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In-flight cardiac arrest and in-flight cardiopulmonary resuscitation during commercial air travel: consensus statement and supplementary treatment guideline from the German Society of Aerospace Medicine (DGLRM)
Abstract
By the end of the year 2016, approximately 3 billion people worldwide travelled by commercial air transport. Between 1 out of 14,000 and 1 out of 50,000 passengers will experience acute medical problems/emergencies during a flight (i.e., in-flight medical emergency). Cardiac arrest accounts for 0.3% of all in-flight medical emergencies. So far, no specific guideline exists for the management and treatment of in-flight cardiac arrest (IFCA). A task force with clinical and investigational expertise in aviation, aviation medicine, and emergency medicine was created to develop a consensus based on scientific evidence and compiled a guideline for the management and treatment of in-flight cardiac arrests. Using the GRADE, RAND, and DELPHI methods, a systematic literature search was performed in PubMed. Specific recommendations have been developed for the treatment of IFCA. A total of 29 specific recommendations for the treatment and management of in-flight cardiac arrests were generated. The main recommendations included emergency equipments as well as communication of the emergency. Training of the crew is of utmost importance, and should ideally have a focus on CPR in aircraft. The decision for a diversion should be considered very carefully.
... 5 Between 1 in 14,000 and 1 in 50,000 passengers will experience an in-flight acute medical problem. 6 Nonetheless, in-flight cardiopulmonary resuscitation (CPR) and automatic external defibrillator (AED) use occur in one per 5 to 10 million passengers every year, or, according to the German Society of Aerospace Medicine, up to 0.3% of all in-flight emergencies. 6,7 Ventricular fibrillation (VF) is usually the first documented rhythm (up to 70% of sudden cardiac arrest victims), making defibrillation one of the first interventions to be done with real life-saving possibilities. ...
... 6 Nonetheless, in-flight cardiopulmonary resuscitation (CPR) and automatic external defibrillator (AED) use occur in one per 5 to 10 million passengers every year, or, according to the German Society of Aerospace Medicine, up to 0.3% of all in-flight emergencies. 6,7 Ventricular fibrillation (VF) is usually the first documented rhythm (up to 70% of sudden cardiac arrest victims), making defibrillation one of the first interventions to be done with real life-saving possibilities. In-flight cardiac arrest (IFCA) has shown a different pattern, although a significant 25 to 50% of subjects showed VF as the initial rhythm. ...
... Seven out of 27 subjects had an initial asystole and did not recover. 6,11 In the context of out-of-hospital cardiac arrest (OHCA), successful reversion of the arrest has been reported in up to 30% of cases, given timely interventions are performed (hands-only cardio-pulmonary resuscitation [CPR], early defibrillation and proper emergency cardiac care). Those survival numbers strongly rely on early defibrillation: if an effective shock is applied within the first three minutes of the OHCA, most patients will regain spontaneous circulation. ...
The number of air travelers has increased over the past years, and after the limitations imposed by the COVID-19 pandemic, are expected to increase further. Given these conditions, the possibility for a health professional to find himself needing to assist an in-flight cardiac arrest is also increased. The present work describes some of the most common problems in managing an inflight cardiac arrest and emphasizes the relevance of cardiopulmonary resuscitation (CPR) performance and automated external defibrillators (AED) use on board of commercial airliners.
... A full range of medical complaints have been reported for GBME and IFME, including emergency events associated with gastrointestinal, respiratory, and cardiovascular symptoms or existing diseases, and life-threating events such as heart attack, cardiac arrest and stroke (6,7,10). The types of management required for these medical events varies according to where and when they occur. ...
... The types of management required for these medical events varies according to where and when they occur. Events occurring during flight may be treated on-board the aircraft if medical personnel and or equipment are present, but are more likely to be treated by emergency medical personnel on the ground after landing (6,10). Pediatric emergencies are almost always treated in-flight although additional care may be provided after landing (11). ...
... Although medical in-flight events are reported to occur about once in every 40 commercial flights, actual emergency events occur about 1 in every 150 flights, and relatively few flights are diverted to other airports compared to on the ground (5). Decisions to divert are based on the type and severity of the event (treatable or not), remaining time of the flight, distance to the destination vs. nearest airport, and availability of emergency medical services in-flight vs. on the ground (6,10,12). If passengers present with a shockable rhythm that can be addressed with on-board cardiopulmonary resuscitation, the flights may not be diverted (12). ...
Background: Limited information is available covering all medical events managed by the airport-based outreach medical service. This study explores the clinical demand for emergency medical outreach services at Taoyuan International Airport (TIA), Taiwan.
Methods: Electronic medical records collected from TIA medical outreach services from 2017 to 2018, included passengers' profiles, flight information, events location, chief complaints, diagnosis (using ICD-9 -CM codes), and management outcomes. Medical events distribution was stratified by location and ages, and were compared statistically.
Results: Among 1,501 eligible records, there were 81.8% ground-based emergency medical events (GBME), 16.9% in-flight medical events (IFME) managed after scheduled landing, and 1.3% IFME leading to unscheduled diversion or re-entry to TIA. The top three GBME diagnoses were associated with neurological (23.3%), gastrointestinal (21.2%), and trauma-related (19.3%) conditions. The top three IFME diagnosis that prompted unscheduled landings via flight diversion or re-entry were neurological (47.4%), psychological (15.8%), and cardiovascular (10.5%). The chief complaints that prompted unscheduled landings were mostly related to neurological (42.1%), cardiovascular (26.3%), and out-of-hospital cardiac arrest (OHCA) (10.5%) symptoms. A higher frequency of IFME events due to dermatologic causes in patients aged ≤ 18 years compared with adults and older adults (19 vs. 1.5% and 0, respectively); and a higher frequency of IFME due to cardiovascular causes in adults ≥ 65 years compared with patients aged ≤ 65 (15.1 vs. 9%). Among all IFME patients, six out-of-hospital deaths occurred among passengers from scheduled landings and two deaths occurred among 18 IFME passengers who were transferred to local hospitals from flight diversion or re-entry. A statistically significant difference in outcomes and short-term follow-up status was found between patients with IFME and those with GBME (p < 0.001).
Conclusion: Ground-based emergency medical events exceeded in-flight medical events at TIA. The most frequent events were related to neurological, gastrointestinal symptoms, or trauma. Results of this study may provide useful information for training medical outreach staff and preparing medical supplies to meet the clinical demand for airport medical outreach services.
... Ein AED und ein Erste-Hilfe-Kasten sollen sofort vom Kabinenpersonal angefordert werden, da die Zeit bis zur ersten Defibrillation einer der wichtigsten Überlebensfaktoren bei einem Kreislaufstillstand ist [495]. Atemwegsmanagement Abhängig von den Platzverhältnissen im Flugzeug kann die Verwendung einer SGA für das Atemwegsmanagement bei Reanimationen während einer Flugreise anderen Maßnahmen überlegen sein [496]. Die Verwendung einer Kapnometrie kann bei einem Kreislaufstillstand während des Flugs hilfreich sein. ...
... Die Verwendung einer Kapnometrie kann bei einem Kreislaufstillstand während des Flugs hilfreich sein. Ein (einfaches) qualitatives Kapnometer soll verfügbar sein [496]. [496,498]. ...
... Ein (einfaches) qualitatives Kapnometer soll verfügbar sein [496]. [496,498]. Wenn telemedizinische Unterstützung verfügbar ist, soll diese genutzt werden, um Therapieempfehlungen zu erfragen und den weiteren Verlauf zu besprechen. ...
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
... Adapted to the aircraft environment, the use of SGA may be superior for airway management in inflight resuscitation. 493 The use of capnometry/capnography might be helpful during an inflight cardiac arrest. A (simple) qualitative capnometer should be available. ...
... A (simple) qualitative capnometer should be available. 493 Environment Emergency equipment location should be clearly signposted. Brief information how to act in case of cardiac arrest should be printed on the seat pocket safety instruction card. ...
... 494 Cabin crew must be trained in CPR and AED defibrillation and should be retrained every six months. 493 Diversion and post-resuscitation care A typical scenario to perform an emergency diversion before ROSC is when leaving land and expecting a flight over open-water during an ongoing CPR event. Furthermore, when near an airport, an early diversion might also be useful. ...
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
... 4,5 Similarly, CPR in confined spaces like aeroplanes or helicopters add complexities that demand adaptations to traditional CPR protocols. 6 Avalanche situations, marked by the burial of individuals under layers of snow, require considerations for both the challenging physical environment of high altitude, limited patient access and the potential trauma sustained during the event. 7 In aquatic settings, where drowning incidents are prevalent, the efficacy of chest compressions is influenced by the buoyancy of the body and the intricacies of performing CPR in water. ...
Background: Cardiopulmonary resuscitation (CPR) is essential for saving lives during cardiac arrest, but performing CPR in extreme environments poses unique challenges. In scenarios ranging from hypogravity or microgravity to confined spaces like aeroplanes and underwater scenarios, traditional CPR techniques may be inadequate. This scoping review aims to identify alternative chest compression techniques, synthesise current knowledge, and pinpoint research gaps in resuscitation for cardiac arrest in extreme conditions. Methods: PubMed and the Cochrane Register of Controlled Trials as well as the website of ResearchGate was searched to identify relevant literature. Studies were eligible for inclusion if they evaluated alternative chest compression techniques, including manual or mixed CPR approaches, whilst assessing feasibility and effectiveness based on compression depth, rate, and/or impact on rescuer effort. Results: The database search yielded 9499 references. After screening 26 studies covering 6 different extreme environments were included (hypogravity: 2; microgravity: 9, helicopter: 1, aeroplane: 1, confined space: 11; avalanche: 2). 13 alternative chest compression techniques were identified, all of which tested using manikins to simulate cardiac arrest scenarios. Conclusion: To address the unique challenges in extreme environments, novel CPR techniques are emerging. However, evidence supporting their effectiveness remains limited.
... Also, in the unlikely event of cardiac arrest in space, special circumstances presented by microgravity and spaceflight must be considered with relation to central points, such as the rescuer's position, the methods used for performing chest compressions, airway management, and defibrillation. Moreover, in this area, the literature lacks suggestions for tailored training [57,58]. ...
Background: Basic life support (BLS) is a life-saving link in the out-of-hospital cardiac arrest chain of survival. Most members of the public are capable of providing BLS but are more likely to do so confidently and effectively if they undertake BLS training. Lay members of the public comprise diverse and specific populations and may benefit from tailored BLS training. Data on this topic are scarce, and it is completely unknown if there are any benefits arising from tailored courses or for whom course adaptations should be developed. Methods: The primary objective of this scoping review was to identify and describe differences in patient, clinical, and educational outcomes when comparing tailored versus standard BLS courses for specific layperson populations. This review was undertaken as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation. Results: A primary search identified 1307 studies and after title, abstract, and full-text screening, we included eight publications reporting on tailored courses for specific populations. There were no studies reporting direct comparisons between tailored and standardized training. Seven (88%) studies investigated courses tailored for individuals with a disability, and only one study covered another specific population group (refugees). Overall, the quality of evidence was low as the studies did not compare tailored vs. non-tailored approaches or consisted of observational or pre–post-designed investigations. Conclusions: Tailored BLS education for specific populations is likely feasible and can include such groups into the pool of potential bystander resuscitation providers. Research into comparing tailored vs. standard courses, their cost-to-benefit ratio, how to best adapt courses, and how to involve members of the respective communities should be conducted. Additionally, tailored courses for first responders with and without a duty to respond could be explored.
... The Federal Aviation Administration (FAA) requires the presence of an automatic external defibrillator (AED) and an emergency medical kit in all American commercial airlines weighing 7500 pounds or more and serviced by at least one flight attendant [11]. The use of an AED during commercial flights has been validated as both safe and effective [12]. In addition, flight attendants must be trained to perform cardiopulmonary resuscitation (CPR); this training is usually valid for two years and must be renewed regularly [13]. ...
In-flight medical emergencies (IMEs) are common during commercial airline flights. These events occur once every 100 to 1000 flights with pressurization corresponding to an altitude of 5000 to 8000 feet during the flight, low oxygen partial pressures and low humidity. This study was designed to evaluate the knowledge, confidence and attitudes of medical students in Saudi Arabia with regards to managing in-flight medical emergencies. A cross-sectional study targeting all medical students in Saudi Arabia was conducted using an online questionnaire. In total, we analyzed 378 medical students and interns; only 18% possessed an adequate perception of knowledge relating to IMEs; 36.8% felt assured in their IME response, 36.5% believed they could provide competent care, and only 34.5% considered their medical education was adequate for the treatment of IMEs. Our analyses showed that medical students in Saudi Arabia have inadequate confidence and knowledge in managing IMEs. Consequently, there is a significant gap in current medical school curricula in the Kingdom of Saudi Arabia that could be filled by implementing focused training on the management of IMEs.
... Although commercial aircraft are safe and passenger flight is one of the most widely used means of transport, the millions of persons carried, the fact that some will have pre-existing medical conditions and the long distances often flown all increase the chances of an in-flight emergency happening [1]. It has been estimated that cardiorespiratory arrests (CRA) occur in-flight once in every 5-10 million flights [2][3][4]. ...
"Introduction: The incidence of cardiorespiratory arrest (CRA) in aircraft is estimated at one per 5-10 million flights. The early initiation of cardiopulmonary resuscitation (CPR) can double or quadruple survival rates after CRA, and is associated with a better prognosis in terms of decreased brain damage and better quality of life. The aim of the present study is to evaluate the effectiveness of basic CPR procedures carried out by the flight crew in a clinical simulation performed in a real environment, during the landing of a military training flight. Methodology: The clinical simulation was carried out with 20 members, grouped in ten pairs, of the Méndez Parada Military Parachuting School at the Alcantarilla Air Base (Murcia, Spain). At an altitude of approximately 1,100 feet, each pair simulated CPR on a Little Anne® manikin fitted with a SimPad® PLUS. The results obtained were recorded by SkillReporter ™. Results: The mean duration of the procedure was approximately five minutes. During the flights, the compression depth achieved with CPR was correct in only six of the ten cases. In only one case was the “patient” checked for consciousness and respiration. In 50% of the simulations, the forehead-chin manoeuvre was not performed (i.e., the airway was not opened). Conclusions: The lack of standard recommendations in current guidelines on CPR during aircraft landing may provoke discrepancies in the management of this critical situation and reduce the quality of the treatment provided. "
... It is best to build excellent social bonds in the family or at work. One study found that people now feel twice as lonely as they did in the 1970s [476][477][478][479][480]. In other words, in 1980 this rate was 20 percent, now it is 40 percent [481][482][483][484][485]. Loneliness not only causes mental harm, but also physical harm [486][487][488][489][490]. Medical science says that when someone talks to someone, the brain communicates with the heart through the release of hormones [491][492][493][494][495]. The activity of the heart became very active [496][497][498][499]. ...
Cardiac Arrest is a non-communicable disease related with unusually high levels of blood pressure. Yet Medical specialists are facing the intolerable augmenting causes of cardiac arrest towards human body as a very key global issue for a number of years. The study aims to assess the applications of the radio frequency that affects on individual's heart within body boundary. Key health information tools poised from experimental specimens on cats and dogs and their living status challenges in risks with fundamental principles are highlighted. The study shows that the prevalence of cardiac arrest was in peak in the world gradually within the period of 2010 to 2020. The study represents the blood circulation speed fluctuates with infection due to misuse of prevaricated radio frequency within GPS locations due to active open-eyes, self-voice, over excess weight and nearby cellular phone. The findings reflect the significance in cardiac arrest through effective prevention and medication that the physicians provide. The study also found the municipal hospitals are in risks due to expansion of insecure innovative technology. Scientific healthcare knowledge is indispensable for recovery from sensor effect on sudden cardiac arrest but such knowledge is poorly identified. Health providers and patients extremely use wireless sensor networks, but clinical supports are still below par. Overall, the study contributes to the heart foundation society through development of dynamic healthcare innovative technological framework indicating effective solutions on cardiac arrest. The study suggests future research trajectories of a new sophisticated alternative treatment approach to promote mental health and well-being linking with Sustainable Development Goals 2030.
... ¶ ¶ Heterogeneidad entre los estudios. IC 95%: intervalo de confianza del 95%; RR: razón de riesgo; ECA: ensayo clínico aleatorizado; RCE: retorno de la circulación espontánea Tabla I. 10. Pregunta PICO. ...
... ¶ ¶ Heterogeneidad entre los estudios. IC 95%: intervalo de confianza del 95%; RR: razón de riesgo; ECA: ensayo clínico aleatorizado; RCE: retorno de la circulación espontánea Tabla I. 10. Pregunta PICO. ...
El objetivo de este consenso es estandarizar la identificación y el tratamiento de pacientes adultos en paro cardiaco, mejorando la eficacia, seguridad y calidad de la reanimación cardiopulmonar. El consenso está dirigido a profesionales de la salud médicos, enfermeros, técnicos y paramédicos, de ámbitos prehospitalario y hospitalario.
... (3) The German Society of Aerospace Medicine recently published recommendations for commercial flights, including management of IFCA, with basic life support and use of an AED. (4) Cardiac arrest (CA) is the cessation of cardiac activity, frequently due to sustained abnormal heart arrhythmias ventricular tachycardia (VT) or ventricular fibrillation (VF). (5) By its nature, cardiac arrest can occur suddenly and unpredictably in any environment. ...
p> ABSTRACT
Introduction
Automated external defibrillators (AEDs) are increasingly available in public places for the treatment of cardiac arrest. Some commercial aircraft carry an AED, but little is known about international policies and requirements. The aim is to review policy regarding AED placement on commercial aircraft, summarising reported incidence and outcomes of AED utilisation for individuals experiencing an in-flight cardiac arrest (IFCA).
Methods
A scoping review was undertaken. Online databases (Medline and CINAHL) were searched using prespecified terms to identify reports evidencing use, outcome and policy of AEDS for IFCA on commercial aircraft. Reports were screened and data extracted following scoping review extraction methods. Data were analysed to describe incidence of AED use and outcomes following IFCA, and policies regarding AED placement on commercial aircraft.
Results
9 observational studies were identified. 8 reported instances of successful shock delivery using AED. No published reports of safety incidents involving in-flight AED use were found. 7 studies reported survival following AED use: of these, 6 reported administration of a shock for IFCA survivors, whilst 1 study reported deployment of an AED without shock delivery. Overall, survival following in-flight AED use was 9%, with 37% survival reported where patients presented with shockable rhythm. Only one policy mandating AED placement on commercial aircraft was identified.
Conclusion
Despite the small, retrospective and observational nature of the reports identified, findings suggest in-flight AED use is feasible and associated with improved outcomes from IFCA.
Keywords: cardiac arrest; defibrillators; AED; aircraft; flight </p
... With more easy access to commercial air travel, the likelihood of an in-flight CA and performing in-flight CPR is increasing. Hinkelbein et al. 77 provide guidance on how to effectively attempt resuscitation of a CA patient while in-flight. ...
Objectives:
The Interdisciplinary Cardiac Arrest Research Review (ICARE) group was formed in 2018 to conduct a systematic annual search of peer-reviewed literature relevant to cardiac arrest (CA). The goals of the review are to illustrate best practices and help reduce knowledge silos by disseminating clinically relevant advances in the field of CA across disciplines.
Methods:
An electronic search of PubMed using keywords related to CA was conducted. Title and abstracts retrieved by these searches were screened for relevancy, separated by article type (original research or review), and sorted into 7 categories. Screened manuscripts underwent standardized scoring of overall methodological quality and importance. Articles scoring higher than 99 percentiles by category-type were selected for full critique. Systematic differences between editors and reviewer scores were assessed using Wilcoxon signed-rank test.
Results:
A total of 9119 articles were identified on initial search; of these, 1214 were scored after screening for relevance and deduplication, and 80 underwent full critique. Prognostication & Outcomes category comprised 25% and Epidemiology & Public Health 17.5% of fully reviewed articles. There were no differences between editor and reviewer scoring.
Conclusions:
The total number of articles demonstrates the need for an accessible source summarizing high-quality research findings to serve as a high-yield reference for clinicians and scientists seeking to absorb the ever-growing body of CA-related literature. This may promote further development of the unique and interdisciplinary field of CA medicine.
... Während im Krankenhaus häufig mehrere ärztliche Kollegen verschiedener Disziplinen verfügbar sind und kurzfristig konsultiert werden können, fehlt einem Notarzt diese Möglichkeit außerhalb einer Klinik meist völlig. Gerade Reanimationen in entfernten Bereichen stellen den Helfer vor besondere Herausforderungen (5,6,7). ...
... 23 The FAA requires automated external defibrillators on all airplanes with "a maximum payload capacity of more than 7,500 pounds and with at least one flight attendant," 46 but automated external defibrillators are not currently mandated for European airlines. 48,49 The FAAmandated medical kit contains protective gloves and equipment for a basic medical assessment, hemorrhage control, and initiation of an intravenous line ( Table 3). The FAA-mandated medical kit contents also include medications to treat mild pain, allergic reactions, bronchoconstriction, hypoglycemia, dehydration, and some cardiac conditions. ...
Importance
In-flight medical emergencies (IMEs) are common and occur in a complex environment with limited medical resources. Health care personnel are often asked to assist affected passengers and the flight team, and many have limited experience in this environment.
Observations
In-flight medical emergencies are estimated to occur in approximately 1 per 604 flights, or 24 to 130 IMEs per 1 million passengers. These events happen in a unique environment, with airplane cabin pressurization equivalent to an altitude of 5000 to 8000 ft during flight, exposing patients to a low partial pressure of oxygen and low humidity. Minimum requirements for emergency medical kit equipment in the United States include an automated external defibrillator; equipment to obtain a basic assessment, hemorrhage control, and initiation of an intravenous line; and medications to treat basic conditions. Other countries have different minimum medical kit standards, and individual airlines have expanded the contents of their medical kit. The most common IMEs involve syncope or near-syncope (32.7%) and gastrointestinal (14.8%), respiratory (10.1%), and cardiovascular (7.0%) symptoms. Diversion of the aircraft from landing at the scheduled destination to a different airport because of a medical emergency occurs in an estimated 4.4% (95% CI, 4.3%-4.6%) of IMEs. Protections for medical volunteers who respond to IMEs in the United States include a Good Samaritan provision of the Aviation Medical Assistance Act and components of the Montreal Convention, although the duty to respond and legal protections vary across countries. Medical volunteers should identify their background and skills, perform an assessment, and report findings to ground-based medical support personnel through the flight crew. Ground-based recommendations ultimately guide interventions on board.
Conclusions and Relevance
In-flight medical emergencies most commonly involve near-syncope and gastrointestinal, respiratory, and cardiovascular symptoms. Health care professionals can assist during these emergencies as part of a collaborative team involving the flight crew and ground-based physicians.
... We have read with interest the paper of Hinkelbein et al. [1] published recently in Internal and Emergency Medicine. We are gratified to see the level of interest taken in the subject of in-flight cardiac arrest by the authors of this paper, and appreciate their efforts in carrying out the study. ...
... Empfehlungen für die Behandlung eines Herz-Kreislauf-Stillstands während eines Flugs a. (Nach Hinkelbein et al. [32]) lungen finden Sie auf der Homepage der AWMF unter http://www.awmf.org. ...
Background: In 2017, more than 3 billion people worldwide will travel by aircraft and commercial air transport. Although air travel is safe, between 1 out of 14,000 to 1 out of 50,000 passengers will experience acute medical problems (in-flight medical emergencies, IFME) during their flight. Cardiac arrest during air travel accounts for 0.3% of all IFME, but it is the cause of 86% in-flight deaths. Methods and results: By using a systematic literature search including the GRADE, RAND, and DELPHI methods, 28 specific recommendations on this topic have been created. Where evidence was lacking, an expert consensus was built. The main recommendations in the guideline are: emergency equipment location as well as content should be mentioned in the preflight safety announcement; it is very important to request help by an on-board announcement after identification of a patient with cardiac arrest; two-person CPR is considered optimum and should be performed if possible; the crew should be trained regularly in basic life support—ideally with a focus on CPR in aircraft; a diversion should immediately be performed if the patient has a return of spontaneous circulation. © 2017 Springer Medizin Verlag GmbH, ein Teil von Springer Nature
Air traveler numbers are predicted to reach 4.0 billion in 2024. Between 1/15,000–50,000 passengers will experience acute medical problems inflight with cardiac arrests requiring cardiopulmonary resuscitation (CPR) accounting for 0.3% of medical emergencies. Hypoxia in airplane cabins could impair oxygenation and physical performance of caregivers. We conducted a randomized controlled, double-blind study to test the hypothesis that hypoxia decreases the effectiveness in performing CPR. We randomized 24 healthcare professionals to two different study arms, each consisting of two conditions: arm (1) ‘hypoxia (FiO2 15%, equivalent to 2400 m altitude)’ versus ‘normoxia’; arm (2) ‘hypoxia + supplemental oxygen’ versus ‘normoxia + supplemental oxygen’. The order of conditions was counterbalanced and a minimum wash-out period of 24 h was granted between conditions. In each condition participants performed a 5-min cardiac compression only CPR (CCO-CPR) using a full-body manikin after one, three and six hours in an altitude chamber. Mixed ANOVAs with post-hoc false-discovery-rate adjusted pairwise comparisons indicated that although compression frequency was maintained, the number of compressions with correct depth was decreased at all times during hypoxia compared to normoxia (all p < 0.002). After 6 h hypoxia exposure, mean compression depth was below the recommended compression depth defined by ERC/AHA guidelines and reduced compared to normoxia (42.4 ± 12.6 mm vs. 54.6 ± 4.3 mm, p < 0.0001). Supplemental oxygen during CCO-CPR in hypoxia prevented the decrease of compression-depth (55.3 ± 3 mm). Extended hypoxia exposure akin to conditions in airplane cabins can reduce quality of chest compressions during CPR. Supplemental oxygen for healthcare providers is an effective countermeasure.
ZUSAMMENFASSUNG
Zwischen 1/15 000 und 1/50 000 Passagiere haben während eines Fluges akute medizinische Probleme, wobei Herzstillstände, die eine kardiopulmonale Wiederbelebung (CPR) erfordern, 0,3 % der medizinischen Notfälle ausmachen. Hypoxie in der Flugzeugkabine könnte die Sauerstoffversorgung und die körperliche Leistungsfähigkeit des Helfenden beeinträchtigen, deshalb wurde eine randomisierte, kontrollierte Doppelblindstudie durchgeführt, um die Hypothese zu testen, dass Hypoxie die Effektivität der CPR verringert. 24 medizinische Fachkräfte wurden in 2 verschiedene Studienarme randomisiert, die jeweils 2 Bedingungen testeten. Mixed ANOVAs mit Post-hoc-False-Discovery-Rate mit paarweisen Vergleichen zeigten, dass eine längere Hypoxieexposition, die den Bedingungen eines Langzeitflugs entspricht, die Qualität der Thoraxkompressionen beeinträchtigen kann. Zusätzlicher Sauerstoff für das medizinische Personal ist eine wirksame Gegenmaßnahme.
Medical emergencies occur always and everywhere. The care of patients on board means of transport is not possible with the quality and routine that takes place in ground- or air-based emergency services. Nevertheless, there are some concepts for patient care. The article describes typical emergency medical problems for the scenarios of train, ship and air travel and presents the existing possibilities for practical emergency medical assistance.
Medical emergencies on board of airliners are frequent and take place in a complexenvironment with limited access to medical resources. As any doctor may be required to becalled upon for assistance by the on-board staff, it is important to know the epidemiology ofthe pathologies encountered, the diagnosis’ constraints and the therapeutic management. Wewill also discuss the physiological consequences of hypobaria
Australasian Anaesthesia (the Blue Book) is produced every two years, and contains a diverse range of topics of interest to anaesthetists, intensive care physicians and pain medicine specialists.
Cardiac diseases represent the most frequent in-flight emergencies and the overwhelming majority of diversions. In addition to their frequency, the acute presentation of cardiac diseases may result in a poor outcome, with some situations requiring immediate emergency treatment. This chapter provides epidemiological information, an approach to risk stratification of patients when considering the need to divert the aircraft, and a suggested guide on how to handle in-flight cardiac emergencies including cardiac arrest, acute myocardial infarction, and decompensated congestive heart failure.KeywordsFlightCardiacCardiovascular
BACKGROUND: In-flight medical emergencies (IME) are challenging situations: aircraft cabins are noisy and narrow, medical supplies are scarce, and high-altitude related physiological changes may worsen chronic respiratory or cardiac conditions. The aim of this study was to assess the extent to which anesthetist-intensivists and emergency physicians are aware of IME specificities. METHODS: A questionnaire containing 21 items was distributed to French anesthetist-intensivists and emergency physicians between January and May 2020 using the mailing list of the French Society of Anesthesia and Intensive Care Medicine and the French Society of Emergency Medicine. The following topics were evaluated: high-altitude related physiological changes, medical and human resources available inside commercial aircraft, common medical incidents likely to happen on board, and previous personal experiences. RESULTS: The questionnaire was completed by 1064 physicians. The items corresponding to alterations in the arterial oxygen saturation, respiratory rate, and heart rate at cruising altitude were answered correctly by less than half of the participants (respectively, 3%, 42%, and 44% of the participants). Most responders (83%) were interested in a complementary training on IME management. DISCUSSION: The present study illustrates the poor knowledge in the medical community of the physiological changes induced by altitude and their consequences. In addition to offering specific theoretical courses to the medical community, placing sheets in commercial aircraft summarizing the optimal management of the main emergencies likely to happen on board might be an interesting tool. Diop S, Birnbaum R, Cook F, Mounier R. In-flight medical emergencies management by anesthetist-intensivists and emergency physicians . Aerosp Med Hum Perform. 2022; 93(8):633–636.
Infections of the skin and soft tissue are among the most common infections. They are diverse in terms of the extent of the changes, the severity of development and disease group etiological factors. There are a broad range of such infections, from superficial skin infections to deep necrotizing soft tissue infections which are so serious that they can lead to permanent disability or even death. Paramedics are often the first link in the chain of medical treatment for a patient with necrotizing soft tissue infection, which is why it is vital for them to be familiar with the alarm symptoms which indicate that urgent hospitalization is necessary. A key issue for Medical Response Teams when treating patients with skin and soft tissue infections is distinguishing infections that require surgical intervention – a priority for paramedics, from those that require only preventative treatment. It must be remembered that failure to take the correct decisions regarding treatment and logistics can significantly reduce a patient’s chances of survival.
Aim: Stigmatization is about making a division – people are grouped into better and worse, people with mental disorders are very often perceived as different, which is why they are largely stigmatized. Mental illnesses are a growing problem among the society of developed countries, therefore, the problem of stigmatization of these people has also become noticeable, which may adversely affect their mental condition and the convalescence process. The aim of the study is to assess the degree of stigmatization of mentally ill people by paramedics. Material and methods: An original questionnaire was used to collect the data, distributed from February 15, 2020 to April 7, 2020. among paramedics working in various medical rescue units and in units cooperating with the National Medical Rescue system. We collected 91 respondents replied. The research was a pilot study. Results: Paramedics are a professional group that does not show any particular signs of stigmatization in relation to the mentally ill, but single responses were obtained, which may indicate a given respondent’s lack of understanding for the mentally ill. Conclusions: In order to prevent stigmatization of the mentally ill, it is very important to educate not only paramedics, but also representatives of other medical professions who have contact with people suffering from mental disorders.
Aim: To determine the importance of electrocardiogram (ECG) teletransmission on the time required for decisions on diagnosis and treatment and the transport of patients with myocardial infarction. Material and methods: This study is retrospective in character and concerns the regional activities of the Bielsko Emergency Medical Services and the possibility of sending medical data electronically from a patient’s location to the clinic of interventional cardiology (CIC). Group A (n=237) included patients in whom the Medical Response Team (MRT) confirmed ST-Elevation Myocardial Infarction (STEMI) and carried out an ECG with data teletransmission to the CIC. Group B (n=101) included patients in whom the MRT confirmed STEMI and carried out an ECG without teletransmission. For both groups, the MRT recorded the time of arrival at the patient’s location and the time when the patient was handed over to the CIC. Results: A group of 638 patients were identified in whom the chest pain was of cardiac origin. Of these patients, 338 were identified as patients with diagnosed STEMI. A significant dependence was demonstrated of the time t [mins] of teletransmission (p=0.00308). A significant dependence was demonstrated of the effect of distance s [kms] (p=0.00000). A significant dependence was demonstrated of the time t from the place of residence, taking into account the distance s (p=0.00929). Conclusions: Using ECG teletransmission in pre-hospital procedures shortens the time for diagnosis and transport of patients with STEMI, and thus improves the results of treatment.
Aim: The study aims to compare Polish methods of health promotion and prevention (prophylaxis) of mental disorders among children and adolescents with solutions have their effect in other countries when assessing the effectiveness (in both groups). Material and methods: Based on legal acts concerning mental health protection and data on preventive programs conducted both in Poland and in other countries, not only the methods of operation and the differences between them were compared but also recommendations were made regarding making possible changes to the current activities in Poland. Results: In territorial self-government units, where help is offered mainly to teenagers, introducing the intervention may be too late. Besides, due to the limited number of places offering such aid, incl. municipal programs, the issue emerges – concerning the ensuring of appropriate preventive measures – which results in the deterioration of the situation in this age group category and eventuate in the escalation of the current situation. Conclusions: To prevent the widespreadness of the disorders mentioned above, it is necessary to modify and extend the scope of preventive measures and activities regarding mental health promotion in Poland.
Aim: To compare the effectiveness of ventilation of each of three methods: mouth-to-mouth ventilation using a foil face mask with a filter pad, mouth-to-mask technique with a pocket face mask and bag valve mask ventilation using a self-inflating bag and a face mask, performed during CPR by qualified non-medical rescuers. Material and methods: Ventilation effectiveness was assessed on manikin and compared for mouth-to-mouth, mouth-to-mask and bag valve mask ventilation method. 46 qualified non-medical rescuers-lifeguards participated in the study. Tidal Volume of 0,4-0,7L was considered as effective. The length of chest compressions pauses was recorded. The ventilation methods were also evaluated subjectively by participants in the questionnaire. Results: Effectiveness 90,75% vs. 92,38% vs. 69,5%; average number of effective rescue breaths: 7,26 vs. 7,39 vs. 5,65; average length of chest compressions pause: 7,7s vs. 8,1s vs. 9,9s for MTM, MPFM and BMV respectively. MPFM method was considered as the easiest, the second in terms of the difficulty in use was MTM, and BMV was described as the most difficult to use. Conclusions: Artificial ventilation using the pocket mask, in the course of resuscitation performed by one qualified non-medical rescuer, e.g. the water lifeguard, is an effective method ensuring adequate tidal volume and is more effective than mouth-to-mouth method and bag valve mask ventilation.
Lower respiratory tract infections are one of the most common causes of death. From many years Poland was ranked fourth among the EU countries with the highest number of deaths from pneumonia. No observational studies among Polish patients with pneumonia have been conducted so far that would enable to determine the true scale of the problem, and no risk and etiological factors that are specific to the population of the country have been defined. Despite continuous advances in medicine, managing pneumonia remains a challenge for the clinician, especially in the Emergency Department. The greatest challenge is the correct diagnosis of pneumonia, qualification for admission to the hospital ward, as well as outpatient treatment and immediate treatment. Problems in patient care may include: non-specific symptoms, especially in elderly patients who are the most common ED patients, a limited number of tests that can be performed on ED in a short period of time, no clear recommendations regarding the management of the patient, a wide spectrum of pathogens involved in the pathogenesis of pneumonia (and new pathogens, e.g. SARSCoV- 2), bacterial resistance to antibiotics and finally emphasis on profitability of therapy. The paper describes the epidemiological data and possible etiological factors of community acquired pneumonia. In second part, we will focus on the diagnostic possibilities (including SARS-CoV-2 infections) and the issues related to the treatment.
In recent times, air transport has become more common, and so the number of passengers using it has increased. As travellers increased, so did the risk of any adverse event related to the health or life of those on board. The staff of the aircraft should be properly trained to be able to help the victim and at the same time be able to stay calm on board the plane. It is also not uncommon for a person with medical education to be present on board the plane – it is importantthat healthcare professionals know their rights and obligations arising from the situation. The paper presents the procedures applicable to the cabin crew, health care workers present on board and passengers who are at increasedrisk of a life-threatening episode during the flight.
INTRODUCTION: A topic in aviation medicine that attracts much attention from the scientific community as well as from the media concerns medical incidents on board commercial airline flights. It was noticed that many papers on the subject were written by authors whose specialization was outside that of aviation medicine and that they sometimes made basic errors concerning the application of scientific principles of the subject. A review was undertaken to determine if there were any patterns to the observed errors and, if so, to consider whether recommendations might be provided that could reduce their frequency.METHOD: A literature search was undertaken of MEDLINE using PubMed for English-only articles published between January 1, 1974, and February 1, 2019, employing the following search terms: air emergency, air emergencies, air passenger, air travel, aircraft, airline, aviation, commercial air, flight, and fitness to fly. In addition, other relevant papers held in the personal collection of the authors were reviewed.RESULTS: Many cases of misinterpretation or misunderstanding of aviation medicine were found, which could be classified into eight main categories: references; cabin altitude; pressure/volume relationship; other technical aspects of aircraft operations; regulations; medical events; in-flight deaths; and automated external defibrillator.CONCLUSION: Papers were identified as having questionable statements of fact or of emphasis. Such instances often appeared to result from authors being unfamiliar with the subject of aviation medicine and/or the commercial aviation environment. Simple steps could be taken by authors to reduce the future rate of such instances and recommendations are provided.Thibeault C, Evans AD. Medical events on board aircraft: reducing confusion and misinterpretation in the scientific literature. Aerosp Med Hum Perform. 2021; 92(4):265273.
Background
Medical emergencies frequently occur in commercial airline flights, but valid data on causes and consequences are rare. Therefore, optimal extent of onboard emergency medical equipment remains largely unknown. Whereas a minimum standard is defined in regulations, additional material is not standardized and may vary significantly between airlines.
Methods
European airlines operating aircrafts with at least 30 seats were selected and interviewed with a 5-page written questionnaire including 81 items. Besides pre-packed and required emergency medical material, drugs, medical devices, and equipment lists were queried. If no reply was received, airlines were contacted up to three times by email and/or phone. Descriptive analysis was used for data interpretation.
Results
From a total of 305 European airlines, 253 were excluded from analysis (e.g., no passenger transport). 52 airlines were contacted and data of 22 airlines were available for analysis (one airline was excluded due to insufficient data). A first aid kit is available on all airlines. 82% of airlines (18/22) reported to have a “doctor’s kit” (DK) or an “Emergency Medical Kit” (EMK) onboard. 86% of airlines (19/22) provide identical equipment in all aircraft of the fleet, and 65% (14/22) airlines provide an automated external defibrillator.
Conclusions
Whereas minimal required material according to European aviation regulations is provided by all airlines for medical emergencies, there are significant differences in availability of the additional material. The equipment of most airlines is not sufficient for treatment of specific emergencies according to published in-flight medical guidelines (e.g., for CPR or acute myocardial infarction).
En este último período, ha aumentado el número de personas que deben ser asistidas en las raves y en los servicios de urgencias por intoxicación con drogas de diseño. Los casos mortales tienen gran impacto en los medios de comunicación y redes sociales, por un lado, y en la sociedad, por otro, dado que suele ser una persona joven la que fallece o queda discapacitada. Además de las campañas educativas y preventivas que deben realizar las instituciones gubernamentales, en esta publicación, se emiten recomendaciones elaboradas por profesionales de las sociedades científicas que se vinculan a la atención de estos pacientes (urgencia prehospitalaria, recepción en departamentos de
emergencias, clínica médica, toxicología y terapia intensiva) y se describen aspectos toxicológicos de las drogas. Se debe hacer hincapié en la presentación aguda de estas intoxicaciones como tres probables síndromes: síndrome serotoninérgico (con hipertermia), hiponatremia y delirio con agitación. Se remarca la posibilidad de inicio temprano del tratamiento. Se enumeran formas graves de presentación en intoxicaciones agudas y diagnósticos diferenciales. Se relata una experiencia de atención en nuestro medio en un hospital de campaña.
El Grupo de Trabajo Latinoamericano para la mejora de la atención del paciente con infección en Urgencias (GT-LATINFURG), consciente de la gravedad e importancia para todo el mundo de la Pandemia originada por el nuevo Coronavirus SARS-CoV-2 (COVID-19) ha elaborado un documento informativo y técnico destinado a los profesionales de los sistemas de Urgencias y Emergencias de nuestros países. Con la información científica e institucional más actualizada (que cambia día a día y debe ser revisada constantemente), el objetivo de este documento, pretende constituir una ayuda para la toma de decisiones durante la asistencia de pacientes adultos portadores de COVID-19. Si bien está basada en la más reciente evidencia publicada disponible sobre el tema, no es de obligado cumplimiento ni sustituye el juicio clínico del personal de salud en cada caso particular.
IntroductionIn order to deliver the highest standards of evidence-based care, physicians develop clinical questions that are informed by the literature including recommendations developed by organizations that have the necessary expertise and authority in their respective fields. Guidelines, defined by the IOM as “statements that include recommendations intended to optimize patient care” [1], are a valuable resource increasingly available to clinicians allowing them to make decisions consistent with the best evidence available, while considering the overall balance of benefits and harms as well as resource implications [2]. This paper will explore some of the challenges that have prevented guidelines from being readily interpreted, and hence not being used to their full potential. We will also explain how the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology addresses some of the existing challenges, and where it fits in the overall guideline develop ...
Introduction:
Supraglottic devices have mostly eliminated the need of hemodynamically stressful routine endotracheal intubation for ambulatory surgeries. We aimed to compare hemodynamics- like blood pressure (BP) and heart rate (HR) alterations caused by stress response due to i-gel™ and LMA-ProSeal™ usage in Day care surgeries. Secondary outcomes included ease of insertion, time and number of attempts for the placement of devices.
Materials and methods:
From April 2008 to July 2009, Sixty adult ASA I-II patients of either sex, aged 20-30, were randomly allocated into two groups (Group i-gel (n=30) receiving i-gel and Group PLMA (n=30) receiving LMA-ProSeal for airway maintenance) undergoing day care surgical procedures under general anaesthesia (GA).The ease of insertion and time taken for placement of device, postoperative complications were assessed. Haemodynamic parameters (HR, BP) were noted. It was a prospective, double blinded, and randomized controlled study. Parametric data were analyzed with the unpaired t-test and non-parametric data were analyzed with the Chi-square test. Unless otherwise stated, data are presented as mean (+ SD). p <0.05 was considered statistically significant.
Results:
Demographically both the groups were similar. i-gel was more easily inserted than LMA-ProSeal (90% vs. 83.33% respectively). i-gel insertion time was shorter than PLMA (14.9 vs. 20.0 sec respectively) and was statistically significant. Hemodynamics (HR, BP) were less altered in i-gel than PLMA and the results were statistically significant (p <0.05).
Conclusion:
i-Gel; a relatively newer and cheap supraglottic device; insertion is easier and quicker as well as hemodynamically less stressful when compared with LMA-ProSeal in a day care setting.
We consider the Lagrangian of a vector field with derivative
self-interactions with a priori arbitrary coefficients. Starting with a flat
space-time we show that for a special choice of the coefficients of the
self-interactions the ghost-like pathologies disappear. This constitutes the
Galileon-type generalization of the Proca action with only three propagating
physical degrees of freedom. The longitudinal mode of the vector field is
associated to the usual Galileon interactions. In difference to a scalar
Galileon theory, the generalized Proca field has more free parameters. We then
extend this analysis to a curved background. The resulting theory is the
Horndeski Proca action with second order equations of motion on curved
space-times.
Research and data regarding in-flight medical emergencies during commercial air travel are lacking. Although volunteer medical professionals are often called upon to assist, there are no guidelines or best practices to guide their actions. This paper reviews the literature quantifying and categorizing in-flight medical incidents, discusses the unique challenges posed by the in-flight environment, evaluates the legal aspects of volunteering to provide care, and suggests an approach to managing specific conditions at 30,000 feet.
We conducted a MEDLINE search using search terms relevant to aviation medical emergencies and flight physiology. The reference lists of selected articles were reviewed to identify additional studies.
While incidence studies were limited by data availability, syncope, gastrointestinal upset, and respiratory complaints were among the most common medical events reported. Chest pain and cardiovascular events were commonly associated with flight diversion.
When in-flight medical emergencies occur, volunteer physicians should have knowledge about the most common in-flight medical incidents, know what is available in on-board emergency medical kits, coordinate their therapy with the flight crew and remote resources, and provide care within their scope of practice.
Background:
Worldwide, 2.75 billion passengers fly on commercial airlines annually. When in-flight medical emergencies occur, access to care is limited. We describe in-flight medical emergencies and the outcomes of these events.
Methods:
We reviewed records of in-flight medical emergency calls from five domestic and international airlines to a physician-directed medical communications center from January 1, 2008, through October 31, 2010. We characterized the most common medical problems and the type of on-board assistance rendered. We determined the incidence of and factors associated with unscheduled aircraft diversion, transport to a hospital, and hospital admission, and we determined the incidence of death.
Results:
There were 11,920 in-flight medical emergencies resulting in calls to the center (1 medical emergency per 604 flights). The most common problems were syncope or presyncope (37.4% of cases), respiratory symptoms (12.1%), and nausea or vomiting (9.5%). Physician passengers provided medical assistance in 48.1% of in-flight medical emergencies, and aircraft diversion occurred in 7.3%. Of 10,914 patients for whom postflight follow-up data were available, 25.8% were transported to a hospital by emergency-medical-service personnel, 8.6% were admitted, and 0.3% died. The most common triggers for admission were possible stroke (odds ratio, 3.36; 95% confidence interval [CI], 1.88 to 6.03), respiratory symptoms (odds ratio, 2.13; 95% CI, 1.48 to 3.06), and cardiac symptoms (odds ratio, 1.95; 95% CI, 1.37 to 2.77).
Conclusions:
Most in-flight medical emergencies were related to syncope, respiratory symptoms, or gastrointestinal symptoms, and a physician was frequently the responding medical volunteer. Few in-flight medical emergencies resulted in diversion of aircraft or death; one fourth of passengers who had an in-flight medical emergency underwent additional evaluation in a hospital. (Funded by the National Institutes of Health.).
In the GRADE approach, the strength of a recommendation reflects the extent to which we can be confident that the composite desirable effects of a management strategy outweigh the composite undesirable effects. This article addresses GRADE's approach to determining the direction and strength of a recommendation. The GRADE describes the balance of desirable and undesirable outcomes of interest among alternative management strategies depending on four domains, namely estimates of effect for desirable and undesirable outcomes of interest, confidence in the estimates of effect, estimates of values and preferences, and resource use. Ultimately, guideline panels must use judgment in integrating these factors to make a strong or weak recommendation for or against an intervention.
Since improvements were made in the technique of pulse oximetry by Takuo Aoyagi, it has become a standard monitoring technique during perioperative anaesthesia, intensive care therapy and emergency medical treatment of severely ill or injured patients. Pulse oximetry can enhance patient safety due to its ability to detect perioperative hypoxia earlier than other methods.
Many mobile phones allow two-way video communication, which permits callers to hear and see each other. If used during medical emergencies, bystanders can receive supervision and guidance from medical staff based on visual information. We investigated whether video calls from mobile phones could improve the confidence of lay rescuers. High school students (n = 180) were randomly assigned in groups of three to communicate via video calls or via ordinary mobile phone calls. They received realtime guidance from experienced nurse dispatchers at an emergency medical dispatch centre during 10-min scenarios of simulated cardiac arrest. Each student answered a questionnaire to assess understanding, confidence and usefulness of the technology. The mean age was 17.3 years in the video group and 17.9 years in the audio group. There were 27% male participants in the video group and 34% male participants in the audio group. Seventy-three percent of the students in the video group and 71% in the audio group reported previous cardiopulmonary resuscitation training. Rescuers who had not used video phones had a greater tendency to comment on immature video call technology, while some who had used video phones complained about poor sound quality during video calls. The majority of rescuers in both groups believed that video calls were superior to audio calls during medical emergencies, and this proportion was significantly higher in the video group (P = 0.0002). We found that visual contact and supervision through video calls improved rescuers' confidence in stressful emergencies.
Laboratory investigations suggest that exposure to hyperoxia after resuscitation from cardiac arrest may worsen anoxic brain injury; however, clinical data are lacking.
To test the hypothesis that postresuscitation hyperoxia is associated with increased mortality.
Multicenter cohort study using the Project IMPACT critical care database of intensive care units (ICUs) at 120 US hospitals between 2001 and 2005. Patient inclusion criteria were age older than 17 years, nontraumatic cardiac arrest, cardiopulmonary resuscitation within 24 hours prior to ICU arrival, and arterial blood gas analysis performed within 24 hours following ICU arrival. Patients were divided into 3 groups defined a priori based on PaO(2) on the first arterial blood gas values obtained in the ICU. Hyperoxia was defined as PaO(2) of 300 mm Hg or greater; hypoxia, PaO(2) of less than 60 mm Hg (or ratio of PaO(2) to fraction of inspired oxygen <300); and normoxia, not classified as hyperoxia or hypoxia.
In-hospital mortality.
Of 6326 patients, 1156 had hyperoxia (18%), 3999 had hypoxia (63%), and 1171 had normoxia (19%). The hyperoxia group had significantly higher in-hospital mortality (732/1156 [63%; 95% confidence interval {CI}, 60%-66%]) compared with the normoxia group (532/1171 [45%; 95% CI, 43%-48%]; proportion difference, 18% [95% CI, 14%-22%]) and the hypoxia group (2297/3999 [57%; 95% CI, 56%-59%]; proportion difference, 6% [95% CI, 3%-9%]). In a model controlling for potential confounders (eg, age, preadmission functional status, comorbid conditions, vital signs, and other physiological indices), hyperoxia exposure had an odds ratio for death of 1.8 (95% CI, 1.5-2.2).
Among patients admitted to the ICU following resuscitation from cardiac arrest, arterial hyperoxia was independently associated with increased in-hospital mortality compared with either hypoxia or normoxia.
Limited information exists about the in-flight use and outcomes associated with automated external defibrillators (AEDs) on commercial airlines.
To describe the characteristics and outcomes of AED use during in-flight emergencies including in-flight cardiac arrest and the associated ground medical consultation patterns.
We collected cases of AED use that were self-reported to an airline consultation service from three U.S. airlines between May 2004 and March 2009. We reviewed all available data files, related consultation forms, and recordings. For each case, demographics, initial rhythm, shock delivery/success, survival to admission, and ground medical consultation use were obtained. Success was defined as the return of a perfusing rhythm. Initial rhythms were classified as sinus, heart block, supraventricular tachycardia (SVT), atrial fibrillation/flutter, asystole, pulseless electrical activity (PEA), and ventricular fibrillation (VF)/ventricular tachycardia (VT).
There were a total of 169 AED applications with 40 cardiac arrests. The mean patient ages were 58 years (standard deviation [SD] 15) and 63 years (SD 12), respectively; both populations were 64% male. AEDs were applied for monitoring in 129 (76%) cases with the following initial rhythms: sinus, 114 (88%); atrial fibrillation/flutter, seven (5%); complete heart block, four (3%); and SVT, four (3%). Presenting rhythms among the cardiac arrest population were as follows: asystole, 16 (40%); VF/VT, 10 (25%); and PEA, 14 (35%). Fourteen patients were defibrillated, including nine of the 10 patients with initial VF/VT and five for the presence of VF/VT after resuscitation for initial PEA/asystole. Defibrillation was advised but not performed in the remaining case of initial VF/VT, and no medical consultation was obtained. All five successful defibrillations occurred in patients with initial VF/VT. There were six (15%; 95% confidence interval [CI] 3-27%) survivors, with five survivals occurring after successful defibrillation for initial VF/VT and one with return of a perfusing rhythm after cardiopulmonary resuscitation (CPR) for a junctional rhythm. Survival in those with VF/VT was five of 10 (50%; 95% CI 14-86%). Medications were delivered in two cases. The median time to first shock was 19 seconds (interquartile range [IQR] 12-24 seconds) after AED application. Medical consultation was obtained in 42 (33%) of the 129 AED monitoring cases and 14 (35%) of the 40 cardiac arrest cases.
Use of AEDs resulted in 50% survival among those with VF/VT in flight and 15% overall survival for cardiac arrest. Survival is poor among patients presenting with nonshockable rhythms. AEDs are used extensively for in-flight monitoring, with significant rhythms identified. Ground medical consultation is sought in only one-third of AED uses and cardiac arrests.
We have conducted a three-year prospective study of medical incidents on a commercial airline. A telemedicine service was available via an on-board satellite phone. During the study period there were 3364 medical incidents. The most common incident was collapse (n = 2310, 57%). Telemedicine was used in 323 of the cases (9%). Neurological patients, mostly stroke and seizures, excluding psychiatric diseases, were seen in 27% of the telemedicine cases (n = 83). Most of the cases involved middle-aged people, not the elderly. The group of patients that needed diversion (n = 27) was compared to the cases staying on board (n = 275). None of the patients in the non-diversion group deteriorated. All unstable patients forced a diversion. Doctors on board used the service in more severe cases, whereas laymen used the service in less severe cases. The results of the present study demonstrate the advantage of using simple teleconsultation in cases of medical emergency on board an aircraft.
The scope of illnesses that may befall international travelers is broad. A guide to preparing for the preventable causes of illness is provided. Physicians may find it useful in counseling their patients who travel internationally.
Uber die genaue Anzahl, Haufigkeit und Art von medizinischen Notfallen an Bord von Flugzeugen (IFME, in-flight medical emergencies) ist allgemein vergleichsweise wenig bekannt. Ein einheitliches nationales oder internationales Register ist nicht verfugbar. Eine zielgerichtete notfallmedizinische Ausstattung an Bord von Luftfahrzeugen sowie die Auswertung von medizinischen Notfallen an Bord von Luftfahrzeugen erfordern sowohl eine systematische Erhebung wie auch eine Datenakquisition in einer standardisierten Datenbank. Das Notfallprotokoll der DGLRM in deutscher und englischer Sprache kann hierzu wichtige Dienste leisten und sollte zukunftig fur nationale und internationale Fluge im „emergency medical kit“ mitgefuhrt werden, damit es von Arzten bei der Behandlung verwendet werden kann.
Background:
High-quality cardiopulmonary resuscitation (CPR) by laypersons is a key determinant of both outcome and survival for out-of-hospital cardiac arrest. Dispatcher-assisted CPR (telephone-CPR, T-CPR) increases the frequency and correctness of bystander-CPR but results in prolonged time to first chest compressions. However, it remains unclear whether instructions for rescue ventilation and/or chest compressions should be recommended for dispatcher-assisted CPR.
Objective:
The aim of this study was to evaluate both principles of T-CPR with respect to CPR quality.
Design:
Randomised controlled single-blinded manikin trial.
Setting:
University Hospital of Cologne, Germany, 1 July 2012 to 30 September 2012.
Participants:
Sixty laypersons between 18 and 65 years. Medically educated individuals, medical professionals and pregnant women were excluded. Participants were asked to resuscitate a manikin and were randomised into three groups: not dispatcher-assisted (uninstructed) CPR (group 1; U-CPR; n = 20), dispatcher-assisted compression-only CPR (group 2; DACO-CPR; n = 19) and full dispatcher-assisted CPR with rescue ventilation (group 3; DAF-CPR; n = 19).
Main outcome measures:
Specific parameters of CPR quality [i.e. no-flow-time (NFT) as well as compression and ventilation parameters] were analysed. To compare different groups we used Student[Combining Acute Accent]s t test and P less than 0.05 was considered significant.
Results:
Initial NFT was lowest in the DACO-CPR group (mean 21.3 ± 14.4%), followed by dispatcher-assisted full CPR (mean 49.1 ± 8.5%) and by unassisted CPR (mean 55.0 ± 12.9%). Initial NFT covering the time of instruction was lower in DACO-CPR (12.1 ± 5.4%) as compared to dispatcher-assisted full CPR (20.7 ± 8.1%). Compression depth was similar in all three groups: 40.6 ± 13.0 mm (unassisted CPR), 41.0 ± 12.2 mm (DACO-CPR) and 38.8 ± 15.8 mm (dispatcher-assisted full CPR). Average compression frequency was highest in the DACO-CPR group (65.2 ± 22.4 min) compared with the unassisted CPR group (35.6 ± 24.2 min) and the dispatcher-assisted full CPR group (44.5 ± 10.8 min). Correct rescue ventilation was given in 3.1 ± 11.1% (unassisted CPR) and 1.6 ± 16.1% (dispatcher-assisted full CPR) of all ventilation attempts.
Conclusion:
Best quality of CPR was achieved by DACO-CPR because of superior compression frequencies and reduced NFT. In contrast, the full dispatcher-assisted CPR with a longer initial instructing phase (initial NFT) did not result in enhanced CPR quality or an optimised compression depth.
According to the International Civil Aviation Organization (ICAO) and other sources of information, this year, approximately 3.2 billion people will travel by air worldwide.1 – 3 Although this mode of transportation is quite safe from a technical point of view, passengers with all their individual health problems (eg, age, preexisting diseases, or the onset of new acute issues) are increasingly at risk of becoming a patient during flight.
Besides larger aircraft (eg, Airbus A380 or Boeing B747-8), the rising number of passengers,4 and more and more long-distance flights,1 it is likely that the incidence of in-flight medical emergencies will increase during the forthcoming years. Data from research studies conducted during the last few years have resulted in significant attraction worldwide, but there are still limited data and knowledge on the incidences, causes, and consequences in this field.2,4 – 6
Recently published data are primarily based on numbers gathered by individual airlines.1,7 – 9 These results are often significantly limited and might be biased due to the relatively small number …
Corresponding Author: Jochen Hinkelbein, MD, EDIC, FAsMA, Department for Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Str. 62, Cologne D-50937, Germany. E-mail: jochen.hinkelbein{at}uk-koeln.de
This executive summary provides the essential treatment algorithms for the resuscitation of children and adults and highlights the main guideline changes since 2010. Detailed guidance is provided in each of the ten sections, which are published as individual papers within this issue of Resuscitation. The sections of the ERC Guidelines 2015 are:
of changes since 2010 Guidelines The traditional medical-centred approach with an emphasis on beneficence has shifted towards a balanced patient-centred approach with greater emphasis on patient autonomy. This has resulted in a readiness for understanding and interaction between patient and healthcare professionals. Future guidelines may benefit from involvement of all stakeholders: members of the public, patients, survivors and the society as active partners in understanding and implementing the ethical principles. The content and implementation of the traditional ethical principles are placed in the context of a patient-centred approach to resuscitation: Autonomy, including respect for personal preferences expressed in advance directives, which implies correct information and communication. Beneficence, including prognostication, when to start, futility, ongoing CPR during transportation, special situations, with clear distinction between sudden cardiac arrest and expected cessation of cardiac function and respiration in terminal situations. Non-maleficence, including DNAR/DNACPR, when to stop/withhold and involvement of patient or proxy. Justice and equal access, including avoiding inequalities. Whilst the sad reality is that the majority of those that sustain a cardiac arrest do not survive, recent studies provide evidence of steady improvement in outcomes particularly where the formula of survival is well implemented. Specific cases of refractory cardiac arrest, which would historically have been fatal, may benefit from additional interventional approaches. A further improvement in survival may be expected by applying clear guidance for starting, not starting, withdrawing or withholding resuscitation attempts, and by identifying refractory cases that may respond to advanced interventions. Europe is a patchwork of 47 countries (Council of Europe) with differences in national laws, jurisdiction, culture, religion, and economic capabilities. European countries interpret the ethical recommendations of resuscitation in the context of these factors. A survey of current ethical practice across Europe was conducted in the context of these guidelines. A significant variability in the approach to cardiopulmonary resuscitation (CPR) and end-of-life was documented. Whilst areas for improvement were identified, it highlighted a trend towards better application of ethical principles. The need for harmonisation in legislation, jurisdiction, terminology and practice remains. The mission of the ERC and its Guidelines is to contribute to this harmonisation. New European Union (EU) regulation permitting deferred consent will harmonise and foster research of emergency interventions across EU Member States. Healthcare professionals are responsible for maintaining their knowledge, understanding and skills, and to understand the ethical principles before being involved in a real situation where resuscitation decisions must be made.
When a medical emergency occurs during a commercial flight, health care providers should be prepared to respond. This review offers guidance on how to respond to the more common emergencies and on roles and liabilities in offering medical assistance aboard an airplane.
This study evaluated the incidence and status of urgent medical conditions, the attitudes of health professionals who encounter such conditions, the adequacy of medical kits and training of cabin crew in data-received-company aircrafts suggested by Aerospace Medical Association, and the demographic data of patients.
Data were collected from medical records of a major flight company from 2011 through 2013. All patients with complete records were included in the study. Numerical variables were defined as median and interquartiles (IQR) for median, while categorical variables were defined as numbers and percentage.
During the study period, 10,100,000 passengers were carried by the company flights, with 1,312 (0.013%) demands for urgent medical support (UMS). The median age of the passengers who requested UMS was 45 years (IQR: 29-62). Females constituted 698 (53.2%) among the patients, and 721 (55%) patients were evaluated by medical professionals found among passengers. The most common nontraumatic complaints resulting in requests for UMS were flight anxiety (311 patients, 23.7%) and dyspnea (145 patients, 11%). The most common traumatic complaint was burns (221 patients, 16.8%) resulting from trauma during flight. A total of 22 (1.67%) emergency landings occurred for which the most frequent reasons were epilepsy (22.7%) and death (18.2%). Deaths during flights were recorded in 13 patients, whose median age was 77 years (IQR: 69-82), which was significantly higher compared to the age of patients requiring UMS (p < 0.0001). A total of 592 (45%) patients did not require any treatment for UMS. Medical kits and training were found to be sufficient according to the symptomatic treatments.
Most of the urgent cases encountered during flights can be facilitated with basic medical support. "Traumatic emergency procedures inflight medical care" would be useful for additional training. Medical professionals as passengers are significantly involved in encountered emergency situations. Adding automated external defibrillator and pulse oximetry to recommended kits and training can help facilitate staff decisions such as emergency landings and tele-assistance.
© 2015 International Society of Travel Medicine.
To evaluate the long-term effectiveness of 15-min refresher basic life support (BLS) training following 45-min chest compression-only BLS training.
After the 45-min chest compression-only BLS training, the participants were randomly assigned to either the refresher BLS training group, which received a 15-min refresher training 6 months after the initial training (refresher training group), or to the control group, which did not receive refresher training. Participants' resuscitation skills were evaluated by a 2-min case-based scenario test one year after the initial training. The primary outcome measure was the number of appropriate chest compressions during a 2-min test period.
140 participants were enrolled and 112 of them completed this study. The number of appropriate chest compressions performed during the 2-min test period was significantly greater in the refresher training group (68.9±72.3) than in the control group (36.3±50.8, p=0.009). Time without chest compressions was significantly shorter in the refresher training group (16.1±2.1seconds versus 26.9±3.7seconds, p<0.001). There were no significant differences in time to chest compression (29.6±16.7seconds versus 34.4±17.8seconds, p=0.172) and AED use between the groups.
A short-time refresher BLS training program 6 months after the initial training can help trainees retain chest compression skills for up to one year. Repeated BLS training, even if very short, would be adopted to keep acquired CPR quality optimal. (UMIN-CTR UMIN 000004101).
Copyright © 2015. Published by Elsevier Ireland Ltd.
We performed a one-year prospective survey of emergency medical responses to travelers at an international airport to observe the frequency and type of emergencies experienced in flight and before and after travel. Emergency personnel evaluated a total of 1107 people; 754 (68%) were travelers, 232 (21%) were employees of the airport or airlines, and 118 (11%) were area residents. Of the 754 travelers, 190 (25%) experienced their problem during flight; the aircraft made an unscheduled landing for seven of these travelers. The frequency of in-flight emergencies was 1 per 753 inbound flights, or 1 per 39 600 inbound passengers. The most common emergency problems among all travelers were abdominal pain, chest pain, shortness of breath, syncope, and seizures; 25% of the emergencies were caused by minor trauma. The majority of emergencies among air travelers (75% [564/754]) happened on the ground within the air terminal. Most problems (84% [633/754]) were effectively handled by personnel trained as emergency medical technicians. The types of problems encountered suggest that the "doctors only" medical kit now required aboard US air carriers contains clinically useful items and should continue to be required on board.
JAMA 1989;261:1295-1299)
Consensus development sprang from a desire to synthesize clinician and expert opinions on clinical practice and research agendas in the 1950s. And since the American Institute of Medicine formally defined "guidelines" in 1990, there has been a proliferation of clinical practice guidelines (CPG) both formally and informally. This modern decision-making tool used by both physicians and patients, requires extensive planning to overcome the challenges of consensus development while reaping its rewards. Consensus allows for a group approach of multiple experts sharing ideas to form consensus on topics ranging from appropriateness of procedures to research agenda development. Disagreements can shed light on areas of controversy and launch further discussions. It has five main components: three inputs (defining the task, participant identification and recruitment, and information synthesis), the approach (consensus development by explicit or implicit means), and the output (dissemination of results). Each aspect requires extensive planning a priori as they influence the entire process, from how information will be interpreted, the interaction of participants, the resulting judgment, to whether there will be uptake of results. Implicit approaches utilize qualitative methods and/or a simple voting structure of majority wins, and are used in informal consensus development methods and consensus development conferences. Explicit approaches aggregate results or judgments using explicit rules set a priori with definitions of "agreement" or consensus. Because the implicit process can be more opaque, unforeseen challenges can emerge such as the undue influence of a minority. And yet, the logistics of explicit approaches may be more time consuming and not appropriate when speed is a priority. In determining which method to use, it is important to understand the pros and cons of different approaches and how it will affect the overall input, approach, and outcome.
Background:
Medical emergencies often occur on commercial airline flights, but valid data on their causes and consequences are rare. Therefore, it is unclear what emergency medical equipment is necessary. Although a minimum standard for medical equipment is defined in regulations, additional material is not standardized and may vary significantly between different airlines.
Methods:
German airlines operating aircrafts with more than 30 seats were selected and interviewed with a 5-page written questionnaire between August 2011 and January 2012. Besides pre-packed and required emergency medical material, drugs, medical devices, and equipment lists were queried. If no reply was received, airlines were contacted another three times by e-mail and/or phone. Descriptive analysis was used for data presentation and interpretation.
Result:
From a total of 73 German airlines, 58 were excluded from analysis (eg, those not providing passenger transport). Fifteen airlines were contacted and data of 13 airlines were available for analysis (two airlines did not participate). A first aid kit was available on all airlines. Seven airlines reported having a doctor's kit, and another four provided an "emergency medical kit." Four airlines provided an automated external defibrillator (AED)/electrocardiogram (ECG). While six airlines reported providing anesthesia drugs, a laryngoscope, and endotracheal tubes, another four airlines did not provide even a resuscitator bag. One airline did not provide any material for cardiopulmonary resuscitation (CPR).
Conclusions:
Although the minimal material required according to European aviation regulations is provided by all airlines for medical emergencies, there are significant differences in the provision of additional material. The equipment on most airlines is not sufficient for the treatment of specific emergencies according to published medical guidelines (eg, for CPR or acute myocardial infarction).
Background:
Laryngeal mask insertion (LMI) represents a fundamental skill for anesthesiologists in routine management as well as in difficult airway situations. This study aimed to evaluate the time needed by first year anesthesiology residents to perform 40 LMIs and assessed the associated success rates and the number of attempts needed for successful LMI.
Methods:
This prospective single center study evaluated the number of work days, the success rate and the attempts needed for successful LMI (LMA ProSeal™) in consecutive blocks of five LMI procedures and the related difficulties and complications.
Results:
From 2007 to 2010 a total of 10 anesthesiology resident physicians were evaluated consecutively. These residents needed a mean of 18.3 ± 4.1 (mean ± standard deviation) working days to successfully perform 40 LMIs. The LMI success rate after the first 5 LMIs increased steadily up to the results after 40 LMIs per resident (LMI success rate within 1 attempt 72 versus 86 %, p = 0.09, LMI success rate within all LMI attempts 74 versus 96 %, p = 0.001). The mean number of attempts required until successful LMI decreased from 1.45 ± 0.82 after the first 5 LMIs to 1.16 ± 0.37 after 40 LMIs (p = 0.03). The most common difficulties associated with unsuccessful LMI by residents that led to handing over to an experienced colleague were small oral aperture (9.8 %), short thick neck, large tongue, blood/mucus in the mouth or throat (each 7.3 %) and retrognathy (4.9 %).
Conclusions:
The increasing LMI success rate and the decreasing rate of LMI attempts for successful airway management correlated to a learning curve and development of LMI dexterity over time.
Background:
Since the introduction of basic life support in the 1950s, on-going efforts have been made to improve the quality of bystander cardiopulmonary resuscitation (CPR). Even though bystander-CPR can increase the chance of survival almost fourfold, the rates of bystander initiated CPR have remained low and rarely exceed 20%. Lack of confidence and fear of committing mistakes are reasons why helpers refrain from initiating CPR. The authors tested the hypothesis that quality and confidence of bystander-CPR can be increased by supplying lay helpers with a basic life support flowchart when commencing CPR, in a simulated resuscitation model.
Materials and methods:
After giving written informed consent, 83 medically untrained laypersons were randomised to perform basic life support for 300s with or without a supportive flowchart. The primary outcome parameter was hands-off time (HOT). Furthermore, the participants' confidence in their actions on a 10-point Likert-like scale and time-to-chest compressions were assessed.
Results:
Overall HOT was 147±30 s (flowchart) vs. 169±55 s (non-flowchart), p=0.024. Time to chest compressions was significantly longer in the flowchart group (60±24 s vs. 23±18 s, p<0.0001). Participants in the flowchart group were significantly more confident when performing BLS than the non-flowchart counterparts (7±2 vs. 5±2, p=0.0009).
Conclusions:
A chart provided at the beginning of resuscitation attempts improves quality of CPR significantly by decreasing HOT and increasing the participants' confidence when performing CPR. As reducing HOT is associated with improved outcome and positively impacting the helpers' confidence is one of the main obstacles to initiate CPR for lay helpers, charts could be utilised as simple measure to improve outcome in cardiopulmonary arrest.
Human exposure to high altitude is increasing, through inhabitation of areas of high altitude, expansion of tourism into more remote areas, and air travel exposing passengers to typical altitudes equivalent to 8005ft (2440m). With ascent to high altitude, a number of acute and chronic physiological changes occur, influencing all systems of the human body. When considering that cardiac arrest is the second most common cause of death in the mountains and that up to 60% of the elderly have significant heart disease or other health problems, these changes are of particular importance as they may have a significant impact on resuscitation efforts. Current guidelines for resuscitation lack specific recommendations regarding treatment of cardiac arrest after ascent to high altitude or in aircraft. Therefore, we performed a comprehensive search in PubMed, CINAHL, Cochrane Library, and Scopus databases for studies relevant to resuscitation at high altitude. As no randomized trials evaluating the effects of physiological changes after ascent to high altitude on cardiopulmonary resuscitation were identified, our search was expanded to include all studies addressing important aspects on high altitude physiology which could have a potential impact on the resuscitation of cardiac arrest victims. The aim of this review is to discuss the major physiological changes occurring after ascent to high altitude and their potential effects on cardiopulmonary resuscitation. Based on the available data, specific suggestions are proposed regarding resuscitation at high altitude.
One in every 10 000 to 40 000 passengers on commercial aircraft will have a medical incident while on board. Many physicians are unaware of the special features of the cabin atmosphere, the medical equipment available on airplanes, and the resulting opportunities for medical intervention.
A selective literature search was performed and supplemented with international recommendations and guidelines and with data from the Lufthansa registry.
Data on in-flight medical emergencies have been collected in various ways, with varying results; it is generally agreed, however, that the more common incidents include gastrointestinal conditions (diarrhea, nausea, vomiting), circulatory collapse, hypertension, stroke, and headache (including migraine). Data from the Lufthansa registry for the years 2010 and 2011 reveal the rarity of cardiopulmonary resuscitation (mean: 8 cases per year), death (12 cases per year), childbirth (1 case per year), and psychiatric incidents (81 cases per year). If one assumes that one medical incident arises for every 10 000 passengers, and that there are 400 passengers on board each flight, then one can calculate that the probability of experiencing at least one medical incident reaches 95% after 24 intercontinental flights.
An in-flight medical emergency is an exceptional event for the physician and all other persons involved. Physician passengers can act more effectively if they are aware of the framework conditions, the available medical equipment, and the commonly encountered medical conditions.
Securing the airway by means of endotracheal intubation (ETI) represents a fundamental skill for anaesthesiologists in emergency situations. This study aimed to evaluate the time needed by first-year anaesthesiology residents to perform 200 ETIs and assessed the associated success rates and number of attempts until successful ETI.
This prospective single centre study evaluated the number of working days, the success rate, the attempts needed until successful ETI in consecutive blocks of 25 ETI procedures and the related difficulties and complications.
From 2007 to 2010, 21 residents were evaluated consecutively. These residents needed a mean (mean ± standard deviation) of 15.6 ± 3.0 days for 25 ETIs. Out of all residents 52% reached the target value of 200 ETIs after 50.2 ± 14.8 weeks of total working time. The ETI success rate after the first 25 ETIs increased steadily to the results after 200 ETIs (ETI success rate within one ETI attempt: 67% vs. 83%, P = 0.0001; ETI success rate within all ETI attempts: 82% vs. 92%, P = 0.0001). The number of attempts required until successful ETI decreased from 1.6 ± 0.8 after the first 25 ETIs to 1.3 ± 0.6 after 200 ETIs (P = 0.0001).
The increasing rate of relative ETI success and the decreasing rate of necessary attempts for successful airway management suggest a steadily increasing gain in ETI experience. The complications that developed during the first 200 ETI procedures justify supervision by a specialist in the field or a senior physician. Moreover, these results may influence the minimum requirement for qualification in anaesthesiology and emergency medicine.
Cardiac arrest occurring on board aeroplanes is rare, but remains a common cause of inflight incidents. This review examines some of the management problems unique to inflight cardiac arrests, and emphasises the use of cardiopulmonary resuscitation and automated external defibrillators.
Laboratory and recent clinical data suggest that hyperoxemia after resuscitation from cardiac arrest is harmful; however, it remains unclear if the risk of adverse outcome is a threshold effect at a specific supranormal oxygen tension, or is a dose-dependent association. We aimed to define the relationship between supranormal oxygen tension and outcome in postresuscitation patients.
This was a multicenter cohort study using the Project IMPACT database (intensive care units at 120 US hospitals). Inclusion criteria were age >17 years, nontrauma, cardiopulmonary resuscitation preceding intensive care unit arrival, and postresuscitation arterial blood gas obtained. We excluded patients with hypoxia or severe oxygenation impairment. We defined the exposure by the highest partial pressure of arterial oxygen (PaO(2)) over the first 24 hours in the ICU. The primary outcome measure was in-hospital mortality. We tested the association between PaO(2) (continuous variable) and mortality using multivariable logistic regression adjusted for patient-oriented covariates and potential hospital effects. Of 4459 patients, 54% died. The median postresuscitation PaO(2) was 231 (interquartile range 149 to 349) mm Hg. Over ascending ranges of oxygen tension, we found significant linear trends of increasing in-hospital mortality and decreasing survival as functionally independent. On multivariable analysis, a 100 mm Hg increase in PaO(2) was associated with a 24% increase in mortality risk (odds ratio 1.24 [95% confidence interval 1.18 to 1.31]. We observed no evidence supporting a single threshold for harm from supranormal oxygen tension.
In this large sample of postresuscitation patients, we found a dose-dependent association between supranormal oxygen tension and risk of in-hospital death.
Cardiopulmonary resuscitation (CPR) during flight is challenging and has to be sustained for long periods. In this setting a mechanical-resuscitation-device (MRD) might improve performance. In this study we compared the quality of resuscitation of trained flight attendants practicing either standard basic life support (BLS) or using a MRD in a cabin-simulator.
Prospective, open, randomized and crossover simulation study. Study participants, competent in standard BLS were trained to use the MRD to deliver both chest compressions and ventilation. 39 teams of two rescuers resuscitated a manikin for 12 min in random order, standard BLS or mechanically assisted resuscitation. Primary outcome was "absolute hands-off time" (sum of all periods during which no hand was placed on the chest minus ventilation time). Various parameters describing the quality of chest compression and ventilation were analysed as secondary outcome parameters.
Use of the MRD led to significantly less "absolute hands-off time" (164±33 s vs. 205±42 s, p<0.001). The quality of chest compression was comparable among groups, except for a higher compression rate in the standard BLS group (123±14 min(-1) vs. 95±11 min(-1), p<0.001). Tidal volume was higher in the standard BLS group (0.48±0.14 l vs. 0.34±0.13 l, p<0.001), but we registered fewer gastric inflations in the MRD group (0.4±0.3% vs. 16.6±16.9%, p<0.001).
Using the MRD resulted in significantly less "absolute hands-off time", but less effective ventilation. The translation of higher chest compression rate into better outcome, as shown in other studies previously, has to be investigated in another human outcome study.
The "Grades of Recommendation, Assessment, Development, and Evaluation" (GRADE) approach provides guidance for rating quality of evidence and grading strength of recommendations in health care. It has important implications for those summarizing evidence for systematic reviews, health technology assessment, and clinical practice guidelines. GRADE provides a systematic and transparent framework for clarifying questions, determining the outcomes of interest, summarizing the evidence that addresses a question, and moving from the evidence to a recommendation or decision. Wide dissemination and use of the GRADE approach, with endorsement from more than 50 organizations worldwide, many highly influential (http://www.gradeworkinggroup.org/), attests to the importance of this work. This article introduces a 20-part series providing guidance for the use of GRADE methodology that will appear in the Journal of Clinical Epidemiology.
In cases of critical medical situations on board commercial aircraft, access to emergency medical kits can be lifesaving. Thus, this comparative study investigated acute care medication and equipment supplied in emergency medical kits on board both low-cost carriers and full-service carriers.
Thirty-two European airlines (sixteen low-cost carriers and sixteen full-service-carriers) were asked to provide anonymous data on the contents of their emergency medical kits. All emergency medical equipment and medication carried on board were subject to a descriptive analysis with regards to International Civil Aviation Organization (ICAO) standards for emergency medical kits, as well as variation and differences between low-cost carriers and full-service carriers.
A total of twelve airlines (seven full-service carriers and five low-cost carriers) participated in this study. None complied with ICAO standards. Emergency medical kits from both full-service carriers and low-cost carriers exhibited a high degree of variability. Two European low-cost carriers were assessed as being insufficiently equipped for a medical emergency requiring acute care.
This study demonstrates the high degree of variability in the contents of emergency medical kits. Additionally, some airlines were equipped insufficiently for a critical medical situation on board their aircraft. Frequent checks of national authorities and further evaluation of acute care equipment are required to prepare for potentially life-threatening critical conditions occurring in special environments, such as in airplane during flight.
Each year, close to 2 billion passengers travel on commercial airlines. In-flight medical events result in suboptimal care due to a variety of factors. Flight diversions due to medical emergencies carry a significant financial and legal cost. The purpose of this study was to determine the causes of in-flight medical diversions from Air Canada.
This was a review of in-flight medical emergencies from 2004-2008. Both telemedicine and Air Canada databases were crossreferenced to capture all incidents. Presenting complaints were categorized by systems. Descriptive statistics were used to analyze the data.
Over the 5 yr, there were 220 diversions, of which 91 (41.4%) of the decisions were made by pilots or onboard medical personnel. During this period there were 5386 telemedicine contacts with ground support providers, who on average recommended 2.4 diversions per 100 calls. The rate for diversions almost doubled from 2006 to 2007, with a sharp drop in telemedicine contacts during the same period. The four most common categories resulting in diversions were cardiac (58 diversions, 26.4%), neurological (43 diversions, 19.5%), gastrointestinal (GI) (25 diversions, 11.4%), and syncope (22 diversions, 10.0%). Only 6.8% of all diversions were due to cardiac arrest.
Medical conditions most commonly leading to diversions were cardiac, neurological, gastrointestinal, and syncope. Our study showed that a decrease in telemedicine contact during this period was accompanied by an increase in diversions, while increased pre-screening of passengers did not prove effective in decreasing diversion rates.
Author Contributions: Dr Hung had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Hung, Cocks, and Graham. Acquisition of data: Cocks and Ong. Analysis and interpretation of data: Hung, Chan, Cocks, Rainer, and Graham. Drafting of the manuscript: Hung and Cocks. Critical revision of the manuscript for important intellectual content: Hung, Chan, Cocks, Ong, Rainer, and Graham. Statistical analysis: Hung, Chan, and Graham. Obtained funding: Hung and Graham. Administrative, technical, and material support: Rainer and Graham. Study supervision: Chan, Cocks, and Graham.
Sudden cardiac arrest is one of the leading causes of death, and early defibrillation of ventricular fibrillation (VF) is the single most important intervention for improving survival. The automated external defibrillator (AED) and the concept of public access defibrillation provide a solution to shorten defibrillation delays. Commercial aircraft create a unique environment for the use of the AED since an emergency medical service system (EMS) response is not available. We review published studies on this subject and describe the case of a passenger who developed VF during an intercontinental flight and was successfully resuscitated despite recurrent episodes of VF.
A 60-yr-old man developed VF during a flight from Tokyo to Helsinki. VF frequently recurred and shocks were delivered 21 times altogether. The aircraft was diverted to the city of Kuopio. When the local EMS crew encountered the patient 3 h after the onset of the cardiac arrest, the rhythm again converted to VF and three further shocks were delivered. The patient recovered, and 3 wk later he was transported to his home country, fully alert.
There are three large studies reporting placing AEDs on commercial aircraft. No harm for co-passengers or malfunctions were reported. Survival rates have been higher than those obtained by well-performing EMS. According to previous studies, placing AEDs on commercial aircraft is also cost effective. The absence of a suitable diversion destination should not influence the rescuers' decision to attempt CPR on board.
Almost 2 billion people travel aboard commercial airlines every year. Health-care providers and travellers need to be aware of the potential health risks associated with air travel. Environmental and physiological changes that occur during routine commercial flights lead to mild hypoxia and gas expansion, which can exacerbate chronic medical conditions or incite acute in-flight medical events. The association between venous thromboembolism and long-haul flights, cosmic-radiation exposure, jet lag, and cabin-air quality are growing health-care issues associated with air travel. In-flight medical events are increasingly frequent because a growing number of individuals with pre-existing medical conditions travel by air. Resources including basic and advanced medical kits, automated external defibrillators, and telemedical ground support are available onboard to assist flight crew and volunteering physicians in the management of in-flight medical emergencies.