic episodes may be given PO or IV dextrose, vasovagal syncope may be given PO fluids or placed in leg-elevated position, etc.
  • Be aware of available options
    • Emergency medical kit, oxygen, and AED
    • May ask crew to lower altitude of plane (increases cabin pressure)[6]
    • May request to speak with ground-based physician consult service
    • May request diversion of flight to closer airport (ultimate decision rests with captain)

Medicolegal Issues

  • Responding to a request for assistance creates a "doctor-patient" relationship[7]
  • Duty to respond[4]
    • There is no legal duty for a physician to respond to an in-flight emergency in the USA, Canada, and the UK (in the absence of a pre-existing doctor-patient relationship)
    • In Australia and many European countries, there is a legal duty to respond
  • Legal jurisdiction is usually determined by the country in which the aircraft is registered, but the location of the incident may apply as well[7]

United States

  • The Aviation Medical Assistance Act (AMAA) of 1998 provides liability coverage for "medically qualified individuals" who provide medical care aboard an aircraft and imposes a standard of "gross negligence or willful misconduct"
    • Covers a wide range of medically trained passengers, including physicians, nurses, PAs, paramedics, EMTs, etc.
    • Provider is not prohibited from accepting compensation in order to receive liability protection under the AMAA[7]
________

"An individual shall not be liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct."

—Aviation Medical Assistance Act of 1998, Public Law 105–170—April. 24, 1998.pdf

See Also

References

  1. ↑ 1.0 1.1 Peterson DC, et al. "Outcomes of Medical Emergencies on Commercial Airline Flights" N Engl J Med 2013;368:2075-83. DOI: 10.1056/NEJMoa1212052
  2. ↑ NOAA. Air Traffic. http://sos.noaa.gov/Datasets/dataset.php?id=44 Accessed 03/08/2016
  3. ↑ Goodwin T. In-flight medical emergencies: an overview. BMJ : British Medical Journal. 2000;321(7272):1338-1341.
  4. ↑ 4.0 4.1 Bukowski JH, Richards JR. Commercial Airline In-Flight Emergency: Medical Student Response and Review of Medicolegal Issues. J Emerg Med. 2016 Jan;50(1):74-8.
  5. ↑ Thibeault C et al. Emergency medical kit for commercial airlines: an update. Aviat Space Environ Med. 2007 Dec;78(12):1170-1.PDF
  6. ↑ 6.0 6.1 6.2 Gendreau MA, DeJohn C. Responding to medical events during commercial airline flights. N Engl J Med. 2002 Apr 4;346(14):1067-73.
  7. ↑ 7.0 7.1 7.2 Nable JV, Tupe CL, Gehle BD, Brady WJ. In-Flight Medical Emergencies during Commercial Travel. N Engl J Med. 2015 Sep 3;373(10):939-45.
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