Guideline on Treatment of Patients with Severe and Multiple ... - AWMF

S3 <strong>Guideline</strong> on Treatment of Patients with Severe and Multiple Injuries
1.2 Airway management, ventilation and emergency anesthesia
Summary
Endotracheal intubation and ventilation, and hence definitive securing of the airways, with the
aim of the best possible oxygenation and ventilation of the patient, is a central therapeutic
measure in emergency medicine [80]. The basic vital functions directly linked to survival have to
be secured. The “A” for airway and “B” for breathing are First Aid measures found in
established standards on trauma care and therefore have a particular value in terms of weighting
in both the prehospital and the early hospital management [3, 74, 107].
Variations in the emergency medical services (EMS) internationally pose a problem. Whereas
paramedics are often used in the Anglo-American region, the emergency physician system is
widely used in continental Europe. But even here there are differences. In Germany, (specialist)
physicians in all disciplines can be involved in the emergency service after acquiring an
appropriate additional qualification but in Scandinavian countries this is mainly the prerogative
of anesthesiologists [9]. Consequently, the evaluation of international studies on the topic of
securing the airway in the prehospital phase reveals that emergency services personnel have
different levels of training. Depending on the personnel employed and how commonly they
perform intubation, a high rate of esophageal intubations is found in up to 12% of cases in the
literature [20]. In addition, there is a high rate of failed intubations (up to 15%) [99]. In
paramedic systems, non-guideline-compliant airway management is more common [39]. Due to
the different clinical routine of the users, negative outcomes in particular cannot be transferred
directly from paramedic systems to the German emergency services and emergency physician
system [60, 89]. In the Federal Republic of Germany, the agreed minimum qualification of
“Additional qualification in emergency medicine” and the introduction of emergency anesthesia
in the emergency physician system offers a different scenario compared to the Anglo-American
paramedic system.
The following features of the prehospital setting can and must influence the establishing of
indications and planning of anesthesia, intubation and ventilation:
� level of experience and routine training of emergency physician
� circumstances of the medical emergency (e.g., patient is trapped, rescue time)
� type of transport (land-based versus air support)
� transport time
� concomitant injuries around the airway and anything (assessable) that impedes intubation
Depending on the individual case, the indication to carry out or not to carry out prehospital
anesthesia, intubation/airway management and ventilation ranges between the extremes of
“advanced training level, long transport time, simple airway” and “little experience, short
transport time, predicted difficult airway management”. In any event, sufficient oxygenation
must be secured by appropriate measures.
Prehospital – Airway management, ventilation and emergency anesthesia 17