What is the management of a myocardial infarction (heart attack) on an airplane?

Management of Myocardial Infarction on an Airplane

The management of a heart attack on an airplane requires immediate recognition, basic life support, use of available emergency medical equipment including automated external defibrillators (AEDs), and consideration of aircraft diversion based on the patient's condition and rhythm. 1, 2

Initial Assessment and Management

• Recognize symptoms of myocardial infarction: chest pain (which may radiate to left arm or neck), shortness of breath, sweating, nausea, vomiting, abnormal heart beating, anxiety, and fatigue 3
• Administer oxygen (2-4 L/min) if available, especially if the patient is breathless or shows signs of heart failure 4
• Place the patient in a position that facilitates breathing and reduces cardiac workload 4
• Request the cabin crew to announce the need for medical assistance to identify if healthcare professionals are on board 1

Pain Management and Initial Treatment

• Administer aspirin if available, which prevents further blood clotting 3
• Provide nitroglycerin if available for chest pain relief 4, 3
• Consider opioid analgesics (if available in the emergency medical kit) for pain relief - typically 4-8 mg morphine intravenously with additional 2 mg doses at 5-minute intervals until pain is relieved 4
• Monitor for side effects of opioids including nausea, vomiting, hypotension, bradycardia, and respiratory depression 4

Use of Emergency Medical Equipment

• All commercial aircraft carrying approximately 30 or more passengers with at least one flight attendant are mandated to have an emergency medical kit and AED 4
• Establish ECG monitoring using the AED to determine cardiac rhythm 4, 2
• If ventricular fibrillation (VF) or pulseless ventricular tachycardia is detected, immediate defibrillation should be performed 4, 2
• For cardiac arrest, initiate high-quality cardiopulmonary resuscitation (CPR) immediately 4, 2

Communication and Decision Making

• Establish direct voice communication with ground-based medical services if available 4, 1
• Communicate with the flight crew regarding the patient's condition and potential need for diversion 1, 2
• Consider aircraft diversion for patients with:
  • Recurrent pain despite initial treatment 4
  • Hemodynamic instability (persistent heart failure, hypotension, or cardiogenic shock) 4
  • Resistant or recurrent ventricular arrhythmias 4
  • Shockable rhythm (VF or unstable ventricular tachycardia) with return of spontaneous circulation after defibrillation 2

Special Considerations

• For patients with non-shockable rhythms (asystole or pulseless electrical activity), the prognosis is poor, and the decision for diversion should carefully weigh the potential benefit against operational considerations 2, 5
• Survival rates from in-flight cardiac arrest with VF can be comparable to effective pre-hospital emergency services when AEDs are available and used promptly 5
• If the patient stabilizes, monitor vital signs and cardiac rhythm continuously until landing 4, 2

Post-Landing Care

• Ensure a complete medical record is transferred with the patient to emergency medical services 4
• Provide information about treatments administered during the flight 4
• The patient should be transferred to a facility with appropriate cardiac care capabilities 4

Prevention for At-Risk Travelers

• Patients with recent myocardial infarction should avoid air travel within the first 2 weeks unless there is no angina, dyspnea, or hypoxemia at rest 4
• Travelers with known cardiovascular disease should:
  • Carry sufficient medication in carry-on luggage 4
  • Have a copy of their most recent prescription and medical information 4
  • Consider compression stockings for flights to prevent deep vein thrombosis 4, 6