Medical history of event |
A detailed and careful occupational history of the fume event, including timing, severity and duration of the fume event. Also record the frequency, duration and intensity of previous fume exposures: |
 • Record total flying hours (Pilots will know this from their logbooks. Cabin crew can estimate total hours from contracted annual hours x length of service less time for absences such as annual and sick leave, part-time work and maternity leave). |
 • Record symptoms and progression of symptoms including those observations made by other people, such as crew members and passengers (important in assessment of affected persons), any treatment given/used, whether oxygen was used and when/duration including flow rate and unusual behaviour (e.g. impaired balance, cognitive status, short term memory) as outlined in Table 5. |
Clinical examination |
 • Record general appearance (for example, breathlessness, pallor, agitation). |
 • Measure and record respiratory and heart rate, blood pressure. |
 • Auscultation of heart and lungs. |
 • General physical examination. |
 • Record percutaneous oxygen saturation, record inspired oxygen concentration). |
 • Monitor SpO2, if initial SpO2 < 95%. |
 • Assess neurological status (conscious state, balance, muscle weakness, numbness, pupils, muscle reflexes, check for tingling of limbs, muscle cramps, tremor). |
 • Assessment using the Mini-Mental State Examination MMSE: (Orientation for time and place; attention and calculation; memory and processing speed). |
 • Other abnormal findings. |
General investigations |
General investigations should be undertaken as soon as possible following a fume event, but should ideally be within two to four hours and three days to complement the above clinical examination and may include: |
 Routinely available: |
  • Full blood examination (Hb, WCC and differential count). |
  • Acute phase reactants (e.g., C-reactive protein, ESR, fibrinogen). |
  • Routine biochemistry (U&E/Cr, LFTs, LDH). |
  • Muscle enzymes (e.g., troponin, CKMM and CKMB, aldolase); |
  • Bloods for cholinesterase – (AChE, BChE)a see below for details |
  • Others, as clinically indicated. |
  • Carboxyhaemoglobin – HbCO (should be undertaken within 2–4 h post flight post flight for accurate measurements due to short half-life). Record time since exposure and/or time of last cigarette. |
  • Methaemoglobin (should be undertaken within two to four hours post flight for best assessment due to short half-life). |
  • Neurobehavioural: basic quick (5 min) testing of processing speed using the Symbol Digit Modalities test (SDMT) (oral and written) and/or digit span forwards and backwards is recommended initially, followed by early referral for more detailed neuropsychological testing if required. |
 Non-routinely available |
  • Blood for neuropathy target esterase (NTE)a,b – see Table 1 for details; |
  • Urine for OPsa,b – As soon as possible after a fume event: see Table 2 for details; Blood for VOCsb – As soon as possible after a fume event: see Table 2 for details. |
Auto-antibodies against neuronal and glial proteins in blood biomarker testing (at present not available): See emerging issues and supplement (emerging issues & appendix 8). |