AS TWO PHARMACIST LEARNED ON A RECENT TRIP, domestic passenger-carrying airplanes with a flight attendant also have onboard an emergency medical kit with a small assortment of medications and supplies.
The Federal Aviation Administration (FAA) has required such a kit since 1986.
Since 2004, this kit (see sidebar) at a minimum has contained several medications in addition to the originally required 50% dextrose injection, epinephrine injection 1 mg/mL, diphenhydramine injection, and nitroglycerin tablets.
That was also the year by which airplanes with a capacity of at least 30 passengers had to start carrying an automated external defibrillator (AED).
FAA in addition requires the airlines to ensure that each crewmember receives training for in-flight medical events.
Some of that training was put to the test this past December, after a passenger lost consciousness on a United Airlines flight from Houston to Los Angeles.
DeeDee Hu, a clinical specialist in critical care at Memorial Hermann Memorial City Medical Center in Houston, said she reached the man ahead of the flight attendants, did not detect a pulse, and repositioned him across the row of coach-class seats in preparation for chest compressions.
When he suddenly regained consciousness, albeit temporarily, Hu said she further assessed him and asked about his medical history.
The flight attendants “immediately pulled out the AED,” said Sapana Desai, a clinical pharmacy specialist in emergency medicine at Memorial Hermann who, like Hu, happened to be seated near the ill passenger.
But the emergency medical kit did not surface until a physician asked for an i.v. set to infuse fluid, she said.
The family practice physician and a nurse had responded to the overhead page for medical personnel.
Before the physician arrived, however, Hu had called out for aspirin in case the man was having a myocardial infarction.
“I didn’t know that they had this kit,” she said, “so my first thought was, let’s find someone on the plane with aspirin.”
A passenger did provide a tablet of low-dose aspirin, Desai said, and the ill man chewed it between episodes of unresponsiveness.
Desai said the flight attendants’ primary focus had appropriately been on pulling out the AED from where it had been stowed in the cabin.
“But it would have been helpful to have known that the kit was available to us for use,” she said.
The list of minimum contents for the current FAA-approved emergency medical kit was proposed in 2000 and finalized in 2001.
An FAA-led study of in-flight medical care provided in 1996–97 found justification for addition of the following items to the 1986-issued list: oxygen, supportive care items, equipment for closely monitoring a patient, analgesics, a bronchodilator inhaler, and an oral antihistamine.
In at least 70% of the cases in which one of the foregoing items had been deployed, the research team reported in 2000, the passenger in need of medical care improved.
The research was based in part on a survey of U.S.-based air carriers that contract with MedAire Inc. for in-flight medical support.
Heidi MacFarlane, a vice president at MedAire, said FAA undertook the research because passenger-carrying airplanes would soon be equipped with AEDs.
The Aviation Medical Assistance Act of 1998 had directed the FAA administrator to decide whether to require AEDs on passenger-carrying airplanes. If the answer was yes, the law required a decision as to the AED-associated equipment and medications that must be in the emergency medical kit.
At the time, the American Heart Association’s algorithm for providing advanced cardiac life support to an adult after defibrillation for cardiac arrest included the possibility of i.v. injections of epinephrine followed by an antiarrhythmic drug.
FAA selected lidocaine as the antiarrhythmic drug for the emergency medical kit.
In 2010, the American Heart Association declared amiodarone the first-line antiarrhythmic drug to be given during cardiac arrest.
They pointed to the need to have an injectable drug product for passengers having a breakthrough or acute seizure.
In addition, the pharmacists said, the medical emergency kit should have glucagon for injection, which would immediately help passengers having an episode of hypoglycemia and, unlike dextrose injection, does not require i.v. access.
MacFarlane said the airlines can augment their medical emergency kits without seeking FAA’s approval but cannot provide a substitute for or smaller amount of any item on the agency’s list.
“We recommend that they have EpiPens onboard,” she said, referring to a branded version of 1-mg/mL epinephrine injection 0.3 mL in an autoinjector. “But they’re significantly more expensive, and even if they have the EpiPens they still have to have the [1-mL] epinephrine as it’s . . . required by the regulation.”
That regulation specifies two strengths of epinephrine injection. The 1-mg/mL concentration, commonly used in the emergency treatment of allergic reactions, must be present as two single-dose 1-mL units. The 0.1-mg/mL concentration, which is the common strength of epinephrine for treating cardiac arrest, must be present as two single-dose 2-mL units, which would provide two 0.2-mg doses; the American Heart Association’s recommendations for advanced cardiac life support of adults call for 1-mg doses.
MedAire’s Paulo Alves, global director of aviation health, said the requirement for 2-mL units, rather than 10-mL units, must be a typo or mistake. To his knowledge, every supplier of medical emergency kits to the airlines provides the 0.1-mg/mL epinephrine in 10-mL units, said Alves, who is chair of the Air Transport Medicine Committee of the Aerospace Medical Association.
“There are some basic things that we do recommend . . . , typically drugs that are in a form that could be delivered by a layperson under the instruction of somebody from our ground-based medical service,” she said.
Ondansetron, an antiemetic available as an oral disintegrating tablet, is another common recommendation, especially for long-haul flights, MacFarlane said. “If you can stop [the passenger] from vomiting, then we can prevent dehydration, which may allow the flight to continue rather than having to make a medical diversion.”
As for the task of finding items in the kit, MacFarlane said the presumption is that items, some of which are prescription drug products, “would only be dispensed by someone who’s qualified to do that.”
For example, a flight attendant would not pull out items from the kit unless under the direction of a ground-based physician who knows the arrangement of the kit, she said.
Airlines’ medical emergency kits have not escaped the nation’s drug shortages. FAA has at times granted temporary exemptions from the onboard requirements for specific drugs. For example, an exemption from the requirement for dextrose injection is in place until March 31, 2016, unless FAA rescinds or modifies the exemption.
FAA has not updated the kit’s list since 2001, an agency spokeswoman confirmed, and has not scheduled a review of it. Suggestions, however, may be directed to Federal Air Surgeon James R. Fraser, Office of Aerospace Medicine, Federal Aviation Administration, 800 Independence Avenue, SW, Washington, DC 20553-0001.
–By Cheryl A. Thompson, reprinted with permission from AJHP
(Feb. 1, 2015; volume 72, pages 176, 178, 180)