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Table 7 Immediate post flight medical protocol

From: Health consequences of exposure to aircraft contaminated air and fume events: a narrative review and medical protocol for the investigation of exposed aircrew and passengers

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).

  1. aLevel of OP exposure may not be high enough to show enzyme inhibition or TCP urinary metabolites. Lack of inhibition or metabolites does not indicate that OP exposure did not take place
  2. bTesting is not routinely available and requires specialist laboratories (discuss with your laboratory)
  3. Blood and urine sampling – additional information
  4.  • Bloods should be taken to assess plasma and red cell cholinesterase and, where possible, NTE levels, taking into account the clinical presentation of the person, cost and practicality of testing. While not routinely available, urine samples could be taken to assess for specific organophosphates, and blood samples could be used for selected VOCs