1. Paulo M. Alves, MD Medaire 27 th International Aircraft Cabin Safety Symposium

2. People flydie Some fly & die

3. 1 death Per every 7M pax.05 deaths Per billion RPKs 4.8 deaths Per month Source: MedLink Global Response Center

4. Onboard cardiac arrests & deaths extremely stressful situations for cabin crew and passengers

5. Individual Pre-existing conditions Environment Environment Altitude Time Length of the flight

7. Severe medical condition that is unknown Passenger has: 1 1 2 2 3 3 Severe medical condition and is travelling to better level of care Severe/terminal medical condition and is travelling to die in home country

9.  Male  62 years old (SD = 16.7)  No reported pre-existent condition  Departing from LHR  Going to LHR  HKG-LHR (5 cases only)

10. Some people fly… (try to die) but don’t die! The Advent of AEDs

11.  Ventricular fibrillation (VF) ◦ 70% out-of-hospital Sudden Cardiac Arrests - Typical for MI ◦ Importance of witnessed vs. un-witnessed collapse  Pulseless electrical activity (PEA) ◦ Trauma, pulmonary embolism, massive MI, etc  Asystole ◦ Hypoxia ◦ Common final pathway (both VF and PEA evolves to asystole )  The only chance to resuscitate someone is to remove the causing factor!! CPR keeps life only...

12. 1986 British Caledonian (Chapman and Chamberlain) 2001 FAA – Appendix A – Part 121 - AEDs required by April 2004 2005 New Guidelines from AHA 1991 Qantas 2010 Virtually all major international airlines carrying AEDs 1990 Virgin Atlantic – Public Access Defibrillation (AHA-ERC- ILCOR) 1996 American Airlines

14. 48% Overall Survival Rate 56% Survival rate from VF Caffrey et al N Engl J Med 2002; 347:1242-7 26 uses + 4 4 cases no-SCA 21 cases 19 male / 2 fem 1 case trauma 20 witnessed 2 PEA 18 VF 11 ROSC 10 alive after 1 year 7 deaths

15. O’Rourke et al - Circulation 1997 33% 22% 23%

16. Note: 46 (82% long-term saves)

17. All Utilizations 947 cases Monitoring only 609 (64.3%) AED 338 (35.7%) No Shock Advised 256 (75.7%) Shock Advised (VF) 82 (24.3%) Survival to Hospital 21 -23 (25.6%-28.0%)

22.  A large proportion of sequences were of only 5 to 8 compressions  Cycles of 5-47 compressions  Most common cycle = 5 compressions  Very long pauses for ventilation observed  Compressions given above 120 per minute  Low number of compressions in a minute

23. CPR in progress while AED being connected Too long a pause for breathing…

24. CPR – 30 compressions Short breathing pause Overall frequency: 140 cpm

25. Shock promptly delivered CPR promptly resumed after shock Short breathing pause 15 compressions cycle

26. CPR compressions over VF Conversion of VF after shock CPR promptly resumed after shock

27. It’s a Save!!!!!

28.  Congratulations—it’s working! ◦ Survival-to-hospital rates of 25% are impressive  Training focused on AHA recommendations ◦ Less interruptions  High level of awareness

29. Hercules Fighting Death to Save Alcestis by Frederic Lord Leighton slightly modified by PM Alves