1.

Aeromedical Problems
Accelerations
Normally, the effect of an ordinary airliners acceleration on passengers is insignificant.
Regarding the positioning of patients, it is usual to place the head facing the direction of
flight because the impact of the acceleration at take-off is greater than that of
deceleration during landing. Due to these reasons, patients with increased intracranial
pressure must be positioned with their head facing the direction of flight (these patients
should also only be transported by air ambulance at a cabin pressure of 1 atm.
Vibration, noise and turbulence
!he effects of "ibration, noise and turbulence are generally much less in a #et aircraft
than in a propeller dri"en aircraft. $light altitude and speed are also of "ital importance
as turbulence is usually greater at lower altitudes and at lower speeds. $or this reason,
#et rather than propeller-dri"en air transport is preferable for long distance flights.
%ropeller-dri"en aircraft may be used for short flights, and they ha"e the ad"antage of
being able to land on smaller airfields should this be necessary.
&elicopter transportation en#oys the significant ad"antage of being able to carry patients
almost directly between hospital and airport. !his can sa"e both time and a difficult
#ourney o"er bad roads, mountains, and so on. 'n the other hand, helicopters are noisy
and sub#ect to "ibration and shaking. !he cabin pressure is appro(imately 1 atm, which is
an ad"antage for some patients. &elicopter ambulances are being used more often for
primary e"acuation, taking patients straight from the location where trauma occurred to
the hospital.
Humidity
!he humidity is low in the cabin. !he relati"e humidity is low, as the pressurised cabin air
is from 1) km altitude, heated from appro(imately * +), - to cabin temperature. !he
humidity does not reach ) because it is being mi(ed with a fraction of the recirculating
air ha"ing already been humidified by the passengers.
!he low humidity often gi"es rise to irritation of the mucous membranes * especially of
the eyes and airways, creating a particular risk for patients ha"ing had surgery performed
recently in these areas.
Thromboembolic prophylaxis
During long flights, when seated passengers are immobile for many hours, stasis occurs in
the deep "eins of the lower leg. !his is a cofactor in de"eloping deep "enous thrombosis
(D.!.
The risk of developing a DVT is very small; however, it increases on flights lasting
longer than hours and also if the passenger has other risk factors for developing
DVT!
/s dehydration is also a cofactor in de"eloping D.!, it is "ery important to drink plenty of
water during a flight. $urthermore, alcohol and coffee should be consumed with caution,
as they ha"e a diuretic effect on the body.
0leeping pills can cause long periods of immobilisation, therefore passengers with risk
factors for de"eloping D.! are ad"ised against such use.
1nee-length graduated compression stockings ha"e pro"en to ha"e an effect in pre"enting
the de"elopment of D.! on long distance flights as well as simultaneously pre"enting
oedema in the lower legs, which a lot of passengers suffer from during a flight.
"eneral advice when flying#
$tay as active as possible during the flight! "oing for a short walk every hour and
moving your feet fre%uently when seated are recommended! Drink plenty, but
alcohol and coffee should be consumed with caution! Avoid the use of sleeping pills!
&ore and more airline companies have information about the exercises one should do
during the flight!
'f one is at risk of developing DVT prior to a flight that is longer than hours, one
should consider the following guidelines while still keeping general advice in mind#
(onditions causing slightly increased risk#
/ge o"er 2)
3arger "aricose "eins
'besity (45678)
Recent laparoscopic surgery
Recent bed rest (78 days
)ecommendations# No prophyla(is is needed. 'ptionally, graduated compression
stockings.
(onditions causing moderate increased risk#
%re"ious D.!
3ate pregnancy9first weeks of postnatal period
5oderate congesti"e heart failure
0e"ere respiratory conditions
0e"ere infectious diseases during the last couple of weeks
4lood diseases or conditions causing an increase in coagulation
!reatment with oestrogen, including birth control pills
3ower leg surgery, including knee arthroscopy
)ecommendations# :raduated compression stockings.
(onditions causing high risk#
5a#or fractures in leg or pel"ic region
5a#or traumas especially pel"ic
Recent hip or knee alloplastic surgery
Recent ma#or surgery
5alignancy, especially during chemotherapy
4lood diseases or conditions causing a se"ere increase in coagulation
0e"ere congesti"e heart failure
%re"ious pulmonary embolus
)ecommendations# :raduated compression stockings plus prophyla(is with low
molecular heparin (35;& in#ected subcutaneously <-2 hours before the flight. 'b"iously,
this should only be gi"en if the patient is not recei"ing actual anticoagulant treatment.
*eople with more than one risk factor should be evaluated individually#
$or e(ample, a passenger who is far into their pregnancy or who has #ust gi"en birth, and
who has pre"iously suffered from D.!, should be mo"ed from the moderate risk category
to the high-risk group and hereby be gi"en 35;&. 3ikewise, a flight lasting longer than =
hours can change the risk profile for an elderly immobile passenger from, e.g. low to
moderate.
The recommendations written above are only intended as a guide and, if there are
any %uestions of doubts concerning prophylaxis, one should always consult the
treating physician!
/cetylsalicylic acid has not pro"en to ha"e an effect in pre"enting D.!.
6n the future ri"aro(aban and other N'/- drugs, which can be prescribed as tablets, will
probably be used in the way we use 35;& today. &owe"er, the drugs cannot be used by
pregnant women.
> %re"ious page Ne(t page 7
%hoto?
6"er 0@ndergaard
*ressure conditions
!he a"erage passenger airliner cruises at an altitude of appro(imately 8).)))-8A.))) ft.,
eBui"alent to 1)-1< km. !he outside pressure at this altitude is about C atm
(atmosphere or 1D) mm &g (fig. 1.
Fig.1.
Relationship between altitude in ft.
and pressure in mm Hg.
!hese days, all ci"il airliners are eBuipped with a so-called pressurised cabin.
-ompressors maintain the difference in pressure between the cabin and the outside
atmosphere. /t normal cruising altitude, the cabin pressure corresponds to A.)))-=.)))
ft. (E atm, depending somewhat on the type of airliner. Regarding pressure, this
corresponds to the passengers being situated on a mountain at a height of <.)))-<.+)) m.
-ruising altitude is usually reached within 1) to 1+ minutes after take-off and descent
begins appro(imately 8) minutes before landing. During short flights that last about 8) to
2) minutes, the airliner only reaches a cruising altitude of about +-A km, and the cabin
pressure will be reduced correspondingly.
/t normal cruising altitude, where cabin pressure is E atm, trapped air tries to e(pand
by 8=F.
!hus, trapped air in the bowel will lead to a more distended abdomen. 6n more serious
cases, air can be trapped elsewhere, e.g. intracranial, where the e(pansion of air can
lead to increased pressure on the brain.
Due to these conditions, some patients with, e.g. intracranial air, untreated
pneumothora(, or lager subcutaneous emphysema should not be transported using
commercial flights. 6f such patients are to be transported by air, it has to be done at a
cabin pressure of 1 atm, which corresponds to sea le"el. 6f an aeroplane is to maintain a
cabin pressure of 1 atm, it can fly at a ma(imal altitude of +-= km, depending on the
construction of the plane. 6n such cases air ambulances are used.
+xygen pressure and hypoxia
!he composition of the atmosphere remains "ery constant up to e(tremely high altitudes.
6ts most important constituent elements are nitrogen (GDF and o(ygen (<1F.
/t sea le"el, the al"eolar partial pressure of o(ygen is 1)8 mm &g, and it falls linearly to
an altitude of appro(imately 1).))) ft., corresponding to 8.8 km. /t this point
hyper"entilation takes effect and deflects the linear progression. 5oreo"er, 1).))) ft. is
the highest permitted flying altitude without an o(ygen supply, unless the aircraft cabin
is pressurised. !he al"eolar partial pressure of o(ygen at this height is A) mm &g9= k%a
(fig. <.
Fig. 2.
Relationship between altitude in ft. and alveolar partial oxygen-pressure in mm Hg.
4esides the partial pressure of o(ygen, the bloods o(ygen bearing capacity plays a part
in o(ygen supply to the critical tissues * abo"e all the brain and the heart. $igure 8 shows
the haemoglobin-o(ygen dissociation cur"e for a normal person with a normal
haemoglobin concentration. /t sea le"el, the blood is almost fully saturated with an
o(ygen saturation of D=-1))F. /t normal cruising altitude, where cabin pressure is E atm,
the o(ygen saturation has decreased to appro(imately D)-D<F.
!his will not cause the a"erage healthy passenger any problems, but can do so in the case
of passen-gers suffering a cardio-pulmonary disease or anaemia. -onditions causing an
increased metabolism, e.g. fe"er leading to an increase in the demand of o(ygen, should
not fly and in general neither should patients suffering from fe"er.
Fig. 3.
Haemoglobin-oxygen dissociation curve for a normal adult at 37oC and pH 7!.
a" #xygen saturation at sea level.
b" #xygen saturation at cabin pressure in normal
cruising altitude.
001. Frontpage
001. Foreword
001.Contributors
001.Aeromedical Problems
012.Planning the Air Transportation of Patients
013.Airline Reuirements
01!.Air Ambulance Transport
01".Transportation of #isabled Persons
01$.Cardiac #isorders
01%.Circulator& #isorders
01'.Respirator& #isorders
01(.)astrointestinal #isorders
010.Central *er+ous ,&stem #isorders
011.-ar. *ose. and Throat #isorders
012.-&e #isorders
013./ental #isorders
01!.)&naecological and Pregnanc& Problems
01".Transportation of ,ic0 Children
01$.1nfectious #iseases
01%.2rthopaedic 1n3uries
01'.Cancer
01(.2ther /edical #isorders
120.Acute /ountain and #ecompression ,ic0ness
021.4urns and Plastic ,urgical Problems
122.Airsic0ness
123.5et 6ag
12!.The ,T-P ,&stem
12".,peciali7ed Transportation of Patients
12$.First Aid on 4oard 8 6egal Considerations
12%.The 9istor& of Patient Air Transport
12'.Con+ersion Tables
12(.4ibliograph&
16atest update: 1(.0!.201!