In-flight cardiac arrest and in-flight cardiopulmonary resuscitation during commercial air travel: consensus statement and supplementary treatment guideline from the German Society of Aerospace Medicine (DGLRM)


By the end of the year 2016, approximately 3 billion people worldwide travelled by commercial air transport. Between 1 out of 14,000 and 1 out of 50,000 passengers will experience acute medical problems/emergencies during a flight (i.e., in-flight medical emergency). Cardiac arrest accounts for 0.3% of all in-flight medical emergencies. So far, no specific guideline exists for the management and treatment of in-flight cardiac arrest (IFCA). A task force with clinical and investigational expertise in aviation, aviation medicine, and emergency medicine was created to develop a consensus based on scientific evidence and compiled a guideline for the management and treatment of in-flight cardiac arrests. Using the GRADE, RAND, and DELPHI methods, a systematic literature search was performed in PubMed. Specific recommendations have been developed for the treatment of IFCA. A total of 29 specific recommendations for the treatment and management of in-flight cardiac arrests were generated. The main recommendations included emergency equipments as well as communication of the emergency. Training of the crew is of utmost importance, and should ideally have a focus on CPR in aircraft. The decision for a diversion should be considered very carefully.

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  1. 1.

    (EASA) European Aviation and Space Agency (2014) acceptable means of compliance (AMC) and guidance material (GM) to part-CAT. Decision 2014/015/R

  2. 2.

    Abella BS, Sandbro N, Vassilatos P et al. (2005) Chest compression rates during cardiopulmonary resuscitation are suboptimal—a prospective study during in-hospital cardiac arrest. Circulation 111

    Article  Google Scholar 

  3. 3.

    Akyol C, Kesapli M, Gungor F et al (2015) Inflight Emergencies During Euroasian Flights. J Travel Med 22:361–367

    Article  Google Scholar 

  4. 4.

    Andrews J, Guyatt G, Oxman AD et al (2013) GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. J Clin Epidemiol 66:719–725

    Article  Google Scholar 

  5. 5.

    Andrews JC, Schünemann HJ, Oxman AD et al (2013) GRADE guidelines: 15. Going from evidence to recommendation-determinants of a recommendation’s direction and strength. J Clin Epidemiol 66:726–735

    Article  Google Scholar 

  6. 6.

    Aoyagi T, Kishi M, Yamaguchi K et al. Improvement of the earpiece oximeter. In: Abstracts of the 13th annual meeting of the Japanese Society of Medical Electronics and Biological Engeneering. 1974: 90–91 (Jap)

  7. 7.

    Association International Air Transport (2016) Accessed 20 Jul 20

  8. 8.

    Bayat Z, Lang E (2015) Guidelines helping clinicians make the GRADE. Intern Emerg Med 10:87–92

    Article  Google Scholar 

  9. 9.

    Berden H, Bierens J, Willems F et al (1994) Resuscitation skills of lay public after recent training. Ann Intern Med 23:1003–1008

    CAS  Google Scholar 

  10. 10.

    Bernhard M, Mohr S, Weigand MA et al (2012) Developing the skill of endotracheal intubation: implication for emergency medicine. Acta Anaesthesiol Scand 56:164–171

    Article  CAS  Google Scholar 

  11. 11.

    Bolle SR, Johnsen E, Gilbert M (2011) Video calls for dispatcher-assisted cardiopulmonary resuscitation can improve the confidence of lay rescuers–surveys after simulated cardiac arrest. J Telemed Telecare 17:88–92

    Article  Google Scholar 

  12. 12.

    Bossaert L, Perkins GD, Askitopoulou H et al (2015) European Resuscitation Council Guidelines for Resuscitation 2015 Section 11. Resuscitation 95:301–310

    Article  Google Scholar 

  13. 13.

    Brown AM, Rittenberger JC, Ammon CM et al (2010) In-flight automated external defibrillator use and consultation patterns. Prehosp Emerg Care 14:235–239

    Article  Google Scholar 

  14. 14.

    Chalkias A, Georgiou M, Böttiger B et al (2013) Recommendations for resuscitation after ascent to high altitude and in aircrafts. Int J Cardiol 167:1703–1711

    Article  Google Scholar 

  15. 15.

    Chandra A, Conry S (2013) In-flight Medical Emergencies. West J Emerg Med 14:499–504

    Article  Google Scholar 

  16. 16.

    Charles RA (2011) Cardiac arrest in the skies. Singap Med J 52:582–585

    CAS  Google Scholar 

  17. 17.

    Cocks R, Liew M (2007) Commercial aviation in-flight emergencies and the physician. Emerg Med Australas 19:1–8

    PubMed  Google Scholar 

  18. 18.

    Cummins RO, Schubach JA (1989) Frequency and types of medical emergencies among commercial air travellers. J Am Med Assoc 261:1295–1299

    Article  CAS  Google Scholar 

  19. 19.

    Das A, Majumdar S, Mukherjee A et al (2014) i-gel in Ambulatory surgery: a comparison with LMA-ProSeal in paralyzed anaesthetized patients. J Clin Diagn Res 8:80–84

    PubMed  PubMed Central  Google Scholar 

  20. 20.

    Delaune EF 3rd, Lucas RH, Illig P (2003) In-flight medical events and aircraft diversions: one airline’s experience. Aviat Space Environ Med 74:62–68

    PubMed  Google Scholar 

  21. 21.

    Eisenberger P, Safar P (1994) Life supporting first aid training of the public-review and recommendations. Resuscitation 4:3–18

    Google Scholar 

  22. 22.

    Europäische Union (20.9.2008) VERORDNUNG (EG) Nr. 859/2008 DER KOMMISSION vom 20. August 2008 zur Änderung der Verordnung (EWG) Nr. 3922/91 des Rates in Bezug auf gemeinsame technische Vorschriften und Verwaltungsverfahren für den gewerblichen Luftverkehr mit Flächenflugzeugen. Amtsblatt der Europäischen Union L254:1-238

  23. 23.

    Fink A, Kosecoff J, Chassin M et al (1984) Consensus methods: characteristics and guidelines for use. Am J Public Health 74:979–983

    Article  CAS  Google Scholar 

  24. 24.

    Fischer H, Neuhold S, Hochbrugger E et al (2011) Quality of resuscitation: flight attendants in an airplane simulator use a new mechanical resuscitation device—a randomized simulation study. Resuscitation 82:459–463

    Article  Google Scholar 

  25. 25.

    Fitch K, Bernstein SJ, Aguilar MD et al. (2001) The RAND/UCLA appropriateness method user’s manual. Santa Monica, CA: RAND Corporation, 2001. Accessed 13 Feb 2018

  26. 26.

    Freedman DO, Chen LH, Kozarsky PE (2016) Medical Considerations before International Travel. N Engl J Med 375:247–260

    Article  Google Scholar 

  27. 27.

    Graf J, Stüben U, Pump S (2012) In-flight medical emergencies. Dtsch Aerztebl Int 109:591–602

    Google Scholar 

  28. 28.

    Guyatt GH, Oxman AD, Kunz R et al (2008) Going from evidence to recommendations. Brit Med J 336:1049–1051

    Article  Google Scholar 

  29. 29.

    Guyatt GH, Oxman AD, Schünemann HJ et al (2011) GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol 64:380–382

    Article  Google Scholar 

  30. 30.

    Handley AJ, Handley JA (2004) Performing chest compressions in a confined space. Resuscitation 61:55–61

    Article  Google Scholar 

  31. 31.

    Harve H, Hämäläinen O, Kurola J et al (2009) AED use in a passenger during a long-haul flight: repeated defibrillation with a successful outcome. Aviat Space Environ Med 80:405–408

    Article  Google Scholar 

  32. 32.

    Havel C, Schreiber W, Riedmuller W et al (2007) Quality of closed chest compression in ambulance vehicles, flying helicopters and at the scene. Resuscitation 73:264–270

    Article  Google Scholar 

  33. 33.

    Hinkelbein J (2015) Significant more research required: no further progress without sound medical data and valid denominators for in-flight medical emergencies. J Travel Med 22:355–356

    Article  Google Scholar 

  34. 34.

    Hinkelbein J, Dambier M, Schwalbe M et al (2010) Lack of denominator data in aviation accident analysis. Aviat Space Environ Med 81:77

    Article  Google Scholar 

  35. 35.

    Hinkelbein J, Glaser E (2008) Evaluation of two oxygen face masks with special regard to inspiratory oxygen fraction (FiO2) for emergency use in rescue helicopters. Air Med J 27:86–90

    Article  Google Scholar 

  36. 36.

    Hinkelbein J, Glaser E (eds) (2007) Flugmedizin. UniMed Sci, Bremen

    Google Scholar 

  37. 37.

    Hinkelbein J, Glaser E, Doerrstein J et al (2006) Oxygen delivery comparison of two constant-flow masks during flight to 6863 m. Aviat Space Environ Med 77:540–544

    PubMed  Google Scholar 

  38. 38.

    Hinkelbein J, Hose D, Fiedler F (2005) Comparison of three different sensor sites for pulse oximetry in critically ill patients. Int J Intensive Care 12:159–163

    Google Scholar 

  39. 39.

    Hinkelbein J, Kalina S, Braunecker S et al (2016) Standardisiertes Erfassungsprotokoll der DGLRM für Notfälle an Bord von Luftfahrzeugen. Flugmed Tropenmed Reisemed 23:19–22

    Article  Google Scholar 

  40. 40.

    Hinkelbein J, Neuhaus C, Wetsch WA et al (2014) Emergency medical equipment on board German airliners. J Travel Med 21:318–323

    Article  Google Scholar 

  41. 41.

    Hinkelbein J, Spelten O, Wetsch WA et al (2013) Emergencies in the sky: in-flight medical emergencies during commercial air transport. Trends Anaesth Critical Care.

    Article  Google Scholar 

  42. 42.

    Hung KK, Chan EY, Cocks RA et al (2010) Predictors of flight diversions and deaths for in-flight medical emergencies in commercial aviation. Arch Intern Med 170:1401–1402

    Article  Google Scholar 

  43. 43.

    Kaye W, Rallis SF, Mancini ME et al (1991) The problem of poor retention of cardiopulmonary resuscitation skills may lie with the instructor, not the learner of the curriculum. Resuscitation 21:67–87

    Article  CAS  Google Scholar 

  44. 44.

    Kaye W, Wynne G, Marteau T et al (1990) An advanced resuscitation course for pre-registration house officers. J R Coll Phys Lond 24:51–54

    CAS  Google Scholar 

  45. 45.

    Kea B, Sun BC (2015) Consensus development for healthcare professionals. Intern Emerg Med 10:373–383

    Article  Google Scholar 

  46. 46.

    Kilgannon JH, Jones AE, Parrillo JE et al (2011) Relationship between supranormal oxygen tension and outcome after resuscitation from cardiac arrest. Circulation 123:2717–2722

    Article  CAS  Google Scholar 

  47. 47.

    Kilgannon JH, Jones AE, Shapiro NI et al (2010) Association between arterial hyperoxia following resuscitation from cardiac arrest and in-hospital mortality. J Am Med Assoc 303:2165–2171

    Article  CAS  Google Scholar 

  48. 48.

    Mahony PH, Griffiths RF, Larsen P et al (2008) Retention of knowledge and skills in first aid and resuscitation by airline cabin crew. Resuscitation 76:413–418

    Article  Google Scholar 

  49. 49.

    McIntosh SE, Swanson ER, McKeone A et al (2008) Location of airway management in air medical transport. Prehosp Emerg Care 12:438–442

    Article  Google Scholar 

  50. 50.

    Mohr S, Weigand MA, Hofer S et al (2013) Developing the skill of laryngeal mask insertion. Anaesthesist 62:447–452

    Article  CAS  Google Scholar 

  51. 51.

    Monsieurs KG, Nolan JP, Bossaert LL et al (2015) European resuscitation council guidelines for resuscitation 2015: section 1. Executive summary. Resuscitation 95:1–80

    Article  Google Scholar 

  52. 52.

    Nable JV, Tupe CL, Gehle BD et al (2015) In-flight medical emergencies during commercial travel. N Engl J Med 373:939–945

    Article  CAS  Google Scholar 

  53. 53.

    Neumar RW, Shuster M, Callaway CW et al (2015) American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 132:S315–S367

    Article  Google Scholar 

  54. 54.

    Nishiyama C, Iwami T, Murakami Y et al (2015) Effectiveness of simplified 15-min refresher BLS training program: a randomized controlled trial. Resuscitation 90:56–60

    Article  Google Scholar 

  55. 55.

    Ochoa FJ, Ramalle-Gómara E, Lisa V et al (1998) The effect of rescuer fatigue on the quality of chest compressions. Resuscitation 37:149–152

    Article  CAS  Google Scholar 

  56. 56.

    Page RL, Joglar JA, Kowal RC et al (2000) Use of automated external defibrillators by a US airline. N Engl J Med 343(17):1210–1216

    Article  CAS  Google Scholar 

  57. 57.

    Panczyk M, McNally BF, Bobrow BJ (2013) Telephone CPR: saving lives around the world. New program will help dispatchers and track vital data. EMS. World 42(35–36):39

    Google Scholar 

  58. 58.

    Parnell MA (2007) Larsen PD Poor quality teaching in lay person CPR courses. Resuscitation 73:271–278

    Article  Google Scholar 

  59. 59.

    Pedersen T, Moller AM, Pedersen BD (2003) Pulse oximetry for perioperative monitoring: systematic review of randomized, controlled trials. Anesth Analg 96:426–431

    Article  Google Scholar 

  60. 60.

    Perkins GD, Stephenson BT, Smith CM et al (2004) A comparison between over-the-head and standard cardiopulmonary resuscitation. Resuscitation 61:155–161

    Article  Google Scholar 

  61. 61.

    Peterson DC, Martin-Gill C, Guyette FX et al (2013) Outcomes of medical emergencies on commercial airline flights. N Engl J Med 368:2075–2083

    Article  CAS  Google Scholar 

  62. 62.

    Qureshi A, Porter KM (2005) Emergencies in the air. Emerg Med J 22:658–659

    Article  CAS  Google Scholar 

  63. 63.

    Rössler B, Ziegler M, Hüpfl M et al (2013) Can a flowchart improve the quality of bystander cardiopulmonary resuscitation? Resuscitation 84:982–986

    Article  Google Scholar 

  64. 64.

    Sand M, Bechara FG, Sand D et al (2009) In-flight medical emergencies. Lancet 374:1062–1063

    Article  Google Scholar 

  65. 65.

    Sand M, Bechara FG, Sand D et al (2009) Surgical and medical emergencies on board European aircraft: a retrospective study of 10189 cases. Crit Care 13:R3

    Article  Google Scholar 

  66. 66.

    Sand M, Gambichler T, Sand D et al (2010) Emergency medical kits on board commercial aircraft: a comparative study. Travel Med Infect Dis 8:388–394

    Article  Google Scholar 

  67. 67.

    Siedenburg J (2015) Epidemiology of “In-flight Emergencies”. In: Siedenburg J, Küpper T (eds) Moderne flugmedizin. Gentner Verlag, Stuttgart, pp 653–655

    Google Scholar 

  68. 68.

    Silverman D, Gendreau M (2009) Medical issues associated with commercial flights. Lancet 373:1067–2077

    Article  Google Scholar 

  69. 69.

    Spelten O, Warnecke T, Wetsch WA et al (2016) Dispatcher-assisted compression-only cardiopulmonary resuscitation provides best quality cardiopulmonary resuscitation by laypersons: a randomised controlled single-blinded manikin trial. Eur J Anaesthesiol 33:575–580

    Article  Google Scholar 

  70. 70.

    Thomas SH, Stone CK, Bryan-Berge D (1994) The ability to perform closed chest compressions in helicopters. Am J Emerg Med 12:296–298

    Article  CAS  Google Scholar 

  71. 71.

    Truhlář A, Deakin CD, Soar J et al (2015) European Resuscitation Council Guidelines for Resuscitation 2015: section 4. Cardiac arrest in special circumstances. Resuscitation 95:148–201

    Article  Google Scholar 

  72. 72.

    Valani R, Cornacchia M, Kube D (2010) Flight diversions due to onboard medical emergencies on an international commercial airline. Aviat Space Environ Med 81:1037–1040

    Article  Google Scholar 

  73. 73.

    Weinlich M, Nieuwkamp N, Stueben U et al (2009) Telemedical assistance for in-flight emergencies on intercontinental commercial aircraft. J Telemed Telecare 15:409–413

    Article  Google Scholar 

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The manuscript was prepared by the working group “guidelines, recommendations, and statements” of the German Society of Aerospace Medicine and reviewed by the board of the German Society of Aerospace Medicine (DGLRM). The authors thank Prof. Douglas Boyd (University of Texas) sincerely for his critical comments, language editing, and improving the quality of this manuscript.

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Correspondence to Jochen Hinkelbein.

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Conflict of interest

C.N. is the Treasurer of the German Society for Aviation and Space Medicine (DGLRM). E.D.R. received honorarium from MSD. E.G. is the CEO of the German Academy for Aviation and Travel Medicine (DAFR). H.G. received travel reimbursement for presentations from Ambu and VBM, Germany. J.H. is the President of the German Society for Aviation and Space Medicine (DGLRM) and Treasurer of the European Society of Aerospace Medicine (ESAM) as well as Chairman of the ESAM Space Medicine Group; J.S. is employed at Lufthansa. C.A., A.H., M.B., S.J., J.A., P.K., F.C., I.J., and M.K. have no conflicts of interest.

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Jochen Hinkelbein is the Chairman of the task force.

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Hinkelbein, J., Böhm, L., Braunecker, S. et al. In-flight cardiac arrest and in-flight cardiopulmonary resuscitation during commercial air travel: consensus statement and supplementary treatment guideline from the German Society of Aerospace Medicine (DGLRM). Intern Emerg Med 13, 1305–1322 (2018).

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  • CPR
  • Cardiopulmonary resuscitation
  • Cardiac arrest
  • Airplane
  • In-flight medical emergencies
  • BLS
  • AED