Supplementary Online Content

Management of
In-Flight Medical Emergencies
This supplementary material has been provided by the authors
to give readers additional information about their work.
Martin-Gill C, Doyle TJ, Yealy DM. In-flight medical emergencies: a review.
JAMA. doi:10.1001/jama.2018.19842

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 SYNCOPE / NEAR-SYNCOPE
30% of all in-flight emergencies
Initial assessment-suspect
Vasovagal: Pale, diaphoretic, improves
with simple measures in 15-30 min.
Cardiac cause (eg, myocardial infarction):
Chest pain, dyspnea, arm or jaw pain,
persistent bradycardia.
Pulmonary: Dyspnea, pleuritic chest pain.
Stroke: Slurred speech, facial droop,
or arm weakness.
Hypoglycemia: Diaphoretic, cool skin;
assess with glucometer if available.

Management and expected course

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

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 GASTROINTESTINAL ILLNESS
15% of all in-flight emergencies
Initial assessment
Identify extent and timing of symptoms,
including nausea, vomiting, diarrhea, bleeding,
and specifics of any abdominal pain (location,
quality, and severity).

Management and expected course

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

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 RESPIRATORY DISTRESS
10% of all in-flight emergencies
Initial assessment
Identify history of respiratory disease,
scuba diving, extremity swelling,
or infectious symptoms.
If available, check pulse oximetry.

Management and expected course

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

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

Management and expected course

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

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 SEIZURE
Up to 5% of all in-flight emergencies
Initial assessment
Identify the symptoms the passenger exhibited
during the event:
Including onset, duration of movement activity,
quality of movements (eg, tonic-clonic),
and loss of bowel or bladder function.

Management and expected course

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

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 TRAUMA
5% of all in-flight emergencies
Initial assessment
Assess all injuries for any open wounds,
tenderness, deformity, or active bleeding.
Assess patients with injury to the head, neck,
or back for any neurological symptoms.

Management and expected course

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

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 CARDIOVASCULAR
GASTROINTESTINAL
SYNCOPE
STROKE-LIKE
PSYCHIATRIC
RESPIRATORY
TRAUMA
SEIZURE
/ NEAR-SYNCOPE
SYMPTOMS
DISTRESS
SYMPTOMS
ILLNESS
Up30%
15%
10%
7%
5%
to 3%
5%
of
ofall
of
allall
in-flight
in-flight
in-flight
emergencies
emergencies
emergencies
Initial assessment
assessment-suspect
Vasovagal:
A
Identify
Assess
Aimfocused
to all
create
if
extent
history
the history
injuries
any
Pale,
symptoms
aprior
and
rapport
ofdiaphoretic,
should
for
respiratory
timing
myocardial
any the
with
include
open
of
passenger
the
symptoms,
improves
disease,
wounds,
infarction
thepassenger
time exhibited
of
with
including
scuba
or
symptom
during
tenderness,
to other
deescalate
simple
diving,
the
cardiovascular
onset,
nausea,
event:
measures
deformity,
extremity
thespecific
situation.
vomiting,
inor
history.
motor
swelling,
15-30
active
diarrhea,
andmin.
bleeding.
sensory
bleeding,
and
or
components,
Including
In infectious
Cardiac
Assess
Elicit
somespecifics onset,
information
patients
cause
settings,and
symptoms.
of
(eg, any
duration
any
with
aand abdominal
other
myocardial
12-lead
injury of
considerassociated
tomovement
pain
electrocardiogram
the
infarction):
the head,(location,
symptoms
activity,
passenger’s
neck, may
quality,
including
quality
Chest
If
be
or
use available,
back
obtained of
and
of pain, headache
movements
severity).
mood-altering
for any dyspnea,
and
check or
neurological
transmitted
pulse sensorium
arm(eg, tonic-clonic),
substances.
oximetry.
or jaw changes.
symptoms.
for ground
pain, review
and loss offor
persistent
(and/or
Screening bowel or bladder function.
Identify volunteer bradycardia.
if patientstroke: review
takesSpeech if qualified
disturbance,
specific to read).
psychiatric
facial
Management
Pulmonary:
Suspected droop,
medications, or
acute arm
and
Dyspnea,
dosing, weakness.
expected
coronary last
pleuritic
dose course
syndrome:
taken,
chest pain. Chest pain,
Management
Management and
and expected
expected course
course
dyspnea,
and
If if
Management
If available
nausea/emesis
ongoing
Stroke: arm or
dyspnea
Slurred on
jaw
and
speech,aircraft.
pain.
expected
Use
or an
known oral course
antiemetic
facial oxygen
droop, saturation
Injuries from falling luggage Typically minor
Management
if
If
is available;
unresponsive
<95% if notand Lay expected
tolerated,
passenger course
consideron a on side,
floor
or
Suspected
and armmay beAdminister
weakness.
arrhythmia:
assessed oxygen.
Persistent
further at the bradycardia,
destination.
parenteral
Administer
Management
monitor
tachycardia, antiemetic.
airway,oxygen,
or and unless
andexpected
irregular assess saturations
vitalcourse
heartbeat. signs with are known
If passenger’s
Hypoglycemia:
Active bleeding portable
Diaphoretic,
Control oxygen coolconcentrator
bleeding skin;
with direct
to
If be
ongoing
Provide
verbal
fails ornear or
isusing
not at
neurological
oral normal
hydration
deescalationused levels.
examination
if
forIsolated
aif tolerated.
ineffective
patient as above.
with preexisting
assess
Suspected
pressure with dyspepsia:
glucometer
a gloved available.
hand. epigastric burning
Consider
If patient
ongoing
lung
with
Use no ahas
disease, benzodiazepine
associated
sugar-containingongoing
seizing consider
symptoms. trialifof
neurological
Administer
liquids available
Thisparenteral
ifoxygen from
isdeficits
therapy.an
a consideration
symptoms
Ongoing
extended
suggestive heavy
emergency
of a extremity
stroke medical bleeding
Contact kit. ground-based
benzodiazepines
ofIf
ofexclusion,
hypoglycemia.
passenger if
supported
uses available in
by history the emergency
Consider
Management
medical applying
support.
kit (not and a≥4
usually
L/min
tourniquet.
expected oncourse
available
the ground,
ofBenzodiazepines
thesimilar
onboard
Ifunconscious
oral intake symptoms.
oxygen are not
supply commonly
may not available
be enough in
If
Suspected
onthe US longnot
commercial
emergency
Recommendation
Lie
bone tolerated,
flat,
or joint
airlines).
medical
may kit
include
consider
elevate
injuries
and legs,
are apply
infrequently
diversion,
to reverse
Management
intravenous
oxygen. hypoxia.
Ifmaterial
no and
fluids.
pulse expected
or signs course
of life, found in the
Splinting a isprolonged
tonot
necessary
which may even
not when
be the commonly
available.
closest airport seizure
If
If alert
suspected
Monitor
follow following
flow
cardiac acute
rate
arrest coronary
of oxygen
card. or recurrent
syndrome
administered;
If dyspepsia
emergency Use
medical an
kit,antacid
but may if available
be improvised in the
if stroke
Ground-based
If combative
Aspirin,
canister 325 care mg is
consumption not
medical
Refer
orally; present
to support
flight at that
may
crew
nitroglycerin,
is variable airport.
recommend
for
and individual
0.4 mg legs.
aircraft
emergency
from
If available
transient medical
equipment
syncope kit. Supine (eg, a U-shaped
position, elevate
an added
airline
sublingually
may not dose
security
Ground-based have of
every the
protocols,
team 5-10
sufficient patient’s
shouldminwhich
oxygen own
have
(if take antiepileptic
precedence
information
systolic
for blood
continuous
half-rolled
Oral
If fluids
diarrhea magazine
with
Use head
an secured
raised
antidiarrheal with
if nausea tape
ifand will
absent.
available in the
medication
over attempts
on capabilities
pressure (if
is ≥100 history
at medical
for
mm ofthe
medical
Hg). seizures
management.
care near mostavailable)
Ifuse
make
or
for
improves
emergency
an oral
the
a good induration
forearm
15-30
medical
benzodiazepine
of
or
kit.min, wrist flight.
slowly
(if splint).
availablesit upin the
Ifmajor
Airline
any airports.
security
dyspnea
bronchospasm orprotocols
respiratory vary by airline and may
distress
and return
emergency to seat
medical if tolerated.
If patient
include has
restrainingfeverkit). andpassenger
the persistent or diarrhea
diverting
Give oxygen,
Administer unless
albuterol, saturations
2.5 mg are25known
inhaled.
If(>14
If hypoglycemia
seizure
the d),
aircraft contact
resolves
for Oral
and glucose
ground-based
patient
the safety or
regains medical g ofsupport,
of other passengers dextrose
to
If be near
allergic or at
reaction normal levels.
50%
as
normal intravenously.
local
and crew. public
mental health
status authorities may need to be
If dyspepsia
Refer suspected
to conditions
allergic reaction Antacids
card. or other
Ifcontacted
Diversion
other at
is not the destination.
commonlysuspected necessary.
analgesics
If passenger candoesbe card.
given
not after appropriate risk
improve
Refer
severe to relevant
abdominal pain, tenderness on examination,
stratification.
Contact ground-basedAlternative causes
medical should first
support
rigid
If no improvement or notinprogressing
abdomen, or blood bodily fluid
be
for considered.
additional recommendations.
Contact ground-based
as expected Contact ground-based medical support
If
for persistent
additional orrecommendations.
additional symptoms
medical support for additional recommendations.
Contact ground-based medical support
for additional recommendations.
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rights reserved.
 SUBSTANCE
CARDIOVASCULAR
GASTROINTESTINAL
SYNCOPE
STROKE-LIKE
PSYCHIATRIC
RESPIRATORY
ABUSE
TRAUMA
SEIZURE
/ NEAR-SYNCOPE
SYMPTOMS
DISTRESS
ANDSYMPTOMS
WITHDRAWAL
ILLNESS
Up30%
15%
10%
7%
5%
to 3%
5%
of
ofall
of
allall
in-flight
in-flight
in-flight
emergencies
emergencies
emergencies
Initial assessment
assessment-suspect
Vasovagal:
A
Assess
Aim
Identify
focused
to all
create
if
extent
history
the
type,
history
injuries
any
Pale,
symptoms
aamount,
prior
and
rapport
ofdiaphoretic,
should
for
respiratory
timing
myocardial
any and
the
with
include
open
of
passenger
timing
the
symptoms,
improves
disease,
wounds,
infarction
thepassenger
time exhibited
of
with
including
scuba
or
symptom
during
tenderness,
to
of substances
other
deescalate
simple
diving,
the
cardiovascular
onset,
nausea,
event:
measures
deformity,
extremity
the
used.
specific
situation.
vomiting,inor
history.
motor
swelling,
15-30
active
diarrhea,
andmin.
bleeding.
sensory
bleeding,
and
or
components,
Including
infectious
Cardiac
In
Assess
Elicit
Identify
somespecifics onset,
information
patients
cause
settings,
symptoms and
symptoms.
of
(eg, any
duration
any
with
aand abdominal
other
myocardial
12-lead
andinjury of
consider
mentalassociated
tomovement
pain
electrocardiogram
the
infarction):
status,
the head,(location,
symptoms
activity,
passenger’s
neck, may
quality,
including
quality
Chest
If
be
or
use
along
available,
back
obtained
of withof
and
pain, headache
movements
severity).
mood-altering
for vital
any
dyspnea,
and
check or
neurological
signs.
transmitted
pulse sensorium
arm(eg, tonic-clonic),
substances.
oximetry.
or jaw changes.
symptoms.
for ground
pain, review
and loss offor
persistent
(and/or
Screening bowel or bladder function.
Identify volunteer
Suspected bradycardia.
if patientstroke:
opioid review
Speech
ingestion:
takes if qualified
disturbance,
specificAltered to read).
psychiatric
mentation,
facial
Management
Pulmonary:
Suspected droop,
medications,
constricted or
acute arm
pupils,and
Dyspnea,
dosing, weakness.
expected
coronary
respiratory
last
pleuritic
dose course
syndrome:
taken,
chest
depression.pain.
Chest pain,
Management
Management and
and expected
expected course
course
dyspnea,
and
If if
Management
If ongoing
Stroke:
Suspected available
nausea/emesis arm or
dyspnea
Slurred
alcohol on
jaw
and
speech,aircraft.
pain.
expected
Use
or an
known
ingestion: oral course
antiemetic
oxygen
facialAltered
droop, saturation
mentation,
Injuries from falling luggage Typically minor
Management
if
If
is available;
unresponsive
<95% if notand Lay expected
tolerated,
passenger course
consideron a on side,
floor
or
Suspected
slurred
and armmay beAdminister
weakness.
speech,
arrhythmia:
assessedbehavior oxygen.
Persistent
further changes.
at the bradycardia,
destination.
parenteral
Administer
Management
monitor
tachycardia, antiemetic.
oxygen,
airway, or and unless
andexpected
irregular assess saturations
vitalcourse
heartbeat. signs are known
with
If passenger’s
Hypoglycemia:
Suspected
Active stimulant
bleeding portable
Diaphoretic,
Control oxygen
ingestion: concentrator
coolAltered
bleeding skin;
with mentation,
direct
to
If be
ongoing
Provide
verbal
fails ornear or
isusing
not at
neurological
oral normal
hydration
deescalationused for levels.
examination
if
aif tolerated.
ineffective
patient as above.
with preexisting
assess
Suspected
tachycardia,
pressure with dyspepsia:
glucometer
dilated
a gloved pupils,
Isolated available.
hand. agitation.
epigastric burning
Consider
If patient
ongoing
lung
with
Use no ahas
disease, benzodiazepine
associated
sugar-containingongoing
seizing consider
symptoms. trialifof
neurological
Administer
liquids available
Thisparenteral
ifoxygen from
isdeficits
therapy.an
a consideration
symptoms
Ongoing
extended
suggestive heavy
emergency
of a extremity
stroke medical bleeding
Contact kit. ground-based
benzodiazepines
ofofexclusion,
If hypoglycemia.
Management
passenger and
uses if
supported available
expected in
by history the
oncourse emergency
Consider
Management
medical applying
support.
kit (not and a≥4
usually
L/min
tourniquet.
expected available
the ground,
course
of
Ifthesimilar
Benzodiazepines
normalonboard
Ifunconscious
oral intake symptoms.
vital oxygen
signs are
and not
supply
no commonly
may
respiratory not available
be enough
compromise in
If
Suspected
onthe US longnot
commercial
emergency
Recommendation
Lie
bone tolerated,
flat,
or joint
airlines).
medical
may kit
include
consider
elevate
injuries
and legs,
are apply
infrequently
diversion,
to reverse
Observation
Management
intravenous
oxygen. hypoxia.
only.
Ifmaterial
no and
fluids.
pulse expected
or signs course
of life, found in the
Splinting a isprolonged
tonot
necessary
which may even
not when
be the commonly
available.
closest airport seizure
If
If alert
Monitor
suspectedfollowing
flow acute
rate
opioid coronary
of oxygen
ingestion or recurrent
syndrome
administered;
with
follow
If dyspepsia
emergency
if stroke
cardiac arrest
Use
medical
care is not
an card.
kit,antacid
but may
present
if
at berespiratory
available
that improvised
airport.
in the
Ground-based
If combative
Aspirin,
canister
depression 325 mg medical
Refer
consumption orally;
Naloxone, to support
flight
nitroglycerin,
is variable
0.4-0.8 may
crewmg and recommend
for individual
0.4 mg legs.
aircraft
intravenously
emergency
from
If available
transient medical
equipment
syncope kit. Supine (eg, a U-shaped
position, elevate
an added
airline
sublingually
ormay2 mgnot dose
security
Ground-based have of
every the
protocols,
team 5-10
sufficient patient’s
should
intramuscularly/intranasally. minwhich
oxygen(if own
have take antiepileptic
precedence
information
systolic
for blood
continuous
half-rolled
Oral
If fluids
diarrhea magazine
with
Use head
an secured
raised
antidiarrheal with
if nausea tape
ifand will
absent.
available in the
medication
over
on
pressure
use attempts
capabilities
for (if
is ≥100
the history
at medical
for
mm ofthe
medical
Hg). seizures
management.
care near mostavailable)
make
If
or a good
suspected
improves
emergency
an oral induration
forearm
alcohol
15-30
medical
benzodiazepine kit.
of
or
overdose
min, wrist flight.
slowly
(if splint).
availablesit upin the
Ifmajor
Airline
any airports.
security
dyspnea
bronchospasm orprotocols
respiratory vary by
distress airline and may
Observe
and return
emergency and to provide
seat
medical antiemetic
if tolerated. therapy.
If patient
include has
restrainingfeverkit). andpassenger
the persistent or diarrhea
diverting
Give
If oxygen,
Administer
suspected unless
albuterol,
stimulant saturations
2.5 mg
ingestion are
inhaled. known
If hypoglycemia
(>14
seizure
the d),
aircraft contact
resolves
for Oral
ground-based
and
the safety glucose
patient or
regains 25
medical g ofsupport,
of other passengers dextrose
to
If be near
allergic
Observe and or at
reaction normal
hydrate (for levels.
tachycardia).
50%
as
normal intravenously.
local
and crew. public
mental health
status authorities may need to be
If dyspepsia
Refer
Consider suspected
to conditions
allergic reaction
benzodiazepine Antacids
card.
ifnecessary.
available or from
otherthe
Ifcontacted
Diversion
other at
is not the destination.
commonly suspected
analgesics
emergency
If passenger can be card.
medical
does given
not kit. after appropriate risk
improve
Refer
severe to relevant
abdominal pain, tenderness on examination,
stratification.
Contact
If ongoing ground-basedAlternative
respiratory causes
medical
distress should
support
or first
combativeness
rigid
If no improvement or notinprogressing
abdomen, or blood bodily fluid
be
for considered.
additional
Contact ground-basedrecommendations. medical support for
as expected Contact ground-based
If
for persistent
additional
additional or additional
recommendations.
recommendations. symptoms
Refer to airline crew
medical support for additional recommendations.
Contact
for individual ground-based
airline security medical support
protocols.
for additional recommendations.
© 2018
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rights reserved.
 SUBSTANCE
CARDIOVASCULAR
GASTROINTESTINAL
SYNCOPE
STROKE-LIKE
PSYCHIATRIC
RESPIRATORY
ALLERGIC
ABUSE
TRAUMA
SEIZURE
/ NEAR-SYNCOPE
REACTION
SYMPTOMS
DISTRESS
ANDSYMPTOMS
WITHDRAWAL
ILLNESS
Up30%
15%
10%
7%
5%
2%
to 3%
5%
of
ofall
of
allall
in-flight
in-flight
in-flight
emergencies
emergencies
emergencies
Initial assessment
assessment-suspect
Vasovagal:
A
Assess
Aim
Identify
focused
to all
create
if
extent
history
the
type,
anyhistory
injuries
any
Pale,
symptoms
known
aamount,
prior
and
rapport
ofdiaphoretic,
should
for
respiratory
timing
myocardial
orany likely
and
the
with
include
open
of
passenger
timing
allergen
the
symptoms,
improves
disease,
wounds,
infarction
the
passenger
time exposure;
exhibited
of
with
including
scuba
or
symptom
during
tenderness,
to
of
duration
substances
other
deescalate
simple
diving,
thecardiovascular
and
onset,
nausea,
event:
measures
deformity,
severity
extremity
the
used.
specific
situation.
vomiting,
of
inor
history.
motor
swelling,
symptoms;
15-30
active
diarrhea,
and min.
bleeding.
sensory
and bleeding,
any
and
or
components,
Including
airway
In infectious
Cardiac
Assess
Elicit
Identify
somespecifics
swelling,
onset,
information
patients
cause
settings,
symptomsand
symptoms.
of
(eg, any
duration
respiratory
any
with
aand abdominal
other
myocardial
12-lead
andinjury
considerof
mental associated
toinvolvement,
movement
pain
electrocardiogram
the
infarction):
status,
thehead, (location,
symptoms
activity,
passenger’s or signs
neck, may
quality,
including
quality
of
Chest
If
be
or
use
alongsystemic
available,
back
obtained
of withof
and
pain, headache
movements
reaction
severity).
mood-altering
for vital
any
dyspnea,
and
check or
neurological
signs. such
transmitted
pulse sensorium
arm(eg,
substances.as
tonic-clonic),
generalized
oximetry.
or jaw changes.
symptoms.
for ground
pain, review hives.
and loss offor
persistent
(and/or
Screening
Suspected bowel or bladder function.
Identify volunteer
Suspected bradycardia.
localstroke:
if patient
opioid allergic
review
Speech
ingestion:
takes reaction:
if qualified
specificdisturbance,
Altered Localized
to read).
psychiatric
mentation,
facial
pruritic
Management
Pulmonary:
Suspected droop,
medications,
constricted rash or
or
acute
pupils,arm
isolated
and
Dyspnea,
dosing, weakness.
expected
coronary
respiratory
last hives.
pleuritic dose
syndrome:course
taken,
chest
depression. pain.
Chest pain,
Management
Management and
and expected
expected course
course
dyspnea,
and
Suspected
If if
Management
If ongoing
Stroke:
Suspected available
nausea/emesis arm
anaphylaxis:
or
dyspnea
Slurred
alcohol on
jaw
and
speech,aircraft.
pain.
expected
Use
or
ingestion: Airway
an
known oral
facialAltered swelling,
course
antiemetic
oxygen
droop, saturation
mentation,
Injuries from falling luggage Typically minor
respiratory
Management
if
If
is available;
unresponsive
<95% distress,
if not and generalized
expected
tolerated,
Lay passenger consider hives,
course
on a on side,
floor
or
Suspected
slurred
and armmay beAdminister
weakness.
speech,
arrhythmia:
assessed behavior oxygen.
Persistent
further changes.
at the bradycardia,
destination.
hypotension,
parenteral
Administer
Management
monitor
tachycardia, airway, ornausea/vomiting.
antiemetic.
oxygen, and unless
andexpected
irregular assess saturations
vitalcourse
heartbeat. signs are known
with
If passenger’s
Hypoglycemia:
Suspected
Active stimulant
bleeding portable
Diaphoretic,ingestion:
Control oxygen concentrator
coolAltered
bleeding skin;
with mentation,
direct
to
If be
ongoing
Provide
verbal
fails ornear or
isusing
not at
neurological
oral normal
hydration
deescalationused for levels.
examination
if
aif tolerated.
ineffective
patient as above.
with preexisting
assess
Suspected
tachycardia,
pressure with dyspepsia:
glucometer
dilated
a gloved pupils,
Isolated available.
hand. agitation.
epigastric burning
Consider
Management
If patient
ongoing
lung
with
Use no ahas
disease, benzodiazepine
seizing
associated
sugar-containing andsymptoms.
ongoing
consider expected trialifof
neurological
Administer
liquids available
ifcourse
This parenteral
oxygen from
isdeficits
therapy.an
a consideration
symptoms
Ongoing
extended
suggestive heavy
emergency
of a extremity
stroke medical bleeding
Contact kit. ground-based
benzodiazepines
If
of local allergic
ofexclusion,
If hypoglycemia.
Management
passenger supported
and
uses if
reaction available
expected in
by history the
oncourse emergency
Consider
Management
medical applying
support.
kit (not and a≥4
usually
L/min
tourniquet.
expected available
the ground,
course
Diphenhydramine,
of
Ifthesimilar
Benzodiazepines
normalonboard symptoms.
vital oxygen
signs 25-50
are
and not
supply
no mg in adults
commonly
may
respiratory beorenough
not available 1 mg/kg
compromise in
IfIfunconscious
oral intake
Suspected long not Lie
bone tolerated,
flat,
or elevate
joint consider
injuries legs, apply
on
inthe US commercial
children
emergency
Recommendation
to reverse
Observation orally.
hypoxia.
only. airlines).
medical
may kit
include and are infrequently
diversion,
Management
intravenous
oxygen.
Splinting Ifmaterial
no pulse and
fluids. expected
ornot signs course
of life, found in the
a isprolonged
necessary commonly
If
Ifwhich
Ifalert
unable
Monitor
suspected
may toeven
following
flow not
tolerate
acuterate
opioid
when
be to
oforal
coronary
available.
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oxygen
ingestion
closest
ingestion,or
syndrome airport
recurrent seizure
diphenhydramine
administered;
with
follow
If dyspepsia
emergency
if stroke
cardiac medical
care
arrest
Use
is not
an card.
kit,antacid
presentbut may if
at berespiratory
available
that improvised
airport.
in the
Ground-based
If combative
Aspirin,
canister
depression 325 mg medical
intravenously/intramuscularly
consumptionRefer
orally;
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flight crew
nitroglycerin,
is variable
0.4-0.8 may
at
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above
for 0.4 dose.
individual
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aircraft
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aownU-shaped elevate
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orTry
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mg dose
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different
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protocols,
5-10
histamine
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intramuscularly/intranasally.should min which
oxygen have
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blocker take antiepileptic
systolic
for precedence
information
blood
continuous
half-rolled
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with
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an secured
raised
antidiarrheal with
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ifand will
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available in the
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for
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medical
Hg). seizures
management.
care near most available)
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or
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forearm
alcohol
medical15-30
benzodiazepine
emergency
of
or
overdose
kit.min, wristslowly
(if
medical
flight.
splint).
availablesit upinkit. the
Ifmajor
Airline
any airports.
security
dyspnea
anaphylaxis
bronchospasm protocols
orEpinephrine,
respiratory vary by
distress
1 mg/mL airline (0.3andmLmay
Observe
and return
emergency and to provide
seat
medical antiemetic
if tolerated. therapy.
If patient
include has
restraining feverkit). andpassenger
the persistent or diarrhea
diverting
Give
in oxygen,
adults,
Administer
If suspected or unless
0.15
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in
2.5 children
mg
ingestion are known
intramuscularly),
inhaled.
If hypoglycemia
(>14
seizure
the d),resolves
aircraft contact
for Oral
ground-based
and
the glucose
patient
safety ofregains
otherormedical
25 g ofsupport,
passengers dextrose
to
If beintravenously.
near
diphenhydramine,
allergic
Observe and or hydrate
at normal
reaction and (for levels.
steroids if available
tachycardia). in the
50%
as
and crew. medical kit. Epinephrine may be to be
normal local public
mental health
status authorities may need
emergency
If dyspepsia
Refer
Consider suspected
to conditions
allergic reaction
benzodiazepine Antacids
card.
ifnecessary.
available or from
otherthe
Ifcontacted
Diversion
other
available as
at
is not the destination.
commonly
an autoinjector suspected orappropriate
in an ampoule
analgesics
emergency
If passenger can
medical
does be given
not kit. after
improve risk
Refer
to severe to relevant
be drawn abdominal
up viacard. pain,
syringe. tenderness on examination,
stratification.
Contact
If ongoing ground-based Alternative
respiratory medical
distress causes should
support
or combativenessfirst
rigid
If no abdomen,
improvement or bloodor not inprogressing
bodily fluid
be
If
for considered.
there isground-based
additional
Contact no improvement
recommendations. medical support for
as expected
Contact ground-based Contact ground-based
medical support
If
for persistent
additional
additional or additional
recommendations.
recommendations. symptoms
Refer to airline crew
medical
for support for additional recommendations.
for additional
Contact ground-based
individual recommendations.
airline medical
security support
protocols.
for additional recommendations.
© 2018
Downloaded From: American Medical Association.
https://edhub.ama-assn.org/ onAll03/03/2023
rights reserved.
 OBSTETRIC EMERGENCIES
1% of all in-flight emergencies
Initial assessment
Identify onset and detailed description
of symptoms, along with information about the
pregnancy (eg, parity, gestational age, and any
preceding complications).
Vaginal bleeding: Assess duration and severity
(ie, equivalent of pads per h).
Labor suspected: Regular contraction,
gush of vaginal fluid.

Management and expected course

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

© 2018
Downloaded From: American Medical Association.
https://edhub.ama-assn.org/ onAll03/03/2023
rights reserved.
 SUBSTANCE
CARDIOVASCULAR
GASTROINTESTINAL
SYNCOPE
OBSTETRIC
STROKE-LIKE
PSYCHIATRIC
RESPIRATORY
ALLERGIC
CARDIAC
ABUSE
TRAUMA
SEIZURE
/ NEAR-SYNCOPE
EMERGENCIES
REACTION
ARREST
SYMPTOMS
DISTRESS
ANDSYMPTOMS
WITHDRAWAL
ILLNESS
Up0.2%
30%
15%
10%
7%
5%
2%
1%
to 3%
5%
of
of
ofall
of
all
allall
in-flight
in-flight
in-flight
in-flight
emergencies
emergencies
emergencies
emergencies
Initial assessment
assessment-suspect
Vasovagal:
A
Assess
Aim
Identify
Check
focused
tobreathing
all
create
if
extent
history
the
type,
any
onset
history
injuries
any
Pale,
symptoms
known
aamount,
prior
andand
rapport
ofdiaphoretic,
and
should
for
respiratory
detailed
timing
myocardial
orpulse;
any
likely
and
the
with
include
open
of
passenger
timing
description
limit
allergen
the
symptoms,
improves
disease,
wounds,
infarction
thepassenger
pulse
time exposure;
exhibited
checks
of
with
including
scuba
or
symptom
during
tenderness,
duration
of
to substances
symptoms,
other
deescalate
<10 simple
diving,
the
seconds.
cardiovascular
and
onset,
nausea,
event:
measures
deformity,
severity
extremity
the
used.
along
specific
situation.
vomiting,
with
of
inor
history.
motor
swelling,
symptoms;
15-30
information
active
diarrhea,
and min.
bleeding.
sensory
and about
bleeding,
any the
and
or
components,
Including
airway
pregnancy
infectious
Cardiac
In
Assess
Elicit
Identify
somespecifics
swelling,
onset,
information
patients
cause (eg,
settings,
symptoms and
symptoms.
of parity,
(eg, any
duration
respiratory
any
withaand abdominal
other
gestational
myocardial
12-lead
andinjury
considerof
mental associated
toinvolvement,
movement
pain age,
electrocardiogram
the
infarction):
status,
thehead, (location,
symptoms
and
activity,
passenger’s
neck,orany
signs
may
quality,
including
quality
of
preceding
If
be
or
use
alongsystemic
Management
Chest
available,
back
obtained
of withof
and
pain, headache
movements
complications).
reaction
severity).
mood-altering
for vital
any
dyspnea,
and
check and or such
neurological
signs.
transmitted
pulse sensorium
arm(eg,
expected
substances.as
tonic-clonic),
oximetry.
or jawgeneralized
changes.
course
symptoms.
for ground
pain, review hives.
and
If noloss
pulse
persistent
(and/or
Screening
Suspected
Vaginal ofbradycardia.
bowel
or
bleeding:
volunteer signs or bladder
ofSpeech
lifespecific function.
Identify
Suspected if for
local stroke:
patient
opioid allergic
Assess
review
ingestion:
takes reaction:
duration
if qualified
disturbance,
Altered Localized
and toseverity
psychiatric read).
mentation,
facial
pruritic
(ie, equivalent
Management
Pulmonary:
Suspected droop,
Start chest
medications,
constricted rash oror arm
of
isolated
and padsweakness.
compression-only
acute
pupils,
Dyspnea,
dosing,coronary per
expected
respiratory
last hives.
pleuritic h).
dose
syndrome: course
cardiopulmonary
taken,
chest
depression. pain.
Chest pain,
Management
Management and
and expected
expected course
course
If
Ifresuscitation,
dyspnea,
and
Suspected
Labor if
Management available
suspected:
nausea/emesis
ongoing
Stroke:
Suspected arm
dyspnea
Slurred
alcohol with
anaphylaxis:
or on
andjaw
speech, addition
Regular
aircraft.
pain.
expected
Use
or Airway
an
known
ingestion: oral of
contraction,bag-valve-mask
swelling,
course
antiemetic
oxygen
facialAltereddroop, saturation
mentation,
Injuries from falling luggage Typically minor
if
If
isventilation
respiratory
gush
Managementofweakness.
available; vaginal
unresponsive
<95% if(30
distress,
not compressions
fluid.
and Lay generalized
expected
tolerated,
passenger toon
course
consider 2 ventilations)
hives, a on side,
floor
or
Suspected
slurred
and armmay beAdminister
speech,arrhythmia:
assessed behavior oxygen.
Persistent
further changes.
at the bradycardia,
destination.
when the
hypotension,
parenteral
Administer
Management
monitor
tachycardia, emergency
airway, ornausea/vomiting.
antiemetic.
oxygen, and unless
andexpected
irregular medical
assess kit
saturations
vitalcourse
heartbeat. is available
signs are known
with
If
Active
and passenger’s
Hypoglycemia:
Suspected bleeding
someone stimulant portable
Diaphoretic,
ingestion:
Control
skilled is oxygen
bleeding
present. concentrator
coolAlteredskin;
with mentation,
direct
to
If be
ongoing
Provide
verbal
Management
fails ornear or at
neurological
oral
deescalation
isusing
not normal
hydration
and
used for levels.
examination
if
aif tolerated.
ineffective
expected patient course as above.
with preexisting
assess
Suspected
tachycardia,
pressure with dyspepsia:
glucometer
dilated
a gloved pupils,
Isolated available.
hand. agitation.
epigastric burning
Obtain
Consider
Management andahas apply
benzodiazepine automated
andsymptoms.
expected ifof external
available defibrillator
from an
If patient
ongoing
lung
with
Use
Ongoing
no
vaginal disease, seizing
associated
bleeding
sugar-containing
heavy
ongoing
consider <1
extremity
neurological
Administer
pad trial
liquids per hcourse
This
bleeding if isdeficits
parenteral
oxygen therapy.
a consideration
symptoms
as soon
extended
suggestive
benzodiazepines
If
of local as
allergic possible
emergency
of a stroke
if
reaction andmedical
available follow
Contact in kit.instructions
the ground-based
emergency
ofexclusion,
Expectant
If hypoglycemia.
Management
passenger
Consider
Management applying
supported
managementand
uses
and a≥4expected
L/minby
tourniquet.
expected
history
is common.
oncourse
the ground,
course
for
medical defibrillation.
Diphenhydramine,
of similar support.
kit (not
symptoms. usually
25-50 available
mg in adults orenough
1 mg/kg
IfBenzodiazepines
the
normalonboard
preterm
Ifunconscious
oral intake vital
labor oxygen
signs
not in are
and
third not
supply
tolerated, no commonly
may
respiratory
trimesterconsider not available
be
compromise in
If
Suspected
on
inIf
the US
no shock
emergency long
commercial
children orally.
is Lie
bone
advised,
medical flat,
or
airlines). or elevate
jointAFTER
kit injuries
and legs,
a
are shock applyis
infrequently
Recommendation
to
Place reverse
Observation
Management hypoxia.
theIfmaterial
intravenous only.
passenger and
fluids. may
expected
onsigns include
left side diversion,
course
andfoundconsider fluid
oxygen.
Splinting noresume
pulse or of life,
a isprolonged
delivered,
necessary not commonly
cardiopulmonary in the
resuscitation
If
Ifwhich
Ifalert
unable
intravenously
Monitor
suspected
follow
may
cardiactoeven
following
flownot
tolerate
if
acute
when
be
any
rate
opioid
arrest
to
oforal available.
the
concerns
coronary
oxygen
ingestion
card.
closest
ingestion,orexist
syndrome airport
recurrent
for
administered;
with blood
respiratory seizure
diphenhydramine loss
If dyspepsia
emergency medicalUse an antacid if available in the
or
If
if
if there
stroke
Ground-based
distress.
combative
Aspirin,
canister
iscare
325
no
mg
pulse.
consumption notkit,
isRefer
medical
intravenously/intramuscularly orally; presentbut may
tosupport
flight atcrew
nitroglycerin,
is variable
be improvised
that
may
at airport.
recommend
above
for
and 0.4 dose.
individual
mg legs.
aircraft
depression
emergency
from
If available
transient Naloxone,
medical
syncopeequipment kit. 0.4-0.8
Supine (eg, a mg intravenously
U-shaped
position, elevate
anIf added
no
airline
sublingually
orTry
may2 a
mg responsedose
security
Ground-based
different
not have everyof to the
team 5-10
histamine
sufficient patient’s
cardiopulmonary
protocols,
intramuscularly/intranasally.should min whichhave
(if
blocker
oxygen own take antiepileptic
resuscitation
precedence
information
systolic
for blood
continuous
Active
half-rolled
Oral
If diarrhea labor,
fluids withongoing/severe
magazine
Use head
an secured
raised
antidiarrheal vaginal
with
if nausea tape
ifand bleeding,
will
absent.
available in the
medication
and
over
on
pressure automated
attempts
capabilities (if
is ≥100 history
at external
medical
formm ofthe
medical
Hg). seizures
defibrillator,
management.
care near most available)
initiate an
Ifif
or
or
use
make available
for
suspected
improves
emergency
an oral
intravenous
the
increasing/severe
a good inin the
duration
forearm
alcohol
medical15-30
benzodiazepine
emergency
of
abdominal
or
overdose
kit.min, wrist
line. Administer epinephrine slowly
(if
medical
flight. pain
splint).
available sit up in
kit.
the
Ifmajor
Contact
Airline
any airports.
ground-based
security
dyspnea protocols medical vary 1 support
by airline andmLmay
anaphylaxis
bronchospasm
Observe
and return
emergency
(0.1
If mg/mL)
patient
and to
medical
has 1or
provide
seat mg
fever
respiratory
Epinephrine,
antiemetic
ifkit).
tolerated.
intravenously,
andpassenger
distress
persistent or
mg/mL
therapy.
along (0.3
diarrhea with
for
Give
in additional
includeoxygen,
adults,
Administer restraining
or 0.15 recommendations.
unless
albuterol, mL the
saturations
in
2.5 children
mg are diverting
known
intramuscularly),
inhaled.
If
Ifconsideration
suspected
hypoglycemia
(>14
seizure d),resolves
contact ofand
stimulant causal
Oral
ground-based reversible
ingestion
glucose
patient conditions
ormedical
25 g ofsupport,
dextrose
tothe aircraft
beintravenously.
near
diphenhydramine, for
or hydrate the
at normal and safety levels.
steroids ofregains
other passengers
if available in the
Ifsuch
50%
asallergic
Observe as hypovolemia
andreaction and
(for tension
tachycardia). pneumothorax.
and crew. medical kit. Epinephrine may be to be
normal local
emergency
public
mental health
status authorities may need
If dyspepsia
Refer
Consider to conditions
allergic suspected
benzodiazepinereaction Antacids
card.
ifnecessary.
available or from
other the and
Ifcontacted
Diversion
Instruct
other
available as
at
is not
flight the
an crew
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