medical issues in aviation · 2013-09-18 · medical issues in aviation passenger fitness to fly...
TRANSCRIPT
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02/04/2009Lima 2009 1
Medical Issues in Aviation
Passenger Fitness to Fly
Lima, Peru, April 2009
Claude Thibeault MDMedical Advisor
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02/04/2009Lima 2009 2
Passenger Fitness to FlyPlan
- Review real cases based on altitude physiology- Review real cases based on other considerations- Review contraindications to fly (as passenger)- Discuss rationale for medical clearance
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02/04/2009Lima 2009 3
0 200 400 600 760
Atmospheric PressureDECREASES
With Altitude
Atmospheric Pressure mm Hg
30,000
20,000
10,000
Sea Level
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02/04/2009Lima 2009 4
Passenger Fitness to FlyAt cruising altitude (ex:39000 feet), the cabin of a
commercial aircraft (ex:A320):
1. is pressurized to ground pressure equivalent
2. is pressurized to 6000-8000 feet
3. is pressurized to 2000-3000 feet
4. is not pressurized
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02/04/2009Lima 2009 5
Decrease of Atmospheric PressureDecrease of Atmospheric Pressure
Decrease of Decrease of Partial PressurePartial Pressure
Trapped GasProblem
Evolved GasProblem
•Ear trauma•Sinus barotrauma•Abdominal problem•Etc.
•Decompressionsickness
Decrease ofTotal Pressure
Hypoxia
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02/04/2009Lima 2009 6
The total pressure of a given mixture of gases is equalto the sum of the partial pressures of the gases
Partial Pressures - mm HgVolume of Gas - per cent
NITROGEN60079
OXYGEN16021*
AIR760100
*constant to 70,000 feet
ATMOSPHERE SEA LEVEL - DRY
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02/04/2009Lima 2009 7
Gas Pressure Variation and O2 Saturation At Altitude
ALTITUDE PRESSURE
Atmospheric Ambient air02
AlveolarCO2 O2
ArterialCO2 O2
SaturationO2
Sea Level 760 159 37 107 40 98
71 64
55
50
37
59
55
42
97
6000 (1800 m) 610 125 37 40 92
8000 (2400 m) 565 116 37 39 90
10000 (3000 m) 525 100 36 36 82
15 000 (4500 m) 430 80 33 30 70
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02/04/2009Lima 2009 8
Hypoxia- J.K. 64 y/o male
- MI (heart attack)10 days ago with cardiac failure and poorly controlled arrhythmia
- Wants to travel alone from Toronto to Los Angeles to visit his daughter
- Can he travel on a commercial airline?
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02/04/2009Lima 2009 9
HypoxiaJ.K. (cont.)
- Travel not approved- Travel could be approved as medical evacuation with:
• Stretcher• Physician• Monitoring equipment and medication• O2, 4 LPM
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02/04/2009Lima 2009 10
Hypoxia- M.V. 57 y/o female- Quebec – New York (2.0 hours)- C.O.P.D. with exertion dyspnea- Patient uses O2 at home 2 LPM for 18 hours. Not a CO2
retainer. Stable.- 15% O2 test = PO2 drop to 40- Flight in one month with husband- Treating physician requests O2 4 LPM
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02/04/2009Lima 2009 11
Hypoxia
- M.V. 57 y/o female (Cont’d)
- Flight approved if no change until the flight,with:• O2 4 LPM• Wheelchair• Non medical escort
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02/04/2009Lima 2009 12
PRE FLIGHT ASSESSMENT (Adults)
- Predicting hypoxemia from equations- Hypoxic challenge test
• 15% o2
- The 50 meter walk
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02/04/2009Lima 2009 13
HypoxiaCOPD
- IF PaO2 < 70 mmHg on room air = supplemental oxygen 2L/min.- Inhaler in hand luggage- Spacer as effective as nebuliser- Consider requesting wheelchair at airport- Check for bullae
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02/04/2009Lima 2009 14
Hypoxia- C.C. 82 y/o female- Paris – Toronto - Vancouver (13.0 hrs 10 min.)- Stroke 5 days ago- Residual left hemiparesia. Stable. Controlled HBP. Non
insulin dependent diabetes.- Flight 7 days post stroke- Traveling alone with wheelchair
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02/04/2009Lima 2009 15
Hypoxia
- C.C. 82 y/o female (cont’d)- Flight could be approved with:
• Stretcher • O2 2 LPM• Medical escort
- Otherwise wait for at least 14 days and travel with non medical escort
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02/04/2009Lima 2009 16
Conditions affected by hypoxia
- Anemia
- Shock
- Poisoning
- Eye trauma
- Coronary disease
- Heart failure
- Pulmonary disease
- Stroke
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02/04/2009Lima 2009 17
Ventilation and available oxygen
In an airplane that recirculates air, there is a significant decrease in available oxygen?
A) True
B) False
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02/04/2009Lima 2009 18
Oxygen Consumption vs. Oxygen SuppliedOxygen Consumption vs. Oxygen Supplied
Oxygen Supplied on
Aircraft WithoutRecirculation
Oxygen Supplied on
Aircraft With 50 %Recirculation
0
.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Oxygen Consumed
OXYGENcfm/passenger
4.20 cfm 4.19 cfm
0.015 cfm *
* Cubic feet per minute
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02/04/2009Lima 2009 19
Decrease of Atmospheric PressureDecrease of Atmospheric Pressure
Decrease of Decrease of Partial PressurePartial Pressure
Trapped GasProblem
Evolved GasProblem
•Ear trauma•Sinus barotrauma•Abdominal problem•Etc.
•Decompressionsickness
Decrease ofTotal Pressure
Hypoxia
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02/04/2009Lima 2009 20
Gas Expansion
E.W. 50 y/o female
• Car accident two days ago with thoracic injury
• Small pneumothorax still visible on x-rays
• Fine otherwise
• Wants to travel Montréal to Paris
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02/04/2009Lima 2009 21
Gas Expansion
You are the airline physician, do you accept to transport E. W.?
A)Yes
B)No
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02/04/2009Lima 2009 22
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02/04/2009Lima 2009 23
PNEUMOTHORAX
• Closed pneumothorax is contraindication to air travel
• Pneumothorax under drainage(Heimlich valve) = Medical escort
• Resolved pneumothorax: needs at least 5 days before travelling and chest x-ray before the flight
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02/04/2009Lima 2009 24
BULLAEBULLAE
• Pneumothorax
• Pneumo mediastinum
• Air embolism
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02/04/2009Lima 2009 25
Gas expansion- G.G. 38 y/o male- Going home from Montreal via Toronto to Port of
Spain (5 hrs 30 min.)- Widely spread intestinal cancer- Had a known Crohn’s disease, but required an
emergency laparotomy for sub-occlusion.Generalized carcinomatosis. Stable. No anemia.Gastric tube in place drain 600 cc/8 hrs
- Flight 5 days post-op. Stretcher with a nurse escort.
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02/04/2009Lima 2009 26
Gas expansion
- G.G. 38 y/o male (cont’d)- X-Ray shows no air level at this time- Approved if X-Ray normal the morning of the flight- Stretcher- Nurse with appropriate medication
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02/04/2009Lima 2009 27
Structures affected by gas expansion
- Gastrointestinal tract
- Middle ear
- Sinus
- Lung
- Any other structures where gas has been introduced by
accident, by surgery or for investigation
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02/04/2009Lima 2009 28
Structures affected by gas expansion
Do not forget equipment with air:
- Air splint
- Catheters
- Anti-shock trousers
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02/04/2009Lima 2009 29
Henry’s lawHenry’s law
The amount of gas dissolved in solution is directly proportional to the pressure of the gas over the solution
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02/04/2009Lima 2009 30
Evolved Gas
- L.K. 39 y/o female- Barbados to Toronto (5 hrs 30 min.)- Passenger is crazy about SCUBA diving and has done
18 dives in 6 days- Wants her money’s worth and plan a dive the morning
before the flight departure. No health problem.- What do you recommend?
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02/04/2009Lima 2009 31
Evolved Gas
- L.K. 39 y/o female (cont’d)- High risk of decompression sickness- Minimum delay of 12 hrs between last dive and the
flight- The Undersea Medical Society recommends 24 hrs if
several repeated dives during the previous days.
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02/04/2009Lima 2009 32
Evolved Gas- M.G. 32 y/o male- Miami to Montreal (3 hrs 20 min.)- Professional underwater photographer presently in
transit in Miami after a trip to Honduras where he made several dives in the last 10 days
- Pain in left elbow during flight to Miami with paresthesia of left 5th finger
- No previous medical problem
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02/04/2009Lima 2009 33
Evolved Gas- M.G. 32 y/o male (cont’d)- Rule out type II Decompression Sickness- Contraindication to commercial flight- Consultation in hyperbaric medicine- Reference given: “Divers Alert Network”- If Decompression Sickness proven, should probably
be treated on the spot. Otherwise need 0 – 500 feet cabin altitude
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02/04/2009Lima 2009 34
Other ConsiderationsSpecific conditions
- Contagious disease
- Active psychiatric condition
- Pregnancy
- Newborn
- Epilepsy
- Diabetes
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02/04/2009Lima 2009 35
Contagious Disease- R.C. 2.5 y/o male- Val d’Or to Montreal with mother (1 hrs 10
min.)- Anemia for 1 month, Hb at 7.3 gr- Transfer for complete investigation- Chickenpox in the last 72 hours- Flight the same day
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02/04/2009Lima 2009 36
Contagious Disease
- R.C. 2.5 y/o male (cont’d)
- Flight refused
- Could be considered again with oxygen when not contagious
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02/04/2009Lima 2009 37
Psychiatry
- R.A. 23 y/o male- London UK to Toronto (8 hrs 35 min.)- Schizophrenia:
• First episode in Prague• Transferred to London 2.5 weeks ago• Partial insight, relatively stable• Taking Haldol 15 mg die and Kemadrin 5 mg die
- Flight in 3 days- No escort recommended by treating physician
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02/04/2009Lima 2009 38
Psychiatry
- R.A. 23 y/o male (cont’d)- Flight approved with:
• Medical escort (psychiatric nurse)• Sedation• Supply of appropriate medication for the trip
- Treating physician not happy with the decision
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02/04/2009Lima 2009 39
Other Considerations
Turbulence
- Air sickness
- Anxiety
- Traction
- Unstable fracture
- Intravenous line
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Air Sickness- A.H. 17 y/o female
- Ottawa to Halifax (1 hr. 30 min.)
- Jaw fracture reduced with wiring
- Liquid diet
- Flight 4 days post-op
- Mother will accompany the patient
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Air Sickness
- A.H. 17 y/o female (cont’d)
- Flight approved
- Patient should preferably have anti-emetic
- Mother must be taught how to release the wiring
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02/04/2009Lima 2009 42
Unstable Fracture- D.B. 32 y/o male
- Port au Prince to Montreal (4 hrs. 10 min.)
- L 1 fracture 2 days ago; paraplegic
- Acute schizophrenia. Fell from the roof while watching the stars.
- X-Ray shows cuneiform fracture with vertical posterior displacement.
Needs surgery asap.
- Dexamethasone, Haldol, Foley catheter
- Stretcher with escort nurse (family member) the same day
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Unstable Fracture- D.B. 32 y/o male (cont’d)
- Our orthopedic consultant does not recommend commercial air
transport because of unstable fracture. Risk also increased if patient
is agitated.
- Many aspects to discussion:
• Medical
• Social
• Public Relations
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02/04/2009Lima 2009 44
Other considerations
Specific factors- Acceleration/deceleration
- Low humidity
- Noise and vibration
- Delayed or cancelled flights
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02/04/2009Lima 2009 45
Contraindications to Commercial air transport
- Uncontrolled psychotic
patient
- Acute diverticulitis or
ulcerative colitis
- Recent stapedectomy
- Recent eye surgery
- Untreated pneumothorax
- Bowel occlusion or
subocclusion
- Recent bowel surgery
(< 10 days)
- Decompression sickness
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02/04/2009Lima 2009 46
Need for medical clearance
- Rule out contraindications for air transport
- Protect health of the passenger
- Avoid extra safety risk of unscheduled landing
- Minimize inconvenience for other passengers
- Cost
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Air Taxivs
Air Ambulance
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Thank you for your attention