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

S3 <strong>Guideline</strong> on Treatment of Patients with Severe and Multiple Injuries
Alternative methods for securing an airway
Key recommendations
A difficult airway must be anticipated when endotracheally intubating a
trauma patient.
Alternative methods for securing an airway must be provided when
anesthetizing and endotracheally intubating a multiply injured patient.
Fiberoptic intubation must be available as an alternative when anesthetizing
and endotracheally intubating in-hospital.
If difficult anesthetization and/or endotracheal intubation are expected, an
anesthesiologist must carry out or supervise this procedure in-hospital
provided this does not cause a delay in an emergency life-saving measure.
Suitable measures must be in place to ensure that an anesthesiologist is
normally on site in time
After more than 3 intubation attempts, alternative methods must be
considered for ventilation and securing an airway.
Explanation:
GoR A
GoR A
GoR A
GoR A
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Due to the framework conditions, the endotracheal intubation of an emergency patient is
markedly more difficult in the prehospital environment than in-hospital. A difficult airway must
therefore always be anticipated when endotracheally intubating a trauma patient [74]. In a large
study of 6,088 trauma patients, risk factors and difficulties in endotracheal intubation consisted
of foreign bodies in the pharynx or larynx, direct injuries to the head or neck with loss of normal
anatomy in the upper airway, airway edema, pharyngeal tumors, laryngospasms and a difficult
pre-existing anatomy[88]. In another study, trauma patients presented difficult airway securing
markedly more frequently (18.2%) than, for example, patients with cardiac arrest (16.7%) and
patients with other diseases (9.8%). Reasons described for difficult airway management were the
position of the patient (48.8% of cases), difficult laryngoscopy (42.7% of cases), secretion or
aspiration in the oropharynx (15.9% of cases) and traumatic injuries (including bleeding/burns)
in 13.4% of cases [94]. Technical problems occurred in 4.3% and other causes in 7.3% of cases.
Further studies show a similar frequency of causes of difficult intubation (blood 19.9%, vomit
15.8%, hypersalivation 13.8%, anatomy 11.7%, changes in anatomy caused by trauma 4.4%,
position of patient 9.4%, lighting conditions 9.1%, technical problems 2.9% [48]. In a
prospective study with 598 patients, adverse events and complications occurred significantly
more frequently in patients with severe injuries than non-traumatized patients (p = 0.001) [92].
At least one event was documented in 31.1% of traumatized patients. The number of attempts
required for intubation was also significantly increased in traumatized patients (p = 0.007) [92].
Prehospital – Airway management, ventilation and emergency anesthesia 25