M. Roessler

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.

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.

Early out-of-hospital non-invasive ventilation is superior to standard medical treatment in patients with acute respiratory failure: a pilot study

Objective To assess in patients with acute respiratory failure (ARF) whether out-of-hospital (OOH) non-invasive ventilation (NIV) is feasible, safe and more effective compared with standard medical therapy (SMT). Patients and Interventions Patients with OOH ARF were randomly assigned to receive either SMT or NIV. Measurements and Results Fifty-one patients were enrolled, 26 of whom were randomly assigned to SMT and 25 of whom received NIV. Two patients were excluded because of protocol violations. OOH NIV was safe and effective in all patients. In the SMT group, treatment was not effective in five of 25 patients who required OOH mechanical ventilation (p=0.05). Patients in the SMT group were admitted to an intensive care unit (ICU) more frequently (n=17) (p<0.05) and for longer periods (3.7±6.4 days) (p=0.03) compared with patients in the NIV group (n=9, 1.3±2.6 days). Six patients in the SMT group required subsequent inhospital intubation and invasive ventilation during their hospital stays; only one patient in the NIV group required intubation (p=0.10). In contrast, patients in the NIV group received NIV more frequently (n=14) in hospital compared with patients in the SMT group (n=5) (p<0.01). Conclusions OOH NIV proved to be feasible, safe and more effective for the treatment of ARF compared with SMT. OOH NIV promotes inhospital treatment with NIV and may reduce the frequency and length of ICU stays. Because the risks of OOH emergency intubation can be avoided, NIV should be the first-line treatment in OOH ARF if no contraindications are present.

The European Trauma Course (ETC) and the team approach: past, present and future.

The European Trauma Course (ETC) was officially launched during the international conference of the European Resuscitation Council (ERC) in 2008. The ETC was developed on behalf of ESTES (European Society of Trauma and Emergency Surgery), EuSEM (European Society of Emergency Medicine), the ESA (European Society of Anaesthesiology) and the ERC. The objective of the ETC is to provide an internationally recognised and certified life support course, and to teach healthcare professionals the key principles of the initial care of severely injured patients. Its core elements, that differentiates it from other trauma courses, are a strong focus on team training and a novel modular design that is adaptable to the differing regional European requirements. This article describes the lessons learnt during the European Trauma Course development and provides an outline of the planned future development.

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.

Out-of-hospital airway management with the LMA CTrach™ : A prospective evaluation

AIM OF THE STUDY Airway management in an out-of-hospital setting is a critical and demanding skill. Previous studies evaluated the intubating laryngeal mask airway (ILMA) as a valuable tool in this area. The LMA CTrach Laryngeal Mask Airway (CTrach) may increase intubation success. Therefore, we evaluated the CTrach as the primary tool for airway management in the out-of-hospital setting in adult patients. METHODS From October 2006 until September 2007 EAN and SGR included all patients who needed advanced airway management during out-of-hospital emergency medicine service. Ventilation and intubation has been performed via the CTrach as the primary choice. Before intubation, visualization of the vocal cords was optimized under continuous ventilation via the CTrach. The time needed, manoeuvres to optimize vision, grades of vision and success rates have been documented. RESULTS 16 patients have been included. Ventilation and intubation via the CTrach was possible in all patients. Ventilation was mostly established in less than 15s and was established in 15 of 16 (94%) patients at the first attempt. Intubation was successful in 15 of 16 (94%) patients on the first attempt. Visualization of the laryngeal structures was achieved in 69% of patients, while intubation without sight was performed in 31%, respectively. CONCLUSION In this study, ventilation and intubation via the CTrach was successful and could be rapidly established in all patients. Our data suggest that the use of the CTrach may be suitable for the out-of-hospital setting as it provides ventilation and facilitates intubation with a very high success rate.

[Medical emergency teams: current situation and perspectives of preventive in-hospital intensive care medicine].

ZusammenfassungBei bis zu 10% aller hospitalisierten Normalstationpatienten treten während ihres Krankenhausaufenthalts schwerwiegende medizinische Zwischenfälle auf. Diese Zwischenfälle gehen mit einer innerklinischen Letalität von 5–8% einher. Wie im präklinischen Bereich auch, können bei der Mehrzahl dieser Patienten Vorzeichen eines lebensbedrohlichen Ereignisses frühzeitig erkannt werden. Studien legen nahe, dass die Einführung eines innerklinischen, medizinischen Notfallteams („medical emergency team“, MET), das bei mehr oder minder objektivierbaren Abweichungen physiologischer Parameter aktiviert wird, die Inzidenz von innerklinischen Kreislaufstillständen sowie unerwarteten bzw. erneuten Aufnahmen auf die Intensivstation wirkungsvoll reduzieren kann. Diesem Konzept entsprechend sollen MET gefährdete Patienten außerhalb von Intensivpflegestationen frühzeitig evaluieren und behandeln, bevor es zu einer ggf. fatalen Progredienz der Symptomatik kommt. Der vorliegende Artikel gibt einen Überblick über die aktuelle Datenlage zur präventiven innerklinischen Intensivmedizin und reflektiert die Rahmenbedingungen für die Etablierung eines MET-Konzeptes im deutschsprachigen Raum.AbstractSevere clinical incidents occur in up to 10% of all non-intensive care unit (ICU) patients, which have an estimated mortality of 5–8%. As in the prehospital setting, early clinical warning signs can be identified in the majority of cases. Studies suggest that introduction of an in-hospital medical emergency team (MET) which responds to objective criteria of physiological deterioration, may effectively reduce the incidence of in-hospital cardiac arrests as well as unanticipated or readmissions to the ICU. According to this concept, METs would evaluate and treat non-ICU patients at risk at an early stage before a potentially fatal deterioration of cardiorespiratory parameters occurs. This article reviews available data on preventive in-hospital intensive care medicine and reflects on the circumstances for an implementation of METs in Germany, Austria and Switzerland.

Low-dose S-ketamine added to propofol anesthesia for magnetic resonance imaging in children is safe and ensures faster recovery – a prospective evaluation

Sir—To undergo magnetic resonance imaging (MRI), infants and young children usually require sedation or anesthesia. Various techniques have been described, including sevoflurane anesthesia and sedation by highdose oral or rectal chloral hydrate (1–3). With further anesthetic experience, intravenous anesthesia with propofol became increasingly popular as a reasonable technique for MRI procedures in the majority of children (3,4). The addition of low-dose ketamine or S-ketamine has been reported to decrease the requirements of propofol and to reduce its adverse respiratory and circulatory effects (5). Furthermore, clinical observation suggests that it also expedites the recovery of children. Here, we report on a comparative observational study in which we evaluated two institutional anesthetic protocols for children undergoing elective MRI: propofol only (group P) vs propofol plus S-ketamine (group PK). After approval by our institutional ethics committee, we included all consecutive unpremedicated and fasted children (American Society of Anesthesiologists (ASA) status £3) aged between 1 month and 10 years. Anesthesia was induced according to one of two protocols and at the discretion of the attending anesthetist: Group P received 1.0 mgÆkg boluses of propofol to achieve an adequate depth of anesthesia followed by 3–10 mgÆkgÆh. Group PK received a single 0.5 mgÆkg bolus of S-ketamine before propofol anesthesia was performed as mentioned earlier. Adequate depth of anesthesia was defined as tolerance of being carried into the MRI scanner (Magnetom 1.5 Tesla or Tim Trio 3 Tesla; Siemens Healthcare, Erlangen, Germany) without eye opening or physical movement. Top off boluses of 0.5 mgÆkg of propofol were given to both groups when the children moved inside the MRI scanner.

[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.

Volumentherapie bei Hämorrhagie

How fluid resuscitation has to be performed for acute hemorrhage situations is still controversially discussed. Although the forced administration of crystalloids and colloids has been and still is practiced, nowadays there are good arguments that a cautious infusion of crystalloids may be initially sufficient. Saline should no longer be used for fluid resuscitation. The main argument for cautious fluid resuscitation is that no large prospective randomized clinical trials exist which have provided evidence of improved survival when fluid resuscitation is applied in an aggressive manner. The explanation that no positive effect has so far been observed is that fluid resuscitation is thought to boost bleeding by increasing blood pressure and dilutional coagulopathy. Nevertheless, national and international guidelines recommend that fluid resuscitation should be applied at the latest when hemorrhage causes hemodynamic instability. Consideration should be given to the fact that damage control resuscitation per se will neither improve already reduced tissue perfusion nor hemostasis. In acute and possibly rapidly progressing hypovolemic shock, colloids can be used. The third and fourth generations of hydroxyethyl starch (HES) are safe and effective if used correctly and within prescribed limits. If fluid resuscitation is applied with ongoing re-evaluation of the parameters which determine oxygen supply, it should be possible to keep fluid resuscitation restricted without causing undesirable side effects and also to administer a sufficient quantity so that survival of patients is ensured.