Commercial in-flight medical emergencies

Background

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

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%)

Emergency Medical Kit

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

Common Airline Emergency Medical Kit Contents

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

• 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 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 perform a focused physical exam based on chief complaint
• 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 applying AED pads to use as a cardiac monitor and rhythm strip (if AED has display screen)

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.
• 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

Aftercare

• 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 and give documentation to medical personnel on arrival at the destination with transfer of care

Medicolegal Issues

• Responding to a request for assistance creates a "doctor-patient" relationship
• Duty to respond
  • 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

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, EMTs, etc.
  • Provider is not prohibited from accepting compensation in order to receive liability protection under the AMAA

________

"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

• High Altitude Medicine