Commercial in-flight medical emergencies

Background

• 1 per 604 flights
  • 0.3% of cases died

Epidemiology

• syncope or presyncope (37.4%)
• respiratory symptoms (12.1%)
• nausea or vomiting (9.5%)
• Cardiac symptoms (7.7%)
• Seizures (5.8%)
• Abdominal pain (4.1%)
• Infectious disease (2.8%)
• Agitation or psychiatric symptoms (2.4%)
• Allergic reaction (2.2%)
• Possible stroke (2.0%)
• Trauma, not otherwise specified (1.8%)
• Diabetic complication (1.6%)
• Headache (1.0%)
• Arm or leg pain or injury (1.0%)
• Obstetrical or gynecologic symptoms(0.5%)

Ear pain (0.4%)

• Cardiac arrest (0.3%)
• Laceration (0.3%)

Management

General Approach

• Identify yourself and level of medical training
• Ask a flight attendant to obtain the emergency medical kit (EMK) and administer oxygen as needed
• Patient assessment:
  • Identify chief complaint and HPI
  • Obtain vital signs (pulse and blood pressure)
    • If you are unable to assess blood pressure by means of auscultation, assess it by palpating the radial pulse
  • Assess mental status and if there are focal neurologic deficits
• If the patient is in cardiac arrest, obtain and apply an automated external defibrillator (AED)
  • For patients with a pulse but a suspected cardiac problem, consider using an AED if it has monitoring capabilities
    • 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
• Consider discussing administration of medications or intravenous fluids with ground-based consultant
• Aircraft diversion, ground-based medical assistance, or both should be coordinated with ground-based consultation
• Document the clinical presentation and care rendered
  • Provide to medical personnel on arrival at the destination with transfer of care

Management of Syncope or Presyncope

• Confirm breathing and pulse
• Move the patient to an aisle or galley, place the patient in a supine position with legs raised, and provide oxygen
• Check vital signs
  • Most patients will be hypotensive immediately after the episode
• If the patient has diabetes, a glucometer from the patient or a fellow passenger may be used for glucose assessment
  • 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

• Check vital signs
• Provide oxygen
• If chest pain may be cardiac in origin, administe aspirin
• If systolic blood pressure is more than 100 mm Hg, consider administering sublingual nitroglycerin every 5 minutes
  • Check blood pressure after each dose
• 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

• Peterson DC, et al. "Outcomes of Medical Emergencies on Commercial Airline Flights" N Engl J Med 2013;368:2075-83. DOI: 10.1056/NEJMoa1212052