Arnd Timmermann

The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians.

BACKGROUND:Rapid establishment of a patent airway in ill or injured patients is a priority for prehospital rescue personnel. Out-of-hospital tracheal intubation can be challenging. Unrecognized esophageal intubation is a clinical disaster. METHODS:We performed an observational, prospective study of consecutive patients requiring transport by air and out-of-hospital tracheal intubation, performed by primary emergency physicians to quantify the number of unrecognized esophageal and endobronchial intubations. Tracheal tube placement was verified on scene by a study physician using a combination of direct visualization, end-tidal carbon dioxide detection, esophageal detection device, and physical examination. RESULTS:During the 5-yr study period 149 consecutive out-of-hospital tracheal intubations were performed by primary emergency physicians and subsequently evaluated by the study physicians. The mean patient age was 57.0 (±22.7) yr and 99 patients (66.4%) were men. The tracheal tube was determined by the study physician to have been placed in the right mainstem bronchus or esophagus in 16 (10.7%) and 10 (6.7%) patients, respectively. All esophageal intubations were detected and corrected by the study physician at the scene, but 7 of these 10 patients died within the first 24 h of treatment. CONCLUSION:The incidence of unrecognized esophageal intubation is frequent and is associated with a high mortality rate. Esophageal intubation can be detected with end-tidal carbon dioxide monitoring and an esophageal detection device. Out-of-hospital care providers should receive continuing training in airway management, and should be provided additional confirmatory adjuncts to aid in the determination of tracheal tube placement.

Prospective Clinical and Fiberoptic Evaluation of the Supreme Laryngeal Mask Airway

Background:In March 2007, a new disposable laryngeal mask airway (LMA) became available. The LMA Supreme™ (The Laryngeal Mask Company Limited, St. Helier, Jersey, Channel Islands) aims to combine the LMA Fastrach™ feature of easy insertion with the gastric access and high oropharyngeal leak pressures of the LMA ProSeal™. Methods:The authors performed an evaluative study with the LMA Supreme™, size 4, on 100 women to measure the ease of insertion, determinate the laryngeal fit by fiberoptic classification, evaluate the oropharyngeal leak pressure, and report adverse events. Results:Insertion of the LMA Supreme™ was possible in 94 patients (94%) during the first attempt, and in 5 patients (5%) during the second attempt. In one small patient, the LMA Supreme™ could not be inserted because of limited pharyngeal space. This patient was excluded from further analysis. Insertion of a gastric tube was possible in all patients at the first attempt. The median time for LMA Supreme™ insertion was 10.0 s (±4.7 s; range, 8–30 s). Laryngeal fit, evaluated by fiberscopic view, was rated as optimal in all patients, both immediately after insertion of the LMA Supreme™ and at the end of surgery. After equalization to room pressure, the mean cuff volume needed to achieve 60 cm H2O cuff pressure was 18.4 ml (±3.8 ml; range, 8–31 ml). The mean oropharyngeal leak pressure at the level of 60 cm H2O cuff pressure was 28.1 cm H2O (±3.8 cm H2O, range, 21–35 cm H2O). Eight patients (8.1%) complained of a mild sore throat. No patient reported dysphagia or dysphonia. Conclusions:Clinical evaluation of the LMA Supreme™ showed easy insertion, optimal laryngeal fit, and low airway morbidity. Oropharyngeal leak pressure results were comparable to earlier data from the LMA ProSeal™.

Novices ventilate and intubate quicker and safer via intubating laryngeal mask than by conventional bag-mask ventilation and laryngoscopy

Background:Because airway management plays a key role in emergency medical care, methods other than laryngoscopic tracheal intubation (LG-TI) are being sought for inadequately experienced personnel. This study compares success rates for ventilation and intubation via the intubating laryngeal mask (ILMA-V/ILMA-TI) with those via bag–mask ventilation and laryngoscopic intubation (BM-V/LG-TI). Methods:In a prospective, randomized, crossover study, 30 final-year medical students, all with no experience in airway management, were requested to manage anesthetized patients who seemed normal on routine airway examination. Each participant was asked to intubate a total of six patients, three with each technique, in a randomly assigned order. A task not completed after two 60-s attempts was recorded as a failure, and the technique was switched. Results:The success rate with ILMA-V was significantly higher (97.8% vs. 85.6%; P < 0.05), and ventilation was established more rapidly with ILMA-V (35.6 ± 8.0 vs. 44.3 ± 10.8 s; P < 0.01). Intubation was successful more often with ILMA-TI (92.2% vs. 40.0%; P < 0.01). The time needed to achieve tracheal intubation was significantly shorter with ILMA-TI (45.7 ± 14.8 vs. 89.1 ± 23.3 s; P < 0.01). After failed LG-TI, ILMA-V was successful in all patients, and ILMA-TI was successful in 28 of 33 patients. Conversely, after failed ILMA-TI, BM-V was possible in all patients, and LG-TI was possible in 1 of 5 patients. Conclusion:Medical students were more successful with ILMA-V/ILMA-TI than with BM-V/LG-TI. ILMA-TI can be successfully used when LG-TI has failed, but not vice versa. These results suggest that training programs should extend the ILMA to conventional airway management techniques for paramedical and medical personnel with little experience in airway management.

Paramedic versus emergency physician emergency medical service: role of the anaesthesiologist and the European versus the Anglo-american concept

Purpose of review Much controversy exists about who can provide the best medical care for critically ill patients in the prehospital setting. The Anglo-American concept is on the whole to provide well trained paramedics to fulfil this task, whereas in some European countries emergency medical service physicians, particularly anaesthesiologists, are responsible for the safety of these patients. Recent findings Currently there are no convincing level I studies showing that an emergency physician-based emergency medical service leads to a decrease in overall mortality or morbidity of prehospital treated patients, but many methodical, legal and ethical issues make such studies difficult. Looking at specific aspects of prehospital care, differences in short-term survival and outcome have been reported when patients require cardiopulmonary resuscitation, advanced airway management or other invasive procedures, well directed fluid management and pharmacotherapy as well as fast diagnostic-based decisions. Summary Evidence suggests that some critically ill patients benefit from the care provided by an emergency physician-based emergency medical service, but further studies are needed to identify the characteristics and early recognition of these patients.

Characteristics of out-of-hospital paediatric emergencies attended by ambulance- and helicopter-based emergency physicians

BACKGROUND In Germany, as in many other countries, for the vast majority of cases, critical out-of-hospital (OOH) paediatric emergencies are attended by non-specialised emergency physicians (EPs). As it is assumed that this may lead to deficient service we aimed to gather robust data on the characteristics of OOH paediatric emergencies. METHODS We retrospectively evaluated all OOH paediatric emergencies (0-14 years) within a 9-year period and attended by physician-staffed ground- or helicopter-based emergency medical service (EMS or HEMS) teams from our centre. RESULTS We identified 2271 paediatric emergencies, making up 6.3% of all cases (HEMS 8.5%). NACA scores IV-VII were assigned in 27.3% (HEMS 32.0%). The leading diagnosis groups were age dependent: respiratory disorders (infants 34.5%, toddlers 21.8%, school children 15.0%), convulsions (17.2%, 43.2%, and 16.0%, respectively), and trauma (16.0%, 19.5%, and 44.4%, respectively). Endotracheal intubation was performed in 4.2% (HEMS 7.6%) and intraosseous canulation in 0.7% (HEMS 1.0%) of children. Cardiopulmonary resuscitation (CPR) was commenced in 2.3% (HEMS 3.4%). Thoracocentesis, chest drain insertion and defibrillation were rarities. HEMS physicians attended a particularly high fraction of drowning (80.0%), head injury (73.9%) and SIDS (60.0%) cases, whereas 75.6% of all respiratory emergencies were attended by ground-based EPs. CONCLUSIONS Our data suggest that EPs need to be particularly confident with the care of children suffering respiratory disorders, convulsions, and trauma. The incidence of severe paediatric OOH emergencies requiring advanced interventions is higher in HEMS-attended cases. However, well-developed skills in airway management, CPR, and intraosseous canulation in children are essential for all EPs.

Positive impact of crisis resource management training on no-flow time and team member verbalisations during simulated cardiopulmonary resuscitation: a randomised controlled trial.

OBJECTIVES To evaluate the impact of video-based interactive crisis resource management (CRM) training on no-flow time (NFT) and on proportions of team member verbalisations (TMV) during simulated cardiopulmonary resuscitation (CPR). Further, to investigate the link between team leader verbalisation accuracy and NFT. METHODS The randomised controlled study was embedded in the obligatory advanced life support (ALS) course for final-year medical students. Students (176; 25.35±1.03 years, 63% female) were alphabetically assigned to 44 four-person teams that were then randomly (computer-generated) assigned to either CRM intervention (n=26), receiving interactive video-based CRM-training, or to control intervention (n=18), receiving an additional ALS-training. Primary outcomes were NFT and proportions of TMV, which were subdivided into eight categories: four team leader verbalisations (TLV) with different accuracy levels and four follower verbalisation categories (FV). Measurements were made of all groups administering simulated adult CPR. RESULTS NFT rates were significantly lower in the CRM-training group (31.4±6.1% vs. 36.3±6.6%, p=0.014). Proportions of all TLV categories were higher in the CRM-training group (p<0.001). Differences in FV were only found for one category (unsolicited information) (p=0.012). The highest correlation with NFT was found for high accuracy TLV (direct orders) (p=0.06). CONCLUSIONS The inclusion of CRM training in undergraduate medical education reduces NFT in simulated CPR and improves TLV proportions during simulated CPR. Further research will test how these results translate into clinical performance and patient outcome.

Neue Perspektiven der simulatorunterstützten Ausbildung in Kinderanästhesie und Kindernotfallmedizin

Anaesthesia and emergency medical care for infants and toddlers is often associated with high clinical demands and specific challenges. Nevertheless, a significant proportion of interventions is performed by anaesthetists and emergency physicians with no specialised paediatric training and little experience in the management of anaesthetic incidents and emergencies specific to these age groups. Extensive studies have demonstrated a close inverse correlation between the level of specialisation and perioperative morbidity and mortality. However, clinical circumstances and the relatively small number of paediatric cases at many institutions often hinder the establishment of improved training concepts. Recently, high-fidelity infant simulators have become available, which permit authentic exposure to a large spectrum of scenarios in paediatric anaesthesia and emergency medicine. A multimodular concept of training, including such simulator-based techniques, may relieve the widespread shortage in clinical experience, and hence greatly facilitate improvement of quality of care and patient safety.ZusammenfassungDie anästhesiologische und notfallmedizinische Versorgung von Säuglingen und Kleinkindern ist mit hohen klinischen Anforderungen verbunden. Dabei erfolgt ein Großteil der Maßnahmen durch pädiatrisch nichtspezialisierte Anästhesisten und Notärzte, die häufig wenig Routine im Umgang mit kinderanästhesiologischen Zwischenfällen und pädiatrischen Notfällen besitzen. Die Korrelation zwischen höherem Spezialisierungsgrad einerseits und verminderter perioperativer Morbidität und Mortalität andererseits ist durch umfangreiche Untersuchungen gut belegt. Die Etablierung verbesserter Ausbildungskonzepte scheitert jedoch häufig an den klinischen Strukturen und an den relativ geringen pädiatrischen Fallzahlen der meisten Einrichtungen. Seit kurzem nun stehen leistungsfähige Säuglingssimulatoren zur Verfügung, die ein sehr realitätsnahes Training eines großen Spektrums aus Kinderanästhesie und Kindernotfallmedizin ermöglichen. Ein multimodales Ausbildungskonzept, unter Einbeziehung simulatorunterstützter Techniken, könnte die weit verbreiteten Erfahrungsdefizite lindern und damit Behandlungsqualität und Patientensicherheit nachhaltig verbessern.AbstractAnaesthesia and emergency medical care for infants and toddlers is often associated with high clinical demands and specific challenges. Nevertheless, a significant proportion of interventions is performed by anaesthetists and emergency physicians with no specialised paediatric training and little experience in the management of anaesthetic incidents and emergencies specific to these age groups. Extensive studies have demonstrated a close inverse correlation between the level of specialisation and perioperative morbidity and mortality. However, clinical circumstances and the relatively small number of paediatric cases at many institutions often hinder the establishment of improved training concepts. Recently, high-fidelity infant simulators have become available, which permit authentic exposure to a large spectrum of scenarios in paediatric anaesthesia and emergency medicine. A multimodular concept of training, including such simulator-based techniques, may relieve the widespread shortage in clinical expierience, and hence greatly facilitate improvement of quality of care and patient safety.

Adaptive coordination development in student anaesthesia teams: a longitudinal study

Although adaptive coordination has been highlighted by several studies, research dealing with how adaptive coordination develops is still rare. Thus, the aim of this study was to investigate the development of coordination mechanisms and their task-related adaptation in a longitudinal observation of medical simulation-based training of final year students. We recorded six anaesthesia teams during a sequence of four task scenarios, and each scenario comprised of a routine and a complication phase. After trained observers rated sub-tasks within each scenario for explicit and implicit coordination, statistical analysis revealed a statistically significant effect of previous scenarios on coordination development in the routine phases. While the amount of explicit coordination decreased, implicit coordination increased, revealing adaptive coordination as a skill developed through repeated group interaction. We conclude that anaesthesia training should consider cost- and patient safety-benefits of implicit and explicit coordination and focus on adaptive coordination. Practitioner Summary: Group coordination is crucial to anaesthesia team performance. Results of this longitudinal observation of six anaesthesia teams during four medical simulation-based training scenarios document that teams develop adaptive patterns of coordination. This study also demonstrates that adaptive coordination is a trainable skill within crisis resource management training.

Laryngeal mask LMA Supreme. Application by medical personnel inexperienced in airway management

BACKGROUND The Laryngeal Mask Airway Supreme (LMA-S) is a new disposable airway device that combines features of the LMA ProSeal (PLMA, gastric access) and LMA Fastrach (curved shaft to ease insertion) and has been available since April 2007. METHODS In a prospective study, 10 final year medical students or first year anesthesia residents, all with limited experience in LMA anesthesia, were requested to manage the airway of anesthetized female patients with the LMA-S size 4, who seemed normal on routine airway examination. Data collection included the success rates and duration for insertion, oropharyngeal leak pressures (OLP), fiber optic position and airway morbidity. RESULTS A total of 30 patients were enrolled in the study. Insertion of the LMA-S was possible in 27 (90%) patients at the first attempt and in 3 (10%) at the second attempt. Ventilation was established in 18.3 s (range 10-30 s, standard deviation +/-4.2 s). Insertion of a gastric tube was possible in all patients at the first attempt. Mean OLP at the level of 60 cmH2O cuff pressure was 29.1 cmH2O (range 21-35 cmH2O, standard deviation +/-4.8 cmH2O). Laryngeal fit evaluated by fiber optic control was rated as optimal in all patients both immediately after insertion of the LMA-S and after end of surgery. Three patients (10%) complained of mild sore throat. No patient reported dysphagia or dysphonia. CONCLUSION Insertion of the LMA-S was successful and possible in all patients in < or = 30 s with an optimal laryngeal fit, high OLPs and low airway morbidity. The LMA-S seems to be a device suitable for use in routine anesthesia and which can be safely used by medical personnel with limited clinical experience.

Simulation and airway management

ZusammenfassungDie Inzidenz respiratorisch bedingter Morbidität und Mortalität als Folge von Intubationsschwierigkeiten und unerkannter ösophagealer Intubation bleibt hoch, obwohl zahlreiche neue Atemwegstechniken und Strategien zur Bewältigung des schwierigen Atemwegs entwickelt wurden. Die Problematik liegt offenbar im Transfer dieser Techniken in die klinische Praxis. Vorträge und Übungen am Phantom und am Tierkadaver sind bislang die üblichen Methoden der Anleitung. Patientensimulatoren geben die Möglichkeit, unter sehr realistischen Bedingungen Fertigkeiten und Lösungen spezieller Situationen zu trainieren, erleichtern die Umsetzung von kognitiven, psychomotorischen und affektiven Fähigkeiten im klinischen Alltag und helfen, das Verhalten in kritischen Situationen zu verbessern. Dieser Artikel erläutert die Möglichkeiten von neuen Trainingskonzepten zur Sicherung der Atemwege, die mithilfe spezieller Simulationen und Simulatoren durchgeführt werden können. Es werden die technischen Voraussetzungen beschrieben und Hinweise zur praktischen Durchführung von schwierigen Atemwegsszenarien gegeben.AbstractDespite the development of new devices and strategies to manage and secure the difficult airway, morbidity and mortality in anaesthesia due to airway problems such as difficult intubation or unrecognised failed intubation remain high. The problem seems to lie in the transfer of skills and strategies to daily clinical practice. Common methods for airway management training include theoretical instructions and hands-on sessions with manikins, animal models and cadavers. Simulation provides the opportunity to train skills and resolve specific situations embedded in a realistic scenario, facilitate the transfer of cognitive, psychomotor and affective abilities into daily clinical practice and help to improve behaviour in critical situations. This article outlines new training concepts in airway management with the help of simulation and simulators. We describe technical prerequisites and provide information on the implementation of difficult airway scenarios.