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

S3 <strong>Guideline</strong> on Treatment of Patients with Severe and Multiple Injuries
emergency physician, desaturation with an SpO2 < 90% was documented in 18% of cases and
hypotension with systolic blood pressure < 90 mmHg in 13% of cases. The two complications
did not occur in parallel in any of the cases [72]. Overall, a low complication rate can be
accordingly assumed.
Preoxygenation
To avoid a fall in oxygen saturation during the introduction of anesthesia and endotracheal
intubation, the multiply injured patient should, if practicable, be preoxygenated for up to 4
minutes with an oxygen concentration of 100% via a face mask with reservoir [74]. In a nonrandomized
controlled study of 34 intensive-care patients, the mean paO2 was (T0) 62
± 15 mmHg at the start of preoxygenation, (T4) 84 ± 52 mmHg after 4 minutes, (T6) 88
± 49 mmHg after 6 minutes and (T8) 93 ± 55 mmHg after 8 minutes. The differences in paO2
were significantly different between T0 and T4–8 , but no statistical differences could be obtained
between the paO2 between T4, T6 and T8. 24% of patients even showed a reduction in the paO2
between T4 and T8. A longer period of preoxygenation for 4 to 8 minutes did not lead to any
further marked improvement in arterial oxygen partial pressure and delayed securing the airway
in critical patients [67, 68]. Accordingly, sufficient preoxygenation for 4 minutes has special
importance in securing the airway in multiply injured patients.
Training
Key recommendation:
Emergency medical personnel must be regularly trained in emergency
anesthesia, endotracheal intubation, and alternative ways of securing an
airway (bag-valve-mask, supraglottic airway devices, emergency
cricothyroidotomy).
Explanation:
GoR A
In a survey recently carried out among prehospital trained emergency physicians, they were
questioned on their knowledge of and experience in endotracheal intubation and the alternative
methods for securing an airway [93]. This survey included the responses from 340
anesthesiologists (56.1%) and 266 non-anesthesiologists. It revealed that all anesthesia-trained
emergency physicians could demonstrate more than 100 endotracheal intubations performed in
hospital in contrast to only 35% of non-anesthesiologists performing more than 100 in-hospital
intubations. A similar picture emerges for alternative methods for securing an airway as well.
97.8% of anesthesia-trained emergency physicians had used alternative methods for securing an
airway on more than 20 occasions while only 11.1% of non-anesthesia-trained emergency
physicians had equivalent experience (p < 0.05). In addition, it emerges that only 27% of
emergency equipment was equipped with CO2 monitors. From this study it can be concluded
that there is an urgent training need for non-anesthesia-trained emergency physicians in
endotracheal intubation, capnography and alternative methods for securing an airway [74].
Studies on first-year anesthesiology residents showed that more than 60 intubations were
Prehospital – Airway management, ventilation and emergency anesthesia 23