Quality and safety in prehospital airway management - retrospective analysis of 18,000 cases from an air rescue database in Germany.

BACKGROUND: Prehospital airway management remains crucial with regard to the quality and safety of emergency medical service (EMS) systems worldwide. In 2007, the benchmark study by Timmermann et al. hit the German EMS community hard by revealing a significant rate of undetected oesophageal intubations leading to an often-fatal outcome. Since then, much attention has been given to guideline development and training. This study evaluated the incidence and special circumstances of tube misplacement as an adverse peri-intubation event from a Helicopter Emergency Medical Services perspective. METHODS: This was a retrospective analysis of a German helicopter-based EMS database from January 1, 2012, to December 31, 2020. All registered patients were included in the primary analysis. The results were analysed using SPSS 27.0.1.0. RESULTS: Out of 227,459 emergency medical responses overall, a total of 18,087 (8.0%) involved invasive airway management. In 8141 (45.0%) of these patients, airway management devices were used by ground-based EMS staff, with an intubation rate of 96.6% (n = 7861), and alternative airways were used in 3.2% (n = 285). Overall, the rate of endotracheal intubation success was 94.7%, while adverse events in the form of tube misplacement were present in 5.3%, with a 1.2% rate of undetected oesophageal intubation. Overall tube misplacement and undetected oesophageal intubation occurred more often after intubation was carried out by paramedics (10.4% and 3.6%, respectively). In view of special circumstances, those errors occurred more often in the presence of trauma or cardiopulmonary resuscitation, with rates of 5.6% and 6.4%, respectively. Difficult airways with a Cormack 4 status were present in 2.1% (n = 213) of HEMS patients, accompanied by three or more intubation attempts in 5.2% (n = 11). CONCLUSIONS: Prehospital airway management success has improved significantly in recent years. However, adverse peri-intubation events such as undetected oesophageal intubation remain a persistent threat to patient safety. TRIAL REGISTRATION: The study was registered in the German Register for Clinical Studies (number DRKS00028068).

[Physician-assisted interhospital transfer-an analysis from Schleswig-Holstein]. / Arztbegleitete Interhospitaltransporte ­ eine Analyse aus Schleswig-Holstein.

BACKGROUND: The need for interhospital transport (IHT) of intensive care patients is increasing due to changes in the hospital environment. Interhospital transports are challenging and require careful operational planning of personnel and rescue vehicles. OBJECTIVE: To investigate the need for IHT, an analysis was conducted in the service area of the emergency medical service central dispatch center (IRLS) in Schleswig-Holstein. MATERIAL AND METHODS: Emergency physician-assisted IHT were analyzed in the period from 01.10.2021 to 30.09.2022. RESULTS: Of a total of 158,823 documented IRLS missions, 2264 (1.4%) records could be identified and included as IHT: 1389 IHT (61.4%) were managed by specialized ambulances, 875 (38.6%) by primary care ambulances. Primary care ambulances were mainly used for time-critical transfers and outside the duty hours of the intensive care ambulances, 21.2 % were by air. Of all IHT, 43.1% were required to hospitals with a higher level of medical care. CONCLUSION: Emergency physician-assisted IHT are a relevant part of the emergency service's operational spectrum and concern both primary care and specialized rescue vehicles. A relevant number of urgent IHT were recorded outside the duty hours of the intensive care ambulances. For emergency transports during nighttime, an expansion of air-based transfer capacities should be considered due to the time advantage. For less urgent IHT, an adjustment of the capacities of specialized ground-based vehicles in Schleswig-Holstein seems reasonable.

[Ultrasound diagnostics in prehospital emergency care-do we need a standardized educational approach?] / Ultraschalldiagnostik in der prähospitalen Notfallmedizin ­ brauchen wir eine standardisierte Ausbildung?

BACKGROUND: Limited diagnostic capabilities represent an ongoing obstacle in out-of-hospital emergency settings. Prehospital deployment of ultrasound might reduce this particular diagnostic gap. So far, little is known about the availability and usage of ultrasound in emergency medical services (EMS) or about the level of education of EMS physicians regarding prehospital ultrasound (point-of-care ultrasound, POCUS). METHODS: A nationwide survey was conducted among emergency physicians in Germany focusing on POCUS education and experience. RESULTS: Between 02/2022 and 05/2022, 1079 responses were registered, of which 853 complete responses were analyzed. Of the emergency physicians, 71.9% consider POCUS beneficial for out-of-hospital diagnostics and 43.8% had participated in a certified POCUS training prior to the survey. The self-evaluation of POCUS skills among emergency physicians depended significantly on their participation in a certified training (p < 0.001) and frequent ultrasound routine (p < 0.001). CONCLUSION: The majority of participating emergency physicians in Germany consider POCUS to improve out-of-hospital diagnostic capabilities. Participation in a certified POCUS training and frequent use of ultrasound facilitated higher self-confidence in POCUS skills.

Pre-hospital analgesia in pediatric trauma and critically ill patients: An analysis of a German air rescue service.

BACKGROUND: Pain management in the pre-hospital setting remains a particular challenge for paramedics and emergency physicians, especially in children. This study evaluates the pre-hospital use and effect of analgesics in children with trauma or pain due to other reasons. METHODS: This study is a retrospective analysis of the database of a German air rescue service and was conducted over a period of 9 years (2012-2020) to assess pain in general and whether patients with trauma pain due to other reasons received treatment with analgesics. We included all patients in the registry under the age of 16 years. Patients with a Glasgow Coma Scale of 3 at hospital admission and incomplete records were excluded. The intensity of pain was determined by the emergency physician on scene at arrival and hospital admission in a ten-point rating scale (0 = no pain). Effective pain reduction was analyzed. RESULTS: Out of 227,458 cases, a total of 22,025 emergency cases involved pediatric patients aged 0-16 years. 20,405 cases were included in the study. 12,000 (58.8%) children had suffered a trauma, 8108 (39.7%) had pain due to other reasons and 297 (1.5%) had both. In total, 4,608 (38.4%) of the children with trauma were assessed having a numerical rating scale (NRS) > 4 at EMS arrival. These patients received mainly ketamine (34.5%) and the opioids fentanyl (38.7%) and piritramide (19.1%). The value on the NRS was significantly lower at admission to hospital (mean 1.9) compared with the EMS arrival (mean 6.9). In 4.9% the NRS at hospital admission was still > 4. 282 patients within the non-trauma group had a pre-hospital NRS of > 4. The pain therapy consisted of opioids (35.8%) and ketamine (2.8%). 28.4% patients in the non-trauma group received no pain medication. In 16.0% the NRS at hospital admission was still > 4. CONCLUSIONS: German emergency physicians achieved a sufficient pain therapy in pediatric patients with a NRS > 4 after trauma. In case of non-trauma, the pain management by the emergency physicians is restrained and less successful. The most common analgesic medications administered were ketamine and fentanyl, followed by piritramide. TRIAL REGISTRATION: The study has been retrospectively registered at DRKS (DRKS00026222).