M. Bernhard

Präklinisches Management des Polytraumas

ZusammenfassungRund 8.000 polytraumatisierte Patienten werden jährlich in den Notaufnahmen der Bundesrepublik aufgenommen. Die Prognose dieser schwerstverletzten Patienten wird insbesondere durch ein begleitendes Schädel-Hirn-Trauma, ein Abdominal- oder Thoraxtrauma beeinflusst. Die mit einem hämorrhagisch-traumatisch bedingten Schock assoziierte Hypoxie und Hypotension stehen beim Polytrauma im Vordergrund. Das präklinische Management beinhaltet daher die Untersuchung des Verletzten, die Immobilisation der Wirbelsäule, die Sicherung der Atemwege, die kardiovaskuläre Stabilisierung unter Berücksichtigung eines differenzierten Vorgehens je nach Verletzungsmuster, die entsprechende Versorgung von Teilverletzungen, die Schmerztherapie sowie den raschen und schonenden Transport in das nächste geeignete Traumazentrum. Dabei stellt das präklinische Management von polytraumatisierten Patienten eine besondere Herausforderung für die Einsatzkräfte dar. Der vorliegende Weiterbildungsartikel geht daher auf die aktuellen Algorithmen zur präklinischen Versorgung von polytraumatisierten Patienten unter besonderer Berücksichtigung des wesentlichen Faktors Zeit ein.AbstractApproximately 8000 patients with multiple trauma are admitted annually to an emergency room in Germany. The prognosis of these severely injured patients is influenced in particular by concomitant craniocerebral injury, an abdominal wound, or thoracic trauma. Hypoxia and hypotension subsequent to shock induced by hemorrhagic-traumatic effects are of prime importance. Preclinical management thus includes examining the injured patient, immobilizing the spine, ensuring airway patency, stabilizing cardiovascular status suiting the approach to the injury pattern, commensurate care of partial injuries, pain therapy, as well as rapid and careful transportation to the nearest qualified trauma center. Management of patients with multiple trauma poses a particular challenge to the responding team. This article in the continuing education series deals with current algorithms for preclinical management of patients with multiple injuries with particular focus on the significant factor of time.

Methoden des Atemwegsmanagements in der präklinischen Notfallmedizin

ZusammenfassungIn den meisten Fällen gelingt es in Notfallsituationen, mit oder ohne vorangehender Maskenbeatmung, durch die endotracheale Intubation eine definitive Atemwegskontrolle zu erzielen. Maskenbeatmung und endotracheale Intubation können jedoch aufgrund vielfältiger Ursachen scheitern. Daher müssen sowohl für Routine- als auch für Notfallsituationen alternative Methoden zur Sicherung der Atemwege und zur Beatmung vorgehalten werden. Die vorliegende Übersicht weist auf mögliche Probleme im Rahmen des konventionellen Atemwegsmanagements hin und gibt einen Überblick über die aktuell verfügbaren Alternativen.AbstractIn the majority of emergency situations definite airway control can be achieved by endotracheal intubation with or without preceding bag valve mask ventilation. However, both techniques can fail because of many different reasons. Therefore, alternative techniques for routine anaesthesia and emergency situations are required. In the present article difficulties that may arise using bag valve mask ventilation and endotracheal intubation are discussed and an overview of available alternatives is given.

Patientenspektrum im Notarztdienst

ZusammenfassungHintergrundBundesdeutsche Notarzt(NA)-Systeme vermelden über die Jahre hinweg steigende Einsatzzahlen. Ziel der Untersuchung war es, die Entwicklung des Patientenspektrums eines NA-Systems über einen Zeitraum von 20 Jahren zu evaluieren, um die wesentlichen Veränderungen aufzuzeigen.Material und MethodeIn einer retrospektiven Untersuchung wurden die Einsatzprotokolle der Jahrgänge 2004, 1992 und 1984 hinsichtlich Demographie, Einsatzkategorien, Erkrankungs-/Verletzungsschwere (NACA), Bewusstseinslage (GCS) und notärztlichen Maßnahmen analysiert. Ergebnisse Im Jahr 2004 (3825) gab es im Vergleich zu 1992 (2114) und 1984 (957) das 2- bzw. 4-fache an Einsätzen. In allen drei untersuchten Zeiträumen waren nichttraumatologische (74%; 2812 vs. 66%; 1390 vs. 51%; 485) vor traumatologischen Einsätzen (18%; 690 vs. 22%; 464 vs. 39%; 375), Fehlfahrten (3%; 126 vs. 7%; 154 vs. 6%; 56) und Todesfeststellungen (5%; 197 vs. 5%; 106 vs. 4%; 41) führend. Obwohl der prozentuale Anteil der Patienten mit NACA IV–VI (39% vs. 50 %) und der Patienten mit GCS ≤8 (18% vs. 34%) im Jahr 2004 niedriger war, lagen auch hier die Absolutzahlen über denen von 1984 (NACA IV–VI: 1434 vs. 448, p<0,01; GCS: 672 vs. 303, p<0,01).SchlussfolgerungDie Untersuchung zeigt, dass heute der prozentuale Anteil von traumatologischen, schwer erkrankten/–verletzten und schwer bewusstseinsgestörten Notfallpatienten niedriger ist als in den vorangegangenen Jahren. Die höheren absoluten Patientenzahlen zeigen jedoch, dass der NA heute insgesamt einer größeren Zahl sowohl vital-bedrohter, schwer bewusstseinsgetrübter und traumatologischer Patienten begegnet. Prozentuale Änderungen über die Jahre hinweg dürfen jedoch nicht dazu führen, die bisher für das Management akut vital bedrohter Patienten als notwendig erachtete notärztliche Qualifikation in Frage zu stellen.AbstractBackgroundIn Germany the physician staffed emergency systems have announced an increase in rescue missions over the years. The aim of this study is to analyse the development of the spectrum of patients in an emergency system over the last 20 years in order to highlight the significant changes.MethodsIn a retrospective study we analyzed the prehospital chart views from 2004, 1992 and 1984 with respect to patients’ demography, type of rescue mission, degree of internal disease or injury (NACA), state of consciousness (GCS), as well as prehospital interventions perfomed by prehospital emergency physician.ResultsIn 2004 (3,825), the absolute number of missions was 2 and 4 times higher than 1992 (2,114) and 1984 (957), resp. In all of these investigated time periods non-trauma missions (74%; 2,812 vs. 66%; 1,390 vs. 51%; 485) were leading, followed by trauma missions (18%; 690 vs. 22%; 464 vs. 39%; 375), aborted missions (3%; 126 vs. 7%; 154 vs. 6%; 56), and dead on arrival (5%; 197 vs. 5%; 106 vs. 4%; 41). Although, the percentage of patients with NACA IV–VI (39% vs. 50%) or patients with GCS ≤8 (18% vs. 34%) was lower in 2004, the absolute number of patients in each categorie was higher than in 1984 (NACA IV–VI: 1,434 vs. 448, p<0.01; GCS: 672 vs. 303, p<0.01).ConclusionsThe results of this study demonstrate, that the percentage of trauma, severely ill/injured or unconscious patients is lower than in previous years. However, the higher absolute numbers of patients demonstrate that the emergency physician now encounters more critically ill/injured, unconscious and trauma patients. It does not seem necessary to question the qualifications for an emergency physician, which have previously been considered essential for the management of acute life-threatening situations.

Radiation exposure in whole-body computed tomography of multiple trauma patients: bearing devices and patient positioning.

BACKGROUND Whole-body computed tomography (WBCT) plays an important role in the management of severely injured patients. We evaluated the radiation exposure of WBCT scans using different positioning boards and arm positions. METHODS In this retrospective study, the radiation exposure of WBCT using a 16-slice multislice computed tomography scanner was evaluated. Individual effective doses (E, mSV) was calculated. Patients were assigned to two groups according to placement on a plastic transfer mat (PTM, group 1) or on the Trauma Transfer™-Board (TTB, group 2). Data were collected for each group with arm placement on the abdomen (a) or in raising position (b), respectively. The maximum ventro-dorsal diameter [VDD] at the trunk was measured. RESULTS 100 patients with potentially life-threatening injuries were analysed. Patient demographics and VDD did not differ in the two groups. Radiation exposure in term of E did not reveal any significant differences between the two positioning boards using same arm position [group 1a (n=26) vs. 2a (n=24) (mSV): 16.7±4.7 vs. 17.1±4.4, group 1b (n=26) vs. 2b (n=24) (mSV): 13.1±3.9 vs. 14.3±1.5]. The arm raising positioning showed a significant reduction in E in comparison to the placement on abdomen position [group 1b vs. 1a (mSV): 13.1±3.9 vs. 16.7±4.7, p<0.05, group 2b vs. 2a (mSV): 14.3±1.5 vs. 17.1±4.4, p<0.05]. CONCLUSIONS Patient arm positioning for WBCT has an important influence on radiation exposure. Effective dose was 16-22% lower when arms were raised. An individual placement algorithm may lead to a relevant reduction of radiation exposure of severely injured patients.

Spectrum of patients in prehospital emergency services. What has changed over the last 20 years

ZusammenfassungHintergrundBundesdeutsche Notarzt(NA)-Systeme vermelden über die Jahre hinweg steigende Einsatzzahlen. Ziel der Untersuchung war es, die Entwicklung des Patientenspektrums eines NA-Systems über einen Zeitraum von 20 Jahren zu evaluieren, um die wesentlichen Veränderungen aufzuzeigen.Material und MethodeIn einer retrospektiven Untersuchung wurden die Einsatzprotokolle der Jahrgänge 2004, 1992 und 1984 hinsichtlich Demographie, Einsatzkategorien, Erkrankungs-/Verletzungsschwere (NACA), Bewusstseinslage (GCS) und notärztlichen Maßnahmen analysiert. Ergebnisse Im Jahr 2004 (3825) gab es im Vergleich zu 1992 (2114) und 1984 (957) das 2- bzw. 4-fache an Einsätzen. In allen drei untersuchten Zeiträumen waren nichttraumatologische (74%; 2812 vs. 66%; 1390 vs. 51%; 485) vor traumatologischen Einsätzen (18%; 690 vs. 22%; 464 vs. 39%; 375), Fehlfahrten (3%; 126 vs. 7%; 154 vs. 6%; 56) und Todesfeststellungen (5%; 197 vs. 5%; 106 vs. 4%; 41) führend. Obwohl der prozentuale Anteil der Patienten mit NACA IV–VI (39% vs. 50 %) und der Patienten mit GCS ≤8 (18% vs. 34%) im Jahr 2004 niedriger war, lagen auch hier die Absolutzahlen über denen von 1984 (NACA IV–VI: 1434 vs. 448, p<0,01; GCS: 672 vs. 303, p<0,01).SchlussfolgerungDie Untersuchung zeigt, dass heute der prozentuale Anteil von traumatologischen, schwer erkrankten/–verletzten und schwer bewusstseinsgestörten Notfallpatienten niedriger ist als in den vorangegangenen Jahren. Die höheren absoluten Patientenzahlen zeigen jedoch, dass der NA heute insgesamt einer größeren Zahl sowohl vital-bedrohter, schwer bewusstseinsgetrübter und traumatologischer Patienten begegnet. Prozentuale Änderungen über die Jahre hinweg dürfen jedoch nicht dazu führen, die bisher für das Management akut vital bedrohter Patienten als notwendig erachtete notärztliche Qualifikation in Frage zu stellen.AbstractBackgroundIn Germany the physician staffed emergency systems have announced an increase in rescue missions over the years. The aim of this study is to analyse the development of the spectrum of patients in an emergency system over the last 20 years in order to highlight the significant changes.MethodsIn a retrospective study we analyzed the prehospital chart views from 2004, 1992 and 1984 with respect to patients’ demography, type of rescue mission, degree of internal disease or injury (NACA), state of consciousness (GCS), as well as prehospital interventions perfomed by prehospital emergency physician.ResultsIn 2004 (3,825), the absolute number of missions was 2 and 4 times higher than 1992 (2,114) and 1984 (957), resp. In all of these investigated time periods non-trauma missions (74%; 2,812 vs. 66%; 1,390 vs. 51%; 485) were leading, followed by trauma missions (18%; 690 vs. 22%; 464 vs. 39%; 375), aborted missions (3%; 126 vs. 7%; 154 vs. 6%; 56), and dead on arrival (5%; 197 vs. 5%; 106 vs. 4%; 41). Although, the percentage of patients with NACA IV–VI (39% vs. 50%) or patients with GCS ≤8 (18% vs. 34%) was lower in 2004, the absolute number of patients in each categorie was higher than in 1984 (NACA IV–VI: 1,434 vs. 448, p<0.01; GCS: 672 vs. 303, p<0.01).ConclusionsThe results of this study demonstrate, that the percentage of trauma, severely ill/injured or unconscious patients is lower than in previous years. However, the higher absolute numbers of patients demonstrate that the emergency physician now encounters more critically ill/injured, unconscious and trauma patients. It does not seem necessary to question the qualifications for an emergency physician, which have previously been considered essential for the management of acute life-threatening situations.

The First Shot Is Often the Best Shot: First-Pass Intubation Success in Emergency Airway Management.

November 2015 • Volume 121 • Number 5 www.anesthesia-analgesia.org 1389 Copyright

Notfallnarkose, Atemwegsmanagement und Beatmung beim Polytrauma

Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate <6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (S(p)O(2)<90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS)<9], trauma-associated hemodynamic instability [systolic blood pressure (SBP)<90 mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate >29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation and oxygenation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices and a fiber-optic endoscope need to be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.

[Emergency anesthesia, airway management and ventilation in major trauma. Background and key messages of the interdisciplinary S3 guidelines for major trauma patients].

Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate <6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (S(p)O(2)<90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS)<9], trauma-associated hemodynamic instability [systolic blood pressure (SBP)<90 mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate >29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation and oxygenation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices and a fiber-optic endoscope need to be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.

Die notfallmäßige Koniotomie

ZusammenfassungAlle internationalen Empfehlungen zum Management des schwierigen, mit konventionellen Mitteln nicht beherrschbaren Atemweges beinhalten als „ultima ratio“ die Notfallkoniotomie. Diese invasive Notfalltechnik stellt eine relativ sichere und schnelle Möglichkeit der notfallmäßigen Atemwegsicherung dar. Dennoch kann die Notfallkoniotomie insbesondere in der Prähospitalphase mit Komplikationen behaftet sein. Als Verfahren stehen die chirurgisch-anatomische Präpariertechnik und diverse Punktionsverfahren zur Verfügung. Neben der reinen Beherrschung der Notfalltechniken muss sich der potentielle Anwender bereits vor dem Notfall über die Indikationen der Notfallkoniotomie, den entsprechenden Entscheidungsprozess und das gewählte Vorgehen bei einer schwierigen Atemwegsicherung im Klaren sein. Diese invasive Notfalltechnik muss trainiert werden, um sie im Ernstfall effektiv einsetzen zu können. Hierbei eignen sich sowohl Kurse an Leichenpräparaten als auch an Phantommodellen.AbstractAll international recommendations on management of the difficult airway which cannot be mastered by conventional means include emergency coniotomy (cricothyrotomy) as the final option. This invasive emergency procedure is a relatively safe and rapid option to secure the airway in an emergency situation. However, emergency coniotomy can lead to complications, especially in the prehospital phase. The procedure includes surgical anatomical preparation techniques and a variety of puncture methods. In addition to purely mastering emergency techniques, the potential user must be fluent with the indications for emergency coniotomy, the necessary decision-making process and the selected method for a difficult airway prior to the emergency situation. This invasive emergency technique must be practiced in order to be implemented in an emergency. This can be achieved by suitable courses with practice on corpses or phantom models.

Schockraummanagement kritisch erkrankter Patienten

ZusammenfassungDie Schockraumversorgung kritisch kranker Patienten unterscheidet sich in der initialen Versorgungsphase in Bezug auf das „ABCDE“-Schema nicht von der Vorgehensweise bei schwer verletzten Patienten. Nach der initialen Stabilisierung der Vitalfunktionen wird dann aber eine an das vorliegende Leitsymptom angepasste weitere Versorgungsstrategie unter intensivmedizinischen Gesichtspunkten notwendig. Aspekte einer adäquaten strukturellen, logistischen und personellen Versorgungsorganisation sind für die Behandlung von nichttraumatologisch kritisch kranken Patienten im Schockraum erforderlich. Für den schwer verletzten Patienten bestehende Empfehlungen in der S3-Leitlinie „Polytrauma/Schwerverletzten-Behandlung“ und das Weißbuch Schwerverletztenversorgung der Deutschen Gesellschaft für Unfallchirurgie (DGU) können herangezogen werden, um entsprechende Forderungen für das Schockraummanagement nichttraumatologischer kritisch kranker Patienten zu unterstützen. Zukünftig werden dem Advanced Trauma Life Support (ATLS®)/European Trauma Course (ETC®) vergleichbare Ausbildungskonzepte für das Schockraummanagement nichttraumatologischer kritisch kranker Patienten notwendig, die weit über ACLS®/ALS®-Kursformate hinausgehen. Letztlich ist die Entwicklung eines Advanced-Critical-Ill-Life-Support(ACILS®)-Konzepts für nichttraumatologisch kritisch kranke Schockraumpatienten sinnvoll und zu fordern.AbstractThe general approach to the initial resuscitation of non-trauma patients does not differ from the ABCDE approach used to evaluate severely injured patients. After initial stabilization of vital functions patients are evaluated based on the symptoms and critical care interventions are initiated as and when necessary. Adequate structural logistics and personnel organization are crucial for the treatment of non-trauma critically ill patients although there is currently a lack of clearly defined requirements. For severely injured patients there are recommendations in the S3 guidelines on treatment of multiple trauma and severely injured patients and these can be modeled according to the white paper of the German Society of Trauma Surgery (DGU). However, structured training programs similar to the advanced trauma life support (ATLS®)/European resuscitation course (ETC®) that go beyond the current scope of advanced cardiac life support training are needed. The development of an advanced critically ill life support (ACILS®) concept for non-trauma critically ill patients in the resuscitation room should be supported.The general approach to the initial resuscitation of non-trauma patients does not differ from the ABCDE approach used to evaluate severely injured patients. After initial stabilization of vital functions patients are evaluated based on the symptoms and critical care interventions are initiated as and when necessary. Adequate structural logistics and personnel organization are crucial for the treatment of non-trauma critically ill patients although there is currently a lack of clearly defined requirements. For severely injured patients there are recommendations in the S3 guidelines on treatment of multiple trauma and severely injured patients and these can be modeled according to the white paper of the German Society of Trauma Surgery (DGU). However, structured training programs similar to the advanced trauma life support (ATLS®)/European resuscitation course (ETC®) that go beyond the current scope of advanced cardiac life support training are needed. The development of an advanced critically ill life support (ACILS®) concept for non-trauma critically ill patients in the resuscitation room should be supported.