Airway management for anaesthesia in the ambulatory setting.

PURPOSE OF REVIEW: The number of anaesthetic procedures in the ambulatory setting is steadily increasing. During the last years, more and more patients with complex medical conditions undergo ambulatory interventions. This review will focus on airway management practices, but especially on techniques used in the ambulatory setting. It will highlight recent literature published in the focus of ambulatory anaesthesia and will discuss relevant findings of the last year. METHODS: Literature search and analysis performed independently by two reviewers. RECENT FINDINGS: Practical points to improve success of anaesthesia and to avoid complications in the ambulatory setting are provided. In addition to concepts for the (un)expected difficult airway, new supraglottic devices, and modern concepts for teleconsultation, are discussed. SUMMARY: There are several points which should be considered for ambulatory anaesthesia. Selected patient groups (e.g., obstructive sleep apnoea, obesity) may have a higher anaesthesia-related risk. To handle the more and more complex conditions in a growing number of ambulatory patients, straightforward concepts, especially for the (un)expected difficult airway, are required.

Incidents, accidents and fatalities in 40 years of German helicopter emergency medical system operations.

CONTEXT: Currently, approximately 100 000 helicopter emergency medical service (HEMS) missions for patients are undertaken in Germany each year. Compared to the early years, risk has reduced significantly, but is still higher than commercial aviation or other airborne operations. OBJECTIVE: The aim of the present study was to evaluate helicopter accidents and fatalities related to HEMS operations. DESIGN: Retrospective study of HEMS accidents in Germany. SETTING: Analysis of accidents in the published flight accident reports of the German Federal Agency for Flight Accident Investigation (40-year period from 1970 to 2009). Data were collected by telephone interview with the operators, manual search of publications and by supplemental internet information. MAIN OUTCOME MEASURES: Data were analysed per 10 000 missions. For statistical analysis, Fisher[Combining Acute Accent]s exact test was used. A P value less than 0.05 was considered significant. RESULTS: During the period analysed, a total of 1.698 million HEMS missions (1970 vs. 2009: 61 vs. 98 471) were flown by a mean of 50 ±â€Š27 (1 vs. 81) helicopters. To date, missions resulted in a total of 99 accidents with a mean of 2.4 ±â€Š1.7 accidents per year (range 0-7). The accident rate was 0.57 (0-11.4) per 10 000 missions and the fatal accident rate was 0.11 (0-0.5). Some 64% of missions did not result in any injuries to occupants, whereas 19.2% were fatal. From the accidents analysed, 43.4% were due to collision with an obstacle during landing, take-off or hovering. Landing was the phase of flight most often associated with accidents (44.4%). CONCLUSION: The present study is the largest on HEMS accidents and the only one analysing an entire 40-year time course beginning with inception. In comparison to previous data, a significantly lower accident rate per 10 000 missions was found. Gathering data on the early years is nearly impossible, and further analysis is required to calculate the risk of fatality or identify injury patterns.

Success rates and endotracheal tube insertion times of experienced emergency physicians using five video laryngoscopes: a randomised trial in a simulated trapped car accident victim.

CONTEXT: No randomised controlled trial has yet compared different video laryngoscopes in respect of the success rates and the time taken to achieve endotracheal intubation in trapped car accident victims. OBJECTIVE: The aim of the present study was to evaluate whether five video laryngoscopes facilitate tracheal intubation more quickly or more securely than conventional laryngoscopy. DESIGN: Prospective, controlled, randomised crossover trial. SETTING: An airway manikin was placed on the driver's seat of a compact car. Access was possible only through the opened driver's door. PARTICIPANTS: Twenty-five experienced anaesthetists. INTERVENTION: Tracheal intubation in a simulated trapped patient using video laryngoscopes in a typical out-of-hospital setting. MAIN OUTCOME MEASURES: Times to achievement of a view of the glottis, tracheal intubation, cuff inflation, first ventilation and tracheal tube position were compared using a standard Macintosh laryngoscope or Glidescope Ranger, Storz C-MAC, Ambu-Pentax AWS, Airtraq and McGrath Series 5 video laryngoscopes in a randomised order. Wilcoxon signed-rank test and McNemar test were used for statistical analysis. A P value of less than 0.05 was considered statistically significant. RESULTS: Twenty-five anaesthetists (35.1 ±â€Š7.3 years; 16 male, nine female) with an intubation experience of 374 ±â€Š96 intubations per year and an experience of 9.1 ±â€Š7.3 years participated. Glottic view, tracheal intubation, cuff inflation and first ventilation were achieved most rapidly with the Macintosh laryngoscope, although the Airtraq and Pentax AWS video laryngoscopes were not significantly slower. Times were significantly longer when the Glidescope Ranger, McGrath Series 5 or Storz C-MAC video laryngoscopes were used (P < 0.05), failure to place the endotracheal tube correctly was significantly commoner with the McGrath Series 5 than with the Macintosh (P = 0.031). CONCLUSION: When attempting to intubate a trapped car accident victim, video laryngoscopes provide a better view of the glottis, but some delay tracheal intubation significantly. The devices with a tube guide (Airtraq and Ambu Pentax AWS) enable tracheal intubation to be achieved significantly faster and with a lower failure rate than devices without a tube guide. No video laryngoscope outperformed direct laryngoscopy with a Macintosh laryngoscope in this simulation study.

Reperfusion rate and inhospital mortality of patients with ST segment elevation myocardial infarction diagnosed already in the prehospital phase: results of the German Prehospital Myocardial Infarction Registry (PREMIR).

AIMS: We sought to evaluate the in-hospital fate of patients with ST segment elevation myocardial infarction (STEMI) diagnosed already in the prehospital phase by physican equipped ambulances. METHODS: A total of 2326 consecutive STEMI patients were included in PREMIR. For this analysis 218 patients with prehospital cardiopulmonary resuscitation were excluded. RESULTS: The median time between symptom onset and 12-lead ECG was 85 min. The median time intervals between the diagnostic 12-lead ECG and prehospital fibrinolysis were 10 min, until inhospital fibrinolysis 52 min and until primar PCI 86min, respectively. Reperfusion therapy with prehospital fibrinolysis (24%), inhospital fibrinolysis (13%) or primary PCI (45%) was performed in 82% of the patients. Inhospital mortality was 6.0% in patients with prehospital fibrinolysis (n = 504), 5.8% in patients with inhospital fibrinolysis (n = 278), 4.5% in patients with primary percutaneous coronary intervention (n = 962) and 16.2% in patients without early reperfusion therapy (n = 377), respectively. In the multivariate propensity score analysis comparing prehospital fibrinolysis and primary PCI we observed no significant difference in the odds for in-hospital mortality (odds ratio: 1.57, 95% CI: 0.94-2.63). The final discharge diagnosis was STEMI in 90% of the patients, in patients with prehospital fibrinolysis 95%. CONCLUSIONS: In patients with STEMI already diagnosed in the prehospital phase the ischemic time is short, accuracy of the diagnosis is high and reperfusion therapy is performed in over 82%. Inhospital mortality was not different between prehospital fibrinolysis and primary PCI.

A 6-year analysis of German emergency medical services helicopter crashes.

BACKGROUND: Annually, there are about 80,000 helicopter emergency medical services (HEMS) missions for patients in Germany. In comparison to the commercial transport of passengers, the risk of aviation crashes increases during rescue operations. The aim of this study was to evaluate helicopter crashes related to HEMS in Germany within a 6-year period (1999-2004) and to analyze contributing factors. METHODS: Flight crashes were identified in the annually published flight crash reports of the Federal Agency for Flight Accident Investigation. Data were completed by telephone interview of the operators and by additional internet information. For statistical analysis, Fisher's exact test was used. A p < 0.05 was considered significant. RESULTS: Twenty-four helicopter crashes (n = 22 during day, n = 2 at night) of German HEMS were identified within the 6 years. Three crashes were fatal, another two caused nonfatal injuries. Seven persons were killed, four injured severely and four slightly. Patients were not hurt within the analyzed period. The crash rate per 10,000 missions sank significantly (p < 0.05), whereas no reduction was found per 100,000 flight hours (not significant) compared with previously published data. Fifty-four percent (n = 13) of all crashes were reported during approach and landing. Seventeen percent (n = 4) of the crashes occurred during ground run and 29% (n = 7) during the remaining flight phases (takeoff and cruise flight). CONCLUSIONS: In comparison to previous data a significantly lower crash rate per 10,000 missions was found. With the analysis of the same data per 100,000 flying hours, this trend was not evident. The majority of crashes occurred during the day and landings.

In-flight cardiac arrest and in-flight cardiopulmonary resuscitation during commercial air travel: consensus statement and supplementary treatment guideline from the German Society of Aerospace Medicine (DGLRM).

By the end of the year 2016, approximately 3 billion people worldwide travelled by commercial air transport. Between 1 out of 14,000 and 1 out of 50,000 passengers will experience acute medical problems/emergencies during a flight (i.e., in-flight medical emergency). Cardiac arrest accounts for 0.3% of all in-flight medical emergencies. So far, no specific guideline exists for the management and treatment of in-flight cardiac arrest (IFCA). A task force with clinical and investigational expertise in aviation, aviation medicine, and emergency medicine was created to develop a consensus based on scientific evidence and compiled a guideline for the management and treatment of in-flight cardiac arrests. Using the GRADE, RAND, and DELPHI methods, a systematic literature search was performed in PubMed. Specific recommendations have been developed for the treatment of IFCA. A total of 29 specific recommendations for the treatment and management of in-flight cardiac arrests were generated. The main recommendations included emergency equipments as well as communication of the emergency. Training of the crew is of utmost importance, and should ideally have a focus on CPR in aircraft. The decision for a diversion should be considered very carefully.

[Role of intraosseous access in emergency]. / Der intraossäre Zugang. Eine wichtige Alternative im Notfall.

As alternative for drug administration, the intraosseous access is an important option in emergency medicine. Plasma concentrations of drugs, safety and rapidity as well as rate of complications are comparable to the intravenous access. These findings are reflected in the recent resuscitation guidelines, which recommend intraosseous access as an alternative to intravenous access both in children and adults, considering the tracheal route as backup only if the other two options fail. Rescuers should learn safe techniques of establishing an intraosseous access. Equipment of rescue vehicles with adequate devices for children and adults should be considered standard.

Fate of patients with prehospital resuscitation for ST-elevation myocardial infarction and a high rate of early reperfusion therapy (results from the PREMIR [Prehospital Myocardial Infarction Registry]).

Patients with acute ST-segment elevation myocardial infarction (STEMI) needing prehospital cardiopulmonary resuscitation (CPR) have a very high adverse-event rate. However, little is known about the fate of these patients and predictors of mortality in the era of early reperfusion therapy. From March 2003 through December 2004, 2,317 patients with prehospital diagnosed STEMI were enrolled in the Prehospital Myocardial Infarction Registry. One hundred ninety patients (8.2%) underwent prehospital CPR and were included in our analysis. Overall 90% of patients were treated with early reperfusion therapy, 56.3% received prehospital thrombolysis and 1/2 of these patients received early percutaneous coronary intervention after thrombolysis, 28.4% of patients were treated with primary percutaneous coronary intervention, and 5.3% received in-hospital thrombolysis. Total mortality was 40.0%. The highest mortality was seen in patients with asystole (63%) or pulseless electric activity (64%). Independent predictors of mortality were need for endotracheal intubation and older age, whereas ventricular fibrillation as initial heart rhythm was associated with survival. In conclusion, in this large registry with prehospital diagnosed STEMI, incidence of prehospital CPR was about 8%. Even with a very high rate of early reperfusion therapy, in-hospital mortality was high. Especially in elderly patients with asystole as initial heart rhythm and with need for endotracheal intubation, prognosis is poor despite aggressive reperfusion therapy.

Tonsillectomy in children.

INTRODUCTION: Tonsillectomy is one of the most frequently performed surgical interventions in children. In the following, indications, preoperative evaluation, surgical techniques and postoperative complications will be discussed. METHODS: Literature search in PubMed (National Library of Medicine) focusing on publications in German or English up to June 2008. RESULTS: Indications are selected infectious diseases, upper airway obstruction for example due to tonsillar hypertrophy, and a suspected malignancy. Viral infections of the tonsils without upper airway obstruction are not an indication for surgery; in the case of acute bacterial tonsillitis, tonsillectomy is no longer recommended. In recurrent tonsillitis, tonsillectomy is only effective in specific and narrow indications. The indication for tonsillectomy in sleep-disordered breathing due to adenotonsillar hypertrophy has to be based on clinical assessment, medical history, and a sleep history. The most relevant risk factors are obstructive sleep apnea and coagulation disorders. A standardized history regarding hemostasis and bleeding is mandatory, and is superior to routine coagulation tests. Postoperative bleeding is still the most relevant complication of tonsillectomy and is always an emergency situation. CONCLUSION: Tonsillectomy is one of the most frequently performed interventions in children but should be considered with care, as life-threatening complications can occur.