Review articleAnaesthesia in prehospital emergencies and in the emergency room☆
Introduction
Anaesthesia in prehospital emergencies and in the emergency room may save the life of a critically ill or injured patient. Nevertheless, if not performed properly, anaesthesia may put a patient at an even higher risk of morbidity and mortality.1, 2 There is ongoing controversy whether patients benefit from prehospital anaesthesia.3 For example, emergency tracheal intubation is associated with a relatively high rate of life-threatening oesophageal intubations, and mortality is increased in haemodynamically unstable patients.4 Similarly, in a German study the tracheal tube was misplaced bronchially in ∼11% of patients and in ∼7% oesophageally; mortality in patients with tracheal tubes misplaced in the oesophagus was 80%.5 Moreover, prehospital intubations may fail more often than in the emergency room.6 Additionally, a patient being intubated in the field is at double risk of aspiration when compared to a patient being intubated in the emergency room.7 Also, in a prehospital study from the United States 14 out of 15 children with an oesophageally placed or a disconnected tracheal tube died.8 In a prehospital study from France, senior emergency physicians encountered intubation difficulties (>2 intubation attempts) only in 2% of patients.9 Furthermore, severely head-injured patients being anaesthetised in the emergency room compared to a prehospital setting had only half the mortality.10 These observations indicate that heterogeneity exists among emergency medical service (EMS) systems worldwide, and the intent to improve patient outcome with prehospital anaesthesia may even increase morbidity and mortality of critically ill or injured patients, at least in some EMS systems.
This review discusses new developments in prehospital and emergency room anaesthesia, especially focusing on airway management and drugs, as these fields have seen impressive scientific advances during the last years.
Section snippets
Methods
A literature search in the PubMed database was performed; articles published between January 1st 1950 and July 31st 2009, listed with the keywords “anaesthesia”, “difficult airway”, “emergency medicine”, “prehospital”, “resuscitation”, and “ventilation” were retrieved. References of retrieved articles were hand-searched for additional articles. Eighty-seven articles were found relevant and included in this non-systematic review.
Airway management according to training level
Securing the airway depends largely on the training level of a given rescuer. For example, in order to achieve a 90% success rate within two tracheal intubation attempts, first-year anaesthesiology residents required a case load of ∼60 intubations.11 Recently, a “gold” level of competence was proposed for a healthcare provider with daily airway management practice, and a “silver” or “bronze” level for a moderately or lesser skilled rescuer performing airway management in the field.12 Thus, a
Conclusions
For pre-oxygenation, high-flow oxygen should be delivered with a tight-fitting face-mask provided with a reservoir. In haemodynamically unstable patients ketamine may be the induction agent of choice. The rocuronium antagonist Sugammadex may have the potential to make rocuronium a first-line neuromuscular blocking agent in emergency induction. An experienced health-care provider may consider prehospital anaesthesia induction. A moderately experienced health-care provider should optimise
Conflict of interest
None to declare.
References (87)
The incidence and risk factors for cardiac arrest during emergency tracheal intubation: a justification for incorporating the ASA Guidelines in the remote location
J Clin Anesth
(2004)- et al.
Survey of out-of-hospital emergency intubations in the French prehospital medical system: a multicenter study
Ann Emerg Med
(1998) - et al.
Aspiration of gastric contents: association with prehospital intubation
Am J Emerg Med
(2005) - et al.
Use of the intubating laryngeal mask airway in emergency pre-hospital difficult intubation
Resuscitation
(2008) - et al.
Pre-oxygenation in the obese patient: effects of position on tolerance to apnoea
Br J Anaesth
(2005) - et al.
Preoxygenation—the importance of a good face mask seal
Br J Anaesth
(1995) - et al.
Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial
Lancet
(2009) - et al.
Effects of decreasing peak flow rate on stomach inflation during bag-valve-mask ventilation
Resuscitation
(2004) - et al.
The respiratory system during resuscitation: a review of the history, risk of infection during assisted ventilation, respiratory mechanics, and ventilation strategies for patients with an unprotected airway
Resuscitation
(2001) - et al.
Gastric rupture following bag-valve-mask ventilation
J Emerg Med
(2002)
Effects of stomach inflation on haemodynamic and pulmonary function during spontaneous circulation in pigs
Resuscitation
Effects of stomach inflation on haemodynamic and pulmonary function during cardiopulmonary resuscitation in pigs
Resuscitation
Excessive stomach inflation causing gut ischaemia
Resuscitation
The assessment of three methods to verify tracheal tube placement in the emergency setting
Resuscitation
A suction laryngoscope facilitates intubation for physicians with occasional emergency medical service experience—a manikin study with severe simulated airway haemorrhage
Resuscitation
Out-of-hospital airway management with the LMA CTrach—a prospective evaluation
Resuscitation
Airway management in cardiac arrest—comparison of the laryngeal tube, tracheal intubation and bag-valve mask ventilation in emergency medical training
Resuscitation
The use of laryngeal tube by nurses in out-of-hospital emergencies: preliminary experience
Resuscitation
Laryngeal tube suction II for difficult airway management in neonates and small infants
Resuscitation
Esophageal rupture with the use of the Combitube: report of a case and review of the literature
J Oral Maxillofac Surg
Tight control of prehospital ventilation by capnography in major trauma victims
Br J Anaesth
Invasive airway techniques in resuscitation
Ann Emerg Med
Simulator-based training in paediatric anaesthesia and emergency medicine—thrills, skills and attitudes
Br J Anaesth
Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts
Anesth Analg
Prehospital intubation: the right tools in the right hands at the right time
Anesth Analg
Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations
Anesthesiology
The out-of-hospital esophageal and endobronchial intubations performed by emergency physicians
Anesth Analg
Effect of out-of-hospital pediatric endotracheal intubation on survival and neurological outcome: a controlled clinical trial
JAMA
The impact of hypoxia and hyperventilation on outcome after paramedic rapid sequence intubation of severely head-injured patients
J Trauma
Learning manual skills in anesthesiology: is there a recommended number of cases for anesthetic procedures?
Anesth Analg
Field airway management disasters
Anesth Analg
Positive end-expiratory pressure during induction of general anesthesia increases duration of nonhypoxic apnea in morbidly obese patients
Anesth Analg
Optimizing preoxygenation in adults
Can J Anaesth
Preoxygenation is more effective in the 25 degrees head-up position than in the supine position in severely obese patients: a randomized controlled study
Anesthesiology
Preoxygenation in critically ill patients requiring emergency tracheal intubation
Crit Care Med
Extending the preoxygenation period from 4 to 8 mins in critically ill patients undergoing emergency intubation
Crit Care Med
Preoxygenation remains essential before emergency tracheal intubation
Crit Care Med
One single dose of etomidate negatively influences adrenocortical performance for at least 24 h in children with meningococcal sepsis
Intensive Care Med
Anaesthesia in haemodynamically compromised emergency patients: does ketamine represent the best choice of induction agent?
Anaesthesia
Haemodynamic changes and heart rate variability during midazolam–propofol co-induction
Anaesthesia
Ketamine or alfentanil administration prior to propofol anaesthesia: the effects on ProSeal laryngeal mask airway insertion conditions and haemodynamic changes in children
Anaesthesia
Clinical anesthesiology
Reversal of profound, high-dose rocuronium-induced neuromuscular blockade by sugammadex at two different time points: an international, multicenter, randomized, dose-finding, safety assessor-blinded, phase II trial
Anesthesiology
Cited by (61)
Evaluation of six different airway devices regarding regurgitation and pulmonary aspiration during cardio-pulmonary resuscitation (CPR) - A human cadaver pilot study
2016, ResuscitationCitation Excerpt :Difficulties with conventional ETI as well as airway-associated adverse outcomes led to the concept of “difficult airway management”.9,10 To meet this issue, various supraglottic airway (SGA) devices have been developed over the years as possible alternatives to conventional ETI.11,12 Securing the airway with SGA devices is less invasive and much easier to perform than ETI and may help to reduce time to intubation/ventilation, especially in patients with a difficult airway.3,13–15
Prehospital emergency anesthesia in adults: Current recommendations for performing prehospital emergency anesthesia based on the recommendations for prehospital emergency anesthesia in adults
2023, Medizinische Klinik - Intensivmedizin und NotfallmedizinEmergency endotracheal intubation: best practice versus reality
2022, Swiss Medical WeeklyCompetencias en la formación de enfermeros para asistir la vía aérea de pacientes adultos en urgencia y emergencia
2021, Revista Latino-Americana de Enfermagem
- ☆
A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.10.023.