A. Thierbach

The EasyTube for Airway Management in Emergencies

Background. The EasyTube (EzT) is a new sterile, disposable airway device approved by the European Union in February 2003 andby the U.S. Food andDrug Administration in January 2005. The two-lumen design of the EzT enables it to be used as an endotracheal tube or as a supraglottic emergency airway. Objective. To report the preliminary experiences with the EzT airway device in prehospital andin-hospital emergency airway management procedures. Methods. All airway management procedures involving the EzT were recorded for a period of 18 months. Results. The EzT was successfully used to intubate 15 patients with unanticipated airway difficulties during either anesthesia induction or prehospital airway management. In all patients, the EzT was positioned successfully in the first attempt, within a median time of 31 seconds until start of ventilation. Effective supraglottic ventilation andoxygenation was achieved within 25 to 40 seconds. In three patients, the EzT needed one additional repositioning maneuver. On removal of the EzT, no blood was observed on the surface of the device, as a sign of absence of potential mucosal lesion. No injuries were observed in the mouth, pharynx, or esophagus. Conclusions. The first experiences with the use of the EzT are promising. In emergency airway management procedures presenting problems, the device successfully established sufficient ventilation andoxygenation. Further studies are needed to compare its value with those of other supraglottic devices.

Medical support for children's mass gatherings.

INTRODUCTION Medical care must be well-planned for mass gatherings. Events such as fairs, concerts, parades, and rallies cause many people to gather in one place, increasing the chance of injuries and for the development of a disaster. In this study, the level and quality of medical care were evaluated at a mass gathering of approximately 100,000 children. The event was a television-sponsored fun fair. METHODS Every patient contact was documented on printed forms, including data such as the number of patients treated, gender of the patients, presence or absence of a parental escort, time distribution of patient contacts, the diagnoses for the patient contacts, specific therapies applied, duration of the treatment, and patient discharge information. All data were coded after the event and transferred into a computer database. These data were analyzed using descriptive statistics. RESULTS Of the 100,000 spectators, 192 patients (81 male [42.2%] and 111 female [57.8%]) were treated during the nine-hour period, from 09:00 hours (h) until 18:00 h. Twenty percent of all the children up to the age of 10 years needing medical assistance were not accompanied by an adult. Seventy-five percent of all patient contacts were made during the afternoon. Of those treated, 164 patients (85.4%) suffered only minor injuries and were seen for <10 minutes. The most common type of complaint was minor trauma (103 patients, 53.6%); followed by minor medical problems such as headaches or light allergic reactions (21 patients, 10.9%); insect bites (20 patients, 10.4%); and serious medical problems or trauma such as severe arterial hypertension or long bone fractures (19 patients, 9.9%). Treatment included, but was not limited to, dressings (100 patients; 52.1%), local therapy (68 patient, 35.4%), and analgesic therapy (10 patients, 5.2%). Four patients (2%) were transferred to local hospitals. CONCLUSION Most of the medical needs in the patients attending the childrens fun fair were minor. Nevertheless, for similar events in the future, the medical team should be qualified for all serious medical emergencies, as well as major trauma; and should be prepared to meet the requirements of the specific group of spectators. The overall usage rate in the childrens fun fair described was 19.2 patient encounters per 10,000 spectators. Half of all of the patients were children below the age of 14 years. Medical services should consider that this study shows that up to 33% of children seeking medical assistance may not be accompanied by adults.

Monitoring in der Notfallmedizin

ZusammenfassungIn der modernen Notfallmedizin werden hohe Ansprüche an die technische Überwachung der Patienten gestellt.Diese soll die Sicherheit des Patienten erhöhen, die Diagnostik spezifischer medizinischer Probleme erleichtern sowie die Beatmung oder die Gabe potenter Medikamente überwachen.Die verwendeten Medizingeräte müssen an die besonderen Erfordernisse in der Präklinik angepasst sein. Hier sind eine lange Unabhängigkeit von der Stromversorgung, anwenderfreundliche Bedieneroberfläche, kompakte Bauweise und geringes Gewicht zu fordern.Zu den Minimalstandards des Monitoring gehören die nicht invasive Blutdruckmessung, Pulsoximetrie und Elektrokardiographie.Situations- und patientenabhängig können die Messung des endexspiratorischen Kohlendioxidpartialdrucks und der Körpertemperatur hinzukommen. Zur Lagekontrolle des Endotrachealtubus bietet sich die Kapnometrie an, ergänzt durch klinische Untersuchungen, bei Patienten im Herz-Kreislauf-Stillstand auch das Esophageal Detector Device.Eine Ergänzung kann die Sonographie darstellen, mit Hilfe der Telemetrie können Parameter und Befunde an die Zielklinik übermittelt werden.Bei allen zur Verfügung stehenden technischen Möglichkeiten bleibt jedoch die Ausbildung und Erfahrung des medizinischen Personals die wichtigste Komponente.AbstractMonitoring of emergency patients in the pre-hospital setting requires high standards for the technical equipment to ensure the patients safety as well as to diagnose specific medical problems and to administer therapeutic measures such as artificial ventilation and potent drugs.Monitors have to be adapted to the specific necessities of the pre-hospital setting.They should be compact and light weighted, should have an independent power supply and a user friendly software interface.Minimal monitoring standards include non-invasive blood-pressure monitoring, pulse oxymetry, and electrocardiography. Depending on the individual patient,end tidal carbon dioxide concentration or body temperature should be registered.The position of the endotracheal tube should be assessed by capnometry, oesophageal detector devices are especially recommendable for patients in cardiac arrest.The use of ultrasonography and the development of telemedicine may serve to extended diagnostic and therapeutic options in the pre-hospital setting.Despite of all sophisticated technical equipment, the well trained and experienced medical professional remains the most important component of pre-hospital monitoring.

Comparison of two different techniques of fibreoptic intubation.

Background and objective The application of analgesics and sedatives during fibreoptic intubation (FOI) may result in a transient decrease in arterial oxygen saturation. This study evaluates two different techniques of FOI and respective effects on procedural duration, arterial oxygen saturation, and coughing by the patient. Methods Thirty-four patients received a standardized conscious sedation with fentanyl (1.5 μg kg−1) and midazolam (12.5 μg kg−1). All patients were randomly allocated to one of the following techniques: the ‘vaporization’ (VAP) technique included four applications of 2 ml lidocaine 2% administered through the working channel of the fibrescope supplying an oxygen flow of 3 l min−1; the ‘standard’ (STAN) technique included the insufflation of 3 l min−1 oxygen via a nasal probe and two applications of 4 ml of lidocaine 2%, each followed by a maximum of 2 min to take effect. Results FOI was successful in all patients (STAN 15; ‘vaporization’ 17 patients). The overall intubation time interval was significantly (P < 0.001) shorter in the VAP group. There was no difference in oxygen saturation between the two groups prior to the start of FOI, but a significant (P = 0.008) decrease in oxygen saturation levels was detected in the STAN group after completion of FOI. Patients in the VAP group coughed less; a significant difference in the number of coughs (P = 0.036) was found during the application of lidocaine into the proximal trachea. Conclusion The VAP technique decreases overall intubation time, increases the oxygen saturation of the patient until completion of the intubation, and reduces cough.

Planung deutscher Krankenhäuser für Großschadensfälle

ZusammenfassungAußergewöhnliche Notfallsituationen in Krankenhäusern, bei denen der Bedarf an medizinischer Versorgung den tatsächlichen Bedarf bei weitem übersteigt, können nur mit Hilfe suffizienter und an die personelle und geographische Situation des jeweiligen Krankenhauses angepaßte Katastrophenschutzpläne (KSP) bewältigt werden. Ziel dieser Umfrage mit 522 teilnehmenden deutschen Krankenhäusern war, einen aktuellen Überblick über die Qualität und Verfügbarkeit von KSP zu erhalten. Dabei stellte sich heraus, daß 83,5% aller Krankenhäuser über einen KSP verfügen, welcher jedoch in 54,8% nicht zwischen der internen, das Krankenhaus unmittelbar betreffenden und externen Notfällen unterscheidet. Auch waren 22,4% der KSP nie oder nur gelegentlich überarbeitet worden, Katastrophenschutzübungen wurden in 51,2% der Krankenhäuser noch nie durchgeführt. Demgegenüber steht die Tatsache, daß bereits 14,5% aller Kliniken ihren KSP aktivieren mußten. Gemäß den Erwartungen von 51,6% der Krankenhausträger hat die Aktivierung durch die diensthabenden Assistenzärzte initiiert zu werden. Jedoch setzen nur 25,3% aller Kliniken ihre ärztlichen Mitarbeiter über den gültigen KSP in Kenntnis. Ein adäquates Management von außergewöhnlichen Notfallsituationen ist derzeit in Deutschland nicht durchgehend gewährleistet. Zur Garantierung eines suffizienten Katastrophenschutzes müssen KSP mindestens 1- bis 2mal pro Jahr überarbeitet werden, die Umsetzung des KSP muß durch regelmäßige Übungen trainiert und sichergestellt werden, jeder Plan muß auf das individuelle Krankenhaus mit spezifischen lokalen Gegebenheiten ausgerichtet sein.SummaryDuring disaster situations in hospitals the need for medical care exceeds by far the actual medical capacity and supplies of the particular hospital. Therefore adequate management of these situations can only be assured by disaster management plans (DMP) individually adapted to the characteristic situation of the hospital. The purpose of this survey in 522 participating hospitals is to gain a general overview of DMP in Germany. Only 83.5% of all hospitals were actually in possession of a DMP. However, 54.8% of these plans did not differentiate between internal and external disasters. Additionally 22.4% of these DMPs were never or only very irregularly revised and disaster excercises never been performed in 51.2% of the hospitals. In contrast to this, 14.5% of all hospitals had to activate their DM in the past and 51.6% of the management boards of these hospitals expected their residents to initiate the DMP, but only 25.3% of the management boards inform their medical staff about the existence and content of the DMP. Therefore it must be concluded that, currently, adequate management of disasters in German hospitals cannot be guaranteed. In order to be well prepared for these extraordinary emergency situations in all hospitals, DMPs must be revised at least once or twice a year and the medical staff must be informed about the contents of DMPs. Additionally, disaster excercises should be performed so that the staff is confident in the practical handling of the DMP.

AIRWAY MANAGEMENT IN TRAUMA PATIENTS

Complications related to airway management in traumatized patients are common and, because of the importance and vulnerability of the ventilatory system, can be life threatening within a very short time. 25,39,48 Therefore, airway management is perhaps the most vital component in the treatment of traumatized patients. Patients who have suffered major trauma can present the most complex airway management problems, especially in the prehospital setting. 19 Because the treatment is time-critical, the evaluation of injuries is usually incomplete at the time airway management is undertaken. If the airway is injured, attempts to secure the airway by performing endotracheal intubation or insertion of other devices may cause even further injury. It is widely accepted that intensive preparation and training for the management of airway problems help to prevent and solve most reported complications. Airway management involves far more than just proficiency with tracheal intubation techniques. Clearly, several techniques are available, and the method chosen depends on the availability of equipment, the level of training and expertise, and the patients specific injury. Traumatologists must understand the physiologic consequences and complications of the procedures and techniques and have knowledge of the anatomy and pathologic conditions of the airway and of methods of assessment. Perhaps most important of all, they must be able to recognize patients in whom airway management may be difficult and be able to formulate and implement alternative plans in various situations. Many times, difficult airways are not those that present obvious concerns in advance (and thus promote preemptive procedures and techniques) but rather those that look easy but are not. Difficult airways demand the confluence of all the skills, experience, training, knowledge, and innovation of advanced traumatologists.

Franz Kuhn, his contribution to anaesthesia and emergency medicine.

Franz Kuhn (1866-1929), a German surgeon, made a significant practical and scientific contribution towards the development of modern anaesthesia and emergency medicine. He developed modern, scientifically based concepts in close correlation to practical inventions for every day use. All of his studies and developments were patient orientated and led to remarkable improvements in patient safety. Kuhn was a major protagonist of endotracheal intubation, perfected his flexo-metallic endotracheal tubes, worked on different techniques of intubating the trachea, applied positive pressure to the lungs during thoracic surgery and developed anaesthesia machines. In the early 20th century, he wrote several papers on this topic including a remarkable monograph, dealing with the techniques, indications in anaesthesia and emergency medicine and his experiences of endotracheal intubation. Due to a dispute with Sauerbruch on the methods of avoiding a pneumothorax during thoracic surgery and the development of local and regional anaesthesia techniques, the value of his work and his revolutionary ideas were not appreciated until 40 years later.

Bewegungen der Kiefergelenke während der endotrachealen Intubation

ZusammenfassungZwischen der Funktion der Kiefergelenke und der Intubation besteht eine wechselseitige Beziehung: Dysfunktionen können ein Intubationshindernis darstellen. Die Intubation kann umgekehrt auch zu Funktionsstörungen im orofazialen System führen oder Auslöser akuter Kiefergelenkbeschwerden sein. Eine Aussage zu der nach Aufhebung der physiologischen Schutzmechanismen möglicherweise veränderten Motilität war bislang nicht möglich. Die Arbeit beschreibt die Anwendung einer Methode zur Erfassung der Kiefergelenkbewegungen sowie typische Befunde während der Intubation.Das Prinzip der elektronischen Achsiographie wurde dahingehend modifiziert, daß der Vergleich einer aktiven Mundöffnungsbewegung mit der Intubationsbewegung möglich wurde. Anhand der Ergebnisse von 40 Patienten (orale oder nasale Intubation, Relaxation mit Suxamethonium oder Vecuronium) konnten typische Kiefergelenkbewegungen demonstriert werden: Die Narkoseeinleitung führte zu einer Passivverlagerung nach kaudal, während der Einführung des Layngoskops verblieben die Gelenke in einer reinen Rotationsbewegung (physiologisch: Translationsbewegung). Die Einstellung der Trachea führte zu einer massiven (pathologischen) Distraktion. In einem Fall wurde die Ruptur des Ligamentum laterale dokumentiert. Die Methode erlaubt erstmals die Visualisierung der Kiefergelenkbewegungen während der Intubation. Als potentiell schädigende Momente wurden die unphysiologisch weite initiale Rotation und eine massive Kiefergelenkdistraktion identifiziert. Das Verfahren eröffnet die Möglichkeit, verschiedene Techniken, Medikamente und Instrumente zu untersuchen.AbstractLaryngoscopy causes temporary postoperative dysfunction of the temporomandibular joint (TMJ): during iatrogenic TMJ manipulation in anaesthetised patients, the TMJs have lost the protection afforded by the tone of the surrounding muscles. Thus far, the exact type and extent of TMJ movements have not been known. The purpose of this study was to develop a method to visualise and assess TMJ movements during intubation by means of electronic axiography, a diagnostic monitor of TMJ movements used in dentistry: registration of the hinge axis (HA) as an equivalent of the condylar paths on extra-oral sagittally mounted, parallel plates. The HA is individually defined in each patient by the pure, rotating TMJ movement during initial mouth opening (no farward gliding of the condyles, incisor distance up to 10 mm). The parallel plates are placed in the TMJ region in the skull-mounted plate bow; both registration tips („drawing“ the HA tracings on the electronic plates) are connected to the mandible by a face bow, paraocclusally fixed to the teeth. The face bow is individually shaped for each patient to allow mask ventilation and free movement of the laryngoscope during intubation. HA tracings are registered and calculated for both sides independently every 24 ms with the SAM/Klett system and presented on sagittal and frontal projections. In the operating theatre, the active mouth-opening traces (MOT) are registered first and the passive endotracheal intubation traces (EIT) after induction of anaesthesia (same head position). With informed consent and approval by the ethics committee of the Landesärztekammer Rheinland-Pfalz, 40 male patients (ASA I, Mallampati I, limb surgery) were randomly allocated to four groups (n=10 each). OS: Oral intubation, suxamethonium (1.5 mg/kg); OV: Oral intubation, vecuronium (0.1 mg/kg); NS: Nasal intubation, suxamethonium (1.5 mg/kg); and NV: Nasal intubation, vecuronium (0.1 mg/kg). Intubation was performed 100 s after injection of the relaxant. Pre- and postoperatively (every 24 h over 3 days, in case of positive findings longer) recorded were: active movements of the mandible (maximal mouth opening/max. laterotrusion); dysfunction of the TMJ; and pain sensation in the TMJ (Helkimo rating). MOTs and EITs were recorded and analysed with the system described and typical EIT patterns were identified: bland, clinically uneventful intubations (n=7), massive distraction and laterotrusion of the EIT compared to the MOT (n=24), and blocked or limited TMJ movements resulting in intubation problems (n=1). With the method presented, TMJ movements could be visualised during endotracheal intubation for the first time. It can be used to assess techniques, routes, and instruments for intubation as well as to evaluate potential traumatising movements during endotracheal intubation.

Theoretische Ausbildung für den Notarztdienst

ZusammenfassungDie Erlangung der in den Rettungsdienstgesetzen der Länder definierten Qualifikation, als Notarzt tätig zu werden, setzt u.a.einen 80-stündigen, interdisziplinären Kurs “Fachkundenachweis Rettungsdienst” voraus.In diesem Kurs wurde in den letzten Jahren zunehmend deutlich, dass lediglich wenige Teilnehmer die Absicht haben, aktiv im Notarztdienst tätig zu werden, sondern versuchen, allgemeine notfallmedizinische Defizite ausgleichen, die im Rahmen ihrer klinischen Tätigkeit deutlich werden.Kollegen, die vor Beginn ihrer notärztlichen Tätigkeit stehen,beklagen hingegen den zu geringen Anteil spezieller Fragestellungen der präklinischen Notfallmedizin zur Vertiefung des Basiswissens.Hieraus resultiert der Vorschlag,den bisher 80-stündigen Kurs zur Erlangung des “Fachkundenachweis Rettungsdienst” in die beiden Teile “ erste klinische Versorgung von Notfallpatienten” sowie “präklinische Notfallmedizin” zu gliedern und auf insgesamt 100 Unterrichtseinheiten zu verlängern.Dadurch können verstärkt praktische, einsatztaktische und technische Aspekte berücksichtigt werden sowie eine stärkere Gewichtung der Lehrinhalte auf typische Fehler gelegt werden.Das vorgestellte Konzept soll eine Verbesserung der notfallmedizinischen Ausbildung zur Folge haben und sich an den Belangen des klinischen Alltags orientieren.AbstractTo qualify as an emergency physician as defined in the state laws on emergency medical services requires attendance at an 80-h interdisciplinary course “certificate of qualification in emergency services.” In the past few years, it has become ever more evident that only a few of the participants actually intend on becoming active in the field of emergency medicine and that most are attempting to gather general experience in emergency medicine to offset apparently inadequate clinical training. In contrast, colleagues on the brink of becoming emergency physicians complain that too little training is devoted to specific questions of prehospital emergency medicine to expand their basic knowledge.As a result the suggestion has emerged that the hitherto 80-h course for certification in emergency medicine be divided into two parts consisting of “initial clinical care of emergent patients” and “prehospital emergency medicine” and to lengthen the course to 100 study units. It would thus become possible to stress practical, logistic, and technical aspects and during the course focus more on typical errors.The concept presented here should result in an improvement of training for emergency medicine and be oriented to the concerns of everyday clinical practice.

Die Transilluminationstechnik@@@Transillumination: an alternative to conventional tracheal intubation?

ZusammenfassungBei der Transilluminationstechnik führt eine Lichtquelle zur transkutanen Durchleuchtung im Larynxbereich. Das Trachlight®ist ein hierfür neues Instrument mit wesentlichen Weiterentwicklungen: längenadaptierbares Führungsstilett mit innerem Metalldraht, hellere Lichtquelle, stabiler Handgriff mit Fixation des Tubus und Zeitautomatik zur Warnung vor zu langer Intubationsdauer. Das neue Instrument wurde randomisiert im Vergleich zur konventionellen Intubation eingesetzt (n=120). Meßparameter: Anzahl, Verlauf der Intubationsversuche und Komplikationen. Bei jeweils 20 Patienten wurden die Kreislaufparameter invasiv erfaßt. Mit dem Trachlight® konnten 54 Patienten erfolgreich intubiert werden (Zeitbedarf 29,9±14,8 s [6–61 s]), konventionell 23,6±10,4 (12–60 s). Positiva: Einfache Handhabung, keine Verletzungen, korrekte Einführtiefe des Tubus. Probleme: Ausreichende Transillumination erst nach völliger Abdunkelung, unzureichende Kontrolle über distales Tubusende, unbeabsichtigtes Ausschalten der Lichtquelle, Schwierigkeiten beim Zurückziehen des Metalldrahts sowie Störung durch den Blinkmechanismus. Gründe für Intubationsversager: Einführung des Instruments in den Ösophagus trotz vermeintlich korrekter Position, Unmöglichkeit der Plazierung sowie unzureichende Transillumination. Die Kreislaufparameter zeigten in beiden Gruppen keine Veränderungen während der laryngealen Manipulation, jedoch einen deutlichen Anstieg beim Vorschieben des Tubus in die Trachea. Die Transilluminationstechnik kann als eine Alternative im Airway-Management bezeichnet werden. Im präklinischen Bereich ist sie problematisch, bei Patienten mit schwierigen Intubationsverhältnissen sollte der Fiberoptik der Vorzug gegeben werden.AbstractThe technique of light-guided intubation is based on the principle that a source of light brought into the trachea results in clearly visible and defined transcutaneous illumination, while no illumination can be observed with the light source in the oesophagus (Fig. 1–7). The Trachlight® is a reintroduced instrument for this alternative intubation technique. The essential developments are: a length-adjustable stylet with a removable internal metal wire, a brighter light source, a stable handle with tight fixation of the endotracheal tube, and a time-dependent warning device to avoid extended intubations. One hundred twenty patients (Mallampati I, ASA I–III) were included in the study (conventional intubation [group KL, n=60], Trachlight® intubation [group TT, n=60]. The goals of the investigation were to examine the handling, application, problems, limitations, and possible indications of the method. The recorded parameters were: number of intubation attempts: course and duration of intubation; complications; and difficulties. In 40 patients (20 in each group) the indication for invasive blood presure measurement was given due to the surgical procedure, and circulatory parameters were recorded at defined moments during the intubation course. In group KL 55 patients were intubated in the attempt, 4 on the second, and 1 on the third (mean duration 23.6±10.4 s, range 12–60 s). Complications were: unilateral intubation (3 patients), bradycardia (2), asystole (1) and soft-tissue injury (1). Of the 60 patients in group TT, 54 were intubated successfully, the mean time needed being 29.9±14.8 s (range: 6–61 s). The remaining 6 were then intubated by the conventional method. Positive results in group TT included: easy handling and application, no injury to soft tissues or teeth, and invariably correct placement of the tube. Problems included: sufficient transillumination was achieved only after (entire) dimming of the room, insufficient control over the distal end of the tube due to an unfixed metal wire, unintentional switching off of the light while with-drawing the metal wire, difficulties in with-drawing the metal wire (too strong fixation), as well as disturbing effects of the warning device (blinking of the light 30 s after switching on). Reasons for the 6 intubation failures were introduction of the instrument into the oesophagus despite a supposed correct position, impossibility of correct placement in a patient with an extremely large goiter, and insufficiently clear transillumination in 3 extremely obese patients. The cardiovascular parameters showed no changes during laryngeal manipulation; a clear rise in heart rate and blood pressure was recorded, however, when the tube was inserted into the trachea. The cardiovascular parameters during conventional intubations were similar. The light-guided intubation technique can be regarded as a further alternative for airway management, due to the described improvements of the instrument. The indication for the technique is given in patients in whom no difficulty with intubation is expected, to avoid soft tissue damage and traumatising temporomandibular joint movements. Preclinical use may be limited due to environmental brightness. In patients with expected difficult airway management, fiberoptic intubation will remain the method of choice.