In-flight cardiac arrest is extremely rare, yet catastrophic, and responsible for up to 86 % of all deaths in the air. A new comprehensive literature review highlights systemic and policy shortcomings of current aviation safety standards, calling for global alignment. Recommendations include regulated and mandated automated external defibrillators (AEDs) on board, standardized cardiopulmonary resuscitation (CPR) protocols training, and integration of telemedicine. The article in the Canadian Journal of Cardiology, published by Elsevier, aims to inform policy regulators, airlines, and international aviation bodies to improve in-flight medical emergency preparedness and response protocols.
In-flight medical emergencies are an expected challenge, given the global air travel passenger volume of nearly four billion passengers annually. The most prominent risk factors for in-flight cardiac arrest include male sex, age, pre-existing cardiac disease, and duration of flight time. With an aging global passenger population and increasing flight durations due to advancing aircraft technology, the risk and frequency of in-flight cardiac arrest are expected to rise.
“Improving survival rates following a flight passenger’s cardiac arrest hinges on several critical considerations,” states senior author Adrian Baranchuk, MD, Queens University, Canada.
The cabin environment poses a unique challenge, including the confined space of the fuselage, limitations to equipment accessibility, and inconsistent crew CPR and AED training. Currently, only the US legally mandates defibrillators on commercial flights, whereas Canada only federally recommends it and leaves it to the discretion of the airline itself to include them.”
Adrian Baranchuk, MD, Queens University, Canada
Prompt defibrillation is crucial
AED utilization has a significant impact on survival outcomes in multiple environments. The likelihood of survival for shockable sudden cardiac arrest decreases by 7–10% per minute without defibrillation. Due to the narrow intervention window, diverting a plane for an emergency landing is often unattainable, as it often takes longer than 20 minutes from cruising altitude to a safe landing.
The disparities in AED implementation may hinder swift emergency responses. Without an onboard AED, only approximately 6% of in-flight cardiac arrest patients survive to hospital. Further projections suggest that equipping all commercial aircraft with AEDs could save 35–93 lives annually worldwide.
First author Mario D. Bassi, MD, University of Ottawa, Canada, points out, “Currently, the data show that AEDs are consistently reliable, sensitive to detecting and treating in-flight cardiac arrest, and cost-effective to airlines. AEDs are proven to be safe, with no evidence of detriment or reduced functionality emerging in the compromised environment of the aircraft cabin, such as turbulence. While prompt recognition of a cardiac arrest and CPR initiation are vital, the chances of survival jump from 6% to up to 70% when an AED is used. However, up to one third of EU aircraft were found to not have an AED available in-flight.”
Based on their comprehensive review of the existing literature, the authors recommend:
Universal implementation of easily accessible onboard AEDs to reduce time to defibrillation
Standardized airline-specific CPR training for crew
Integration of telemedicine for real-time guidance and triage (e.g., CPR coaching)
“The primary determinant impacting sudden cardiac arrest survival is the time to defibrillation,” concludes Dr. Baranchuk. “We believe our recommendations and appropriate measures must be strongly considered by policymakers and airlines alike to improve passenger safety and survival rates.”
