What is Medicine – Air Travel Emergencies
DESCRIPTION OF AIR TRAVEL EMERGENCIES IN GENERAL When there are in-flight medical incidents (IME), doctors frequently assist. Numerous IME are outside of a practitioner's typical area of expertise. There are few medical resources available in the confined space of the aircraft. Despite these challenges, healthcare professionals should be ready to offer aid when necessary. EPIDEMIOLOGY Incidence throughout 4 billion people travel throughout the world each year. The precise frequency of IMEs is unknown. Airlines estimate that an IME happens on 1 in every 40 flights; the flight crew usually deals with minor incidents. Other datasets that only cover IMEs that are more significant estimate the incidence at 1 in 600 flights (2). According to airline estimates, there are 250 to 1,500 IME occurrences every day around the world for every 7,500 to 40,000 aircraft passengers (3). Larger planes, longer flights, and an ageing population all increase the probability of running into an IME. Syncope/near syncope (32.7%), gastrointestinal (14.8%), respiratory (10.1%), and cardiovascular symptoms (7%) are the most frequent IMEs (3). Up to 90% of IMEs in otherwise healthy travellers are caused by vasovagal syncope. Five percent of passengers (5%), who account for two-thirds of IMEs, have a chronic disease. 15% of ground-based doctor calls are for children travelling with you (1). 3% of IMEs result in death; however, because it is frequently not stated in flight, deaths can go unreported. PATHOPHYSIOLOGY AND AETIOLOGY When travelling at cruising altitude in a pressurised cabin, the atmospheric pressure of oxygen falls from 160 mm Hg at sea level to 120 mm Hg. In healthy individuals, the arterial oxygen tension falls from 100 to approximately 60 mm Hg, resulting in mean inflight oxygen saturations of 93% (85–98%). As a result of their lower baseline PaO2, passengers with chronic obstructive pulmonary disease (COPD) or other respiratory illnesses may experience a drop in oxygen tension that occurs on the steep portion of the haemoglobin dissociation curve and causes more severe hypoxemia. It may be impossible for passengers with unstable angina or heart failure to compensate for hypoxia. Gas expansion: In flight, gases expand by around 30%. In children with ear infections, this can result in a pneumothorax, wound dehiscence or perforation from bowel gas expansion, sinus pressure, and tympanic membrane rupture. Venous thromboembolism: Prolonged sitting, low oxygen levels, and dehydration all raise the risk of blood clotting. Deep vein thromboses (DVTs) are more likely to occur on longer flights and in travellers with preexisting medical issues. Travelling is physically and mentally taxing, which increases the risk of psychiatric problems or acute coronary syndrome (ACS). Passengers' altered circadian rhythms, which could lead to seizures and medication non-adherence, cause insomnia. Turbulence: Passengers frequently experience motion sickness, and fallen bags can cause serious injuries. Non-adherence to medication: Forgotten or checked medications may result in glycemic control issues, seizures, blood pressure instability, and inability to access drugs when needed. Limited access to food and liquids: Dehydration may be the cause of vasovagal syncope. Hypoglycemia can occur in diabetics. Low relative humidity in the cabin contributes to dehydration, epistaxis, and asthma or COPD flare-ups. Cabin air is less than 20% relative humidity. Virus infections: Influenza and parainfluenza are the most often transmitted viruses through close contact. The filtered, non-infectious cabin air. Travel by air may result in SARS-CoV2 viral transmission. Similar to other viruses, cabin air flow is less of a risk than proximity to sick, perhaps asymptomatic passengers. By adhering to the relevant rules for mask use, social isolation, and quarantining, risk can be reduced. RISK ELEMENTS Recent surgery: Due to gas expansion, passengers are at risk for wound dehiscence, intestinal perforation, and compartment syndrome. Passengers who have COPD, asthma, CHF, or coronary artery disease may experience hypoxemia and be unable to compensate correctly. Recent cast placement: Tissue edoema puts passengers at risk for compartment syndrome. Hypercoagulability: Individuals who have inherited or acquired hypercoagulable disorders, are pregnant, on medication, have heart disease, or have recently undergone surgery are more likely to develop DVTs. Passengers who have recently dived are at risk of developing decompression symptoms. Long flights: Hypoxia has accumulative and time-dependent effects. GENERAL PREVENTION General recommendations: Consult your doctor before taking any drugs, and bring any essential supplies with you. Patients with a baseline PaO2 70 mm Hg or who are unable to walk 150 feet without getting out of breath or suffering angina must use additional in-flight oxygen. pregnant women's issues It is normally safe for women to fly up until 36 weeks of pregnancy. Child Safety Considerations Children's travellers should bring liquid medication in the permitted quantity on the aircraft. A rescue inhaler with spacer and facemask should be available for children with asthma. Flying should be avoided 10 to 14 days after surgery (depending on the procedure). - If casts are applied 24 to 48 hours before a flight, they might need to be bivalved. - Do not dive 24 hours before taking off. - Preventing DVT (5)[C]: Drink enough water. Passengers with risk characteristics may require compression stockings, aspirin, or anticoagulants. Prevent venous stasis by standing, stretching, and exercising legs throughout flight. DISEASE HISTORY Depending on the situation, the symptoms can vary; if the patient is awake, get as much background information as you can. Inquire about any prior surgeries or medical conditions, the use of drugs, and allergies. Enquire about the use of illegal drugs or alcohol. Create a safe copy of your findings and recommendations and save a copy for your records. PHYSICAL EXAM – Wear all PPE accessible. On board, there are safety gloves available. Due to noise, it could be necessary to take blood pressure by palpitation. Examine the vital signs. Skin perfusion is one sign of dehydration General appearance and mental state; and, if a stethoscope is included in the in-flight package, the optimum auscultation technique By keeping an ear out for contralateral tracheal deviation and diminished lung sounds, check for tension pneumothorax. Needle decompression is required for a tension pneumothorax. Syncope or near-syncope: vasovagal syncope, dehydration, hypoglycemia, intoxication, adverse drug reaction or toxicity, acute coronary syndrome (ACS), arrhythmia, cerebrovascular accident, pulmonary thrombosis/air embolism, and hypoxia Chest pain, shortness of breath, and anxiety are all symptoms of the following conditions: acute coronary syndrome (ACS), pulmonary embolism, pneumothorax, bronchospasm, aortic dissection, gastric reflux, and musculoskeletal aetiology. Stroke-like symptoms include cerebrovascular accident, transient ischemic attack, hypoglycemia, seizure, syncope, intracranial mass, and complex migraine. Seizure symptoms include syncope, hypoglycemia, eclampsia, and cardiac arrest. Gastrointestinal illnesses include motion sickness, food poisoning, gastritis, enteritis, gastroesophageal reflux disease, pancreatitis, and drug withdrawal. Obste Trauma: caused by falling luggage or turbulence. DETECTION & INTERPRETATION OF DIAGNOSIS It is possible to use the automated external defibrillator (AED) as a cardiac monitor. ● Request equipment from other passengers, such as a glucometer, MDI spacer, or pulse oximeter. GENERAL TREATMENT MEASURES First aid and CPR: Begin CPR, BLS, ALS, and PALS if necessary if there is no pulse or breathing. First aid and CPR instruction is provided to airline crew members. Ask for aid: Request equipment, medications, knowledge, and lifting assistance from the flight crew and other passengers. Oxygen is provided on every trip at a rate of 2 to 5 L per minute through facemask. At cruising altitude, the oxygen delivery resembles the atmosphere at ground level. In all instances of respiratory distress, chest discomfort, convulsions, and altered mental status, oxygen should be administered. Support from ground-based doctors: Many airlines have agreements with businesses that provide in-flight medical advice, interpreter services, suggestions for diversions, and occasionally telemedicine technology. Requesting a flight at a lower attitude will allow you to experience the oxygen pressure at sea level while flying below 22,500 feet. Flying slower and lower may not be the best option to get to a hospital quickly because it requires more fuel. Request a diversion: The pilot may ask for a quicker landing, arrival-time medical assistance, or a closer location. Consideration should be given to diverting medical crises including resuscitation, prolonged abnormal vital signs, chest pain, stroke symptoms, respiratory distress, unconsciousness, obstetrics, or psychiatric emergencies. MEDICATION All commercial aeroplanes operated by the United States are equipped with emergency medical kits (EMKs) and standard first aid supplies. Different nations, airlines, and aircraft have different contents. All aeroplanes are outfitted with an AED, and many airlines have adopted a more thorough EMK. Child Safety Considerations Medication in EMKs does not come in liquid or suppository form. Think about breaking tablets or requesting supplies from other passengers. To create a spacer, tape a toilet paper roll or a cut soda bottle to an albuterol pump. ADVANCED THERAPIES Cardiac arrest: CPR, early defibrillation, epinephrine (1 mg IV for adults, 0.01 mg/kg IV for children), lidocaine, or atropine if needed. Recommend diversion. Aspirin (325 mg PO) and nitroglycerin (0.4 mg sublingually every 5–10 minutes if systolic blood pressure is greater than 100 mm Hg) are recommended for acute coronary syndrome. Apply AED. Encourage distraction. Oxygen, albuterol 2.5 mg inhaled (as needed), steroid (if available), and epinephrine 1:1,000 (autoinjector: adult: 0.3 mg, paediatric [25 kg]: 0.15 mg IM; ampule: adult: 0.3 mg, paediatric: 0.01 mg/kg) if there is considerable respiratory distress are the treatments for asthma and COPD exacerbations. Think about a diversion. ● Allergic reaction: diphenhydramine (PO or IV, adult: 25 to 50 mg, paediatric: 1 mg/kg); if anaphylaxis, epinephrine 1:1,000 (autoinjector: adult: 0.3 mg, paediatric [<25 kg]: 0.15 mg IM; ampule: adult: 0.3 mg, paediatric: 0.01 mg/kg); NS (IV, adults: 1 L, paediatric: 20 mL/kg) steroid (if available); divert if anaphylaxis. Vasovagal syncope: Lift your legs. If you're oriented and alert, offer oral drinks. Think about an IV fluid bolus. Give oral glucose and take into account hypoglycemia. Observe your blood pressure. If the patient still exhibits symptoms or continues to show abnormal vital signs, consider diversion. Digestive: The EMK or other passengers may have oral antiemetic and antacid supplies. Consider diversion if you are experiencing stomach pain. Tension pneumothorax: anterior axillary line needle thoracostomy in the fourth or fifth intercostal space Psychological crisis: Think about hypoxia, hypo/hyperglycemia, and intoxication. Try to defuse the situation verbally. Prior to using chemical restraint, established airline practise should be followed if there is hostility. Ask the patient and other travellers if they are taking any oral sedatives. If restraint is required, four passengers should do so, one on each limb. If the patient is constrained, keep an eye out for symptoms of ACS or respiratory distress. Consider diversion. Ingestion of opioids: Use rescue breathing as necessary. Naloxone 0.4 to 0.8 mg IV, 2 mg intranasally, or IM, if accessible in the EMK or from other passengers. CONTINUING CARE/DIAGNOSIS Volunteer in-flight medical professionals are shielded from negligence by the Aviation Medical Assistance Act of 1998. In the US, no doctor has ever been successfully sued for providing free care during an IME. Medical professionals reacted to overhead pages for assistance 76% of the time, with doctors responding in 48% of the cases. About 80% of in-flight diagnoses and hospital diagnoses agree. With assistance from a healthcare professional, 60% of IMEs get better.
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