Jan Florian Heuer

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.

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.

Accuracy of prehospital diagnoses by emergency physicians: comparison with discharge diagnosis.

Objective A correct prehospital diagnosis of emergency patients is crucial as it determines initial treatment, admitting specialty, and subsequent treatment. We evaluated the diagnostic accuracy of emergency physicians. Methods All patients seen by six emergency physicians staffing the local emergency ambulance and rescue helicopter services during an 8-month period were studied. The ambulance and helicopter physicians had 3 and 4 years, respectively, training in anesthesia and intensive care medicine. The admission diagnoses were compared with the discharge diagnoses for agreement. Time of day of the emergency call, patients’ age, and sex, living conditions, and presenting symptoms were evaluated as contributing factors. Results Three hundred and fifty-five ambulance and 241 helicopter deployment protocols were analyzed. The overall degree of agreement between initial and discharge diagnoses was 90.1% with no difference attributable to years of experience. The lowest agreement rate was seen in neurological disorders (81.5%), with a postictal state after an unobserved seizure often being diagnosed as a cerebrovascular accident. Inability to obtain a complete medical history (e.g. elderly patients, patients in nursing homes, neurological impairment) was associated with a lower agreement rate between initial and discharge diagnoses (P<0.05). Conclusion Medical history, physical examination, ECG, and blood glucose enabled a correct diagnosis in most cases, but some were impossible to resolve without further technical and laboratory investigations. Only a few were definitively incorrect. A detailed medical history is essential. Neurological disorders can present with misleading symptoms and when the diagnosis is not clear it is better to assume the worst case.

Larynxmaske LMA Supreme

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.

[Teaching and simulation. Methods, demands, evaluation and visions].

ZusammenfassungIn der seit 01.10.2003 gültigen neuen ärztlichen Approbationsordnung (ÄAppO) wird eine praxisnahe, interdisziplinäre Lehre in Form eines Kleingruppenunterrichts gefordert. Die Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) hat im Jahr 2004 viele deutsche anästhesiologische Lehrstühle mit Patientensimulatoren für den Einsatz in der studentischen Lehre ausgestattet. Dieser Artikel beschreibt Methoden simulationsbasierter Lehre in den unterschiedlichen klinischen Abschnitten. Mindestanforderungen für einen erfolgreichen simulationsgestützten Unterricht sind die Schaffung einer logistischen und materiellen Infrastruktur, die Schulung der Dozenten mit Instruktorenkursen, die thematische Einbettung in ein strukturiertes Gesamtcurriculum und ein Verhältnis von Dozenten zu Studierenden von 1:3, entsprechend den Empfehlungen zum Unterricht am Krankenbett. Werden diese Anforderungen eingehalten, evaluieren die Studierenden die verschiedenen Szenarien „Narkoseeinleitung“, „akute Lungenembolie“, „Versorgung eines Polytraumas“ und „postoperative hämodynamische Insuffizienz“ mit 1,5; 1,6; 1,5 und 1,5 (Schulnotenskala 1–6). Im direkten Vergleich werden die Szenarien besser als andere curriculare Abschnitte beurteilt.AbstractSince 1st October 2003 the new German “Approbationsordnung für Ärzte” (Medical Licensing Regulations) requires an increasing amount of small group teaching sessions and encourages a multidisciplinary and more practical approach to the related topics. In 2004 the German Society of Anaesthesiology and Intensive Care Medicine has provided almost all anaesthesia faculties of German Universities with equipment for full-scale simulation. This article describes methods for a simulation-based medical education training programm. Basic requirements for a successful training programm using full scale simulators are the provision of an adequate logistical and material infrastructure, teacher attendance of train-the-trainer courses, implementation in the medical curriculum and an instructor–student ratio of 1:3, equivalent to that for bedside teaching. If these requirements were fulfilled, medical students scored the simulation scenarios “induction of anaesthesia”, “acute pulmonary embolism”, “acute management of a multiple trauma patient” and “postoperative hypotension” as 1.5, 1.6, 1.5 and 1.5, respectively, on a scale of 1–6. These scores were better than those given for other segments of the curriculum.

Hemodynamic Changes in a Model of Chronic Heart Failure Induced by Multiple Sequential Coronary Microembolization in Sheep

Although a large variety of animal models for acute ischemia and acute heart failure exist, valuable models for studies on the effect of ventricular assist devices in chronic heart failure are scarce. We established a stable and reproducible animal model of chronic heart failure in sheep and aimed to investigate the hemodynamic changes of this animal model of chronic heart failure in sheep. In five sheep (n = 5, 77 +/- 2 kg), chronic heart failure was induced under fluoroscopic guidance by multiple sequential microembolization through bolus injection of polysterol microspheres (90 microm, n = 25.000) into the left main coronary artery. Coronary microembolization (CME) was repeated up to three times in 2 to 3-week intervals until animals started to develop stable signs of heart failure. During each operation, hemodynamic monitoring was performed through implantation of central venous catheter (central venous pressure [CVP]), arterial pressure line (mean arterial pressure [MAP]), implantation of a right heart catheter {Swan-Ganz catheter (mean pulmonary arterial pressure [PAP mean])}, pulmonary capillary wedge pressure (PCWP), and cardiac output [CO]) as well as pre- and postoperative clinical investigations. All animals were followed for 3 months after first microembolization and then sacrificed for histological examination. All animals developed clinical signs of heart failure as indicated by increased heart rate (HR) at rest (68 +/- 4 bpm [base] to 93 +/- 5 bpm [3 mo][P < 0.05]), increased respiratory rate (RR) at rest (28 +/- 5 [base] to 38 +/- 7 [3 mo][P < 0.05]), and increased body weight 77 +/- 2 kg to 81 +/- 2 kg (P < 0.05) due to pleural effusion, peripheral edema, and ascites. Hemodynamic signs of heart failure were revealed as indicated by increase of HR, RR, CVP, PAP, and PCWP as well as a decrease of CO, stroke volume, and MAP 3 months after the first CME. Multiple sequential intracoronary microembolization can effectively induce myocardial dysfunction with clinical and hemodynamic signs of chronic ischemic cardiomyopathy. The present model may be suitable in experimental work on heart failure and left ventricular assist devices, for example, for studying the impact of mechanical unloading, mechanisms of recovery, and reverse remodeling.

Lehre und Simulation

ZusammenfassungIn der seit 01.10.2003 gültigen neuen ärztlichen Approbationsordnung (ÄAppO) wird eine praxisnahe, interdisziplinäre Lehre in Form eines Kleingruppenunterrichts gefordert. Die Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) hat im Jahr 2004 viele deutsche anästhesiologische Lehrstühle mit Patientensimulatoren für den Einsatz in der studentischen Lehre ausgestattet. Dieser Artikel beschreibt Methoden simulationsbasierter Lehre in den unterschiedlichen klinischen Abschnitten. Mindestanforderungen für einen erfolgreichen simulationsgestützten Unterricht sind die Schaffung einer logistischen und materiellen Infrastruktur, die Schulung der Dozenten mit Instruktorenkursen, die thematische Einbettung in ein strukturiertes Gesamtcurriculum und ein Verhältnis von Dozenten zu Studierenden von 1:3, entsprechend den Empfehlungen zum Unterricht am Krankenbett. Werden diese Anforderungen eingehalten, evaluieren die Studierenden die verschiedenen Szenarien „Narkoseeinleitung“, „akute Lungenembolie“, „Versorgung eines Polytraumas“ und „postoperative hämodynamische Insuffizienz“ mit 1,5; 1,6; 1,5 und 1,5 (Schulnotenskala 1–6). Im direkten Vergleich werden die Szenarien besser als andere curriculare Abschnitte beurteilt.AbstractSince 1st October 2003 the new German “Approbationsordnung für Ärzte” (Medical Licensing Regulations) requires an increasing amount of small group teaching sessions and encourages a multidisciplinary and more practical approach to the related topics. In 2004 the German Society of Anaesthesiology and Intensive Care Medicine has provided almost all anaesthesia faculties of German Universities with equipment for full-scale simulation. This article describes methods for a simulation-based medical education training programm. Basic requirements for a successful training programm using full scale simulators are the provision of an adequate logistical and material infrastructure, teacher attendance of train-the-trainer courses, implementation in the medical curriculum and an instructor–student ratio of 1:3, equivalent to that for bedside teaching. If these requirements were fulfilled, medical students scored the simulation scenarios “induction of anaesthesia”, “acute pulmonary embolism”, “acute management of a multiple trauma patient” and “postoperative hypotension” as 1.5, 1.6, 1.5 and 1.5, respectively, on a scale of 1–6. These scores were better than those given for other segments of the curriculum.

Effects of pulmonary acid aspiration on the lungs and extra-pulmonary organs: a randomized study in pigs

IntroductionThere is mounting evidence that injury to one organ causes indirect damage to other organ systems with increased morbidity and mortality. The aim of this study was to determine the effects of acid aspiration pneumonitis (AAP) on extrapulmonary organs and to test the hypothesis that these could be due to circulatory depression or hypoxemia.MethodsMechanically ventilated anesthetized pigs were randomized to receive intrabronchial instillation of hydrochloric acid (n = 7) or no treatment (n = 7). Hydrochloric acid (0.1 N, pH 1.1, 2.5 ml/kg BW) was instilled into the lungs during the inspiratory phase of ventilation. Hemodynamics, respiratory function and computer tomography (CT) scans of lung and brain were followed over a four-hour period. Tissue samples of lung, heart, liver, kidney and hippocampus were collected at the end of the experiment.ResultsAcid instillation caused pulmonary edema, measured as increased extravascular lung water index (ELWI), impaired gas exchange and increased mean pulmonary artery pressure. Gas exchange tended to improve during the course of the study, despite increasing ELWI. In AAP animals compared to controls we found: a) cardiac leukocyte infiltration and necrosis in the conduction system and myocardium; b) lymphocyte infiltration in the liver, spreading from the periportal zone with prominent areas of necrosis; c) renal inflammation with lymphocyte infiltration, edema and necrosis in the proximal and distal tubules; and d) a tendency towards more severe hippocampal damage (P > 0.05).ConclusionsAcid aspiration pneumonitis induces extrapulmonary organ injury. Circulatory depression and hypoxemia are unlikely causative factors. ELWI is a sensitive bedside parameter of early lung damage.

[Out-of-hospital pediatric emergencies. Perception and assessment by emergency physicians].

ZusammenfassungHintergrundPräklinische Kindernotfälle sind aufgrund ihrer relativ niedrigen Prävalenz keine notärztliche Routine, zumal sie in Deutschland überwiegend von nichtspezialisierten Notärzten versorgt werden. Dies führt häufig zu Unsicherheit oder gar Angst. Unklar ist, wie Notärzte Kindernotfälle wahrnehmen und einschätzen bzw. wie sie besser darauf vorbereitet werden können.Material und MethodeMithilfe eines strukturierten Fragebogens wurden alle zum Studienzeitpunkt aktiven Notärzte (n=50) des Zentrums Anaesthesiologie, Rettungs- und Intensivmedizin der Universitätsmedizin Göttingen bezüglich ihrer Wahrnehmung und Einschätzung von präklinischen Kindernotfällen befragt.ErgebnisseDie 43 teilnehmenden Notärzte machten sehr differenzierte Angaben zu den mutmaßlichen Charakteristika präklinischer Kindernotfälle. Das Sicherheitsempfinden stieg mit zunehmendem Alter der Kinder (p<0,03) und der eigenen Erfahrung (p<0,01). Persönliche Defizite wurden vor allem in der kardiopulmonalen Reanimation (n=18) und der Traumaversorgung (n=8) gesehen. Simulatortraining (n=24) sowie Praktika in der Kinderanästhesie und -intensivmedizin (n=12) wurden als Fortbildungsstrategien favorisiert.SchlussfolgerungenNotärzte können die Häufigkeit und Schwere von Kindernotfällen realistisch einschätzen, auch wenn sie selbst damit selten konfrontiert werden. Das größte Erfahrungsdefizit wurde im Bereich eher seltener, jedoch vitalbedrohlicher Notfälle gesehen. Es können drei Ausbildungsbereiche unterschieden werden: innerklinisch an Kindern erlernbare Kenntnisse und Fertigkeiten; an Erwachsenen erworbene, auch an Kindern anwendbare Expertise sowie Training am Phantom oder Simulator von seltenen Krankheitsbildern und Interventionen.AbstractBackgroundOut-of-hospital (OOH) pediatric emergencies have a relatively low prevalence. In Germany the vast majority of cases are attended by non-specialized emergency physicians (EPs) for whom these are not routine procedures. This may lead to insecurity and fear. However, it is unknown how EPs perceive and assess pediatric emergencies and how they could be better prepared for them.MethodsAll active EPs (n=50) of the Department of Anaesthesiology, Emergency and Intensive Care Medicine at the University Medical Centre of Göttingen were presented with a structured questionnaire in order to evaluate their perception and assessment of OOH pediatric emergencies.ResultsThe 43 participating EPs made highly detailed statements on the expected characteristics of OOH pediatric emergencies. Their confidence level grew with the children’s age (p<0.03) and with their own experience (p<0.01). The EPs felt particular deficits in the fields of cardiopulmonary resuscitation (n=18) and trauma management (n=8). The preferred educational strategies included simulator-based training (n=24) as well as more exposure to pediatric intensive care and pediatric anesthesia (n=12).ConclusionsDespite their own limited experience EPs can realistically assess the incidence and severity of pediatric emergencies. They felt the greatest deficits were in the care of infrequent but life-threatening emergencies. Three educational groups can be differentiated: knowledge and skills to be gained with children in hospital, clinical experience from adult care also applicable in children and rare diagnoses and interventions to be trained with manikins or simulators.BACKGROUND Out-of-hospital (OOH) pediatric emergencies have a relatively low prevalence. In Germany the vast majority of cases are attended by non-specialized emergency physicians (EPs) for whom these are not routine procedures. This may lead to insecurity and fear. However, it is unknown how EPs perceive and assess pediatric emergencies and how they could be better prepared for them. METHODS All active EPs (n=50) of the Department of Anaesthesiology, Emergency and Intensive Care Medicine at the University Medical Centre of Göttingen were presented with a structured questionnaire in order to evaluate their perception and assessment of OOH pediatric emergencies. RESULTS The 43 participating EPs made highly detailed statements on the expected characteristics of OOH pediatric emergencies. Their confidence level grew with the childrens age (p<0.03) and with their own experience (p<0.01). The EPs felt particular deficits in the fields of cardiopulmonary resuscitation (n=18) and trauma management (n=8). The preferred educational strategies included simulator-based training (n=24) as well as more exposure to pediatric intensive care and pediatric anesthesia (n=12). CONCLUSIONS Despite their own limited experience EPs can realistically assess the incidence and severity of pediatric emergencies. They felt the greatest deficits were in the care of infrequent but life-threatening emergencies. Three educational groups can be differentiated: knowledge and skills to be gained with children in hospital, clinical experience from adult care also applicable in children and rare diagnoses and interventions to be trained with manikins or simulators.