v

Contents
Introduction vii
1
Aviation Physiology 114
The Atmosphere 2
Effects of Flying on the Body 6
Effects of Low Oxygen Levels 7
Effects of Pressure Changes 9
2
Travel Health Preparedness 1546
Travel Preparation 16
Infectious Diseases 18
Infectious Diseases Charts 28
Aircraft Disinsection 40
Alertness Management 41
3
Victim Assessment 4760
Managing a Medical Incident 48
Surveying a Victim 50
4
Life-saving Procedures 6186
Life-saving Procedures 62
CPRAdult and Child Resuscitation 63
Automated External Debrillator (AED) 73
Infant Resuscitation 77
Relief of Choking 81
86344_00_fm_i-viii.indd v 6/3/08 8:26:45 AM
vi
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Medical Emergencies 87126
Respiratory System Disorders 88
Cardiovascular Disorders 92
Abdominal/Pelvic Disorders 99
Nervous System Disorders 105
Behavioral and Psychological Disorders 110
Other Medical Disorders 112
Pregnancy and Childbirth 120
6
Traumatic Emergencies 127152
Wounds 128
Chest Injuries 134
Abdominal Injuries 136
Bone, Joint, and Muscle Injuries 137
Environmental Injuries 144
Eye Injuries 149
7
Procedures and Resources 153179
MedAire, Inc. 154
Procedures for an Incident during Flight 158
The Mechanics of Lifting 160
Oxygen Systems 162
Medical Equipment 166
Pandemic Planning 176
Translation Glossary 180
Index 201
Figure Sources 207
System Requirements for CD Use 208
86344_00_fm_i-viii.indd vi 6/3/08 8:26:49 AM
C
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Manual of
In-Flight
Medical Care
K E N D A L L / H U N T P U B L I S H I N G C O M P A N Y
4 0 5 0 W e s t m a r k D r i v e D u b u q u e , I o w a 5 2 0 0 2
AN INTERNATIONAL SOS COMPANY
Patricia M. Campbell RN MSN CCRN ANP CS
Adult Nurse PractitionerEmergency Medicine
Education Consultant
MedAire, Inc.
Tempe, Arizona
SECOND EDITION
86344_00_fm_i-viii.indd i 6/3/08 2:25:59 PM
iii
Acknowledgments
The author would like to recognize the contributors to the rst edition:
Dr Nigel Dowdall MSc MbChB MRCGP MFOM DRCOG DFFP Dip Av Med, Senior Consultant
Occupational Physician, British Airways Health Services; Patricia M. Campbell RN MSN
CCRN ANP CS, Education Consultant, MedAire, Inc., Emergency Nurse Practitioner, Good
Samaritan Regional Medical Center, Phoenix, Arizona; Chantalle Collins RGN Cert. ed.,
Senior Aviation Medical Trainer, British Airways; Pauline Bishop RGN, Aviation Medical
Trainer, British Airways; Alison Neave RN Cert. ed. BA (Hons), Senior Aviation Medical
Trainer, British Airways; Gill Sparrow RN, formerly Deputy Coordinator, Aviation Medical
Training Department, British Airways.
Contributors to the First Edition
The production of this book would not have been possible without the ongoing support of
Richard Gomez, Vice President of Education Services and Quality, MedAire, Inc. Richard
championed the need for this text and provided ongoing support as well as the manage-
ment of the nancial and contractual details.
Lorraine Bailey RGN MSc (Med Sci)
Travel Medicine France
Senior Instructor
MedAire, Ltd
Farnsbourgh, England
Joan Sullivan Garrett
Founder/Chairman of the Board
MedAire, Inc.
Tempe, Arizona
Rita Mody RN; BSc. (Hons); MSc.
Medical Training Manager, Europe
MedAire, Ltd
London, England
Kathleen Rice, R.N.
Senior Instructor
MedAire, Inc.
Peoria, Arizona
Lacy Stattelman
Marketing Coordinator
MedAire, Inc.
Phoenix, Arizona
Linda Augustine RN BSN
Senior Medical Instructor
MedAire, Inc.
Atlanta, Georgia
Lin Gholson RN
Senior Medical Instructor
MedAire, Inc.
Old Glory, Texas
Heidi Giles MacFarlane
VP Global Response Services
MedAire, Inc.
Tempe, Arizona
Dr. David Streitwieser MD
MedLink Medical Director
Emergency Center Director
Banner Good Samaritan Medical Center
Phoenix, Arizona
Contributors
86344_00_fm_i-viii.indd iii 6/3/08 2:26:06 PM
vii
Introduction
There is a world of difference between providing rst aid to someone
on the ground and trying to manage a medical situation at 30,000 feet.
Thats why this book has been written. It represents a major milestone
by putting medical management information and instruction into the
context and environment of where you workonboard an aircraft.
Managing medical situations in such a remote environment can be
quite challenging considering the amount of time before any medical
help can be obtained, the resources that are available to you, and the
altitude-related issues that affect the victim. But you will quickly see
that the information that follows will help you carry out your responsi-
bilities with a high degree of condence and peace of mind. It reects
the most current thinking in emergency medical care, taking into
account the preceding issues as well as the policies and protocols
unique to your job. In addition, it meets all regulatory requirements.
The authors who have contributed to this book know what you are
up against. They are aviation physiology professionals, physicians, and
nurseswith many years of experience personally managing in-ight
medical emergencies. In fact, through the MedLink

Emergency Tele-
medicine Center at MedAire, the real-life experiences that help make up
this book cover many thousands of medical incidents, all managed
through to their nal outcome.
A medical event does not discriminate as to whether a person is at
home, at the ofce, in the car, or onboard an aircraft. It will happen.
And when it happens to someone onboard your ight, thanks to your
time and commitment to this training, that person may be one of the
most fortunate people in the world.
Joan Sullivan Garrett
Founder/Chairman of the Board, MedAire, Inc.
86344_00_fm_i-viii.indd vii 6/3/08 2:26:11 PM
Aviation
Physiology
Changes in atmospheric pressure
and oxygen levels during air travel
cause certain physical effects. This
section describes the atmosphere,
gas composition, and the physical
gas laws. The subsequent pages
show the effects of ying and pres-
sure changes on the human body.
It also addresses particular disorders
that can result from pressure
changes and provides suggestions
for the relief of these problems.
The Atmosphere 2
Atmospheric Layers 2
Atmospheric Pressure 3
Physical Gas Laws 4
Atmosphere in Flight 5
Effects of Flying on the Body 6
Factors That Affect the Body 6
Effects of Low Oxygen Levels 7
Hypoxia 7
Factors That Affect the Bodys
Response to Low Oxygen Levels
(Hypoxia) 8
Preventing and Treating Hypoxia 8
Effects of Pressure Changes 9
Pressure Changes in the Ear 9
Pressure Changes in the Sinuses 10
Trapped Air in the Lungs 11
Trapped Air in the Gastrointestinal
Tract 11
Decompression Sickness (DCS) 12
Effects of Rapid Decompression 12
1
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The Atmosphere
The earth is wrapped in a blanket of gases known as the atmosphere, which extends to
an altitude of over 400 miles (645 km) above the earths surface. The atmosphere pro-
tects the earth from ultraviolet radiation and extremes of temperature and is held in
place by the earths gravitational pull.
The atmosphere is divided
into a number of layers. Air-
craft normally cruise in the
lower two layers: the tropo-
sphere and the stratosphere.
The troposphere extends
from the earths surface (sea
level) to approximately 50,000
feet (15,000 m) at the equator
Atmospheric Layers
Aircraft Cruising Altitudes
Aircraft cruise at the upper level of the troposphere and in the stratospherethe lower two levels of the
atmosphere.
50,000 ft
(15,000 m)
Stratosphere
Tropopause
Troposphere
Sea level
Ground level
Subsonic jets cruise near the
top of the troposphere,
around 30,00040,000 ft
(9,00012,000 m)
Supersonic jets fly up
to 60,000 ft (18,000 m)
and becomes thinner at the
poles. This layer of the atmo-
sphere contains water vapor,
which forms clouds, and
becomes pro gressively colder
as altitude increases. The
stratosphere extends approxi-
mately 50,000 feet (15,000 m)
to 50 miles (80 km). This layer
contains no water vapor or air
currents, and the temperature
is fairly constant. The bound-
ary layer between the tropo-
sphere and the stratosphere is
called the tropopause. The
thickness of the tropopause
varies according to latitude
and season.
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There are two factors present
in the atmosphere that crew
may be concerned about:
ozone and cosmic radiation.
Ozone
Ozone is an unstable gas
formed when ultraviolet light
from the sun interacts with
oxygen molecules in the
atmosphere.
Exposure to higher-than-
normal concentrations of
ozone can irritate the lungs,
eyes, and other tissues.
However, ozone reaches poten-
tially harmful levels only at an
altitude of 40,000 to 140,000
feet (12,00042,600 m).
Although it seldom causes
of cosmic radiation that
reaches the earths surface;
radiation levels are higher at
the North and South Poles,
where the magnetic eld is
weaker.
Exposure to excessive radia-
tion can increase the risk of
some cancers, so protection is
recommended. Exposure is
measured in millisieverts
(mSv). Maximum occupational
exposure is 20 mSv per year;
for pregnant women, exposure
should be kept to a minimum.
Studies of aircraft radiation
levels show that the annual
exposure rate is about 2 mSv
for short-haul crew and 4 mSv
for long-haul crew.
problems in ight, some ozone
is present in the air used for
cabin air-conditioning. Most of
the ozone is removed by the
aircrafts ozone converters, or
by heat from the aircrafts
compressors, before the air
enters the cabin.
Cosmic Radiation
Cosmic radiation is radiation
originating mainly from outer
space, with a smaller compo-
nent coming from the sun.
Some radiation is absorbed in
the atmosphere, so levels are
greater at higher altitudes,
where the atmosphere is
thinner. The earths magnetic
eld also affects the amount
OZONE AND COSMIC RADIATION IN THE ATMOSPHERE
The atmosphere is made up of a mixture of
gases, mainly nitrogen (78%) and oxygen (21%).
The weight of all the gas molecules in the air
creates atmospheric (barometric) pressure,
which is measured as millimeters of mercury
(mmHg). The atmospheric pressure is greatest
at the earths surface (at sea level) and gradu-
ally diminishes as altitude increases.
Atmospheric Pressure
80
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60
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40
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0 100 200 300 400 500 600 700 800
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Atmospheric Pressure (mmHg)
Stratosphere
Tropopause
Troposphere
Sea level
Ground level
Effect of Altitude on Atmospheric Pressure
Atmospheric (barometric) pressure falls as altitude
increases. At sea level, the pressure is 760 mmHg. At
18,000 feet (5,500 m), atmospheric pressure is
reduced by half, and at 33,700 feet (10,270 m), it is
reduced by three-quarters.
Composition of Air
Air consists almost entirely of nitrogen and oxygen.
Other atmospheric gases, such as carbon dioxide,
make up a relatively small percentage of the total.
Nitrogen
78.08%
Helium
0.0005%
Neon 0.0018%
Hydrogen 0.00006%
Carbon dioxide 0.03 %
Argon 0.93%
Oxygen
20.95%
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The behavior of gases, such as those that make up the atmosphere, is described in a series of laws.
Their effects on the body in ight are outlined on the following pages.
Physical Gas Laws
Boyles Law
Boyles law states
that as long as
temperature
remains con-
stant, the volume
of a gas is
inversely propor-
tional to its pres-
sure. As altitude
increases, atmo-
spheric pressure falls and the same amount of gas
occupies a larger space. Therefore, during ight, any
pocket of gas within the body will expand as alti-
tude increases.
Ten gas
molecules
Ten gas molecules
occupy more space
Volume at
sea level
Volume at
high altitude
(lower pressure)
Daltons Law
Daltons law states that the total pressure of any gas
mixture, such as the atmosphere, is equal to the sum
of its partial pressure, that is, the pressure of each
of the individual gases within the mixture. Although
the proportion of each gas remains the same regard-
less of altitude, the expansion of gases that occurs
as altitude increases reduces the amount of each
gas present.
Relative number
of gas molecules
at sea level
Relative number
of gas molecules
at 18,000 ft (5,500 m)
Nitrogen Oxygen Nitrogen Oxygen
Grahams Law
Grahams law states when gases are dissolved in
liquids, the relative rate of diffusion of the gas is pro-
portional to its solubility in the liquid and inversely
proportional to the square root of the molecular
mass. This is the law of simple diffusion. Gases will
diffuse from a higher concentration to lower concen-
tration. This explains why oxygen and carbon dioxide
readily exchange during the process of respiration.
Carbon dioxide is 22 times more soluable than oxygen.
Henrys Law
Henrys law states that at equilibrium, the amount of
gas dissolved in a liquid is proportional to the pressure
of gas on that liquid. When altitude increases, the
atmospheric pressure falls. During ight, the pressur-
ization in the cabin maintains an atmospheric pressure
that is compatible with life (5,0008,000 feet). If there
is a sudden fall in pressure (cabin decompression), the
dissolved gas (nitrogen) in body tissues is released in
the body, which releases gas bubbles into the blood,
joints, etc. This is also known as decompression sick-
ness. An example of this gas law occurs when a cork is
popped off of a carbonated liquid, resulting in the
release of gas bubbles in the liquid.
Charles Law
Charles law states that the volume of a xed mass of
gas held at a constant pressure varies directly with
absolute temperature. That is, the volume of a gas is
directly proportional to temperature. If the tempera-
ture increases, gas volume expands; if the temperature
decreases, gas volume decreases. This directly applies
to an oxygen tank. As the ambient temperature rises,
the volume of oxygen in the tank expands. Likewise, if
the oxygen tank is cold, the volume decreases.
Normal
pressure
Pressure
released
Drop in
pressure
releases
dissolved
gases
Gas
molecules
dissolved in
liquid
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Most modern aircraft cruise at an altitude of
30,000 to 40,000 feet (about 9,00012,000 m). At
these high altitudes, the atmospheric pressure is
low, resulting in the expansion of the atmo-
spheric gases. This results in fewer available
oxygen molecules per volume of air than at sea
level. A lack of oxygen is called hypoxia.
Humans cannot survive at these altitudes unless
the supply of oxygen is increased. Oxygen
levels on an aircraft can be raised by either
increasing the atmospheric pressure inside the
cabin or administering supplemental oxygen.
Cabin Atmospheric Pressure
In theory, the aircraft cabin could be pressurized
to an atmospheric pressure equivalent to that at
sea level. At high altitudes, however, the atmo-
spheric pressure is so low that the aircraft fuse-
lage would have to be extremely strong and
heavy to withstand the difference in pressure
between the inside and outside of the aircraft.
Passenger aircraft cabins are usually pressurized
to an atmosphere of 5,000 to 8,000 feet (1,500
2,400 m) above sea level when ying at cruising
altitude. In these conditions, the oxygen pres-
sure is about 15% to 20% lower than at sea
level, which may cause hypoxia in some people.
The atmospheric pressure inside the cabin is
regulated by the aircrafts environmental control
system, which also controls the ozone levels and
the recirculation of the cabin air.
Cabin Pressurization
Cabin air comes from several sources. During
ight, air from the aircrafts engines (known as
bleed air) may be mixed with recycled air;
when the aircraft is on the ground, air for the
cabin environment may be provided by the air-
crafts auxiliary power unit or supplied by a
ground compressor unit.
When the aircraft is in ight, bleed air from
the engines passes through cooling packs and
is mixed with recycled air from the cabin. The
air ows along supply ducts and enters the
cabin through vents in the ceiling, which are
angled to ensure that the air is distributed
throughout the cabin. From there, the air passes
into the lower sections of the aircraft through
vents in the oor. Cabin airow varies among
different types of aircraft.
The cabin pressure is controlled automati-
cally to maintain a safe and com fortable level
for the occupants. As the aircraft climbs or
descends, the atmospheric pressure in the cabin
changes more gradually than the pressure
outside the aircraft. Pressurization is primarily
regulated by outow valves, which control the
rate at which air leaves the cabin. The system
also includes pressure relief valves, which
release excess pressure if the outow valves
become stuck in the closed position.
Cabin Air-Conditioning
The cabin air-conditioning system, which con-
trols airow through the cabin, has to meet
certain regulatory standards. It must maintain an
adequate supply of oxygen, remove carbon
dioxide, and remove contaminants and odors.
Some aircraft are tted with ozone converters,
which remove ozone from the bleed air.
The air-conditioning system regulates the
temperature in the aircraft cabin by adding hot
bleed air from the engines to the cold air that
comes from the cooling packs. The overall
cabin temperature is set on the ight deck and
controlled by the ight crew; in large aircraft,
the crew can adjust the temperature in different
sections of the cabin.
Recycling of Air
On many aircraft, up to 50% of the cabin air is
recycled. The air normally passes through high-
efciency particulate lters (HEPA lters), which
remove possible contaminants, such as bacteria
and viruses, before mixing with engine bleed
air from the cooling packs.
The use of recycled air improves comfort for
the people on board the aircraft by increasing
humidity levels. This is accomplished by retain-
ing air that contains moisture from the breath-
ing of crew/passengers. It also reduces ozone
levels, which can be irritating. In addition, recy-
cled cabin air helps lower nancial and envi-
ronmental costs by reducing the aircrafts fuel
consumption.
Atmosphere in Flight
Cabin Altitude
Although aircraft usually cruise at an altitude of
30,000 to 40,000 feet (9,00012,000 m), the pres-
sure in the cabin, sometimes called cabin altitude,
is maintained at a level equivalent to 5,000 to 8,000
feet (1,5002,400 m).
40
30
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20
15
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Take-off
Atmospheric pressure
in cabin
Actual aircraft
altitude
Landing
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Effects of Flying on the Body
During ight, the body is subjected to a number of environmental stressors, primarily
related to changes in pressure and lower-than-normal oxygen levels. Cabin pressuriza-
tion minimizes some of these effects, but other stressors related to ying still have an
impact on the human body. The effects may vary for each individual.
The human body functions
most efciently at sea level. At
higher altitudes, such as those
encountered when ying, the
body has to cope with a
number of external changes.
The most signicant changes
are a reduced oxygen level,
which can result in hypoxia, as
well as changes in atmospheric
(barometric) pressure. Aircraft
cabins are pressurized to
create an articial altitude to
reduce the effects of hypoxia
and pressure changes on the
body. However, factors such as
low humidity, temperature
changes, noise, and vibration
can also have an adverse effect
on the body. Changes in gravi-
tational (G) forces are gener-
ally not important on civil
aircraft, but pilots of high-
performance aircraft are
exposed to high G forces,
which may lead to impairment
of the circulation and even loss
of consciousness.
Reduced Oxygen Levels
During ight, the cabin pres-
surization is equivalent to an
altitude of 5,000 to 8,000 feet
(1,5002,400 m), which results
in reduced oxygen levels.
Cabin pressurization helps
restore oxygen to near-normal
levels. However, people with
chronic heart or lung disease
may still be at risk for lower-
than-normal oxygen levels
(hypoxia) in normal cabin
conditions and may need
additional oxygen in ight.
Atmospheric Pressure
Changes
Rapid changes in pressure
during ascent and descent can
affect parts of the body where
turning, climbing, or descend-
ing. These aircraft maneuvers
may lead to a mismatch in
the signals from the eyes and
the balance organs in the ears,
which may result in motion
sickness.
The susceptibility to motion
sickness varies from person to
person. Most people nd that
the sensation decreases if they
y frequently. Because of vari-
ations in the way each aircraft
moves, some people may
experience motion sickness on
one type of aircraft but not on
another.
The likelihood of motion
sickness is increased by low-
frequency vibration in the air-
craft, which occurs during
turbulence. Alcohol, medica-
tions, and illnesses such as
upper respiratory tract infec-
tions may affect the middle ear
and cause motion sickness.
People who suffer from
motion sickness may feel
worse in a warm or poorly
ventilated cabin.
Inactivity
During periods of inactivity,
blood tends to pool in the legs
and feet, causing the ankles
and feet to swell; this problem
is common in passengers on
long-haul ights. Inactivity
also increases the risk of
blood clots forming in the
veins of the legs, a disorder
called deep vein thrombosis
(DVT). Performing lower body
exercises in the seat and
walking around the aircraft
cabin whenever possible can
help minimize swelling of the
ankles and feet and lessen the
risk of developing DVT.
Factors That Affect the Body
gases are trapped and cannot
escape naturally. For example,
if the eustachian tubes in the
ears or the sinuses are blocked
because of a cold or sinusitis,
air may be trapped in these
areas. Altitude and pressure
changes can cause severe
headache, earache, or facial
discomfort.
Low Humidity
Reduced moisture and humid-
ity in the cabin air can make
the skin, lips, nose, and mouth
feel dry. Skin moisturizers can
help relieve dry skin. Drinking
plenty of uids, such as water
and juices, can prevent dehy-
dration and help relieve
dryness of the mucous mem-
branes. Caffeinated drinks
(e.g., soda, coffee, tea) and
alcohol can increase the likeli-
hood of dehydration and
should be avoided.
Temperature Changes
Extremes of heat and cold can
increase the bodys demand
for oxygen and thereby
decrease the individuals toler-
ance to low oxygen levels.
Noise and Vibration
Long-term exposure to noise
can cause progressive hearing
loss. Hearing protection is an
important consideration for
preventing hearing loss.
Low-frequency vibration
occurs in aircraft during turbu-
lence and can cause motion
sickness; it may contribute to
fatigue.
Aircraft Motion
Flight operations expose the
body to a range of forces,
especially when the aircraft is
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Effects of Low Oxygen Levels
Oxygen is essential for life. All cells need a constant supply of oxygen to carry out their
normal function. Oxygen from inhaled air passes through the walls of the air sacs
located in the lungs (alveoli) into the blood. From there it goes to the heart and is
pumped into the aorta and the arteries, which then carry the oxygen to all body cells.
Lack of oxygen (hypoxia) has life-threatening consequences.
The pressure of oxygen in the
atmosphere allows oxygen to
move from the lungs into the
blood. When altitude
increases, atmospheric pres-
sure decreases and the oxygen
pressure is reduced, resulting
in less oxygen entering the
body. This is called hypoxia.
When hypoxia is caused by
reduced oxygen pressure,
the condition is known as
hypoxic hypoxia.
Oxygen is carried in the
blood by hemoglobin (which
causes the color in red blood
cells). As blood passes
through the lungs, almost all
of the hemoglobin becomes
saturated with oxygen. In
healthy people, it remains
almost fully saturated until the
oxygen pressure has fallen
substantially. However, if the
pressure falls too low, hemo-
globin cannot become satu-
rated and the blood no longer
carries enough oxygen to the
body tissues.
The Bodys Response
to Hypoxia
If oxygen levels fall, the body
tries to compensate by making
changes in the respiratory
system and the cardiovascular
system.
As a person ascends to
higher altitudes, the respira-
tory system increases the rate
and depth of breathing to
increase oxygen intake. The
heart rate increases with
altitude once a person ascends
above 6,000 to 8,000 feet
(approximately 1,8002,500 m).
tude increases, until the victim
rapidly becomes unconscious.
The severity of hypoxia,
how fast it develops, and the
order in which symptoms
appear vary among individu-
als. The onset and severity of
hypoxia are inuenced by the
starting altitude, the rate of
ascent, the nal altitude, and
underlying illnesses. In addi-
tion, any factors that increase
the bodys oxygen require-
ments (e.g., physical exertion)
as well as factors that prevent
the body from taking in
enough oxygen (e.g.,
smoking) reduce the individu-
als tolerance to hypoxia.
Hypoxia
At 15,000 feet (4,500 m), the
heart rate is about 10% to 15%
higher than it would be at sea
level; at 20,000 feet (6,000 m),
the rate is 20% to 25% higher;
and at 25,000 feet (7,600 m),
the rate is doubled. In addi-
tion, changes occur in the
blood vessels so that more of
the blood supply is sent to the
vital organs, such as the heart
and brain.
Signs of Hypoxia
At low altitudes, one of the
rst signs of hypoxia may be
reduced night vision, which
can occur as low as 5,000 feet
(1,500 m). Signs of hypoxia
progressively worsen as alti-
EFFECTS OF ALTITUDE ON FUNCTION
Altitude Effects of Hypoxia in Healthy Adults
5,000 feet (1,500 m) Impaired night vision
10,00015,000 feet
(3,0004,500 m)
Headache
Reduced capacity for work
Impaired performance at skilled tasks
15,00020,000 feet
(4,5006,000 m)
Rapid breathing and hyperventilation
Blue lips, earlobes, and nail beds
(cyanosis)
Impaired color vision followed by loss
of peripheral vision and total vision loss
Impaired muscle coordination
Poor judgment
Euphoria or depression
Impaired memory
20,00025,000 feet
(6,0007,600 m)
Rapid loss of consciousness
Seizures
Respiratory and cardiac failure
Death
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Hypoxia occurs either when
body cells do not receive
enough oxygen or when they
cannot use oxygen effectively.
There are four main types
of hypoxia.
Hypoxic hypoxiareduc-
tion in oxygen pressure
(high altitude)
Hypemic hypoxiainabil-
ity of the red blood cells to
carry enough oxygen to the
tissues (anemia)
Stagnant hypoxiadimin-
ished blood ow resulting
in insufcient blood supply
to the body tissues (shock)
Histotoxic hypoxia
toxins that impair the ability
of body cells to use oxygen
(e.g., medications, alcohol)
During ight, the most
common cause of hypoxia is
reduced oxygen pressure in the
aircraft cabin. Individuals vary
in their response to the lower
oxygen levels; some people
develop hypoxia at certain alti-
tudes while others are relatively
These conditions can increase
the risk of hypoxia for several
different reasons.
Lung diseases, such as
severe asthma, pneumonia,
and chronic lung disease,
prevent sufcient oxygen
from entering the blood. Dis-
orders that affect the hemo-
globin (the oxygen-carrying
pigment in red blood cells)
prevent the blood from taking
up enough oxygen and
reduce the amount of hemo-
globin available to carry
oxygen. The most common of
these conditions is anemia or
severe bleeding. Circulatory
problems, such as heart
failure, can prevent sufcient
oxygen from reaching body
cells. Severe infections caused
by organisms that produce
toxins can impair the ability of
body cells to use oxygen.
Finally, certain medications
can also reduce oxygen utili-
zation in the body.
Factors That Affect the Bodys Response
to Low Oxygen Levels (Hypoxia)
unaffected at the same altitude.
Several factors increase a per-
sons risk of developing
hypoxia; these factors fall into
three main groups.
Smoking
Tobacco smoke produces
carbon monoxide gas, which
binds much more readily to
hemoglobin than oxygen.
When carbon monoxide is
inhaled, it can block the
uptake of oxygen in the lungs.
As a result, less oxygen can be
carried in the blood.
Alcohol Consumption
Alcohol is a cellular toxin.
There is some evidence that
it may increase a persons
susceptibility to hypoxia by
impairing the ability of the
bodys cells to utilize
available oxygen.
Medical Conditions
Many medical conditions can
impair the bodys ability to
take in and utilize oxygen.
For ights above 10,000 feet
(approximately 3,000 m),
oxygen levels in the aircraft
must be articially maintained
to prevent hypoxia. The
oxygen levels are normally
regulated through cabin pres-
surization. In addition, supple-
mental oxygen may be
required for people with
medical conditions such as
lung or circulatory problems
that affect their bodys intake
of oxygen. In the event of a
sudden decompression, oxygen
is required for emergency use
by all passengers and crew.
The oxygen may be carried
as a gas contained in pressur-
ized cylinders, as a liquid, or
as chemical generators, which
release oxygen in a continu-
ous ow after a reaction has
been triggered. Portable
oxygen concentrators (POCs)
Preventing and Treating Hypoxia
draw in ambient air and
extract nitrogen to provide a
pure form of oxygen for the
passenger. Several of these
units have been approved by
the Federal Aviation Adminis-
tration (FAA) and are used by
some passengers who require
extra oxygen in ight.
Supplemental Oxygen
A variety of personal oxygen
systems are found on aircraft.
Examples include the POCs
and oxygen equipment used
in medical emergencies, xed
installations with masks on the
ight deck, and the drop-
down emergency systems for
passenger use in the event of
a cabin decompression. In-line
therapeutic oxygen is also
available in many aircraft for
use in medical emergencies.
Drop-down Masks
In the event of sudden decompres-
sion, drop-down masks provide all
passengers with supplemental
oxygen. The masks are attached
by tubing to an oxygen supply
overhead.
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Effects of Pressure Changes
During ight, changes in atmospheric pressure due to ascent or descent cause gas in
the body cavities to expand or contract. If gas movement can occur freely, this change
in gas volume does not create problems. However, trapped gas in various parts of the
body can cause discomfort or injury to sensitive tissues.
The ear is particularly vulnera-
ble to the effects of pressure
changes. These changes affect
the middle ear, which lies
behind the eardrum and is a
small, air-lled cavity within the
skull. It is connected to the
back of the throat by a narrow
tube called the eustachian tube.
Normally, part of the eusta-
chian tube is attened, like a
deated bicycle tire. As the
aircraft ascends, the air in the
middle ear expands. The
expanded gas can usually pass
freely down the eustachian
tube without causing discom-
fort, and the pressure in the
middle ear stays the same as
that in the outer ear.
Pressure Changes in the Ear
Malleus
(hammer)
Skull
Pinna
Auditory canal
Tympanic
membrane
Incus (anvil)
Stapes (stirrup)
Vestibular
apparatus
Cochlea
Eustachian
tube
Round
window
Oval
window
Vestibulo-
cochlear
nerve
INNER EAR MIDDLE EAR
EXTERNAL EAR
Anatomy of the Ear
The eardrum is a thin, exible membrane that separates the middle ear and outer ear.
The eustachian tube connects the middle ear with the back of the throat.
As the aircraft descends, air
is drawn down the eustachian
tube to equalize the pressure
between the outer ear and the
middle ear. The attened part
of the eustachian tube may
obstruct the ow of air, result-
ing in a higher pressure in the
outer ear than in the middle
ear. The eardrum is then
pushed inward, causing a
feeling of pressure or discom-
fort in the ear.
Conditions Causing
Blockage
The eustachian tubes may
become partially blocked in
any condition that leads to
inammation or swelling in
the ears or the sinuses. Colds,
sinus conditions, and seasonal
allergies can increase the pro-
duction of mucus, which can
contribute to sinus congestion.
Obstruction of one or both
eustachian tubes seldom
causes problems during
ascent. However, if the ears
cannot be cleared as the air-
craft descends, the increased
pressure may damage the
eardrum. Severe pain and
rupture of the eardrum may
occur. For these reasons, it is
advisable not to y with a cold
or sinus condition.
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The sinuses are air-lled cavities in the facial
bones, connected to the nasal cavity by narrow
passages. They share the same tissue as the
nasal cavity, so they are also affected by condi-
tions that cause swelling and increased mucus
production (such as a respiratory infection).
Normally, air passes freely in and out of the
sinuses. However, if the connecting passages
are blocked, pressure changes can produce
severe pain. Blockage of the maxillary sinuses
causes pain in the cheekbones and upper teeth;
blockage of the other sinuses leads to pain
under the eyebrows and in the corners of the
eyes. Nasal decongestant sprays temporarily
reduce swelling and open the passages.
Caution: Use of these may be restricted by
the FAA and may cause dependency.
Pressure Changes in the Sinuses
Adults and children can
usually open the eustachian
tubes by yawning or swallow-
ing. These actions allow air to
pass into the middle ear,
equalizing the pressure on the
two sides of the eardrum. If
yawning or swallowing does
not unblock the ears, the Val-
salva maneuver can be used.
This maneuver involves
attempting to blow out gently
while pinching the nose and
keeping the mouth closed. Air
is then forced up the eusta-
chian tube from the back of
the throat. Caution: It is
important that this maneuver
be done very gently. Avoid
forceful exhalation against a
pinched nose.
Babies should be offered a
feeding or given a pacier to
suck during the aircrafts
descent to encourage them to
swallow.
CLEARING THE EARS
Valsalva Maneuver
In this technique, a person
pinches his or her nose and
blows out gently to clear the
ears. The maneuver can be
helpful for young children, who
cannot yawn at will.
Location of Sinuses
The sinuses are cavities in the facial bones. They lie on
both sides of the nose and just above the eyebrows.
Frontal sinus
Sphenoid sinus
Ethmoid sinus
Maxillary sinus
Pressure Changes in the Ear, continued
Effects of Pressure Changes
on the Eardrum
Changes in pressure push the eardrum
outward during assent and inward
during descent. If the eustachian tube
is blocked, air cannot move freely to
equalize the pressure.
Eardrum pushed outward
Eardrum on ascent
Eardrum pushed inward
Eardrum on descent
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Equilibration of air pressure inside the lungs is not
usually a problem during ight. This is because, under
normal circumstances, there is free passage of air along
the airways, and lung tissue can stretch as air expands.
However, there are certain situations in which damage
to the lungs may occur.
If air is trapped in pockets of abnormal lung
tissue (bullae)
In rapid decompression, if expanding air
cannot escape
Trapped Air in the Lungs
Chest Cavity
The lungs occupy the chest cavity and are pro-
tected by the ribs. Air is rarely trapped in normal
lung tissue because this tissue is fairly elastic
and can accommodate air expansion.
Lung
Rib
Heart
Diaphragm
Tongue
Liver
Gallbladder
Duodenum
Pancreas
Ascending
colon
Appendix
Pharynx
Esophagus
Stomach
Transverse
colon
Descending
colon
Rectum
Intestines
The stomach and intestines contain swal-
lowed air as well as gases produced by
bacteria in the large intestine. The amount
of gases may be increased by consuming
gas-forming food and drinks, such as
beans or carbonated drinks, or as a result
of intestinal infections. In normal ight,
the gases can readily expand and be
released by passing gas. Occasionally,
expansion of the gases on ascent may
cause some discomfort. A rapid reduction
in pressure, such as in a cabin decompres-
sion, may produce severe discomfort.
Trapped Air in the Gastrointestinal Tract
Intestines
The small and large intestines occupy the
lower part of the abdomen. Gas expansion
inside the intestines can produce gas and
occasionally cause abdominal discomfort.
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The air we breathe contains
78% nitrogen gas. Some of the
nitrogen is dissolved in body
uids and tissues. Normally,
as altitude increases, the nitro-
gen is released and expelled
through the lungs. However,
if sudden decompression
occurs at a high altitude, the
nitrogen gas is rapidly
released and can form bubbles
in the blood or the body
tissues. This process results in
a condition called decompres-
sion sickness (DCS).
In healthy people, DCS
does not usually develop at
altitudes below 25,000 feet
(7,600 m). However, DCS may
develop at normal cabin pres-
sure and can occur in people
who have been in conditions
person complains of aching
joints, itching, breathlessness,
and/or numbness or tingling,
suspect DCS and ask if he or
she has been diving.
Decompression Sickness (DCS)
of raised atmospheric pres-
sure, such as scuba diving. In
these cases, more nitrogen gas
than normal is dissolved in the
body uids and tissues. If a
Allow at least 24 hours
before ying if there were
several dives in one day or
over a number of days, or
if there was a dive that
required a decompression
stop.
Allow at least 12 hours
before ying for a single
dive that did not require a
decompression stop.
ADVICE FOR SCUBA DIVERS
It is recommended that scuba divers allow as much time as possi-
ble at sea level before ying so that excess nitrogen can be cleared
from body tissues. This will reduce the risk of DCS. The current
recommendation regarding ying after scuba diving is as follows.
In certain situations, the cabin
pressurization may fail. This
failure may occur slowly (e.g.,
failure of the pressure control
system or leaks around door
seals), or it may occur rapidly if
there is a structural failure (e.g.,
loss of a door or window).
Slow decompression is
dened as a loss of cabin pres-
surization that takes longer
than 10 seconds. It is usually
detected by indicators on the
ight deck and/or by automatic
deployment of the passenger
drop-down mask system. The
crew and passengers may grad-
ually develop symptoms of
hypoxia, such as shortness of
breath, and other symptoms
due to gas expansion.
Rapid decompression is
dened as a total loss of cabin
pressurization within 1 to
10 seconds. In explosive
decompression, cabin pressure
is lost within 1 second.
Effect of Rapid
Decompression
on Consciousness
If cabin pressure drops sud-
denly, there is only a short
Certain other factors may
reduce the time of useful
consciousness.
Factors that increase the
bodys need for oxygen,
such as exercise and
extreme temperatures
Factors that reduce the
bodys ability to cope with
hypoxia, such as alcohol
consumption, smoking, and
certain medical conditions
Effects of Rapid Decompression
time during which a person
can remain sufciently alert to
respond, even though he or
she may not yet have become
unconscious. This period is
called the time of useful con-
sciousness. In rapid decom-
pression this period may be
very short. This time is deter-
mined by the initial and nal
cabin altitude, as well as the
speed of decompression.
ALTITUDE AND TIME OF USEFUL
CONSCIOUSNESS
This table shows typical times of useful consciousness in healthy
seated people following rapid loss of cabin pressure.
Altitude at Which
Decompression Occurs
Time of Useful
Consciousness
22,000 feet (6,700 m) 510 minutes
25,000 feet (7,600 m) 35 minutes
30,000 feet (9,000 m) 12 minutes
40,000 feet (12,000 m) 1520 seconds
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Notes

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Travel Health
Preparedness
It is important to safeguard your
health during travel while on duty
and when managing medical
incidents. This chapter includes
information about pre-travel
preparation/planning and preven-
tion of common infectious diseases
encountered during international
travel. In addition, there are strate-
gies to help combat problems such
as fatigue and jet lag.
Travel Preparation 16
Pre-travel Planning 16
Preparation of In-Country Resources 17
Prevention of Illness and Injury 17
Post-travel Monitoring 17
Infectious Diseases 18
How Infections Are Transmitted 18
Protection from Infection 20
Caring for an Ill Passenger during
Flight 21
Reporting Infectious Disease during
Flight 22
Clinical WasteCleanup/Disposal 23
Prevention of Blood-borne Diseases 24
Prevention of Air-borne/Respiratory
Diseases 24
Prevention of Food-borne and
Water-borne Diseases 25
Prevention of Vector-borne Diseases 25
Prevention of Zoonotic Diseases
Animals and Insects 27
Prevention of Sexually Transmitted
Diseases 27
Prevention of Other Diseases 27
Infectious Diseases Charts 28
Aircraft Disinsection 40
Disinsection Procedure 40
Checks by Port Health Authority
Inspectors 40
Alertness Management 41
Fatigue 41
Circadian Rhythm 42
Sleep Physiology 43
Jet Lag 44
Travel Health Resources 44
2
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Travel Preparation
Travel planning includes four important steps:
Pre-travel planning
Preparation of in-country resources
Prevention of illness and injury
Post-travel health monitoring
It is very important to become
informed and educated on
travel health issues prior to a
trip. Know before you go is
key to avoiding infections,
accidents, and injuries. Health
risks vary all over the world as
a result of various factors,
such as different seasons, alti-
tude, and changes in public
health measures against infec-
tious diseases. The type of
travel and itineraries to be
pursued also inuence associ-
ated risks. Travelers should
know how to access current
information on travel health
issues. Preparation for travel is
very important for aviation
crews who are constantly in a
state of pre-travel planning
and post-travel. Crews must
be continually vigilant regard-
ing vaccine updates and
health monitoring.
Prepare the following docu-
ments/items for travel and
take the following information
with you:
Current medical history,
allergies, and medications
(Keep in a wallet card.)
Names, phone numbers,
and fax numbers of your
personal physicians
Names and phone numbers
of emergency contacts
Personal prescriptions in the
original bottles with your
name on them (Take
enough medication for
your trip. Carry in your
hand luggage.)
Copy of your eyeglass pre-
scription and spare glasses
or contacts
and access to funds are not
frozen.
Resources for Pre-travel
Planning
MedAire Global Response
Center
MedAire Travel Health
Nurses
Travel health advisories
issued by state departments,
Centers for Disease Control
and Prevention (CDC), and
the World Health Organiza-
tion (WHO)
Vaccination recommenda-
tions appropriate to the
destination
Current country informa-
tion regarding security,
disease outbreaks, cultural
issues, etc.
Current CDC/WHO
information
MedAire website, www.
medaire.com (Contact your
sales representative to
access the Global Travel
Watch website.)
Pre-travel Planning
Travel documents (pass-
port, visas, insurance
documents)
Two copies of your pass-
port (one copy for home/
ofce and one kept separate
from your passport)
Copies of all your credit
cards and emergency
numbers (kept at home/
ofce)
First aid kit and protective
equipment appropriate to
the area of travel
In addition, consider the fol-
lowing prior to traveling:
Register with your countrys
embassy or consulate in
each country you are
visiting.
Obtain travel health insur-
ance, including medical,
dental, and evacuation cov-
erage appropriate to your
trip plans.
Notify your bank/credit card
companies of your travel
plans so that credit cards
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It is very important to take resources into the
country that may be needed in the event of a
medical or other emergency. The following is a
list of information that should be prepared.
Emergency contact information for the desti-
nation country (to take with you)

Local emergency response phone number

(ambulance/re)
Preparation of In-Country Resources

Embassy phone number

Local contacts for your company

Updated emergency contact information (to
be kept at home/ofce)
Identication of local appropriate healthcare
resources at your destination, such as hospi-
tals and clinics (to take with you)
Obtain updates regarding
travel advisories, health
alerts, etc., and plan to
avoid those areas during
your travel to minimize your
risk of exposure.
Obtain recommended/
required vaccinations for
each destination (see your
travel clinic 4 to 6 weeks
prior to travel). Keep sea-
sonal inuenza vaccines
and tetanus immunization
updated, as well as other
appropriate vaccines neces-
sary for travel.
Keep your immunization
record with you and keep a
copy at home/ofce.
Take a rst aid kit that
includes hand sanitizer, a
sure it is safe and well
maintained. Rent a larger
vehicle if available. Know
the rules of the road and
obey local trafc laws.
Avoid motorcycles or bicy-
cles. Always wear restraints
(lap belt/shoulder harness).
Use appropriate restraints/
car seats for children. Hiring
a reputable local driver may
be safer in some areas.
Avoid swimming in local
ponds/lakes, where
water-borne disease can
be contracted.
Avoid high-risk activities,
such as drinking local water,
having unprotected sex,
and getting tattoos or
body piercing.
Prevention of Illness and Injury
thermometer, and protective
equipment (e.g., mosquito
netting) as well as rst aid
equipment. Additional kit
contents will be determined
by your own health needs/
personal medications, the
destination, etc.
Incorporate the information
in the following chapters of
this text in your plan to
prevent contracting infec-
tious diseases.
Accidents and injuries are
common during travel.
Avoid high-risk/extreme
sports and activities and
other risky behavior.
Motor vehicle crashes are
common during travel. If
you rent a vehicle, make
For many of the infectious dis-
eases contracted during travel,
symptoms do not even begin
to show until days, weeks, or
months later. It is important to
remain vigilant in monitoring
your health after you travel. If
you become ill after traveling,
seek immediate care and
advise your healthcare pro-
vider where you have trav-
eled. This information is key
in providing diagnostic clues
as to the possible cause of
the illness.
cautions you took (e.g.,
malaria prevention, immuni-
zations), and recent health
advisories in those areas.
Continue to monitor the
health alerts from the coun-
tries where you traveled for
several weeks after your
trip.
The CDC website has exten-
sive travel health planning
resources: http://wwwn.cdc.
gov/travel/default.aspx.
Post-travel Monitoring
Monitor your health for 7 to
10 days (even longer for
diseases such as malaria
and hepatitis C).
Continue taking any medi-
cations (e.g., malaria pro-
phylaxis) as directed after
you return from traveling.
Report any illness to your
healthcare provider (see
specic symptoms for each
disease) and advise your
provider of the countries
where you traveled.
Provide a history of the
countries you visited, pre-
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Infectious Diseases
Infections are caused by organisms such as bacteria, viruses, and parasites entering the
body. Organisms that cause infection are referred to as pathogens. This section explains
how infections are transmitted and provides protective measures that can be taken to
prevent contracting an infection. Charts describing the main signs and symptoms of
important infectious diseases follow.
Organisms that cause disease
are referred to as pathogens.
They may be transmitted to a
person by various routes: by
direct contact with infected
blood or other body uids, by
air-borne droplets, through
consumption of contaminated
water or food, or through
contact with an animal or
insect. Infections can also be
contracted during bathing,
swimming, or while engaging
in water sports in contami-
nated water.
animals. The organisms are
usually transmitted to humans
through a bite.
Zoonoses are diseases
that are transmitted by animals
to humans through a bite,
a scratch, or contact with
body uids/feces or consump-
tion of animal products (e.g.,
milk, meat). Examples of
zoonoses include rabies, bru-
cellosis, and certain viral hem-
orrhagic fevers.
Sexually transmitted dis-
eases (STDs) are transmitted
from one person to another
through unprotected sexual
contact. Examples of sexually
transmitted infections include
hepatitis B, syphilis, and
human papilloma virus (HPV).
Emerging diseases are
new or changing infections
that present new challenges
and threats to humans. Dis-
eases that are common in
humans, animals, or birds can
mutate and spread, causing
severe illnesses depending on
the degree of natural immu-
nity in the population. Some
diseases that mutate have
never before circulated in the
human population. This results
in widespread infection with
increased morbidity and
How Infections Are Transmitted
Blood-borne diseases
include several serious infec-
tions, notably hepatitis B, hep-
atitis C, and HIV (the virus
responsible for AIDS), which
are spread by contact with
blood and/or other body
uids. Some of these viruses
cannot survive very long
outside the body, but the hep-
atitis B virus can survive for
up to 7 days on surfaces. Hep-
atitis C can survive for up to
4 days outside the body.
Air-borne or respiratory
diseases are caused by bacte-
ria or viruses. They are usually
contracted when someone
coughs or sneezes into the air
and the organisms are inhaled
or ingested by other people.
Examples include inuenza,
measles, and tuberculosis.
Other diseases, such as the
Norwalk virus, which is an
enteric (gastrointestinal)
disease, may be spread by the
air-borne route when vomit or
diarrhea becomes aerosolized
during cleanup or during
active vomiting. Meningococ-
cal infection is also spread by
droplet transmission.
Food-borne and water-
borne diseases are caused by
many different infectious
organisms, such as salmonella
and hepatitis A, and are
spread by bacteria, viruses, or
parasites in food and water.
These pathogens are a particu-
lar risk to anyone traveling to
areas with poor sanitation.
It is important to avoid expo-
sure to contaminated water
and food; this also includes
water used for bathing and
water sports.
Vector-borne diseases are
caused by pathogens transmit-
ted via the bite of an animal
or insect. Some organisms
spend part of their life cycle in
another host (a vector), such
as mosquitoes, ticks, or other
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mortality because there is no
immunity in the population.
Pandemic inuenza is an
example of this type of illness.
Emerging diseases that are of
concern include SARS and
avian inuenza (H5N1).
Other illnesses of concern
include skin infections, such
as Staphylococcus aureus and
a drug-resistant form called
MRSAmethacillin-resistant
Staphylo coccus aureus, which
can be contracted by exposure
to infected individuals or envi-
ronments. Tetanus is another
disease that is contracted by
exposure to the soil through
open cuts or wounds. Shingles
is caused by the same virus as
chickenpox, but it causes blis-
ters and a skin rash that can
transmit the virus.
There are many other dis-
eases of concern to travelers
that are not included in this
text. For specic diseases not
addressed in this text, or for
current information, consult
the resource websites at the
end of this chapter.
Passengers with
Contagious Disease
Passengers who have a conta-
gious disease should not travel
or y according to Interna-
tional Health Regulations.
Changes in altitude and the
stresses of ight can make
many health conditions worse.
In addition, there is the risk of
passing the infection on to
other passengers and crew.
World health authorities are
also concerned about the risk
of domestic and international
spread of infections. It is pos-
sible that passengers may be
unaware that they have a con-
tagious disease or may not
declare their condition. Many
of these diseases, particularly
viral illnesses in children, are
often difcult to identify.
People who appear ill with a
fever and/or a rash should not
be allowed to travel unless
they have a letter from a
doctor conrming that they
do not have a contagious
illness. If in doubt, seek advice
from MedLink.
Exposure Risks to Crew
Crew may be exposed to
infections through physical
proximity to passengers with
contagious diseases, through
contact with infected blood
and body uids during emer-
gency medical assistance, or
while performing routine
duties such as checking the
cabin. Crew may also be at
risk of acquiring infectious dis-
eases during layovers. Infor-
mation regarding common
infectious diseases, signs and
symptoms, and how to
prevent infection is included
in the chart at the end of this
section. Further information
on immunizations that may be
needed for particular destina-
tions and information on local
health risks in those places
can be obtained from health
and immunization advisory
services or from the CDC
(www.cdc.gov) or the WHO
(www.who.int). MedAire
clients can obtain travel-
specic information at
www.medaire.com.
How Infections Are Transmitted, continued
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Prevention of blood-borne
pathogen exposure during
travel or when managing a
medical situation includes the
following.
During a Medical Situation
Wash your hands with soap
and water, using friction,
and dry with a towel
before and after caring for
a victim.
Use hand sanitizer between
handwashings.
Treat all blood and body
uids as potentially infec-
tious material and use pro-
tective equipment and
Hand Sanitizers
The use of hand sanitizers is recommended by
the WHO and CDC as an effective means of
cleaning hands that are not heavily soiled or
when handwashing is not available. Hand
sanitizers that are at least 60% alcohol are
most effective.
Apply the recommended amount of hand
sanitizer to your hands; follow the manufac-
turers instructions.
Rub hands together to spread sanitizer
between ngers and over all the surfaces of
your hands.
Continue rubbing until the hand sanitizer
is dry.
Wash your
hands with
soap and
water as
soon as
possible.
Protection from Infection
Handwashing
Handwashing is the
most important
measure in prevent-
ing infection. Wash
your hands before
preparing or eating
food; after using the
toilet; before and
after caring for
someone who is
ill/injured; after
blowing your nose, coughing, or sneezing; and
after cleaning or handling trash/garbage.
Wash your hands thoroughly as follows:
Use warm running water (not hot).
Use soap.
Use friction and rub the soap between the
ngers and over the palms and tops of your
hands to your wrists.
Continue washing your hands for a minimum
of 20 seconds.
Rinse thoroughly to remove all soap.
Dry your hands with a paper towel.
Use the towel to open the door to the
lavatorydispose of properly.
mask to protect yourself
and the victim.
Take care when handling
needles and syringes. Put on
gloves. Do not recap used
needles. Dispose of used
syringes, needles, and
lancets in a sharps container
using tongs. If a sharps con-
tainer is not available, use a
clear water bottle, secure the
top, clearly label the bottle
as biohazard, and dispose of
appropriately. Avoid unnec-
essary medical injections or
other invasive procedures
(e.g., dental work) in devel-
oping countries.
standard precautions to
avoid exposure.
Wear gloves. Dispose of
gloves and soiled items in a
biohazard bag (see follow-
ing discussion). If an expo-
sure occurs, wash the area
with soap and water
immediately.
Avoid exposure of blood or
body uids to open
wounds, broken skin, eyes,
and mucous membranes.
Pathogens can enter the
body through these routes.
When giving rescue breath-
ing to a victim, use a plastic
face shield or a pocket
Wear Gloves
Use disposable gloves if there
is any likelihood of coming
into contact
with blood
or other
body uids.
Wad up the glove in other
gloved hand.
Slide nger of ungloved
hand underneath glove and
slide off the other glove and
the wadded up glove
together so that the glove is
inside out with the rst
glove inside it.
Place gloves in biohazard
bag.
Wash hands.
Glove Removal
Remove gloves as follows.
Remember that the inside of
the gloves are considered clean
and the outside of the gloves
are considered contaminated.
Proper glove removal is impor-
tant to prevent contamination.
Pinch the outside cuff of
one glove and slide off the
hand.
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A simple surgical face mask
should be used by the ill pas-
senger to prevent the spread of
a respiratory infectious disease
during speaking, coughing, or
sneezing. The appropriate pro-
cedure for donning and remov-
ing the mask follows:
Mask Donning
1
Open the mask.
2
Bend the nosepiece so that
it ts snuggly over the
bridge of the nose.
3
If the mask has ties, tie the
top ties rst at the top of
the head and then tie the ties
at the neck. If the mask has
elastic loops, place the loop
around each ear.
top tie. For a mask with elastic
loops, remove the loop from
each ear.
2
Remove the mask away
from the facetouching
only the ties or loops.
3
Dispose of the mask in the
trash or biohazard bag,
holding only the ties or loops.
4
Wash your hands.
4
Once the mask is in place,
press the nosepiece so that
it ts snuggly across the bridge
of the nose.
5
Check to make sure there is
no blow by (air move-
ment that escapes from the
top, bottom, or sides of the
mask). A properly tted mask
will reduce blow by.
Mask Removal
Remove/change the mask
when it becomes moist or
soiled or is no longer needed.
To prevent contamination,
avoid touching the mask face
piece.
1
If the mask has ties, remove
the mask by untying the
bottom tie rst and then the
USE OF A SURGICAL FACE MASK
Use of a Pocket Mask
A pocket mask can be used for protec-
tion during rescue breathing, and some
models can be attached to oxygen.
Use of a Face Shield
For protection when giving rescue
breathing, use a plastic face shield,
which forms a hygienic barrier.
Protection from Infection, continued
Passengers who are complaining of illness that
may be contagious should be isolated to
prevent the spread of disease. Symptoms such
as excessive coughing, fever, rash, bleeding,
etc., should be considered potentially conta-
gious, and these passen-
gers should be isolated
from others if possible.
Move the passenger
away from others if
possible.
Offer tissues and bag
for disposal.
Caring for an Ill Passenger during Flight
Encourage handwashing or use of hand sani-
tizer to clean hands.
Instruct passenger in cough etiquette.

Cover mouth and nose with a tissue when

sneezing or coughing.

Wash hands frequently and use hand sani-

tizer between handwashings.

Dispose of used tissues in a trash bag.

Give passenger a mask to wear if tolerated.
If passenger is unable to tolerate the mask
due to difculty breathing, the ight atten-
dant should wear a mask when caring for
the passenger.
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Most countries worldwide are
working together to develop
reporting strategies for pre-
venting the global spread of
serious infectious diseases.
The CDC regulation for report-
able diseases for aircraft des-
tined for the United States
provides specic criteria for
reporting signs and symptoms
of infectious diseases.
Although most countries
requirements are similar, it
is important to check with
the specic country of your
suspects that a passenger or
crew member may be suffer-
ing from a contagious disease.
The Port Health Authority at
the destination may decide
that the sick person should be
assessed by a Port Health
doctor and stipulate that all of
the passengers and crew must
remain on board the aircraft
until the assessment has been
carried out. This is in accor-
dance with international
health control regulations.
Reporting Infectious Disease during Flight
destination for their
reporting requirements.
If you identify a passenger
with reportable symptoms,
seek advice from MedLink.
MedLink can assist with the
care of the passenger or crew
member. Information regard-
ing reporting information can
also be provided.
In other countries, the Port
Health Authority at the desti-
nation airport should be con-
tacted as soon as the crew
REQUIRED
Temperature of 100F (38C) or greater
accompanied by a rash
Temperature of 100F (38C) or greater
accompanied by glandular swelling (swollen
lymph nodes)
Temperature of 100F (38C) or greater
accompanied by jaundice (yellow eye/skin)
Temperature of 100F (38C) or greater
which has persisted for more than 48 hours or
Diarrhea dened as the occurrence in a 24
hour period of three or more loose stools or a
greater than normal amount of loose stools.
Upon learning that a passenger or crew is
exhibiting any of these signs/symptoms on board,
the captain or designee must immediately contact
Flight Control who will notify the Quarantine
Station or the CDC Quarantine Duty Ofcer on
call at 1-866-694-4867.
Reference: Centers for Disease Control and Prevention, Division of Global Migration and
Quarantine, National Center for Infectious Diseases.
In addition, the CDC requests that passen-
gers/crew with the following symptoms also be
reported because these symptoms may also be a
reportable illness.
REQUESTED
Hemorrhagic fever syndrome (persistent fever
accompanied by abnormal bleeding from any
site); or
Acute respiratory syndrome (a fever accompa-
nied by severe cough or severe respiratory
disease of less than 3 weeks duration) or
Acute neurological syndromeonset within
3 weeks of severe neurological system dysfunc-
tion without predisposing factors (i.e., severe
headache accompanied by stiff neck, change in
level of consciousness)
NOTIFICATION TO PUBLIC HEALTH AUTHORITIES OF ILL PASSENGERS
AND CREW ON FLIGHTS DESTINED FOR THE UNITED STATES
The CDC has issued specic regulations for reporting potentially infectious passengers
on board an aircraft destined for the United States.
According to 42 CFR Part 71.21(b), the Centers for Disease Control and Prevention requires the
commander of an aircraft destined for a U.S. airport to report the presence on board of any death or
any ill person among passengers or crew to the Quarantine Station at or nearest the port of arrival.
An immediate report of illness must be made for any passenger or crew member who exhibits:
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Resources
Personal protective equip-
ment (eye protection, face
mask, protective apron/suit,
gloves, shoe covers)
Biohazard bag
Scoop
Surface cleaner
Package of solidier agent
Waste that is generated from
ill or injured victims is called
clinical waste. It can spread
infectious disease and presents
a health risk to anyone who
handles it or is accidentally
exposed. Clinical waste is also
an environmental hazard. For
these reasons, it is essential
that the waste be handled and
disposed of with appropriate
precautions. Clinical waste on
an aircraft may include the fol-
lowing items:
Soiled items, gloves,
needles, and other sharp
instruments
Used medical equipment
(which may come from the
aircrafts rst aid kits or the
passengers own supplies)
Human body tissue, blood,
and any other body uids
or excretions (e.g., vomit,
diarrhea)
Handling and Disposing
of Clinical Waste
Isolate and control the con-
taminated area to prevent
exposures.
Always wear gloves and
appropriate personal protec-
tive equipment when han-
dling waste. If there is a
risk of splashing or contact
with your face/eyes, use
full personal protective
equipment to protect your
nose, eyes, mouth, and
mucous membranes.
If the infectious material is
wet (e.g., vomit), place a
dry, absorbent material over
wet areas. Once the wet
material has been absorbed,
use a scoop to carefully
scrape the material up and
Clinical WasteCleanup/Disposal
put in a biohazard bag.
Avoid any cleaning proce-
dures that cause aerosoliza-
tion because this may result
in inhalation of the infec-
tious material.
Place all used or opened
sharps, needles, lancets, and
razors in a sharps container.
Place all other clinical
waste, including contami-
nated napkins, blankets,
used gloves, used personal
protective equipment, etc.,
in a biohazard disposal bag
and secure with a tie.
Dispose of the bag accord-
ing to your company policy
unless the contents are non-
disposable equipment.
Place nondisposable con-
taminated items/equipment
in a biohazard bag and
arrange for cleaning per
company policy.
Wash your hands thor-
oughly with soap and water,
using friction, and dry with
a towel.
Disposal of Used Syringes
or Lancets
Sharp items such as needles,
syringes, and lancets can
cause puncture wounds,
which may cause infections.
Follow the precautions out-
lined here to minimize the
risks of a sharps injury. If a
sharps injury does occur, refer
to Chapter 7.
Safety Precautions
Always put on disposable
gloves before handling
sharp items.
Dispose of used syringes,
needles, and lancets imme-
diately in a sharps
container. These containers
are usually found in aircraft
medical kits. If no sharps
container is available, use a
plastic container (e.g., a
water bottle) that can be
labeled and sealed.
Use tongs or other imple-
ments to pick up needles or
other contaminated objects.
Never use your ngers.
Always take the sharps
container to the sharp
object; never walk through
the aircraft cabin with a
sharp item.
To dispose of a needle and
syringe, hold the syringe by
the barrel and insert it into
the sharps container with
the needle end rst.
Never put a used needle
back in its cover.
If a passenger wishes to
dispose of a personal
needle (e.g., a diabetic with
an insulin needle), give the
sharps container to the pas-
senger and ask him or her
to place the item in the
container.
Dispose of the sharps con-
tainer according to your
company policy.
After a medical emergency,
search the area around the
victim for any sharps.
Never put your hand or
foot in a trash can or in a
seat back pouch or cushion
in case there is a sharp
object inside.
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Prevention of blood-borne
pathogen exposure during
travel or when managing a
medical incident includes the
following.
During a Medical Incident
Follow these standard precau-
tions to prevent exposures
during a medical incident:
Wash your hands with soap
and water, using friction for
a minimum of 20 seconds,
and dry your hands with a
paper towel before and
after treating a victim.
Treat all body uids or
excretions as potentially
infectious material and
avoid exposure.
Wear gloves. Dispose of
gloves and soiled items in a
biohazard bag (see follow-
ing discussion).
Use safe sex practices; use
good-quality condoms and
do not engage in unpro-
tected sexual contact. Avoid
unprotected sexual activity
with multiple partners.
Avoid intravenous drug use.
Avoid body piercing/tattoos,
acupuncture, and barber
shop shavings.
Obtain the hepatitis B
vaccinations.
Avoid blood transfusions,
which may carry a risk of
infection even in developed
countries (although in these
countries, the risk may be
minimal).
Avoid unnecessary medical
injections or other invasive
procedures (e.g., dental
work) in developing
countries.
Avoid exposure to open
wounds, broken skin, eyes,
and mucous membranes.
Pathogens can enter the
body via these routes.
If splashing of blood or
body uids is possible, use
eye protection (goggles/
shield), apron/jumpsuit, and
gloves for protection.
When giving rescue breath-
ing to a victim, use a plastic
face shield or a pocket
mask to protect yourself
and the victim.
Follow guidelines for
Clinical WasteCleanup/
Disposal
Additional Precautions
Additional precautions for
blood-borne pathogen preven-
tion include the following:
Respiratory diseases are very
common and can be transmit-
ted when an infected person
coughs, sneezes, or talks. Ill-
nesses such as inuenza,
measles, and chickenpox are
examples of respiratory dis-
eases. These diseases are typi-
cally very contagious and
spread easily from one person
to another. The viruses/bacteria
can be sneezed into the air
and inhaled or ingested by
another person, or they can be
coughed, sneezed, or vomited
on surfaces where another
person touches the contami-
nated surface and then touches
his or her mouth or nose. This
self-inoculates the victim with
the virus, and illness can
result. The following are pre-
vention measures that can
reduce the spread of air-borne
and respiratory diseases:
Stay home and do not travel
if you are sick.
Clean work surfaces fre-
quently with approved
surface cleaner/disinfectant;
follow manufacturers
instructions for use.
Use cough etiquette if you
are ill (see following box).
Prevention of Air-borne/Respiratory Diseases
Avoid contact with others
who are ill.
Wash hands frequently and
use hand sanitizer between
handwashings.
Avoid touching your eyes,
mouth, and nose with your
hands.
1
Cover your mouth and
nose with a tissue when
you cough or sneeze.
2
If you do not have tissues
available, do not use your
hands; instead, turn your
head and cough or sneeze
into your sleeve.
3
Wash you hands after
handling soiled tissues.
4
Use hand sanitizer fre-
quently between
handwashings.
COUGH/SNEEZE ETIQUETTE
Prevention of Blood-borne Diseases
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Travelers diarrhea (TD), a gas-
trointestinal infection, is the
most common illness among
travelers and may effect up to
80% of people who are
traveling in high-risk areas.
TD affects approximately two-
thirds of travelers13% are
conned to bed and 40% are
forced to change their travel
plans.
In many countries, it is
important to take the follow-
ing precautions to avoid gas-
trointestinal infections:
Drink canned or bottled
beverages. Check that
bottles are properly sealed
before opening them. Use a
drinking straw.
Boil water for tea and
coffee.
Avoid unpasteurized milk
products.
Avoid ice unless it has been
made from boiled or puri-
ed water.
Do not eat raw vegetables.
Do not eat cold food plat-
ters, ice cream, custard, or
pastries.
Do not eat shellsh unless it
is well cooked.
Do not eat food from street
vendors.
Take care not to ingest
water while bathing or
swimming or during water
sports.
Avoid pools, spas, and
whirlpools that may not be
properly treated.
Minimize handling of
money, which can be very
dirty.
Avoid chipped crockery or
glasses.
Use disinfectant wipes to
wipe glass or bottle rims,
crockery, and cutlery.
Carry a penknife for peeling
and cutting fruit.
Prevention of Food-borne and Water-borne Diseases
Brush your teeth with
boiled or puried water.
Choose sparkling water or
carbonated drinks, which
are generally safer than
still water.
Choose well-cooked meat
and sh dishes and eat
them while still hot.
Avoid food buffets where
the food could be on the
serving line for hours. Order
food off the menu.
Peel all fruit, including
tomatoes. Before peeling,
inspect the fruit to ensure
that the skin has not been
punctured; then wash it with
puried or boiled water.
Avoid dishes containing raw
or undercooked eggs.
Avoid seafood dishes in
countries where poisonous
biotoxins may be present in
sh and shellsh. Local
advice may be useful
regarding sh and shellsh.
The most common vector-
borne diseases are spread by
insects such as mosquitoes
and ticks. These diseases
include malaria, dengue fever,
yellow fever, and Lyme
disease. Prevention measures
are very important in order to
prevent exposure. Remember
the following ABCD acronym:
A AWARENESSBe aware of
the risk, incubation period,
and symptoms.
B BITESAvoid mosquito,
tick, and ea bites.
C CHEMOPROPHYLAXIS
Take antimalarial drugs/
vaccines when appropriate.
D DIAGNOSISEarly diagno-
sis is important for prompt
treatment. Seek medical
care if fever develops 1 week
to 1 year after exposure or
if other specic symptoms
occur.
mosquitoes may be able
to bite a person if the
net is in contact with
the body.

Use a knock-down spray

before retiring.
Use an insect repellent on
all exposed skin.

DEET in concentrations
of 30% to 50% should be
used and applications
repeated every 3 to
4 hours.

DEET in concentrations
as high as 50% are rec-
ommended for both
adults and children
older than 2 months
of age.

Protect infants younger

than 2 months of age by
using a carrier draped
with mosquito netting
with an elastic edge to
ensure a tight t.
Prevention of Vector-borne Diseases
During travel, consider the
following information to help
prevent mosquito and tick
bites:
Mosquitoes that transmit
malaria are most active
during twilight periods
(dusk until dawn).
Mosquitoes that transmit
yellow fever and dengue
fever bite during the day.

Stay in air-conditioned or
well-screened hotels.

Sleep under an insecticide-

treated bed netwith all
the sides tucked under the
mattress. Bed nets can be
sprayed with a repellant if
not pretreated.

Bed nets should be strong

with a mesh size no larger
than 1.5 mm. Check nets
for tears or holes.

Ensure that the net does

not touch the body;
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Mosquito netting should be tucked under the mattress on all sides. There should be no holes or tears,
which would render the net ineffective. The net should not touch the person lying underneath it. (Photos
courtesy of Lorraine Mooney RGN MSc [Travel Medicine])
Mosquito netting should be sprayed reg-
ularly with insect repellant if not already
treated. (Photo courtesy of Lorraine
Mooney RGN MSc [Travel Medicine])

Picaridin (7% to 15%)

needs more frequent
application.

If DEET cannot be used,

a product containing p-
methane-diol (Mosiguard
Natural) may be used. It
is as long lasting as
DEET and does not
attack plastics. Smell may
also be more acceptable
to travelers.

Precautions when apply-

ing repellant include:

Avoid spraying repel-

lant on the face or
making contact with
the mouth, eyes, or
mucous membranes.
Repellant should be
applied to the hands
and then to the face,
avoiding the mouth
and eyes.

Always wash hands

after applying
repellant.
permethrin-treated clothing
is effective for up to ve
washings. Permethrin is
not approved for use on
the skin.
Avoid areas of standing
water, lakes, and irrigation
ditches, which attract mos-
quitoes, as well as densely
populated woodlands/
forests, where ticks reside.
Consult a travel health
physician for malaria pro-
phylaxis medications appro-
priate for the area of travel.
Take as directed.
Maintain a current yellow
fever vaccination and keep
the certicate with your
travel documents.
Research areas to be visited
prior to travel and be aware
of symptoms of endemic
diseases and the possible
seriousness of infection.
Apply sunscreen rst, then
the repellant.
Repellent should be washed
off at the end of each day
before retiring.
Wear long-sleeve shirts
tucked in and long pants
and hats to cover all
exposed skin in high-risk
areas.
In areas with ticks or eas,
wear boots and tuck the
pant legs into the socks.
Wear light-colored clothing
in order to see ticks; check
for ticks and remove
promptly if found.
Apply permethrin-containing
repellant (e.g., Permanone)
or DEET to clothing, shoes,
tents, mosquito nets, and
other gear for protection.
Most repellants are removed
from clothing/gear after a
single washing. However,
Prevention of Vector-borne Diseases, continued
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Travelers are occasionally
exposed to animals/reptiles or
insects that may transmit
disease. Zoonotic diseases are
transmitted to humans by
bites, saliva, or scratches. Dis-
eases transmitted in this
manner include rabies and
bites or stings from venomous
insects or reptiles.
Prevention strategies
include the following:
Avoid contact with domestic
and wild animals.
Familiarize yourself with the
preventive measures for the
common venomous crea-
tures in the area of travel.
Check your shoes and
clothing for hidden reptiles
and insects before putting
them on.
Seek immediate medical
attention if you wake up to
nd a bat in your room or
tent or if you were bitten or
stung by a venomous reptile
or insect.
Rabies vaccine is recom-
mended if you are traveling
to areas where rabies is
prevalent, if you are travel-
ing for prolonged periods of
time, or if you will be more
than 24 hours from quality
medical facilities.
Prevention of Zoonotic DiseasesAnimal and Insects
Diseases that are transmitted
through sexual contact are
prevalent worldwide.
Common sexually transmitted
diseases (STDs) include chla-
mydia, syphilis, and gonor-
rhea, among others. Current
research has shown that cervi-
cal cancer in women can be
caused by a common STD
Avoid engaging in sexual
activity with multiple
partners.
Consider vaccination against
human papillomavirus
(available as childhood
vaccine for girls).
Consider the hepatitis B
vaccine.
Prevention of Sexually Transmitted Diseases
human papilloma virus. The
following prevention strategies
should be followed to prevent
transmission of STDs:
Avoid unprotected sexual
activity.
Use a good-quality condom.
Male or female condoms are
available in most countries.
Avoid behavior that may
startle or frighten wild or
domestic animals or
reptiles.
Do not pick up any snakes,
insects, or animals.
Do not walk barefoot or in
sandals in areas with ven-
omous snakes, reptiles, or
scorpions.
Exercise heightened caution
when walking at night
because many animals and
reptiles are nocturnal.
Never put your hands or
feet in locations where ven-
omous reptiles or insects
may be hiding.
Many diseases are spread via
contact with contaminated
environments or contact with
infected individuals. Breaks in
the skin allow bacteria and
viruses to enter the body,
which can cause an infection.
Infections caused by organ-
isms such as Staphylococcus
aureus can cause skin infec-
tions as well as more serious
systemic infections in some
people. Methacillin-resistant
Staphylococcus aureus (MRSA)
is a staph infection that has
developed resistance to
common antibiotics. It is
important to protect yourself
from exposure to these organ-
isms. Tetanus is another
disease that is contracted from
Keep all cuts, scrapes, and
wounds covered with clean
dressings/bandages until
healed.
Follow the guidelines for
wound care in Chapter 6,
Traumatic Injuries.
Avoid contact with other
peoples wounds or ban-
dages; use gloves and
follow blood-borne patho-
gen prevention guidelines.
Wipe environmental sur-
faces that are shared to
avoid exposure (e.g., exer-
cise equipment, computers).
Maintain updated tetanus
immunization.
Prevention of Other Diseases
the soil through a wound. Pre-
vention strategies as outlined
by the CDC include the
following:
Wash hands frequently
before and after eating,
using the toilet, or provid-
ing medical assistance or
wound care.
Avoid sharing personal
items (e.g., towels, clothing,
razors).
Avoid skin-to-skin contact
with someone with an open
wound.
Practice good personal
hygiene.
Use alcohol-based hand
sanitizers between
handwashings.
86344_02_015-046.indd 27 5/27/08 1:14:39 PM
28
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Aircraft Disinsection
A number of countries require incoming aircraft to be sprayed with insecticide to ensure
that disease-carrying insects, such as mosquitoes, are not brought into those countries.
This procedure is known as disinsection. The cabin crew may need to spray insecticide
inside the aircraft cabin, while the ground crew treat other parts of the aircraft.
The term aircraft disinsection
is used by the WHO to refer to
a procedure that is designed to
rid the cabin of any disease-
carrying insects, such as mos-
quitoes, that may be in the
aircraft after the cabin doors
have been closed. There are
two different types of disinsec-
tion currently in use:
The residual methodinter-
nal surfaces, including food
preparation areas, seats, and
tray tables are all treated
prior to passenger loading.
Spraying before and during
ight using aerosols
single-shot cans, which
contain the appropriate
amount of insecticide to
treat the entire aircraft, are
used. The ight deck, holds,
and wheel wells are treated
before departure by the
ground staff.
The procedures for disinsec-
tion vary with each airline and
destination country. A basic
description of disinsection is
provided in the highlighted
box; for details, refer to your
company policy.
Disinsection Procedure
Resources:
Single-shot aerosol sprays
of insecticide
Gloves
1
After the cabin doors are
shut, an announcement is
made before disinsection
begins. Passengers who have
respiratory disorders, aller-
gies, or chemical sensitivities
and pregnant women may
wish to cover their mouths
and noses during disinsec-
tion. Parents of infants and
small children may wish to
cover the childrens mouths
and noses.
2
Spraying is carried out
between push-back and
take-off, with the overhead
bins closed. (Note that
different protocols are used
depending on the destination
country and company policy.)
3
The entire cabin is
sprayed at a rate of no
more than one seat row per
second. The galleys and the
toilets are also sprayed. The
cans should be held above
shoulder height and the
spray aimed above the heads
of the passengers.
4
Once the disinsection pro-
cedure has been com-
pleted, the empty cans are
kept for inspection at the port
of arrival if requested by Port
Health Authority. The cans
have serial numbers, which
are recorded.
HOW TO PERFORM A DISINSECTION
PROCEDURE
Strict protocols have been
developed to ensure that dis-
insection procedures comply
with the local legislation at the
aircrafts destination. Port
Health Authority inspectors
can board any aircraft arriving
from countries where insect-
craft can be impounded until
the correct treatment is com-
pleted. Spraying of aircraft is
mandatory in countries requir-
ing it. In the United States,
however, disinsection must be
carried out in the air rather
than on U.S. soil.
Checks by Port Health Authority Inspectors
borne diseases are prevalent.
In many countries, checks are
made by Port Health Authority
inspectors who travel incog-
nito. The inspectors assess the
disinsection procedure to
decide whether or not it is
adequate. If it is not, the air-
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Alertness Management
Duty times demand continuous alertness from members of the crew. However, ight
schedules and the effects of long-haul ights can result in fatigue, which may be com-
pounded by disruption to the internal body clock (see Circadian Rhythm and Jet Lag).
This section addresses the causes and prevention of fatigue.
When people are suffering from fatigue, their
ability to carry out tasks is impaired. During
ight operations, reduced alertness or perfor-
mance from fatigue can reduce the efciency of
the crew and may even pose a safety risk.
This problem usually results from lack of
sleep or disruption of normal sleep patterns.
However, many other factors can also contrib-
ute to fatigue. Illness (either physical or psycho-
logical), stress, side effects of medication
(including over-the-counter drugs), alcohol,
noise and/or vibration, discomfort because of
temperature extremes, and insufcient oxygen
(hypoxia) may all increase the level of fatigue
or impair concentration. In addition, the feeling
of fatigue may be exacerbated by boredom
resulting from poor motivation or an unstimu-
lating environment.
There are many signs and symptoms of
fatigue, such as discomfort after exercise,
difculty in concentrating, or difculty
staying awake.
Fatigue
The following guidelines are
intended for use before and
during a trip to improve sleep
and reduce the risk of fatigue.
They focus on the physiology of
sleep and are aimed at reducing
the adverse effects of fatigue,
sleep loss, and disturbance to
the internal body clock or circa-
dian rhythms. General advice is
given here, but it should be tai-
lored to the specic needs of
each individual. Combining dif-
ferent prevention strategies is
usually best.
Sleep Scheduling before
and during Trips
Before starting a trip, try to
get a good nights sleep at
home.
On a trip, try to get as
much sleep in every
24 hours as you would
during a normal 24-hour
period at home.
Further Tips
There are some further practi-
cal measures that crew
members can take to help
prevent or reduce fatigue
during periods of duty.
Avoid alcoholic drinks and
drinks containing caffeine.
Avoid temperature
extremes.
Avoid boredom; stay active
and task-oriented.
Engage in physical exercise
(but not just before sleep).
Plan sleep or a nap for
times when you are natu-
rally sleepy.
Do not use any medications
(including herbal or other
alternative medications)
that may cause drowsiness
or impair performance.
Avoid heavy meals prior to
periods of duty or prior to
going to sleep.
Sleep if you feel tired and
circumstances permit.
Napping
Naps can be an important
part of managing your sleep
cycle.
A nap can improve your
subsequent alertness and
performance.
A nap will decrease the side
effects of continuous
wakefulness.
If you want to take a nap
just before a duty period or
an appointment, limit the
nap to no more than 45
minutes.
At other times, naps can be
longer. A nap of 2 hours or
more will allow at least one
full cycle of deep and
dreaming sleep.
Even a small amount of
sleep is better than none.
HOW TO PREVENT FATIGUE
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Effects on Performance
Fatigue can adversely affect physical and mental
performance in several ways.
Reaction times are much slower.
Loss of situational awareness results in an
excessive focus on specic tasks.
Judgment may be impaired and decision
making may be more difcult or slow.
Attention is more likely to be easily
disrupted.
Flight and Fatigue
Flight duties can affect sleep and circadian
factors in three main ways.
Changing duty times or shifts can disrupt
regular sleep routines.
On long-haul ights, passing through several
time zones may lead to prolonged periods of
continuous wakefulness (see Jet Lag).
If the physiological timing for sleep does not
coincide with the scheduled sleep opportu-
nity, a cumulative sleep decit can result.
The body has a natural 24-
hour (circadian) rhythm that
affects many of its functions.
The internal body mechanisms
that control circadian rhythm
are complex and are inu-
enced by a number of external
factors.
Exposure to daylight has an
important role in synchroniz-
ing the circadian rhythm with
local time. In general, expo-
sure to bright light during the
morning advances the circa-
dian clock, while exposure to
light during the evening delays
it. Other factors that also play
a part include work/rest
schedules and regular social
interaction.
3 pm to 5 pm. These times
can be used for sleep or naps
(see previous discussion).
Crossing Time Zones
On transmeridian ights (those
in which several time zones
are crossed), the circadian
clock becomes out of step
with local time. This affects
not only sleep patterns but
also body functions such as
digestion. Once in a new time
zone, the body begins to
adjust, but different functions
tend to adjust at different
paces, so they may become
out of sync with one another.
Circadian Rhythm
For long-haul aircraft crews,
the major factor that causes
disruption of circadian rhythm
is passing through several time
zones during ights.
Patterns of Sleepiness
Circadian rhythms determine
patterns of sleepiness as well
as inuence internal processes
such as the regulation of body
temperature and digestion. In
a normal 24-hour cycle, there
are two periods during which
the brain triggers sleepiness.
One is the time from 3 am to
5 am, which is a low point for
body temperature, perfor-
mance, and alertness. The
other, for most people, is
Fatigue, continued
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Like food and water, sleep is a
physiological need that is
essential to human survival.
Although it is widely believed
that sleep is a time when the
brain and body shut off,
sleeping is in fact a highly
complex process.
Normal Sleep Cycles
There are two distinct types of
sleep: rapid eye movement
(REM) sleep and non-REM
(NREM) sleep. REM sleep is
associated with dreaming,
during which the brain is
extremely active, with bursts
of rapid eye movements.
NREM sleep is a period in
which physiological and
mental activities slow down.
This form of sleep is divided
into four stages. In stages
1 and 2, sleep is very light and
people are easily awakened.
The deepest sleep occurs in
stages 3 and 4 of NREM sleep.
If people are awakened during
this time, sleep inertia may
occur, which is a continued
feeling of grogginess and dis-
orientation that may last for
10 to 15 minutes.
Over the course of a typical
nights sleep, NREM and REM
during sleep. Several glasses of
wine or beer can largely elimi-
nate the REM sleep in the rst
half of the sleep period.
Developing Good
Sleep Habits
Sleeping well when you
are not on duty is often a
matter of maintaining sensible
habits and creating a restful
environment.
Develop and use a regular
pre-sleep routine and stick
to it whenever possible.
Make sure that your
bedroom is as comfortable
as possible. Use eye shades
if you cannot make your
room dark enough and ear-
plugs if it is too noisy.
Maintain regular sleep
habits.
Do not go to bed hungry,
but do not eat or drink
heavily before going to bed.
Do not have any drinks
containing alcohol or caf-
feine just before bedtime.
If you are unable to get
to sleep within 15 to
30 minutes of going to bed,
get up and do something
else for a while.
Sleep Physiology
sleep occur in cycles of about
90 minutes. Most deep sleep
occurs in the rst third of the
nighttime sleep.
Changing Sleep Patterns
with Age
With increasing age, sleep
becomes lighter and more
easily disrupted. Older people
tend to have increased periods
of wakefulness, and their total
amount of nighttime sleep
decreases. As a result, previ-
ous strategies for achieving
sufcient sleep may no longer
be effective.
Cumulative Sleep Decit
Sleep loss can be additive and
will result in a cumulative
sleep decit. This loss of sleep
will increase the likelihood of
adverse effects resulting from
fatigue.
The Effect of Alcohol
Although alcohol is often used
to promote relaxation and help
people fall asleep, it actually
has major disruptive effects on
the sleep cycle. Alcohol
reduces the length of REM
sleep and affects certain physi-
ological processes that occur
Waking state
REM or dreaming sleep state
Cycle 1 Cycle 2 Cycle 3
The typical 7-8 hour nightly sleep pattern (each cycle lasts c.90 mins)
Cycle 4 Cycle 5
Non-REM or deep sleep
Stage 1 Non-REM sleep
Stage 4 Non-REM sleep
Stage 3 Non-REM sleep
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Stage 2 Non-REM sleep
Normal Sleep Cycle
Sleep occurs in cycles of REM and NREM sleep. The accompanying chart shows when the
ve different stages of sleep occur during a typical 9-hour sleep period. The deepest levels of
sleep, stages 3 and 4 of NREM sleep, occur within the rst 3 hours of falling asleep.
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The term jet lag describes the symptoms that
develop after trips in which the traveler passes
through several time zones over a short period
of time. During such trips, the circadian
rhythms are disrupted, causing jet lag.
For most people, traveling west toward the
sun allows for an easier transition between time
zones. Eastward travel is more difcult, and a
longer time is needed to adjust. In general, the
Jet Lag
body needs 1 day to acclimatize for every time
zone crossed.
Signs and Symptoms of Jet Lag
Fatigue
Disturbed digestion and bowel habits
Disturbed sleep and sleepiness during the day
Changes in mood and in judgment
The World Health Organization
www.who.int
The Centers for Disease Control and Prevention
www.cdc.gov
United Kingdom Health & Safety Executives
www.hse.gov.uk/pubns/indq174
Health Protection Agency
www.hpa.org.uk
Occupational Safety and Health Organization
(OSHA)
www.osha.gov
MedAire, Inc.
www.Medaire.com
Travel Health Resources
World Time Zones
This map shows all the time zones across the world, based on Greenwich Mean Time (Zulu time).
The gures show times to the east and west of the Greenwich Meridian line.
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Notes

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Victim
Assessment
When caring for a victim who is ill
or injured, it is helpful to have a
clear plan of action. This chapter
includes a general overview of how
to manage a medical incident and
the specic roles that each crew
member or passenger may assume.
A complete guide to the medical
assessment of a victim, including
the primary and secondary survey,
history, physical exam, and vital
sign monitoring, is included.
Managing a Medical Incident 48
The Medical Action Plan 48
Procedures for an Incident in Flight 49
Plan of Action 49
Surveying a Victim 50
Conducting a Primary Survey 50
Conducting a Secondary Survey 51
Measuring Vital Signs 52
Look for External Clues 54
Examining a Victim 55
Identifying Specic Signs and
Symptoms 56
Documenting Information 58
3
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Managing a Medical Incident
Managing a medical incident can be very stressful if the rescuers are unprepared. This
section provides a Medical Action Plan with specic roles for the rescuers. This plan is
intended as a guide and provides a role for three rescuers; however, it may need to be
revised for your specic crew conguration and company policy.
In-ight medical situations are
best managed by the crew as
a team. The following plan is
an example of the roles and
duties that may be assumed by
three rescuers. The plan out-
lines three roles: the First
Rescuer, who assesses and
cares for the victim; the
Second Rescuer, who assists
the First Rescuer and obtains
any necessary medical equip-
ment; and the Third Rescuer,
who liaises with the ight
crew. The number of rescuers
will vary widely depending on
the type of aircraft, the size,
and the location of the emer-
gency; if fewer than three res-
cuers are available, the
responsibilities may need to
be combined to ensure that all
the tasks in the Medical Action
Plan are addressed.
mated External Debrillator
[AED]).
Assists the First Rescuer in
providing rst aid and care
for the victim.
Third Rescuer
This person is the third
rescuer on the scene of the
incident. The Third Rescuer
performs the following tasks:
Communicates with the
ight crew or with MedLink.
Requests additional medical
assistance on board the air-
craft if needed and available.
Documents the care that has
been provided by the First
and Second Rescuers.
Supports and communicates
with any family members
or traveling companions of
the victim.
The Medical Action Plan
First Rescuer
This person is the rst rescuer
on the scene of a medical inci-
dent. The First Rescuer per-
forms the following tasks:
Assesses the victim and then
determines the medical
problem.
Stays with the victim at all
times and calls for help and
medical equipment.
Provides immediate rst aid.
Second Rescuer
This person is the second
rescuer on the scene. The
Second Rescuer performs the
following tasks:
Obtains the necessary
medical equipment for
assessment and treatment
(such as medical kits,
oxygen, and/or an Auto-
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During any medical situation, it is helpful to follow an organized response plan, which will help
ensure that the incident is managed effectively. This section provides guidelines on gathering infor-
mation about the victim and his or her illness or injury, performing a primary and secondary survey,
and seeking medical advice.
Procedures for an Incident in Flight
In order to effectively manage a medical inci-
dent, it is helpful to use crew or, if necessary,
passengers to assist you. The following diagram
outlines the Medical Action Plan, which uses
three rescuers. The First Rescuer should stay
with the victim and perform an assessment of
the victim and begin care. The Second Rescuer
should obtain the necessary equipment, and the
Third Rescuer should document the care and
keep the ight crew informed.
Plan of Action
YES
YES
NO
NO
Scene Safety
Look for hazards.
Are you or the victim in danger?
Prepare personal protection equipment.
Do not approach victim. Eliminate hazard.
Response
Gently shake victims shoulders.
Call to victim.
Is the victim responsive?
Unconscious Victim
Call for help.
Second Rescuerobtain AED, medical
kit, oxygen.
Third Rescuerinform ight crew to call
MedLink.
Assess for Other Conditions
Call for help.
Check for severe bleeding.
Perform a secondary survey.
Treat any condition found if possible.
Second Rescuerobtain AED, oxygen,
medical kit.
Third Rescuerinform ight crew about
emergency and seek medical advice if
necessary.
Monitor Victim
Monitor victims condition.
Third Rescuerkeep ight crew informed.
A*B*C*D
AOpen the airway.
BLook, listen, and feel for normal breathing.
CIf unresponsive and not breathing normally, begin CPR at a rate of 100 compressions/minute.
CPR2 rescue breaths/30 compressions (AHA)
CPR30 compressions/2 breaths (ERC)
DApply the AED as soon as it is available; follow prompts.
Note: AHAAmerican Heart Association Guidelines
ERCEuropean Resuscitation Council Guidelines
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Scene Safety
Check for scene safety. Ensure there are no
hazards to yourself or the victim. Hazards in the
hangar include live electrical wires, obstacles,
heavy equipment, water/oil spills, and so on.
In-ight hazards include turbulence, improperly
stowed luggage, or broken glass. If there is any
danger, attempt to make the scene safe before
approaching the victim. Prepare personal pro-
tection equipment.
Response
If the victim is not obvi-
ously conscious, shake
both shoulders gently and
ask, Are you OK?
Observe the victim for
any response to your
voice or touch.
Request for Help
If you are alone, seek help
from other crew members
or passengers. The Second Rescuer should obtain the
necessary equipment. The Third Rescuer should
inform the ight crew of the medical incident.
Airway
Open the victims airway
using the head tilt/chin
lift maneuver. Tilt the
victims head by placing
one hand on the forehead
and tilting his or her chin
with two ngers of the
other hand.
Breathing
Check for signs of breath-
ing (chest movement or
sounds of breathing) for
no more than 10 seconds.
If there are no signs of
breathing, give two
breaths. (ERC guidelines
are to omit initial
breaths and proceed
to compressions.)
Circulation
If the victim is not respon-
sive and not breathing
normally, begin CPR at a
rate of 100 times/minute
(30 compressions and
2 breaths). Apply the AED
if available.
Surveying a Victim
Performing a primary and secondary survey will help rescuers determine what problem
is affecting the victim and allow them to initiate emergency care. The primary survey
helps identify potentially life-threatening conditions, such as a lack of breathing, which
necessitates cardiopulmonary resuscitation (CPR), or severe bleeding. The secondary
survey is used to obtain a history of the current problem or injury and identify other
injuries or medical conditions.
The primary survey is used to help rescuers identify life-threatening conditions in which a victim
may be unconscious and in need of resuscitation. The First Rescuer should stay with the victim and
perform the primary survey. If the victim is conscious and stable, the First Rescuer should proceed
quickly through the primary survey and go to the secondary survey (see next pages).
The primary survey consists of the following parts: scene safety, response, request for help,
airway, breathing, circulation, and debrillation. A quick assessment to look for severe bleeding is
also done at this time.
Conducting a Primary Survey
Move a victim only if necessary to provide
care or to remove the victim from danger.
If you suspect any neck or back injuries,
avoid moving the victim if possible.
An unconscious victim who is breathing
normally should be placed in the recovery
position. If the victim is not breathing
normally, put in a suitable position
for resuscitation.
MOVING A VICTIM
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If the victim is responsive and
breathing adequately, the First
Rescuer will proceed to the
secondary survey to identify
any other conditions that may
need to be addressed. This
survey must include a check
for severe bleeding, because
this problem can lead to a life-
threatening condition called
hypovolemic shock.
While the First Rescuer is
performing the secondary
survey, the Third Rescuer
should record the ndings of
the survey. This will provide a
record of the medical incident
and will help the ight crew
communicate with MedLink.
Signs and Symptoms
All injuries and illnesses have
particular signs and symptoms
that are helpful in determining
incident and about underlying
conditions that the victim may
have. Listed in the following
panel are the ve main ques-
tions to ask when obtaining a
history: what, when, where,
why, and how.
Conducting a Secondary Survey
the possible cause of the
problem. These include signs
(what you can see or
measure) and symptoms (what
the victim feels). To identify
specic signs or symptoms,
obtain a history of the incident
from the victim or any travel-
ing companions and then
examine the victim.
History of the Incident
The history is the information
that a victim can provide
about what happened and any
current medical problems.
This information is usually the
most important factor in iden-
tifying medical conditions, the
causes, and possible action. If
the victim is unable to answer
your questions, ask traveling
companions or witnesses for
information about the medical
What Happened?
Cover the following points.
How did the problem
occur?
What was the order in
which symptoms appeared?
Has the problem occurred
before? If so, are the symp-
toms the same now as they
have been in previous
instances?
What makes the condition
better or worse?
When Did It Happen?
Cover the following points.
What time did the problem
occur or start?
Was the problem caused by
a previous accident or
illness?
Did the problem occur in
relation to a specic event
such as while eating, drink-
ing, or taking medication or
following an injury?
Is the victim taking medica-
tion for a known medical
condition? If so, when was
the last dose of medication
taken?
How Long Has It Been
Going On?
Cover the following points.
Did this problem just start,
or has it happened before?
If the problem is recurring,
when did this episode start?
If the problem is a persis-
tent condition, has it
changed in nature since it
started?
H * A * M
A quick acronym to
remember the components
of obtaining a medical
history is HAM.
Hhistory
Aallergies
Mmedications
Where Did It Happen?
Cover the following points.
Did the problem develop on
the aircraft?
Did the problem develop in
a potentially hazardous
area?
Did the problem develop
before the ight?
Why Did It Happen?
Cover the following points.
Was the victim in good
health at the time or was he
or she already feeling ill?
Is the problem connected
with a previous illness,
injury, or operation?
Has the problem occurred
before? If so, does the
victim know why it
happens?
Does the victim have any
medical condition that pre-
disposes him or her to this
problem?
QUESTIONS TO ASK WHEN OBTAINING THE HISTORY
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The measurement of vital signs is very important in the assessment and monitoring of a victim.
Vital signs include temperature, blood pressure, pulse, and respiration. Record this information
so that you can keep a record of the vital signs. This information will be very helpful to the
MedLink physician.
head for 30 seconds to obtain
a reading. If using a digital
thermometer, place the end
under the victims tongue for
an oral temperature (normal
reading 98.6F [37C]). To
obtain an axillary temperature,
place the thermometer under
the armpit (axilla) for 30 to
60 seconds to obtain a
reading. Note that an axillary
(under the arm) temperature
will be 1F (17.22C) lower
than an oral reading. If you
use a rectal thermometer for
children, the reading will be
Measuring Vital Signs
Respiratory Rate
The normal respiratory rate in
adults is about 12 to 16 breaths
per minute; in babies and
young children, the normal
rate is fasterabout 20 to 30
breaths per minute. An unusu-
ally rapid respiratory rate may
indicate a breathing problem or
an underlying medical problem.
Watch the victims breath-
ing; place your hand on the
chest of a child to feel the
breathing if necessary. Count
the number of breaths in one
full minute to check whether
the breathing seems abnor-
mally fast or slow. One respi-
ration consists of one
inhalation (chest rises) and
one exhalation (chest falls). If
possible, count the respira-
tions when the victim is not
aware you are counting;
awareness of being watched
could alter the victims breath-
ing rate and depth. Note
whether the victim is having
difculty breathing, and listen
to the breathing to detect
coughing, wheezing, or any
other sounds. Normal breath-
ing is effortless, automatic,
and regular (even) in rhythm,
and it does not produce noise
or discomfort.
Temperature
The normal body temperature
is usually 98.6F (37C) when
taken orally (by mouth), but
this will normally vary slightly
among individuals. An abnor-
mally high temperature may
be due to an illness such as an
infectious disease; an unusu-
ally low temperature may indi-
cate a serious condition such
as hypothermia. There are
several ways to check the vic-
tims body temperature. If
using a forehead thermometer,
press it on the victims fore-
1F (17.22C) higher than an
oral reading. These are the
normal temperatures at the
three sites used for
temperature measurement.
As the heart pumps blood through the body,
a pulse can be felt in some of the blood
vessels (arteries) close to the skins surface.
Use your index and middle ngertips to feel
for the victims pulse on the inside (at the
bend) of the wrist (radial artery) just below the
thumb. To obtain a pulse on a baby, feel the
inside of the upper arm and nd the brachial
artery. Gently press down and count the
number of beats in a minute. The pulse should
be strong and regular.
Pulse
The pulse of a healthy person at rest is strong
and regular. In adults, the normal pulse rate is
about 72 beats per minute but can vary from
60 to 80 beats per minute; babies and young chil-
dren have faster heart
rates. If the strength,
rhythm, or rate of the
pulse is abnormal,
this may indicate a
medical problem.
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Blood Pressure
The blood pressure is a measurement of the amount of pressure applied to the walls of the arter-
ies as the heart pumps blood through the body. Blood pressure is continually changing depending
on activity, temperature, diet, emotional state, posture, physical state, and medication use. Blood
pressure readings are measured in millimeters of mercury (mmHg) and usually recorded as two
numbers, such as 110/70 mmHg:
Systolic pressurethe top numberis the measure of the maximum pressure in the artery
when the heart contracts and is pumping blood through the body.
Diastolic pressurethe bottom numberrepresents the pressure in the arteries when the heart
is at rest.
Normal blood pressure for an adult is 120/70 mmHg. It is important to ask the victim what his or
her normal blood pressure is because it can vary widely among individuals. A blood pressure
reading can be taken in two ways; by auscultation using a blood pressure cuff and stethoscope or
by palpation using the pulse.
Measuring Vital Signs, continued
Measuring Blood Pressure by Auscultation
1. Position is important when taking a blood
pressure reading. If possible, the victim
should sit with the back supported and the
elbow about the height of the heart with the
arm supported. Wrap the blood pressure cuff
around the upper arm with the cuffs lower
edge about 1 inch (2 cm) above the bend of
the elbow. Line up the arrow indicating the
artery with the inside of the elbow.
2. Place the earpieces of the stethoscope in
your ears and place the stethoscope bell over
the brachial artery, which is found in the
inside of the extended elbow. It should not
rub the cuff or any clothing because these
noises may block the sounds of the pulse.
3. Tighten the screw at the side of the rub-
ber bulb by turning counterclockwise and
squeeze the bulb rapidly. Inate the cuff
until the blood ow through the brachial
artery stops, usually no more than 180 to
200 mmHg.
4. Slowly deate the cuff by loosening the
valve in the bulb slightly. This will lessen the
air pressure gradually. Listen with a stetho-
scope until you begin to hear the heartbeat,
Blood Pressure by Palpation Method
It is often difcult to adequately hear a blood
pressure in the aircraft. In those instances, you
may measure the systolic blood pressure by
feeling for a pulse inside the elbow (antecubital
space) or the wrist (radial pulse) while you are
slowly releasing the cuff. The moment you
begin to feel the pulse is the systolic pressure
and is recorded as 120/Pwhere P stands for
palpation. The blood pressure by palpation
will be approximately the same systolic number
or slightly lower than by the auscultation
method. You will not get a diastolic pressure
measurement using this technique.
which will sound like a thump, thump.
Continue deating the cuff and listening until
you can no longer hear the heartbeat. When
the cuff decompresses to the point that
blood ows freely in the artery, the thump
is no longer heard in the stethoscope.
5. The systolic number is recorded when you
rst hear the heartbeat, a steady thump.
6. The diastolic number is the point when you
no longer hear the heartbeat or at the point
at which it becomes mufed.
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To assess for normal circulation in an injured
limb or for shock check capillary rell. This
term refers to evaluating the normal blood ow
to body tissues by compressing the nail of one
of the ngers or toes and evaluating the length
of time it takes to return to a pink color.
1
Compress the nail of a nger or toe until it
blanches and turns pale (make sure there is
no polish on the nail).
2
Release the compression and watch for the
normal pink color to return.
3
The nail should return to a pink color in less
than 2 secondsnearly as soon as you let go.
If the color is slow to return or stays white/pale,
this is a good indicator that the circulation to
that limb is not normal or the person may be in
shock.
CAPILLARY REFILL CHECK
Measuring Vital Signs, continued
In some cases, you may need to look for clues on or around the victim that can suggest the cause
of a medical incident. External clues may be especially helpful if a victim is unconscious or unable
to answer your questions. Look for any medications and medical warning alerts that indicate that
the victim has a medical condition such as diabetes or epilepsy. Look for additional clues, includ-
ing the following:
Medications
Inhalers
Needles or syringes
Objects that may have caused the injury
Medications
People on regular medications are likely to carry it with
them. In most cases, they will have bottles of their oral
medications. Diabetics or victims with severe allergies
may carry medications and syringes for injection of
medications such as insulin or the epinephrine auto-
injector. In addition, people with asthma may carry
an inhaler.
Look for External Clues
Medical Warning Alerts
People who have particular medical conditions, such
as diabetes, epilepsy, or severe allergies, may wear a
bracelet/pendant or carry a wallet card to alert others
of their condition.
Tablets Inhaler
Epinephrine auto-injector
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A thorough examination of the victim is an
important part of the secondary survey. Check
the victim systematically, from head to toe, to
identify any specic signs or symptoms. Look
and listen for abnormalities. You may not need
to touch the victim during the examination if he
or she cooperates and follows your directions.
Ask if he or she is in pain or has felt any
unusual sensations, such as a bone breaking or
palpitations (an abnormally fast or erratic heart-
beat). Remember: Look, listen, and feel for any-
thing that seems abnormal.
Look
Is there any obvious sign of severe bleeding,
deformity, or burns?
Does the victim appear to be distressed,
anxious, or in pain?
Is the victim having difcultly breathing?
Are there any other visible signs of injury or
difculty in using an arm or leg? Compare
one side of the body to the other, such as
both arms. Is there any deformity or differ-
ence noted?
Are there any visible signs of illness, includ-
ing abnormalities in appearance, such as pale
skin, rash, bodily discharge, bleeding, or a
change in behavior?
Listen
Is the victim wheezing or coughing? Is there
difculty breathing?
Is the victims speech clear? Is he or she
unable to speak or having difculty nding
the right words to say?
Can you hear any unusual sounds, such as
sucking or cracking sounds from a chest
wound?
Examining a Victim
Feel
In a conscious, cooperative victim, an examina-
tion can usually be completed without the
rescuer having to touch the victim (the No
Touch Method).
Ask the victim to take a deep breath. Is
breathing difcult or painful?
Ask the victim to move each part of the
body. Can he or she move the area normally?
Does it hurt? NOTE: Advise the victim not
to move any painful or deformed areas.
Does the victim feel pain, numbness, or tin-
gling in any part of the body? If so, ask the
victim to point to the affected area.
Does the victim feel unusually hot or cold?
If the victim cannot respond to your questions,
adopt the same systematic approach.
Feel the pulse. Is it strong and regular, or is it
fast, slow, or weak?
Feel the skin. Is it warm or cold, dry, or
clammy?
Feel for any lumps, swelling, and/or defor-
mity; check the victim systematically, from
head to toe.
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To identify specic signs and symptoms of ill-
nesses or injury, examine the victim and obtain
a history by asking specic questions. The fol-
lowing chart shows parameters for a complete
head-to-toe assessment. It may not be necessary
Identifying Specic Signs and Symptoms
to perform all of these checks on conscious
victims, because they will usually tell you what
is wrong. The Third Rescuer should record the
signs and symptoms that are found.
General
Check for drowsiness, con-
fusion, or anxious behavior.
Such behavior can be due
to a lack of oxygen (such as
hypoxia), head injury, hypo-
glycemia, alcohol intoxica-
tion, or substance abuse.
Assess the victim for short-
ness of breath or unusually
rapid, slow, shallow, or
deep breathing.
Feel the pulse in the wrist;
check to see whether it is
strong or weak, abnormally
fast, slow, or irregular.
Ask if the victim is in pain.
Identify the site. Ask if the
pain is mild, moderate, or
severe; sharp, cramping,
aching, or throbbing; con-
stant or variable.
Rate the pain on a scale
of 110
1 no pain
10 extreme pain
Ask if the victim is dizzy or
feeling faint.
Is the victim bleeding?
Check for weakness or
trembling.
Ask if the victim is unusually
thirsty or hungry or has a
decreased appetite, nausea/
vomiting, or diarrhea.
Ask the victim if he or she
has had a fever or chills.
Skin
Look at the color of the
face and ngers. Pale or
blue skin can indicate a lack
of blood and/or oxygen, as
Eyes
Look for bleeding, bruising,
or swelling.
Check for visual distur-
bances, such as blurring or
difculty in focusing. If the
vision is affected, ask if the
victim has a history of
migraine headaches.
If the victim has a head
injury, look at the pupils;
they should be equal in size.
Shine a light into each eye
to see if the pupil contracts.
Any abnormalities (unequal
size or widely dilated) may
indicate a head injury or
stroke.
If the eyes are painful or
itchy, check for exposure to
irritants or burning sub-
stances or for allergies.
Look for any foreign objects
in the eye.
Ears
Look for a discharge of
blood or clear uid from
the ears.
Look for swelling or
deformity.
Ask if the victim has any
pain, fullness, or a
blocked feeling in the
ears.
Nose
Look for a discharge of
blood or clear uid.
Look for bruising, swelling,
or deformity.
Ask if the victim has any
pain, fullness, or a
blocked feeling in the
nose or sinuses.
in hypoxia and shock or
possibly exposure to cold. A
red or ushed face could be
due to fever or a heat
illness.
Look for bleeding, bruising,
or foreign objects in
wounds.
Look for any deformity at
the site of injury.
Look for burns or scalds.
Feel exposed skin to detect
whether the victim is sweat-
ing or if the skin is cold and
moist (clammy) or hot
and dry.
Look for lumps, a rash, or
swollen or inamed areas.
Head and Neck
Look for bleeding, bruising,
lumps, or a depressed area
(which could indicate
trauma to the skull).
Ask if the victim has neck
pain.
Check for neck injuries, ten-
derness, or pain.
If a neck injury is suspected,
ask if the victim can move
his or her arms and legs and
if there is any numbness,
tingling, or weakness.
Ask if the victim has a head-
ache or a history of
migraine headaches.
Ask if there was any loss of
consciousness and for how
long.
SIGNS AND SYMPTOMS IN DIFFERENT BODY SYSTEMS
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Mouth
Look in and around the
mouth for bleeding, bruis-
ing, burns, or other injuries.
Listen for abnormal
breathing.
Check to see if the victim
has difculty speaking or
slurred speech.
Check to see if the breath
smells abnormal.
Check vomit for any foreign
object, blood, or black
material that resembles
coffee grounds, which may
indicate bleeding from the
digestive tract.
Chest
Look for wounds, bruising,
or abnormal movement of
the chest or ribs.
Listen for coughing or
wheezing. Ask the color of
the phlegm (sputum).
Ask the victim to breathe in
deeply; check to see if
breathing is difcult or
painful.
Ask if the victim has any
burning, heaviness, pres-
sure, or pain in the chest.
Ask if the victim has had
palpitations (an abnormally
fast or erratic heartbeat).
Ask if the victim has heart
or lung disease.
Abdomen
Look for bleeding, bruising,
or swelling.
If the victim has abdominal
pain, ask him or her to
point to the location of the
pain with one nger. This
will help isolate the origin
of the pain.
Assess the victim for other
symptoms, such as nausea/
vomiting/diarrhea, bleed-
ing, or fever.
Ask the victim if his or her
hands and ngers feel
colder than normal.
Check the circulation by
using capillary rell.
Ask the victim to move his
or her hands and ngers.
Check for numbness, tin-
gling, or weakness in the
hands and ngers.
Legs
Check the legs for bleeding,
bruising, swelling, or
deformity.
Ask if the victim has pain in
the legs or hips. Compare
the two legs to check for
swelling/differences in skin
color or the presence of
shortening of one leg when
compared to the other.
If no deformity is noted, ask
the victim to move the legs
and bend the ankles and
knees to assess for pain or
limited range of motion.
Feet
Look for bleeding, bruising,
or deformity.
Check the toes for a normal
color. Gray or blue toes
could indicate poor circula-
tion, hypoxia, shock, or
hypothermia.
Ask the victim if his or her
feet and toes feel colder
than normal.
Ask the victim to move his
or her feet and toes.
Check for numbness, tin-
gling, or weakness in the
feet and toes.
Check to see whether the
victim can walk or bear
weight.
Ask if there is any pain or
burning with urination.
If the victim is female and
of childbearing age, ask
when the last menstrual
cycle was and if she thinks
she might be pregnant.
If the victim is female, ask if
there is any vaginal
bleeding/discharge.
Back
If an injury has occurred,
ask if there is any back pain.
If the victim has severe pain
or any difcultly moving
normally, suspect back
injury. If this is the case, do
not move the victim to check
the back unless the scene
is unsafe.
If the victim has back pain
but no sign of injury, ask if
there is a history of back
pain/injury or previous
surgery.
If you suspect a back injury,
ask the victim if he or she
has any numbness/tingling/
weakness of the arms or
legs.
Arms
Check the arms, shoulders,
and collarbones for bleed-
ing, bruising, or deformity.
If no deformity is noted, ask
the victim to move the arms
and bend the elbows to
determine whether pain is
present or range of motion
is limited.
Hands
Look for bleeding, bruising,
or deformity.
Check the nail beds for a
normal color. Gray or blue
nail beds could indicate
poor circulation, hypoxia,
shock, or hypothermia.
SIGNS AND SYMPTOMS IN DIFFERENT BODY SYSTEMS (continued)
Identifying Specic Signs and Symptoms, continued
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Obtain information about the
victim and the incident while
contact with the MedLink
service is under way. Record
this information on the patch
checklist. If the victim cannot
provide information, talk to
any traveling companions or
witnesses. Obtain the follow-
ing information as outlined in
the MedLink checklist.
The ight crew/captain will
also provide specic informa-
tion regarding the aircraft tail
number, origination/destina-
tion, estimated time of arrival
to destination (in Zulu), and
consideration for diversion.
Documenting Information
History of the victims
current illness or injury
this should include details
on what, how, and why it
happened
Medical history (medica-
tions, allergies, past/
present medical problems
or surgeries)
Vital signs
In-ight Medical Support
+1-602-239-3627
ARINC: PHXMACR
Step One: Initiate phone patch with
MedLink
Step Two: Please provide the following
information:
1. Aircraft registration number
2. Aircraft type
3. Origination, destination and ETA
(in Zulu)
4. Patient information (see reverse side
for information)
5. Position of patient (principal or crew)
6. Revised destination and ETA in Zulu
(if diversion is necessary)
7. Preferred FBO/handling agent at
destination (if medical assistance is
required upon arrival)
In-ight Medical Support
+1-602-239-3627
ARINC: PHXMACR
Please provide the following patient informa-
tion to the physician:
Reg. #: ______________________ Age: __________
Gender: _______________________________________
Position (crew/principal):
________________________________________________
WorldWide ID # (if applicable):
________________________________________________
Conscious (y/n/in & out):
________________________________________________
Problem/complaint:
________________________________________________
________________________________________________
Medical alert tag? (if yes, explain):
________________________________________________
Medical history:
________________________________________________
________________________________________________
Current medications:
________________________________________________
________________________________________________
Allergies:
________________________________________________
Blood pressure: ____________ /____________
Pulse: ______________
Respirations:
________________________________________________
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Notes

86344_03_047-060.indd 60 5/27/08 1:15:30 PM
Life-saving
Procedures
This section of the book covers the
most current guidelines for cardio-
pulmonary resuscitation (CPR) and
the automated external debrillator
(AED) as provided by the 2005
International Consensus Conference
on Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care
Science. The information in this
manual conforms to the American
Heart Association (AHA) guidelines
and the European Resuscitation
Council (ERC) guidelines for cardio-
pulmonary resuscitation and
obstructed airway. This section
includes CPR for adults, children,
and infants and the use of the AED
for adults and children older than
1 year of age. It also addresses mea-
sures to relieve choking caused by
an obstructed airway. This section
also includes the most recent recom-
mendation for hands-only CPR.
Life-saving Procedures 62
Cardiopulmonary System 62
CPRAdult and Child
Resuscitation 63
Resuscitation PlanAHA 63
Resuscitation PlanERC 64
Preliminary Actions 65
Open the Airway 65
Clear the Airway 66
Check Breathing 67
Recovery Position 68
Rescue Breathing 69
Hands-Only CPR 71
Cardiopulmonary Resuscitation
(CPR) 71
Automated External Debrillator
(AED) 73
Sequence of Prompts from the AED 75
Use of the AED in Children 76
Infant Resuscitation 77
Preliminary Actions 77
Open and Clear the Airway 77
Check Breathing 78
Recovery Position 78
Rescue Breathing 79
Cardiopulmonary Resuscitation
(CPR) 80
Relief of Choking 81
Choking in a Conscious Adult/
Child 1 Year and Older 81
Choking in an Unconscious Adult/
Child 1 Year and Older 83
Evaluation of the Airway After
ChokingAdult/Child 1 Year
and Older 83
Choking in a Conscious Infant 84
Choking in an Unconscious Infant 85
4
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Life-saving Procedures
This section reviews the anatomy and physiology of the cardiopulmonary system as it
relates to the performance of CPR.
The human body relies on a fully functioning
cardiopulmonary system in order to sustain life.
The respiratory system, consisting of the
airway/lungs, and the circulatory system, com-
prising the heart and blood vessels, work
together to supply and circulate oxygen. To
ensure an adequate oxygen supply to the body,
three processes (known as the ABCs) have to
function properly.
A: AirwayThe airway to the lungs must be
open and clear, allowing air and oxygen to
enter the lungs.
B: BreathingThe lungs and chest muscles
must function normally so that air can move
in and out of the lungs. This is necessary so
that oxygen and carbon dioxide can be
exchanged in the lungs.
C: CirculationThe heart must pump suf-
cient blood to carry oxygen from the lungs to
the vital organs and remove waste products
from the tissues.
How Cardiopulmonary Resuscitation
(CPR) Works
If the airway, breathing, and circulation do not
function adequately, the body cells will not
receive enough oxygen and will eventually die.
If the brain is without oxygen for several
minutes, perma nent brain damage will occur. It
is pos sible, however, to supply oxygen to the
body by using resuscitation techniques that
combine rescue breaths and chest compressions.
CPR is a skill that provides a temporary sub-
stitution for cardiac function and respirations.
CPR includes two manual skills: rescue breath-
ing and chest compressions. When a victim is
unresponsive and not breathing, rescue breaths
are initiated to provide temporary breathing for
the victim, which delivers oxygen to the blood.
Chest compressions are initiated to mechani-
cally compress the heart between the breast
bone and spine to pump blood from the heart
throughout the body.
Cardiopulmonary System
Alveoli in lungs
Breathing
External
respiration
Venous
capillary
Internal
respiration
Arterial
capillary
Tissue
cells
CO
2
O
2
O
2
CO
2
Jugular veins
Common
carotid arteries
Superior
vena cava
Right atrium
and ventricle
Inferior
vena cava
Liver
Femoral artery
and vein
Abdominal
aorta
Kidney
Left atrium
and ventricle
Right lung
Left lung
Structures Involved in Supplying Oxygen
The airway, lungs, and heart work together to supply oxygen to the body. As air is inhaled, the lungs expand and
absorb oxygen into the blood via the air sacs (alveoli); the lungs then contract during exhalation, releasing carbon
dioxide. This process is called respiration. The heart pumps oxygen-rich blood from the lungs into blood vessels
(arteries), which carry it to all the body cells. The arteries connect to the capillaries (very small blood vessels that lie
very close to the body cells). In the capillary bed, oxygen and carbon dioxide are exchanged and the blood continues
out of the capillaries into the veins. The blood ows through the veins back to the heart, where carbon dioxide is
exhaled and oxygen is inhaled. If any of these structures do not function properly, CPR is indicated.
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CPRAdult and Child Resuscitation
This section explains how to perform resuscitation procedures (CPR) if a victim is unre-
sponsive and has no signs of breathing or has abnormal breathing, such as agonal
breathing or gasps. The new guidelines are the same for adults and children older than
1 year of age. The American Heart Association (AHA) and European Resuscitation
Council (ERC) guidelines are both included.
If a victim appears to be seriously ill or injured,
take the following steps. Ensure scene safety
for yourself and the victim. Look for a
response in the victim. Send for help. Open
the airway and give 2 breaths if the victim is
not breathing normally. Begin chest compres-
sions at a rate of 100 per minute (30 compres-
sions/2 breaths) and consider debrillation.
An easy way to remember these four steps is
by their initials: ABCD.
Resuscitation PlanAHA
American Heart Association Algorithm for CPR
NO
YES
NO
NO
Scene Safety
Look for any hazards to yourself or the victim.
Are you or the victim in danger?
Do not approach the victim. Eliminate the
hazard rst.
Send for Help and Equipment
Second Rescuer should get medical kit, AED,
and oxygen.
Third Rescuer should inform ight crew and
ask them to contact MedLink.
YES
Assess the victim for other conditions.
Perform a secondary survey.
Treat any condition found if possible.
Seek advice from MedLink.
Place the victim in the recovery position.
Apply oxygen.
Seek urgent advice from MedLink.
Assess victim for other conditions.
Perform a secondary survey.
Treat any condition found if possible.
Circulation and Debrillation
Begin CPR cycles of 30 chest compressions
followed by 2 breaths.
Apply AED as soon as available.
YES
Response
Gently shake the victims shoulders and call
out to see if he or she responds.
Is the victim conscious?
Airway and Breathing
Open airway using the head tilt/chin lift
maneuver.
Look, listen, and feel for normal breathing.
If the victim is not breathing, give 2 breaths.
Begin CPR.
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NO
YES
NO
NO
Scene Safety
Look for any hazards to yourself or the victim.
Are you or the victim in danger?
Do not approach the victim. Eliminate the
hazard rst.
Send for Help and Equipment
Second Rescuer should get medical kit, AED,
and oxygen.
Third Rescuer should inform ight crew and
ask them to contact MedLink.
YES
Assess the victim for other conditions.
Perform a secondary survey.
Treat any condition found if possible.
Seek advice from MedLink.
Place the victim in the recovery position.
Apply oxygen.
Seek urgent advice from MedLink.
Assess the victim for other conditions.
Perform a secondary survey.
Treat any condition found if possible.
Circulation and Debrillation
Begin CPR cycles of 30 chest compressions
followed by 2 breaths.
Apply AED as soon as available.
YES
Response
Gently shake the victims shoulders and call
out to see if he or she responds.
Is the victim conscious?
Airway and Breathing
Open airway using the head tilt/chin lift
maneuver.
Look, listen, and feel for normal breathing.
If the victim is not breathing, begin chest
compressions.
European Resuscitation Council Algorithm for CPR
If a victim appears seriously ill or injured, take
the following steps. Ensure scene safety for
yourself and the victim. Look for response in
the victim. Send or shout for help. Stay with
the victim and begin resuscitation efforts. Open
the airway if victim is not breathing, immedi-
ately begin chest compressions at 30 compres-
sions followed by 2 breaths. Consider
debrillation when the AED is available.
Resuscitation PlanERC
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When managing an unrespon-
sive victim, it is important to
follow an emergency response
plan. Ask other crew members
or, if necessary, passengers to
assist you as the Second
Response
If the victim is unconscious,
check for response by shaking
the victims shoulders gently
and calling a command or a
question such as, Are you
OK? An unconscious victim
will not respond.
Send for Medical Help
If the victim is unconscious
and does not respond to you,
call for help and the medical
equipment. The Second
Rescuer should obtain the
medical kit, the AED, and the
oxygen equipment. The Third
Rescuer should inform the
ight crew of the emergency
so that they can contact
MedLink.
Preliminary Actions
Rescuer and Third Rescuer
(see Resuscitation Plan).
Before you begin assessment
and treatment, perform the
following steps:
Scene Safety
Check that the area near the
victim contains no hazards to
you or the victim. Include
environmental safety (e.g.,
re, turbulence, electricity,
blood, or vomit) and personal
safety (e.g., pocket mask,
gloves). If there are hazards,
safely eliminate them, if possi-
ble, to ensure that the scene is
safe before you approach the
victim. Put on disposable
gloves and use the pocket
mask to protect yourself.
ADULT/CHILD
RESUSCITATION SEQUENCE
Scene safety
Response
Send for help
Airway
Breathing
Circulation
Debrillation
When a victim is
unconscious, all the
muscles, including
those of the throat
and tongue, are
relaxed. If a victim is
lying on his or her back,
the tongue can fall to the
back of the throat and block
the airway. The tongue is the
most common cause of
airway obstruction in an
unconscious victim. Open
the airway by gently tilting the
victims head back. This pre-
vents the tongue from block-
ing the airway and opens the
airway.
Open the Airway
ADULT/CHILD
RESUSCITATION SEQUENCE
Scene safety
Response
Send for help
Airway
Breathing
Circulation
Debrillation
1
Place one hand on the vic-
tims forehead and gently
tilt the head back. Place two
ngers of your other hand
under the chin and lift the jaw
slightly. This is called the
head tilt/chin lift maneuver.
This maneuver will lift the
tongue away from the back of
the throat and keep the airway
open.
2
Once the airway is open,
check for breathing.
3
If you know the airway is
obstructed (see Relief of
Choking), put on disposable
gloves and remove any visible
obstruction. Prepare your
pocket mask for rescue
breathing.
HOW TO OPEN THE AIRWAY
Head tilted
Airway open
Head Tilt/Chin Lift
These two diagrams illustrate how
tilting the head back and lifting
the chin lifts the tongue away
from the back of the throat.
Tongue blocking
airway
Head
straight
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Clear the Airway
ADULT/CHILD
RESUSCITATION SEQUENCE
Scene safety
Response
Send for help
Airway
Breathing
Circulation
Debrillation
The airway must be clear
before rescue breaths are given
to ensure adequate ventilation.
Anything in the victims mouth,
such as loose dentures or
vomit, can block the airway
and should be removed. It is
very common for victims of
cardiac arrest to vomit. Rescu-
ers should be prepared and
use protective equipment.
Carefully remove any visible
loose objects with your gloved
nger. Clear away vomit or
other uids using a manual
suction device. Insert the end
of the suction device into the
victims mouth, then squeeze
and release the bulb repeatedly
to suck uid out of the mouth.
Alternatively, you could use a
mechanical vacuum pump
called an aspirator.
1
Put on gloves. If the victim
is vomiting, turn the victim
on his or her side.
2
Remove any visible loose
objects from the victims
mouth with a gloved nger.
3
To remove uid, use a
manual suction device or
an aspirator. Hold the victims
mouth open with one hand.
Sweep the end of the device
around the mouth to suck out
all the uid. Do NOT put the
aspirator too far inside the vic-
force the mouth open and
be aware of possibly being
bitten. If in doubt, do not
put your ngers in the
mouth.
Treat body uids as poten-
tially infectious material.
Dispose of gloves, soiled
items, and suction contents
in a biohazard bag.
Never use a mechanical
aspirator on a child
younger than 10 years
of age.
tims mouth; AVOID the back
of the throat.
4
Once the airway is clear,
check the victims breath-
ing (see later discussion).
Warning
Never perform a blind
sweep in the mouth.
Remove only those foreign
objects that you can see
and easily access. Be cau-
tious if the victim has
clenched teeth; do not
HOW TO CLEAR THE AIRWAY
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After the victims airway is
open, assess whether or not
the breathing is normal. If the
victim is breathing normally
but is unconscious, place him
or her in the recovery posi-
Check Breathing
ADULT/CHILD
RESUSCITATION SEQUENCE
Scene safety
Response
Send for help
Airway
Breathing
Circulation
Debrillation
tion (see following discus-
sion) and monitor the airway,
breathing, and response. If
breathing is not normal, posi-
tion the victim on his or her
back and begin CPR.
1
Open the airway using the
head tilt/chin lift method.
2
Put your head close to the
victims nose and mouth,
and turn your face toward his
or her chest.
3
Observe for signs of
breathing for no more than
10 seconds.
Look at the victims chest
to see if it is rising and
falling.
Listen for sounds of normal
breathing.
Feel for breathingair
movement or chest
movement.
5
If the victims breathing is
normal, place the victim in
the recovery position and
administer oxygen. Monitor
the victims airway, breathing,
and response.
Note: Victims of cardiac
arrest may have irregular/
abnormal shallow breathing
or infrequent gasps called
agonal breathing in the rst
few minutes following a
cardiac arrest. This is not
normal breathing and CPR
should be initiated, including
giving rescue breaths.
4
If the victim is not breath-
ing normally, begin rescue
breathing. Give two breaths
for 1 second each. Watch to
make sure the chest rises and
falls. Use a pocket mask or
face shield for protection.
ERC Guidelines
Open the airway using
the head tilt/chin lift
maneuver.
Look, listen, and feel for
normal breathing.
If the victim is not
breathing normally (or
not breathing), begin
CPR starting with
30 chest compressions
and 2 breaths.
HOW TO CHECK BREATHING
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If the victim is unconscious
but breathing normally, place
him or her in the recovery
position. There are several
ways to perform this proce-
dure, but the goals are the
Constraints Onboard
Aircraft
Onboard an aircraft, it may be
difcult to place a victim in
the recovery position because
of limited space. However, it is
essential to keep the airway
open to allow secretions to
drain out of the mouth. Stay
with the victim.
If you suspect a neck or
spinal injury, you should turn
the victim by performing the
log roll technique (see Neck
and Back Injuries), which
keeps the victims head, neck,
and spine in alignment while
being turned.
Recovery Position
same regardless of the
technique.
Maintain an open airway.
Allow vomit and other
uids to drain from the
mouth and prevent an
obstruction.
Maintain neck and spine
alignment and stability.
A commonly used recovery
position is shown here. It is
assumed that the victim has
been found lying on his or her
back. Before placing a victim
in the recovery position,
attempt to determine what
caused the illness or injury
and consider the possibility of
a neck or spinal injury.
ADULT/CHILD
RESUSCITATION SEQUENCE
Scene safety
Response
Send for help
Airway
Breathing
Circulation
Debrillation
1
If the victim is lying on his
or her back, tilt the head
back to open the airway to
ensure continued breathing.
Remove glasses or any other
items that may cause injury.
2
Take the victims arm
closest to you and bend it
at the elbow. Position the arm
so that the hand is in line with
the victims head.
3
Bring the victims other
arm across the chest; place
the hand under his or her
cheek. Grasp the victims far
leg just above the knee and
pull it toward you.
4
Continue
holding the vic-
tims knee and grasp
the far shoulder with
your other hand.
Then pull the victim
toward you, rolling
the victim onto his
or her side.
Watch for any signs of deterio-
ration. If the victim vomits,
clear the airway using a
suction device.
7
Perform a secondary survey
to identify any other condi-
tions and initiate treatment as
indictated.
8
If the victim has been lying
in the recovery position
longer than 15 minutes, roll
them onto their back and then
onto the opposite side using
the method shown in steps
15 earlier. This measure will
relieve undue pressure on the
areas of the body that are in
contact with a rm surface.
5
Position the victims bent
leg to support the body
and prevent forward rolling.
The victims head, neck, and
spine should be in a straight
line. The hand under the cheek
should be supporting the
head. Maintain an open
airway.
6
Seek urgent advice from
MedLink. Stay with the
victim. Cover the victim with a
blanket to maintain normal
body temperature. Monitor
airway, breathing, and
response. Administer oxygen.
HOW TO PLACE AN ADULT OR CHILD IN THE RECOVERY POSITION
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brief period of time. A barrier
device such as a plastic face
shield or pocket mask should
be used to protect the rescuer
and the victim.
If rescue breaths cannot be
given through the mouth
because of facial injury or pre-
vious surgery (e.g., laryngec-
tomy or tracheostomy), use
alternative rescue breathing
methods (see next page).
Rescue Breathing
Rescue breathing is used for a
victim who is unconscious and
not breathing normally.
During rescue breathing, the
rescuer exhales air from his or
her lungs into the victims
airway to supply oxygen to
vital organs such as the brain
and the heart. The air that is
exhaled contains approxi-
mately 17% oxygen and 4%
carbon dioxide, which is
enough to sustain life for a
ADULT/CHILD
RESUSCITATION SEQUENCE
Scene safety
Response
Send for help
Airway
Breathing
Circulation
Debrillation
1
Use gloves and a facial
barrier (shield or mask).
2
Open the victims airway
by using the head tilt/chin
lift method. Check for normal
breathing.
3
If using a mask, apply
enough pressure on the
mask to maintain a tight seal
over the mouth and nose.
Blow into the mask port. For
mouth-to-mouth breathing
(if mask is not available),
pinch the victims nose, then
seal your mouth over his or her
open mouth and deliver
breaths. For an infant or child,
seal your mouth around the
victims entire mouth/nose
and breathe.
4
Maintain an airtight seal
with your mouth or mask,
lift the chin, and breathe
into the victims mouth for
1 second. Look at the chest; it
should rise as you deliver the
breath.
5
Remove your mouth/mask
to let the air leave the vic-
tims lungs. You should see the
victims chest fall. Each rise
and fall of the chest is called
an effective breath.
6
Repeat the second breath,
1 second in duration.
9
Give 30 chest compres-
sions at a rate of 100 com-
pressions per minute followed
by 2 breaths. Continue
30 chest compressions
and 2 breaths until the AED
is available.
7
If you are
unable to
give two effective
rescue breaths,
reposition the
head and reat-
tempt two
breaths. If you
still cannot give
effective rescue
breaths, the
victim may have
an obstructed
airway (see
Choking in an Unconscious
Adult/Child 1 Year and Older).
Remember, the tongue is the
most common cause of airway
obstruction.
8
Once two effective breaths
have been given, begin
chest compressions.
HOW TO GIVE MOUTH-TO-MOUTH/MOUTH-TO-MASK
RESCUE BREATHING
ERC Guidelines
Adult
The ERC does not give the initial 2 breaths in the adult
victim. After opening the airway and conrming that
there is no normal breathing/response, proceed to
30 chest compressions followed by 2 breaths.
Child (1 year to puberty)
Open the airway.
Check for normal breathing.
If the child is not breathing normally, proceed with
30 chest compressions followed by 2 breaths.
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Alternative Methods of Rescue Breathing
The mouth-to-mouth method of rescue breath-
ing may need to be adapted in certain situa-
tions. If a victim has a mouth or jaw injury, it
may not be possible to open his or her mouth,
in which case rescue breathing is done through
the nose. If a victim has had an operation to
Mouth-to-Nose Breathing
Open and clear the victims airway. Hold the victims
mouth closed with your hands. Seal your mouth over
his or her nose and deliver breaths into the nose. After
each breath, lift your mouth/shield and hand away to
allow the air to escape from the lungs. If a pocket
mask is available, cover the mouth and nose (see How
to Use Face Protection) and use the pocket mask
using the usual technique.
Mouth-to-Stoma Breathing
Hold the victims nose and mouth closed with one
hand. Place your mouth over the stoma to make an
airtight seal, then deliver breaths into the stoma. After
giving each breath, lift your mouth/face shield away
to allow air to escape from the lungs.
Rescue Breathing, continued
remove the voice box (laryngectomy) or to
open the windpipe (tracheostomy), he or she
will breathe through a hole (stoma) in the neck.
In this case, give rescue breaths through the
stoma, using a plastic face shield to protect
yourself and the victim.
Face protection minimizes the risk of infection for you and the victim during rescue breathing. There
are several types of face protection, but the most common are simple barrier devices such as the
plastic face shield or the pocket mask. Once you have nished using the barrier device, dispose of it
in a biohazard bag.
Pocket Mask
Place the mask on the
victims face, pressing
gently to make an air-
tight seal. Give breaths
into the one-way valve.
If possible, attach the
oxygen tubing to the
oxygen inlet port.
Plastic Face Shield
This device consists of
a plastic sheet with a
lter. Place the shield
on the victims face
with the lter over the
mouth. Pinch the nose
and give rescue breaths
through the lter.
HOW TO USE TO FACE PROTECTION
Caution: If the AED is providing a shock, the oxygen should not be owing near the victims
face during the shock and should be turned off or moved away from the area.
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If an unconscious victim
shows no signs of response
or normal breathing, begin
CPR. This is a technique that
combines rescue breathing
ow to the body. Compressing
the heart between the breast
bone (sternum) and the spine
moves blood from the heart
into the arteries and through
the rest of the body. When the
pressure is released, blood
ows back into the heart from
the veins.
Cardiopulmonary Resuscitation (CPR)
and chest compressions.
Rescue breathing supplies
oxygen to the victim, and
chest compressions provide
circulation by forcing oxygen-
ated blood through the heart
and into the blood vessels.
CPR does not usually
restore a normal heart rhythm.
However, an AED may restore
the hearts normal rhythm if
the victim is in ventricular
brillation. Therefore, the AED
should be applied as soon as
it is available (see Automated
External Debrillator [AED]).
Chest Compressions
Chest compressions during
CPR provide minimal blood
ADULT/CHILD
RESUSCITATION SEQUENCE
Scene safety
Response
Send for help
Airway
Breathing
Circulation
Debrillation
Breastbone
Vein
Artery
Ribs
Heart
Spine
The American Heart Associa-
tion (AHA) has issued new
guidelines in 2008 for lay res-
cuers to use hands-only or
compression-only CPR for an
adult witnessed arrest victim.
This is a very simple form of
CPR that uses chest compres-
sions only, without the rescue
breathing. Recent studies have
Hands-only CPR is indicated
in the following situations:
There is sudden cardiac
arrest (victim is unrespon-
sive and not breathing).
The arrest is witnessed (the
rescuer sees the victim
collapse).
The victim is an adult
Hands-Only CPR
shown that adult victims who
have a witnessed cardiac arrest
and receive hands-only CPR
by lay rescuers have similar
survival rates to those who
receive conventional CPR
(compressions and rescue
breathing) in the rst few
minutes of a cardiac arrest.
If the rescuer sees an adult
suddenly collapse:
1
Call for help; if someone
responds have that person
call the emergency response
system or MedLink.
2
Check for responsiveness
and normal breathing.
3
If the victim is unrespon-
sive, begin chest compres-
sions; push hard and fast with
minimal interruptions.
should be used in these
situations:
The victim is an infant or
child
The cardiac arrest is unwit-
nessed (victim is found
unresponsive and not
breathing normally).
The cardiac arrest resulted
from breathing problems.
The cardiac arrest occurred
during drowning.
4
Continue chest compres-
sions until the AED is
applied and ready to analyze.
5
Continue CPR/AED as
indicated.
Note:
Hands-only CPR is not indi-
cated in the following victims
and conventional CPR
(30 compressions/2 breaths)
HOW TO DO HANDS-ONLY CPR
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American Heart Association Guidelines
Adults and children older than 1 year of age:
Give 2 rescue breaths per 30 chest compres-
sions (30:2).
Push hard and push fast.
Minimize interruptions during CPR.
European Resuscitation Council Guidelines
Adults and children older than 1 year of age:
Give 30 compressions per 2 breaths (30:2).
Push hard and push fast.
Minimize interruptions during CPR.
ADULT/CHILD CPR RATES
CPR with Two Rescuers
If there are two rescuers who
are trained in CPR, the two-
rescuer technique may be
used. One rescuer maintains
an open airway and performs
person CPR (breathing and
compressions) for 1 to
2 minutes. After that time, the
second rescuer takes over for
the rst.
rescue breathing while the
other rescuer performs chest
compressions.
Another method endorsed
by the ERC is for each rescuer
to alternate performing one-
1
Check for scene safety. Use gloves and face
mask/shield.
2
Check for responsiveness. Does the victim
move or respond?
3
Call for help and medical equipment.
4
Position the victim on his or her back on a
rm, at surface. Kneel next to the victims
chest.
5
Remove all clothing covering the victims
chest. Use scissors to cut shirts/undergar-
ments or pull them up out of the way.
6
Position your hands as shown below.
7
Lean over the victim, with your shoulders
directly over your hands. Keeping your arms
straight, compress the chest to the depth appro-
priate for the size of the victim. Release the pres-
sure without removing your hands from the
chest wall, which will allow the chest to recoil
upward between compressions.
HOW TO GIVE CARDIOPULMONARY RESUSCITATION (CPR)
Adult victim
Put the heel of your
hand in the center of the
victims bare chest
between the nipples. Put
the heel of your other
hand on top of the rst.
Compress the chest
1.5 to 2 inches (45 cm).
Interlock your ngers or
place one hand on top
of the other, making sure
that they are not press-
ing on the victims ribs.
Child victim
Put the heel of one hand
or two ngers (depend-
ing on the size of the
child) in the center of the
childs bare chest
between the nipples.
Compress the chest one-
third to one-half the
depth of the chest with
each compression.
8
Give 30 regular, smooth compressions, at a
rate of 100 per minute, keeping your hands
on the breastbone throughout. Push hard and
push fast. Give 2 effective rescue breaths after
each set of 30 compressions.
9
Minimize interruptions in chest compres-
sions. Continue cycles of 30 chest com-
pressions and 2 breaths. Maintain a rate of
100 compressions per minute.
10
Continue CPR until one of the following
occurs.
Breathing and circulation resume.
The scene becomes unsafe.
The AED is available/attached and ready to
analyze.
CPR has continued for 30 minutes with no
response and landing is not imminent.
You are too tired to continue.
MedLink advises you to stop.
The aircraft lands and care is transferred to
emergency medical services.
Cardiopulmonary Resuscitation (CPR), continued
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Automated External Debrillator (AED)
The most common cause of cardiopulmonary arrest in adults is ventricular brillation
(VF). VF is a chaotic heart rhythm that does not allow the heart to pump blood to body
cells. If a victim is unresponsive and not breathing (cardiopulmonary arrest), immedi-
ately begin CPR and continue until the AED is available. The AED analyzes the heart
rhythm, and if VF is detected, it will advise the user to deliver a shock to the heart
(debrillation), which is the only effective treatment for VF. The chance of successful
debrillation decreases by 10% per minute following a cardiac arrest, so it is important
to apply the AED as soon as possible.
The following electrocardiogram (EKG) strip shows an abnormal heart rhythm that deteroriated into
ventricular brillation and cardiac arrest. The AED delivers a shock to the heart to interrupt this
rhythm and convert it to a normal heart rhythm (not shown).
VENTRICULAR FIBRILLATION
Indications for Use
The debrillator must be used only by
trained rescuers. It should be
applied only to a victim who
ts all of the following
criteria:
Unconscious/
unresponsive
Not breathing normally
Victims 8 years of age and
older: Start CPR and use the
AED as soon as it is available
Victims age 18 years: Perform
5 sets of 30 compressions and
2 breaths (2 minutes), then apply
the AED.
ERC Guidelines
The AED should be applied as soon as it is
available for all victims.
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Resources:
Debrillator Medical kit
Oxygen Razors
MedLink Scissors
Using the Debrillator
1
Clear the area around the
victim. Place the AED
beside the victim near you and
turn it on. Continue CPR until
the AED is applied and ready to
analyze. It is important to mini-
mize any interruptions in CPR.
2
Expose the victims chest
and remove any jewelry,
medication patches, and body
hair that could interfere with
the electrode pads. Put on
gloves before removing medi-
cation patches or hair. (Some
AED kits include razors for
shaving chest hair.) Wipe
excess moisture from the
chest. Dispose of used razors
carefully.
3
To apply each AED pad,
remove the backing paper,
then place the AED pad on the
chest as shown on the diagram
on the back of the pads.
Adult Placement
Place the rst pad on the
upper right side of the
chest, just below the
collarbone.
Place the second pad to the
left of the nipple a few
inches below the armpit on
the left side of the chest.
Child Placement
Ages 18
Apply child pads as illus-
trated on the pads.
If adult pads are used,
apply one pad on the back
press the SHOCK button to
deliver the shock.
8
After the shock has been
delivered, immediately
begin CPR, starting with chest
compressions.
9
After 2 minutes of CPR, the
AED will re-analyze and
advise if a shock is indicated.
Follow AED prompts. Continue
CPR if victim remains unre-
sponsive and is not breathing.
10
Leave the AED con-
nected to the victim.
Do not turn the AED off until
the aircraft has landed and the
victim has been turned over to
the care of emergency medical
services on the ground, even if
the victim appears to have
recovered. The AED will con-
tinue to monitor the victim.
Special Considerations
If the victim is a member of
the ight crew, remove him
or her from the ight deck
if possible. If it is not pos-
sible to move the victim,
most AEDs can be safely
used on the ight deck.
Exercise extreme caution
so as not to interfere with
the remaining ight crew.
The AED can be applied to
a victim in the seat if he or
she cannot be moved safely
or quickly.
It is safe to use the AED
on wet or metal surfaces.
Remove all medication
patches with gloves.
Remove body jewelry that
is in the way of the AED
pads; ensure that the pads
are not touching any body
jewelry.
Always place AED pads to
the side of an implanted
pacemaker, not directly
over it or touching it.
Extreme heat or cold may
alter the performance and
function of the AED.
between the shoulder
blades and the other pad in
the upper right side of the
chest below the collarbone.
Ages 8 Years and Older
Use adult pads.
Do not use child pads or a
child dose.
Note: See Use of the AED
in Children.

4
Ensure that the connector
from the electrodes is
secured to the AED.
5
Move the oxygen tank away
from the immediate area
at least 5 to 6 feet awayor
turn it off.
6
The AED will issue a series
of verbal and visual
prompts. Make sure that no
one is touching the victim
because that will interfere with
the AEDs ability to read and
analyze the heart rhythm. The
AED will analyze the heart
rhythm and advise if it is a
shockable rhythm.
7
If the AED advises no
shock, follow the rest of
the prompts. If the AED
advises a shock, call, Stand
clear! Again, make sure that
no one is touching the victim.
Once the AED has charged,
HOW TO USE A DEFIBRILLATOR
Automated External Debrillator (AED), continued
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Turn on the AED.
The AED will prompt: Plug in pad connector.
Plug in the pad connector to the AED.
The AED will prompt: Apply pads to bare chest.
Attach the pads to the victims bare chest.
The AED will prompt: Analyzing/do not touch the victim.
Do not touch the victim.
If the AED does not
detect a shockable
rhythm, it will prompt:
No shock advised.
Continue CPR, leave the
AED in place, and follow
pompts.
If the victim is being moved, the AED will prompt: Motion
detected.
Do not touch the victim; avoid movement/turbulence. Ensure
that the area is clear and the victim is not moving.
The AED prompts: Shock advised.
Stand clear.
The AED will charge. When ready, a light ashes and an alarm
sounds.
The AED prompts: Deliver shock now.
Stand clear; make sure no one is touching the victim.
Push the SHOCK button.
The AED prompts: After the shock, immediately begin CPR,
beginning with chest compressions: 30 compressions/2 breaths.
The AED will analyze the heart rhythm after 2 minutes of CPR.
If the AED prompts, No shock advised, continue CPR if the
victim is unresponsive and not breathing.
The AED will begin to give
visual and verbal prompts as
soon as it has been turned on.
It will analyze the victims
heart rhythm and advise
whether or not to deliver a
shock. If a shock is advised,
follow the prompts. Even if a
shock is not advised, keep the
AED turned on, connected to
shock. The sequence of
prompts is shown below;
instructions that may be given
by the AED are shown in
bold type.
Note: The exact prompts
will vary with each AED
manufacturer. Consult your
AED to become familiar with
the prompts for your AED.
Sequence of Prompts from the AED
the victim for the rest of the
ight and follow any instruc-
tions. Ask for additional help
in case CPR is indicated. Make
sure that the area around the
victim remains clear while the
AED is turned on. Do not
touch the victim while the
AED is analyzing the heart
rhythm or when delivering a
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Cardiopulmonary arrest in children is rare and
is often associated with a respiratory arrest rst.
As a result, effective CPR is especially important
in children, and according to AHA guidelines, it
should be continued for 2 minutes (5 sets of
30 compressions/2 breaths) prior to attaching
the AED.
The ERC recommends that the AED be
attached to children as soon as it is available.
If the AED is indicated in children 8 years
old or older:
Use adult pads and continue as per the adult
sequence (see How to use a Debrillator).
If the AED is indicated in children 1 to
8 years old:
Use pediatric/child pads if available.
If pediatric/child pads are not available, use
adult pads in the anterior/posterior position
(front/back). Make sure the edges of the
pads do not touch (see How to Use a
Debrillator).
If the AED has a special key or switch to
deliver a child dose, use according to manu-
facturers instructions.
It is recommended that the specic AED
manufacturer be contacted about its proce-
dure/recommendation for use of the AED
in children.
Pediatric Pads
Use of the AED in Children
Lone Rescuer with AED Adult
If a lone rescuer nds an unconscious/unre-
sponsive victim (unwitnessed) and has access to
an AED, the rescuer should do the following:
Call for help. If someone responds, send
them to call for help and get the AED.

Begin CPR.

If no one responds, the lone rescuer should

quickly call for help and get the AED.
Return to the victim, apply the AED.
If the victim is a witnessed arrest and the
rescuer has immediate access to the AED (e.g.,
in an aircraft):
Call for help.
Obtain the AED.
Return to the victim, apply the AED, and
follow prompts.
SPECIAL CONSIDERATIONS WHEN USING AN AED FOR LONE RESCUER
Special Pediatric Considerations
AHA GuidelinesIf a lone rescuer nds an unresponsive
child, the rescuer should do the following:
If the child is unresponsive/not breathing, begin CPR
(2 breaths/30 compressions) and continue for 2 minutes
(5 cycles).
Call for help after 2 minutes of CPR.
Obtain the AED.
ERC GuidelinesIf a lone rescuer nds an unresponsive
child, the rescuer should do the following:
If the child is unresponsive/not breathing, call for help
and the AED.
Begin CPR (30 compressions/2 breaths) and continue
until the AED is applied and ready to use.
Follow the AED prompts.
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Infant Resuscitation
This section explains how to assess and resuscitate an unconscious infant 12 months or
younger. It is easier to treat an infant if you lay him or her on a rm surface level with
your waist. To treat children older than 12 months of age, refer to adult/child resuscita-
tion (see previous section).
To resuscitate an infant who is
unconscious, ask other crew
members or passengers to
assist you as the Second
his or her body slightly or by
tapping the sole of one foot
gently. An unconscious infant
will not respond. You must
never shake an infant.
Send for Medical Help
If the infant is unconscious,
call for help and the medical
equipment. The Second
Rescuer should obtain medical
kits and oxygen. The Third
Rescuer should inform the
ight crew of the emergency
and contact MedLink.
Preliminary Actions
Rescuer and Third Rescuer
(see Resuscitation Plan).
Before you begin assessment
and treatment, perform the
following steps.
Scene Safety
Check that the area does not
contain hazards to you or the
infant. If there are hazards,
ensure that the scene is safe
before you approach the
infant. Put on disposable
gloves to protect yourself.
Response
If the infant is unconscious,
check for response by moving
INFANT RESUSCITATION
SEQUENCE
Scene safety
Response
Send for help
Airway
Breathing
Circulation
When an infant becomes
unconscious, all the muscles,
including those of the mouth
and throat, are relaxed. If the
infant is lying on his or her
back, the tongue can fall to
the back of the throat and
block the airway. The tongue
is the most common cause
of airway obstruction.
Before beginning resuscitation,
open the airway by using the
head tilt/chin lift method.
Open and Clear the Airway
INFANT RESUSCITATION
SEQUENCE
Scene safety
Response
Send for help
Airway
Breathing
Circulation
1
Place the infant on a rm,
at surface in front of you.
2
Place one hand on the
head and tilt it back
slightly. Place two ngers of
the other hand under the
bony part of the chin. Lift the
jaw slightly to bring it forward
(head tilt/chin lift).
3
The head should be in a
neutral position. Avoid
hyperextending the head/neck
because this may block the
airway.
4
If you know the airway is
obstructed, look in the
mouth and, using a gloved
hand, remove any visible
object. Do not perform a
blind nger sweep.
5
Once the infants airway is
open and clear, check for
normal breathing.
Warning
Never use a mechanical
aspirator on an infant.
Never try to clear the
mouth with your nger if
you cannot see or easily
remove an obstruction.
Treat body uids as
potentially infectious
material. Dispose of
gloves and soiled items in
a biohazard bag.
HOW TO OPEN AND CLEAR THE AIRWAY
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After opening the airway, assess the infant
for normal breathing for no more than
10 seconds.
Look for the rise and fall of the chest wall.
Listen by putting your ear to the infants
mouth/nose and listen for normal breathing.
Feel for air movement to indicate signs of
breathing and feel for chest wall movement.

If the infant is breathing normally but

unconscious, hold him or her in the recov-
ery position (see Recovery Position) and
monitor the airway and breathing.

If there is no breathing or abnormal,

agonal breathing/gasps, begin CPR.

AHA: 2 breaths/30 compressions

ERC: 30 compressions/2 breaths

Check Breathing
If an infant is unconscious and breathing nor-
mally or adequately, hold him or her in the
recovery position. This position will keep the
airway open, allow any uids to drain from the
mouth, and keep the neck and spine aligned.
Seek urgent advice from MedLink. Administer
oxygen. Monitor the airway, breathing, and
signs of response.
Recovery Position
INFANT RESUSCITATION SEQUENCE
Scene safety
Response
Send for help
Airway
Breathing
Circulation
Check for Signs of Breathing
Watch for chest wall movements. Listen for sounds of
normal breathing and feel for breath on your cheek.
Infant Recovery Position
Hold the infant securely, with the infants head lower than the
body. Tilt the infants head back slightly to keep the airway open,
and keep the head, neck, and back aligned.
INFANT RESUSCITATION SEQUENCE
Scene safety
Response
Send for help
Airway
Breathing
Circulation
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This procedure is used for an infant who is
unconscious and not breathing normally. To
provide rescue breathing, exhale air into the
infants mouth/nose (airway). The exhaled air
contains enough oxygen (17% oxygen and
4% carbon dioxide) to sustain life temporarily.
The technique shown on the right is for mouth-
to-mouth-and-nose breathing. Use a pocket
mask or a face shield to protect yourself and
the infant. If the infant resumes breathing, hold
him or her in the recovery position and admin-
ister oxygen.
Rescue Breathing
1
Open and clear the airway.
Place your mouth over the
infants nose and mouth to
make an airtight seal or use a
pocket mask or plastic face
shield. If using an adult mask,
turn it upside down to provide
a good tting.
2
Keep the infants chin
lifted with your nger and
breathe gently into his or her
nose and mouth for 1 second.
Use only small puffs of
airavoid deep breaths to
prevent over-ination of the
infants lungs. Look for the
5
If you are unable to deliver
an effective breath, reposi-
tion the head and reattempt
an effective breath. If the
second breath is unsuccessful,
the airway may be obstructed
(see Relief of Choking). Begin
chest compressions.
rise and fall of the infants
chest as you deliver the rescue
breaths.
3
Remove your mouth and
check that the chest falls.
Each rise and fall of the chest
is called an effective breath.
4
AHA guidelines: Deliver 2
effective breaths, 1 second
each, and begin chest com-
pressions at 30 compressions
per 2 breaths.
ERC guidelines: Begin chest
compressions at 30 compres-
sions per 2 breaths.
HOW TO GIVE RESCUE BREATHING
INFANT RESUSCITATION SEQUENCE
Scene safety
Response
Send for help
Airway
Breathing
Circulation
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by forcing oxygenated blood
through the heart and into the
blood vessels and body cells.
During chest compressions,
the pressure on the breast-
bone squeezes blood from the
heart into the arteries. When
the pressure is released, blood
from the veins ows back into
the heart.
Cardiopulmonary Resuscitation (CPR)
If an unconscious infant is not
responding/moving and not
breathing normally, begin
CPR. CPR is a temporary
measure to sustain life. It is
very effective in infants who
are victims of cardiac arrest.
Rescue breathing provides the
infant with oxygen, and chest
compressions aid circulation
INFANT RESUSCITATION
SEQUENCE
Scene safety
Response
Send for help
Airway
Breathing
Circulation
1
Check for scene safety; use
gloves and a face shield/
pocket mask.
2
Check for response. Gently
tap the infants foot.
3
Call for help and medical
equipment.
4
Lay the infant on his or her
back on a rm, at surface
at waist height.
5
Open the airway, using
head tilt/chin lift method;
check for normal breathing for
no more than 10 seconds.
6
AHA guidelines: If the
infant is not breathing nor-
mally, give 2 effective breaths
of 1 second each. ERC guide-
lines: If the infant is not
breathing normally, begin with
30 compressions, then 2
breaths. Use small puffs of
airjust enough to make the
chest rise.
7
Hold the infants head with
one hand. Place the index
and middle ngers of your
other hand on the lower
breastbone (sternum), just
below the level of the infants
The scene becomes unsafe.
CPR has continued for
60 minutes with no
response and landing is not
imminent.
You are too tired to
continue.
MedLink advises you to stop.
The aircraft lands and care
is transferred to emergency
medical services.
11
When breathing and
circulation resume,
hold the infant in the recovery
position (see earlier discus-
sion). Administer oxygen.
Monitor the airway, breathing,
and signs of response.
Infant CPR Ratio
30 chest compressions to
2 rescue breaths (30:2)
Note: There are currently no
scientic data to recommend
for or against the use of an
AED in infants younger than
1 year of age according to the
AHA and ERC.
nipple line in the center of the
chest.
8
Compress the chest one-
third to one-half the depth
of the chest. Release the pres-
sure without removing your
ngers from the infants
breastbone.
9
Give 30 compressions at a
rate of at least 100 com-
pressions per minute. Keep
your ngers on the breastbone
throughout the compression
cycle.
10
Continue cycles of
30 chest compressions
and 2 breaths. Maintain a rate
of at least 100 compressions
per minute. Continue until one
of the following occurs:
The infant responds and
begins normal breathing.
HOW TO GIVE CARDIOPULMONARY RESUSCITATION
Special Considerations for the Lone Rescuer
AHA: If you are a lone rescuer, administer 5 cycles (2 minutes) of CPR before leaving to call
for help. Consider taking the infant with you to the phone to minimize interruptions in CPR.
ERC: If you are a lone rescuer, call/go for help rst, then return to the infant and begin CPR
(30 compressions to 2 breaths). Consider taking the infant with you to the phone to minimize
interruptions in CPR.
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Relief of Choking
This section covers rst aid for choking, a condition that may occur when the airway is
obstructed by food, uid, or any other foreign object. The section is divided into two
parts: (1) adults and children older than 1 year of age and (2) infants. Each part
describes the management for conscious and unconscious victims. The AHA and ERC
guidelines are included.
The signs and symptoms of
choking vary depending on
the degree of the obstruction
in the victims airway. The
actions to relieve an
obstructed airway have been
divided into mild and severe
airway obstruction. If the
airway is only partially
blocked, resulting in a mild
obstruction, the victim will be
distressed and coughing. If the
airway is completely blocked,
the victim will be unable to
speak, breathe, or cough and
will eventually lose conscious-
ness. The specic signs and
symptoms and rescuer actions
are as follows.
Severe airway obstruction:
Little or no air exchange is occurring.
Victim has difculty or is unable to breathe
or speak.
High-pitched wheezing sound may be heard.
Victim may grasp his or her neck.
Victims face may turn blue.
Breathing may cease, and there may be no
sign of air movement.
Victim may become unconscious.
Choking in a Conscious Adult/Child 1 Year and Older
Signs and Symptoms
Mild airway obstruction:
Air exchange (breathing) is normal.
Victim is responsive and can cough.
Wheezing may be audible between coughs.
SEQUENCE OF ACTIONS
Scene safety
Response
Abdominal thrusts
ERC Guidelines for Choking
Adult/Child
Apply ve back blows.

Stand to the side and

behind the victim. Kneel
behind a small child

Lean the victim forward

and support the chest
with your hand.

Give ve sharp back

blows between the
shoulder blades with the
heel of your hand.

Check to see if the back

blows have relieved the
obstruction.
Apply ve abdominal
thrusts.

If obstruction is still
present, administer ve
abdominal thrusts (see
earlier discussion).

Continue to alternate
ve back blows/ve
abdominal thrusts until
the obstruction is
relieved or the victim
becomes unconscious.
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Resources
Medical kit
MedLink
Oxygen
Mild Airway Obstruction
1
Assess the severity of the
breathing difculty. Ask,
Are you choking?
2
If the obstruction is mild
and air exchange is ade-
quate, encourage coughing,
which may help the victim dis-
lodge the obstruction.
3
Do not interfere with the
victims attempt to relieve
the obstruction.
4
Call MedLink or activate
the EMS service if the mild
airway obstruction continues.
5
Continue to stay with the
victim and monitor for
worsening symptoms.
Severe Airway Obstruction
If signs of severe airway
obstruction are present and
the victim becomes weaker or
stops coughing, you will need
to use the abdominal thrusts
(Heimlich maneuver) to relieve
the choking.
1
Position yourself close
behind the victim and put
your arms under his or her
arms, encircling the victims
torso.
2
With one hand, make a st
and place the thumb side
of your st against the victims
upper abdomen, slightly above
the navel and well below the
tip of the breastbone. Grasp
your st with your other hand.
3
Give quick upward thrusts
into the abdomen. Pull
your st sharply inward and
upward against the victims
abdomen. Each thrust should
around the chest. Place one
st with the thumb side on
the breastbone between
the nipples (same position
as for chest compressions
for CPR). Grasp your st
with the other hand and
pull sharply backward.
Continue chest thrusts until
the obstruction is dis-
lodged or the victim
becomes unconscious.
Treat objects that are dis-
lodged from the throat as
potentially infectious mate-
rial. Dispose of gloves,
soiled items, and objects
from the throat in a bio-
hazard bag.
Always seek medical advice
if chest thrusts or abdomi-
nal thrusts are given to
evaluate the victim for any
underlying injury.
be a quick, separate move-
ment. The thrusts should be
sufcient to force air out of
the lungs. The pressure may
dislodge the obstruction.
4
Continue giving abdominal
thrusts until the blockage
is cleared or the victim
becomes unconscious.
Warning
If the victim becomes
unconscious, treat as
directed in the following
section.
Do not give abdominal
thrusts on or near the tip of
the breastbone or the base
of the rib cage because this
may cause internal injury.
For a pregnant or obese
victim, use chest thrusts
rather than abdominal
thrusts. Stand behind the
victim and place your arms
HOW TO RELIEVE CHOKING: CONSCIOUS ADULT/CHILD
1 YEAR AND OLDER
Choking in a Conscious Adult/Child 1 Year and Older,
continued
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injured. Call for help and the
medical equipment. Open and
clear the victims airway,
remove any visible obstruc-
tions with a gloved nger, and
begin chest compressions.
Attempt 2 effective breaths.
Choking in an Unconscious Adult/Child
1 Year and Older
If a choking adult or child
1 year or older has not
relieved their airway obstruc-
tion by coughing, they will
soon become unconcious.
Gently assist the victim to the
ground so they dont become
SEQUENCE OF ACTIONS
Send for help
Airway
Breathing
CPR/debrillation
Resources
Medical kit
Oxygen
AED
For a Choking Victim Who
Becomes Unconscious
1
Ensure scene safety. Check
the victims response. The
Second Rescuer should obtain
medical equipment, and the
Third Rescuer should notify
the ight crew and MedLink.
2
Assist the victim to the
ground and place the
victim on a rm, at surface
on his or her back.
3
Open the airway. Put on
gloves. Look in the mouth;
remove only visible obstruc-
tions with a gloved nger.
4
Check for normal breath-
ing. Look, listen, and feel
for breathing for no more than
10 seconds.
Warning
Treat dislodged objects as
potentially infectious mate-
rial. Dispose of gloves, any
soiled items, and objects
from the throat in a bio-
hazard bag.
Never use a mechanical
aspirator on a child
younger than 10 years of
age.
5
If the victim is breathing
normally, place him or her
in the recovery position and
administer oxygen.
6
If the victim is not breath-
ing normally:
AHA: Give 2 effective
breaths and 30 chest com-
pressions; continue CPR.
ERC: Start 30 chest com-
pressions per 2 breaths;
continue CPR.
Note: If unable to give
an effective breath, reposi-
tion the head.
Every time the airway is
opened for the 2 breaths,
look inside the victims
mouth for a foreign object.
If an object is visualized,
remove it with a gloved
hand. Proceed with 2 effec-
tive breaths.
HOW TO RELIEVE CHOKING: UNCONSCIOUS ADULT/CHILD
1 YEAR AND OLDER
Once the obstruction has been removed, it is
important to assess the airway if the victim
remains unresponsive.
Open the airway using the head tilt/chin lift
method.
Look, listen, and feel for normal breathing.
If normal breathing is present, put the victim
in the recovery position and administer
oxygen.
If normal breathing is not present:
AHA: Give 30 chest compressions/2 breaths.
Begin CPR (30:2) (see Cardiopulmonary
Resuscitation [CPR]).
ERC: Give 30 chest compressions/2 breaths.
Begin CPR (30:2)
Evaluation of the Airway After Choking
Adult/Child 1 Year and Older
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The signs and symptoms of
choking in an infant vary
depending on the degree of
obstruction of the airway to
the lungs. If the airway is
partially blocked, the infant
The signs and symptoms of
severe airway obstruction
are as follows.
High-pitched wheezing may
be heard, or no sound at all.
Infant is having difculty
breathing.
Cough is poor or ineffective.
Infant is in severe distress.
Infant is unable to cry or
make sounds.
Infants face may turn blue.
Breathing may cease.
Infant may become
unconscious.
Choking in a Conscious Infant
will be distressed and cough-
ing. If it is completely
blocked, the infant will be
unable to breathe or cough
and will eventually become
unconscious.
Signs and Symptoms
The signs and symptoms of
mild airway obstruction are
as follows.
Infant is responsive and
coughing.
Wheezing may be present.
There is good air exchange
(breathing).
SEQUENCE OF ACTIONS
Scene safety
Response
Back blows
Chest thrusts
Resources
Medical kit
Oxygen
MedLink
Mild Airway Obstruction
1
Assess the severity of the
breathing difculty.
2
If the obstruction is mild
and good air exchange is
present, do not interfere with
the infants attempt to relieve
the obstruction.
3
Call MedLink/EMS service
if the mild airway obstruc-
tion continues.
4
Continue to stay with the
infant and monitor for
worsening symptoms.
If the infant gets weaker
or stops coughing, follow
these steps to relieve the
obstruction:
1
Sit or kneel with the infant
in your lap.
2
Hold the infant face down
with the head lower than
the chest. Support the infants
head/jaw in your hand.
chest thrust should be a quick,
separate movement. The chest
thrust should be sufcient to
force air out of the infants
lungs. The pressure of the air
may dislodge the obstruction.
6
Continue the ve back
blows (slaps) and ve
chest thrusts until the obstruc-
tion is relieved or the infant
becomes unresponsive.
Warning
If the infant becomes
unconscious, treat as
directed in the following
section.
Never perform a blind
nger sweep in infants or
children because this may
cause the ob struction to be
moved further into the
airway.
Never perform abdominal
thrusts on an infant
because this may cause
internal injury.
Dispose of gloves, any
soiled items, and objects
from the throat in a bio-
hazard bag.
Always seek medical advice
if chest compressions are
delivered.
3
Using the
heel of
your other
hand, give up
to ve back
blows (slaps)
between the
shoulder
blades.
4
If back
blows
(slaps) do
not dislodge
the obstruction, give chest
compressions. Turn the infant
over on his or her back along
your forearm, with your hand
supporting the head and neck.
Place your
index and
middle n-
gertips on
the lower
breastbone
(sternum);
just below
the nipple
line in the
middle of
the chest.
5
Give up to ve chest
thrusts at a rate of one per
second. Press down sharply
against the breastbone. Each
HOW TO RELIEVE CHOKING: CONSCIOUS INFANT
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and clear the airway, remove
any visible obstructions with a
gloved nger, and attempt
2 effective breaths. If unable to
give rescue breaths, begin CPR.
Choking in an Unconscious Infant
If a choking infant has not had
their airway cleared by cough-
ing, they will soon become
unconscious. Call for help and
the medical equipment. Open
SEQUENCE OF ACTIONS
Send for help
Airway
Breathing
CPR
Resources
Medical kit
Oxygen
MedLink
For a choking infant who
becomes unconscious:
1
Ensure scene safety. Check
the infants response. Call
for help and medical equip-
ment. The Second Rescuer
should get equipment, and the
Third Rescuer should notify
the ight crew and MedLink.
2
Place the infant on a rm,
at surface on his or her
back, preferably waist high.
3
Open the airway. Put on
gloves. Look in the mouth
and remove only visible
objects. Do not do a blind
nger sweep.
4
Open the airway using the
head tilt/chin lift method.
Look, listen, and feel for
normal breathing for no more
than 10 seconds. If infant is
breathing normally, hold him
or her in the recovery position
and administer oxygen.
response and landing is not
imminent.
You are too tired to
continue.
MedLink advises you to
stop.
The aircraft lands and care
is transferred to emergency
medical services.
Warning
Never use a mechanical
aspirator on an infant.
Never use an AED on an
infant 1 year or younger.
Never do a blind nger
sweep in infants/children.
Treat dislodged objects as
potentially infectious mate-
rial. Dispose of gloves, any
soiled items, and objects
from the throat in a bio-
hazard bag.
5
AHA guidelines: If the
infant is not breathing
normally, attempt to give two
effective rescue breaths and
begin CPR (30 chest compres-
sions per 2 breaths). ERC
guidelines: If the infant in not
breathing normally, begin
30 chest compressions and
then 2 breaths.
Continue CPR until:
The scene becomes unsafe.
CPR has continued for at
least 60 minutes with no
HOW TO RELIEVE CHOKING: UNCONSCIOUS INFANT
Special Considerations for the Lone Rescuer
AHA: If you are alone, give 5 cycles (2 minutes) of rescue breaths and chest compressions to the
infant before you leave to call the emergency response system. Consider taking the infant with you
to the phone to minimize interruptions in CPR.
ERC: If you are alone, leave to call the emergency response system. On returning to the infant,
begin CPR with 30 compressions, then 2 rescue breaths. Consider taking the infant with you to the
phone to minimize interruptions in CPR.
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Notes

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Medical
Emergencies
There are a number of different
medical conditions that can affect
passengers and crew during a
ight. The initial assessment and
care is the responsibility of the
crew onboard in consultation with
the MedLink physician. This
chapter addresses the initial assess-
ment and management of common
medical situations which are orga-
nized according to body systems.
Onboard resources and initial care
are addressed for each medical
condition to assist the crew in man-
aging medical emergencies.
Respiratory System Disorders 88
Anatomy of the Respiratory System 88
Asthma 89
Hyperventilation 90
Chronic Lung Disease 91
Pneumothorax 91
Cardiovascular Disorders 92
Anatomy of the Cardiovascular System 92
Heart Disease 94
Heart Failure 94
Angina Pectoris (Chest Pain) 95
Heart Attack (Myocardial Infarction) 95
Fainting (Vasovagal) 96
Deep Vein Thrombosis (DVT) 97
Shock 98
Low-Volume Shock (Hypovolemic Shock) 98
Abdominal/Pelvic Disorders 99
Anatomy of the Abdomen/Pelvis 99
Abdominal/Pelvic Pain 100
Nausea, Vomiting, and Diarrhea 102
Indigestion and Heartburn 103
Bleeding from the Digestive Tract 103
Motion Sickness and Vertigo 104
Urinary Retention 104
Nervous System Disorders 105
Anatomy of the Nervous System 105
Stroke (CVA) 106
Headache and Migraine 108
Seizures 109
Behavioral and Psychological
Disorders 110
Panic Attacks and Phobias 110
Irrational Behavior and Substance Abuse 111
Other Medical Disorders 112
Diabetes 112
Hyperglycemia (High Blood Sugar) 112
Hypoglycemia (Low Blood Sugar) 113
Anaphylaxis 114
Allergy 115
Eye Irritation 116
Nosebleed 116
Sickle Cell Anemia 117
Ear and Sinus Pain 118
Decompression Sickness 119
Pregnancy and Childbirth 120
The Stages of Labor 120
First Stage: Dilation of the Cervix 121
Second Stage: Birth of the Infant 122
Third Stage: Delivery of the Placenta 123
Complications of Pregnancy and
Childbirth 124
5
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Bronchiole
Pulmonary
vein
Capillaries
Pulmonary
artery
Alveolus
Alveolar sac
Capillary with
red blood cells
Capillary lumen
Red blood
cell
Alveolus
A.
B.
C. D.
Respiratory System Disorders
This section covers the respiratory system, which includes a brief review of anatomy/
physiology and describes medical conditions that can prevent normal respiratory func-
tion. In-ight management of common respiratory conditions is also included.
This system includes the nose, mouth, air pas-
sages, and lungs. Inhaled air containing 21%
oxygen enters the nose and mouth and passes
down the windpipe (trachea) into the lungs,
where oxygen is absorbed into the blood. At
the same time, carbon dioxide (a by-product of
metabolism not required by the body) passes
from the blood into the lungs, to be exhaled.
This exchange of gases is called respiration.
Breathing is the chest move ment that causes the
lungs to take in and expel air. At rest, an adult
breathes 12 to 16 times per minute. (Children
and babies breathe 20 to 30 times per minute.)
The rate and depth of breathing is controlled by
the brain, normally in response to the amount
of carbon dioxide in the blood.
Anatomy of the Respiratory System
Respiratory Tract and Gas Exchange
There are two parts to the respiratory tract. The upper part of the respiratory tract extends from the nose and
mouth, where air is warmed and moistened, to the windpipe (trachea). The lower part consists of the air pas-
sages in the lungs (one bronchus leading to each lung, which divides into bronchioles, then into tiny air sacs
[alveoli], where gas exchange occurs).
In the lungs, oxygen passes through the walls of the air sacs (alveoli) into red blood cells, to be carried to
other body cells. In the capillaries, oxygen moves from the blood into the cells and is exchanged for carbon
dioxide, which is taken back to the lungs and exhaled.
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Asthma is a serious medical
condition that causes difculty
breathing as a result of spasms
of the airways (bronchioles),
which cause airway constric-
tion. In addition, the lining of
the airway becomes inamed
and produces excess mucus,
which can block some of the
smaller airway passages. Mild
asthma attacks cause wheez-
ing and shortness of breath.
Severe attacks can deprive the
body of oxygen, which can
cause severe respiratory dis-
tress and possibly death. Most
people who suffer from
Signs and Symptoms
Dry cough
Wheezing and/or feeling of
tightness in the chest
Difculty breathing
Distress and anxiety
Difculty speaking because
of breathlessness; inability
to speak in full sentences
Blue lips, earlobes, and nail
beds if attack is prolonged
and/or severe
Possible loss of
consciousness
Asthma
asthma carry medication with
them. Asthma attacks can also
occur in people who have no
previous history of asthma.
Trigger Factors
Factors that trigger asthma
attacks vary among individu-
als. Triggers include upper
respiratory tract infections
such as a cold or u; exercise;
stress; allergic reactions to
substances such as dust,
pollen, or animal fur; expo-
sure to cold air or air pollu-
tion; and a change in weather
conditions.
How to Use the Inhaler
and Spacer
Resources
Albuterol inhaler
Spacer
1
Remove the mouthpiece
cover. Test the inhaler by
shaking it and then pressing
the metal canister down to
release one puff of medication
into the air.
4
If the victim needs another
dose, advise repeating
steps 2 and 3 once.
5
If there is no immediate
improvement in the vic-
tims condition, seek urgent
advice from MedLink.
6
If the victim nds it dif-
cult to use the inhaler, t
the device to the spacer to
deliver the medication.
2
Give the inhaler to the
victim. Advise the victim to
breathe out and then close his
or her lips around the
mouthpiece.
3
Instruct the victim to press
the top of the canister
while taking a deep breath
from it, then to hold his or her
breath for a few seconds.
ADMINISTERING ALBUTEROL
Resources
Pillows
Oxygen
Medical kits (the MedLink
physician may advise
albuterol inhaler)
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
6
Help the victim sit forward,
resting his or her arms on a
table. Use pillows to support
the victim. Loosen tight
clothing.
7
If the victims condition
does not improve at once,
give oxygen on a high setting
and consult MedLink.
8
Stay with the victim.
Provide reassurance and
coach the victims breathing
into a more normal rate/
rhythm.
4
Assess the nature and
severity of the asthma
attack. Assess the victims
breathing. Ask if there is a
history of breathing problems
or asthma.
5
Reassure the victim. If the
victim has medication for
asthma (i.e., an inhaler),
advise him or her to use it.
Assist the victim as necessary.
If the victims breathing is not
improving with the inhaler or if
the victim does not have an
inhaler, call MedLink.
INITIAL CARE
Albuterol is given to victims who are having an asthma attack or who have chronic lung disease.
Most people with asthma or chronic lung disease carry their own medication.
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1
Insert the mouthpiece of
the inhaler into the end of
the spacer. Advise the victim to
breathe out and close his or
her lips around the mouth-
piece of the spacer.
2
Instruct or help the victim
to press the canister and
release a dose of medication
into the spacer. Advise the
victim to inhale the medication
and hold his or her breath for
a few seconds. The standard
does of albuterol is 2 puffs
30 to 60 seconds apart.
3
To give another dose,
repeat the previous steps.
Warning
If a victim has severe respira-
tory distress or becomes
unconscious, see Life-saving
Procedures. Som inhalers
may be contraindicated in
some lung diseases. Consult
MedLink.
USE OF A SPACER WITH AN INHALER
Hyperventilation occurs when
the rate and depth of breath-
ing increase, causing the
carbon dioxide (CO
2
) level in
the blood to fall abnormally
low. The breathing rate is par-
tially inuenced by the level
of CO
2
present in the blood.
When the level of CO
2
falls,
chemical changes occur in the
blood, leading to problems
such as numbness in the
hands and feet. Hyperventila-
tion is usually caused by
anxiety brought on by a panic
attack, a phobia such as a fear
of ying, or emotional stress.
The condition can also occur
in people with certain medical
conditions, such as diabetes,
or in cases of a drug overdose.
Signs and Symptoms
Rapid, deep breathing
Anxiety
A feeling of difculty
breathing
Pale appearance and
sweating
Light-headedness or
dizziness
Tingling and numbness in
ngers, toes, and face
Possible cramps or rigidity
in hands and feet
In severe cases, brief loss of
consciousness
Hyperventilation
Resources
Oxygen
Medical kit
MedLink
1
Assess scene safety and
the victims responsive-
ness, airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical
condition.
5
Advise the victim to
breathe normally;
suggest that he or she
mimic your breathing,
and breathe slowly and
regularly.
6
Assess the color and
feeling in the victims
face, hands, and feet.
Check for possible
causes of anxiety or for
medical problems such
as diabetes.
7
Reassure the victim.
8
If the symptoms persist,
give oxygen on a high
setting, using an oxygen mask.
Advise the victim to slow his
or her breathing until the
symptoms have been relieved.
9
To help calm the victim,
explain what has hap-
pened. If the victim is still
anxious, consult MedLink.
Warning
Never have the victim
breathe in a paper bag; use
an oxygen mask on a high
setting.
INITIAL CARE
Asthma, continued
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Long-term lung diseases such
as chronic obstructive pulmo-
nary disease (COPD) cause
permanent lung damage, short-
ness of breath, and progressive
damage to the heart and lungs.
The airways become inamed
(bronchitis) and cause damage
to the air sacs in the lungs
(emphysema). COPD com-
monly affects elderly people,
especially those who have
smoked cigarettes. Passengers
with COPD are more likely to
develop hypoxia under normal
cabin conditions and may need
to use supplemental oxygen
throughout the ight.
Signs and Symptoms
Shortness of breath,
wheezing
Cough that is dry or pro-
ductive of sputum
History of chronic lung
disease (e.g., COPD,
emphysema, or asthma)
Chronic Lung Disease
Blue lips, earlobes, and nail
beds
Resources
Pillow Medical kit
Oxygen MedLink
1
Assess scene safety and
the victims responsive-
ness, airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical
condition.
5
Help the victim sit up.
Support the victim with
pillows. Give oxygen on a high
setting.
6
Advise the victim to take
his or her medication.
Assist the victim as needed.
Reassess the victim, and if
there is no improvement with
the medications, call MedLink.
Warning
If the victim becomes uncon-
scious, see Life-saving
Procedures.
INITIAL CARE
A pneumothorax (collapsed
lung) occurs when air enters
the space between the lung
and the lining of the chest wall.
This causes a partial or com-
plete collapse of the lung and
results in difculty breathing
and chest pain. A pneumotho-
rax can occur from a direct
injury to the chest wall or
without any obvious reason
(spontaneous pneumothorax).
A tension pneumothorax occurs
when the air in the chest is
under pressure and compresses
the lungs, heart, and vital chest
organs; this is a life-threatening
emergency and must be treated
as soon as possible. If a person
has a pneumothorax before
boarding a ight, the air will
expand during ascent, causing
Sudden shortness of breath,
usually starting during or
just after ascent
Possible blue lips, earlobes,
and nail beds
Possible loss of conscious-
ness
History of recent chest injury
or previous pneumothorax
Pneumothorax
symptoms to develop or
become worse.
Signs and Symptoms
Possible sudden, sharp
chest pain (as a result of
trauma or may occur
spontaneously)
Collapsed
lung
Resources
Pillow Medical kit
Oxygen MedLink
1
Assess scene safety and
the victims responsive-
ness, airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
medical condition,
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical
condition.
5
Check the victim for chest
pain, chest injuries, or a
history of pneumothorax.
6
Reassure the victim. Help
the victim assume a com-
fortable position and support
the victims body with pillows.
7
Administer oxygen on a
high setting.
8
Consult MedLink.
Warning
If the victim becomes
unconscious, see Life-
saving Procedures.
If there is an open chest
wound, cover the wound
with a dressing on three
sides only (see Open chest
wounds).
INITIAL CARE
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Jugular veins
Common
carotid arteries
Superior
vena cava
Right atrium
and ventricle
Inferior
vena cava
Liver
Femoral
artery
Abdominal
aorta
Kidney
Left atrium
and ventricle
Right lung
Left lung
Cardiovascular Disorders
This section describes the initial care for victims with conditions that affect the cardio-
vascular system, which includes the heart (cardio) and blood vessels (vascular).
Common medical conditions include shock, heart attack, and deep vein thrombosis
(DVT). A brief review of the anatomy and physiology of the cardiovascular system is
included in the following section.
This system consists of the
heart (muscular pump) and
blood vessels (arteries, veins,
and capillaries), which trans-
port the blood. Oxygen-rich
blood passes from the lungs to
the left side of the heart,
where it is pumped out of the
left ventricle into the aorta
(the main artery in the body).
The aorta connects to a com-
back into the blood. Once this
exchange occurs, the unoxy-
genated blood travels out of
the capillaries and into the
veins and venous system and
back to the right side of the
heart, where it goes back to
the lungs for gas exchange
(CO
2
is exchanged for oxygen
during respiration).
Anatomy of the Cardiovascular System
prehensive arterial system,
which delivers oxygenated
blood to all body cells. At the
cellular level, the smallest
arteries connect to the capillar-
ies, where the actual exchange
of oxygen and waste products
(CO
2
) occurs. Oxygen moves
out of the blood into body
cells in exchange for CO
2
,
which moves out of cells and
Structure of the Cardiovascular System
The heart is at the center of the cardiovascular system.
Arteries carry blood from the heart to other tissues and
body cells. Capillaries connect the arteries and veins,
which allows the exchange of oxygen and CO
2
in the cells.
Veins return the unoxygenated blood to the heart. Every
part of the body is supplied with arteries/capillaries and
veins; the main blood vessels are shown here.
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The Heart
This is a muscular organ about the size
of a st. It has its own blood supply
(coronary arteries) and pacemaker,
which stimulates continual contractions
(heartbeats). In adults, the heart beats
about 72 times per minute at rest; the
rate is faster in babies and children.
(to head and arms)
Superior vena
cava (from
head and arms)
Pulmonary
arteries
Right
atrium
Tricuspid
valve
Right
ventricle
Inferior vena cava
(from trunk and legs)
Left
ventricle
Mitral
valve
Aortic
semi-lunar
valve
Pulmonary
veins
Aorta
(to
aorta)
Aorta (to
trunk and legs)
Types of Blood Vessels
Arteries have thick, muscular walls because they
carry waves of high-pressure blood. These
waves can be felt in certain areas of the body
and are called the pulse. Veins have thinner
walls with valves to keep blood owing toward
the heart. Capillaries are tiny vessels that link
arteries to veins. They have thin walls through
which oxygen and waste products (CO
2
) pass
during gas exchange.
Arteriole
Capillaries
Venule
Anatomy of the Cardiovascular System, continued
Superior vena cava
Pulmonary trunk
(cut to expose left
coronary artery)
Left
coronary
artery
Circumflex
branch of
left coronary
artery
Left anterior
descending
coronary artery
Right
ventricle
Abdominal aorta
Inferior
vena cava
Marginal branch
of right coronary
artery
Right
coronary
artery
Aorta
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There are many types of heart
disease, but only the most
common conditions are
reviewed in this section. When
the heart muscle is weak or
damaged, it can no longer
pump blood efciently
throughout the body. Coro-
nary artery disease (CAD) is a
term that refers to conditions
in which the arteries that
supply blood to the heart
muscle (coronary arteries) are
diseased or blocked by fatty
deposits or blood clots. As a
result, the heart muscle does
not receive sufcient blood
and oxygen to function effec-
tively, which can result in
chest pain (angina pectoris) or
a heart attack (acute myocar-
dial infarction; AMI). There are
risk factors that place individu-
Modiable risks (those that
can be controlled or elimi-
nated with lifestyle changes,
diet, and medication) include:
Smoking
High triglycerides
Diabetes
Obesity
High blood pressure
High cholesterol
Lack of exercise
Stress
Additional risk factors for
women include:
Oral contraceptive use
Hormone replacement
therapy
Excessive alcohol intake
Heart Disease
als at increased risk for devel-
oping CAD. Although men
and women share most risk
factors, women have a few
additional risk factors, as listed
here.
Risk Factors
Unmodiable risk factors
(those that cannot be con-
trolled) include:
Increasing age

Males: Increased risk of

heart attack earlier in life;
increases with age

Females: Increased risk

with increasing age; pre-
vious heart attack
increases chance of a
second one
Heredity (including race,
family history)
When the heart is damaged, either by chronic
disease or by a severe heart attack, heart failure
can occur. As a result, the heart cannot pump
blood efciently. This results in inadequate cir-
culation, which causes uid to accumulate in
the lungs and lower extremities. Heart failure
commonly affects people with heart problems,
high blood pressure, or chronic lung disease.
The symptoms may become worse during ight
because of the reduced oxygen and inactivity.
Signs and Symptoms
Difculty breathing, shortness of breath,
wheezing
Cough with pink frothy sputum
Blue lips, earlobes, and nail beds
Swelling of the legs and ankles
Possible loss of consciousness
History of heart disease or high blood
pressure
Chest pain (may or may not be present)
Heart Failure
Resources
Oxygen
Medical kit
AED
Pillow
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
6
Reassure the victim. Help
the victim settle into the
most comfortable position.
Use a pillow for support.
7
Contact MedLink.
Warning
If the victim becomes uncon-
scious, see Life-saving
Procedures.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical con-
dition. Assess the victim for
difculty breathing.
5
Apply oxygen at a high
setting.
INITIAL CARE
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s
This condition, usually called
angina, is chest (heart) pain
caused by a temporary inade-
quate blood supply to the
heart muscle. In many cases,
this results from narrowing of
one or more of the coronary
arteries that feed the heart
muscle. The buildup of plaque
or a blood clot can cause con-
striction of the coronary arter-
ies. Angina can occur during
increased activity, such as
exercising, walking upstairs, or
engaging in other strenuous
activities that increase the
demand for oxygen on the
heart. It may also be caused by
shoulder, or down one arm
(usually left)
Difculty breathing or short-
ness of breath
Fatigue/weakness
Nausea/vomiting
Sweating/clammy skin
Anxiety or fear
Denial
History of angina, coronary
artery disease, heart attack,
or presence of known risk
factors
Women, elderly persons,
and diabetics may have
vague symptoms
Note: Pain that lasts less
than a minute is unlikely to
be heart pain.
Angina Pectoris (Chest Pain)
spasms of the coronary arteries
that constrict blood ow to the
heart muscle. Angina may
occur during ight because of
the increased altitude and
reduced oxygen in the aircraft
cabin. Victims often have a
history of coronary artery
disease or angina and may
carry their own medication.
Signs and Symptoms
Pressure, heaviness, or
tightness across the chest
Cramping central chest pain
Pain, numbness, or tingling
in the chest and possibly
radiating to the neck, jaw,
A heart attack (myocardial
infarction; MI) occurs when a
blood clot blocks a coronary
artery and the heart muscle
beyond the clot is deprived of
oxygen. Chest pain develops,
and if the blockage continues,
the heart muscle eventually
becomes necrotic and dies. The
severity of a heart attack
depends on the amount and
location of the muscle damage.
A severe heart attack may result
in the inability of the heart
muscle to pump blood effec-
tively, resulting in heart failure
or cardiac arrest. It is very dif-
cult to distinguish between
a heart attack and angina.
Difculty breathing/
shortness of breath
Restlessness, anxiety, or fear
(feeling of doom)
Loss of consciousness and
cardiac arrest
History of angina, heart
attack, or known risk factors
for coronary artery disease
Note: Chest pain lasting
longer than 20 minutes may
indicate a heart attack.
Heart Attack (Myocardial Infarction)
Signs and Symptoms
Persistent chest heaviness,
pressure, or pain (may feel
like indigestion).
Radiation of pain, pressure,
numbness or tingling to the
neck, jaw, shoulder, or
down one arm (usually left)
Pale or gray (ashen), cool,
clammy skin
Nausea and/or vomiting
Right coronary
artery
Vessel lumen
Plaque
Blockage of a
Coronary Artery
Fatty deposits on the artery walls can
increase the risk of clot formation. If
a clot forms and blocks a coronary
artery, a heart attack will result.
Resources
Oxygen AED
Medical kits MedLink
1
Assess scene safety and
the victims responsive-
ness, airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
medical history, current
medications, and allergies.
4
Assess the nature and
severity of the medical
condition.
5
Administer oxygen on a
high setting. Help the
victim settle into a comfort-
able position.
6
Reassure the victim.
Help him or her settle
into a comfortable position.
7
Contact MedLink; the
physician may advise
you to give aspirin and
nitroglycerin.
8
Prepare for a possible
cardiac arrest. Obtain
the AED so that it is imme-
diately availablebut keep
out of the patients view.
Warning
If the victim becomes
unconscious, see Life-
saving Procedures.
Nitroglycerin may
reduce the blood pres-
sure and cause light-
headedness. Have the
victim sit or lie down.
Do not administer if the
blood pressure is low.
Consult with MedLink.
INITIAL CARE FOR CHEST PAIN
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A very brief period of uncon-
sciousness is referred to as
fainting or a vasovagal event.
This condition occurs when
the brain temporarily receives
too little blood/oxygen. One
contributing factor is sitting or
standing for a long time
period, which causes blood to
pool in the legs. Fainting can
also be caused by low blood
Signs and Symptoms
Light-headed or dizzy
feeling
Pale, cool, clammy skin
Nausea
Brief loss of consciousness
that resolves once the victim
is lying at
Fainting (Vasovagal)
sugar if a person has diabetes
or if he or she has not eaten
for several hours. In addition,
it can result from emotional
upsets or exhaustion or as a
side effect of medications
(e.g., medications to treat high
blood pressure). The victim
normally recovers quickly after
being laid down at.
Resources
Bulky items such as blan-
kets and pillows
Oxygen
Medical kit
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
medical condition, medical
history, current medications,
and allergies from bystanders
or traveling companions.
8
Once the victim is respon-
sive, obtain a medical
history: last meal/snack,
medications, medical history
(diabetes?).
9
Consult MedLink.
Warning
Do not let the victim stand
up until fully recovered.
If the victim remains
unconscious for longer
than a few seconds after
having been laid down, see
Life-saving Procedures.
4
Assess the nature and
severity of the medical
condition.
5
Assist the victim to lie at.
Raise the legs above the
level of the heart to improve
blood ow to the brain.
Support the feet with blankets
and pillows.
6
Administer oxygen at a
high ow.
7
Loosen any tight clothing
around the victims neck,
chest, and waist.
INITIAL CARE
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This is a condition in which a
blood clot forms on the wall
of a large vein, usually in the
leg. DVT is potentially very
serious because the clot may
break off, travel through the
bloodstream, and lodge in an
artery in the brain, lungs, or
heart, causing a blockage
called an embolism. A lung
(pulmonary) embolism (PE)
can cause cardiovascular col-
lapse and sudden death.
Signs and Symptoms
Pain and tenderness in
one leg
Swelling, warmth, and
redness in affected leg
Enlarged veins just under
the surface of the skin
(compare affected leg with
the other leg)
History of DVT or presence
of known risk factors (see
earlier discussion).
Chest pain, shortness of
breath, or rapid pulse (may
indicate a pulmonary
embolus)
Note: bilateral leg swelling,
which is common during
ight, is unlikely to be
a DVT.
Deep Vein Thrombosis (DVT)
Risk Factors
Previous history of DVT
Hormone therapy, birth
control pills
Recent surgery or childbirth
Cancer
Blood-clotting disorders
Long-haul ights or pro-
longed periods of sitting/
inactivity
Sitting for 6 hours or more,
with the seat pressing on
the back of the leg (a major
risk)
Family history of blood clots
Blood
flow
Normal
Resources
Medical kit
Oxygen
Pillow
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical prob lem,
medical history (include risk
factors for DVT), current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical
condition.
Prevention of DVT
During Travel
1
Stay well hydrated; drink
water and juices and avoid
alcohol.
2
Walk around the cabin reg-
ularly to encourage blood
ow.
3
Perform stretching exer-
cises in the seat.
4
Travelers who are at risk
for DVT should consult
their physician regarding spe-
cic prevention strategies (e.g.,
compression stockings,
medications).
5
Assess the victims legs.
Look for swelling, redness,
asymmetry, or tenderness.
6
Raise the affected leg and
support with a pillow.
7
Consult MedLink.
Warning
Never massage the
affected area or leg
because this may dislodge
the clot.
Do not encourage the
victim to walk if you
suspect DVT.
INITIAL CARE
DVT
Blood
clots
Valve
Detached
blood
clot
Deep Vein Thrombosis (DVT)
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When the cardiovascular
system cannot supply enough
blood and oxygen to the body
tissues, shock occurs. If left
untreated, shock can be fatal.
The signs and symptoms vary
depending on the underlying
cause. Medical or traumatic
causes of shock should not be
confused with emotional dis-
tress, which is often called
shock.
Types of Shock
Low-volume shock (hypo-
volemic) occurs when the
body loses a large amount
of blood or other body
uid, resulting in too little
blood in the cardiovascular
drop in blood pressure; as a
result, the blood ow and
oxygen to the tissues is
inadequate. The allergic
response causes the airways
to narrow and swell,
causing shortness of breath,
wheezing, and possibly
respiratory arrest.
Infectious shock (septic
shock) occurs during an
acute infection when bacte-
ria release poisons (toxins)
into the blood. The toxins
cause dilation of the blood
vessels, resulting in low
blood pressure and inade-
quate blood ow to the
tissues.
Shock
system. The body cells do
not receive enough oxygen
to function normally. Causes
include severe hemorrhage
or severe dehydration from
vomiting or diarrhea.
Cardiac shock (cardio-
genic) occurs when the
heart does not pump blood
effectively; it most com-
monly results from heart
failure or a heart attack.
This results in an inade-
quate supply of blood and
oxygen to body cells.
Allergic shock (anaphy-
laxis) is caused by a severe
allergic reaction. All the
blood vessels in the body
dilate, causing a severe
This type of shock occurs
when the body loses a large
amount of body uid or
blood. It can be caused by
severe external or internal
bleeding or from severe or
prolonged vomiting or diar-
rhea. It can also result from
severe burns. Many of the
signs and symptoms of hypo-
volemic shock are due to the
bodys protective reactions,
which divert the blood supply
away from nonessential organs
(e.g., stomach, extremities) to
Restlessness and anxiety
Confusion/possible loss of
consciousness
Low blood pressure
Low-Volume Shock (Hypovolemic Shock)
the vital organs such as the
brain and the heart.
Signs and Symptoms
Pale, cool, clammy
skin
Rapid, shallow
breathing
Rapid, weak pulse
Blue lips, earlobes,
and nail beds
Nausea/vomiting;
complaint of thirst
Weakness and
dizziness
Resources
Oxygen
Medical kits
Bulky items such as blan-
kets and pillows
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
medical condition, medical
history (include history of
blood supply to the brain and
heart.
6
Apply oxygen at a high
setting.
7
Loosen any tight clothing
around the victims neck,
chest, and waist. Cover the
victim with a blanket to main-
tain a normal body tempera-
ture. Do not overheat.
8
Consult MedLink.
injury/trauma, vomiting, diar-
rhea), current medications,
and allergies.
4
Assess the nature and
severity of the medical con-
dition. Look for a cause of
shockobvious injury, bleed-
ing, etc. If no injury is found,
evaluate the victim for another
possible cause of shock, such
as allergy.
5
Lay the victim down. Raise
his or her legs and support
the feet with bulky items such
as pillows to improve the
INITIAL CARE
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Abdominal/Pelvic Disorders
This section addresses the initial assessment and management of conditions affecting
the abdomen and pelvis. The abdomen and pelvis contain most of the digestive, repro-
ductive, and genitourinary systems. To assist in understanding abdominal and pelvic
disorders, an anatomy section follows.
The abdomen contains the organs of the diges-
tive system. The main organs include the
esophagus, stomach, duodenum, small and
large intestines, and other organs of digestion.
The function of this system is to break down
and digest food so that it can be used for fuel
and nutrients in the body. The abdomen also
contains the kidneys and the rest of the urinary
system, which lters the blood and maintains
the bodys chemical balance. The lower
abdomen and pelvis hold the reproductive
organs such as the ovaries and uterus.
Anatomy of the Abdomen/Pelvis
Tongue
Liver
Gallbladder
Duodenum
Pancreas
Ascending
colon
Appendix
Pharynx
Esophagus
Stomach
Transverse
colon
Descending
colon
Rectum
Kidney
Ureter
Intestine
Fallopian
tube
Ovary
Uterus
Bladder
Urethra
Vagina
Kidney
Ureter
Intestine
Prostate
gland
Bladder
Urethra
Penis
Testis
Female Male
Genitourinary System
The genitourinary system includes
the urinary and reproductive
systems. The urinary system
includes the kidneys and the
urinary tract (ureters, bladder,
and urethra). The kidneys lter the
blood and produce urine, which is
excreted through the urinary tract.
The reproductive system in
females includes the ovaries, fallo-
pian tubes, and the uterus. The
reproductive system in males
includes the penis, testes (which
are located outside the abdomen/
pelvis), and prostate gland.
Digestive System and Spleen
The digestive organs include the stomach,
liver, pancreas, gallbladder, and the large
and small intestines. The organs in the
digestive system produce juices to break
down food. The liver has many functions,
including regulating blood-clotting
function, storing and utilizing glucose,
and processing toxins (e.g., medications,
poisons). The spleen forms part of the
immune system, which protects the body
against infection. The pancreas produces
insulin and controls blood sugar.
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Pain in the abdomen or pelvis
has a wide range of possible
causes. It may be due to infec-
tion, inammation, intestinal
blockage, or other causes.
Pain can also result from inter-
nal abdominal injuries as a
result of trauma. The victim
may feel the pain directly in
the affected area, in another
area of the abdomen (referred
pain), or throughout the
abdomen. Abdominal pain
may be accompanied by other
Possible bleeding
Possible nausea, vomiting,
and diarrhea
Possible urinary symptoms
In females of childbearing
age, possible pregnancy
The information in the fol-
lowing box includes a series
of questions that you should
ask any victim who has
abdominal pain. Relay the
information to the MedLink
physician.
Abdominal/Pelvic Pain
symptoms, such as fever,
nausea, vomiting, diarrhea, or
bleeding. To perform an
assessment of the victim,
obtain a history, assess the
pain, examine the victim for
any other symptoms, and
consult MedLink.
Signs and Symptoms
Possible signs of shock
Abdominal or pelvic pain
Possible fever or other gen-
eralized symptoms
Q: Is the Victim in Pain?
Has this pain, or any similar
symptom, occurred before?
Where is the pain located?
(See accompanying
diagram.)
What is the degree of pain?
On a scale of 1 to 10
(1 minimal; 10 worst
pain), rate the pain.
Is the pain continuous, or
does the intensity of the
pain vary?
When did the pain start?
Is the pain getting worse, or
is it changing in intensity,
pattern, or site?
Does movement, coughing,
or breathing relieve the pain
or make it worse?
Q: Are There Any
Generalized Symptoms?
Does the victim have a fever
or chills?
Does the victim feel anxious
or restless?
Q: Is There Any Bleeding?
Where is the blood coming
from?
Is the bleeding mild, moder-
ate, or heavy?
Q: Are There Any Urinary
Problems?
When did the victim last
urinate?
Does the urine pass freely, or
does it dribble?
Is there any blood in the
urine?
Is it painful to urinate?
Is it difcult to urinate?
Is there urinary frequency?
What is the color of the
urinedark to clear?
Q: Is the Victim a Woman
or Young Girl?
Does the victim think she is
pregnant?
Has the victim missed a
menstrual period, or is her
period late?
What was the date of her
last normal menstrual
period?
Is there any vaginal bleeding
or discharge?
Q: Has the Victim Been
Vomiting?
How often has the victim
vomited?
Does vomiting make the
victim feel better or worse?
What does the vomit look
like?
Does the vomit contain any
blood or dark, gritty mate-
rial that looks like coffee
grounds?
Q: Does the Victim Have
Diarrhea?
How often do the bouts of
diarrhea occur?
Does the victim have
stomach cramps?
Does the victim feel better
after going to the
bathroom?
Is there any blood in the
diarrhea?
ABDOMINAL PAIN ASSESSMENT
Top
Upper
right
Upper
left
Center
Lower
right
Lower
left
Bottom
Areas of the Abdomen
The abdomen has been divided into
areas to help dene the location of
the abdominal pain. Ask the victim
to specify where the pain occurs;
relay this information to the
MedLink physician.
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Resources
Oxygen
Medical kit
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
Warning
If the victim becomes
unconscious, see Life-
saving Procedures.
Do not give the victim any-
thing to eat or drink until
you have consulted
MedLink.
Treat any body uids as
potentially infectious mate-
rial. Dispose of gloves and
soiled items in a biohazard
bag.
4
Assess the nature and sever-
ity of the abdominal pain or
symptoms. Assess the victims
symptoms, using the questions
for abdominal pain assessment
(see previous box) as a guide.
5
If the victim shows signs of
shock, treat for shock.
6
Help the victim settle into
a comfortable position and
provide reassurance.
7
Consult MedLink for advice
on medications or other
treatment recommendations.
INITIAL CARE
Common Serious Causes of Abdominal Pain
There are many serious conditions that can cause severe abdominal pain and may need urgent
medical attention. The following chart describes some of the most common conditions. Use the
questions for abdominal pain assessment as a guide. Relay the information to MedLink.
Disorder Description Signs and Symptoms
Peptic ulcer A peptic ulcer is an inammation/infec-
tion in the stomach or the duodenum. In
severe cases, the ulcer pierces through
(perforates) the wall of the stomach or
intestine, causing severe, generalized
abdominal pain, as well as internal
bleeding.
Intermittent discomfort in the upper
abdomen, often relieved by food, milk,
or antacids and worsened by spicy food
or alcohol
Possible indigestion
Presence of risk factors such as
smoking, stress, or use of certain medi-
cations, such as aspirin
History of peptic ulcer disease
Appendicitis Appendicitis is caused by inammation of
the appendix, a tiny pouch attached to
the large intestine. It is most common in
children and young adults, but it can
occur at any age. If left untreated, the
appendix may rupture, causing a serious
abdominal infection and death in severe/
untreated cases.
Pain and tenderness, usually starting in
the center of the abdomen (around the
navel) and moving to the right lower
quadrant of the abdomen
Low-grade fever
Loss of appetite and, in some cases,
nausea and vomiting
Renal colic Severe pain deep inside the abdomen,
around the kidneys (in the back or ank
area), is called renal colic. It is usually
caused by a kidney stone, causing
severe pain and possible blockage as it
moves down the ureter.
Waves of severe pain, usually felt in the
lower back and often radiating to the
lower abdomen and groin
Discomfort and difculty in passing urine
In some cases, blood in the urine
Restlessness; inability to nd comfort-
able position
Ectopic
pregnancy
A fertilized egg embeds in an area such as
a fallopian tube, instead of in the uterus.
The woman may be unaware that she is
pregnant. If an ectopic pregnancy is not
treated, rupture may occur, causing life-
threatening internal bleeding, hypovole-
mic shock, and death.
Lower abdominal/pelvic pain
History of known early pregnancy,
missed or late menstrual period, or pre-
vious ectopic pregnancy
Possible vaginal bleeding
Note: There are many other serious causes of abdominal pain, such as heart attack, aortic aneurysm, bowel
obstruction/perforation, infection, etc. Consult MedLink for advice.
Abdominal/Pelvic Pain, continued
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Nausea/Vomiting
When nausea or vomiting occurs onboard an
aircraft, it is often due to motion sickness. Other
causes include digestive disorders such as food
poisoning, which can cause irritation or inam-
mation of the digestive tract. In addition, nausea
or vomiting may result from alcohol intoxica-
tion or medical conditions such as diabetes or
infection. Prolonged vomiting can result in
dehydration and electrolyte imbalances.
Signs and Symptoms
Nausea/vomiting
Abdominal pain
Pale, sweaty, clammy skin
Dizziness/light-headedness/weakness if
dehydration is severe
Diarrhea
This condition causes a frequent or urgent need
to have bowel movements, which may be
runny or watery. The most likely causes of diar-
rhea are food poisoning or an infection of the
intestines, but it can also result from other dis-
orders. If not treated, diarrhea can cause exces-
sive loss of body uids, resulting in dehydration
or hypovolemic shock.
Signs and Symptoms
Frequent urge to have bowel movements
Runny or watery bowel movements
Cramping abdominal pains
Fever (may be present)
Blood (may appear as bright red or black/
tarry in appearance)
Dizziness/light-headedness/weakness if
dehydration is severe
Nausea, Vomiting, and Diarrhea
Resources
Medical kit
Gloves/biohazard bag
Cool, wet washcloth
Clear liquids to sip or ice
chips
Oxygen
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical con-
dition. Obtain a medical
historyuse the questions for
abdominal pain (see following
section). Ask if the victim has
recently had any food, drink,
medication, drugs, or alcohol.
Is there a history of diabetes?
Warning
If you suspect the victim
has taken a drug overdose,
carefully look at the vomit
for pill fragments and
dispose of it in a biohazard
bag.
Seek urgent advice from
MedLink for infants or
elderly with severe
diarrhea.
Look for blood in the
vomit, which can be a sign
of bleeding in the digestive
tract. Blood may appear as
clots, red streaks, or black,
gritty material that looks
like coffee grounds.
Severe diarrhea is a report-
able symptom. If anyone
onboard has severe diar-
rhea, it must be reported
by the captain of the air-
craft to the Port Health
Authority/Quarantine
Station at your
destination.
5
If you know that the victim
has diabetes, look for
other signs and symptoms of
hypoglycemia.
6
Ask if the victim has been
in contact with anyone
with diarrhea.
7
Inquire about travel
history.
8
Offer antidiarrheal medica-
tions to relieve symptoms.
9
Offer the victim a cool, wet
washcloth to wipe his or
her face. If the victim has
vomited, offer clear liquids or
ice chips to prevent
dehydration.
10
Consider all vomit and
diarrhea to be infec-
tious; use gloves and personal
protection equipment. Wash
hands after patient contact
and after glove removal.
11
Dispose of all contami-
nated material in a bio-
hazard bag.
12
Consult MedLink.
INITIAL CARE
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Indigestion is discomfort in
the upper abdomen often
caused by eating a large or
rich meal. Heartburn is caused
by stomach acid owing back
up the esophagus, producing
a burning sensation behind
the breastbone. This is also
called gastroesophogeal
reux disease, or GERD.
Signs and Symptoms
Pain or discomfort in the
upper abdomen/epigastric
area
Burning feeling in the chest
Acid taste in the mouth
Feeling of bloating and gas
Possible nausea/vomiting
Increased symptoms with
spicy/fried foods, caffeine,
or alcohol (food intolerance)
Indigestion and Heartburn
Resources
Medical kit
MedLink
1
Assess scene safety and
the victims responsive-
ness, airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the abdominal
pain. Assess the victims
symptoms, using the ques-
tions on abdominal pain as a
guide. Ask what the victim has
eaten recently and if he or she
is prone to episodes of indi-
gestion or heartburn. Ask if
the victim has chest pain or
history of heart disease.
5
Consult MedLink for
advice.
Warning
Advise the victim to avoid
consuming any carbon-
ated drinks, tea, coffee, or
alcohol.
If the pain persists or
worsens, assess the victim
for signs and symptoms of
a heart attack. A heart
attack can often mimic
heartburn or indigestion.
Consult MedLink for advice.
INITIAL CARE
Vomiting blood or bleeding
from the rectum can be a sign
of bleeding in the digestive
tract. If the bleeding is severe,
it can lead to hypovolemic
shock. Bright red blood in
vomit usually comes from
ulcers in the stomach or the
upper part of the small intes-
tine (duodenum). Blood that
has been in the stomach for a
while may be dark brown and
grainy, like coffee grounds.
vagina, can be mistaken for
bleeding from the digestive
tract.
Signs and Symptoms
Abdominal pain
Nausea and vomiting
Diarrhea
Blood or black material in
vomit or stools
History of digestive tract
problems
Weakness/signs of shock
Bleeding from the Digestive Tract
Bleeding from the rectum may
be due to infections, inam-
mation of the large intestine,
tumors, or hemorrhoids. Blood
may appear as red streaks if it
comes from the lower part of
the intestine or rectum, or as a
black, tarlike substance if the
bleeding is higher up in the
intestinal tract. Sometimes,
bleeding that comes from
other areas, such as blood
from a nosebleed or from the
Resources
Bulky items such as blan-
kets and pillows
Medical kit
Oxygen
Personal protection
equipment/biohazard bag
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
6
Monitor the victim for
signs of hypo volemic
shock. Treat accordingly.
7
Contact MedLink for
advice.
Warning
Treat blood, vomit, diar-
rhea, and stool as poten-
tially infectious material.
Use gloves and personal
protection equipment.
Wash hands frequently.
Dispose of all contami-
nated materials in a bio-
hazard bag.
3
Assess the symptoms; use
the questions on abdomi-
nal pain assessment as a guide.
Ask about any illness or sub-
stance that may have irritated
the digestive tract. Obtain a
medical history (include
abdominal diseases/problems,
abdominal surgeries/medica-
tions, and allergies).
4
Estimate how much blood
has been lost.
5
Allow the victim to drink
clear liquids if thirsty, but
do not give anything to eat.
INITIAL CARE
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Motion sickness is caused by a
mismatch of messages from
the inner ear, eyes, and mus-
culoskeletal system and the
brain relative to the bodys
position in the environment.
This can cause dizziness,
Signs and Symptoms
Sensation of spinning
or motion
Nausea and possible
vomiting
Pale, clammy skin
Motion Sickness and Vertigo
vertigo, and nausea/vomiting.
The motion of the aircraft, the
inability to visualize the
horizon, and a warm, poorly
ventilated environment may
contribute to the symptoms.
Resources
Cool, damp cloth
Clear liquids to drink
Oxygen
MedLink
Personal protection
equipment/biohazard bag
Medical kit
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
or look out the windows.
Advise the victim to look
toward the front of the aircraft.
8
Offer clear liquids to drink
and avoid alcohol.
9
Oxygen may provide effec-
tive relief.
10
If nausea is severe,
contact MedLink.
Warning
Treat vomit as potentially
infectious material. Dispose
of gloves and soiled items in a
biohazard bag.
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical
condition.
5
Ask if the victim is prone to
motion sickness or has
recently had any disorder of
the inner ear or sinuses.
6
Offer the victim a cool,
damp washcloth to place
on the forehead.
7
Open air vents to increase
the airow. Advise the
victim not to read, look down,
INITIAL CARE
Inability to urinate may cause
distension and discomfort.
This condition is known as
urinary retention. It is usually
caused by a blockage of the
urethra (the tube through
which urine passes out of the
body). The most common
cause is an enlarged prostate
gland in men. Usually, the
Inability to urinate normally,
possible dribbling of small
amounts of urine
Pain when passing urine
Distended bladder, which
can be felt as smooth swell-
ing in the lower abdomen
Restlessness
History of urinary infection
or enlarged prostate
Urinary Retention
only treatment is to have a
medical professional insert a
catheter into the bladder to
drain the urine.
Signs and Symptoms
Pain and discomfort in the
lower abdomen
Resources
MedLink (may advise
urinary catheter placement
by medical professional)
Medical kit
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
6
If no medical professional
is immediately available,
restrict the victims uid intake.
7
Call MedLink.
Warning
Never try to insert a
urinary catheter yourself.
Treat urine as potentially
infectious material. Dispose
of gloves and soiled items
in a biohazard bag.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical
condition.
5
Obtain a medical history
(include urinary or pros-
tate problems, infections,
recent surgery).
INITIAL CARE
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Nervous System Disorders
This section addresses the initial assessment and management of disorders affecting the
nervous systemthe brain, spinal cord, and nerves. Nervous system disorders are
potentially serious. To help explain these conditions, the basic anatomy of the nervous
system is described in the following section.
The nervous system consists
of two parts: the central
nervous system (the brain and
spinal cord) and the periph-
eral nervous system (the
nerves in the rest of the body).
The brain receives and inter-
prets information from the
Nervous responses are either
conscious (voluntary), such as
walking, or automatic (invol-
untary), such as breathing;
these responses come from
the autonomic nervous system.
Anatomy of the Nervous System
body, generates thoughts and
emotion, and transmits
responses to the body via the
spinal cord. The nerves of the
peripheral nervous system act
like telephone wires, carrying
messages between the brain
and the other body tissues.
Skull
Vertebrae
Spinal cord
Brain stem
Cerebellum
Cerebrum
Skull
Spinal
cord
Second
lumbar
vertebra
Brain
Dendrites
Nucleus
Cell body
Axon
Schwann
cells
Target cells
Synaptic
terminals
Cell body
Action
potential
(nerve
impulse)
Action
potential
(nerve
impulse)
Functions of the Brain
The brain receives information from the body and produces
responses. The main area (cerebrum) generates voluntary
responses such as walking and thought, and the cerebellum
controls balance and posture. The brain stem governs invol-
untary functions such as breathing and reactions to stress.
Structure of the Nervous System
Nerves branching from the top of the
spinal cord supply the upper body, and
nerves branching from the lower part
supply the lower body. Certain nerves
(cranial nerves) branch from the brain
to supply the eyes, ears, and other
structures of the head and neck.
How Nerves Transmit
Signals
Nerve cells have long bers
leading from them;
bundles of these bers
form nerves. The cells
transmit tiny electrical
signals across gaps, called
synapses, to other cells.
When the signals reach the
tissues, they trigger a
response, such as muscu-
lar contraction.
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Stroke, or cerebral vascular
accident (CVA), occurs when
the blood supply to part of the
brain is disrupted, resulting in
damage to brain tissue. The
damage can lead to paralysis
and impaired speech or death.
A stroke is caused either by a
blood clot blocking an artery
(cerebral thrombosis) or by a
ruptured artery inside the
brain resulting in bleeding in
the brain (cerebral hemor-
rhage). The signs and symp-
toms of a stroke vary
depending on which part of
the brain has been damaged.
Sometimes stroke symptoms
occur but resolve quickly
Signs and Symptoms
Confusion or altered level
of consciousness
Headache; dizziness
Drooping of one side of
the face
Slurred speech; difculty
nding the correct words
Difculty swallowing;
drooling
Slow, erratic, and noisy
breathing
Weakness or paralysis of
one side of the body
See FAST assessment
Stroke (CVA)
without residual symptoms or
damage. This is called a tran-
sient ischemic attack (TIA) or
a mini stroke. These can be
a warning sign of a pending
stroke and should be
evaluated.
Risk Factors
High blood pressure
High cholesterol
Diabetes
Smoking
Hormone therapy/birth
control pills
Previous stroke or TIA
(transient ischemic attack or
mini stroke)
Cerebral Hemorrhage
This type of stroke occurs when an artery
inside the brain ruptures. Blood leaks into the
nearby brain tissue, which compresses the
brain tissue and prevents it from functioning
normally.
Cerebral Thrombosis
This type of stroke occurs when a clot forms or
lodges in an artery, blocking the blood supply. As
a result, the area beyond the clot is deprived of
oxygen and the tissue is damaged or dies.
Bleeding into brain
Ruptured
artery
Normal
artery
Brain
Area of
tissue
deprived
of blood
Brain
Blood clot
in artery
Artery
Blood clot
Fatty
deposit
Blood
flow
Blocked Artery
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Resources
Personal protection
equipment
Blankets and pillows
Medical kits
Wash cloth
Oxygen
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
medical condition, medical
history, current medications,
and allergies.
7
Administer oxygen on a
high setting.
8
Monitor the victim for the
duration of the ight,
watching particularly for any
signs of deterioration.
Warning
Do not give the victim any
medication.
If the victim is unable to
swallow, do not give any-
thing to eat or drink.
If the victim becomes
unconscious, see Life-
saving Procedures.
Seek medical evaluation
upon landing even if symp-
toms resolve.
4
Assess the nature and
severity of the medical con-
dition. Assess for difculty
swallowing or speaking,
altered appearance or behav-
ior, and difculty moving arms
and legs. Use the FAST system
as a guide.
5
Consult MedLink.
6
If the victim is conscious,
help him or her into a
comfortable position with the
head and shoulders raised.
Support weak areas of the vic-
tims body with a blanket and
pillows. Wipe away uids from
the mouth using a cloth.
INITIAL CARE
Stroke (CVA), continued
FAS T
To quickly evaluate a victim of a possible stroke, use the FAST system
as a guide.
F
face: Ask the victim to smile. Do both sides of the face move
equally? Or is there facial droop on one side?
A
arm drift: Have the victim close his or her eyes and hold both
arms straight out in front for 10 seconds. It is abnormal for one
arm to drift down compared to the other.
S
speech: Ask the victim to repeat, You cant teach an old dog
new tricks. If speech is garbled or jumbled or wrong words are
used, it is abnormal.
T
time: The time from the onset of symptoms is important.
Document the time of the onset of symptoms and seek help
immediately.
Reference: National Stroke Association
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Headache
The most common neurologi-
cal condition that people may
experience is a headache. This
condition is not usually
serious. Typical causes include
muscle tension resulting from
neck or shoulder problems,
stress, fatigue, ear or sinus
pain from colds or ear infec-
tions, and dehydration. Serious
causes of headaches are rare.
Conditions that can cause
severe headaches include
infections, such as meningitis;
bleeding inside the brain
(stroke); head injuries; and
brain tumors. Warning signs of
such conditions may include
fever, nausea/vomiting, or per-
sistent headaches.
to a migraine, such as abnor-
mal smells or disturbances in
vision. Factors that can trigger
migraines include certain
foods (e.g., cheese, chocolate),
red wine, stress, and in
women hormonal changes
associated with the menstrual
cycle.
Signs and Symptoms
Headache that follows the
victims typical migraine
pattern
Visual disturbances
Nausea and/or vomiting
Sensitivity to bright light
and loud noise
In some cases, weakness or
abnormal sensations affect-
ing part of the body
Headache and Migraine
Signs and Symptoms
Mild pain that may range
from a dull ache to a sharp
or throbbing sensation
In some cases, pain that
feels like a tight band
around the head
Migraine
The main symptom of a
migraine is a severe, throbbing
headache, usually affecting
one side of the head. The pain
is accompanied by other signs
and symptoms, such as
nausea, vomiting, and sensitiv-
ity to bright light. The condi-
tion recurs at varying intervals.
People who have already had
several attacks may notice
warning signs that occur prior
Resources
Cool, wet washcloth
Eye shades to provide dark
environment
Medical kit
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical con-
dition. If victim has an altered
level of consciousness, it may
be a serious sign. Inquire
about previous headaches,
stroke, fever, neck stiffness, or
confusion.
9
Consult MedLink for advice
on further treatment.
Warning
Seek urgent advice from
MedLink if a victim has the
following symptoms, because
they may indicate a serious
condition:
Recent head injury
Sudden, severe headache
described as the worst
headache of my life
Weakness, numbness, or
abnormal sensations, espe-
cially on one side of the
body
Fever, stiff neck, and sensi-
tivity to bright light
Confusion, difculty
talking and/or walking
Persistent vomiting
5
Obtain a medical history
to include past history of
headaches or migraine. Ask if
this is a typical migraine
pattern. Evaluate for any
symptoms included in the pre-
vious Warning section.
Obtain current medications
and allergies.
6
Advise the victim to rest. If
possible, darken the sur-
rounding area by shutting
window blinds and turning off
reading lights. Offer eye shades
to create a dark environment.
7
Offer a cool, wet cloth for
the forehead.
8
If the victim is carrying his
or her own medications for
migraine treatment, encourage
the victim to take it as
prescribed.
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This disorder is due to abnor-
mal electrical activity in the
brain. Seizures can occur with
a variety of conditions, includ-
ing epilepsy, fever, infection,
hypoglycemia, hypoxia, and
head trauma. People who
have had seizures before (e.g.,
those with epilepsy), often
wear a medical warning brace-
let or pendant. Febrile seizures
are the most common type of
seizures affecting children
between 6 months and 5 years
of age. A seizure usually lasts
no longer than a few minutes.
Afterward, the victim can be
Eyes rolling upward or a
staring gaze
Loss of consciousness; may
collapse suddenly and cry
out
Stiff arms/legs and arched
back, followed by jerky,
uncontrolled movements
Brief cessation of breathing,
resulting in blue lips, ear-
lobes, and nail beds
Possible tongue or lip biting
Loss of bladder or bowel
control
Lethargy and sleepiness fol-
lowing a seizure
Seizures
aroused but may be confused
and sleepy. This is called a
postictal state and is normal
following a seizure.
A series of seizures or a
prolonged seizure that does
not resolve is called status
epilepticus and is a medical
emergency. Call MedLink
immediately for advice.
Signs and Symptoms
Before a seizure, possible
warning signs (aura), such
as abnormal taste, smell,
sound, or sight
Resources
Pillows and blankets
Oxygen
Medical kits
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical
condition.
5
Obtain a medical history
from traveling companions
or bystanders. Include a
history of epilepsy, diabetes,
head injury, drug ingestion,
etc. Look for a warning brace-
let or pendant.
6
Loosen tight clothing. Put
pillows and blankets
around the victim to prevent
injury.
7
Once the seizure is over,
open the victims airway
and check breathing/color. If
the victim is very drowsy, place
in the recovery position and
give oxygen on a high setting.
4
Assess the nature and
severity of the medical con-
dition; include previous history
of seizures, infection, or fever.
5
To cool the child, ask the
parents to take the childs
clothes off, except for the
underpants, but prevent the
child from getting chilled. Put
pillows and rolled blankets
around the child to prevent
injury. Reassure the childs
parents.
6
Once the seizure is over,
record how long it lasted.
Check the childs temperature
with a thermometer.
Warning
If the childs breathing and
color do not return to
normal after a seizure,
treat as if an unconscious
victim.
The child will need further
medical assessment upon
landing, especially if he or
she has no history of con-
vulsions and/or appears ill.
8
Check for signs of injury.
9
Record how long the
seizure lasted. Stay with
the victim until fully recovered.
Observe for more seizures.
10
Consult MedLink for
advice on further
treatment.
Warning
Do not try to restrain the
victim.
Do not put anything in the
victims mouth during a
seizure.
If the seizure lasts longer
than a few minutes,
repeated seizures occur, or
the victim remains uncon-
scious, seek urgent advice
from MedLink.
Febrile Seizures in Children
Resources
Pillows and rolled blankets
Medical kit
Thermometer
MedLink
3
Obtain history of the
medical condition, medical
history, current medications,
and allergies.
INITIAL CARE
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Behavioral and Psychological Disorders
The information in this section addresses behavioral conditions that might pose a
problem during a ight. Irrational behavior or intoxication can develop in passen-
gers who have taken an overdose of drugs or had too much alcohol. Irrational
behavior can also result from mental illness or certain other medical/psychiatric
conditions. Panic attacks and phobias may occur if a passenger nds ying particu-
larly stressful.
When people have panic
attacks, they feel acute physi-
cal stress and anxiety. Such
attacks may be associated with
a condition called generalized
anxiety disorder, in which the
attacks occur for no obvious
reason. Panic attacks may also
occur in people who have a
Sweating
Palpitations (an abnormally
fast or erratic heartbeat)
Trembling
Irrational behavior
Headache or feeling of
pressure in the chest
Panic Attacks and Phobias
phobiaan intense fear of
certain objects, such as
spiders, or particular situa-
tions, such as ying.
Signs and Symptoms
Intense anxiety or fear
Hyperventilation/shortness
of breath
Resources
Oxygen
Medical kits
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical
condition.
victim to maintain a slow
breathing pattern until the
symptoms have resolved.
8
If the victim does not
improve or has recurrent
episodes of panic, call
MedLink.
Warning
When obtaining the victims
medical history, be careful not
to confuse a panic attack with
other conditions that have
similar symptoms, such as
hypoglycemia.
5
Assess the victims behav-
ior and look for signs such
as abnormally fast breathing
or trembling. Ask the victim if
he or she is afraid of ying.
Provide reassurance and ask if
the victim has a history of
panic attacks.
6
To relieve any signs of
hyperventilation, advise the
victim to breathe normally;
suggest that he or she copy
your breathing rate, and
breathe slowly and regularly.
7
If the symptoms of hyper-
ventilation persist, give
oxygen on a high setting, using
an oxygen mask. Advise the
INITIAL CARE
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Passengers who present with
aggressive, hostile, or agitated
behavior pose a threat to ight
safety and other passengers. It
is essential to ensure that the
passenger remains calm and
does not become a threat.
Causes of such behavior may
result from the abuse of pre-
scribed or over-the-counter
medications, panic/anxiety
attacks, use of illegal drugs, or
use of substances such as
household chemicals. It can
also be caused by alcohol
intoxication. Drugs and other
substances may affect users in
different ways, and the effects
may be delayed. Some people
combine alcohol with drugs,
which makes the effects worse.
Other possible causes of
irrational behavior during a
ight include physical changes
resulting from hypoxia or
hypoglycemia.
Signs and Symptoms
Unusual, irrational, or
violent behavior
hypoxia (histotoxic hypoxia).
Excessive amounts of alcohol
may also suppress protective
brain mechanisms, such as the
cough reex, which prevents
uids or other foreign objects
from being inhaled into the
airways or lungs. Take care
not to confuse alcohol intoxi-
cation with hypoxia or hypo-
glycemia, which produce
similar symptoms.
Signs and Symptoms
History of recent or regular
alcohol intake
Change in behavior, often
with aggression or sudden
mood changes
Lack of coordination
Flushed face
Slurred speech
Possible smell of alcohol on
the breath
Possible nausea and
vomiting
Possible loss of
consciousness
Irrational Behavior and Substance Abuse
Increased level of energy,
activity, or agitation
Hallucinations or paranoid
thoughts
Disorientation
Hyperventilation
Blank or wild stare
Shaking and sweating
Nausea and vomiting
Vague complaints
Unusual breath odor
Slow, shallow breathing
Possible blue lips, earlobes,
and nail beds
Needle marks on arms or
legs
Drowsiness or loss of
consciousness
Alcohol Intoxication
When people drink excessive
amounts of alcohol, they
become intoxicated. Alcohol
causes the brain to function
less efciently, leading to
changes in behavior, lack of
coordination, and possibly
unconsciousness. Alcohol also
disrupts the bodys ability to
use oxygen and can cause
Resources
Personal protection
equipment
Medical kits
MedLink
Oxygen
Biohazard bag
Sharps container
Restraints (if victim
becomes a threat to ight
safety, self, or others)
1
Ensure that the victim does
not pose a hazard to you,
other crew members, passen-
gers, or the aircraft. Reassure
the victim.
2
If victim becomes a threat
to ight safety, consider
using restraints to secure the
victim to prevent injury to self
and others.
3
Assess the victims behav-
ior and check for signs of
other medical conditions. Ask
the victim if he or she has
Warning
Medical conditions such as
hypoxia or hypoglycemia
(low blood sugar) are
often mistaken for sub-
stance abuse or mental
illness. Always consider the
medical conditions as a
possibility and treat
accordingly (see Hypogly-
cemia [low blood sugar]).
Never induce vomiting
unless directed to do so by
MedLink.
Avoid confrontation, which
may provoke the victim and
result in injury to others or
compromise ight safety.
If the victim becomes
unconscious, see Life-
saving Procedures.
Always keep ight safety
the rst priority and
restrain the victim if neces-
sary. Follow your company
policy.
recently taken medication or
any other drugs or alcohol.
Inquire if there is a history of
diabetes.
4
If possible, inquire if the
victim is carrying items
such as medication bottles or
syringes.
5
If the victim shows signs of
hypoxia or difculty
breathing, administer oxygen
on a high setting.
6
Consider all body uids to
be potentially infectious;
use personal protection equip-
ment. Save any vomit and drug
containers. When handling
these items, take precautions
to avoid injury or contamina-
tion. Treat vomit as potentially
infectious material, and
dispose of it in a biohazard
bag. Place used needles and
syringes in a sharps container.
INITIAL CARE
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Other Medical Disorders
This section addresses the initial care for several common medical disorders. Some of
these conditions, such eye irritation and nosebleeds, are often relatively minor and can
be easily treated. Other conditions, such as anaphylaxis and diabetes, are potentially
life-threatening and require immediate medical attention.
Diabetes occurs when the
body is unable to produce or
utilize insulin, which is essen-
tial to transport glucose to all
body cells. All body cells need
glucose to produce energy
and perform normal body
functions. Normally, the level
of glucose in the blood (blood
sugar) is controlled by a
hormone called insulin, which
warning bracelet or pendant.
People who are taking medi-
cation for diabetes may have
episodes of hypoglycemia
(low blood sugar) or hypergly-
cemia (high blood sugar). It is
often difcult to keep the
blood sugar at a normal level,
especially during travel, stress,
or illness.
Diabetes
is produced in the pancreas.
People with diabetes cannot
produce enough insulin or are
unable to use it appropriately.
This results in an elevation of
the blood sugar. People with
diabetes follow a special diet
and may also carry tablets or
insulin injections to control
their blood sugar levels. They
may also wear a medical
An abnormally high blood
sugar level is known as
hyperglycemia. This condition
is most likely to develop in a
person with diabetes who has
not taken his or her medica-
tion or who has not followed
a diabetic diet. It can be dif-
cult to distinguish between
hyperglycemia and hypogly-
cemia. Hyperglycemia devel-
ops more slowly than
hypoglycemia, but if left
untreated, the victim can
become seriously ill.
Signs and Symptoms
Extreme thirst
Frequent urination
Dry, ushed skin
Deep breathing
Sweet, fruity smell on
breath
In severe cases, loss of
consciousness
Hyperglycemia (High Blood Sugar)
Resources
Water and sugar-free
drinks
MedLink
Medical kit
1
Assess scene safety and
the victims responsive-
ness, airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical
condition. If the victim is dia-
betic, check when he or she
last took medication and
last ate.
5
Call MedLink.
6
If the victim has checked
his or her blood sugar
level with a glucometer and
nds that it is high, give plenty
of water and sugar-free drinks.
Monitor the victims condi-
tion. If the victim is confused
or cannot check his or her
sugar level, treat as if
hypoglycemia.
Warning
Crew must never give
insulin injection to a
victim.
If in doubt whether the
condition is hypoglycemia
or hyperglycemia, always
give sugar.
INITIAL CARE
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This condition occurs when
the blood sugar level falls
below normal; it can be life-
threatening if left untreated. If
it is not treated quickly, the
victim will become uncon-
scious. Hypoglycemia is most
common in people with
insulin-dependent diabetes.
Low blood sugar often devel-
ops if they have had an insulin
Pale, sweaty skin
Weakness, fatigue, and
slurred speech
Hunger, trembling, and
rapid pulse
Confused, vague, or aggres-
sive state/change in
behavior
Possible loss of
consciousness
Warning bracelet or pendant
Hypoglycemia (Low Blood Sugar)
injection or taken their oral
medication but have not
eaten. Most people with dia-
betes carry food, such as hard
candy or sugar, to relieve
symptoms of hypoglycemia.
Signs and Symptoms
Recognition by the victim
that he or she is developing
hypoglycemia
Resources
Personal protection
equipment
Sweet drink with two sugar
packets
Glucose gel
Light meal or snack
Oxygen
Medical kit
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical con-
dition (include history of dia-
betes, medications, and
allergies).
5
Assess the victim for symp-
toms such as sweating,
trembling, and confusion.
6
Offer the victim a sweet
drink, a soft drink, or
orange juice with two packets
of sugar. Do not offer a diet
drink because it does not
contain sugar.
7
Once the victim has n-
ished the drink, evaluate
for improvement.
11
Call MedLink.
Warning
Hypoglycemia can easily be
mistaken for alcohol intoxica-
tion or belligerent behavior.
Hypoglycemia is a life-threat-
ening condition and should be
treated immediately.
8
If the victim recovers, offer
a light meal or snack.
9
If the victim is breathing,
place in the recovery posi-
tion. Squeeze glucose gel
under his or her tongue, and
keep the airway clear. Adminis-
ter oxygen on a high setting.
10
Monitor the victim for
response.
INITIAL CARE
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This condition is a life-threat-
ening allergic reaction (ana-
phylactic shock). The most
common triggers include nuts
(especially peanuts), insect
stings, seafood, and certain
medications. The airways in
the lungs rapidly swell and
constrict, interfering with
breathing. The blood vessels
throughout the body dilate,
leading to allergic shock.
Victims who have severe aller-
Difculty breathing and
talking
Wheezing
In some cases, loss of
consciousness
Known history of
anaphylaxis
Victim may be carrying an
epinephrine auto-injector
(EpiPen)
Anaphylaxis
gic reactions need an immedi-
ate injection of epinephrine.
People who know they are at
risk may carry their own
supplies.
Signs and Symptoms
Anxious, agitated state
Swollen lips, tongue, face,
and eyes
Blotchy, possibly itchy rash
on face and body
Nausea and vomiting
Resources
Medical kit
AED
Personal protection
equipment
Sharps container
Oxygen
MedLink (may advise
EpiPen/Twinject
auto-injector)
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical con-
dition (include allergies and
previous episodes of
anaphylaxis).
5
If there is a history of ana-
phylaxis and the victim has
used an epinephrine auto-
injector before, advise him or
her to use it. Place the used
injector in a sharps container.
6
If the victim does not have
his or her own medication,
offer the EpiPen/Twinject from
the aircrafts medical kit.
Dispose of used auto-injector
in the sharps container.
Give the EpiPen/Twinject
only under the direction of
MedLink unless the victim
has previously been pre-
scribed an epinephrine
auto-injector.
Never use an adult EpiPen
on children who weigh
less than 66 lb (30 kg)
or to children younger
than 6 years of age. Pedi-
atric EpiPens are available
at smaller doses; seek
advice from the MedLink
physician.
7
If there is no history of
anaphylaxis and the victim
has no EpiPen, call MedLink.
8
Give oxygen on a high
setting. Make the victim
comfortable and monitor for
worsening of symptoms.
9
Call MedLink.
Warning
If the victim becomes
unconscious, see Life-
saving Procedures.
INITIAL CARE
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An allergy is an abnormal sen-
sitivity to a particular sub-
stance, such as dust, pollen,
animal fur, or certain foods or
medications. The signs and
symptoms of an allergy vary
depending on the type of
reaction; common complaints
include coughing, wheezing,
itchy eyes, runny nose, sneez-
ing, rashes, and asthma.
Signs and Symptoms
Shortness of breath/
wheezing
Raised, pale or red areas of
skin (wheals or hives) or
a rash
Runny, itchy nose, and
sneezing
Itchy, red, watery eyes
Victim may be carrying anti-
allergy medication
Allergy
Many people with a known
allergy carry medication to
take when symptoms develop.
Most allergies are mild, but
some people can develop life-
threatening reactions, such as
severe breathing difculties
and allergic shock, such as
anaphylaxis.
Resources
Medical kits Oxygen
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
7
Consult MedLink for
advice on further
treatment.
8
Monitor the victim for signs
of anaphylaxis.
Warning
If the symptoms of an allergic
reaction persist or recur
during the ight, consult
MedLink.
medical history, current medi-
cations, and allergies.
4
Assess the nature and sever-
ity of the medical condition.
5
Assess the victims symp-
toms. In particular, ask if
he or she is allergic to any spe-
cic substance.
6
Ask if the victim has taken
any anti-allergy medication
and the time of the last dose.
INITIAL CARE
What You Need
Epinephrine auto-injector
(EpiPen)
Sharps container
Medical kits
Personal protection
equipment
1
Unpack the EpiPen and
remove the gray safety cap.
Grasp the EpiPen around the
middle, keeping your ngers
and thumb away from the
ends. Place the black tip on
the victims outer thigh at a
Warning
Never use an adult EpiPen
on children who weigh less
than 66 lb (30 kg) or chil-
dren younger than 6 years
of age.
Pediatric EpiPens are avail-
able; seek advice from
MedLink.
Note: Refer to the manufac-
turers instructions for the
Twinject. This auto-injector
requires additional steps to
administer a second dose.
right angle. The EpiPen can be
injected through normal cloth-
ing as well as bare skin.
2
Press the injector rmly
against the
victims outer thigh until the
mechanism clicks.
3
Hold the EpiPen in place for
10 seconds. Massage the
injection site for 10 seconds.
4
Dispose of the EpiPen in
the sharps container.
HOW TO USE AN EPINEPHRINE AUTO-INJECTOR (EpiPen)
Single Dose
The EpiPen contains epinephrine (adrenalin) for injection. It is used to treat anaphylaxis or a severe
allergic reaction. There are different doses for adults and children. The EpiPen/Twinject should be
used only under the direction of MedLink. Some EpiPens contain just one dose, whereas another
brand (Twinject) contains two doses of epinephrine. Directions are on the EpiPen/Twinject; refer to
the specic guidelines for each manufacturer.
Anaphylaxis, continued
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Bleeding from the nose usually
occurs when blood vessels in
the nose or sinuses become
dry or irritated. The most
common cause is an infection,
such as a cold or sinusitis.
Nosebleeds can also result
from injuries. In rare cases,
Signs and Symptoms
Bright red blood running
from the nose
Blood going down the back
of the throat
Nosebleed
they may be associated with
high blood pressure, head inju-
ries, or blood-thinning medica-
tions. They are not usually
serious; however, severe or
prolonged bleeding can lead to
signicant blood loss and pos-
sibly hypovolemic shock.
This condition usually results
from an environmental irritant
such as dust, an infection in
one or both eyes (conjunctivi-
tis), or an allergic reaction.
Such problems may be more
common in people who wear
contact lenses. Conjunctivitis is
Signs and Symptoms
Red or bloodshot eye
Sticky discharge or watering
eye
Itchy, gritty, painful feeling
Excessive blinking
Difculty focusing
Eye Irritation
contagious, so victims with
this condition should wash
their hands after touching their
eyes and should avoid sharing
items such as washcloths and
towels to prevent spreading
the infection to other people.
Resources
Medical kit
Personal protection equipment
Eyewash
Biohazard bag
MedLink
1
Assess scene safety and the victims respon-
siveness, airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the current medical
problem, medical history, current medica-
tions, and allergies.
4
Assess the nature and severity of the medical
condition.
5
Assess the eyes. If the victim has contact
lenses, ask him or her to remove them.
6
If the discomfort is due to an environmental
irritant, ush the eye with eyewash or
running water. If the symptoms persist after the
eyewash has been applied, consult MedLink for
advice on further treatment. Advise the victim to
seek medical advice upon landing.
Warning
Advise the victim not to rub the eyes.
Do not allow eyewash from the affected eye
to contaminate the other eye.
Advise victims with eye infections to wash
their hands after touching their eyes to
avoid spreading the infection.
Treat eye uid as potentially infectious
material; use gloves when caring for the
victim.
INITIAL CARE
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Resources
Medical kit
Personal protection
equipment
Plastic cup to collect blood
Tissues and washcloth
Biohazard bag
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
the mouth/throat but to spit it
out in the cup.
7
If the victims nose is still
bleeding after 10 minutes,
tell him or her to pinch it for
another 10 minutes and call
MedLink.
8
Monitor the victim, watch-
ing particularly for signs of
shock.
9
Once the bleeding has
stopped, advise the victim
to avoid blowing the nose
because this may cause the
bleeding to start again.
Warning
Do not insert anything into
the nose.
Treat blood as potentially
infectious material.
Ice packs do not help to
control nosebleeds.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical con-
dition. Evaluate for signs of
trauma.
5
Assess the severity of the
bleeding. Check for any
other nose or head problems,
such as a recent cold, sinus
infection, or injury.
6
Ask the victim to lean
forward, breathe through
the mouth, and pinch the
soft part of the nose for
10 minutes. Provide a cup to
collect blood from the nose or
mouth. Tell the victim not to
swallow blood in the back of
INITIAL CARE
Sickle cell anemia is an inher-
ited disorder that usually affects
people whose families or
ancestors are from Africa or the
Caribbean. The sickle-shaped
red blood cells carry normal
amounts of hemoglobin, but
the shape of the cells can cause
problems. During a sickle cell
crisis, the red blood cells
become sickle-shaped and
clump together, resulting in the
Signs and Symptoms
History of sickle cell disease
Pain, which gradually
worsens and may become
severe; joint, back, feet/
hands, and abdominal pain
Signs of hypoxia
In a few cases, shortness of
breath/painful breathing
Symptoms of stroke or heart
attack
Possible seizures in children
Sickle Cell Anemia
blockage of small blood
vessels. This blockage reduces
circulation and deprives body
tissues of oxygen and nutrients.
A crisis may be triggered by
infection, dehydration, hypoxia,
or exposure to cold, but in
most cases, there is no obvious
trigger factor. There is also a
decreased number of hemoglo-
bin molecules in this condition,
which results in anemia.
Resources
Medical kit
Oxygen
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
6
Give oxygen on a high
setting.
7
Consult MedLink
8
Help the victim settle into
a comfortable position and
advise him or her to rest.
3
Obtain history of the
medical condition, medical
history, current medications,
and allergies.
4
Assess the nature and
severity of the medical con-
dition (include history of sickle
cell disease).
5
Assess the victim for pain
and signs of hypoxia.
INITIAL CARE
Nosebleed, continued
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During ascent or descent, air
pressure in the ears and
sinuses changes, which can
cause discomfort. Usually,
symptoms can be eased by
swallowing. Pain may occur if
a person has a cold or an ear
or sinus infection because the
sinuses or the eustachian
tubes inside the ears can
become blocked. It is also
Pain behind the eyes and
spreading down face
Cracking and popping sen-
sation in the ears or sinuses
Possible crying in infants
and children
Rupture of the eardrum,
which can cause a sharp
pain or relief of pain; possi-
ble bleeding from the ear
Ear and Sinus Pain
more likely to occur in chil-
dren because their air pas-
sages are smaller and easily
blocked. Symptoms are
usually more pronounced
during descent.
Signs and Symptoms
Mild to severe pain in the
affected ear or sinus
Eardrum pushed outward
Eardrum on ascent
Eardrum pushed inward
Eardrum on descent
Resources
Medical kit
MedLink
1
Assess scene safety and the victims respon-
siveness, airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the current medical
problem, medical history, current medica-
tions, and allergies.
4
Assess the nature and severity of the medical
condition.
5
Consult MedLink for advice on treatment for
the pain and other symptoms.
6
To relieve painful ears in an infant, advise
the parent to feed the baby or offer him or
her a pacier. These actions should invoke a
swallowing reex and help unblock
the ears.
7
Advise children or adults to clear their ears
by yawning, swallowing, or using the Val-
salva technique. To aid swallowing, advise the
victim to suck candy or chew gum during
descent.
8
If you suspect that the victim has a ruptured
eardrum, advise him or her to seek medical
advice upon landing.
Warning
Do not try to unblock the ears by putting
anything in, on, or over them.
If the victim is scheduled to y again in the
next few days, advise him or her to seek
medical advice rst.
Crew should not y if they have colds, sinus
infections, or untreated seasonal allergies.
INITIAL CARE
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During scuba diving, the body
is exposed to increased atmo-
spheric pressures, which cause
nitrogen to dissolve in body
tissues. When scuba divers
ascend to sea level, they must
do so at a controlled rate so
that their bodies will safely
and slowly reabsorb the nitro-
gen. If a diver ascends to sea
level too rapidly, there is
insufcient time for the body
to reabsorb the nitrogen and
decompression sickness (DCS)
can occur. The amount of time
spent diving, the number of
dives, and the depth of diving
determine the risk for DCS. It
is recommended that divers
remain at sea level for a
minimum of 24 hours prior to
ying to allow the nitrogen to
be expelled from the body. If
a diver travels by air before all
Decompression Sickness
of the excess nitrogen has
been reabsorbed, the nitrogen
gas can form bubbles in body
tissues or blood vessels,
causing symptoms in various
body systems (e.g., joints,
brain, skin, lungs). DCS can
also occur in individuals
during a cabin decompression
in a pressurized aircraft.
Signs and Symptoms
Deep aching pain in the
joints
Shortness of breath/dif-
culty breathing
Chest pain
Headache
Skin rash/itching
Vision loss or double vision
Nausea/vomiting
Extreme fatigue/dizziness
Possible loss of conscious-
ness/seizures
Resources
Medical kit
Oxygen
MedLink (may advise pain
medications, anti nausea
medication, decompression
center)
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
current medical problem,
medical history, current medi-
cations, and allergies.
4
Assess the nature and
severity of the medical
condition.
9
Call MedLink for further
treatment. Decompression
in a hypobaric chamber may
be needed urgently.
Warning
If the victim becomes
unconscious, see Life-
saving Procedures.
Divers should allow at
least 12 hours before ying
for a single dive requiring
no decompression stop
and at least 24 hours for
multiple dives or dives that
require decompression
stops.
5
Inquire if the victim has
been scuba diving and
when the last dive occurred, as
well as the depth of the dive.
6
Assess the symptoms. If the
victim has been diving, ask
the pilot if it is possible to
increase the cabin pressure,
thereby reducing cabin altitude
to as near sea level as possible.
7
Lay the victim at. Give
oxygen on a high setting.
8
If joint pain occurs, advise
the victim to keep the
affected area still or splint it to
avoid movement.
INITIAL CARE
Normal
pressure
Pressure
released
Drop in
pressure
releases
dissolved
gases
Gas
molecules
dissolved in
liquid
Henrys Law
Henrys Law explains how nitrogen
remains dissolved in tissues at sea
level. When atmospheric condi-
tions change (e.g., during cabin
decompression) nitrogen is
released in body tissues and can
cause DCS.
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Pregnancy and Childbirth
Pregnancy usually lasts for approximately 40 weeks. Pregnant women are normally
advised not to y after the 36th

week, and after 28 weeks, they should have a letter from
their doctor stating they are t to travel. However, a woman may go into labor any time
during her pregnancy. This section addresses the management of labor and delivery.
The process of giving birth is
known as labor. There are
three stages. In the rst stage,
the womans body prepares to
give birth. In the second stage,
takes several hours and is
likely to last longer for a
woman who is giving birth for
the rst time.
The Stages of Labor
the infant is born. In the third
stage, the placenta (afterbirth)
is expelled from the uterus.
The entire process generally
Placenta
Cervix
Vagina
Amniotic
sac
Placenta
Uterus
Placenta
Umbilical cord
Fetus
Fetus
Uterus
Cervix
Cervix
Vagina
Head-down Breech
First Stage of Labor
The uterus begins contractions. The neck of the
uterus (cervix) starts to open (dilate). Toward the
end of this stage, the bag of waters around the
infant breaks.
Second Stage of Labor
This stage begins only when the cervix has fully
dilated. The contractions of the uterus push the
infant down the vagina. In most cases, the infant is
born head rst.
Third Stage of Labor
After the infant has been born, the contractions of
the uterus continue. The placenta detaches itself
from the wall of the uterus and is expelled through
the vagina.
Fetal Positioning for Birth
Head-down and breech positions
Before most births, the unborn infant (fetus) turns
upside down so that the head will emerge rst, but
occasionally a fetus lies in a different position. In a
breech birth, the infant is born with the bottom or
feet rst. Apart from the position, this is similar to
normal birth (see following discussion).
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During the rst stage of labor,
the uterus begins strong mus-
cular contractions and the
neck of the uterus (cervix)
gradually thins and dilates so
that the fetus can pass
through. This stage ends when
the cervix is fully dilated. It
may last 12 to 18 hours for a
rst birth but is usually shorter
for subsequent births. The
initial signs of labor may
Discharge of mucus, which
may be streaked with blood
from the vagina (bloody
show or mucous plug)
Discharge of clear or blood-
stained liquid (bag of
waters) from the vagina
Contractions that become
regular, stronger, and more
frequent until they are 1 to
2 minutes apart
First Stage: Dilation of the Cervix
appear in any order or may
not be noticeable at all.
Signs and Symptoms
Low abdominal cramping
that is intermittent and
occurs at regular intervals
with increasing intensity
and frequency
Low backache in some
women
Resources
Medical kit
Personal protection
equipment
Oxygen
Blankets, pillows, and
newspapers
MedLink
1
Assess scene safety. Assess
mother for responsiveness,
airway, and breathing.
2
Obtain medical history
number of pregnancies,
last menstrual period, and due
date for this pregnancy or the
number of weeks she is preg-
nant. Find out if the mother
has any medical problems,
including any complications
with this pregnancy, such as
high blood pressure, diabetes,
or bleeding disorders; obtain
current medications and
allergies.
7
Coach breathing. Encour-
age her to breathe with the
contractions and to pant if she
has the urge to push.
8
If the sac of uid around
the fetus (bag of waters)
has broken, advise the woman
not to walk around because
the umbilical cord (which con-
nects the fetus to the placenta)
could drop down (prolapse).
This can lead to constriction of
the umbilical cord and hypoxia
in the fetus.
Warning
Observe for complications
such as severe, sudden bleed-
ing, the appearance of fetal
feet, or a prolapsed cord
seen in the vagina. These are
all emergenciescontact
MedLink.
3
Call MedLink.
4
If possible, move the
woman to a private space,
such as a galley area, with room
to deliver the baby. Reassure
and stay with her, because she
could give birth very quickly.
5
Use newspapers and blan-
kets to insulate the woman
from the oor and soak up
body uids. Use pillows for
support. Place her in a com-
fortable position. When check-
ing the progress of labor, lay
the woman down, with her
knees bent and apart so that
you have access to the vagina.
Evaluate for bulging of the
vaginal area or crowning (visu-
alization of the fetus head).
6
Time how frequently the
contractions are occurring
and record it.
INITIAL CARE
Placenta
Cervix
Vagina
Amniotic
sac
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Resources
Medical kit
Personal protection
equipment
Biohazard bag
Oxygen
Cord clamps or string to tie
the umbilical cord
Warmed blanket for the
infant
1
Reassure the woman. Con-
tinue to coach breathing.
2
Place a wound dressing on
the womans anal area to
prevent the vaginal opening
from being contaminated with
feces. Treat body uids or
feces as potentially infectious
material. Wear disposable
gloves at all times.
6
Proceed with care of the
infant.
7
Clamp and cut the umbili-
cal cord (see next section).
Warning
Do not tell the mother to
push.
If the infants bottom or
feet appear rst (breech
birth), wrap the body in a
blanket to keep it warm as
the head is delivered. Let
the infant hang at the birth
canal to enable the head to
come. Support the body
with your hands, but do
not pull the infant.
3
Support the infants head
as it emerges. Encourage
the mother to blow out gently
or pant and to avoid pushing
while the head is delivered.
4
Continue to support the
head as the body is born.
The infant will be very slippery
take precautions to avoid drop-
ping the infant. Use a blanket
to catch the infant when born.
DO NOT PULL THE INFANT,
simply support the head while
the shoulders and body are
delivered.
5
Note the time of birth.
INITIAL CARE
This stage of labor begins
when the cervix is fully open
and the infants head enters
the mothers vagina, and it
ends when the infant is deliv-
ered. It may last from a few
minutes to an hour. Normally,
the infants head appears rst,
but occasionally another part
of the body may emerge rst
(see previous section).
Bulging at vaginal opening
as infants head passes
down the vagina
Emergence of infants head,
usually face down; head
will turn to one side to
allow the rest of the body to
be delivered
Second Stage: Birth of the Infant
Signs and Symptoms
Sudden urge to bear down
as if to have a bowel move-
ment (occurs as the infants
head presses on the rectum)
Broken bag of waters (if not
already broken, it will
usually do so at this time)
Strong desire to push
Placenta
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Resources
Medical kits
Personal protection
equipment
Umbilical cord clamps or
string
Scissors
Biohazard bag
Cloth, warm water, and
sanitary wear for mother
MedLink
1
As soon as the infant has
been delivered, clamp and
cut the umbilical cord. Attach
the rst clamp about 3 inches
(7 cm) away from the infants
abdomen and the second
clamp 2 inches (5 cm) farther
away. Check that both of the
clamps are tightly secured. Use
clean scissors, and cut the
cord between the two clamps.
5
Call MedLink.
Warning
Never pull on the cord,
because this may tear it
and cause severe bleeding.
If the mother is bleeding
heavily, see next section.
2
Let the mother bear down
gently when she feels the
need to aid the delivery of the
placenta. Catch the placenta
in your gloved hands.
3
Place the placenta in a bio-
hazard bag to be taken to
the hospital with the mother
and infant upon landing. Label
the bag with the mothers
name.
4
Offer the mother warm
water to clean herself.
Some bleeding,
similar to a heavy
period, is normal,
but observe for
excessive blood
loss, which can
lead to hypovole-
mic shock.
INITIAL CARE
Cut between
clamps
Umbilical
cord
Scissors
Clamp
The nal stage of labor begins
after the infant has been born.
During this time, the placenta
detaches from the wall of the
uterus. This stage ends after the
placenta (afterbirth) has been
expelled from the uterus. It
may last up to 1 hour.
Third Stage: Delivery of the Placenta
Signs and Symptoms
Contractions (mother may
feel labor-type pains and
have an urge to bear down)
In some cases, lengthening
of the umbilical cord
Discharge of blood from
the vagina as the placenta
detaches from the uterine
wall
Uterus
Placenta
Umbilical cord
1
Check the infants responsiveness, airway,
and breathing. An infant may take up to
1 minute to start breathing properly. The skin
will look blue, but it will turn pink once breath-
ing begins. If the skin remains blue, administer
oxygen until the infants color and breathing are
normal.
2
Gently wipe the infants mouth and nose
with a clean gauze square to help clear the
airway of mucus and liquid.
3
Dry the infant. Wrap in a warmed blanket,
with the head and body covered. Give the
infant to the mother. Advise her to place the
infant against her bare abdomen, and cover
both the mother and the infant with another
blanket (newborns lose body heat very quickly).
4
Encourage the mother to breast-feed early
and as often as the infant wants.
Warning
Hold the infant carefully because he or she
will be slippery.
Do not use any suction on the infant,
including the manual
suction device, because
it can damage the
mucous membranes.
If the infant is still
not breathing after
1 minute, see Complica-
tions of pregnancy and
childbirth.
CARING FOR A NEWBORN INFANT
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COMPLICATIONS OF PREGNANCY AND CHILDBIRTH
Occasionally, complications can arise during pregnancy or birth. In these situations, you will need urgent
advice from MedLink. The following panel lists possible complications and includes initial care.
Complication Description Action
Miscarriage This is the loss of the developing
fetus and the placenta, usually
before the 24th week of preg-
nancy. Miscarriage causes vaginal
bleeding and cramps. It is the
most common cause of bleeding
in early pregnancy. Some women
may bleed but not lose the fetus.
Assess the pain and bleeding; use the questions on
abdominal pain assessment as a guide. Ask the woman if
she is pregnant or has had a missed or late period.
Advise the woman to rest and reassure her. Give clear
liquids but nothing to eat.
Assess for blood loss; if the bleeding is very heavy, treat
for hypovolemic shock.
If tissue is expelled, save it in a biohazard bag to trans-
port to the hospital.
If the infant shows signs of life, keep him or her warm,
give oxygen, and be prepared to resuscitate (see Life-
saving Procedures).
Call MedLink.
Prolapsed
umbilical
cord
In this condition, the umbilical
cord slips down when the bag of
waters breaks and may hang out
of the mothers vagina. The cord
can be crushed between the
mothers pelvis and the body of
the fetus, cutting off the circula-
tion to the fetus. There is a greater
risk of a prolapse if the mother
has been standing or walking after
the bag of waters has broken.
Lay the mother down. Raise her hips and support them
with pillows or folded blankets; this will help move the
fetus off her pelvis and relieve the compression on the
umbilical cord. Alternatively, help the mother to turn
over and bring her knees up to her chest in the so-called
knee-chest position.
Lay clean gauze or cloths dampened with clean, luke-
warm water on the cord to keep it moist.
Seek urgent advice from MedLink.
Twin
delivery
About 1 in 80 pregnancies results
in twins. The mother may or may
not know that she is pregnant
with twins.
Deliver each infant in the same way as for a single birth.
Clamp the cord of the rst-born twin immediately after
delivery to prevent the risk of blood passing from one
twin to the other. Seek advice from MedLink.
Baby not
breathing
Usually, infants start to breathe
within 1 minute after birth. If
there are no signs of breathing
and the infant remains blue, see
Life-saving Procedures.
Assess the infants responsiveness, airway, and
breathing.
Check that the infants mouth and nose are clear of secre-
tions. Use a clean gauze to clear the airway.
Stimulate the infant by gently rubbing the infants toes
and feet. Gently rub the torso with the blanket as if
drying off the infant to encourage breathing to start.
Administer oxygen by mask placed near the infants
face.
If the infant is still not breathing, moving, or respond-
ing, see Life-saving Procedures.
Call MedLink.
Excessive
blood loss
Once the placenta has been deliv-
ered, some bleeding, like a heavy
period, is normal. The contrac-
tions of the uterus should stop or
slow this bleeding. Occasionally,
however, the uterus does not con-
tract properly, and as a result, the
bleeding is excessive. You need to
take action if the blood ow is
heavy enough to soak through a
sanitary napkin in less than 10
minutes.
Advise the mother to breast-feed if she is not already
doing so; this will help the uterus contract and control
the bleeding.
Keep the mother warm and reassure her. Give clear
uids but nothing to eat.
If excessive bleeding continues, massage the uterus to
help it contract. Place the side of your hand on the
mothers abdomen, just below the umbilicus, and push
gently until resistance is felt. Cup your hand and massage
the abdomen in slow, rm, circular motions until the
uterus starts to rise and feels rm. As you massage, the
uterus should decrease in size and the bleeding should
lessen.
If the bleeding persists, keep massaging the uterus.
Monitor the mother for hypovolemic shock.
Call MedLink.
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Traumatic
Emergencies
Injuries can occur anytime before,
during, or after ight as a result of
turbulence, accidents, or other
unforeseen events. This chapter
addresses common injuries that
require rst aid treatment. The sub-
jects covered include bleeding,
chest and abdominal injuries, inju-
ries to the bones and joints, burns,
injuries related to heat/cold expo-
sure, and eye injuries.
Wounds 128
Preventing Cross-Infection 129
Small Cuts and Abrasions 130
Severe Bleeding 131
Amputation 133
Chest Injuries 134
Abdominal Injuries 136
Bone, Joint, and Muscle
Injuries 137
Anatomy of the Musculoskeletal
System 137
Fractures 138
Strains and Sprains 139
Leg, Knee, or Foot Injuries 140
Arm, Wrist, or Hand Injuries 141
Head Injuries 142
Neck and Back Injuries 143
Environmental Injuries 144
Assessing the Extent of Burns 144
Burn or Scald 145
Smoke Inhalation 146
Electrical Injuries 146
Hypothermia 147
Frostbite 147
Heat Illness 148
Eye Injuries 149
Foreign Object in the Eye 149
Chemical Splash to the Eye 150
Direct Injury to the Eye 150
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Wounds
A wound is an injury that damages the skin and may extend deeper to include internal
body structures. Bleeding usually occurs from ruptured blood vessels and may result in
a bruise or hematoma (collection of blood under the skin). There may be damage to
bones, organs, and other underlying tissues. This section reviews general principles of
rst aid for wounds and bleeding. All wounds should be considered contaminated and
may be at risk for tetanus.
There are many types of wounds, but most wounds are classied as either open or closed. Con-
tusions (bruises) are closed wounds, in which bleeding is trapped in the tissues around the injured
area. The other types are open wounds, in which the skin is broken, thereby increasing the chance for
infection or foreign particles being imbedded in the wound (e.g., dirt, glass). Wounds can cause
blood loss, which may be external or internal and may result in hypovolemic shock if severe.
TYPES OF WOUNDS
Contusion (Bruise)
An impact from a hard object or
a fall can cause a contusion or
bruise. The injured tissues are
swollen and tender. Blood from
ruptured blood vessels may leak
under the skin, causing a bruise
or hematoma.
Abrasion
An abrasion occurs when the top
layer of skin is scraped off,
exposing the highly sensitive
areas underneath. Abrasions are
often contaminated with parti-
cles such as dirt. Road-rash is
an example of an abrasion.
Laceration
A laceration includes both clean
cuts and jagged tears in the skin.
In large or deep lacerations, the
damaged area may include
underlying structures such as
tendons, nerves, or muscles.
Puncture
A puncture wound is caused by a narrow, pointed
object, such as a knife or a needle. The entry wound
can appear minor, but the puncture may be very
deep. This type of wound has a very high risk of
infection because dirt and clothing may have been
embedded in the tissues at the time the puncture
wound occurred. Puncture wounds can be very
serious.
Missile Injury
Missile injuries are usually caused by rearms/blast
injuries and can cause severe trauma. Gunshot
wounds usually have an entry wound and possibly
an exit wound, which will be larger and more
serious. Blast injuries cause severe trauma, and
shrapnel can be embedded in the body. Damage to
internal organs is common in both types of injuries.
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TYPES OF WOUNDS
Abscesses
An abscess is a collection of pus under the skin.
These commonly occur and often require antibiot-
ics or incision and drainage by medical personnel.
Abscesses are usually caused by a Staphylococcus
infection. Recently, an increasing number of infec-
tions from a drug-resistant form of Staphylococcus
has been seen outside of hospitals. This infection is
called methacillin-resistant Staphylococcus aureus or
MRSA. Because it is very resistant to common anti-
biotics, only a few antibiotics are effective in treat-
ing infection.
Bites
Bacteria can enter wounds created by a human or
animal bite and cause infection. These wounds may
appear insignicant initially but often become
infected days later. Risk for rabies must also be con-
sidered in animal bites.
Personal protection and preparation to assist a victim with wound care begins with planning by the
rescuer. Cleanliness is a vital consideration when treating wounds. By taking simple preventive
measures, rescuers can protect themselves from the risk of infection as well as minimize the risk of
wound infection for the victim.
Preventing Cross-Infection
Wounds, continued
Resources
Soap and water
Medical kit
Disposable gloves
Adhesive bandages or wound dressing
Biohazard bag
MedLink
1
Wash the backs and fronts of your hands
using soap, water, and friction. Wash
your hands for a minimum of 30 seconds.
2
Rinse your hands and dry them thoroughly
on a disposable towel.
3
Put on disposable
gloves before
touching the wound.
Warning
Treat blood and all
body uids as poten-
tially infectious mate-
rial. Dispose of gloves
and soiled items in a
biohazard bag.
Always wash your
hands after glove
removal and disposal.
INITIAL CARE
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Small open wounds, such as
cuts and abrasions, usually
stop bleeding by themselves
or with direct pressure applied
to the wound. The wound still
needs to be cleaned and
dressed to enhance wound
Signs and Symptoms
Laceration or abrasion
Blood oozing or trickling
from the wound
Dirt or other particles in the
wound
Small Cuts and Abrasions
healing and prevent infection.
The most important part in
caring for a wound is cleaning
the wound and removing any
foreign material that may
cause infection.
Resources
Medical kit
Disposable gloves
Bottle of water/running
water
Gauze pads
Adhesive bandages or
wound dressing, tape
Biohazard bag
1
After washing your hands,
put on gloves. Rinse the
wound thoroughly with several
bottles of water or place the
wound under running water in
order to ush out any dirt or
foreign material.
2
Using gauze pads, gently
clean the wound with water
or wound cleaner and dry the
skin around the wound.
5
Advise the victim to rest
the injured area and
elevate it to minimize swelling.
6
Determine the victims
tetanus immunization
status.
Warning
Treat all blood and body
uids as potentially infec-
tious; use personal
protection.
Do not scrub a wound with
a brush; this may damage
the tissue and increase the
risk of infection.
Do not use povidone/
iodine to clean wounds
because this can be dam-
aging to tissues.
3
Apply a dressing large
enough to cover both the
wound and the surrounding
skin. If the wound is small, you
can use an adhesive bandage.
To cover a larger wound, apply
a wound dressing and secure
with tape. If there is a risk of
the wound sticking to the
dressing, use a nonadhesive
dressing.
4
A wound dressing should
be secured with adhesive
tape and, if necessary, a
bandage. After applying a
bandage, always check the
circulation beyond the ban-
daged area.
INITIAL CARE
Bleeding is classied by the
main type of blood vessels
involved: arteries, veins, or
capillaries.
Arterial Bleeding
The arteries are thick-walled,
elastic vessels that carry blood
from the heart in high-pressure
waves; when damaged, bright
red blood spurts out of the
vessels with each contraction
of the heart. Major arterial
blood is darker red because of
the lack of oxygen. If a major
vein is cut, there may be severe
bleeding, which can cause
hypovolemic shock.
Capillary Bleeding
Capillary bleeding is the least
serious type of bleeding. Blood
may either ooze from the skin
or leak under the skin surface
and form a bruise.
bleeding is an emergency; the
victim can develop hypovole-
mic shock and die in minutes if
bleeding is not controlled.
Venous Bleeding
The veins are a low-pressure
system, transporting blood
from the body cells back to the
heart. The venous walls are
less elastic, resulting in bleed-
ing that is slower. Venous
TYPES OF BLEEDING
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A severe injury can result in a
large amount of blood loss,
which may cause hypovolemic
shock. Control of bleeding is a
top priority in managing a
severe injury. In most cases,
applying direct pressure to the
wound with a gloved hand
and a clean dressing will stop
bleeding. Raising the injured
area above the level of the
heart (elevation) to reduce
blood ow to the injury site
can also help stop the bleed-
ing. To stop severe arterial
bleeding from an arm or leg,
quickly, vital organs such as
the brain and heart will be
deprived of oxygen and the
victim may die within a few
minutes.
Signs and Symptoms
Blood spurting or owing
briskly out of a wound
Possible signs of hypovole-
mic shock: pale, cool skin;
rapid, weak pulse; low
blood pressure; signs of
hypoxia; restlessness
Possible loss of
consciousness
Severe Bleeding
compression of the pressure
point (indirect pressure) in
conjunction with direct pres-
sure and elevation may be
necessary.
Hypovolemic Shock
Prolonged or severe bleeding
from a wound can result in
hypovolemic shock. The total
volume of blood in the body
is reduced so drastically that
the heart and blood vessels
cannot deliver sufcient blood
to the body tissues. If hypovo-
lemic shock is not treated
Resources
Medical kits
Oxygen
Disposable gloves
Wound dressing, bandage,
and adhesive tape
Biohazard bag
MedLink
1
Put on gloves. Apply direct
pressure to the wound
by placing a clean gauze dress-
ing on it and pressing on
the injured area rmly for
10 minutes.
2
While continuing to apply
rm pressure on the dress-
ing, raise and support the
injured area above the level of
the heart (elevation).
3
If direct pressure and eleva-
tion do not stop the bleed-
ing, apply a pressure dressing,
which will put more constant,
controlled pressure on the
wound. To do this, leave the
original wound dressing in
place and apply a new dressing
over the rst. Secure both
dressings with a bandage and
adhesive tape.
4
Assess the circulation
beyond the bandage. Feel
the skin, and check the capil-
lary rell. If the capillary rell
is diminished (2 seconds),
loosen the bandage until the
8
Determine the victims
tetanus immunization
status once the victim is stable.
9
Call MedLink.
Warning
Treat blood and other body
uids as potentially infec-
tious material. Dispose of
gloves and soiled items in a
biohazard bag.
If the victim becomes
unconscious, see Life-
saving Procedures.
normal color returns, then
reapply with less constriction.
5
Treat the victim for hypovo-
lemic shock. Lay the victim
at and raise the legs to
improve the ow of blood to
the brain and heart.
6
Administer oxygen at a
high ow setting.
7
Recheck the circulation
beyond the bandage every
10 minutes. Monitor the victim
for continued bleeding, hypo-
volemic shock, or loss of
consciousness.
INITIAL CARE
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1
If arterial bleeding in a limb cannot be con-
trolled by pressing on the wound (direct
pressure) and elevation, use indirect pressure on
a main artery (pressure point).
2
Find the correct pressure point by feeling for
a pulse. Find the brachial artery for wounds
in the arm. For a leg wound, lay the victim at
and feel for the femoral artery in the groin.
3
Press the artery rmly against the adjacent
bone for up to 10 minutes, until the blood
ow has reduced signicantly and bleeding is
controlled.
APPLYING INDIRECT PRESSURE (PRESSURE POINTS)
Brachial pressure
point lies in the
inner arm, under
the biceps
muscle, close to
upper arm bone
(humerus)
Femoral pressure
point lies in the
center of the
groin, where the
inner thigh
meets the body,
and is close to
the pelvic bone
Severe Bleeding, continued
If arterial bleeding from a limb cannot be con-
trolled by direct pressure, elevation, or indirect
pressure (pressure points), call MedLink. In
order to save a life, you must stop severe
bleedingand as a last resort, apply a tourniquet
(a tight band that stops blood ow to an injured
area). Any exible item/material long enough to
go around the limb (rope, oxygen tubing, piece
of material) can be used as a tourniquet. Place
the strip of material above the level of injury and
tie in place. Insert a stick or pencil in the loop
and twist to tighten until the bleeding stops. A
blood pressure cuff can also be used as a tourni-
quet by inating it until the bleeding stops. The
tourniquet should be just tight enough to stop
the bleeding. The decision to apply a tourniquet
is very serious because of the likely possibility of
losing the limb below the level of the tourniquet.
If bleeding cannot be controlled by other
methods, it can be used to save a life. Record the
time when the tourniquet was applied. Do not
cover the tourniquet or the limb. Mark the vic-
tims forehead with a T to alert medical pro-
fessionals that a tourniquet is in place.
TOURNIQUETS
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In severe injuries, body parts
can be partially or completely
severed (amputated). When an
amputation occurs, it is essen-
tial to control the bleeding and
care for the victim and the
amputated part. It is important
Signs and Symptoms
Missing, severed, or partially
severed body part
Bleeding, possibly severe
Signs of hypovolemic shock
Amputation
to seek medical care as soon
as possible because some
body parts can be reim-
planted. Keep the amputated
part clean and cool so that it
can be surgically reattached if
possible.
Resources
Medical kit
Oxygen
Disposable gloves
Wound dressing bandage
Tape
Splint
Soft padding
Plastic bag or container
Ice
Biohazard bag
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Assess the nature and
severity of the injury.
3
Put on gloves. Control the
bleeding through direct
pressure and elevation. If this
does not help, use indirect pres-
sure (pressure points). Apply a
tourniquet only if other mea-
sures to stop bleeding are
unsuccessful. If the body part is
still attached, apply a dressing,
bandage, and splint.
4
If the body part is totally
severed, cover it loosely
with a wound dressing then
wrap soft padding around the
body part. Place the wrapped
body part in a plastic bag or
container. Label the bag or
container with the victims
name and the time of injury.
Place the bag in a container
with ice to keep it cool. Do not
allow the body part to come in
direct contact with the ice or
to freeze.
Warning
Never allow an amputated
body part to freeze.
Never put ice or dry ice
directly against a body
part.
Treat blood and any other
body uids as potentially
infectious material.
If the victim becomes
unconscious, see Life-
saving Procedures.
5
Treat the victim for shock.
Lay the victim down, and
raise the victims legs.
6
Administer oxygen.
7
Obtain history of the
medical condition, medical
history, current medications,
and allergies.
8
Obtain vital signs.
9
Contact MedLink so that
the victim and the body
part can be taken to the hospi-
tal upon landing.
INITIAL CARE
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Chest Injuries
Injuries to the chest may be either blunt (with no breaks in the skin), such as those
resulting from a blow or a fall against a hard surface, or penetrating (open), such as
gunshot injuries and stab wounds. Chest injuries need urgent medical attention. The
victim may have broken ribs and extensive contusions. A wound or an internal injury,
such as a fractured rib, can damage the lungs, heart, or major blood vessels, causing
internal bleeding and hypovolemic shock. The trachea and the esophagus can also be
damaged. Multiple broken ribs can cause instability of the chest wall, resulting in severe
breathing problems and possibly a collapsed lung. Chest injuries can also lead to
hypoxia or loss of consciousness.
Lung
Rib
Heart
Diaphragm
Signs and Symptoms
Penetrating chest injuries: possible visible signs of
injury, such as bleeding, a laceration, an impaled
object, or a gunshot wound with entry and exit wounds
Blunt injuries: possible bruising and swelling
Fractured ribs: unusual movement of chest, sharp pain
in injured area
Chest wounds: difcult, painful breathing with rapid,
shallow breaths
Blue lips, earlobes, and nail beds
Coughing up of blood
Crackling sensation (crepitus) that can be felt under
the skin around the wound (caused by air trapped
in soft tissues)
Open chest wound: possible sucking sound as air
moves in and out of the chest
Anxiety, distress, or fear
Hypovolemic shock: pale, cool skin; rapid,
weak pulse; and hypoxia
Possible loss of consciousness
Blunt Chest Injury
Resources
Medical kit
MedLink
Disposable gloves
Pillows
Oxygen
Biohazard bag
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
medical condition, medical
history, current medications,
and allergies.
4
Assess the nature and
severity of the injury.
Warning
Offer the victim small sips
of water if thirsty, but do
not give anything to eat.
Treat body uids as poten-
tially infectious material.
Dispose of gloves and
soiled items in a biohazard
bag.
If the victim develops
hypovolemic shock, treat
as directed, but help the
victim into a semi-reclining
position with the legs
raised.
If the victim becomes
unconscious, see Life-
saving Procedures.
5
Administer oxygen on a
high setting.
6
Seek urgent advice from
MedLink.
7
Use pillows to support the
victim in a comfortable
position, leaning toward the
injured side. Avoid moving the
victim to prevent further injury
or pain. Movement may aggra-
vate any instability of the chest
wall and cause breathing
problems.
8
Monitor the victim, watch-
ing for any signs of deterio-
ration, hypovolemic shock,
difculty breathing, or loss of
consciousness.
INITIAL CARE
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Chest Injuries, continued
Penetrating Chest Injury
Resources
Medical kit
Oxygen
Disposable gloves
Wound dressing, bandage,
and adhesive tape
For sucking wound, a
plastic bag or sheet of
plastic lm
Pillows
Biohazard bag
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
injury, medical history,
current medications, and
allergies.
4
Assess the nature and
severity of the injury.
5
Seek urgent advice from
MedLink because there
may be other underlying
injuries.
6
To control severe bleeding,
put on gloves and put a
clean gauze dressing on the
wound. Apply direct pressure
for 10 minutes.
otherwise, air will not be
able to escape.
If the victim develops
hypovolemic shock, treat
for shock, but help the
victim into a half-sitting
position with the legs
raised.
Treat blood and other
body uids as potentially
infectious material.
Dispose of gloves and solid
items in a biohazard bag.
If the victim becomes
unconscious, see Life-
saving Procedures.
Immediate Care of a
Sucking Chest Wound
If the chest wound is sucking air,
you need to seal it. Apply a
dressing that is large enough to
cover the wound completely.
Cover the dressing with a seal,
such as a plastic bag or sheet of
plastic lm. Secure the dressings
and covering with tape on three
sides; leave one edge unsealed
so that air can escape from the
chest wound. Never tape the
seal on all four sides. If the seal
is completely closed, the air will
not be able to escape and the
pressure in the victims chest
will increase. This can cause
further breathing and circula-
tion problems, called a tension
pneumothorax.
If the victim begins to deterio-
rate after the dressing is applied,
remove the dressing and re-
apply, taking care to keep one
side open (loose) and unsealed
so that air can escape.
7
If the chest wound is still
bleeding after 10 minutes,
apply a pressure dressing on
top of the rst one. Secure
both of the dressings with
adhesive tape.
8
Use pillows to support the
victim in a comfortable
position, leaning toward the
injured side. Avoid moving the
victim if possible, because
movement may cause further
injury or pain and may aggra-
vate instability of the chest
wall and associated breathing
problems.
9
Administer oxygen on a
high setting.
10
Monitor the victim,
watching for any signs
of deterioration, hypovolemic
shock, difculty breathing, or
loss of consciousness.
Warning
Do not remove an impaled
object. Put padding around
the object and secure with
adhesive tape. Secure the
impaled object so that it
does not move.
Do not give the victim any-
thing to eat or drink.
When dressing a chest
wound that is sucking air,
never seal it completely;
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Abdominal Injuries
The abdominal organs are partially protected by the ribs and the pelvis, but they have
little protection in the front, which leaves the organs vulnerable to injury. Serious inju-
ries, such as damage to the liver and the spleen, can lead to external and/or internal
bleeding, hypovolemic shock, or peritonitis (life-threatening infection and inammation
inside the abdomen).
Signs and Symptoms
Penetrating injuries such
as bleeding, lacerations,
an impaled object, or a
gunshot injury with entry
and exit wounds
Blunt injuries: possible
bruising/swelling/pain
Severe pain either at the
site of injury or in another
area (referred pain)
Hypovolemic shock: possi-
ble pale, cool skin; rapid,
weak pulse; and blue lips,
earlobes, and nail beds
Possible loss of
consciousness
Blunt and Penetrating
Abdominal Trauma
Resources
Medical kit
Disposable gloves
Wound dressing, bandage,
and adhesive tape
Oxygen
Biohazard bag
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
injury, medical history,
current medications, and
allergies.
Warning
Do not remove an impaled
object. Put padding around
the object and secure with
adhesive tape. Secure the
impaled object so that it
does not move.
Do not give the victim any-
thing to eat or drink.
Treat body uids as poten-
tially infectious material.
If the victim develops
hypovolemic shock, treat
as directed. Lay the victim
at with the legs raised.
If the victim becomes
unconscious, see Life-
saving Procedures.
4
Assess the nature and
severity of the injury.
5
Seek urgent medical advice
from MedLink because
there may be underlying inju-
ries in the affected area.
6
To control severe bleeding,
place a clean dressing on
the wound and apply direct
pressure for 10 minutes. If
bleeding continues, keep the
original dressing in place.
Apply a dry wound dressing
over the rst. Secure the dress-
ings with tape.
7
Administer oxygen on a
high setting.
8
Monitor the victim for
signs of hypovolemic shock
or loss of consciousness.
INITIAL CARE
Diaphragm
Liver
Gallbladder
Pancreas
Appendix
Rectum
Spleen
Stomach
Kidney
Small
intestine
Large
intestine
(colon)
Urinary
bladder
Urethra
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Triceps
Biceps
AXIAL SKELETON
Skull
Cranium
Mandible
Thoracic
cage
Sternum
Ribs
(12
pair)
Vertebral
column
(33 bones)
Clavicle
(collar bone)
Scapula
(shoulder
blade)
Humerus
Radius
Ulna
Carpals
Metacarpals
Phalanges
Coxa
(hip bone)
Femur
Patella
Fibula
Tibia
Lower
Bone, Joint, and Muscle Injuries
This section addresses injuries to the musculoskeletal system. It includes a review of the
musculoskeletal anatomy, followed by general advice for managing bone and joint
injuries.
The bones form a framework
called the skeleton. This struc-
ture protects and supports the
bodys organs, ligaments, and
tissues. Many bones are con-
nected by brous tissues
called ligaments to form joints,
most of which allow parts of
the body to move. Joints are
moved by muscles, which are
connected to the bones by
tendons.
Anatomy of the Musculoskeletal System
Function of Skeletal Muscles
Most joints are moved by opposing
pairs of muscles. For example, in the
upper arm, the biceps muscle bends
the elbow and the triceps muscle
straightens it. To produce a move-
ment, one muscle contracts while the
opposing muscle relaxes.
Structure
of the Skeleton
The central part of
the skeleton consists
of the skull, spinal
column, and rib cage,
which protect vital
structures such as the
brain, spinal cord,
lungs, and heart. The
remaining parts are the
pelvis (which supports
the organs of the
lower abdomen)
and the bones of
the arms and legs.
Biceps
Bone
Membrane
enclosing
joint
Cartilage
pad
Ligament
Tendon
Structure of Joints
The places where bones meet are
called joints. The bones are joined by
brous tissue (ligaments) and are
moved by muscles, which are con-
nected by cords of tissue (tendons).
The ends of the bones are protected
by smooth pads (cartilage), which are
lubricated by uid (synovial uid) so
that joint movement is easy and
smooth.
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A broken (fractured) bone may
be very painful, but the injury
can be difcult to detect unless
it causes a deformity in the
area. There are two general
types of fractures: simple
(closed) and compound
(open). In either type, there
may be complications, such as
multiple fractures, dislocations
Signs and Symptoms
History of injury, such as a
severe impact/fall
Victim may have heard or
felt the bone break
Pain or tenderness in the
injured part
Bruising and swelling
Abnormal appearance of
the injured area, such as
shortening of the arm or leg
A wound over the site of
injury, which may indicate
an open fracture even if no
bone fragments are visible
(Muscle contraction may
have pulled the bone ends
back inside after the initial
injury.)
Possible blue or pale, cold
skin beyond the injury site,
indicating poor blood ow
to the area
Pain with weight bearing or
inability to use the injured
part
Possible signs of hypovole-
mic shock
Fractures
(in which bones are pulled out
of position), or damage to
blood vessels or nerves. Keep
the injured area as still as pos-
sible; broken bone ends can
cause further tissue damage if
moved. Suspected fractures
and dislocations should be
treated in the same way as
obvious fractures.
Simple (Closed) Fracture
This is a clean break. The skin
surface is intact, although there
may be bruising and swelling over
the fracture, and the injured area
may be deformed.
Compound (Open) Fracture
The bone ends pierce the skin and
may either stick out or slip back
under the skin. Any fracture with
an open wound should be treated
as an open fracture.
Resources
Medical kit
Oxygen
Disposable gloves
Dressing, bandage, and
adhesive tape
Triangular bandages
Soft material for padding
Wire ladder splint or rolled-
up blankets, newspapers, or
magazines
Biohazard bag
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Assess the nature and
severity of the injury.
4
Administer oxygen if
needed.
5
Make the victim as com-
fortable as possible.
splint, rolled-up blankets, or
newspapers. Secure the splint
to the area with bandages.
10
Check circulation
beyond the injury site.
Feel the skin, and check the
capillary rell. If the skin is pale
or cool, undo the bandages
until the normal color returns
then reapply loosely. Monitor
the victim, watching for signs
of hypovolemic shock.
Warnings
Do not move the injured
limb.
If visible bone ends are
protruding from a wound,
do not push the ends back
inside the wound.
Treat blood and other body
uids as potentially infec-
tious material. Dispose of
gloves and soiled items in a
biohazard bag.
If the victim develops
hypovolemic shock, lay the
victim at with legs raised.
6
Obtain medical history:
how the injury occurred,
current medical conditions,
medications, and allergies.
7
If a leg or knee is injured,
support the leg above and
below the injury site to keep it
secure. To support an arm,
wrist, or hand, lay the arm
across the victims body and
advise him or her to support it
with the other hand.
7
Seek advice from MedLink;
ask for any recommenda-
tions for pain relief.
8
Cover any wound loosely
with a clean dressing.
Secure the dressing with tape
or a bandage.
9
Immobilize the injured area,
including the joints above
and below the fracture. Place
soft padding between bony
areas such as the knees and the
ankles. Place a splint around
the area; use the wire ladder
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How to Make a Sling
A sling is used to support an
injured arm. First aid kits
contain triangular bandages
for use as slings. A sling can
also be made from an item of
the victims clothing, such as a
jacket or shirt.
Improvising a Sling
from a Jacket
Fold the corner of the
jacket up over the
arm, pin it to
the top of the
jacket. Fold
and pin the
fabric
around the
elbow.
These types of injuries affect
the soft tissues of a joint: the
muscles, the tendons (which
connect muscles to bones), or
the ligaments (which connect
bones together). Overstretch-
ing of a muscle or tendon
(strain) or a ligament (sprain)
often results from sudden
twisting movements. The
ankle and knee are frequently
Signs and Symptoms
History of a sudden injury
involving the affected joint,
such as twisting of a limb or
a fall
Pain or tenderness
Bruising and swelling
Inability to use or bear
weight on the injured area
Strains and Sprains
affected. Strains and sprains
are usually painful and cause
swelling and bruising. Distin-
guishing between a fracture
and a strain or sprain can be
difcult, and these injuries
often occur together. It is
recommended that these inju-
ries be treated as a fracture
until medical evaluation is
available.
Resources
Medical kit
Oxygen
Cold compress or ice pack
Soft material for padding
Ladder splint or other mate-
rial for splinting
Bandage and adhesive tape
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Administer oxygen if
needed.
4
Obtain history of the injury,
medical history, current
medications, and allergies.
check the capillary rell.
Recheck the circulation every
10 minutes. Keep the injured
area elevated and supported.
9
Seek advice from MedLink.
5
Assess the nature of the
injury. Treatment for a
strain or a sprain includes rest,
ice, compression, and elevation,
also known as RICE. This
treatment helps reduce swell-
ing, bruising, and pain.
6
Help the victim into a com-
fortable position. Elevate
and support the injured area.
7
Apply a cold compress, or
an ice pack wrapped in a
cloth, to the injured area for
15 minutes to help reduce
swelling and pain.
8
Bandage the area rmly to
apply compression and
minimize swelling. Check the
circulation beyond the
bandage. Feel the skin, and
INITIAL CARE
Resources
Triangular bandage and
safety pins
Medical kit
MedLink
1
Slide the bandage under
the arm, with the longest
side parallel to the body. Pull
the upper end around the neck.
2
Lift the lower end of the
bandage over the arm and
tie the ends together in a knot
just above the collarbone on
the injured side. Tuck in the
fabric around the elbow and
secure it with safety pins.
INITIAL CARE
Fractures, continued
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Injuries to the legs can result
from falls, impacts, or twisting
motions. The most common
problems are sprains and
strains caused by twisting of
the ankle or knee. More
serious injuries include frac-
tures of the pelvis, thigh/leg
bone (femur), the two bones
in the lower leg (tibia and
bula), or the knee bone
(patella). Fracture of a femur
can be particularly serious
because the bone ends may
Bruising and swelling
Abnormal appearance of
the injured area, such as
limb shortening or
deformity
Possible blue/pale or cold
skin beyond the injury, indi-
cating poor blood ow to
area
Inability to walk or bear
weight on the leg
Possible signs of hypovole-
mic shock
Leg, Knee, or Foot Injuries
damage major blood vessels,
causing bleeding within the
tissues and possibly hypovole-
mic shock.
Signs and Symptoms
History of injury, such as a
severe impact or twisting of
the leg, knee, or foot
Victim may have heard or
felt the bone break
Pain or tenderness in the
injured area
Resources
Medical kit
Disposable gloves
Dressings, bandage, and
adhesive tape for wounds
Triangular bandages
Soft material for padding
Wire ladder splint or items
for splinting, such as rolled-
up blankets, newspapers, or
magazines
Biohazard bag
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Administer oxygen if
needed.
4
Obtain history of the
injury, medical history,
current medications, and
allergies.
5
Lay the victim down at.
Support the leg by holding
it securely above and below the
site of the injury. Assess the
nature and severity of the
injured leg by comparing it
with the uninjured leg to iden-
tify any abnormalities.
9
If an ankle or foot is
injured, place soft padding
around it and splint it using a
wire ladder splint or items
such as rolled-up newspapers.
Keep the foot elevated and
supported.
10
Check circulation
beyond the injury site.
Feel the skin, and check capil-
lary rell. If the skin is pale or
cool, undo the bandages and
re-apply loosely. Re-check the
circulation every 10 minutes.
11
Consult MedLink for
advice on pain relief or
further treatment. Monitor the
victim for signs of hypovolemic
shock.
Warning
Never try to straighten or
move a fractured knee.
If visible bone ends are
protruding from a wound,
do not push the ends back
inside the wound.
Treat blood and other
body uids as potentially
infectious material.
Dispose of gloves and
soiled items in a biohazard
bag.
If the victim develops
hypovolemic shock, lay the
victim at with legs raised.
6
If a wound is present, cover
it loosely with a clean
dressing. Secure the dressing
with a bandage and tape.
7
If a fracture of the leg is
suspected, straighten the
leg by pulling gently to align it
with the body. Do not do this
if the knee is injured, and stop
all movement if it causes
further discomfort. Consult
MedLink prior to performing
this maneuver.
8
If a leg is injured, carefully
move the uninjured leg
beside it to use as a splint.
Place soft padding between
the ankles and knees. Tie the
feet and legs together with tri-
angular bandages above and
below the injury site. Tie the
knots of the bandages so that
they lie on the uninjured leg.
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Injuries to the arms, wrists,
and hands can occur in
various ways. The most
common injury includes a
sprained wrist, which can
result from pulling or twisting
an arm. Fractures of the bones
in the arm, wrist, or hand can
result from a heavy impact or
when the victim reaches out to
prevent injury during a fall.
deformity or a wound over
the site of injury, which
may indicate an open
fracture
Possible blue or pale skin
beyond the injury site,
indicating poor blood
circulation
Inability to use arm or hand
Arm, Wrist, or Hand Injuries
Signs and Symptoms
History of the injury, such
as a severe impact, fall, or
twisting of the arm/wrist
Victim may have heard or
felt bone break
Pain or tenderness in the
injured area
Bruising and swelling
Abnormal appearance of
the injured area, such as a
Resources
Medical kit
Oxygen
Disposable gloves
Dressings, bandages, and
adhesive tape
Triangular bandages (sling)
or improvised sling
Soft material for padding
Wire ladder splint, rolled-
up newspapers, or
magazines
Biohazard bag
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
injury, medical history,
current medications, and
allergies.
4
Assess the nature and
severity of the injury.
Compare it with the uninjured
arm to help identify any
abnormalities.
5
If the victim can bend the
elbow, ask him or her to
support it with the uninjured
hand. If the victim cannot bend
the elbow, assist him or her to
a comfortable position.
6
Seek advice from MedLink
for recommendations for
pain medication.
12
Check the circulation
beyond the injury site.
Feel the skin, and check the
capillary rell. If the skin is
pale or cool, undo the ban-
dages and re-apply loosely.
Re-check the circulation every
10 minutes.
13
Consult MedLink for
advice on further
treatment.
Warning
Never try to force an
injured elbow or wrist to
bend.
If visible bone ends are
protruding from a wound,
do not push the ends back
inside the wound.
Treat blood and other
body uids as potentially
infectious material.
Dispose of gloves and
soiled items in a biohazard
bag.
7
Cover any wound loosely
with a clean dressing.
Secure the dressing with a
bandage and adhesive tape.
8
Remove any bracelets or
rings before the hand or
ngers start to swell. Use a
safety pin to secure these items
to the victims shirt or give to
the victim.
9
If the upper arm or elbow
is injured and the victim
can bend the elbow, tuck the
triangular bandage under the
arm. Tie the ends around the
neck, and pin the fabric to
make a sling. If the victim
cannot bend the elbow, secure
the injured arm to the victims
body with triangular
bandages.
10
If the forearm, wrist, or
hand is injured, tuck a
triangular bandage under the
arm and place soft padding
around the forearm. Splint
with a wire ladder splint,
rolled-up newspapers, or mag-
azines. Tie the bandage to
make a sling. If the hand is
injured, secure it in a raised
position if possible.
11
To give the injured arm
extra support, place
soft padding between the arm
and the victims body. Tie
another triangular bandage
around both the arm and the
victims body, taking care to
avoid the injured area.
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Head injuries during ight
may be caused by falling
objects from overhead bins,
falls against hard surfaces, or
other injuries during severe
turbulence. Most head injuries
are minor problems, such as
cuts, abrasions, and bruises.
Occasionally, more severe
evaluated for neck injuries and
monitored for deterioration,
which may indicate more
severe underlying damage.
Signs and Symptoms
Visible signs of head injury,
such as bruising, swelling,
laceration, or bleeding
Possible loss of conscious-
nessbrief or prolonged
Headache; nausea or vomit-
ing; drowsiness; memory
loss; confusion; visual dis-
turbances, such as blurry
vision
Possible complete loss of
consciousness
Possible signs of a skull
fracture, contusion, coma,
or open head wound;
depressed area on the skull;
blood or clear uid leaking
from the nose or ears
Possible other signs of pres-
sure on the brain tissue,
include unconsciousness;
unequal pupils; noisy, slow
breathing; and extremity
weakness
Head Injuries
head injuries occur, such as
lacerations and bleeding, tem-
porary or prolonged loss of
consciousness, fractures of the
skull, or internal bleeding or
swelling of the brain tissue.
Victims who have severe head
injuries need urgent medical
attention. They should also be
Bleeding
Brain
Skull
Compression of Brain Tissue
Swelling or bleeding inside the
brain can put pressure on brain
tissue. As a result, brain function
is severely disturbed. The victim
will deteriorate and may become
unconscious. This is a life-threat-
ening condition and requires
immediate medical evaluation and
treatment.
Fracture
Brain
Skull
Skull Fracture
A fracture of the skull can form an
indented area that presses on the
brain. There is also a risk that
pieces of bone may enter the
brain or an infection may occur.
The victim may deteriorate and
become unconscious.
Resources
Medical kit
Oxygen
Disposable gloves
Wound dressing, bandage,
and adhesive tape
Cold compress or ice pack
wrapped in a cloth
Biohazard bag
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Administer oxygen if
needed.
4
Obtain history of the
injury, medical history,
current medications, and
allergies.
9
Consult MedLink for advice
on further treatment.
10
Monitor the victim,
watching particularly
for signs of deterioration or
loss of consciousness.
Warning
If the victim shows signs of
a severe head injury, seek
urgent advice from
MedLink.
Treat blood and other body
uids as potentially infec-
tious material. Dispose of
gloves and soiled items in a
biohazard bag.
If the victim becomes
unconscious, see Life-
saving Procedures.
5
Put on gloves. Assess the
severity of the injury. Check
for signs of serious injury, such
as loss of consciousness, con-
fusion, altered mental status,
or visible sign of injury (e.g.,
bleeding).
6
Control any bleeding by
placing a clean dressing on
the wound and applying direct
pressure over the wound for
10 minutes. If this action is
unsuccessful, apply a pressure
dressing.
7
Once bleeding is con-
trolled, secure dressings
rmly with tape or a bandage.
Continue to monitor the victim
for recurrence of bleeding.
8
Apply a cold compress or
an ice pack wrapped in a
cloth to minimize swelling and
bruising.
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Neck and back injuries can occur during ight
as a result of objects falling from overhead bins
and falls against hard surfaces, especially during
severe turbulence. Injuries to the neck or spine,
such as fractures or dislocations, are very
serious and may involve damage to the spinal
cord. Spinal injuries can result in paralysis or
weakness below the level of the injury. All
victims who have a head injury or who have
had a fall should be evaluated for possible neck
or back injury.
Signs and Symptoms
Pain or tenderness in the neck or back
Numbness or weakness in the legs and/or
arms; difculty moving limbs
Loss of feeling in areas below the injury site
Difculty breathing (with a neck injury)
Unintentional erections are an indication of
serious spinal injury.
Neck and Back Injuries
Victim with a Suspected
Neck and Back Injury
Resources
Medical kit
Oxygen
MedLink
Bulky items such rolled-up
blankets or coats
Adhesive tape
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Administer oxygen if
needed.
4
Obtain history of the
injury, medical history,
current medications, and
allergies.
5
Keep the victim lying at
and ensure that his or her
head and legs are in alignment
with the body.
6
Assess the nature and
severity of the injury. Ask
the victim to move his or her
toes, feet, legs, hands, and
arms to test for equal move-
ment and strength in all
extremities. Make note if there
is loss of movement or weak-
ness. Ask if the victim can feel
you touching his or her arms
and legs.
7
Stabilize the neck using
cervical spine (C-spine)
stabilization. Ask another
rescuer to help.
head and keep the head and
neck aligned with the body.
11
Ask the other rescuer to
help you turn the victim
slowly and gently as a unit,
keeping the legs and body
aligned, while you hold the
head and neck in alignment
with the body.
12
Call MedLink for
further advice.
Warning
If possible, do not move
the victim from the posi-
tion in which he or she was
found.
If the victim becomes
unconscious, see Life-
saving Procedures.
Cervical Spine
Stabilization
One rescuer
kneels at the top
of the victims
head and holds
the head in align-
ment with the
neck and spine.
The rescuers
hands should be
over the victims
ears, holding the
head rmly in
alignment.
Place thick
padding, such as
rolled-up blan-
kets or coats, on either side
of the victims head to
support it. Secure these
items with adhesive tape.
Monitor the victim, watch-
ing for signs of deterioration
or loss of consciousness.
8
If the victim is unconscious
or complains of nausea or
vomiting, it is important to
turn the victim safely to the
side in a recovery position.
Apply oxygen if needed.
9
If it is necessary to move
the victim, turn the victim
as a unit, keeping the head,
neck, and spine in alignment.
10
Ask another rescuer to
kneel at the victims
side, while you kneel at the
head. Place your hands on the
victims ears to support the
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Environmental Injuries
This section includes rst aid for injuries caused by environmental hazards, such as burns
caused by re, chemicals, or electricity, as well as conditions resulting from excessive
cold and heat exposure. Before approaching a victim ensure that the scene is safe.
Burns cause damage to one or more layers of the
skin. This results in disruption of the normal
functions of the skin: protection of the internal
body structures, a barrier against infection, regu-
lation of body temperature, and sensations such
as touch, pressure, and pain.
There is a very serious risk of infection
because damaged or exposed tissue can no
longer prevent infectious organisms from enter-
ing the body. If a burn is severe, major uid loss
may result in hypovolemic shock. In addition, a
severe burn can cause hypothermia due to loss
of body temperature control. The nature of a
burn depends on the intensity of the burning
agent and the length of exposure. The severity
depends on the following factors: the type of
burn (or whether it is a combination of types),
the extent of the burned area, and the part of
the body that is affected.
Burns are classied according to the depth of
skin that is damaged. Supercial (rst-degree)
burns affect only the surface tissues of the skin.
Partial-thickness (second-degree) burns are
deeper, and full-thickness (third-degree) burns
damage all the layers of the skin and underlying
tissues. A combination of all types of burns may
be present in severe injuries.
TYPES OF BURNS
Surface
of skin
Burned
area
Hair
Supercial (First-Degree)
Burns
Only the surface layer (epider-
mis) of the skin is affected. The
burned area is red, slightly
swollen, and sore. There are no
blisters. The most common
causes of supercial burns are
sunburn or brief contact with
hot liquids or objects.
Burned
area
Fluid-filled
blister
Upper layers
of skin tissue
Partial-Thickness
(Second-Degree) Burns
The upper layers of skin (epider-
mis and dermis) are affected.
Burned areas are very painful
and are red, white, or mottled,
with uid-lled blisters. Possible
causes include severe sunburn,
ash burns from res, contact
with hot items, and caustic
chemicals.
Destroyed
area
Upper layers
of skin tissue
Lower layers
of skin tissue
Full-Thickness
(Third-Degree) Burns
All the layers of skin are affected.
The skin may be dark, leathery or
translucent/white. Pain will vary
with the extent of damage.
Causes include prolonged
contact with re or hot items
and electrical burns.
The surface area and location of a burn can
indicate the severity and the risk of complica-
tions. The greater the surface area burned, the
higher the risk of severe tissue uid loss, leading
to hypovolemic shock. Even some supercial
burns can cause complications if the affected
area is extensive. Burns to the face, eyes, neck,
hands, or groin can also cause severe complica-
tions. Seek urgent medical advice from MedLink
for all full-thickness burns and burns covering
more than 1% of the body (an area about the
same size as the palm of the victims hand). In
addition, seek urgent medical advice from
MedLink for all burns involving infants, young
children, or the elderly because they are at par-
ticularly high risk for developing hypovolemic
shock, hypothermia, and infection.
Assessing the Extent of Burns
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Intense heat, sunlight, re, and
acidic or alkaline chemicals
can burn the skin, airways,
and eyes. Steam or hot liquids
can result in similar injuries
(scalds). Skin damage contin-
ues after burning has stopped,
so it is vital to remove the
burning agent. Cool the
burned area to stop the
burning process with cool
water and cold water com-
and signs of a chemical on
the skin or clothing
Signs of supercial, partial-
thickness, or full-thickness
burns; may be more than
one type of burn
Mild to severe pain
Difculty breathing if face
or airway is affected
Possible signs of hypovole-
mic shock or hypoxia
Burn or Scald
presses. Apply a burn dressing
that covers the wound (e.g.,
Waterjel) to prevent further
contamination and to prevent
exposure to the air, which will
provide some pain relief.
Signs and Symptoms
History of exposure to a
burning agent
Chemical burns resulting in
irritated or inamed skin
Resources
Medical kit
Oxygen
Disposable gloves
Bottles of water for
irrigation/drinking
Cold compress or ice pack
wrapped in a cloth
Gel-soaked burn dressings
(Waterjel)
Blanket
Biohazard bag
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Remove the victim from
danger.
3
Obtain vital signs.
4
Administer oxygen if
needed. Use a humidier if
there are facial burns.
5
Obtain history of the
injury, medical history,
current medications, and
allergies.
6
Assess the nature and
severity of the injury.
7
Put on gloves. Brush off any
dry chemicals with a cloth.
Remove all contaminated
clothing if not stuck to the skin.
To prevent further skin damage,
cool the skin by ushing with
copious amounts of water.
Apply a cold compress, ice
pack wrapped in a cloth, or
burn gel (e.g., Waterjel).
than 1% of the skin; and burns
in the very young or old; also
seek immediate emergency
care if there is any doubt
about the victims condition.
Warning
Treat body uids as poten-
tially infectious material.
Dispose of gloves and
soiled items in a biohazard
bag.
Do not break blisters.
Do not remove clothing
stuck to the skin.
Do not apply ice directly to
a burn; use an ice pack
covered in a dry cloth.
Do not apply cream or
adhesive dressings,
because these can prolong
the burning.
8
Remove jewelry from
injured areas involving the
ngers, toes, and wrists before
swelling occurs. Apply a gel-
soaked burn dressing
(Waterjel).
9
Elevate the injured area if
possible to prevent
swelling.
10
Keep the victim warm.
Maintain normal body
temperature. Avoid cooling the
victim to the point of
shivering.
11
Assess the severity of
the burn. Seek urgent
medical advice from MedLink.
Burns that require immediate
emergency care include burns
on the face, neck, hands, or
groin; burns that cover more
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Heat, smoke, and fumes can
cause severe damage to the
lungs and airways, leading to
extreme difculty breathing.
Burning or smoldering objects
emit hot air and smoke, which
can burn the airways and
lungs. Certain materials, such
as plastic, may produce toxic
fumes as well. Assume that any
person who has been exposed
to a re in an enclosed space
Red or black coloring on
the victims tongue and
inside the mouth
Wheezing and/or difculty
breathing
Burns to other areas, partic-
ularly the face
Possible signs of hypoxia
Different breathing or
respiratory/cardiac arrest
Smoke Inhalation
(e.g., an aircraft cabin) will
have smoke inhalation. In addi-
tion, assess the victim for any
other injuries.
Signs and Symptoms
History of smoke inhala-
tion/exposure to re in an
enclosed space
Singed eyelashes or nostril
hair
Soot in the mouth or nose
Resources
Medical kit
Oxygen and humidier
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the injury,
medical history, current
medications, and allergies.
8
Monitor the victim for
signs of hypoxia, hypovole-
mic shock, loss of conscious-
ness, and respiratory/cardiac
arrest.
9
Treat for shock.
Warning
If the victim becomes uncon-
scious, see Life-saving
Procedures.
4
Assess the nature and
severity of the injury.
5
After the scene is safe,
remove the victim from
danger.
6
Administer oxygen on a
high setting, using bubble
humidier if available.
7
Treat any burns or other
injuries as indicated.
INITIAL CARE
Contact with high-voltage elec-
trical sources in an aircraft or
aircraft hangar can cause
severe or even life-threatening
injuries. Cardiopulmonary
arrest may occur. The victim
may also have severe burns or
other injuries such as fractures
and internal injuries. It is essen-
Possible seizures if the victim
is still in contact with the
source of electrical current
Possible cardiopulmonary
arrest
Burns to areas of the skin
where electrical current has
entered and exited the vic-
tims body
Electrical Injuries
tial to ensure scene safety
before approaching the victim
and beginning treatment.
Signs and Symptoms
Unconscious victim lying
near an electrical power
source
Resources
Oxygen
Medical kit
Dry blanket or cloth
AED
MedLink
1
Assess scene safety. Once
you have determined the
scene is safe, turn off the elec-
trical current or push the elec-
trical item away with a dry,
3
Once breathing and circu-
lation have resumed
administer oxygen.
4
Look for and treat other
injuries.
5
Obtain history of the
injury, medical history,
current medications, and aller-
gies if available.
6
Contact MedLink.
nonmetallic object. If neither
step is possible, wrap a dry
blanket or cloth around the
victims ankles (without touch-
ing him or her directly) and
pull the victim away from the
electrical source.
2
Assess the victims respon-
siveness, airway, and
breathing. See Life-saving Pro-
cedures. Begin CPR. Apply AED
if indicated.
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Extremely cold weather and
cold substances, such as dry
ice, can cause frostbite. Ice
crystals can form in body
tissues, altering cellular metab-
olism and causing damage to
body cells. Frostbite usually
develops in exposed areas,
Signs and Symptoms
History of exposure to
freezing conditions, liquids,
or chemicals
Burning, numbness/tingling
Pale or white color of
affected areas
Frostbite
such as the face, ears, ngers,
and toes. Severe cases may
develop gangrene and require
amputation. Frostbite can
occur with hypothermia when
victims have prolonged expo-
sure to cold temperatures.
Resources
Medical kit
Oxygen
Warm, dry blankets
Warm water
MedLink
1
Treat for hypothermia (see
Initial Care for
Hypothermia).
Warning
Do not rub the affected
part because this can cause
further skin/tissue damage.
Do not break blisters.
If the feet are affected,
advise the victim not to
walk immediately after the
feet have been thawed
because this can cause
further tissue damage.
2
Assess the severity of the
condition. Check any areas
of exposed skin, and examine
the toes and ngers for signs
of frostbite.
3
Immerse affected ngers or
toes in luke-warm water.
4
Raise and support any
affected limbs to minimize
swelling.
INITIAL CARE
Hypothermia is caused by
exposure to cold/wet environ-
ments. The body temperature
falls below 95F (35C).
Normal body temperature is
98.6F (37C). Elderly people
and infants are especially vul-
nerable to hypothermia. Mild
Disorientation/confusion
Lethargy/drowsiness
Slow, weak pulse
Slow, shallow breathing
Loss of consciousness
Possible cardiopulmonary
arrest
Hypothermia
hypothermia can be easily
treated, but severe untreated
cases can result in death.
Signs and Symptoms
Shivering and feeling cold
Lack of shivering with
severe hypothermia
Resources
Medical kit
Oxygen
Warm, dry blankets
Warm, sugary liquids to
drink
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs (measure
body temperature with a
thermometer).
3
Obtain history of the injury,
medical history, current
medications, and allergies.
4
Remove cold, wet clothes
and replace with dry
clothes.
Warning
Never put sources of direct
heat next to the victim.
If the victim becomes
unconscious, see Life-
saving Procedures.
Follow guidelines in Life-
saving Procedures regard-
ing cessation of CPR, but
do not stop CPR until the
victim has a normal body
temperature. Victims of
hypothermia can recover
after prolonged periods of
CPR; therefore, CPR
should be continued as
long as possible and should
not be stopped until a
normal body temperature
has been achieved.
5
Wrap the victim in blankets
and re-warm slowly. Cover
the head to ensure extra
warmth.
6
Provide warm, sugary
uids to increase calories
and warmth.
7
Monitor the victim; watch
particularly for loss of
consciousness.
8
If the victim is unrespon-
sive and not breathing,
begin CPR (see Life-saving
Procedures).
9
Call MedLink.
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Exposure to very hot, humid conditions can
result in heat illnesses, which vary from mild to
severe. These illnesses include heat cramps,
heat exhaustion, and heat stroke. During expo-
sure to extreme temperatures, the body
responds by sweating. As the
exposure continues, sweating
gradually leads to excessive
loss of body uids and elec-
trolytes, which causes cramps,
thirst, etc. If the heat exposure
continues untreated, the body
loses the ability to regulate
temperature. This can progress
to heatstroke, which can be
life-threatening. Heat illness
often occurs in people who
are not acclimatized to a hot
or humid environment or who
are not adequately prepared
for the heat (e.g., not pro-
tected by hats and loose cloth-
ing; not drinking water and
electrolyte drinks). Elderly
people and infants are particu-
larly vulnerable to heat illness.
It can also be caused by
certain medications or illicit
drugs. The risk of heat ill-
nesses can be increased by
drinking alcohol or caffeinated
drinks because these drinks
increase urination, resulting in
a loss of body uids.
Signs and Symptoms
Heat illness progresses from mild to severe
if untreated. See the box below for specic
symptoms.
Heat Illness
Resources
Medical kit
Oxygen
Cool liquids to drink or ice
chips
Cool, damp cloth
Pillows or rolled blankets
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs (measure
the victims temperature
with a thermometer).
3
Obtain history of the
injury, medical history,
current medications, and
allergies.
8
Offer a cool, damp cloth
to place on the forehead.
9
Offer the victim cool
liquids to drink or ice
chips.
10
Monitor the victims
condition, watching for
loss of consciousness. Make
sure that the victim does not
become too cold and begin to
shiver.
11
If unresponsive, see
Life-saving Procedures.
12
Call MedLink.
4
Assess the nature and
severity of the injury.
5
Move the victim to a cool
or shaded area. Spritz with
water and fan the victim. This
technique minimizes shivering
and increases evaporative
cooling.
6
Lay the victim down, raise
the legs and support them
on pillows or rolled blankets to
improve the blood ow to the
brain and heart.
7
Loosen tight clothing and
remove excess clothing to
make the victim more
comfortable.
INITIAL CARE
Types of Heat Illness
Heat Cramps
History of exposure to hot or humid conditions
Muscle cramps
Weakness
Thirst
Pale/cool/moist skin
Rapid pulse
Heat Exhaustion: 98.6F (37C) to 105F (40C)
rectal temperature
Headache
Rapid breathing
Confusion and dizziness
Nausea and vomiting
Sweating with pale, clammy skin
Heat Stroke: 105F (41C) rectal temperature
Hot and dry skin
Absence of sweating in late stages
Decreased level of consciousness/unconscious
Cardiopulmonary arrest
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Eye Injuries
This section describes rst aid for injuries to the eyes, including assessment and removal
of foreign objects. Also included is rst aid for direct injuries to the eye and treatment
for eye irritation caused by chemical splashes. All eye injuries need prompt attention to
avoid complications such as scarring and infection, which might result in long-term
visual impairment.
It is common for tiny objects,
such as eyelashes, dust, and
insects, to enter the eyes. This
problem can occur during
pre-ight checks by the
ground crew or ight crew,
just before a ight, or when
passengers or crew are board-
ing an aircraft. Although the
presence of a foreign object
in the eye is often not serious,
it may be uncomfortable for
the victim.
Foreign Object in the Eye
Signs and Symptoms
History of foreign object
entering eye
Feeling of something under
eyelid
Discomfort or pain, which
may make it difcult to
open the eye
Excessive blinking and
watering
Possible redness
Possible blurred vision
Resources
Medical kit
Eye irrigation solution or
bottle of water
Cloth and blanket
Container such as ice
bucket
Gauze pads
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the
injury, medical history,
current medications, and
allergies.
4
Put on gloves. Assess the
severity of the problem. If
the victim is wearing contact
lenses, ask him or her to
remove them. Secure the lens
in a safe place.
move the object so that it can
be easily seen and removed.
8
If the victim continues to
feel that something is in his
or her eye and the symptoms
are not relieved with ushing
or use of the eyelid maneuver,
call MedLink.
Warning
If the object cannot easily
be removed by ushing the
eye or with the eyelid
maneuver, leave it in and
seek medical advice.
Dispose of gloves, contam-
inated clothing, and other
soiled items in a biohazard
bag.
It is not advisable to
attempt to remove any
foreign object out of the
eye with gauze or other
items. This may result in
injury to the eye.
5
Place a blanket around the
victims neck. Advise the
victim to tilt his or her head
toward the affected side. Posi-
tion a container such as an ice
bucket to catch any run-off
irrigant from the face. Pour the
eye irrigation solution or water
in the inner corner of the eye,
allowing the uid to run across
the eye. Wipe run-off solution
from the victims face with a
cloth.
6
If the victim can still feel a
foreign object in the eye,
examine the eye to look for any
object on the eyeball. Gently
hold the victims eyelids apart
with your gloved ngers so
that the eyeball is exposed as
much as possible.
7
If the victim still feels
something under the upper
eyelid, advise him or her to
pull the upper eyelid down
over the lower one. This may
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Many types of chemicals can cause irritation or
burning if they come into contact with the eyes.
Most cases involve a common substance such
as perfume or hair spray. Around aircraft,
however, chemical splashes are most likely to
affect ground crew or ight crew, because sub-
stances such as hydraulic uid can splash into
the eyes during pre-ight checks.
Chemical Splash to the Eye
Signs and Symptoms
History of exposure to chemicals
Evidence of chemicals on skin or clothing
Discomfort or severe pain, which may make
it difcult to open the eye
Excessive watering of the eye
Irritation or inammation of other exposed
areas
Resources
Medical kit
Eye irrigation solution or
bottle of water
Blanket and cloth
Container such as ice bucket
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
3
Obtain history of the injury,
medical history, current
medications, and allergies.
4
Assess the nature and
severity of the injury. Deter-
mine the type/name of the
chemical.
5
Put on gloves. Assess the
victims eyes to determine
the severity of the problem.
9
If both eyes are affected,
ush each with half of the
solution, then rell the bottle
with water and ush again.
Use copious amounts of solu-
tion to clear the eyes.
10
Advise the victim to
wash his or her
hands to avoid further con-
tamination.
11
Call MedLink.
Warning
Never use milk as an eye
irrigant; it can cause
serious eye infections.
Treat uid from the eyes as
potentially infectious mate-
rial. Dispose of gloves and
soiled items in a biohazard
bag.
6
If the victim is wearing
contact lenses, ask him or
her to remove them. Secure in
a safe place; the contact lenses
will need to be cleaned or dis-
carded depending on the
chemical involved.
7
Place a blanket around the
victims neck. Advise the
victim to tilt his or her head
toward the affected side, and
position a container such as
an ice bucket just under the
victims face. If the victim
cannot open the eye, gently
hold the eyelids apart with
your ngers.
8
Flush the affected eye with
eye irrigation solution or
water. Ensure that no run-off
or chemical enters the other
eye. Wipe the face with a
cloth.
INITIAL CARE
Eye injuries include bruising
around the eye (a black eye),
bleeding around the eye or in
the eyeball, or a puncture
wound. During a ight, direct
injuries can be caused by
falling objects, impacts with
Direct Injury to the Eye
Bleeding in white part of
the eye (sclera)
Possible visual disturbance
or loss of vision
Foreign object protruding
from the eye (impalement)
Resources
Medical kit
Pad of cloth soaked in cold
water (cold compress)
MedLink
1
Assess scene safety and the
victims responsiveness,
airway, and breathing.
2
Obtain vital signs.
6
If there is an impalement
(object sticking out of the
eye), stabilize the object to
prevent movement.
7
Call MedLink for advice on
further treatment.
Warning
Do not apply pressure or a
cold compress if there is a
penetrating injury to the eye.
3
Obtain history of the injury,
medical history, current
medications, and allergies.
4
Put on gloves. Assess the
nature and severity of the
injury.
5
If the area around the eye
is swollen or bleeding,
apply a cold compress.
INITIAL CARE
hard surfaces, impalements,
or assault.
Signs and Symptoms
Bruising or swelling around
the eye
Pain
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Notes

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Notes

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Procedures
and Resources
This chapter describes the variety
of services provided by MedAire
and MedLink. Suggested proce-
dures for various onboard incidents
and post exposure plans for infec-
tious diseases are also addressed.
Mechanics of lifting and assisting
passengers onboard in a safe
manner are included. Onboard
medical resources such as oxygen,
medical kits and equipment are
listed in detail. Finally, resources
for pandemic planning for the
aviation community are included to
assist ight departments with their
company planning.
MedAire, Inc. 154
Services Provided by MedAire, Inc. 154
The MedLink Emergency Service 155
Quality Improvement Program 155
ISO Certication 155
Contacting MedLink 156
MedLink Call Process 157
Pre-ight Medical Screening Services 157
Procedures for an Incident
during Flight 158
Death Onboard 158
Post-exposure Plans 159
The Mechanics of Lifting 160
Anatomy of the Back 160
Injuries to the Back 160
Principles of Lifting 161
Moving a Victim 161
Passengers with a Disability 161
Oxygen Systems 162
Supplemental Oxygen Systems 162
Pre-ight Checks for Oxygen Systems 162
Oxygen Delivery 163
Safety Considerations When Using
Oxygen 163
Portable Oxygen Systems 164
Determining Oxygen Needs for
a Flight 165
Medical Equipment 166
MedAire Aircraft First Aid Kit (AFAK) 166
MedAire Emergency Medical Kit
(EMK) 168
MedAire Pediatric Supplemental Kit 170
MedAire Commercial Airline Kits 171
Telemedicine Devices 172
Automated External Debrillators
(AEDs) 172
Pocket Masks and Face Shields 173
Personal Protection Equipment (PPE) 174
Pandemic Planning 176
Overview of the World Health
Organization Pandemic Phases 176
Nonpharmaceutical Interventions 177
7
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MedAire, Inc.
MedAire, Inc., an International SOS company, provides a life-saving solution that
includes remote medical education, expertise, and equipment for the aviation and mari-
time industries. Whether a medical situation occurs in the air or on the ground, MedAire
provides crew members with the tools to successfully manage any medical situation that
may arise.
This section provides a step-by-step guide to MedAires full line of products and ser-
vices created especially for both the general and commercial aviation environment.
MedAire, Inc., provides a fully integrated
medical support program that is used around
the world, bringing peace of mind to thousands
of people each day. Through a careful blending
of technology, medicine, training programs, and
years of experience in managing remote
medical incidents, MedAire, Inc., has become a
complete, one-stop solution for people who are
isolated from their customary sources of
medical care.
Services for the Aviation Industry
For commercial airlines around the world,
MedAire, Inc., provides a valuable service to
assist crew members when managing passenger
illness and injury while dramatically reducing
the number of aircraft diversions related to
medical incidents. In addition, crew members
also have access to immediate medical assis-
tance through the crew support program if they
experience a personal medical situation while
traveling on duty.
Since 1986, MedAire, Inc., has continually
evolved the range of medical products and ser-
vices offered in order to meet the rigorous and
ever-changing demands of the aviation industry.
The company provides the following services:
MedLink is a worldwide, 24-hour emergency
telemedicine center accessible via radio data,
telephone, and satellite, which provides
direct and immediate consultation with the
on-duty, board-certied emergency
physicians.
The MedLink Passenger Assistance Service
(PAS) program is a consultative service that
helps passengers, in conjunction with their
physicians, identify and manage any poten-
tial medical concerns that might arise from
aviation-related environmental factors, such
as decreased cabin pressurization levels
and reduced oxygen. For example, any
passengers who have chronic heart or
lung conditions and require supplemental
oxygen during a ight can make the
necessary arrangements to have the appro-
priate medical equipment onboard through
this service.
Customized travel assistance information,
including worldwide health and immuniza-
tion advisories, provides guidance to passen-
gers traveling overseas or to remote
locations. Global Travel Watch, an online
resource for important medical and disease
updates for every country in the world, can
be accessed online at www.medaire.com.
Contact your account manager for details.
Experience-based emergency medical training
is conducted by ight nurses and paramedics
to help pilots and ight attendants prevent
and/or effectively manage medical situations
in-ight. MedAire, Inc., incorporates the very
latest technology by providing interactive
Internet-based training programs that actively
involve the participants in the learning
process. These training programs also
provide immediate access to electronic
reports and student data collection for the
clients.
Medical kits that meet and exceed all Federal
Aviation Administration (FAA) and Joint Avia-
tion Requirement on Commercial Air Trans-
portation (JAR-Ops) requirements are
available. In addition, the company produces
highly advanced, emergency medical kits,
which are designed specically for the avia-
tion environment and can be customized
to meet any governing regulations or individ-
ual need.
Telemedicine devices and automated external
debrillators (AEDs) are available for use
onboard aircraft. In addition, training pro-
grams are available to teach crew how to use
this equipment safely and effectively within
the constraints of the aircraft environment.
Services Provided by MedAire, Inc.
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This service is based in a state-
of-the-art, 24/7 MedLink
Global Response Center
(GRC), which provides crew
members access to on-duty
emergency physicians who
help manage in-ight medical
incidents worldwide.
The MedLink Global
Response Center is staffed by
communication specialists who
coordinate each call and by
physicians who understand the
unique constraints associated
with the aircraft environment.
communication specialist will
identify the nearest available
and appropriate medical
resource using MedAires
exclusive database of more
than 15,000 network providers
in 5,000 cities worldwide. The
communication specialist will
organize the emergency
medical response upon
landing and, when necessary,
arrange for the victim to be
transported to the most appro-
priate medical facility.
The MedLink Emergency Service
The MedLink physicians have
access to detailed information
regarding the medical equip-
ment onboard the aircraft and
are skilled in managing medical
emergencies remotely through
the use of a high-tech commu-
nication system. The MedLink
physician will talk the crew
member through the manage-
ment of the ill or injured pas-
senger or crew, utilizing the
onboard medical equipment.
If a diversion or hospitaliza-
tion is recommended, the
MedLink Global Response Center
Communication specialists at MedLink organize responses to calls from around the world. The physi-
cians on duty give comprehensive guidance on managing any medical situations that arise during ights.
MedAire, Inc., has a compre-
hensive Quality Improvement
(QI) program that is designed
to ensure that the needs of the
customers are always being
met by the MedLink service.
tion with the medical director
of the service, the QI nurse
reviews the data on the care
delivered and the outcome of
every call.
Quality Improvement Program
The QI program is directed
by a dedicated QI nurse, who
collects data on the care and
outcome of all medical inci-
dents managed by the
MedLink service. In conjunc-
The International Organization
of Standardization (ISO) Certi-
cation is a set of international
standards for a quality assur-
ance system that is recognized
ISO 9001:2000 standards and
has shown quality improve-
ment with each audit, earning
Certicates of Excellence.
ISO Certication
around the world. In 2002,
MedAire, Inc., received initial
certication to ISO 9002:1994.
In 2003, MedAire, Inc.,
upgraded and recertied to the
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Ensure scene safety.
Assess the victims condition and the extent
of the emergency.
Begin emergency treatmentinitiate CPR or
debrillation (AED) if indicated.
Notify the ight crew of the emergency.
Record information concerning the victim on
the patch checklist.
If an infectious disease is suspected (see
Reporting Infectious Diseases during Flight),
obtain the following information prior to con-
tacting MedLink:
History of the medical incident
Signs and symptoms
Vital signs and temperature (essential for
infectious disease evaluation)
Travel historywhere the victim has traveled
in the past few weeks
Relevant history of potential exposures to
infectious diseases
Contact MedLink.
PATCH PROCEDURE
When an in-ight medical situation occurs, the MedLink service recommends carrying out the follow-
ing procedure:
In the event medical support is
required during an in-ight
medical incident, it is advisable
to contact the MedLink Center.
The communication specialist
the MedLink physician; these
details should provide enough
information for the physician
to advise the crew on how to
manage the situation.
Contacting MedLink
who answers the call will
follow a course of action
called the patch procedure. In
this procedure, information
regarding the victim is given to
In-ight Medical Support
+1-602-239-3627
ARINC: PHXMACR
Step One: Initiate phone patch with MedLink
Step Two: Please provide the following
information:
1. Aircraft registration number
2. Aircraft type
3. Origination, destination and ETA (in Zulu)
4. Patient information (see reverse side for
information)
5. Position of patient (principal or crew)
6. Revised destination and ETA in Zulu
(if diversion is necessary)
7. Preferred FBO/handling agent at destination
(if medical assistance is required upon
arrival)
In-ight Medical Support
+1-602-239-3627
ARINC: PHXMACR
Please provide the following patient information to the
physician:
Reg. #: _______________ Age: ______ Gender: ______
Position (crew/principal): _______________________________
WorldWide ID # (if applicable): __________________________
Conscious (y/n/in & out): _______________________________
Problem/complaint: ____________________________________
________________________________________________________________
Medical alert tag? (if yes, explain): ______________________
Medical history: ________________________________________
________________________________________________________________
Current medications: ___________________________________
_________________________________________________________________
Allergies: ______________________________________________
Blood pressure: _________ /_________ Pulse: __________
Respirations: __________________________________________
Departure and arrival locations
Tail number (corporate aircraft) or ight
number (commercial aircraft)
Geographic location of aircraft (or, in remote
areas, coordinates of aircraft location)
Estimated time of arrival at destination in
Zulu time
Condition of victim
Age, gender, and chief complaint of the
victim
Closest available airport in case of a diversion
CONTACTING MEDLINK
On the ground, the service can be contacted via the emergency telephone number. In-ight, air-to-
ground communication systems can also be used.
The MedLink service will ask crew for the following information:
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When a crew member contacts
MedLink, the call will initially
be answered by a communica-
tion specialist who will coordi-
nate the entire call. The crew
will be asked for information
concerning the victim and for
details concerning the ight.
Typical Emergency
Procedure
The communication specialist
will immediately notify one of
the physicians on duty for the
MedLink Center. The physician
has access to information
regarding the emergency
equipment onboard, which
enables him or her to advise
the crew. If the physician feels
that a diversion should be
considered for medical
reasons, the captain will be
provided with medical infor-
mation upon which he or she
can make the ultimate deci-
Aircraft Diversions
If the captain elects to divert
the aircraft, the MedLink com-
munication specialist will
access MedAires proprietary
global database of medical
resources to help the captain
select a destination airport that
offers appropriate medical
response and care for the
victim. In addition, the
MedLink service will notify the
following authorities and
agencies, as appropriate:
Air trafc control
Customs
Operations/dispatch (com-
mercial aviation)
Airport security
Fixed base operations
(FBOcorporate aircraft)
Port Health Authority
MedLink Call Process
sion. If a diversion is neces-
sary, the MedLink service will
then provide the captain with
information about the appro-
priate medical resources at all
of their destination alterna-
tives. After the initial patch,
the MedLink service will con-
tinue to monitor the progress
of the ight and the victims
condition. Crew are encour-
aged to re-patch if the victims
condition changes or to
provide updates.
Medical Help upon Arrival
If the victim requires further
medical care upon landing,
the MedLink service will coor-
dinate the necessary medical
response. The service will
organize emergency medical
services to meet the aircraft,
and the emergency medical
system will assume care at
that point.
To help commercial airlines
limit possible delays and
costly medical diversions,
MedAire, Inc., can arrange for
passengers special medical
needs to be met before travel-
ing. The service provides pre-
ight screening and ensures
that passengers have essential
approved medical equipment
during the ight.
Passenger Fit-to-Fly
Through the MedLink emer-
gency telemedicine center,
MedAire, Inc., can help gate
agents pre-screen travelers
with questionable health prior
to boarding to ensure that
their physical condition will
allow them to y safely. This
process, called Passenger Fit-
to-Fly, is highly effective and
has proved successful in iden-
tifying high-risk individuals.
Passenger Assistance Service
(PAS) to properly assess the
situation in conjunction with
the passengers doctor and to
determine the in-ight needs.
Based on this assessment, the
passengers travel needs can
be accommodated on the
aircraft.
Pre-ight Medical Screening Services
The Passenger Assistance
Service (PAS)
Some passengers have medical
conditions that require special
attention and resources (e.g.,
supplemental oxygen) during
ight. When these individuals
identify themselves during the
ticketing process, the airline
can refer them to the MedLink
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Procedures for an Incident during Flight
Responding to an in-ight medical emergency has been thoroughly discussed in previ-
ous chapters. However, during the response, situations can occur that may be difcult
to address. This section addresses how to manage a death on board, exposures to infec-
tious diseases, and post-exposure plans.
A death during a ight is a
very distressing experience for
both crew and passengers. If
the aircraft is unable to land
for emergency care (e.g.,
transoceanic ights), resuscita-
tion efforts may be stopped
after a certain period of time if
there is no response. The
MedLink physician will
provide guidance regarding
this situation. The following
guidelines may help the crew
deal with a death with sensi-
tivity and professionalism.
Cessation of Resuscitation
Procedures
If resuscitation efforts have
been stopped, move the body
to a private place in order to
avoid upsetting other passen-
gers if possible.
If possible, place the body
in a clear area, but not in
the galleys, toilets, or block-
ing an emergency exit.
Make the area around the
body as private as possible.
Cover the body with a
blanket. If possible, place
blankets and waterproof
material under the body in
case there is any seepage of
body uids.
If any medical devices, such
as electrode pads, catheters,
or intravenous cannulas, are
attached to the deceased
person, leave these items in
place. Clear away all other
medical equipment, making
sure that it is stowed or dis-
posed of correctly. Complete
the necessary paperwork.
Note the time when life-
saving procedures were
carried out and when they
physician will not pro-
nounce anyone dead in-
ight. This must be done by
a licensed provider once the
aircraft has landed and the
victim is in the care of
medical providers.
Supporting Travel
Companions
If the deceased person was
traveling with any friends or
relatives, take these people to
a private area and advise them
that resuscitation efforts have
stopped. Offer them any
comfort, support, and assis-
tance that they may need.
Obtaining Support
for Crew Members
A death can be distressing for
crew members. If they suffer
any post-incident stress reac-
tions, such as anxiety, depres-
sion, guilt, or persistent
thoughts of the event, they
may nd it helpful to seek pro-
fessional advice for counseling
or other resources that may be
provided by their employers.
Death Onboard
were stopped. This informa-
tion is necessary so that the
death can be ofcially con-
rmed by a licensed
medical practitioner once
the victim is transferred to a
medical facility upon
landing.
Inform the aircraft captain
of the cessation of resuscita-
tion efforts; he or she will
complete the required
paperwork.
Local authorities, such as
the police and the emer-
gency medical services, will
be notied and will respond
upon landing.
Some countries require air-
craft to be impounded upon
landing when a death has
occurred during the ight.
Be sensitive to differing cul-
tural beliefs and practices.
Passengers traveling with
the deceased person may
have specic requests.
Other passengers nearby
may be distressed if they
know of the death, so be
prepared to offer support as
needed. Note: The MedLink
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Caring for victims may involve
risks to personal health and
safety. One signicant risk is
the risk of infection from the
victims body uids, soiled
dressings, or other rst aid
items. Another possible hazard
is a wound from sharp items
such as syringes, needles, and
lancets (see following discus-
sion). Follow the procedures
for preventing exposure and
disposing of clinical waste.
Sometimes, despite all precau-
tions, signicant exposures to
blood-borne pathogens can
occur. It is important for every
company to have a well-
documented post-exposure
plan for all employees.
Recommendations for
Company Post-exposure
Plans
Every company should have a
post-exposure plan to provide
care for employees following
membranes, and needle-
sticks. Disease transmis-
sion does not usually
occur with brief expo-
sure to intact skin and
is not considered a
signicant exposure.
Immediate access to the
companys plan, 24 hours
a day
Follow-up medical and
counseling care
Record keeping
Training of supervisors and
employees, including edu-
cation on prevention of
infection, precautions to
take, and information on
how to access the compa-
nys post-exposure plan
Resources for developing post-
exposure plans are as follows:
www.osha.gov
www.cdc.gov
Post-exposure Plans
situations in which they are
exposed to blood/body uids
or other infectious diseases.
This plan should be available
and made known to all
employees so that they can
seek immediate medical
advice in the event of an
exposure. The plan must
include the following core
principles at a minimum:
Immediate access to
medical consultation for
employees

Each signicant exposure

incident must be evalu-
ated to determine the
degree of risk of infection
and the appropriate treat-
ment. Employees should
be able to seek medical
advice quickly, because
medical evaluations and
treatment options may be
time-sensitive. Risk
increases with exposure
to broken skin, mucous
1
Put on disposable gloves
(if you have not done so
already). Bring the sharps con-
tainer to the sharp item, and
place the item in the container
immediately to prevent any
further injury.
2
If the wound is small,
encourage bleeding to
ush dirt or infectious organ-
isms out of the tissues as much
as possible. Wash the area
with soap and running water.
Use friction when washing
your hands. Dry the wound
with a clean paper towel and
dress the wound.
who used the needle if avail-
able (specically if there is a
history of hepatitis or HIV).
This will assist in the risk
assessment regarding the post-
exposure treatment plan.
5
Immediately notify your
supervisor of the incident.
Arrange for a medical evalua-
tion and activate your com-
panys post-exposure plan.
3
For larger wounds or
wounds affecting mucous
membranes (e.g., the inside of
the nose or mouth), wash the
injured area under running
water. Flush the wound or
mucous membranes with
copious amounts of water.
Avoid jet irrigation of
puncture wounds as this
may increase contamination.
Dress the wound.
4
It is not necessary to save
the needle that caused the
needlestick injury. It is helpful
to obtain medical history
information from the person
MANAGING A SHARPS INJURY
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The Mechanics of Lifting
Travelers and ight crew can be at risk for potential back injuries because of the need
to move passengers, luggage, or other heavy items. This section describes how to lift
objects or people safely. The anatomy section shows the structure of the spine. The
principles of lifting include how to move a victim or assist a person with a disability.
Note that lifting a victim is not recommended except in an emergency.
The back is one of the
strongest parts of the body.
The central structure is the
spine (vertebral column).
The top supports the head;
the central part anchors the
ribs; and the base provides
a stable center of gravity for
movement and helps
support the bodys weight.
The vertebral column also
protects the spinal cord.
Anatomy of the Back
Cervical vertebrae
support neck
and head
Thoracic vertebrae
support rib cage
and upper back
Lumbar vertebrae
support lower back
Sacrum supports
pelvis
Coccyx
Disk
Ligament
Vertebrae
Vertebra
Strenuous activity that involves lifting,
bending, or twisting movements can easily
injure the back. Pain, particularly in the lower
back and neck, is very common. In most
cases, back pain is due to minor strains (see
Strains and Sprains) or injuries to the muscles,
ligaments, or facet joints. More serious but rare
causes include fractures of vertebrae, pro-
lapsed disks between vertebrae, and underly-
ing disorders such as arthritis. Some back
problems may result from aging, such as a
prolapsed intervertebral disk. This occurs
because the core of the disk becomes less
elastic and the outer part becomes weaker,
resulting in a prolapsed disk.
Injuries to the Back
Compressed nerve
Spinal cord
Vertebra
Outer layer
of disk Core of disk
Damaged
area of disk
Structure of the Back
The vertebral column consists of
33 bones (vertebrae) with disks of brous tissue in between. Liga-
ments and muscles help support the spine and, together with the
disks, enable the back to bend. Nerves pass between the vertebrae
from the spinal cord to the rest of the body.
Structures That Connect
Vertebrae
The vertebrae are held together
by ligaments. Between the verte-
brae are disks with a brous cov-
ering and a softer core. The disks
act as shock-absorbers and, with
ligaments, allow exibility of
the spine.
Prolapsed Intervertebral Disk
The brous covering of a disk is bulging or ruptured,
and the softer core is pushed outward. The disk may
press on a spinal nerve, causing severe pain or weak-
ness in the area supplied by that nerve.
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Crew may have to carry out a
variety of heavy manual activi-
ties, such as lifting, pushing,
and pulling, which may cause
injury to the spine if not per-
formed correctly. Correct lifting
techniques can help prevent
back injuries from occurring.
Certain principles should be
followed wherever possible.
Use your leg muscles to
push you up as you lift the
object.
If you are lifting a load a
long way, for example, from
the oor to shoulder height,
try to rest the load halfway
so that you can re-adjust
your grip.
Principles of Lifting
Stop, think, and plan the
task before you begin.
If more than one person is
involved in the task, select
one person to coordinate
the move.
If you have to carry the
object anywhere, make sure
that the path is free of
obstructions rst.
Position yourself as close as
possible to the load, with
feet apart and your leading
leg as far forward as possi-
ble to give yourself a stable
base.
Bend at the knees so that
your hands are as near
Lift smoothly, using your leg
muscles to provide the
power for the lift.
When turning, avoid twist-
ing your bodymove your
feet instead.
waist level as possible when
lifting.
Keep your back straight,
but not rigid.
Put your arms between your
knees.
Take a rm grip on the base
of the object.
TIPS ON LIFTING SAFELY
In general, it is recommended
that you do not move a victim
unless it is absolutely neces-
sary. If you must move a victim
(e.g., the scene is unsafe), con-
sider the following questions:
Can the victim move
unaided?
Is there a risk of aggravating
the victims condition by
moving him or her?
Are there any aids available
on the aircraft that would
are going to move him
or her.
Never ask someone to put
his or her arms around your
neck, because serious inju-
ries can occur.
WARNING: Never move a
victim with neck or spine
injuries unless the persons
life is at risk or you are
unable to provide life-
saving care.
Moving a Victim
make the task easier, such
as an onboard wheelchair?
Are there other people who
can assist in the move and
are willing to help?
In addition, remember the fol-
lowing points to ensure your
safety as well as the victims
safety:
If moving a victim, explain
to him or her what you are
going to do and how you
Passengers with a stable dis-
ability do not need medical
clearance before ying.
However, anyone who will
need assistance during the
ighte.g., going to the
lavatoryshould be accompa-
nied by another person who
can provide the necessary
support. If the passenger does
not have a suitable escort,
consider refusing to let the
person y. If you are in doubt
about a persons tness to y,
seek advice from MedLink.
Maneuvering a wheelchair
and passenger along the
aisle of the aircraft
Assisting a frail passenger
while he or she is walking
Guiding a visually impaired
person through the cabin
and orienting them to the
seat controls
Assisting a passenger to
stow carry-on luggage
Passengers with a Disability
When to Offer Help
to Passengers
Crew should observe their
company policy concerning
expectations for assisting pas-
sengers with disabilities.
Crew may be expected to
assist a passenger in the fol-
lowing ways:
Steadying an onboard
wheelchair while the pas-
senger moves into or out of
a seat
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Oxygen Systems
Atmospheric pressure and oxygen levels decrease with altitude. Aircraft cabins are
usually articially pressurized to a cabin altitude of 5,000 feet to 8,000 feet. This allows
healthy people to breathe normally during ight. Aircraft also carry additional oxygen
for use in the event of a decrease in cabin pressure or medical emergencies.
All aircraft that y above
10,000 feet (3,000 m) are
required to carry supplemental
oxygen for two main pur-
poses: if cabin pressurization
decreases, in which case
oxygen is required to prevent
hypoxia, and for people with
heart or lung problems, who
may need supplemental
oxygen. The oxygen used on
the aircraft, known as aviation
oxygen, is contained in
oxygen bottles situated in the
fuselage of the aircraft or in
portable oxygen cylinders. It
has had the water vapor
removed to prevent freezing at
high altitudes. Aviation oxygen
may be used in medical
emergencies.
Types of Oxygen Flow
Supplemental oxygen systems
release oxygen either by con-
tinuous ow, which delivers a
constant supply to the user, or
by demand, which delivers
oxygen only when the user
oxygen than in continuous-
ow systems. The regulators
are usually used at altitudes
of 35,000 feet to 40,000 feet
(10,66012,000 m).
Pressure-demand systems
are used above 40,000 feet
(12,000 m), in unpressur-
ized aircraft, because other
oxygen systems do not
provide enough pressure to
deliver oxygen into the
lungs. They provide 100%
oxygen under pressure, via
a tight-tting mask. Pres-
sure-demand systems
supply oxygen only when
the user inhales, so waste is
limited. However, the
systems are not recom-
mended for use with
oxygen bottles because they
contain a limited amount of
oxygen. In addition, thick
facial hair may prevent the
oxygen mask from tting
correctly. Grease-based
makeup may cause burns
with prolonged exposure.
Supplemental Oxygen Systems
inhales. In all types of
systems, the rate of oxygen
ow is measured in liters per
minute (Lpm).
Continuous-ow systems
include drop-down masks
in most aircraft, therapeu-
tic or rst aid oxygen in
corporate aircraft, and por-
table oxygen systems. Low-
ow systems which deliver
1 to 3 Lpm can be used
with a nasal cannula. High-
ow systems are capable of
delivering 6 to 15 Lpm but
are usually set at 4 Lpm on
some aircraft. The main dis-
advantage of continuous-
ow systems is that the
oxygen is delivered to the
user during all phases of
breathing which results in
wasted oxygen.
Diluter-demand oxygen
regulators provide a high
percentage of oxygen to the
user during inhalation only
via a tight-tting mask. As a
result, there is less wasted
Pre-ight checks should be
conducted regularly to ensure
that oxygen systems function
properly. The specic proce-
dures depend on the type of
system, but general guidelines
are as follows.
Crew Oxygen System
This system is located in the
cockpit. Specic details regard-
ing a pre-ight check should be
covered in the ight manual.
Locate the oxygen mask.
Check for cracks, tears, and
deterioration.
Onboard Fixed System
Observe panel gauges to
see if the system is at its
maximum level. (A reading
of 1,800 PSI [pounds per
square inch] is considered
full.)
Check the system according
to the criteria established by
the manufacturer.
Portable Oxygen System
Follow pre-ight checks on
portable oxygen systems
and passenger supply units.
Pre-ight Checks for Oxygen Systems
Practice putting on the
oxygen mask. Adjust the
head harness to t the mask.
Locate the oxygen pressure
gauges, ow indicators, and
connections. Check that all
of this equipment functions
correctly.
Check the quantity of
oxygen in the system.
Turn the system on and
ensure that it is functioning
properly.
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Oxygen is delivered through a mask or nasal
tubing (cannula), which increases the percent-
age of oxygen in the air that the user breathes.
Aviation Mask
This is the yellow drop-down mask used by all
passengers and crew members in emergency
situations during a rapid decom pression.
Face Mask
This is a mask supplied with high-ow portable
oxygen systems. It can increase the oxygen
concentration in inhaled air to 40% to 60%. Use
with a high setting of at least 6 Lpm.
Nasal Cannula
The nasal cannula can
increase oxygen concentra-
tion in inhaled air by 4%
for every Lpm of oxygen
ow. Use with a setting of
6 Lpm or less.
Pocket Mask with
Oxygen Inlet Port
This mask is used for
rescue breathing. It has a one-way ow valve
through which the rescuer breathes and an inlet
port for the oxygen supply. The mask increases
oxygen concentration in inhaled air by 5% for
every Lpm of oxygen ow.
Nonrebreather Mask
This item consists of a
face mask attached to a
reservoir bag. It increases
oxygen concentration in
inhaled air by 10% for
every Lpm of oxygen
ow. The reservoir bag
should inate if the ow
is adequate. Use with a
setting of 610 Lpm or
greater.
Humidiers
Aviation oxygen has had water vapor removed
to prevent freezing at high altitude. As a result,
it can dry the mucous membranes of the mouth
and nose. If oxygen is to be used for a long
period, it is advisable to use a humidier, which
adds water vapor back into the oxygen to
prevent the drying effect. Humidier units have
high-pressure tubing and connect to an outlet
such as a wall oxygen unit in the aircraft or an
oxygen bottle.
Oxygen Delivery
Oxygen is a potentially am-
mable substance and can pose
hazards in an aircraft. The fol-
lowing measures must be
taken to ensure that oxygen is
stored and handled safely.
Know your oxygen system
and regularly perform the
necessary pre-ight checks.
oxygen near ammable
products.
When using an AED, keep
the oxygen bottle away
from the area.
Never allow a nonaviation-
certied oxygen cylinder
(e.g., a hospital bottle or a
personal bottle) onboard an
aircraft.
Safety Considerations When Using Oxygen
Inform all passengers how
to use emergency oxygen
supplies correctly.
Secure all portable oxygen
bottles. Never drop an
oxygen bottle or leave it
unsecured in a position
where it might fall.
Do not smoke near an
oxygen supply or use
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Many aircraft have portable oxygen systems for
use in medical emergencies. Any passenger
who needs oxygen is usually given an oxygen
bottle initially. If oxygen is needed for any
length of time, an oxygen unit or the aircrafts
ring main may be accessed.
Oxygen Bottles
These systems usually consist of a bottle of
high-pressure oxygen with a regulator, pressure
gauge, and mask outlet. Oxygen can be
Portable Oxygen Systems
delivered through either a mask or a nasal
cannula. The regulator may show liters per
minute (Lpm), or it may be pre-set for low ow
(2 Lpm) and high ow (4 Lpm). The pressure
gauge shows the amount of oxygen in the
bottle, giving readings in pounds per square
inch (PSI). A reading of 1,800 PSI is considered
full. Some bottles have ports for connecting
two to four masks. Other portable systems have
high-ow and low-ow regulators.
main, to a passenger oxygen
unit if available, or to a thera-
peutic outlet.
Warning
You must never empty the
oxygen bottle completely;
leave at least 500 PSI in it at
all times.
back of the head, then tighten
it to t.
2
To start the oxygen ow,
turn the regulator knob
slowly to the required setting.
3
Once you have nished
with the oxygen, turn it off.
If more oxygen is needed,
transfer the person to the ring
PORTABLE OXYGEN SYSTEMS
Portable Oxygen Bottle
1
Place the oxygen bottle on
the seat next to the person
and secure it. If there is no
vacant seat, you may need to
move the passenger sitting next
to the victim. Place the oxygen
mask on the persons face. Put
the elastic strap around the
Portable Oxygen Concentrators (POCs)
The FAA has approved portable oxygen concen-
trators (POCs) for use on aircraft. These units are
brought onboard by the passengers who are
responsible for operating the units while in
ight. The unit lters nitrogen from ambient air
and delivers concentrated oxygen at varying
percentages.
The passenger must be
able to operate and trouble-
shoot the POC. Extra batter-
ies are recommended. Secure
the POC on takeoff and
landing and during times of
turbulence.
Every 6 months, check the
oxygen ow. First, connect the
mask and tubing and set the
system on the lowest ow rate.
Feel for oxygen ow from the
mask. Next, set the system on
the highest ow rate and feel
for increased ow. If there is a
reservoir bag attached to the
oxygen mask, the bag may or
may not inate, depending on
the system. Finally, turn the
oxygen system off, disconnect
the mask, and store it.
Check that the bottle is
stowed correctly. It should
be stored either upright or
at and should be well
secured. The area where the
bottle is stored should be
free of oil and dirt.
Ensure that the oxygen
equipment will be easy to
access in the event of an
emergency.
Check that the mask con-
nector ts properly into the
outlet.
PRE-FLIGHT CHECKLIST FOR PORTABLE OXYGEN SYSTEMS
Clean your hands before
touching the equipment.
Take particular care to
clean off any petroleum
products, because these
products combined with
oxygen can cause a re.
Ensure that the oxygen bottle
shut-off valve is turned OFF.
Look at the pressure gauge.
It should show a reading of
at least 1,800 PSI. If the
reading is lower than 1,800
PSI, the oxygen bottle
should be serviced.
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If a victim needs oxygen due to a medical con-
dition, it is possible to determine the amount
required for the duration of a ight. The follow-
ing formulas can be used to calculate the
volume of oxygen cylinder needed, how much
oxygen is in a cylinder (actual capacity), and
the duration of the oxygen supply for different
sizes and types of oxygen cylinders.
Determining Oxygen Needs for a Flight
Key: Units of Measurement Used
Oxygen pressure: pounds per square inch (PSI)
Volume: liters (L) and cubic feet (cu ft)
Flow rate: liters per minute (Lpm)
Quick Reference for E Cylinder
Oxygen Bottles
PSI 0.28
Lpm
minutes of available oxygen
Formulas for Larger Bottles
Cylinder capacity in liters:
# cu ft 28.3 L/cu ft # liters
Actual capacity of cylinder in liters:

Actual PSI
1,800 PSI
% ll
Duration of Oxygen Supply:

# L
# Lpm
# minutes of available oxygen
FORMULAS FOR DETERMINING OXYGEN NEEDS
Example 1
An 11-cubic-foot oxygen cylinder is available.
The actual pressure is 1,500 PSI and the
maximum possible pressure is 1,800 PSI. How
long can oxygen be administered at a ow rate
of 4 Lpm? Temperature remains constant.
Cylinder capacity in liters:
11 cu ft 28.3 L/cu ft 311.3 liters
Actual capacity of cylinder:

1,500 PSI
1,800 PSI
0.83 (83% ll)
Actual capacity of cylinder in liters:
311.31 0.83 258.4 liters
Duration of oxygen supply:

258.4 L
4 Lpm
64.6 minutes of oxygen available
Example 2
A 6-hour ight is planned and oxygen must be
administered at a ow rate of 7.5 Lpm. What
volume of oxygen in both liters and cubic feet
will be required for the ight? Temperature
remains constant.
Volume in liters:
# Lpm # minutes of available oxygen
# liters of oxygen required
For example, 7.5 Lpm 360 minutes
2,700 liters of oxygen required
Volume in cubic feet:

# L
28.3 L/cu ft
# cubic feet of oxygen
required
For example,
2,700 L
28.3 L/cu ft
95.4 cubic feet
of oxygen required
Contacting the passenger and his or her phy-
sician to discuss the medical issues and pro-
cedures related to the articial cabin
altitude
Obtaining a written statement from the pas-
sengers physician specifying the persons
oxygen requirements
Determining the oxygen settings to be admin-
istered during the ight
Calculating the total oxygen supply necessary
for the passenger to complete the ight
Documenting and maintaining records for all
communications and outcomes regarding
oxygen use
MANAGING OXYGEN NEEDS
One important part of the MedLink service involves managing the requirements of passengers who
need supplemental oxygen during air travel. The process of accepting a passenger who requires
oxygen can be complex and necessitates medical expertise in aviation physiology. The PAS program
includes the following:
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Medical Equipment
MedAire, Inc., provides a variety of rst aid and medical kits specically designed for
the aviation environment. All of these kits meet and exceed the FAA regulations as well
as JAR-Ops. In addition, aircraft may be equipped with emergency equipment such as a
telemedicine device and an automated external debrillator (AED). This section covers
the main kits available on both corporate and commercial aircraft and also gives exam-
ples of an AED and a telemedicine device.
MEDAIRE AIRCRAFT FIRST AID KIT (AFAK)
MedAire Aircraft First Aid Kit
The Aircraft First Aid Kit (AFAK) is most commonly carried on business aviation air-
craft. It exceeds FAA regulations and JAR-Ops. The AFAK is used for treating
common injuries or illnesses and can be used by ight attendants. The kit contains
four pouches: an orange pouch, containing items for victim assessment; a red
pouch, containing wound care supplies; a black pouch, with medications for
common in-ight conditions; and a blue
pouch, containing equipment for
airway management. The contents
also include a biohazard bag for dis-
posing of potentially infectious
waste items and a wire ladder
splint to stabilize injured limbs. In
addition, there is a content card,
rst aid guide, and a search and
rescue signal code.
Note: Kit contents may vary
due to product revisions after
publication.
CONTENTS
Lid Pocket
Biohazard bag
Content card
Germicidal disinfectant wipe
Ground/air visual code guide
Poly tamper seals
MedLink patch checklist
Inside Perimeter
Dental emergency kit
Ladder splint
Armboard
First Aid record sheet
First aid handbook
EpiPen (Rx kit)
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Black Medications Pouch
Airborne tablets
Cimetidine, 200-mg tabs
Instant cold pack
Glucose 15GM tube (Rx kit)
Nitroglycerin tabs, 0.4 mg (Rx kit)
Oxymetazoline HCl, 0.05% nasal spray
Antacid tablets
Acetaminophen, 500-mg tablets
Ammonia inhalants
Diphenhydramine, 25-mg tablets
Bacitracin ointment
Aspirin, 325-mg tablets
Loperamide HCl, 2-mg tablets
Prednisone, 20-mg tablets (Rx kit)
Water germicidal tablets to treat water
Drinking water packets
Phenazopyridine, 200-mg tablets
MEDAIRE AIRCRAFT FIRST AID KIT (AFAK), continued
Blue Airway Pouch
Alcohol hand gels
CPR pocket mask with oxygen inlet
Manual suction device
Gloves, nonlatex
N95 mask
Surgical masks
Red Wound Pouch
Triangular bandages with safety pins
Adhesive strips, 1
Tape, 1
Gauze pads, 4 4
Bandage scissors
Gloves, nonlatex
Antiseptic towelettes
Gauze bandages, 4 rolls
Burn dressings, 4 4
Abdominal gauze pads, 5 9
Adhesive wound closures
Orange Assessment Pouch
Emergency survival blanket
Stethoscope
Blood pressure cuff
Thermometer, digital
Forceps (tweezers)
Signal mirror
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UPPER LID
Top Compartment/Black
Pouch (#04)
Antacid, 420-mg tablets
Ciprooxacin, 500-mg UD
tablets
Diphenhydramine, 50-mg UD
tablets
Doxycycline, 100-mg tablets
Fluconazole, 50 mg
Ibuprofen, 200 mg
Naprosen, 550-mg tablets
Metronidazole, 500-mg
tablets
Nitroglycerin, 0.4-mg sublin-
gual tablets
Epinephrine auto-injector
First aid thermal blanket
Loperamide HCl, 2-mg tablets
Dimenhydrinate, 50 mg
Oral rehydration salts
Phenylephrine, 10-mg tablets
Sulfamethoxazole/
trimethoprim, 800/160-mg
tablets
Bronchodilator, inhaled meter
dose
Ondansetron, 4 mg
Pepcid complete
Middle Compartment/
Yellow Pouch (#05)
Cephalexin, 500-mg tablets
Ciprooxacin ophthalmic solu-
tion (eyedrops)
MEDAIRE EMERGENCY MEDICAL KIT (EMK)
This kit is designed for the business aviation environment. It exceeds
FAA regulations and JAR-Ops. The EMK contains equipment for
serious or complex conditions. Crew members may use it only under
the direct instructions of MedLink. The EMK has 12 compartments.
Like the other kits, it also has color-coded main pouches as well as
numbered compartments with a visible red tag. Compartments 0103
are the outer pockets. Compartments 0407 are the main sections
inside the kit. The lid has an inner compartment (08), with three
pouches (0911) and a concealed section (12).
Note: Kit contents may vary due to product revisions after
publication.
MedAire Emergency
Medical Kit
LOWER STRAPS
Trauma dressing
TOP ZIPPERED
COMPARTMENT (#08)
Top Pouch (#09)
Ethilon sutures, 3-0 and 5-0
Vicryl suture, 4-0
Middle Pouch (#10)
20-cc syringe
60-cc syringe
Lower Pouch (#11)
18-g and 25-g needles
(needle safe)
20-g needle (needle safe)
10-cc and 3-cc syringes
1-cc syringe with 27-g needle
(needle safe)
Buttery infusion sets, 21 g
(needle safe)
Velcro Sleeve (Hidden
Pouch) (#12)
Biohazard bag
Germicidal disinfectant wipe
Waterjel burn dressings,
2 6
Directions for use of
medications
Content card
MAIN COMPARTMENT
Upper/Blue Pouch (#06)
AeroChamber inhaler
IV catheters, 18 g (needle
safe)
IV catheters, 20 g (needle
safe)
IV administration tubing
with 2 Y connectors
IV start kit
N95 masks
Surgical masks
Lower/Orange Pouch
(#07)
Alcohol hand gel
Dressings, sterile, 4 4
Gauze, 4 roll
Germicidal tablets for water
treatment (25 qt)
Gloves, surgical, sterile
Glucose gel
Instrument tray, all purpose
Needle holder
Povidone-iodine solution
SAM splint
Scalpels, #11
Splash shield
Wound cleanser, 100 mL
Nonlatex gloves
Perimeter
Splint
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EXTERIOR
COMPARTMENTS
Right Exterior Pouch (#01)
Sharps container
MEDAIRE EMERGENCY MEDICAL KIT (EMK), continued
Top Exterior Pouch (#02)
Abdominal pad, sterile
Buttery bandages
Benzoin tincture
Dressings, sterile 4 4
Gauze, 4 roll
Gloves, nonlatex
Knuckle bandages
Pads, nonadherent, 2 3
Pads, petrolatum gauze
Wound closure strips, 1/4 4 (10 pk)
Wound closure strips, 1/2 4 (6 pk)
Left Exterior Pouch (#03)
Bloodstopper compression bandage
Gauze rolls, 2.25 and 4.5
Tape, 1
Trauma shears
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This kit is designed to augment the
MedAire First Aid Kit for clients trav-
eling with children. The kit provides
pediatric medications/doses and
special equipment for children.
Note: Kit contents may vary
due to product revisions after
publication.
MEDAIRE PEDIATRIC SUPPLEMENTAL KIT
CONTENTS
Yellow PouchOver-the-Counter
Medications
Caladryl lotion
Diphenhydramine HCl (Benadryl),
12.5 mg/5 ml
Ibuprofen (Motrin), 100-mg oral tablets
Cough & Cold (nasal decongestant, anti-
histamine, cough suppressant)
Prednisol, 15 mg/5 cc
Rehydration solution
Sulfatrim, 100-mL pediatric suspension
Black Pouch
Albuterol 2 mg/5 mL syrup
Perimeter
Directions for use
Orange Pouch
Acetaminophen (Tylenol), 160 g/5 mL oral
Amoxicil O/S, 400 mg/5 mL
Cefdinir, 125 mg/5 mL suspension
Epinephrine, 0.15 mg auto-injector
Medicine cups
Mylicon infant drops
Nasal spray, oxymetazoline HCl 0.05%
Nystatin ointment
Oral gel for baby
Zithromax, 100 mg/5 mLoral
Blue Pouch
Syringes, 5 cc
Band-Aids
Blankets, emergency survival
Blood pressure cuff
Nasal cannula
Gloves, nonlatex
Ice pack, instant
Ointment, vitamin A&D packets
Oxygen mask
Thermometer, digital oral
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MedAire, Inc., produces a
range of kits that meet and
exceed FAA, CAA regulations,
and JAR-Ops. Many commer-
cial airlines have these kits
customized to meet their
needs. The adapted kits are
compliant with FAA regula-
tions. Two examples of these
equipment for giving injec-
tions. This kit is designed to
be used by medical profes-
sionals who volunteer to assist
during a medical emergency.
Note: Kit contents may
vary due to product revi-
sions after publication.
MedAire Commercial Airline Kits
kits are shown here. The FAA
First Aid Kit contains items for
treating injuries, airway man-
agement, and protection from
infection. The Enhanced Emer-
gency Medical Kit (EEMK)
contains equipment for airway
management and oxygen, as
well as medications and
FAA First Aid Kit
This kit contains basic
items that crew can
use, such as triangular
bandages and gauze
rolls, wound dressings
and burn dressings,
wire splints, plastic
face shields, disposable
gloves, and a biohaz-
ard bag.
MedAire Enhanced Emergency Medical Kit (EEMK)
This kit is carried on commercial aircraft. It meets and exceeds FAA regula-
tions as well as JAR-Ops. The EEMK includes medications and other equip-
ment that should be used only by licensed medical professionals; for this
reason, ight attendants are not normally trained to use the kit. The main
section of the EEMK has color-coded pouches for various types of equip-
ment, such as dressings and medications. It also contains a wire ladder
splint, a urinary catheter, and a contents card. There is a concealed
pocket in the lid, which holds a large wound dressing. In addition, there
is a top compartment between the handles of the kit, containing a
stethoscope and a blood pressure cuff.
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Remote vital sign monitors,
also known as telemedicine
devices, are small, lightweight,
portable units used to aid
remote care during medical
incidents onboard an aircraft.
These devices measure certain
vital signs and produce elec-
tronic readings, which can be
transmitted to the MedLink
physician. The capabilities of
these devices vary, but most
are able to measure pulse,
body temperature, blood pres-
sure, electrical activity in the
heart (electrocardiography, or
Telemedicine Devices
Tempus IC Telemedicine Device Screen
This image shows the information on the screen of the Tempus IC device.
The screen can also show the user where and how to take vital sign and
ECG readings. It will display the results on the screen of the device as well
as in the MedLink Center..
EKG), oxygen levels in the
blood (pulse oximetry), and
carbon dioxide levels in the
blood (capnometry). Some
devices are also capable of
transmitting video images of
the victim to MedLink.
AED Troubleshooting
Follow the procedures set out in Life-saving
Procedures when using an AED. Troubleshoot-
ing indicators vary with different makes and
models of AEDs; check the owners manual for
your unit for specic guidelines. The following
points are general troubleshooting principles.
Electrodes Are Not Connected
If the AED advises to connect the electrodes
after the pads have been applied to the vic-
tims chest, check that the leads are properly
connected.
If the prompt to connect the electrodes con-
tinues, check that the electrode pads are cor-
rectly applied on areas that are free of
excessive moisture or hair.
Motion Is Detected
The AED will give a verbal and visual warning,
such as Motion detected/stop motion, if the
victim is moving or being touched during analy-
sis. Shout STAND CLEAR and check to ensure
that no one is touching the victim. If the
warning continues, excessive turbulence may
be the cause.
No Power
If the AED does not give any instructions once
it is switched on, check that the battery is not
dislodged, disconnected, or dead. Reinsert the
battery or insert a new one.
Low Battery Indicator
The AED will indicate when the battery is low
or has insufcient power and the unit is
unusable.
Maintenance Indicator
The AED will indicate when maintenance is
needed.
Automated External Debrillators (AEDs)
Typical Automated External Debrillator (AED)
This machine gives visual instructions on a screen, as
well as verbal instructions, to guide the user through
every stage of restoring a victims heartbeat.
An automated external debrillator (AED) is a porta-
ble device used to save the life of a victim whose
heart has stopped beating (cardiac arrest). AEDs
are capable of analyzing abnormal heart rhythms
and recommending debrillation (an electric
shock that is given in an attempt to restart the
normal heartbeat) when indicated. The FAA man-
dates that most aircraft carry AEDs, and many air-
lines worldwide equip their aircraft with them. For
guidelines/indications for the use of an AED, see
Life-saving Procedures. It is essential that all
assigned crew members receive regular training
on the operation of the AED carried onboard
their aircraft, according to their company policy.
There are many different makes/models of
AEDs, but they all function similarly. The photo
shown here is one example of an AED.
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Pocket masks and plastic face shields are used
when giving rescue breathing to prevent infec-
tious organisms from passing from the victim to
the rescuer or vice versa. Before using the
pocket mask, attach the one-way valve for
rescue breathing. If supplemental oxygen is
available and the mask has an oxygen inlet
port, attach the oxygen supply to the oxygen
inlet port on the pocket mask.
Pocket Masks and Face Shields
Use of a Pocket Mask
To open the pocket mask:
1
Take the folded pocket
mask out of its case.
2
Push the middle section of
the mask outward with
your thumbs.
Use of the Pocket Mask
for Resuscitation
1
Attach the one-way valve
to the hole at the center of
the pocket mask. If the mask
also has an oxygen inlet port,
attach the tubing from your
supplemental oxygen supply to
this port. Do not delay CPR to
apply oxygen to the mask. If
two rescuers are present, have
one rescuer begin CPR while
the mask is being set up.
saving Procedures as detailed
in Chapter 4.
Use of the Pocket Mask
for Infant Resuscitation
1
Place the mask on the
infants face, with the
narrow end under the chin
(reverse position). Press the
mask gently against the infants
face to form a tight seal.
2
To give rescue breaths,
blow gently through the
hole in the center of the mask
until the infants chest rises.
Use of a Plastic Face Shield
1
Tilt the victims head back
to open the airway, and
then check for breathing.
2
Unfold the face shield and
place it on the victims
face, with the lter over the
mouth. Pinch the victims
nose shut.
3
Put your mouth over the
lter. Blow into the victims
mouth until the chest rises.
Continue Life-saving
Procedures.
2
Tilt the victims head back
to open the airway, and
then check for adequate
breathing.
3
Turn the oxygen supply on
to a high setting.
4
Kneel beside the victims
head. Place the mask over
his or her mouth and nose,
with the narrow end on the
bridge of the nose and the
lower end positioned between
the lower lip and chin. Press
the mask rmly against the vic-
tims face to form a tight seal.
5
To give rescue breathing
with the pocket mask, hold
the mask on either side and
seal your mouth over the one-
way valve. Give rescue breaths
into the valve, watching to see
if the victims chest rises with
each breath. Continue the Life-
HOW TO USE PROTECTIVE FACE MASKS
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Crew members who are part
of an accident response team
or who come in contact with a
large amount of blood and
body uids with the potential
of exposure by splashing are
required to have full personal
protection from blood-borne
pathogens, chemicals, and
other biohazards. Each
company will have its own
equipment to be used and
Full PPE includes the
following:
Apron/jumpsuit (water-
repellant, tear-proof)
Goggles or face shield
Boot protectors (booties)
Gloves
Masks/respirators
Additional equipment may
include respirators or other
protective equipment appropri-
ate for the potential exposures.
Personal Protection Equipment (PPE) for Chemical/
Biohazard/Blood-borne Pathogen (BBP) Exposure
plan to be followed. This
section provides a general
overview for personal protec-
tion equipment (PPE) donning
and dofng procedures. The
following donning and dofng
procedures are examples of
commonly used equipment. It
is essential that your company
develop guidelines/procedures
for your specic equipment.
DONNING INSTRUCTIONS
Jumpsuit
1
Open zipper and step into garment.
2
Slide arms into sleeves and pull jumpsuit
over your shoulders.
3
Zip completely.
Hoods or attached shoe covers may be part
of some jumpsuits.
Gloves
1
Inset hand into glove and pull upward from
cuff.
2
Pull glove over garment cuff to provide full
protection.
Respirator/Mask
1
Open the mask completely.
2
Bend the nose piece to t snuggly over the
nose.
3
Hold the mask to your face and place the
ear loops behind each ear.
4
Adjust the mask and mold to the face for a
snug t.
Boot Covers
1
Insert entire foot with shoe on into the boot
cover and make sure the cover fully protects
the shoe.
2
Pull the jumpsuit leg over the boot cover or
tuck into high boot covers.
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Disposal of All PPEs
Dispose of all PPE in a biohaz-
ard bag; seal and dispose of
according to your company
policy. Wash your hands thor-
oughly with soap, water, and
friction and dry them after
removing your PPE.
For More Information
http://www.osha.gov/SLTC/
personalprotective equipment/
index.html
OSHA
www.dti.gov.uk/innovation/
strd/ecdirect/page12571.html
Department of Trade and
Industry
www.hse.gov.uk/pubns/
indg174.pdf
UK Health and Safety Execu-
tive with 1992 regulations and
a downloadable leaet
www.hpa.org.uk
Health Protection Agency
www.rcn.org.uk.
The Royal College of Nursing
www.hpa.org.uk
The Health Protection
AgencyUK
7
Once the jumpsuit is off,
the outside (contaminated
side) should be completely
rolled into itself so that the
inside of the jumpsuit is now
the outside.
8
Dispose of the jumpsuit in
a biohazard bag.
Boot/Head Covers
1
Remove boot and head
covers carefully so as not
to contaminate your skin or
clothing.
Eye Protection
1
Remove goggles carefully
so that your eyes are not
exposed.
Removal of Mask/
Respirator
1
Remove the mask after the
gloves, jumpsuit, booties,
and eye protection are
removed.
2
With clean hands, grasp
the ear loops and pull from
the ears.
3
Do not touch the face
maskit is con taminated.
DOFFING INSTRUCTIONS
Note: Consider the outside of
the gloves and jumpsuit to be
contaminated and the inside
of the gloves and jumpsuit to
be clean.
Jumpsuit with Front Zipper
and Gloves
1
Unzip the jumpsuit com-
pletely. Do not touch your
clothing or skin with the con-
taminated gloves.
2
Use both hands and rmly
grasp the lower back of the
jumpsuit and slide it off the
shoulders.
3
With your hands behind
your back, use the right
hand to grab the left cuff of
the jumpsuit and turn the
sleeve inside out to the wrist.
4
Grasp the wrist area of
both garment and glove
together and remove your right
hand.
5
Remove the legs, turning
the garment inside out as
you work your way to your feet.
6
Avoid touching the outside
(contaminated side) of the
jumpsuit.
Personal Protection Equipment (PPE), continued
2
Remove the mask away
from the facetouching
only the ties or loops.
3
Dispose of the mask in the
trash or biohazard bag,
holding only the ties or loops.
4
Wash your hands.
ment that escapes from the
top, bottom, or sides of the
mask). A properly tted mask
will reduce blow by.
Dofng
Remove/change the mask
when it becomes moist or
soiled or is no longer needed.
To prevent contamination,
avoid touching the mask face
piece.
1
If the mask has ties,
remove the mask by
untying the bottom tie rst
and then the top tie. For a
mask with elastic loops,
remove the loop from
each ear.
PROTECTIVE FACE MASKSDONNING/DOFFING
Donning
1
Open the mask.
2
Bend the nosepiece so that
it ts snuggly over the
bridge of the nose.
3
If the mask has ties, tie the
top ties rst at the top of
the head and then tie the ties
at the neck. If the mask has
elastic loops, place the loop
around each ear.
4
Once the mask is in place,
press the nosepiece so that
it ts snuggly across the bridge
of the nose.
5
Check to make sure there is
no blow by (air move-
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Pandemic Planning
The World Health Organization (WHO) has alerted the global community of the poten-
tial for a worldwide inuenza pandemic. Historically, there have been several major
inuenza pandemics every century. The most recent pandemics occurred in 19181919,
when the Spanish u (H1N1) resulted in 40 million deaths worldwide; in 19571958,
when the Asian u (H2N2) resulted in 2 million deaths worldwide; and in 19681969,
when the Hong Kong u (H3N1) resulted in 700,000 deaths worldwide.
Scientists worldwide are projecting that
another inuenza pandemic will occur in the
future, but it is impossible to predict the timing
or specic inuenza strain that would be the
likely cause. If another pandemic occurs, pre-
dictions are that it would likely result in 2 to
7.4 million deaths globally.
The development of a pandemic virus occurs
in stages. There are three steps that a virus must
take to develop into a pandemic:
A new strain of u virus develops.
The virus spreads to people and causes illness.
The virus mutates into a human virus,
which is easily spread to people.
A new emerging human virus that has not
circulated in the population previously means
that there is no immunity against the virus. This
results in rapid spread throughtout the popula-
tion with increased morbidity and mortality,
resulting in a global pandemic.
There are many unknowns about the pre-
dicted pandemic for this century. But what is
known is that every nation, government, local
municipality, company, and individual will be
better prepared if planning begins early, before
a crisis develops.
The WHO has developed a phased structure to
describe and dene the level of threat of an
inuenza pandemic and outline the specic
actions that the WHO and individual govern-
ments should take at each phase. This phased
structure provides an excellent template for
companies to develop their internal response
plan in order to address the issues facing any
company in the event of a global pandemic.
The world is currently at Pandemic Stage 3 due
to the avian u virus (H5N1).
Overview of the World Health Organization
Pandemic Phases
Continuous
transmission
Regular human-to-
human
transmission
Involves general
population of large
regions (worldwide)
Human infections
with new subtype
No clusters
No human-to-
human
transmission
Rare clusters
Small number of
cases per cluster
Very limited
human-to-human
transmission
Localized
Frequent clusters
More cases per
cluster
Common human-
to-human
transmission
Localized
Virus with low pandemic potential Virus with high pandemic potential
3 4 5 6
WHO Pandemic Inuenza Phase
No sustained human transmission Sustained human transmission
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It is recognized that the best
protection against a pandemic
inuenza is a well-matched
vaccine. However, the Centers
for Disease Control and Pre-
vention (CDC) and the World
Health Organization (WHO)
agree that this will not likely
be available at the onset of the
pandemic. The CDC has estab-
lished that the most important
interventions during the initial
phases/categories of a pan-
demic are nonpharmaceutical
interventions (NPIs). These
NPIs should be implemented
according to the category des-
ignated in order to delay the
arrival of a pandemic in com-
munities worldwide. Some of
care for passengers who may
be ill with the virus. Up-to-date
information can be obtained at
the following websites:
www.iata.org
www.cdc.gov
Every aviation department
should have a detailed pan-
demic plan. This plan should
cover ight operations,
employees who are traveling,
business operations, etc.
Resources for developing a
plan can be found at the fol-
lowing websites:
www.pandemicu.gov
www.cdc.gov
www.who.int
www.ready.gov
Nonpharmaceutical Interventions
these interventions include the
following:
Social distancing
School closures
Travel restrictions
Voluntary isolation/quaran-
tine at home
In addition, engaging in fre-
quent hand washing, following
cough etiquette, not traveling
while ill, and obtaining an
annual seasonal inuenza
vaccine are essential in pre-
venting the spread of disease.
The CDC and International
Airlines Transport Association
(IATA) have established guide-
lines for travel to countries
with H5N1 as well as how to
86344_07_153-178.indd 177 5/27/08 1:18:58 PM
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Notes

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180
Travel Health
Pathogen
Hepatitis
Jaundice
Vomit
Human Immunodeciency
Virus (HIV)
Acquired Immune Deciency
Syndrome (AIDS)
Tuberculosis
Diphtheria
Chickenpox
Inuenza
Measles
Cholera
Typhoid
Ameba
Giardiasis
Bilharzia (Schistosomiasis)
Malaria
Rabies
Lyme Disease
Ticks
Bacteria
Virus
Parasite
Shingles
Meningitis
Salmonella
Handwashing
Mask
Gloves
Biohazard
Adult/Child FBAO
Cardiopulmonary
Resuscitation
Breathing
Responsive
Unresponsive
Adult/Child CPR
Choking
AED
Pacemaker
Assessment
Pulse
Blood pressure
Tingling
Numbness
Clammy
Rash
Bruise
Breathing
Difculty breathing
Fever
Cough
Wheezing
Palpitations
Allergies
Medical history
Medications
Primary assessment
Secondary assessment
Translation Glossary
Arabic /
English Arabic / English Arabic /
86344_g01_180-181.indd 180 6/2/08 12:08:43 PM
181
Medical Emergencies
Conscious
Asthma
Spasm
Heart attack
Angina
Chest pressure
Cholesterol
Indigestion
Faint
Shock
Convulsion (seizure)
Epilepsy
Aura
Migraine
Stroke (cerebrovascular
accident)
Hallucination
Diabetes
Hypoglycemia
Anaphylaxis
Allergy
Phobia
Esophagus
Stomach
Liver
Kidney
Bladder
Spleen
Pancreas
Gallbladder
Uterus
Fallopian tube
Ovary
Altitude Physiology
Anemia
Hemoglobin
Hypoxia
Time of useful consciousness
Cyanosis
Euphoria
Confusion
Deep Vein Thrombosis (DVT)
Fatigue
Jet lag
MedAire Overview and Traumatic Emergencies
Abrasion
Bruise
Laceration
Tetanus
Bleeding
Shock
Tourniquet
Pneumothorax
Fracture
Strain
Sprain
Paralysis
Blister
Heat illness
Cold exposure
English Arabic / English Arabic /
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A
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182
Travel Health
Pathogen
Hepatitis
Jaundice
Vomit
Human Immunodeciency
Virus (HIV)
Acquired Immune
Deciency Syndrome (AIDS)
Tuberculosis
Diphtheria
Chickenpox
Inuenza
Measles
Cholera
Typhoid
Ameba
Giardiasis
Bilharzia (Schistosomiasis)
Malaria
Rabies
Lyme Disease
Ticks
Bacteria
Virus
Parasite
Shingles
Meningitis
Salmonella
Handwashing
Mask
Gloves
Biohazard
Adult/Child FBAO
Cardiopulmonary
Resuscitation
Breathing
Responsive
Unresponsive
Adult/Child CPR
Choking
AED
Pacemaker
Assessment
Pulse
Blood pressure
Tingling
Numbness
Clammy
Rash
Bruise
Breathing
Difculty breathing
Fever
Cough
Wheezing
Palpitations
Allergies
Medical history
Medications
Primary assessment
Secondary assessment
Translation Glossary
Chinese (Singapore) /
English Chinese (Singapore) / English Chinese (Singapore) /
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Medical Emergencies
Conscious
Asthma
Spasm
Heart attack
Angina
Chest pressure
Cholesterol
Indigestion
Faint
Shock
Convulsion (seizure)
Epilepsy
Aura
Migraine
Stroke (cerebrovascular accident)
Hallucination
Diabetes
Hypoglycemia
Anaphylaxis
Allergy
Phobia
Esophagus
Stomach
Liver
Kidney
Bladder
Spleen
Pancreas
Gallbladder
Uterus
Fallopian tube
Ovary
Altitude Physiology
Anemia
Hemoglobin
Hypoxia
Time of useful consciousness
Cyanosis
Euphoria
Confusion
Deep Vein Thrombosis (DVT)
Fatigue
Jet lag
MedAire Overview and Traumatic Emergencies
Abrasion
Bruise
Laceration
Tetanus
Bleeding
Shock
Tourniquet
Pneumothorax
Fracture
Strain
Sprain
Paralysis
Blister
Heat illness
Cold exposure
English Chinese (Singapore) / English Chinese (Singapore) /
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C
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(
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)

/
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Travel Health
Pathogen
Hepatitis
Jaundice
Vomit
Human Immunodeciency
Virus (HIV)
Acquired Immune Deciency
Syndrome (AIDS)
Tuberculosis
Diphtheria
Chickenpox
Inuenza
Measles
Cholera
Typhoid
Ameba
Giardiasis
Bilharzia (Schistosomiasis)
Malaria
Rabies
Lyme Disease
Ticks
Bacteria
Virus
Parasite
Shingles
Meningitis
Salmonella
Handwashing
Mask
Gloves
Biohazard
Adult/Child FBAO
Cardiopulmonary
Resuscitation
Breathing
Responsive
Unresponsive
Adult/Child CPR
Choking
AED
Pacemaker
Assessment
Pulse
Blood pressure
Tingling
Numbness
Clammy
Rash
Bruise
Breathing
Difculty breathing
Fever
Cough
Wheezing
Palpitations
Allergies
Medical history
Medications
Primary assessment
Secondary assessment
Translation Glossary
Chinese (Hong Kong) /
English Chinese (Hong Kong) / English Chinese (Hong Kong) /
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185
Medical Emergencies
Conscious
Asthma
Spasm
Heart attack
Angina
Chest pressure
Cholesterol
Indigestion
Faint
Shock
Convulsion (seizure)
Epilepsy
Aura
Migraine
Stroke (cerebrovascular accident)
Hallucination
Diabetes
Hypoglycemia
Anaphylaxis
Allergy
Phobia
Esophagus
Stomach
Liver
Kidney
Bladder
Spleen
Pancreas
Gallbladder
Uterus
Fallopian tube
Ovary
Altitude Physiology
Anemia
Hemoglobin
Hypoxia
Time of useful consciousness
Cyanosis
Euphoria
Confusion
Deep Vein Thrombosis (DVT)
Fatigue
Jet lag
MedAire Overview and Traumatic Emergencies
Abrasion
Bruise
Laceration
Tetanus
Bleeding
Shock
Tourniquet
Pneumothorax
Fracture
Strain
Sprain
Paralysis
Blister
Heat illness
Cold exposure
English Chinese (Hong Kong) / English Chinese (Hong Kong) /
T
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l
a
t
i
o
n

G
l
o
s
s
a
r
y

C
h
i
n
e
s
e

(
H
o
n
g

K
o
n
g
)

/
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Travel Health
Pathogen Pathogne
Hepatitis Hpatite
Jaundice Jaunisse
Vomit Vomissement
Human Immunodeciency Virus de
Virus (HIV) limmunodcience
humaine (VIH)
Acquired Immune Syndrome
Deciency Syndrome dimmunodcience
(AIDS) acquise (SIDA)
Tuberculosis Tuberculose
Diphtheria Diphtrie
Chickenpox Varicelle
Inuenza Grippe
Measles Oreillons
Cholera Cholra
Typhoid Typhode
Ameba Amoeba
Giardiasis Giardiase
Bilharzia Bilharzie
(Schistosomiasis) (schistosomiase)
Malaria Malaria
Rabies Rage
Lyme Disease Maladie de Lyme
Ticks Tique
Bacteria Bactrie
Virus Virus
Parasite Parasite
Shingles Zona
Meningitis Mningite
Salmonella Salmonella
Handwashing Lavage des mains
Mask Masque
Gloves Gants
Biohazard Danger biologique
Adult/Child FBAO
Cardiopulmonary Cardiopulmonaire
Resuscitation Ranimation
Breathing Respiration
Responsive Ragissant
Unresponsive Sans raction
Adult/Child CPR
Choking Suffocation
AED
Pacemaker Pacemaker
Assessment
Pulse Pouls
Blood pressure Tension artrielle
Tingling Fourmillement
Numbness Engourdissement
Clammy Moite
Rash ruption
Bruise Contusion
Breathing Respiration
Difculty breathing Difcults
respiratoires
Fever Fivre
Cough Toux
Wheezing Respiration sifante
Palpitations Palpitations
Allergies Allergies
Medical history Antcdents mdicaux
Medications Mdicaments
Primary assessment valuation principale
Secondary assessment valuation secondaire
Translation Glossary
French / Franais
English French / Franais English French / Franais
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Medical Emergencies
Conscious Conscient
Asthma Asthme
Spasm Spasme
Heart attack Crise cardiaque
Angina Angine de poitrine
Chest pressure Pression thoracique
Cholesterol Cholestrol
Indigestion Indigestion
Faint Syncope
Shock Choc
Convulsion (seizure) Convulsion
(crise pileptique)
Epilepsy pilepsie
Aura Aura
Migraine Migraine
Stroke (cerebrovascular Attaque crbrovasculaire
accident) (accident
crbrovasculaire)
Hallucination Hallucination
Diabetes Diabtes
Hypoglycemia Hypoglycmie
Anaphylaxis Anaphylaxie
Allergy Allergie
Phobia Phobie
Esophagus Oesophaphe
Stomach Estomac
Liver Foie
Kidney Rein
Bladder Vessie
Spleen Rate
Pancreas Pancras
Gallbladder Vsicule biliaire
Uterus Utrus
Fallopian tube Trompe de Fallope
Ovary Ovaire
Altitude Physiology
Anemia Anmie
Hemoglobin Hmoglobine
Hypoxia Hypoxie
Time of useful Temps de conscience
consciousness utile
Cyanosis Cyanose
Euphoria Euphorie
Confusion Confusion (mentale)
Deep Vein Thrombosis Thrombose veine
(DVT) profonde (TVP)
Fatigue Fatigue
Jet lag Dcalage horaire
MedAire Overview and Traumatic Emergencies
Abrasion Exulcration
Bruise Contusion
Laceration Dchirure
Tetanus Ttanose
Bleeding Saignement
Shock Choc (tat de choc)
Tourniquet Garrot
Pneumothorax Pneumothorax
Fracture Fracture
Strain Foulure
Sprain Entorse
Paralysis Paralysie
Blister Cloque
Heat illness Coup de chaleur
Cold exposure Exposition au froid
English French / Franais English French / Franais
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188
Travel Health
Pathogen Pathogen
Hepatitis Hepatitis
Jaundice Gelbsucht
Vomit Erbrechen
Human HIV (Human
Immunodeciency Immunodeciency
Virus (HIV) Virus)
Acquired Immune AIDS (Acquired
Deciency Syndrome Immune Deciency
(AIDS) Syndrome)
Tuberculosis Tuberkulose
Diphtheria Diphtherie
Chickenpox Windpocken
Inuenza Inuenza
Measles Masern
Cholera Cholera
Typhoid Typhus
Ameba Amoebiasis
Giardiasis Giardiasis
Bilharzia Bilharziose
(Schistosomiasis) (Schistosomiasis)
Malaria Malaria
Rabies Tollwut
Lyme Disease Lyme-Borreliose
Ticks Zecken
Bacteria Bakterien
Virus Virus
Parasite Parasit
Shingles Grtelrose
Meningitis Meningitis
Salmonella Salmonellen
Handwashing Hnde waschen
Mask Mundschutz
Gloves Handschuhe
Biohazard Biologische
Gefahrenstoffe
Adult/Child FBAO
Cardiopulmonary Herz-Kreislauf
Resuscitation Wiederbelebung
Breathing Atmet
Responsive Ansprechbar
Unresponsive Nicht ansprechbar
Adult/Child CPR
Choking Erstickung
AED
Pacemaker Schrittmacher
Assessment
Pulse Puls
Blood pressure Blutdruck
Tingling Kribbeln
Numbness Taubheit
Clammy Feuchtkalt
Rash Ausschlag
Bruise Bluterguss
Breathing Atmet
Difculty breathing Atemprobleme
Fever Fieber
Cough Husten
Wheezing Stenoseatmung
Palpitations Palpitationen
Allergies Allergien
Medical history Anamnese
Medications Medikamente
Primary assessment Primre Beurteilung
Secondary assessment Sekundre
Beurteilung
Translation Glossary
German / Deutsch
English German / Deutsch English German / Deutsch
86344_g05_188-189.indd 188 6/2/08 12:09:41 PM
189
Medical Emergencies
Conscious Bei Bewusstsein
Asthma Asthma
Spasm Spasmus
Heart attack Herzinfarkt
Angina Angina
Chest pressure Druck im Brustraum
Cholesterol Cholesterin
Indigestion Indigestion
Faint Ohnmacht
Shock Schock
Convulsion (seizure) Krampfanfall
Epilepsy Epilepsie
Aura Aura
Migraine Migrne
Stroke Schlaganfall
(cerebrovascular (Hirndurchblutun
accident) gsstrungen)
Hallucination Halluzination
Diabetes Diabetes
Hypoglycemia Hypoglykmie
Anaphylaxis Anaphylaktischer
Schock
Allergy Allergie
Phobia Phobie
Esophagus Speiserhre
Stomach Magen
Liver Leber
Kidney Niere
Bladder Blase
Spleen Milz
Pancreas Pankreas
Gallbladder Gallenblase
Uterus Gebrmutter
Fallopian tube Eileiter
Ovary Eierstock
Altitude Physiology
Anemia Anmie
Hemoglobin Hmoglobin
Hypoxia Hypoxie
Time of useful TUC (Time of Useful
consciousness Consciousness,
Zeitreserve)
Cyanosis Zyanose
Euphoria Euphorie
Confusion Verwirrung
Deep Vein Thrombosis (DVT) Tiefe Venenthrombose
Fatigue Mdigkeit
Jet lag Jetlag
MedAire Overview and Traumatic Emergencies
Abrasion Abrasion
Bruise Bluterguss
Laceration Fleischwunde
Tetanus Tetanus
Bleeding Blutungen
Shock Schock
Tourniquet Tourniquet
Pneumothorax Pneumothorax
Fracture Fraktur
Strain Dehnung, Zerrung
Sprain Verstauchung
Paralysis Paralyse
Blister Blase
Heat illness Hitzeerkrankung
Cold exposure Klteaussetzung
English German / Deutsch English German / Deutsch
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190
Travel Health
Pathogen Patgeno
Hepatitis Hepatite
Jaundice Ictercia
Vomit Vmito
Human Vrus da
Immunodeciency imunodecincia
Virus (HIV) humana (HIV)
Acquired Immune Sndrome da
Deciency Syndrome imunodecincia
(AIDS) adquirida (AIDS)
Tuberculosis Tuberculose
Diphtheria Difteria
Chickenpox Varicela
Inuenza Gripe
Measles Sarampo
Cholera Clera
Typhoid Febre tifide
Ameba Ameba
Giardiasis Giardase
Bilharzia Bilharzia
(Schistosomiasis) (Esquistossomose)
Malaria Malria
Rabies Raiva
Lyme Disease Doena de Lyme
Ticks Carrapatos
Bacteria Bactria
Virus Vrus
Parasite Parasita
Shingles Hrpes-zster
Meningitis Meningite
Salmonella Salmonela
Handwashing Lavagem das mos
Mask Mscara
Gloves Luvas
Biohazard Perigo biolgico
Adult/Child FBAO
Cardiopulmonary Cardiopulmonar
Resuscitation Ressuscitao
Breathing Respirao
Responsive Responsivo
Unresponsive No-responsivo
Adult/Child CPR
Choking Engasgando
AED
Pacemaker Marcapasso
Assessment
Pulse Pulso
Blood pressure Presso arterial
Tingling Formigando
Numbness Dormncia
Clammy Pegajoso
Rash Erupo cutnea
Bruise Contuso
Breathing Respirao
Difculty breathing Respirao difcil
Fever Febre
Cough Tosse
Wheezing Respirao ofegante
Palpitations Palpitaes
Allergies Alergias
Medical history Histrico mdico
Medications Medicamentos
Primary assessment Avaliao primria
Secondary assessment Avaliao secundria
Translation Glossary
Portuguese (Brazil) / Portugus do Brasil
English Portuguese (Brazil) / Portugus do Brasil English Portuguese (Brazil) / Portugus do Brasil
86344_g06_190-191.indd 190 6/2/08 12:09:54 PM
191
Medical Emergencies
Conscious Consciente
Asthma Asma
Spasm Espasmo
Heart attack Ataque do corao
Angina Angina
Chest pressure Presso torcica
Cholesterol Colesterol
Indigestion Indigesto
Faint Desmaio
Shock Choque
Convulsion (seizure) Convulso (ataque)
Epilepsy Epilepsia
Aura Aura
Migraine Enxaqueca
Stroke (cerebrovascular Derrame (acidente
accident) cerebrovascular)
Hallucination Alucinao
Diabetes Diabetes
Hypoglycemia Hipoglicemia
Anaphylaxis Analaxia
Allergy Alergia
Phobia Fobia
Esophagus Esfago
Stomach Estmago
Liver Fgado
Kidney Rim
Bladder Bexiga
Spleen Bao
Pancreas Pncreas
Gallbladder Vescula biliar
Uterus tero
Fallopian tube Trompa de Falpio
Ovary Ovrio
Altitude Physiology
Anemia Anemia
Hemoglobin Hemoglobina
Hypoxia Hipoxia
Time of useful Tempo de conscincia
consciousness til
Cyanosis Cianose
Euphoria Euforia
Confusion Confuso
Deep Vein Thrombosis Trombose de veia
(DVT) profunda (DVT)
Fatigue Fadiga
Jet lag Fadiga decorrente de
viagem area
MedAire Overview and Traumatic Emergencies
Abrasion Abraso
Bruise Escoriao
Laceration Lacerao
Tetanus Ttano
Bleeding Sangramento
Shock Choque
Tourniquet Torniquete
Pneumothorax Pneumotrax
Fracture Fratura
Strain Disteno
Sprain Deslocamento
Paralysis Paralisia
Blister Bolha
Heat illness Doena do calor
Cold exposure Exposio ao frio
English Portuguese (Brazil) / Portugus do Brasil English Portuguese (Brazil) / Portugus do Brasil
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86344_g06_190-191.indd 191 6/2/08 12:09:55 PM
192
Travel Health
Pathogen Patgeno
Hepatitis Hepatite
Jaundice Ictercia
Vomit Vmito
Human Vrus da
Immunodeciency Imunodecincia
Virus (HIV) Humana (VIH)
Acquired Immune Sndrome da Imuno
Deciency Syndrome decincia
(AIDS) Adquirida (SIDA)
Tuberculosis Tuberculose
Diphtheria Difteria
Chickenpox Varicela
Inuenza Gripe
Measles Sarampo
Cholera Clera
Typhoid Tifide
Ameba Ameba
Giardiasis Giardase
Bilharzia Bilharziose
(Schistosomiasis) (Esquistossomase)
Malaria Malria
Rabies Raiva
Lyme Disease Doena de Lyme
Ticks Carraas
Bacteria Bactria
Virus Vrus
Parasite Parasita
Shingles Zona
Meningitis Meningite
Salmonella Salmonelas
Handwashing Lavagens das mos
Mask Mscara
Gloves Luvas
Biohazard Perigo biolgico
Adult/Child FBAO
Cardiopulmonary Cardiopulmonar
Resuscitation Ressuscitao
Breathing Respirao
Responsive Responsiva
Unresponsive No responsiva
Adult/Child CPR
Choking Sufocao
AED
Pacemaker Pacemaker
Assessment
Pulse Pulso
Blood pressure Presso arterial
Tingling Formigueiro
Numbness Dormncia
Clammy Pegajoso
Rash Erupo cutnea
Bruise Contuso
Breathing Respirao
Difculty breathing Diculdade em
respirar
Fever Febre
Cough Tosse
Wheezing Sibilo
Palpitations Palpitaes
Allergies Alergias
Medical history Histrico mdico
Medications Medicaes
Primary assessment Avaliao primria
Secondary assessment Avaliao secundria
Translation Glossary
Portuguese (Portugal) / Portugus Europeu
English Portuguese (Portugal) / Portugus Europeu English Portuguese (Portugal) / Portugus Europeu
86344_g07_192-193.indd 192 6/2/08 12:10:07 PM
193
Medical Emergencies
Conscious Consciente
Asthma Asma
Spasm Espasmo
Heart attack Ataque cardaco
Angina Angina
Chest pressure Presso no peito
Cholesterol Colesterol
Indigestion Indigesto
Faint Fraca
Shock Choque
Convulsion (seizure) Convulso (ataque)
Epilepsy Epilepsia
Aura Aura
Migraine Enxaqueca
Stroke (cerebrovascular Acidente vascular
accident) cerebral (AVC)
Hallucination Alucinao
Diabetes Diabetes
Hypoglycemia Hipoglicemia
Anaphylaxis Analaxia
Allergy Alergia
Phobia Fobia
Esophagus Esfago
Stomach Estmago
Liver Fgado
Kidney Rim
Bladder Bexiga
Spleen Bao
Pancreas Pncreas
Gallbladder Vescula
Uterus tero
Fallopian tube Trompa de falpio
Ovary Ovrio
Altitude Physiology
Anemia Anemia
Hemoglobin Hemoglobina
Hypoxia Hipxia
Time of useful Tempo de conscincia
consciousness til
Cyanosis Cianose
Euphoria Euforia
Confusion Confuso
Deep Vein Thrombosis Trombose das veias
(DVT) profundas (TVP)
Fatigue Fadiga
Jet lag Efeito de diferena
horria
MedAire Overview and Traumatic Emergencies
Abrasion Abraso
Bruise Contuso
Laceration Lacerao
Tetanus Ttano
Bleeding Hemorragia
Shock Choque
Tourniquet Torniquete
Pneumothorax Pneumotrax
Fracture Fractura
Strain Estirpe
Sprain Entorse
Paralysis Paralisia
Blister Bolha
Heat illness Insolao
Cold exposure Exposio ao frio
English Portuguese (Portugal) / Portugus Europeu English Portuguese (Portugal) / Portugus Europeu
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86344_g07_192-193.indd 193 6/2/08 12:10:08 PM
194
Travel Health
Pathogen
Hepatitis
Jaundice
Vomit
Human
Immunodeciency
Virus (HIV) ()
Acquired Immune
Deciency Syndrome
(AIDS)
()
Tuberculosis
Diphtheria
Chickenpox
Inuenza
Measles
Cholera
Typhoid
Ameba
Giardiasis
Bilharzia
(Schistosomiasis) ()
Malaria
Rabies
Lyme Disease
Ticks
Bacteria
Virus
Parasite
Shingles
Meningitis
Salmonella
Handwashing
Mask
Gloves
Biohazard

Adult/Child FBAO
Cardiopulmonary
Resuscitation
Breathing
Responsive
Unresponsive
Adult/Child CPR
Choking
AED
Pacemaker
Assessment
Pulse
Blood pressure
Tingling
Numbness
Clammy

Rash
Bruise
Breathing
Difculty breathing

Fever
Cough
Wheezing
Palpitations

Allergies
Medical history
Medications
Primary assessment
Secondary assessment
Translation Glossary
Russian /
English Russian / English Russian /
86344_g08_194-195.indd 194 6/2/08 12:10:21 PM
195
Medical Emergencies
Conscious
Asthma
Spasm
Heart attack
Angina
Chest pressure
Cholesterol
Indigestion

Faint
Shock
Convulsion (seizure)
()
Epilepsy
Aura ,



Migraine
Stroke (cerebrovascular
accident) ()
Hallucination
Diabetes
Hypoglycemia
Anaphylaxis
Allergy
Phobia
Esophagus
Stomach
Liver
Kidney
Bladder
Spleen
Pancreas

Gallbladder
Uterus
Fallopian tube
Ovary
Altitude Physiology
Anemia
Hemoglobin
Hypoxia
Time of useful
consciousness

Cyanosis
Euphoria
Confusion
Deep Vein Thrombosis
(DVT)
Fatigue
Jet lag
MedAire Overview and Traumatic Emergencies
Abrasion
Bruise
Laceration
Tetanus
Bleeding
Shock
Tourniquet

Pneumothorax
Fracture
Strain
Sprain
Paralysis
Blister
Heat illness
Cold exposure
English Russian / English Russian /
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196
Travel Health
Pathogen Patgeno
Hepatitis Hepatitis
Jaundice Ictericia
Vomit Vmito
Human Virus de la
Immunodeciency inmunodeciencia
Virus (HIV) humana (VIH)
Acquired Immune Sndrome de
Deciency Syndrome inmunodeciencia
(AIDS) adquirida (SIDA)
Tuberculosis Tuberculosis
Diphtheria Difteria
Chickenpox Varicela
Inuenza Gripe
Measles Sarampin
Cholera Clera
Typhoid Fiebre tifoidea
Ameba Ameba
Giardiasis Giardiasis
Bilharzia Bilharziasis
(Schistosomiasis) (esquistosomiasis)
Malaria Paludismo
Rabies Rabia
Lyme Disease Enfermedad de Lyme
Ticks Garrapatas
Bacteria Bacteria
Virus Virus
Parasite Parsito
Shingles Herpes
Meningitis Meningitis
Salmonella Salmonella
Handwashing Lavado de manos/
Lavarse las manos
Mask Mscara
Gloves Guantes
Biohazard Riesgo biolgico
Adult/Child FBAO
Cardiopulmonary Cardiopulmonar
Resuscitation Resucitacin
Breathing Respiracin/Respirar
Responsive Sensible/Responder
Unresponsive Resistente/
No responder
Adult/Child CPR
Choking Asxia/Asxiarse
AED
Pacemaker Marcapasos
Assessment
Pulse Pulso
Blood pressure Presin arterial
Tingling Hormigueo
Numbness Entumecimiento
Clammy Fro, hmedo
y pegajoso
Rash Sarpullido
Bruise Magulladura
Breathing Respiracin/Respirar
Difculty breathing Dicultad para
respirar
Fever Fiebre
Cough Tos
Wheezing Sibilancias
Palpitations Palpitaciones
Allergies Alergias
Medical history Historia clnica
Medications Medicamentos
Primary assessment Evaluacin primaria
Secondary assessment Evaluacin secundaria
Translation Glossary
Spanish / Espaol
English Spanish / Espaol English Spanish / Espaol
86344_g09_196-197.indd 196 6/2/08 12:10:34 PM
197
Medical Emergencies
Conscious Consciente
Asthma Asma
Spasm Espasmo
Heart attack Ataque cardaco
Angina Angina
Chest pressure Opresin en el pecho
Cholesterol Colesterol
Indigestion Indigestin
Faint Desmayo
Shock Conmocin
Convulsion (seizure) Convulsin (ataque)
Epilepsy Epilepsia
Aura Aura
Migraine Migraa
Stroke Apopleja
(cerebrovascular (accidente
accident) cerebrovascular)
Hallucination Alucinacin
Diabetes Diabetes
Hypoglycemia Hipoglucemia
Anaphylaxis Analaxia
Allergy Alergia
Phobia Fobia
Esophagus Esfago
Stomach Estmago
Liver Hgado
Kidney Rin
Bladder Vejiga
Spleen Bazo
Pancreas Pncreas
Gallbladder Vescula biliar
Uterus tero
Fallopian tube Trompa de Falopio
Ovary Ovario
Altitude Physiology
Anemia Anemia
Hemoglobin Hemoglobina
Hypoxia Hipoxia
Time of useful Tiempo til de
consciousness conciencia
Cyanosis Cianosis
Euphoria Euforia
Confusion Confusin
Deep Vein Thrombosis Trombosis venosa
(DVT) profunda (TVP)
Fatigue Fatiga
Jet lag Descompensacin
horaria (jet lag)
MedAire Overview and Traumatic Emergencies
Abrasion Abrasin
Bruise Magulladura
Laceration Laceracin
Tetanus Ttanos
Bleeding Hemorragia
Shock Conmocin
Tourniquet Torniquete
Pneumothorax Neumotrax
Fracture Fractura
Strain Torcedura/Distensin
Sprain Esguince
Paralysis Parlisis
Blister Ampolla
Heat illness Golpe de calor
(insolacin)
Cold exposure Exposicin al fro
English Spanish / Espaol English Spanish / Espaol
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198
Travel Health
Pathogen Patogen
Hepatitis Hepatit
Jaundice Gulsot
Vomit Krkning
Human Humant
Immunodeciency immundefektvirus
Virus (HIV) (HIV)
Acquired Immune Frvrvat
Deciency Syndrome immunbristsyndrom
(AIDS) (AIDS)
Tuberculosis Tuberkulos
Diphtheria Difteri
Chickenpox Vattkoppor
Inuenza Inuensa
Measles Mssling
Cholera Kolera
Typhoid Tyfus
Ameba Amba
Giardiasis Giardiasis
Bilharzia (Schistosomiasis) Bilharziais
Malaria Malaria
Rabies Rabies
Lyme Disease Lyme borrelios
Ticks Fstingar
Bacteria Bakterie
Virus Virus
Parasite Parasit
Shingles Bltros
Meningitis Hjrnhinneinammation
Salmonella Salmonella
Handwashing Handtvtt
Mask Mask
Gloves Handskar
Biohazard Biologisk risk
Adult/Child FBAO
Cardiopulmonary Hjrta och lungor
Resuscitation terupplivning
Breathing Andning
Responsive Mottaglig
Unresponsive Livls
Adult/Child CPR
Choking Kvvning
AED
Pacemaker Pacemaker
Assessment
Pulse Puls
Blood pressure Blodtryck
Tingling Stickning
Numbness Knsellshet
Clammy Klibbig
Rash Utslag
Bruise Blmrke
Breathing Andning
Difculty breathing Andningssvrigheter
Fever Feber
Cough Hosta
Wheezing Vsande ljud
Palpitations Hjrtklappning
Allergies Allergier
Medical history Sjukdomshistorik
Medications Lkemedel
Primary assessment Primr bedmning
Secondary assessment Sekundr bedmning
Translation Glossary
Swedish / Svenska
English Swedish / Svenska English Swedish / Svenska
86344_g10_198-200.indd 198 6/2/08 12:10:47 PM
199
Medical Emergencies
Conscious Medvetsls
Asthma Astma
Spasm Kramp
Heart attack Hjrtattack
Angina Angina
Chest pressure Tryck p brstkorgen
Cholesterol Kolesterol
Indigestion Matsmltningsbesvr
Faint Svimfrdig
Shock Chock
Convulsion (seizure) Krampryckning (anfall)
Epilepsy Epilepsi
Aura Aura
Migraine Migrn
Stroke Stroke
(cerebrovascular (cerebrovaskulr
accident) sjukdom)
Hallucination Hallucination
Diabetes Diabetes
Hypoglycemia Lgt blodsocker
Anaphylaxis Anafylax
Allergy Allergi
Phobia Fobi
Esophagus Matstrupe
Stomach Mage
Liver Lever
Kidney Njure
Bladder Urinblsa
Spleen Mjlte
Pancreas Bukspottkrtel
Gallbladder Gallblsa
Uterus Livmoder
Fallopian tube ggledare
Ovary ggstock
Altitude Physiology
Anemia Anemi
Hemoglobin Hemoglobin
Hypoxia Syrebrist
Time of useful Tid fr meningsfullt
consciousness medvetande
Cyanosis Cyanos
Euphoria Eufori
Confusion Frvirring
Deep Vein Thrombosis Djup ventrombos
(DVT) (DVT)
Fatigue Trtthet
Jet lag Jetlag
MedAire Overview and Traumatic Emergencies
Abrasion Skrubbsr
Bruise Blmrke
Laceration Rivsr
Tetanus Stelkramp
Bleeding Bldning
Shock Chock
Tourniquet Kompressor
Pneumothorax Pneumotorax
Fracture Fraktur
Strain Pfrestning
Sprain Stukning
Paralysis Frlamning
Blister Blsa
Heat illness Vrmeslag
Cold exposure Frfrysning
English Swedish / Svenska English Swedish / Svenska
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Index
A
Abdomen/pelvis
anatomy of, 99
disorders. See Abdominal/pelvic disorders
injuries to, 136
pain. See Abdomen/pelvis pain
Abdomen/pelvis pain
assessment of, 100
common serious causes of, 101
initial care, 101
signs and symptoms, 57, 100
Abdominal injuries, 136
Abdominal/pelvic disorders
appendicitis, 101
bleeding, 103
diarrhea. See Diarrhea
ectopic pregnancy, 101
heartburn, 103
indigestion, 103
motion sickness, 104
nausea, 102
peptic ulcer, 101
renal colic, 101
urinary retention, 104
vertigo, 104
vomiting, 102
Abrasions, 128, 130
Abscesses, 129
Acquired immunodeciency syndrome, 28
AEDs (automated external debrillators), 73, 172
children, use with, 76
EKG strip, 73
how to use, 74
indications for use, 73
lone rescuers, 76
prompts from, 75
troubleshooting, 172
Aged persons, sleep patterns of, 43
AIDS, 28
Air
composition of, 3
recycling of, 5
Air-borne diseases, 18. See also specic disease
prevention of, 24
Air-conditioning, 5
Aircraft cabin pressure, 5
Aircraft cruising altitudes, 2
Aircraft disinsection, 40
Aircraft diversions, 157
Aircraft First Aid Kit (AFAK), 166167
Aircraft motion, 6
Albuterol, 89
Alcohol consumption
and hypoxia, 8
sleep and, 43
Alcohol intoxication, 111
Alertness
consciousness. See Consciousness
management. See Alertness management
Alertness management, 41
fatigue, 4142
Allergic shock, 98
Allergies, 115
inhalers and spacers, 8990
Altitude
atmospheric pressure, effect on, 3
and consciousness, 12
cruising altitudes, 2
and hypoxia, 7
Amputation(s), 133
Anaphylaxis, 114115
Anaphylaxis shock, 98
Angina pectoris, 95
Animal bites, 27
Appendicitis, 101
Arms
injuries to, 141
signs and symptoms, 57
Assessment of victim. See Victim assessment
Asthma, 8990
Atmosphere, 2
in ight, 5
Atmospheric layers, 2
Atmospheric pressure, 3
cabin, 5
changes in. See Atmospheric pressure changes
Atmospheric pressure changes
decompression. See Decompression
effects of, 6, 912
Automated external debrillators. See AEDs (automated
external debrillators)
Avian inuenza, 32
B
Back
anatomy of, 160
injuries, 143, 160
signs and symptoms, 57
Barometric pressure, 3
Behavioral/psychological disorders, 110
panic attacks, 110
phobias, 110
substance abuse and, 111
Bereavement services, 158
Bilharzia, 34
Biohazard exposure PPE, 174
Bites
animal, 27
insect, 25, 27
wounds from, 129
Black eye, 150
Bleeding, 128. See also Wounds
after childbirth, 124
from digestive tract, 103
nosebleeds, 116117
severe, 131132
types of, 130
Blood-borne diseases, 18. See also specic disease
prevention of, 24
Blood-borne pathogen exposure PPE, 174
Blood pressure, 53
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Blood sugar
high, 112
low, 113
Blood vessels, 93
Blunt abdominal injury, 136
Blunt chest injury, 134
Body. See Human body
Body temperature, 52
Bone fractures. See Fractures
Boyles Law, 4
Brain
cerebral vascular accident, 106107
compression of tissue, 142
Breakbone fever, 36
Bruises, 128
Burns
assessment of, 144
versus scalds, 145
types of, 144
C
Cabin air-conditioning, 5
Cabin pressure, 5
CAD (coronary artery disease), 94
Campylobacter, 34
Capillary rell check, 54
Cardiac shock, 98
Cardiopulmonary system, 62
Cardiovascular disorders
angina pectoris, 95
deep vein thrombosis, 97
fainting, 96
heart attack, 95
heart disease, 94
heart failure, 94
low-volume shock, 98
shock, 98, 131
Cardiovascular system
anatomy of, 9293
disorders. See Cardiovascular disorders
Cerebral hemorrhage, 106
Cerebral thrombosis, 106
Cerebral vascular accident, 106107
Charles Law, 4
Chemical exposure PPE, 174
Chemical splash to eye, 150
Chest
cavity, 11
injuries, 134135
signs and symptoms, 57
Chest compressions, 7172
infant resuscitation, 80
Chest pain, 95
Chickenpox, 29
Childbirth, 122
complications, 124
labor and delivery, 120123
Children
choking in. See Choking in children (1 year and
older)
debrillators, use of, 76
infants. See Infants
Chlamydia, 39
Choking, 81
adults. See Choking in adults
children. See Choking in children (1 year and older)
infants. See Choking in infants
Choking in adults
conscious adults, 8182
evaluation of airway after, 83
unconscious adults, 83
Choking in children (1 year and older)
conscious children, 8182
evaluation of airway after, 83
unconscious children, 83
Choking in infants
conscious infants, 84
lone rescuers, 85
unconscious infants, 85
Cholera, 32
Chronic lung disease, 91
Circadian rhythm, 42
Cleanup of clinical waste, 23
Clinical waste, 23
Collapsed lung, 91
Conjunctivitis, 116
Consciousness
altitude and, 12
choking. See Choking in adults; Choking in children
(1 year and older); Choking in infants
rapid decompression and, 12
Contagious diseases, 19. See also specic disease
Contusions, 128
Coronary artery disease, 94
Cosmic radiation, 3
Cough etiquette, 24
CPR (cardiopulmonary resuscitation)
AHA plan, 63
breathing check, 67
cessation of, 158
chest compressions, 7172
clearing the airway, 66
debrillators. See AEDs (automated external
debrillators)
ERC plan, 64
hands-only CPR, 71
how it works, 62
infant resuscitation. See Infant resuscitation
opening the airway, 65
preliminary actions, 65
recovery position, 68
rescue breathing, 6970
Cramps, heat, 148
Crew oxygen system, 162
Cruising altitudes, 2
Cryptosporidium, 34
CVA (cerebral vascular accident), 106107
D
Daltons Law, 4
DCS (decompression sickness), 119
Death onboard, 158
Decompression, rapid, 12
Decompression sickness, 12, 119
Deep vein thrombosis, 97
Debrillators. See AEDs (automated external
debrillators)
Dengue fever, 36
Diabetes, 112
Diarrhea, 102
travelers, 34
Digestive system, 99. See Gastrointestinal tract
Disabilities, passengers with, 161
Diseases. See Infectious diseases
Disinsection, 40
Disposal of clinical waste, 23
Drop-down masks, 8, 21, 163
DVT (deep vein thrombosis), 97
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E
E. coli, 34
Eardrum, and pressure changes, 10
Ear pain, 118
Ears
anatomy of, 9
clearing, 10
pressure changes in, 910
signs and symptoms, 56
Ectopic pregnancy, 101
EKG strip, 73
Electrical injuries, 146
Emergency Medical Kit (EMK), 168169
Emerging diseases, 18
Enhanced Emergency Medical Kit (EEMK), 171
Environmental injuries, 144148
Eustachian tubes blockage, 9, 118
Examining victims, 55. See also Victim assessment
Eye(s)
chemical splash to, 150
foreign object in, 149
injuries, 149150
irritation, 116
signs and symptoms, 56
F
FAA First Aid Kit, 171
Face masks/shields, 21
during CPR, 70
donning and dofng, 175
oxygen delivery, 163
surgical, 21
use of, 173
Fainting, 96
Fatigue, 41
ight and, 41
performance, effect on, 42
prevention of, 41
Feet
injuries to, 140
signs and symptoms, 57
First aid kits
FAA First Aid Kit, 171
MedAire Aircraft First Aid Kit, 166167
MedAire Emergency Medical Kit, 168169
MedAire Enhanced Emergency Medical Kit, 171
MedAire Pediatric Supplement Kit, 170
First rescuer, 48
Flee bites, 25
Food-borne diseases, 18. See also specic disease
prevention of, 25
Foot. See Feet
Foreign object in eye, 149
Fractures, 138139
skull, 142
Frostbite, 147
G
Gas laws, 4
Gastrointestinal tract
anatomy of, 11
bleeding from, 103
disorders. See Abdominal/pelvic disorders
trapped air in, 11
Genitourinary system, 99. See Gastrointestinal tract
Giardiasis, 34
Global Response Center, 155
Gloves
removing, 20
wearing, 20
Gonorrhea, 39
Grahams Law, 4
H
H5N1, 32
Hands
injuries to, 141
signs and symptoms, 57
Hand sanitizers, 20
Hands-only CPR, 71
Handwashing, 20
HBV, 28
HCV, 28
Head
injuries, 142
signs and symptoms, 56
Headaches, 108
Health authority inspectors, 40
Health resources, 44
Heart, 93
Heart attack, 95
Heartburn, 103
Heart disease, 94
Heart failure, 94
Heat cramps, 148
Heat exhaustion, 148
Heat illness, 148
Heat stroke, 148
Henrys Law, 4, 119
Hepatitis A, 33
Hepatitis B virus, 28
Hepatitis C virus, 28
Herpes, 39
Herpes zoster, 38
High blood sugar, 112
Histoxic hypoxia, 8
HIV, 28
HPV, 39
Human body. See also Body specic systems
effects of ying on, 6
inactivity, effects of, 6
vital signs. See Vital signs
Human immunodeciency virus, 28
Humidiers, 163
Humidity, low, 6
Hypemic hypoxia, 8
Hyperglycemia, 112
Hyperventilation, 90
Hypoglycemia, 113
Hypothermia, 147
Hypovolemic shock, 98, 131
Hypoxia, 78
Hypoxic hypoxia, 8
I
In-country resources, 17
Indigestion, 103
Infant(s)
childbirth. See Childbirth
choking. See Choking in infants
resuscitation. See Infant resuscitation
stillborn babies, 124
Infant resuscitation, 77
breathing check, 78
chest compressions, 80
clearing the airway, 77
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Infant resuscitation (Continued)
how to give, 80
lone rescuers, 80
opening the airway, 77
preliminary actions, 77
recovery position, 78
rescue breathing, 78
Infectious diseases, 18. See also specic type
contagious, 19
emerging diseases, 18
protective measures, 2021
reporting during ight, 22
Staph. See Staphylococcus aureus
transmission of, 1819
Infectious hepatitis, 28
Infectious shock, 98
Inuenza, 29
avian, 32
Inhalers and spacers, 8990
Insect bites, 25, 27
Insect repellent, 26
Intestines, 11. See also Gastrointestinal tract
ISO certication, 155
J
Jet lag, 44
K
Knee injuries, 140
L
Labor and delivery, 120123
Lacerations, 128
Lancets, disposal of, 23
Legs
injuries to, 140
signs and symptoms, 57
Lifesaving procedures, 62
cardiopulmonary resuscitation. See CPR (cardiopul-
monary resuscitation)
choking. See Choking
Lifting objects safely, 160161
Lone rescuers
choking in infants, 85
debrillators, use of, 76
infant resuscitation, 80
Low blood sugar, 113
Low humidity, 6
Low-volume shock, 98
Lungs. See also Respiratory system
anatomy of, 11
chronic lung disease, 91
collapsed lung, 91
trapped air in, 11
Lyme disease, 36
M
Malaria, 35
Masks. See also Face masks/shields
drop-down, 8, 21, 163
mouth-to-mask rescue breathing, 69
nonrebreather, 163
pocket, 21, 70, 163, 173
surgical, 21
Measles, 30
MedAire, Inc., 154
MedAire Aircraft First Aid Kit, 166167
MedAire Emergency Medical Kit, 168169
MedAire Enhanced Emergency Medical Kit, 171
MedAire Pediatric Supplement Kit, 170
MedAire services, 154
MedLink

. See MedLink

pre-ight medical screening, 157

Quality Improvement Program, 155
Medical Action Plans, 48, 49
Medical equipment, 166. See also specic equipment
Medical incidents
documenting information, 58
history of, 51
ill passenger care, 21
in-ight procedures, 49, 158159
lifesaving procedures, 62. See also Choking; CPR
(cardiopulmonary resuscitation)
managing, 4849
post-exposure plans, 159
victim assessment. See Victim assessment
vital signs. See Vital signs
Medical warning alerts, 54
Medications of victims, 54
MedLink

call process, 157

contacting, 156
emergency procedure, 155
emergency service, 157
Global Response Center, 155
in-ight medical support, 58, 156
patch procedure, 156
Meningitis, 30
Methicillin-resistant Staphylococcus aureus, 38
Migraines, 108
Miscarriages, 124
Missile injuries, 128
Mosquito bites, 25
Mosquito netting, 26
Motion sickness, 104
Mouth, signs and symptoms, 57
Mouth-to-mask rescue breathing, 69
Mouth-to-mouth rescue breathing, 69
Moving victims, 50, 161
MRSA, 38
Musculoskeletal system
anatomy of, 137
injuries to. See specic injury
Myocardial infarction, 95
N
Napping, 41
Nasal cannula, 163
Nausea, 102
Neck
injuries, 143
signs and symptoms, 56
Nervous system
anatomy of, 105
disorders. See Nervous system disorders
Nervous system disorders
headaches, 108
migraines, 108
seizures, 109
stroke, 106107
Noise, 6
Nonrebreather mask, 163
Norwalk viruses, 33
Nose, signs and symptoms, 56
Nosebleeds, 116117
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O
Oxygen
delivery, 163. See also Masks
ight needs, 165
levels. See Oxygen levels
supplemental. See Supplemental oxygen
systems. See Oxygen systems
Oxygen bottles, 164
Oxygen levels
during ight, 6
low levels, effects of, 78
Oxygen masks, 8, 21
Oxygen systems, 162
portable, 162, 164
pre-ight checks, 162
safety considerations, 163
supplemental oxygen. See Supplemental oxygen
Ozone, 3
P
Pandemic planning, 176177
Panic attacks, 110
Passenger Assistance Service (PAS), 157
Pediatric Supplement Kit, 170
Pelvis. See Abdomen/pelvis
Penetrating abdominal injury, 136
Penetrating chest injury, 135
Peptic ulcer, 101
Personal protection equipment (PPE), 174. See also
Face masks/shields; Gloves
Phobias, 110
Physical gas laws, 4
Pink eye, 116
Placenta, delivery of, 123
Pneumothorax, 91
Pocket masks, 21, 70, 163, 173
Portable oxygen concentrators (POCs), 164
Portable oxygen systems, 162, 164
Port health authority inspectors, 40
Post-exposure plans, 159
Post-travel monitoring, 17
Pre-ight medical screening services, 157
Pregnancy, 120
complications, 124
ectopic, 101
labor and delivery, 120123
Preparation for travel. See Travel preparation
Pressure
atmospheric. See Atmospheric pressure
cabin, 5
Pressure points, 132
Pre-travel planning, 16
Pre-travel resources, 16
Prolapsed umbilical cord, 124
Psychological disorders. See Behavioral/psychological
disorders
Pulse rate, 52
Punctures, 128
Q
Quality Improvement Program, 155
R
Rabies, 37
Radiation, cosmic, 3
Rapid decompression, 12
Recycling of air, 5
Renal colic, 101
Rescue breathing, 6970
infant resuscitation, 79
Rescuers, 48
CPR with 2 rescuers, 72
lone. See Lone rescuers
Respiratory diseases, 18. See also specic disease
prevention of, 24
Respiratory rate, 52
Respiratory system
anatomy of, 88
disorders. See Respiratory system disorders
Respiratory system disorders
asthma, 8990
chronic lung disease, 91
hyperventilation, 90
pneumothorax, 91
S
Salmonella, 34
Salmonella typhi, 33
SARS, 31
Scalds, 145
Scene safety, 50
Schistosomiasis, 34
Scuba diver advice, 12
Second rescuer, 48
Seizures, 109
Septic shock, 98
Severe acute respiratory syndrome, 31
Sexually transmitted diseases, 18. See also specic
disease
prevention of, 27
Sharps
disposal of, 23
injury management, 159
Shingles, 38
Shock, 98, 131
Sickle cell anemia, 117
Sinuses
location of, 10
pressure changes in, 10
Sinus pain, 118
Skeletal system
anatomy of, 137
injuries to. See specic injury
Skin, signs and symptoms, 56
Skull fractures, 142
Sleep physiology, 43
Sleep scheduling, 41
Slings, 139
Smoke inhalation, 146
Smoking and hypoxia, 8
Sneeze etiquette, 24
Spleen, 99
Sprains, 139
Stagnant hypoxia, 8
Staphylococcus aureus, 19
methicillin-resistant, 38
prevention of, 27
STDs. See Sexually transmitted diseases
Stillborn babies, 124
Strains, 139
Stroke
cerebral vascular accident, 106107
heat, 148
Substance abuse and irrational behavior, 111
Supplemental oxygen, 8
systems, 162
Surgical face masks, 21
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Syphilis, 39
Syringes, disposal of, 23
T
TB, 31
Telemedicine devices, 172
Temperature, body, 52
Temperature changes, 6
Tetanus, 37
Third rescuer, 48
Tick bites, 25
Tourniquets, 132
Travelers diarrhea, 34
Travel health resources, 44
Travel preparation, 16
illness/injury prevention, 17
in-country resources, 17
post-travel monitoring, 17
pre-ight medical screening, 157
pre-travel planning, 16
pre-travel resources, 16
Trichomonas, 39
Tuberculosis, 31
Twins, delivery of, 124
Typhoid fever, 33
U
Umbilical cord, prolapsed, 124
Urinary retention, 104
V
Valsalva maneuver, 10
Varicella, 29
Vasovagal, 96
Vector-borne diseases, 18. See also specic disease
prevention of, 2526
Vibration, 6
Victim(s)
examining, 55. See also Victim assessment
medications of, 54
moving, 50, 161
Victim assessment
burn victims, 144
documenting information, 58
primary survey, 50
questions to ask, 51
scene safety, 50
secondary survey, 51
signs and symptoms, 5657
surveying a victim, 5051
vital signs. See Vital signs
Vital signs
blood pressure, 53
capillary rell check, 54
external clues, 54
measuring, 5254
pulse rate, 52
respiratory rate, 52
temperature, 52
Vomiting, 102
W
Water-borne diseases, 18. See also specic disease
prevention of, 25
World Health Organization pandemic phases, 176177
Wounds, 128
abrasions, 128, 130
cross-infection, prevention of, 129
small cuts, 128, 130
types of, 128129
Wrist injuries, 141
Y
Yellow fever, 36
Z
Zoonotic diseases, 18. See also specic disease
prevention of, 27
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Figure Sources
Chapter One
Page 8: Drop Down Mask: Copyright DK Images
Page 9: Ear: Vernon L. Avila, Biology: Investigating Life
on Earth, 1995 Bookmark Publishers, Jones &
Bartlett Publishers, Sudbury, MA www.jbpub.com.
Reprinted with permission.
Page 10: Pressure Change in Eardrum: Copyright
DK Images
Page 11: Intestines: Kendall/Hunt Publishing
Company
Chapter Two
Page 18: Mosquito: Copyright Robert Redelowski,
2008. Used under license from Shutterstock, Inc.
Page 20: Washing Hands: Copyright Mariusz
Szachowski, 2008. Used under license from
Shutterstock, Inc.
Page 20: Gloves: Copyright Ljupco Smokovski, 2008.
Used under license from Shutterstock, Inc.
Page 23: Syringes and Box: Copyright bhathaway,
2008. Used under license from Shutterstock, Inc.
Page 24: Woman with Tissue: Copyright Dimitrije
Paunovic, 2008. Used under license from Shutter-
stock, Inc.
Page 26: Mosquito Net and Deet Spray (three photos):
Courtesy of Lorraine Mooney RGN MSc (Travel
Medicine)
Page 42: World Time Zones: Copyright Yuliyan Velchev,
2008. Used under license from Shutterstock, Inc.
Page 44: Map of World Time Zones: Copyright DK
Images
Chapter Three
Page 54: Blue Inhaler: Copyright Mark Hicks II, 2008.
Used under license from Shutterstock, Inc.
Page 54: Medic Alert Bracelet: Copyright DK Images
Page 54: Medicine Bottle: Copyright Tom Grill, 2008.
Used under license from Shutterstock, Inc.
Chapter Four
Page 62: Circulation: Kendall/Hunt Publishing
Company
Page 62: CO
2
Exchange: Kendall/Hunt Publishing
Company
Page 71: Chest Compression: Copyright DK Images
Chapter Five
Page 88: Respiratory Tract/Gas Exchange: Kendall/
Hunt Publishing Company
Page 92: Circulation: Kendall/Hunt Publishing
Company
Page 93: Heart Interior: Kendall/Hunt Publishing
Company
Page 93: Heart Exterior: Kendall/Hunt Publishing
Company
Page 99: Digestive System and Spleen: Kendall/Hunt
Publishing Company
Page 105: Brain Diagram: Kendall/Hunt Publishing
Company
Page 105: Nervous System: Vernon L. Avila, Biology:
Investigating Life on Earth, 1995 Bookmark Publish-
ers, Jones & Bartlett Publishers, Sudbury, MA
www.jbpub.com. Reprinted with permission.
Page 105: Nerves: Kendall/Hunt Publishing
Company
Page 118: Pressure Change in Eardrum: Copyright
DK Images
Page 120: First/Second/Third Stages of Labor: Vernon
L. Avila, Biology: Investigating Life on Earth, 1995
Bookmark Publishers, Jones & Bartlett Publishers,
Sudbury, MA www.jbpub.com. Reprinted with
permission.
Page 123: Baby in Blanket: Copyright Kati Molin, 2008.
Used under license from Shutterstock, Inc.
Chapter Six
Page 128: Five Hand Wounds: Copyright DK Images
Page 129: Abscess: Mediscan/Visuals Unlimited
Page 129: Bite Wound: Copyright L. Stack Custom
Medical Stock Photo. All Rights Reserved.
Page 129: Washing Hands: Copyright Mariusz
Szachowski, 2008. Used under license from
Shutterstock, Inc.
Page 129: Gloves: Copyright Ljupco Smokovski, 2008.
Used under license from Shutterstock, Inc.
Page 130: Three Hand Images: Copyright DK
Images
Page 132: Tourniquet: Copyright Rob Byron, 2008.
Used under license from Shutterstock, Inc.
Page 133: Arm in Cast: Copyright Georgy Markov,
2008. Used under license from Shutterstock, Inc.
Page 135: Chest Wounds (two photos): Copyright
DK Images
Page 136: Internal Organs: Kendall/Hunt Publishing
Company
Page 137: Skeleton: Kendall/Hunt Publishing
Company
Page 137: Structure of Joints: Copyright DK Images
Chapter Seven
Page 160: Structures that Connect Vertebrae: Copyright
DK Images
Page 160: Prolapsed Intervertebral Disk: Copyright
DK Images
Page 164: Portable Oxygen Concentrator: Image cour-
tesy of SeQual Technologies, Inc.
Page 172: Telemedicine Device Screen: Image courtesy
of Remote Diagnostic Technologies
All gures not referenced in this section are owned by
MedAire, Inc.
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