What is the management of cardiac arrest on an airplane?

Management of Cardiac Arrest on an Airplane

The management of cardiac arrest on an airplane should follow standard ACLS protocols with immediate CPR, early defibrillation if available, and consideration of diversion to the nearest airport for advanced medical care.

Initial Response and Recognition

• Immediately identify cardiac arrest by checking for unresponsiveness, absence of normal breathing, and no definite pulse within 10 seconds 1
• Activate the aircraft emergency response system by alerting flight attendants
• Request the emergency medical kit and AED (automated external defibrillator) if available
• Begin high-quality CPR immediately, starting with chest compressions 2
• Move the patient to a location with adequate space if possible (e.g., galley area)

High-Quality CPR

• Push hard (at least 2 inches/5 cm) and fast (100-120 compressions/minute) 2
• Allow complete chest recoil after each compression
• Minimize interruptions in compressions to less than 10 seconds
• Rotate compressors every 2 minutes to prevent fatigue and maintain quality 2
• Use a compression-to-ventilation ratio of 30:2 for adults without an advanced airway 1

Airway Management

• Begin with basic airway management using bag-mask ventilation with 100% oxygen if available 2
• Consider using oropharyngeal airways to facilitate ventilation if available 2
• If trained personnel are available and equipment is present, consider supraglottic airway devices as they are easier to place than endotracheal tubes 2
• Avoid prolonged attempts at advanced airway placement as this interrupts chest compressions 2

Defibrillation

• Apply AED/defibrillator as soon as available while continuing CPR 2
• Use the manufacturer's recommended dose for biphasic defibrillators (typically 120-200J) or 360J for monophasic defibrillators 2
• Resume CPR immediately after shock delivery without a rhythm or pulse check 2
• Continue CPR for 2 minutes before the next rhythm check 2

Communication and Diversion Decision

• Communicate with ground medical control if available
• Consider aircraft diversion to the nearest airport with appropriate medical facilities 3
• The decision for diversion should be made carefully, considering:
  • Patient's condition and likelihood of survival
  • Availability of on-board medical resources
  • Distance to nearest appropriate airport
  • Weather conditions and technical feasibility

Addressing Reversible Causes

Consider and treat possible reversible causes of cardiac arrest (the "H's and T's") 2:

• Hypoxia (most common in aircraft environment due to cabin pressure)
• Hypovolemia
• Hydrogen ion (acidosis)
• Hypo/hyperkalemia
• Hypothermia
• Tension pneumothorax
• Tamponade, cardiac
• Toxins
• Thrombosis, pulmonary
• Thrombosis, coronary

Special Considerations for In-Flight Cardiac Arrest

• Limited space may make standard CPR positioning difficult; adapt as necessary
• Cabin altitude (reduced oxygen pressure) may contribute to hypoxia
• Limited medical resources compared to hospital settings
• Consider using the AED for monitoring an acutely ill passenger even before arrest 4
• If VF is present, defibrillation can be initially successful in up to 91% of cases 4

Post-Resuscitation Care

• If return of spontaneous circulation (ROSC) is achieved:
  • Continue oxygen administration
  • Monitor vital signs closely
  • Position patient to optimize airway and circulation
  • Prepare for landing and immediate transfer to emergency medical services

Common Pitfalls and Caveats

• Failure to recognize cardiac arrest promptly
• Inadequate CPR quality due to space constraints or fatigue
• Delayed access to or application of AED
• Excessive ventilation which can decrease venous return and cardiac output 5
• Prolonged interruptions in chest compressions for airway management or other interventions
• Failure to consider diversion to nearest airport with appropriate medical facilities

Research has shown that AEDs in aircraft, with appropriate crew training, can be helpful in managing cardiac emergencies, with survival from VF comparable to effective prehospital emergency services 4. Additionally, the ability to monitor cardiac rhythm can aid in diversion decisions, which can be avoided in clearly futile situations 4.