In-Flight Medical Emergencies: a Review

Supplementary Online Content

Management of In-Flight Medical Emergencies

This supplementary material has been provided by the authors to give readers additional information about their work.

Martin-Gill C, Doyle TJ, Yealy DM. In-flight medical emergencies: a review. JAMA. doi:10.1001/jama.2018.19842

Downloaded From:© 2018 https://jamanetwork.com/ American Medical Association. on 10/01/2021All rights reserved. SYNCOPE / NEAR-SYNCOPE 30% of all in-flight emergencies Initial assessment-suspect Vasovagal: Pale, diaphoretic, improves with simple measures in 15-30 min. Cardiac cause (eg, myocardial infarction): Chest pain, dyspnea, arm or jaw pain, persistent bradycardia. Pulmonary: Dyspnea, pleuritic chest pain. Stroke: Slurred speech, facial droop, or arm weakness. Hypoglycemia: Diaphoretic, cool skin; assess with glucometer if available.

Management and expected course If unconscious Lie flat, elevate legs, apply oxygen. If no pulse or signs of life, follow cardiac arrest card. If transient syncope Supine position, elevate legs. Oral fluids with head raised if nausea absent. If improves in 15-30 min, slowly sit up and return to seat if tolerated. If hypoglycemia Oral glucose or 25 g of dextrose 50% intravenously. If other conditions suspected Refer to relevant card. If no improvement or not progressing as expected Contact ground-based medical support for additional recommendations.

Downloaded From:© 2018 https://jamanetwork.com/ American Medical Association. on 10/01/2021All rights reserved. GASTROINTESTINAL ILLNESS 15% of all in-flight emergencies Initial assessment Identify extent and timing of symptoms, including nausea, vomiting, diarrhea, bleeding, and specifics of any abdominal pain (location, quality, and severity).

Management and expected course If nausea/emesis Use an oral antiemetic if available; if not tolerated, consider a parenteral antiemetic. Provide oral hydration if tolerated. Use sugar-containing liquids if symptoms of hypoglycemia. If oral intake not tolerated, consider intravenous fluids. If dyspepsia Use an antacid if available in the emergency medical kit. If diarrhea Use an antidiarrheal if available in the emergency medical kit. If patient has fever and persistent diarrhea (>14 d), contact ground-based medical support, as local public health authorities may need to be contacted at the destination. If severe abdominal pain, tenderness on examination, rigid abdomen, or blood in bodily fluid Contact ground-based medical support for additional recommendations.

Downloaded From:© 2018 https://jamanetwork.com/ American Medical Association. on 10/01/2021All rights reserved. RESPIRATORY DISTRESS 10% of all in-flight emergencies Initial assessment Identify history of respiratory disease, scuba diving, extremity swelling, or infectious symptoms. If available, check pulse oximetry.

Management and expected course If ongoing dyspnea or known oxygen saturation is <95% Administer oxygen. If passenger’s portable oxygen concentrator fails or is not used for a patient with preexisting lung disease, consider trial of oxygen therapy. If passenger uses ≥4 L/min on the ground, the onboard oxygen supply may not be enough to reverse hypoxia. Monitor flow rate of oxygen administered; canister consumption is variable and aircraft may not have sufficient oxygen for continuous use for the duration of the flight. If bronchospasm Administer albuterol, 2.5 mg inhaled. If allergic reaction Refer to allergic reaction card. If passenger does not improve Contact ground-based medical support for additional recommendations.

Downloaded From:© 2018 https://jamanetwork.com/ American Medical Association. on 10/01/2021All rights reserved. CARDIOVASCULAR SYMPTOMS 7% of all in-flight emergencies Initial assessment Identify if any prior myocardial infarction or other cardiovascular history. In some settings, a 12-lead electrocardiogram may be obtained and transmitted for ground review (and/or volunteer review if qualified to read). Suspected acute coronary syndrome: Chest pain, dyspnea, arm or jaw pain. Suspected arrhythmia: Persistent bradycardia, tachycardia, or irregular heartbeat. Suspected dyspepsia: Isolated epigastric burning with no associated symptoms. This is a consideration of exclusion, supported by history of similar symptoms. Management and expected course If suspected acute coronary syndrome Aspirin, 325 mg orally; nitroglycerin, 0.4 mg sublingually every 5-10 min (if systolic blood pressure is ≥100 mm Hg). If any dyspnea or respiratory distress Give oxygen, unless saturations are known to be near or at normal levels. If dyspepsia suspected Antacids or other analgesics can be given after appropriate risk stratification. Alternative causes should first be considered. If persistent or additional symptoms Contact ground-based medical support for additional recommendations. Downloaded From:© 2018 https://jamanetwork.com/ American Medical Association. on 10/01/2021All rights reserved. STROKE-LIKE SYMPTOMS Up to 5% of all in-flight emergencies Initial assessment A focused history should include the time of symptom onset, specific motor and sensory components, and any other associated symptoms including headache or sensorium changes. Screening for stroke: Speech disturbance, facial droop, or arm weakness.

Management and expected course Administer oxygen, unless saturations are known to be near or at normal levels. If patient has ongoing neurological deficits suggestive of a stroke Contact ground-based medical support. Recommendation may include diversion, which may not be to the closest airport if stroke care is not present at that airport. Ground-based team should have information on capabilities for medical care near most major airports.

Downloaded From:© 2018 https://jamanetwork.com/ American Medical Association. on 10/01/2021All rights reserved. SEIZURE Up to 5% of all in-flight emergencies Initial assessment Identify the symptoms the passenger exhibited during the event: Including onset, duration of movement activity, quality of movements (eg, tonic-clonic), and loss of bowel or bladder function.

Management and expected course If unresponsive Lay passenger on floor on side, monitor airway, and assess vital signs with ongoing neurological examination as above. If ongoing seizing Administer parenteral benzodiazepines if available in the emergency medical kit (not usually available on US commercial airlines). If alert following a prolonged or recurrent seizure Ground-based medical support may recommend an added dose of the patient’s own antiepileptic medication (if history of seizures and available) or an oral benzodiazepine (if available in the emergency medical kit). If seizure resolves and patient regains normal mental status Diversion is not commonly necessary.

Downloaded From:© 2018 https://jamanetwork.com/ American Medical Association. on 10/01/2021All rights reserved. TRAUMA 5% of all in-flight emergencies Initial assessment Assess all injuries for any open wounds, tenderness, deformity, or active bleeding. Assess patients with injury to the head, neck, or back for any neurological symptoms.

Management and expected course Injuries from falling luggage Typically minor and may be assessed further at the destination. Active bleeding Control bleeding with direct pressure using a gloved hand. Ongoing heavy extremity bleeding Consider applying a tourniquet. Suspected long bone or joint injuries Splinting material is not commonly found in the emergency medical kit, but may be improvised from available equipment (eg, a U-shaped half-rolled magazine secured with tape will make a good forearm or wrist splint).

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CARDIOVASCULARGASTROINTESTINALSYNCOPSTROKE-LIKEPSYCHIATRICRESPIRATORYETRAUMASEIZURE/ NEAR-SYNCOPE SYMPTOMS DISTRESS SYMPTOMS ILLNESS Up30%15%10% 7%5%to 5%3% of of all ofall allin-flight in-flight in-flight emergencies emergencies emergencies Initial assessment-suspectassessment Vasovagal:IdentifyAAssessAim focused to allcreate ifextenthistorythe historyinjuriesany Pale, symptoms aprior and rapportof diaphoretic,should for respiratory timingmyocardial any the withinclude open ofpassenger the symptoms,improves disease, wounds,infarctionthe passenger time exhibited of withincludingscubaorsymptomduringtenderness,to otherdeescalate simple diving, the cardiovascular onset,nausea, event: measuresdeformity, extremitythe specific situation.vomiting, in orhistory. motorswelling, 15-30 active diarrhea, and min. bleeding. sensory bleeding, CardiacInAssessElicitandorcomponents,Including someinfectious specifics information patients causesettings, onset, andsymptoms. of(eg, with anyduration anya and myocardial12-lead abdominalinjuryother consider of associated toelectrocardiogram movement the infarction): thepain head, passenger’s (location, symptoms neck,activity, may ChestIfbeorusequality,includingquality available, backobtained of pain,mood-altering offorand headache movements anydyspnea, andcheckseverity). neurological transmitted pulseor armsensoriumsubstances. (eg, oximetry. or tonic-clonic), jawsymptoms.for changes.groundpain, review and loss of bowel or bladder function. Identifypersistent(and/orScreening volunteerif forpatientbradycardia. stroke: reviewtakes Speech specific if qualified disturbance, psychiatric to read). facial droop, or arm weakness. Pulmonary:Suspectedmedications,Management acute Dyspnea, dosing, and coronary expected lastpleuritic dose syndrome: taken,coursechest pain. Chest pain, dyspnea,and if available arm or on jaw aircraft. pain. InjuriesStroke:IfManagement ongoingnausea/emesis Slurredfrom dyspnea falling andspeech, Useorexpected luggage known anfacial oral oxygen droop, courseantiemeticTypically saturation minor Management and expected course andorSuspectedisIfif available;unresponsive <95%arm may weakness. be Administerarrhythmia: assessedif not Laytolerated, further passengeroxygen. Persistent considerat the on bradycardia, destination.floor a on side, monitorAdministerparenteralManagement airway, antiemetic. oxygen, and and expectedunless assess saturationsvital course signs with are known Hypoglycemia:tachycardia,If passenger’s or irregularDiaphoretic,portable heartbeat.oxygen cool concentrator skin; ongoingtoActive be near bleeding neurological or at normal Control examination levels. bleeding as with above. direct pressureassessSuspectedIffailsProvide verbal or with isdeescalation usingoral dyspepsia:not glucometer hydration useda gloved for Isolatedineffective aifhand. patient available.tolerated. epigastric with preexisting burning withIfConsiderlung ongoingpatient no disease, associated ahas seizingbenzodiazepine ongoing consider symptoms. 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Antacids necessary. or other analgesics can be given after appropriate risk IReferIff severepassenger to relevantabdominal does card.not pain, improve tenderness on examination, stratification. Alternative causes should first rigidContact abdomen, ground-based or blood medical in bodily support fluid beIf no considered. improvement or not progressing asContactfor expected additional ground-based recommendations.Contact ground-basedmedical support Ifmedicalfor persistent additional support or recommendations. additional for additional symptoms recommendations. Contact ground-based medical support for additional recommendations. Downloaded From:© 2018 https://jamanetwork.com/ American Medical Association. on 10/01/2021All rights reserved. SUBSTANCECARDIOVASCULARGASTROINTESTINALSYNCOPSTROKE-LIKEPSYCHIATRICRESPIRATORY ABUSEETRAUMASEIZURE/ NEAR-SYNCOPE ANDSYMPTOMS DISTRESS SYMPTOMS WITHDRAWAL ILLNESS Up30%15%10% 7%5%to 5%3% of of all ofall allin-flight in-flight in-flight emergencies emergencies emergencies Initial assessment-suspectassessment Vasovagal:IdentifyAAssessAim focused to allcreate ifextenthistorythetype, historyinjuriesany Pale, symptoms aamount,prior and rapportof diaphoretic,should for respiratory timingmyocardial any andthe withinclude open of passengertiming the symptoms,improves disease, wounds,infarctionthe passenger time exhibited of withincludingscubaorsymptomduringtenderness,toof substancesotherdeescalate simple diving, the cardiovascular onset,nausea, event: measuresdeformity, extremitytheused. specific situation.vomiting, in orhistory. motorswelling, 15-30 active diarrhea, and min. bleeding. sensory bleeding, CardiacInAssessElicitIdentifyandorcomponents,Including someinfectious specifics information patients causesettings,symptoms onset, andsymptoms. of(eg, with anyduration anya and myocardial 12-leadand abdominalinjuryother consider mental of associated toelectrocardiogram movement the infarction): status, thepain head, passenger’s (location, symptoms neck,activity, may ChestIfbeorusealongquality,includingquality available, backobtained of withpain,mood-altering offorand headache movements vitalanydyspnea, andcheckseverity). neurological signs.transmitted pulseor armsensoriumsubstances. (eg, oximetry. or tonic-clonic), jawsymptoms.for changes.groundpain, review and loss of bowel or bladder function. IdentifySuspectedpersistent(and/orScreening volunteerif for patientbradycardia.opioid stroke: ingestion:reviewtakes Speech specific if qualified disturbance,Altered psychiatric mentation,to read). facial droop, or arm weakness. Pulmonary:Suspectedmedications,constrictedManagement acute pupils,Dyspnea, dosing, and coronary respiratory expected lastpleuritic dose syndrome: taken,coursechestdepression. pain. Chest pain, dyspnea,and if available arm or on jaw aircraft. pain. InjuriesStroke:SuspectedIfManagement ongoingnausea/emesis Slurredfrom dyspneaalcohol falling andspeech, ingestion: Useorexpected luggage known anfacial oral Altered oxygen droop, courseantiemeticTypically saturationmentation, minor Management and expected course andorSuspectedslurredisIfif available;unresponsive <95%arm may weakness.speech, be Administerarrhythmia: assessedif not behavior Laytolerated, further passengeroxygen. Persistent changes. considerat the on bradycardia, destination.floor a on side, monitorAdministerparenteralManagement airway, antiemetic. oxygen, and and expectedunless assess saturationsvital course signs with are known Hypoglycemia:Suspectedtachycardia,If passenger’s stimulant or irregularDiaphoretic,portable ingestion: heartbeat.oxygen cool Altered concentrator skin; mentation, ongoingtoActive be near bleeding neurological or at normal Control examination levels. bleeding as with above. direct pressureassessSuspectedtachycardia,IffailsProvide verbal or with isdeescalation usingoral dyspepsia:not glucometer dilated hydration useda gloved forpupils, Isolatedineffective aifhand. patient available.tolerated. agitation. epigastric with preexisting burning withIfConsiderlung ongoingpatient no disease, associated ahas seizingbenzodiazepine ongoing consider symptoms. 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Antacids ifnecessary. available or fromother the analgesicsemergency can medical be given kit. after appropriate risk IReferIff severepassenger to relevantabdominal does card.not pain, improve tenderness on examination, stratification. Alternative causes should first rigidIfContact ongoing abdomen, ground-based respiratory or blood distressmedical in bodily or support combativenessfluid beIf no considered. improvement or not progressing asContactfor expected additional ground-based recommendations.Contact ground-basedmedical support for Ifmedicalforadditional persistent additional support recommendations. or recommendations. additional for additional symptoms Refer recommendations. to airline crew Contactfor individual ground-based airline security medical protocols. support for additional recommendations. Downloaded From:© 2018 https://jamanetwork.com/ American Medical Association. on 10/01/2021All rights reserved. SUBSTANCECARDIOVASCULARGASTROINTESTINALSYNCOPSTROKE-LIKEPSYCHIATRICRESPIRATORYALLERGIC ABUSEETRAUMASEIZURE/ NEAR-SYNCOPE REACTION ANDSYMPTOMS DISTRESS SYMPTOMS WITHDRAWAL ILLNESS Up30%15%10% 7%5%2%to 5%3% of of all ofall allin-flight in-flight in-flight emergencies emergencies emergencies Initial assessment-suspectassessment Vasovagal:IdentifyAAssessAim focused to allcreate ifextenthistorythetype,any historyinjuriesany Pale, symptomsknown aamount,prior and rapportof diaphoretic,should for respiratory timingmyocardialor any likely andthe withinclude open of passengertiming allergenthe symptoms,improves disease, wounds,infarctionthe passenger time exposure; exhibited of withincludingscubaorsymptomduringtenderness,toofduration substancesotherdeescalate simple diving, the cardiovascular and onset,nausea, event: measuresdeformity, severity extremitytheused. specific situation.vomiting, ofin orhistory. motor swelling,symptoms;15-30 active diarrhea, and min. bleeding. sensory and bleeding, any CardiacInAssessElicitIdentifyandorcomponents,Includingairway someinfectious specifics information patientsswelling, causesettings,symptoms onset, andsymptoms. of(eg, with anydurationrespiratory anya and myocardial 12-leadand abdominalinjuryother consider mental of associated toelectrocardiogram involvement,movement the infarction): status, thepain head, passenger’s (location, symptoms neck,activity, or signs may ChestIfbeorusealongquality,includingqualityof available, systemicbackobtained of withpain,mood-altering offorand headache movements vitalany dyspnea, reactionandcheckseverity). neurological signs.transmitted pulseor such armsensoriumsubstances. (eg, oximetry. oras tonic-clonic), jawsymptoms.generalizedfor changes.groundpain, review hives. and loss of bowel or bladder function. IdentifySuspectedpersistent(and/orScreening volunteerif for patientbradycardia.opioidlocal stroke: allergic ingestion:reviewtakes Speech specificreaction: if qualified disturbance,Altered psychiatric Localized mentation,to read). facialpruritic droop, rash oror armisolated weakness. hives. Pulmonary:Suspectedmedications,constrictedManagement acute pupils,Dyspnea, dosing, and coronary respiratory expected lastpleuritic dose syndrome: taken,coursechestdepression. pain. Chest pain, dyspnea,andSuspected if available arm anaphylaxis: or on jaw aircraft. pain. Airway swelling, InjuriesStroke:SuspectedIfManagement ongoingnausea/emesis Slurredfrom dyspneaalcohol falling andspeech, ingestion: Useorexpected luggage known anfacial oral Altered oxygen droop, courseantiemeticTypically saturationmentation, minor respiratoryManagement distress, and expected generalized course hives, andorSuspectedslurredisIfif available;unresponsive <95%arm may weakness.speech, be Administerarrhythmia: assessedif not behavior Laytolerated, further passengeroxygen. Persistent changes. considerat the on bradycardia, destination.floor a on side, monitorAdministerparenteralhypotension,Management airway, antiemetic. oxygen, nausea/vomiting. and and expectedunless assess saturationsvital course signs with are known Hypoglycemia:Suspectedtachycardia,If passenger’s stimulant or irregularDiaphoretic,portable ingestion: heartbeat.oxygen cool Altered concentrator skin; mentation, ongoingtoActive be near bleeding neurological or at normal Control examination levels. bleeding as with above. direct pressureassessSuspectedtachycardia,IffailsProvide verbal or with isdeescalation usingoral dyspepsia:not glucometer dilated hydration useda gloved forpupils, Isolatedineffective aifhand. patient available.tolerated. agitation. epigastric with preexisting burning withIfConsiderManagementUselung ongoingpatient no sugar-containing disease, associated ahas seizingbenzodiazepine ongoing considerand symptoms. expected Administer neurological liquids trial if of availableThis if courseoxygen parenteralsymptoms is deficitsa consideration fromtherapy. an extendedOngoing heavy emergency extremity medical bleeding kit. 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Antacids ifnecessary. available or fromother the availableanalgesicsemergency as can medicalan autoinjecbe given kit. torafter or appropriate in an ampoule risk IReferIff severepassenger to relevantabdominal does card.not pain, improve tenderness on examination, tostratification. be drawn up Alternative via syringe. causes should first rigidIfContact ongoing abdomen, ground-based respiratory or blood distressmedical in bodily or support combativenessfluid Ifbe thereno considered. improvement is no improvement or not progressing Contactfor additional ground-based recommendations. medical support for Contactas expected ground-based Contact ground-basedmedical support Ifmedicalforadditional persistent additional support recommendations. or recommendations. additional for additional symptoms Refer recommendations. to airline crew forContact additionalindividual ground-based airlinerecommendations. security medical protocols. support for additional recommendations. Downloaded From:© 2018 https://jamanetwork.com/ American Medical Association. on 10/01/2021All rights reserved. OBSTETRIC EMERGENCIES 1% of all in-flight emergencies Initial assessment Identify onset and detailed description of symptoms, along with information about the pregnancy (eg, parity, gestational age, and any preceding complications). Vaginal bleeding: Assess duration and severity (ie, equivalent of pads per h). Labor suspected: Regular contraction, gush of vaginal fluid.

Management and expected course If vaginal bleeding <1 pad per h Expectant management is common. If preterm labor in third trimester Place the passenger on left side and consider fluid intravenously if any concerns exist for blood loss or distress. Active labor, ongoing/severe vaginal bleeding, or increasing/severe abdominal pain Contact ground-based medical support for additional recommendations.

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SUBSTANCECARDIOVASCULARGASTROINTESTINALSYNCOPOBSTETRICSTROKE-LIKEPSYCHIATRICRESPIRATORYALLERGICCARDIAC ABUSEETRAUMASEIZURE/ NEAR-SYNCOPE EMERGENCIES REACTION ARRESTANDSYMPTOMS DISTRESS SYMPTOMS WITHDRAWAL ILLNESS Up0.2%30%15%10% 7%5%2%1%to 5%3% of ofof all of allall allin-flight in-flightin-flight in-flight emergencies emergenciesemergencies emergencies Initial assessment-suspectassessment Vasovagal:IdentifyAAssessAimCheck focused to breathingallcreate ifextenthistorythetype,anyonset historyinjuriesany Pale, symptomsknown aamount,priorand and rapportof diaphoretic,andshould for respiratorydetailed timingmyocardialor pulse;any likely andthe withinclude open of passenger timingdescriptionlimit allergenthe symptoms,improves disease, wounds,infarctionthe passengerpulse time exposure; exhibited checks of withincludingscubaorsymptomduringtenderness,toofduration substancessymptoms,otherdeescalate<10 simple diving, theseconds. cardiovascular and onset,nausea, event: measuresdeformity, severity extremitytheused.along specific situation.vomiting, with ofin orhistory. motor swelling,symptoms;15-30 information active diarrhea, and min. bleeding. sensory and aboutbleeding, any the CardiacInAssessElicitIdentifyandorcomponents,Includingairwaypregnancy someinfectious specifics information patientsswelling, causesettings,symptoms onset, (eg, andsymptoms. of(eg, parity,with anydurationrespiratory anya and myocardial 12-leadand abdominalinjuryother considergestational mental of associated toelectrocardiogram involvement,movement the infarction): status, thepain head, age, passenger’s (location, symptoms andneck,activity, or any signs may ChestIfbeorusealongquality,includingqualityofprecedingManagement available, systemicbackobtained of withpain,mood-altering offorand headache movementscomplications). vitalany dyspnea, reactionandcheckseverity). andneurological signs.transmitted pulseor expected such armsensoriumsubstances. (eg, oximetry. oras tonic-clonic), jawsymptoms.generalizedfor course changes.groundpain, review hives. and loss of bowel or bladder function. IdentifySuspectedpersistent(and/orScreeningVaginalIf no pulse bleeding:volunteerif forpatient bradycardia.opioidlocalor stroke:signs allergic ingestion:Assessreviewtakes of Speech life specificreaction: durationif qualified disturbance,Altered psychiatric Localizedand mentation,to severity read). facialpruritic(ie, equivalent droop, rash oror armofisolated pads weakness. per hives. h). Pulmonary:Suspectedmedications,constrictedManagementStart chest acute pupils,Dyspnea, compression-only dosing, and coronary respiratory expected lastpleuritic dose syndrome: taken,coursechestdepression.cardiopulmonary pain. 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