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Air Travel Emergencies

Description:
Physicians may be called to assist with in-flight medical events (IMEs), often beyond usual scope of practice.
The aircraft environment is cramped with limited medical resources, but healthcare workers should be prepared to assist.

Epidemiology

  • 2.9 million passengers travel daily worldwide; in US, 1.7 million daily.
  • IME incidence: approximately 1 per 40 flights or 1 per 7,500 to 40,000 passengers.
  • Most IMEs are minor; 65-70% managed by flight crew (1),(2).
  • Likelihood of IME increasing due to larger planes, longer flights, aging population.
  • Most common IMEs:
  • Syncope/near syncope (32.7%)
  • Gastrointestinal (14.8%)
  • Respiratory (10.1%)
  • Cardiovascular symptoms (7%)
  • Vasovagal syncope accounts for up to 90% in healthy passengers.
  • 5% of passengers with chronic illness account for two-thirds of IMEs.
  • Pediatric passengers: 15% of ground-based physician calls.
  • 3% of IMEs are fatal.

Etiology and Pathophysiology

  • Hypobaric hypoxia: oxygen partial pressure drops from 160 mm Hg (sea level) to ~120 mm Hg at cruising altitude.
  • Healthy arterial PaO2 decreases from 100 to ~60 mm Hg; mean inflight O2 saturations ~93% (85-98%).

  • ALERT: COPD and pulmonary disease patients have lower baseline PaO2 and risk significant hypoxemia. Unstable angina or heart failure may impair compensation.

  • Gas expansion: Gases expand ~30% during flight. Risks: pneumothorax, wound dehiscence/perforation, sinus pressure, tympanic membrane rupture (children with ear infections).

  • Venous thromboembolism (VTE): increased risk on long flights due to prolonged sitting, hypoxia, dehydration.

  • Stress: mental and physical stress can cause psychiatric emergencies or acute coronary syndrome (ACS).

  • Insomnia: disrupted circadian rhythms may trigger seizures and cause medication nonadherence.

  • Turbulence: common motion sickness; trauma risk from falling luggage.

  • Medication nonadherence: forgotten or checked medications lead to glycemic instability, seizures, BP issues, inaccessible PRN meds.

  • Decreased food/drink access: dehydration → vasovagal syncope; diabetics risk hypoglycemia.

  • Low humidity (<20%): contributes to dehydration, epistaxis, asthma/COPD exacerbations.

  • Viral infections: parainfluenza and influenza common; transmission mostly by proximity, not cabin air filtration.

  • ALERT: SARS-CoV-2 transmission occurs primarily by proximity; mask use mitigates risk.

Risk Factors

  • Recent surgery (wound dehiscence, bowel perforation, compartment syndrome).
  • COPD, asthma, CHF, coronary artery disease (hypoxemia risk).
  • Recent cast placement (compartment syndrome risk).
  • Hypercoagulability (inherited/acquired, pregnancy, medications, heart disease, surgery).
  • Recent scuba diving (decompression sickness risk).
  • Long flights (cumulative hypoxia effects).

General Prevention

  • Discuss medication timing with physician; bring necessary meds and equipment onboard.
  • Supplemental oxygen required for baseline PaO2 <70 mm Hg or limited exertional capacity (unable to climb stairs or walk 150 feet without SOB/angina) (3) [C].

Pregnancy Considerations

  • Safe to fly until 36 weeks gestation.

Pediatric Considerations

  • Bring liquid medications in allowed quantities.
  • Asthmatic children need rescue inhaler with spacer and facemask.

Specific Guidelines

  • Avoid flying 10-14 days after surgery (varies).
  • Bivalve casts applied 24-48 hours before flight.
  • Avoid scuba diving 24 hours before flying.
  • DVT prevention: hydration, leg exercises, compression stockings/aspirin/anticoagulation for high risk (3) [C].

Diagnosis

History

  • Tailor history to emergency; obtain PMH, surgical history, medication compliance, allergies, illicit drug/alcohol use.
  • Document findings and save securely.

Physical Exam

  • Use PPE; available on board.
  • BP by palpation may be needed due to noise.
  • Assess vitals, general appearance, mental status, dehydration signs.

  • Auscultate if possible.

  • ALERT: Assess for tension pneumothorax—decreased breath sounds, contralateral tracheal deviation; requires needle decompression.

Differential Diagnosis

Symptom Possible Causes
Syncope Vasovagal, dehydration, hypoglycemia, intoxication, ACS, arrhythmia, CVA, pulmonary embolism, hypoxia
Chest pain ACS, PE, pneumothorax, bronchospasm, aortic dissection, GERD, musculoskeletal, anxiety
Shortness of breath COPD/asthma exacerbation, pneumonia, PE, toxic exposure
Stroke-like CVA, TIA, hypoglycemia, seizure, syncope, mass lesion, migraine
Seizure Seizure, syncope, hypoglycemia, eclampsia, cardiac arrest
GI illness Motion sickness, foodborne illness, gastritis, enteritis, GERD, pancreatitis, withdrawal
Obstetric Preterm labor, miscarriage, eclampsia, placenta previa
Allergic Urticaria, anaphylaxis, dermatitis
Cardiac arrest Arrhythmia, PE, respiratory arrest, ACS, intoxication, syncope
Altered mental status Drug/alcohol use or withdrawal, hypoglycemia, panic attack, DKA, hypoxia, psych emergency

Diagnostic Tests & Interpretation

  • Automated external defibrillator (AED) usable as cardiac monitor.

Treatment

General Measures

  • First aid and CPR: Initiate CPR, BLS, ALS, PALS as appropriate; flight crew trained.
  • Ask for help: flight crew and passengers for equipment, meds, expertise, lifting assistance.
  • Oxygen: Available at 2-5 L/min by facemask; use in respiratory distress, chest pain, seizures, altered mental status.
  • Ground-based support: Many airlines contract medical advice, interpreter services, telemedicine.
  • Request lower altitude (<22,500 feet): mimics sea level O2 pressure but uses more fuel, slower.
  • Request diversion: Consider for resuscitation, persistent abnormal vitals, chest pain, stroke, respiratory distress, unconsciousness, obstetrics, psych emergencies.

FAA-Mandated Emergency Medical Kit Contents

Equipment Medications
Oropharyngeal airways (3 sizes) Analgesic, nonnarcotic
CPR mask Antihistamine injectable (50 mg)
Manual resuscitation devices (3 masks) Antihistamine tablets (25 mg)
Adhesive tape (1-inch) Aspirin tablets (325 mg)
Alcohol sponges Atropine 0.5 mg, 5 mL
IV administration set Bronchodilator inhaled (albuterol)
Needles Dextrose 50% / 50 mL injectable
Protective gloves Epinephrine 1:1,000 (1 mL) injectable
Sphygmomanometer Epinephrine 1:10,000 (2 mL) injectable
Stethoscope Lidocaine 20 mg/mL (5 mL) injectable
Tape scissors Nitroglycerin tablets
Tourniquet Saline solution (≥500 cc)
Instructions on kit use
  • Nurse practitioners and physician assistants may be allowed to use EMK depending on policies.
  • AED available on all aircraft.
  • ALERT: EMK usually lacks glucometers, intubation equipment, ACLS drugs, narcotics, insulin, antibiotics; only 35% include naloxone (2019 data). Ask passengers for needed meds/equipment.

Pediatric Considerations

  • Seizures most common cause of pediatric flight diversion.
  • EMKs often lack anticonvulsants and liquid/suppository meds.
  • Consider crushing tablets or seeking help from passengers.
  • Improvised spacers (e.g., taped toilet paper roll) can aid inhaler use.

Additional Therapies

Condition Treatment Notes
Cardiac Arrest CPR, early defibrillation, epinephrine 1 mg IV q3-5min (peds 0.01 mg/kg), lidocaine/atropine as indicated, recommend diversion
Acute Coronary Syndrome (ACS) Oxygen, aspirin 325 mg PO, nitroglycerin (0.4 mg SL q5-10min if SBP >100 mm Hg), AED, recommend diversion
Asthma/COPD Exacerbation Oxygen, albuterol 2.5 mg inhaled repeat prn, steroids if available, epinephrine (0.3 mg adult, 0.15 mg peds IM), consider diversion
Allergic Reaction / Anaphylaxis Diphenhydramine (PO/IV), epinephrine (0.3 mg adult, 0.15 mg peds IM), NS IV fluids, steroids if available, divert if anaphylaxis
Vasovagal Syncope Elevate legs, oral fluids if alert, consider IV fluids, glucose if hypoglycemia suspected, monitor BP, consider diversion if persistent symptoms or vitals
Gastrointestinal Oral antiemetics/antacids from EMK/passengers, consider diversion for abdominal pain
Tension Pneumothorax Needle thoracostomy (preferred 2nd ICS midclavicular line)
Psychiatric Emergency Consider intoxication, hypo-/hyperglycemia, hypoxia; verbal de-escalation; use airline protocols for restraints; ask about anxiolytics; monitor for distress/ACS; consider diversion
Opioid Ingestion Rescue breathing, naloxone 0.4-0.8 mg IV or 2 mg intranasal/IM if available

Ongoing Care and Prognosis

  • Aviation Medical Assistance Act (1998) protects licensed medical providers assisting in IMEs acting within training and without negligence.
  • No successful malpractice suits against physicians volunteering in IMEs in the US.
  • Health care workers respond 76% of times paged; physicians in 48% cases.
  • 60% of IMEs improve with healthcare provider assistance.

References

  1. Hu JS, Smith JK. In-flight medical emergencies. Am Fam Physician. 2021;103(9):547-552.
  2. Martin-Gill C, Doyle TJ, Yealy DM. In-flight medical emergencies: a review. JAMA. 2018;320(24):2580-2590.
  3. Aerospace Medical Association Medical Guidelines Task Force. Medical guidelines for airline travel, 2nd ed. Aviat Space Environ Med. 2003;74(Suppl 5):A1-A19.

See Also

  • AirRx: smartphone app for protocols, diagnoses, treatments in IMEs

Clinical Pearls

  • Medical emergencies on airplanes are common but mostly minor.
  • Onboard equipment and drugs vary widely by airline, country, aircraft.
  • All flights equipped with AEDs and oxygen.
  • Many airlines have ground-based physician support.
  • Utilize passengers as resources for help, supplies, and information.