• Lothar A Schwarte, Huub J van der Werf, Milan L Ridderikhof, Jan Fräβdorf, Daphne van Embden, and Robert P Weenink.
• Department of Anesthesiology, Amsterdam University Medical Center, Amsterdam, the Netherlands; Helicopter Emergency Medical Service, Trauma Center North/West Netherlands, Amsterdam University Medical Center, Amsterdam, the Netherlands; Department of Hyperbaric Medicine, Amsterdam University Medical Center, Amsterdam, the Netherlands. Electronic address: L.Schwarte@AmsterdamUMC.NL.
• Am J Emerg Med. 2022 Sep 1; 59: 215.e7215.e9215.e7-215.e9.

AbstractSurvival of airplane stowaways is rare. Here we report an exceptional case of successful treatment and full recovery. After a transcontinental flight an unconscious stowaway was discovered in a wheel well of a Boeing 747-400F. Airport paramedics confirmed regular respiration and achieved 100% oxygen saturation (pulse oximetry) by high-flow oxygen. Rectal body temperature was 35.5 °C. On arrival at the emergency department, the patient's vital signs were stable. He did not respond to verbal stimuli. He localized to painful stimuli with both arms, however, there was no reaction to stimuli to both legs. We suspected his neurological deficits were caused by posthypoxic encephalopathy or altitude decompression sickness (DCS), the latter amenable to hyperbaric oxygen therapy (HBOT). HBOT was performed for 5 h (US Navy Treatment Table 6) and afterwards, full neurological recovery was documented. About 24 h after admission a new proximal paresis of the left leg was noted. Assuming recurrence of DCS, daily HBOT was scheduled for three days, after which motor function had again returned to normal. Stowaways travelling in airplane wheel wells experience extreme environmental circumstances. The presented patient survived an eight-hour exposure to calculated barometric pressures as low as 190 mmHg and ambient PO2 of 40 mmHg. Apart from creating awareness of this rare patient category, we want to stress the risk of altitude DCS in unpressurized flights. When DCS is suspected, immediate high-flow oxygen therapy should be initiated, followed by HBOT at the earliest opportunity.Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.

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