Efficacy and Safety of Methoxyflurane for Treatment of Acute Traumatic Pain by EMTs during Alpine Rescue Operations: The "PainDrop" Trial.

Background: Treatment of acute traumatic pain is a core task for mountain rescue services. Intravenous access, however, is often difficult, and the vast majority of missions are carried out without a physician at the scene. The spectrum of analgesics available for use by non-physician personnel is limited. Inhaled analgesics, such as methoxyflurane, might prove useful, but currently no data exist on their application by non-physicians in the alpine setting.Methods: This prospective observational alpine field study was conducted over a period of 15 months. Patients suffering traumatic injuries with moderate to severe pain (pain score ≥ 5) after downhill bike accidents in the Tyrol mountains (1,362 m to 2,666 m above sea level) were enrolled. Teams of four mountain rescue service members, one of them a trained EMT, treated the patients with 3 ml of methoxyflurane by inhaler. We measured efficacy as reduction in pain from baseline to 15 minutes after treatment on a numerical rating scale. Safety was assessed by change in vital signs or occurrence of side-effects. Sample-size calculations were based on the efficacy outcome and yielded a need for 20 patients at a power of 0.8.Results: From June 29, 2020 to September 30, 2021, a total of 20 patients (two females; mean age 37 years) were included. The mean initial pain score was 7.2 (SD 1.0) points. After 15 minutes, pain was significantly reduced by a mean of 2.9 (SD 1.4) points. No major adverse events or relevant changes in vital signs were observed.Conclusion: The use of methoxyflurane by EMTs during alpine rescue operations in our study proved to be safe and efficient. We observed no reduction in the efficacy of the inhaler device at moderate altitude.

Usability and effectiveness of inhaled methoxyflurane for prehospital analgesia - a prospective, observational study.

BACKGROUND: Pain relief in the prehospital setting is often insufficient, as the administration of potent intravenous analgesic drugs is mostly reserved to physicians. In Australia, inhaled methoxyflurane has been in routine use by paramedics for decades, but experience in Central European countries is lacking. Thus, we aimed to assess whether user friendliness and effectiveness of inhaled methoxyflurane as sole analgesic match the specific capabilities of local ground and air-based EMS systems in Austria. METHODS: Observational study in adult trauma patients (e.g. dislocations, fracture or low back pain following minor trauma) with moderate to severe pain (numeric rating scale [NRS] ≥4). Included patients received a Penthrop® inhaler containing 3 mL of methoxyflurane (maximum use 30 min). When pain relief was considered insufficient (NRS reduction < 3 after 10 min), intravenous analgesics were administered by an emergency physician. The primary endpoint was effectiveness of methoxyflurane as sole analgesic for transport of patients. Secondary endpoints were user friendliness (EMS personell), time to pain relief, vital parameters, side effects, and satisfaction of patients. RESULTS: Median numeric pain rating was 8.0 (7.0-8.0) in 109 patients. Sufficient analgesia (reduction of NRS ≥3) was achieved by inhaled methoxyflurane alone in 67 patients (61%). The analgesic effect was progressively better with increasing age. Side effects were frequent (n = 58, 53%) but mild. User satisfaction was scored as very good when pain relief was sufficient, but fair in patients without benefit. Technical problems were observed in 16 cases (14.7%), mainly related to filling of the inhaler. In every fifth use, the fruity smell of methoxyflurane was experienced as unpleasant. No negative effects on vital signs were observed. CONCLUSION: In prehospital use, inhaled methoxyflurane as sole analgesic is effective for transport of trauma patients (62%) with moderate to severe pain. Older patients benefit especially from inhaled methoxyflurane. Side effects are mild and vital parameters unaffected. Thus, inhaled methoxyflurane could be a valuable device for non-physician EMS personnel rescue services also in the central Europe region.

[Volatile anesthetics for prehospital analgesia by paramedics-An overview]. / Volatile Anästhetika zur präklinischen Analgesie durch Rettungssanitäter ­ Eine Übersicht.

Treatment of acute pain is a central task in emergency medicine. Yet, prehospital pain relief is often insufficient or delayed since the administration of potent intravenous analgesic drugs (such as opioids) is mostly limited to physicians due to legal restrictions or training deficiencies in Germany and Austria. Frequently, prehospitally operating emergency physicians have to be demanded later for anguished patients limiting disposability of physicians for patients who are in a potentially life-threatening condition. Thus, inhaled analgesics could represent an interesting alternative.A mixture of 50% nitrous oxide and 50% oxygen (N2O, Livopan®) has been available in Germany and Austria for several years; however, prehospital use of Livopan has been merely realized and only one trial has been published. In addition, methoxyflurane (Penthrop®), a volatile anesthetic from the group of the dialkyl esters (2-dichloro-1:1-difluoroethyl-methyl-ester) was approved for the treatment of moderate to severe pain following trauma in adults in many European countries in recent years and was brought onto the market in Austria in 2018. Several in-hospital trials demonstrated high effectiveness in this setting.This article discusses the effects and prehospital areas of application of both substances in the light of the existing literature. We provide a narrative overview of the current study situation and report on a recently performed prehospital application study of methoxyflurane (Penthrop®) from Austria.The need for pressurized gas cylinders for the use of N2O represents a certain limitation in prehospital use. Furthermore, in certain injuries such as of the inner ear or a pneumothorax N2O should not be used and the risk of diffusion hypoxemia has to be addressed. Users should be particularly careful and limit the use in alcohol addicts and vegans. The advances of N2O are that it is odorless, has a fast onset of action, the usability in patients over 1 month old and has stabilizing effects on the circulation. Plenty of literature regarding prehospital as well as in-hospital use of nitrous oxide in emergency, obstetric and pediatric settings show its effectiveness as a single drug as well as in combination with other analgesics, such as paracetamol or various opioids. Its long tradition in Anglo-American countries is also based on its safety and low rate of side effects.Methoxyflurane is easier to store and handle and may be slightly more effective in severe pain after trauma; however, its approval is restricted to adults, where it works significantly better with increasing age, based on the declining minimal alveolar concentration (MAC) of all inhaled anesthetics with increasing age. Furthermore, decades of use of inhaled methoxyflurane in Australia have shown the drug is effective, safe and low in side effects and has a broad spectrum of applications. The use of methoxyflurane is limited in patients with severe hepatic or renal insufficiency and the characteristic odor has been described as unpleasant by some patients. In Europe, three large in-hospital trials showed strong pain relief in trauma patients, even comparable to opioids.Overall, based on the current evidence, the use of nitrous oxide and even more of methoxyflurane may be recommended also for prehospital use by skilled paramedics.

Anaesthetic considerations for high-risk patient kyphoplasty.

Patients with vertebral compression fractures are often indicated for balloon kyphoplasty. Many of them are elderly with severe comorbidities, which puts them at high risk for general anaesthesia. Surgery under infiltration of local anaesthetic with or without mild sedation is therefore the preferred technique used by many surgeons. However, patients reported moderate­to­severe pain during the procedure. A combination of regional anaesthesia with analgo-sedation offers an interesting alternative to general anaesthesia as well as infiltration administered by the surgeon. In this article we present, apart from general anaesthesia, various regional anaesthetic techniques suitable for high-risk patients, including neuraxial anaesthesia, paravertebral block as well as a novel "erector spinae plane block" at the level of the fractured vertebra. We explore their effectiveness and safety profile, as well as advantage of supplementation of adequate analgo-sedation (Ref. 40). Keywords: erector spinae plane block, kyphoplasty, regional anaesthesia, paravertebral block, neuraxial anaesthesia.

Comparing the McGrath Mac Video Laryngoscope and Direct Laryngoscopy for Prehospital Emergency Intubation in Air Rescue Patients: A Multicenter, Randomized, Controlled Trial.

OBJECTIVES: Tracheal intubation in prehospital emergency care is challenging. The McGrath Mac Video Laryngoscope (Medtronic, Minneapolis, MN) has been proven to be a reliable alternative for in-hospital airway management. This trial compared the McGrath Mac Video Laryngoscope and direct laryngoscopy for the prehospital setting. DESIGN: Multicenter, prospective, randomized, controlled equivalence trial. SETTING: Oesterreichischer Automobil- und Touring Club (OEAMTC) Helicopter Emergency Medical Service in Austria, 18-month study period. PATIENTS: Five-hundred fourteen adult emergency patients (≥ 18 yr old). INTERVENTIONS: Helicopter Emergency Medical Service physicians followed the institutional algorithm, comprising a maximum of two tracheal intubation attempts with each device, followed by supraglottic, then surgical airway access in case of tracheal intubation failure. No restrictions were given for tracheal intubation indication. MEASUREMENTS MAIN RESULTS: The Primary outcome was the rate of successful tracheal intubation; equivalence range was ± 6.5% of success rates. Secondary outcomes were the number of attempts to successful tracheal intubation, time to glottis passage and first end-tidal CO2 measurement, degree of glottis visualization, and number of problems. The success rate for the two devices was equivalent: direct laryngoscopy 98.5% (254/258), McGrath Mac Video Laryngoscope 98.1% (251/256) (difference, 0.4%; 99% CI, -2.58 to 3.39). There was no statistically significant difference with regard to tracheal intubation times, number of attempts or difficulty. The view to the glottis was significantly better, but the number of technical problems was increased with the McGrath Mac Video Laryngoscope. After a failed first tracheal intubation attempt, immediate switching of the device was significantly more successful than after the second attempt (90.5% vs 57.1%; p = 0.0003), regardless of the method. CONCLUSIONS: Both devices are equivalently well suited for use in prehospital emergency tracheal intubation of adult patients. Switching the device following a failed first tracheal intubation attempt was more successful than a second attempt with the same device.

Landiolol for managing post-operative atrial fibrillation.

Beta-blockers are a potential option to manage peri-operative atrial fibrillation. Landiolol is a new ultra-short beta-blocker with a half-life of only 4 minutes and very high beta-1 selectivity which has been used for treatment and prevention of atrial fibrillation in pulmonary surgery and gastro-intestinal surgery. Due to its limited negative inotropic effect and high beta-1 selectivity landiolol allows for control of heart rate with minimal impact on blood pressure. Landiolol is well tolerated by the respiratory system. Additional benefits are related to the regulation of the inflammatory response and blunting of the adrenergic pathway. There is a limited number of trials with total of 61 patients undergoing lung resection or oesophagectomy who developed post-operative atrial fibrillation and were treated with landiolol. The experience with landiolol for prevention is more documented than landiolol application for treatment of post-operative atrial fibrillation. There are 9 comparative studies with a total of 450 patients administered landiolol for prevention of post-operative atrial fibrillation. The use of low dosage (5-10mcg/kg/min) is usually sufficient to rapidly control heart rate which is associated with earlier and higher rate of conversion to sinus rhythm as compared to the controls. The excellent tolerance of landiolol at lower dosage (3-5mcg/kg/min) allows to initiate prophylactic use during surgery and postoperatively. Landiolol prophylaxis is associated with reduced incidence of post-operative atrial fibrillation without triggering adverse events related to a beta-blockade.

Use of the GlideScope Ranger Video Laryngoscope for Emergency Intubation in the Prehospital Setting: A Randomized Control Trial.

OBJECTIVES: We sought to assess whether the GlideScope Ranger video laryngoscope may be a reliable alternative to direct laryngoscopy in the prehospital setting. DESIGN: Multicenter, prospective, randomized, control trial with patient recruitment over 18 months. SETTING: Four study centers operating physician-staffed rescue helicopters or ground units in Austria and Norway. PATIENTS: Adult emergency patients requiring endotracheal intubation. INTERVENTIONS: Airway management strictly following a prehospital algorithm. First and second intubation attempt employing GlideScope or direct laryngoscopy as randomized; third attempt crossover. After three failed intubation attempts, immediate use of an extraglottic airway device. MEASUREMENTS AND MAIN RESULTS: A total of 326 patients were enrolled. Success rate with the GlideScope (n = 168) versus direct laryngoscopy (n = 158) group was 61.9% (104/168) versus 96.2% (152/158), respectively (p < 0.001). The main reasons for failed GlideScope intubation were failure to advance the tube into the larynx or trachea (26/168 vs 0/158; p < 0.001) and/or impaired sight due to blood or fluids (21/168 vs 3/158; p < 0.001). When GlideScope intubation failed, direct laryngoscopy was successful in 61 of 64 patients (95.3%), whereas GlideScope enabled intubation in four of six cases (66.7%) where direct laryngoscopy failed (p = 0.055). In addition, GlideScope was prone to impaired visualization of the monitor because of ambient light (29/168; 17.3%). There was no correlation between success rates and body mass index, age, indication for airway management, or experience of the physicians, respectively. CONCLUSIONS: Video laryngoscopy is an established tool in difficult airway management, but our results shed light on the specific problems in the emergency medical service setting. Prehospital use of the GlideScope was associated with some major problems, thus resulting in a lower intubation success rate when compared with direct laryngoscopy.

Resuscitation of out-of-hospital cardiac arrest victims in Austria's largest helicopter emergency medical service: A retrospective cohort study.

Background: Helicopter emergency medical services (HEMS) play a fundamental role in prehospital care. However, the impact of HEMS on survival of patients with out-of-hospital cardiac arrest (OHCA) is widely unknown. Therefore, the purpose of this study was to assess demographics, treatment, and outcome of patients with OHCA attended by physician-staffed helicopters. Methods: Retrospective cohort study enrolling OHCA patients treated by HEMS during a ten-year period (2010-2019) in Austria. Patients were identified using electronic mission records of 13 HEMS bases run by the Austrian Automobile, Motorcycle and Touring Club (OEAMTC), and subsequently matched with the national register of deaths to determine 30-day and one-year survival rates. Results are reported according to the 2015 Utstein Style. Multivariable logistic regression analysis was used to identify factors associated with patient outcome. Results: In total, 9344 presumed OHCA missions were identified. Cardiopulmonary resuscitation was attempted or continued by HEMS in 3889 cases. Approximately 32.2% of patients achieved return of spontaneous circulation (ROSC) and 22.5% sustained ROSC until arrival at the emergency department. Thirty-day and one-year survival rates were 14.0% and 12.4% respectively. HEMS response time, on-scene time, age, pathogenesis, arrest location, witness-status, first monitored rhythm, bystander automated external defibrillator (AED) use, airway type and administration of adrenaline were independent predictors of 30-day survival. Conclusions: This study provides an extensive insight into the management of OHCA in an almost nationwide HEMS sample. Thirty-day and one-year survival rates are high, indicating high-quality care and systematic selection of patients with favorable prognosis.

Neuroprotective and neuroregenerative drugs after severe traumatic brain injury : A narrative review from a clinical perspective.

Traumatic brain injuries cause enormous individual and socioeconomic burdens. Survivors frequently struggle with motor handicaps as well as impaired cognition and emotion. In addition to the primary mechanical brain damage, complex secondary mechanisms are the main drivers of functional impairment. Many of these pathophysiological mechanisms are now well known: excitotoxic amino acids, breakdown of the blood-brain barrier, neuroinflammation with subsequent damage to cell organelles and membranes, cerebral edema, and apoptotic processes triggering neuronal death; however, paracrine resilience factors may counteract these processes. Specific neuroprotective and neuroregenerative intensive care therapies are few. This review highlights medical approaches aimed at mitigating secondary damage and promoting neurotrophic processes in severe traumatic brain injury. Some pharmacologic attempts that appeared very promising in experimental settings have had disappointing clinical results (progesterone, cyclosporine A, ronopterin, erythropoietin, dexanabinol). Thus, the search for drugs that can effectively limit ongoing posttraumatic neurological damage is ongoing. Some medications appear to be beneficial: N­methyl-D-aspartate receptor (NMDA) antagonists (esketamine, amantadine, Mg++) reduce excitotoxicity and statins and cerebrolysin are known to counteract neuroinflammation. By supporting the impaired mitochondrial energy supply, oxidative processes are inhibited and neuroregenerative processes, such as neurogenesis, angiogenesis and synaptogenesis are promoted by citicoline and cerebrolysin. First clinical evidence shows an improvement in cognitive and thymopsychic outcomes, underlined by own clinical experience combining different therapeutic approaches. Accordingly, adjuvant treatment with neuroprotective substances appears to be a promising option, although more randomized prospective studies are still needed.

Citicoline for the Management of Patients with Traumatic Brain Injury in the Acute Phase: A Systematic Review and Meta-Analysis.

BACKGROUND: Citicoline or CDP-choline is a neuroprotective/neurorestorative drug used in several countries for the treatment of traumatic brain injury (TBI). Since the publication of the controversial COBRIT, the use of citicoline has been questioned in this indication, so it was considered necessary to undertake a systematic review and meta-analysis to evaluate whether citicoline is effective in the treatment of patients with TBI. METHODS: A systematic search was performed on OVID-Medline, EMBASE, Google Scholar, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Ferrer databases, from inception to January 2021, to identify all published, unconfounded, comparative clinical trials of citicoline in the acute phase of head-injured patients- that is, treatment started during the first 24 h. We selected studies on complicated mild, moderate, and severe head-injured patients according to the score of the Glasgow Coma Scale (GCS). The primary efficacy measure was independence at the end of the scheduled clinical trial follow-up. RESULTS: In total, 11 clinical studies enrolling 2771 patients were identified by the end. Under the random-effects model, treatment with citicoline was associated with a significantly higher rate of independence (RR, 1.18; 95% CI = 1.05-1.33; I2, 42.6%). The dose of citicoline or the administration route had no effect on outcomes. Additionally, no significant effects on mortality were found, and no safety concerns were noticed. CONCLUSIONS: This meta-analysis indicates some beneficial effects of citicoline's increasing the number of independent patients with TBI. The most important limitation of our meta-analysis was the presumed heterogeneity of the studies included. REGISTRATION: PROSPERO CRD42021238998.

Influence of positive end-expiratory pressure on arterial blood pressure in mechanically ventilated trauma patients in the field: a retrospective cohort study.

Ventilation with positive end-expiratory pressure (PEEP) may result in decreased venous return to the heart and therefore decrease cardiac output. We evaluated the influence of PEEP ventilation on arterial blood pressure in the field in 296 posttraumatic intubated patients being treated by a helicopter emergency medical service in a retrospective cohort study. Initial systolic blood pressure on the scene, upon hospital admission and their mean difference were compared between patients being ventilated with no/low PEEP (0-0.3 kPa) and moderate PEEP (0.3-1 kPa). In a subgroup analysis of initially hemodynamic unstable patients (systolic blood pressure < 80 mmHg), systolic blood pressure was compared between patients being ventilated with no/low or moderate PEEP Further, the mean difference between initial systolic blood pressure and upon hospital admission was correlated with the chosen PEEP. Systolic arterial blood pressure of patients being ventilated with no/low PEEP improved from 105 ± 36 mmHg to 112 ± 38 mmHg, and that of patients being ventilated with moderate PEEP improved from 105 ± 38 mmHg to 119 ± 27 mmHg. In initially unstable patients being ventilated with no/low PEEP systolic blood pressure improved from initially 55 ± 36 mmHg to 78 ± 30 mmHg upon hospital admission, and in those being ventilated with moderate PEEP, the systolic blood pressure improved from 43 ± 38 mmHg to 91 ± 27 mmHg. There was no significant correlation between the chosen PEEP and the mean difference of systolic blood pressure (Pearson's correlation, r = 0.07, P = 0.17). Ventilation with moderate PEEP has no adverse effect on arterial systolic blood pressure in this cohort of trauma patients requiring mechanical ventilation. Initially unstable patients being ventilated with moderate PEEP tend to be hemodynamically more stable.

A novel pharmacological treatment concept for neuroprotection in severe traumatic brain injury-Two case reports.

Severe traumatic brain injury (sTBI) is a major cause of death and disability worldwide, resulting in a significant individual and socioeconomic burden. Current treatment guidelines do not include any recommendations for neuroprotective or neuoregenerative drugs. Here, we present a combined treatment with Cerebrolysin and Citicoline in two cases. Both drugs are experimentally better than clinically proven in their own effectiveness, but there is almost no clinical data on the combination of the two. Our case study hints at a promising approach that may improve neurological outcome after sTBI. The first patient was a 29 years male motorcyclist suffered polytrauma in a high-speed accident. He had severe bilateral chest trauma and fractures in both thighs and an sTBI. In addition to surgical and standard neurocritical care according to the evidence-based guidelines, he was given neuroprotective therapy with Cerebrolysin (50 ml/day) and Citicoline (3 g/day), by continuous intravenous infusion (IV), for 21 days. The second patient was a 30 years male ski mountaineer who had suffered a fall over 300 m in open terrain. In addition to the sTBI, he had fractures in the cervical spine, ribs, pelvis, and lower extremities, as well as lung contusions and massive soft tissue trauma. After initial treatment in a local hospital, he was transferred to our department and received the same neuroprotective drugs, like all of our patients with sTBI. Considering the severity of the injuries (Injury Severity Score [ISS]: 43/50, Revised Trauma Score [RTS: 5.0304, 2.7794]) and the unfavorable outcome probability (Hukkelhoven Score) of 93.1% and 82.6%, the outcomes of both patients are surprisingly encouraging 1 year after the accident. They achieved a Glasgow Outcome Score of 6 and 5 and grades 2 and 4 on the modified Rankin Scale, respectively. Currently, both are able to take care of themselves in activities of daily life to a large extent. Neuroprotective drugs may improve the regeneration of cell membranes, improve blood brain barrier integrity, and reduce neuroinflammation leading to secondary damage to the injured brain. Our clinical experience and data suggest that the combined administration of Citicoline and Cerebrolysin may contribute to better recovery, without relevant side effects. However, it would be important to validate these results by means of a controlled, prospective study.

Use of the Airtraq laryngoscope for emergency intubation in the prehospital setting: a randomized control trial.

OBJECTIVES: The optical Airtraq laryngoscope (Prodol Meditec, Vizcaya, Spain) has been shown to have advantages when compared with direct laryngoscopy in difficult airway patients. Furthermore, it has been suggested that it is easy to use and handle even for inexperienced advanced life support providers. As such, we sought to assess whether the Airtraq may be a reliable alternative to conventional intubation when used in the prehospital setting. DESIGN, SETTING, AND PATIENTS: Prospective, randomized control trial in emergency patients requiring endotracheal intubation provided by anesthesiologists or emergency physicians responding with an emergency medical service helicopter or ground unit associated with the Department of Anesthesiology, General Hospital, Wiener Neustadt, Austria. MEASUREMENTS AND MAIN RESULTS: During the 18-month study period, 212 patients were enrolled. When the Airtraq was used as first-line airway device (n=106) vs. direct laryngoscopy (n=106), success rate was 47% vs. 99%, respectively (p<.001). Reasons for failed Airtraq intubation were related to the fiber-optic characteristic of this device (i.e., impaired sight due to blood and vomitus, n=11) or to assumed handling problems (i.e., cuff damage, tube misplacement, or inappropriate visualization of the glottis, n=24). In 54 of 56 patients where Airtraq intubation failed, direct laryngoscopy was successful on the first attempt; in the remaining two and in one additional case of failed direct laryngoscopy, the airway was finally secured employing the Fastrach laryngeal mask. There was no correlation between success rates and body mass index, age, indication for airway management, emergency medical service unit, or experience of the physicians. CONCLUSIONS: Based on these results, the use of the Airtraq laryngoscope as a primary airway device cannot be recommended in the prehospital setting without significant clinical experience obtained in the operation room. We conclude that the clinical learning process of the Airtraq laryngoscope is much longer than reported in the anesthesia literature.

Implementation of Crisis-Resource-Management-based Team Training in Lower Austria.

OBJECTIVE: Sequelae of medical errors are a significant problem in acute care. Human-factor-based events are frequent but avoidable causes. Thus, non-technical skills are crucial. In 2008, crisis-resource-management (CRM)-based simulation training was established for the medical staff of the Lower Austria Regional Hospitals, one of the largest hospital operators in Europe. METHODS: Implementation and development of simulation training from 2008 until today are described, costs and performance data retrospectively analysed over a 10-year period. The applied methodology and organisational aspects of CRM training are highlighted. To complete the picture, activities triggered through CRM training throughout the hospitals with potential to further improve patient safety are shown. RESULTS: With an initial funding of €100,000 by the Landeskliniken Holding and course rates of €350 to €500, a simulation programme was established for approximately 1,900 co-workers in the acute care setting. In the past 10 years, more than 2,300 doctors and nurses took part in one of the courses, held by 14 qualified trainers. Training was held in the simulation centre as well as in hospitals. Over the time, simulation facilities have been expanded to 8 different manikins, high-fidelity ventilation and monitoring simulation. In addition, a variety of patient safety activities like implementation of critical incident reporting, OR checklists and anaesthesia briefing was accompanied by the trainer team. The total cost of the project was just under €20, 00,000. CONCLUSION: Simulation-based CRM training was successfully introduced and sustainably institutionalised at the NOE LKH group of hospitals. The demand for and acceptance of the training were both excellent. The previous costs of training were relatively low; the organisational model of an independent, non-profit registered association allowed the training activities to be implemented without reducing the availability of the instructors in their clinical roles.

Vasopressin for hemorrhagic shock management: revisiting the potential value in civilian and combat casualty care.

The evolution of trauma care is driven by a synergistic relationship between civilian and military medical systems. Although the characteristics of civilian injuries differ from those encountered on the battlefield, the pathophysiologic process of dying is the same and dominated by exsanguination and central nervous trauma. As such, therapies that interfere with the physiologic ability to compensate hemorrhage may play a key role to buy time until hemostatic surgery can be initiated. From a variety of remedies with the potential to prolong the compensation phase or to reverse the decompensation phase of shock, arginine vasopressin (AVP) is one of the most promising and best-evaluated drugs. Animal studies and various case report series provide some evidence that AVP may improve blood pressure even when conventional therapies fail, thus preventing hypovolemic cardiac arrest and enabling resuscitation from fatal hemorrhage. On the basis of this civilian experience, it seems reasonable to consider AVP for hypotensive resuscitation in the austere, resource-constrained battlefield environment. However, the significance of AVP as a rescue medication for life-threatening hemorrhage has yet to be proven.

Opiate sparing effect of fixed combination of diclophenac and orphenadrine after unilateral total hip arthroplasty: A double-blind, randomized, placebo-controlled, multi-centre clinical trial.

Multimodal pain management combines analgesics to improve analgesia and reduce side effects. This study investigates the fixed combination of diclophenac and orphenadrin (Neodolpasse(®) Infusion Solution) in patients after unilateral total hip arthroplasty (THA). This prospective, randomized, double-blind, placebo-controlled, multi-centre clinical study enrolled 120 patients receiving patient-controlled analgesia (PCA). Isotonic saline was infused as placebo. The primary efficacy goal was defined as reduction of PCA analgesics used over the first 24 h post-surgery. The study used a three-stage group sequential test design with two interim analyses. Analgesia was monitored by visual analogue scale and verbal rating. Infusion of the Neodolpasse(®) Infusion Solution resulted in a significant reduction in the PCA analgesic requirements by approximately 30% (38.7 ± 21.3 mg vs. 55.9 ± 31.1 mg; p = 0.0004) while maintaining adequate analgesia and patient safety. This study demonstrates that Neodolpasse(®) Infusion Solution significantly reduces PCA analgesic requirements without compromising analgesic effectiveness and safety in THA patients.

Computer tomographic assessment of gastric volume in major trauma patients: impact of pre-hospital airway management on gastric air.

BACKGROUND: Gastric dilation is frequently observed in trauma patients. However, little is known about average gastric volumes comprising food, fluids and air. Although literature suggests a relevant risk of gastric insufflation when endotracheal intubation (ETI) is required in the pre-hospital setting, this assumption is still unproven. METHODS: Primary whole body computed tomographic (CT) studies of 315 major trauma patients admitted to our Level 1 Trauma Centre Salzburg during a 7-year period were retrospectively assessed. Gastric volumes were calculated employing a CT volume rendering software. Patients intubated in the pre-hospital setting by emergency physicians (PHI, N = 245) were compared with spontaneously breathing patients requiring ETI immediately after arrival in the emergency room (ERI, N = 70). RESULTS: The median (range) total gastric content and air volume was 402 (26-2401) and 94 (0-1902) mL in PHI vs. 466 (59-1915) and 120 (1-997) mL in ERI patients (p = .59 and p = .35). PHI patients were more severely injured when compared with the ERI group (injury severity score (ISS) 33 (9-75) vs. 25 (9-75); p = .004). Mortality was higher in the PHI vs. ERI group (26.8% vs. 8.6%, p = .001). When PHI and ERI patients were matched for sex, age, body mass index and ISS (N = 50 per group), total gastric content and air volume was 496 (59-1915) and 119 (0-997) mL in the PHI vs. 429 (36-1726) and 121 (4-1191) mL in the ERI group (p = .85 and p = .98). Radiologic findings indicative for aspiration were observed in 8.1% of PHI vs. 4.3% of ERI patients (p = .31). Gastric air volume in patients who showed signs of aspiration was 194 (0-1355) mL vs. 98 (1-1902) mL in those without pulmonary CT findings (p = .08). CONCLUSION: In major trauma patients, overall stomach volume deriving from food, fluids and air must be expected to be around 400-500 mL. Gastric dilation caused by air is common but not typically associated with pre-hospital airway management. The amount of air in the stomach seems to be associated with the risk of aspiration. Further studies, specifically addressing patients after difficult airway management situations are warranted.

Postponing intubation in spontaneously breathing major trauma patients upon emergency room admission does not impair outcome.

BACKGROUND: Pre-hospital emergency anaesthesia and tracheal intubation are life-saving interventions in trauma patients. However, there is evidence suggesting that the risks associated with both procedures outweigh the benefits. Thus, we assessed whether induction of anaesthesia and tracheal intubation of trauma patients can be postponed in spontaneously breathing patients until emergency room (ER) admission without increasing mortality. METHODS: Retrospective analysis of major trauma patients either intubated on-scene by an emergency medical service (EMS) physician (pre-hospital intubation, PHI) or within the first 10 min after admission at a level 1 trauma centre (emergency room intubation, ERI). Data was extracted from the German Trauma Registry, hospital patient data management and electronic clinical information system. RESULTS: From a total of 946 major trauma cases documented between 2010 and 2017, 294 patients matched the study inclusion criteria. Mortality rate of PHI (N = 258) vs. ERI (N = 36) patients was 26.4% vs. 16.7% (p = 0.3). After exclusion of patients with severe traumatic brain injury and/or pre-hospital cardiac arrest, mortality rate of PHI (N = 100) vs. ERI patients (N = 29) was 6% vs. 17.2%, (p = 0.07). Median on-scene time was significantly (p < 0.01) longer in PHI (30 min; IQR: 21-40) vs. ERI patients (20 min; IQR: 15-28). CONCLUSIONS: There was no statistical difference in mortality rates of spontaneously breathing trauma patients intubated on-scene when compared with patients intubated immediately after hospital admission. Due to the retrospective study design and small case number, further studies evaluating the impact of airway management timing in sufficiently breathing trauma patients are warranted.