Recommended practice for out-of-hospital emergency anaesthesia in adults

Table of content Abbreviations 3 Abstract 4 1.1 Rationale, frequency and indication 5 1.2 Special features of out-of-hospital Emergency Anaesthesia 7 1.3 Preparations, Performance and Monitoring of Emergency Anaesthesia 9 1.4 Anaesthesia Procedures for Common Emergency Situations 14 1.5 Drugs for Emergency Anaesthesia 18 References ?? Abbreviations ARDS Acute Respiratory Distress Syndrome AWMF Working Group of Scientific Medical Associations BMI Body Mass Index EAST Eastern Association for the Surgery of Trauma ECG Electrocardiogram EMS Emergency Medical Service DGAI German Society of Anaesthesiology and Intensive Care Medicine DIVI German Interdisciplinary Association for Intensive Care and Emergency Medicine etCO2 End-tidal carbon dioxide GCS Glasgow Coma Score ICP Intracranial pressure ICU Intensive Care Unit LIKS AirRescue Information and Communication Systems MIND German minimal emergency data record NIBP Noninvasive Blood Pressure NIV Noninvasive Ventilation BP Blood Pressure (according to Riva Rocci) SOP Standard operating procedure SpO2 Oxygen saturation TBI Traumatic Brain Injury Abstract Emergency anaesthesia is an important therapeutic measure in out-of-hospital emergency medicine. The associated risks are considerably higher than those of in-hospital anaesthesia. The primary objectives of emergency anaesthesia are hypnosis, analgesia, oxygenation and ventilation through airway management. The secondary objectives of emergency anaesthesia are amnesia, anxiolysis, the reduction of oxygen consumption and respiratory work, the protection of vital organs and the avoidance of secondary myocardial and cerebral damage. A critical evaluation of the indications for out-of-hospital emergency anaesthesia must take into consideration patient, case and provider-related factors. Rapid sequence induction of emergency anaesthesia includes standard monitoring, preoxygenation, standardised preparation of emergency anaesthesia, drug administration, manual in-line stabilisation during intubation (if necessary), airway management and checking of correct tube placement. Spontaneously breathing casualties should receive preoxygenation for at least 3 to 4 min with a tight-fitting facemask with reservoir using 12 to 15 l min_1 of oxygen or with a demand valve providing 100% oxygen. As an alternative, preoxygenation may be performed as noninvasive ventilation with 100% oxygen. Standardised anaesthesia preparation comprises filling drugs into syringes and labelling them, checking ventilation equipment, preparing endotracheal tube and syringe for inflating the cuff and the introducer, stethoscope and fixation material, preparing alternative instruments for airway management as well as checking suction, ventilation and standard monitoring devices, including capnography. Standard monitoring for out-of-hospital emergency anaesthesia comprises ECG, blood pressure measurement and pulse oximetry. Continuous capnography is always and exclusively performed to check the placement of airway devices, as well as to indirectly monitor haemodynamics. 1.1 Rationale, frequency and indication 1.1.1 Rationale Emergency anaesthesia, airway management and ventilation are important therapeutic measures in emergency medicine.1,2 In physician-based emergency medical service (EMS) systems, every EMS-physician – irrespective of his or her specialty – should be able to safely induce emergency anaesthesia in patients with various injury patterns, clinical pictures and risks despite adverse conditions outside the hospital.3 This leads to the question of what procedure should be recommended for out-of-hospital anaesthesia under complex conditions and what anaesthetic drugs should be used, especially with regard to different groups of patients. It must also be taken into consideration that the induction and performance of out-of-hospital anaesthesia is in many respects more difficult than routine anaesthesia in operating theatres or ICUs in hospitals.4,5 The following recommendations of the German Society of Anaesthesiology and Intensive Care Medicine (DGAI) have been prepared for EMS-physicians and paramedics in two-tier physician-staffed EMS systems. Table 1 shows a list of the central points of these recommendations.Table 1: Overview of the recommendations for out-of-hospital emergency anaesthesia1.1.2 Methods The recommendations contain measures based on the latest scientific findings, which ensure the appropriate provision of out-of-hospital emergency anaesthesia for critically ill or injured patients under various circumstances (e.g. infrastructure, specific situation, patient condition, individual capabilities, knowledge and experience of the physician). To achieve consensus on scientific findings and current practice of out-of-hospital emergency anaesthesia the Emergency Medicine Research Group of the DGAI invited 14 anaesthesiologists experienced in out-of-hospital emergency medicine from German and Austrian medical centres to participate in an Out-of-Hospital Emergency Anaesthesia Working Group. After constructing a frame of contents, single topics were distributed to teams of authors to review relevant literature and provide a first version of the text. In a second step, these results were assembled and a three-round digital Delphi study was conducted to reach consensus. The Delphi technique is a structured approach of debating by experts to converge a discussion towards group consensus, which was initially developed in the 1950s for complex problems exceeding the analytical capabilities of a single person.6 Working group opinion was fed back after each Delphi round to allow the participants to revise their previous opinions and so converge towards group consensus. Recommendations were approved with consensus when agreement of 12 out of 14 participants (> 85%) could be reached. 1.1.3 Frequency According to the German minimal emergency data record data base (82 000 ground deployments of emergency physicians) of Baden-Württemberg, Germany, and the AirRescue Information and Communication Systems data base (47 000 air rescue missions, Germany), every emergency physician induces out-of-hospital anaesthesia every 2 weeks in air rescue missions and every 1.4 months in ground deployments.7 Out-of-hospital anaesthesia is induced in approximate 3 to 5% of all EMS missions and in 4 to 7% of EMS missions to children (age <18 years).8–12 1.1.4 Indications for emergency anaesthesia Emergency anaesthesia must often be induced in unconscious (Glasgow coma scale, GSC <9), uncooperative, severely injured or critically ill patients with a full stomach and unstable cardiopulmonary conditions.13 Emergency anaesthesia is, in most cases, necessary for airway management. An exception to this rule are patients undergoing cardiopulmonary resuscitation who require airway management first and, if necessary, emergency anaesthesia later once spontaneous circulation has returned.14 Indications for emergency anaesthesia can be found in critically ill or injured patients with cardiopulmonary or neurological diseases, trauma patients, and patients who are intoxicated or have markedly impaired conscious level with a reduction in protective reflexes (GCS < 9) and a high risk of pulmonary aspiration.15,16 This does not include rapidly reversible causes of impaired consciousness (e.g. hypoglycaemia) or conditions in which the GCS does not correlate with the extent of the loss of protective reflexes (e.g. stroke with aphasia or dementia). Patients with markedly impaired consciousness (GCS < 9) require emergency anaesthesia to tolerate airway management.17Tables 2 and 3 provide an overview of the indications for and objectives of out-of-hospital emergency anaesthesia.Table 2: Indications for out-of-hospital emergency anaesthesiaTable 3: Objectives of out-of-hospital emergency anaesthesiaIf emergency anaesthesia is required, personnel must take into account the guideline on out-of-hospital airway management18 by the DGAI as well as the information on emergency anaesthesia, airway management and ventilation in the German S3 guideline on treatment of major trauma (S3-Guideline on Treatment of patients with severe and multiple injuries. German Trauma Society. 2011 www.awmf.org Nr. 012-019 Assessed 29 September 2015). Indications for, planning of and performance of emergency anaesthesia are influenced by the following factors: Training, experience and routines of the emergency physician and paramedics Out-of-hospital environment (e.g. illumination, space, weather) Time and type of transport (ground, air ambulance) Circumstances surrounding airway management and (foreseeable) intubation problems (e.g., expected difficult airways of emergency patients with sufficient spontaneous breathing). The EMS-physician must not only consider the situation of the patient but must also critically assess his own skills when deciding to perform out-of-hospital emergency anaesthesia. Emergency anaesthesia is an invasive measure, a on monitoring and management. emergency anaesthesia, the EMS-physician must consider and (e.g. pulmonary airway and the risks and In the skills of the EMS-physician and the paramedics as well as relevant must also be EMS-physicians from a medical or a have been in which severe were by a of experience in out-of-hospital emergency are by and standard operating must to provide experienced emergency teams with a standardised approach to out-of-hospital anaesthesia. the risks for the patient, is that all EMS-physicians the for and out-of-hospital anaesthesia. The Association of of and that out-of-hospital anaesthesia should have the level of and that allow to perform emergency intubation in the emergency 1.2 Special features of out-of-hospital emergency anaesthesia Emergency anaesthesia induced in the in the emergency and especially outside the is associated with a high level of According to these conditions can be as patient and factors. the induction and performance of emergency anaesthesia include a full injury of the of the on account of trauma or cardiopulmonary or of a and Out-of-hospital emergency patients must be to have a full To the risk of in sequence induction is the technique of This anaesthetic induction and airway management This has a on the of The DGAI Anaesthesia Scientific Working Group ventilation in patients to during sequence of is recommended during out-of-hospital anaesthesia in critically ill or severely injured patients to always have a second during induction (e.g. in case of is may also be through drugs may be through using the Blood loss is in many patients (e.g. major Medical personnel must take into account that in the of blood is critically and patients must be have that with severe oxygen saturation of than after only 1 to 2 min of despite emergency anaesthesia is induced in patients with severe at the of the may which is difficult to of the patients or patients in a should be first by appropriate and and by spontaneous patients should be for anaesthesia induction and airway management. The conditions outside can be in an have a of equipment, and drugs at their In an out-of-hospital the of and drugs is considerably on the of the patient, out-of-hospital anaesthesia must often be induced as as Medical personnel in an out-of-hospital environment have a high level of experience to ensure patient 1.3 performance and monitoring of emergency anaesthesia account of the risks and of out-of-hospital emergency anaesthesia, standardised are necessary to out-of-hospital emergency anaesthesia take the following points into evaluation and of the patient of the indications for out-of-hospital emergency anaesthesia of patient through preoxygenation, and (if Standardised for the preparation and performance of out-of-hospital emergency anaesthesia of of the indications for out-of-hospital emergency anaesthesia Information in 1.1.3 and 1.2 must be taken into account in this The to induce out-of-hospital anaesthesia must be to the emergency The must the to induce anaesthesia, the of each the drugs and important A approach must be which is based on a standardised of out-of-hospital anaesthesia Rapid sequence induction is performed to induce emergency anaesthesia. The is to rapidly and a of in which airway management and ventilation are This procedure the of a by drugs may be to or after these or after the airway is Ventilation must be after anaesthesia Drugs must be into syringes and management must be prepared and for Standardised preparation of emergency anaesthesia Performance and procedure of out-of-hospital emergency anaesthesia Table 5 and 1 and 2 provide an overview of the of out-of-hospital emergency anaesthesia.Table Standardised performance of out-of-hospital 1: of the performance and procedure of out-of-hospital emergency 2: of the performance and procedure of out-of-hospital emergency paramedics the drugs and the for airway management and ventilation as by the preoxygenation is as as the EMS-physician to induce emergency anaesthesia To during anaesthesia induction and airway management or to the the oxygen saturation level breathing emergency patients are oxygen for 3 to 4 must be performed only with 100% oxygen through a or the valve each with an oxygen reservoir least 12 to 15 of A demand valve or noninvasive ventilation may be used, which are more and require A reservoir is not sufficient for preoxygenation at the preoxygenation, monitoring is and syringes are with anaesthetic and emergency to the of the emergency Standard monitoring includes ECG and blood pressure monitoring least every 3 and pulse and The German Interdisciplinary Association for Intensive Care and Emergency Medicine the of standardised syringe to in critical for labelling syringes in and emergency medicine Assessed To the should be in if is (e.g. in trauma patients or a unstable After the are anaesthesia is induced to and The paramedics the and of the drugs or by the The drugs are this the of patients with is manual in-line stabilisation by an After the patient has consciousness and the has an the airway is In patients, airway management is performed In cases, ventilation may be necessary to oxygenation despite the risk of (e.g. severe respiratory The of pressure is recommended on account of a of and of problems at the tube The cuff of the endotracheal tube or the airway (e.g. is after placement is and the is In out-of-hospital are to endotracheal tube placement for or and German standard that all must have for monitoring carbon This must be vital information ventilation and the placement of the tube or In carbon dioxide monitoring in than out-of-hospital Continuous capnography also can the or of the endotracheal As intubation can have correct tube placement must be using capnography This does rule out of the tube and can the correct from the to to Continuous standard monitoring must be during the of anaesthesia to monitor vital and to of and problems Out-of-hospital anaesthesia many be and and of or during induction or if the patient airway to must be Anaesthesia must be or must be and once anaesthesia is ventilation during sequence induction in is as is more than in 7 to of all of out-of-hospital BP measurement is, Patients with have an risk of with if necessary, The relevant drugs must be prepared anaesthesia is must be through appropriate should also be as a in patients who have In cases, drugs may In the of the treatment is to or using the and, on the and in and and Out-of-hospital anaesthesia a 14 to 12 higher risk of in and as well as than anaesthesia induced in sequence personnel should have an at all In out-of-hospital anaesthesia, in 5 to of all by a of in patients with injury In many cases, a and especially during sequence To ensure the patient should be may especially on account of or airway anaesthesia is should be that the can of if the does not the indications for anaesthesia induction must be critically a is the of personnel may to a this be the patient should be through a as an As a emergency must be performed of the airway to the DGAI recommendations for out-of-hospital airway management and In the operating the of a situation is This is higher in out-of-hospital may to the of a patient in a In clinical anaesthesia and during a to spontaneous breathing is an in This is if has been used, which has a of has been induced by can be for 3 to 4 which is than spontaneous from the of This and is not in the for out-of-hospital airway management and anaesthesia The management of difficult airways in the out-of-hospital also the for out-of-hospital airway management of the from a of tube the of airway management from ventilation to the of and, if required, to ensure sufficient The to the risk of an difficult airway is the of patients who have difficult this of a difficult airway a to induction of anaesthesia of these are the induction of anaesthesia should be critically In cases, a to the that anaesthesia must be should be if spontaneous breathing can be the patient should be to a in A of patient experienced anaesthesiologists to assess a difficult To intubation conditions in cases, the authors using a when anaesthesia, especially a to spontaneous breathing is only a if the indication is correct of difficult airway management The of in which primary endotracheal intubation is not is higher in out-of-hospital emergency medicine than in a As can be that out-of-hospital emergency patients have full alternative airway management must be performed if primary intubation is not It is to conditions and to an The and the patient in the with the on a an of the are for the of the correct placement of the endotracheal tube can be by intubation the risk of with each intubation the is (according to personnel must check has been this should be endotracheal intubation is not a and approach is necessary to and to the oxygenation SpO2 the first measure is with if required, also for patients with full the is difficult to intubation if can be in (e.g. should be if the level is not their the in airway can be to The of intubation is as high for the induction of anaesthesia in the operating and in out-of-hospital but the to ensure airway management is and in have been in the measures should emergency must be performed as a to ensure sufficient the and of this procedure personnel these must have sufficient and experience in the of and their 1.4 Anaesthesia for emergency trauma to the induction and management of emergency anaesthesia, important are in major trauma (e.g. patient in by and by with of oxygen with risk of airway management trauma patients often have by This can initially be for or by in or (e.g. in As many have the of may after the induction of anaesthesia. is is recommended that be to the induction of anaesthesia. As has only a on the is for emergency anaesthesia in patients. of (e.g. of may be of BP only to patients TBI who have from injuries. have that not only patients with TBI but also patients from trauma TBI when is Trauma patients often and In monitoring of oxygenation is only to a as pulse only measures of In that oxygen can be for the oxygen major trauma patients should be with 100% oxygen to the resuscitation and blood in with relevant should with medical respiratory 12 to 5 to a towards is associated with as a of of 1 1 to 1 with In are for with major trauma and 1: of in the of the recommended to adverse on the of the major trauma patient but induction of anaesthesia under full 2: which does not require in with to ensure intubation conditions and to pressure of or have and anaesthesia always the risk of the of the BP and the myocardial oxygen of the that a anaesthetic is the Table 7 shows a standard procedure for out-of-hospital emergency anaesthesia in of severe trauma and includes a of Emergency anaesthesia for injured Emergency anaesthesia is necessary for airway management in patients with a stroke or the of impaired of consciousness associated with an risk of and Table shows a standard procedure for out-of-hospital emergency anaesthesia in of stroke or and includes a of include the and the in a BP as well as the of and are important for anaesthesia in patients with a stroke or should be for in during the induction and, if required, should be by a syringe Emergency anaesthesia for patients with As a of cerebral BP is as a in of BP monitoring at is for this are to BP a of is to be the this critical can in of higher are more for an pressure of or a In an out-of-hospital is to cerebral and In the surrounding the cerebral blood is and is The of on and in BP should be by all in the A of and a of to are recommended for patients with patients a of are recommended to to and should be of an ICP (e.g. after anaesthesia an of anaesthesia (e.g. by or of or can be performed in with the recommended The patient Emergency anaesthesia may be necessary for a patient on account of (e.g. pulmonary or if a patient with a is in emergency (e.g. of oxygenation (e.g. with pulmonary the of NIV under must be for preoxygenation anaesthesia is in the of of a breathing patient should be should be to as and that have on the in and Table patients often require for during anaesthesia induction and during the of anaesthesia when has or should be for in during the induction and, if required, should be by a syringe Emergency anaesthesia for Patients with respiratory are many different patients with respiratory may require out-of-hospital emergency anaesthesia. The (e.g. oxygenation (e.g. pulmonary ventilation (e.g. Common risk in this group of patients are pulmonary and diseases, a associated with a of and ventilation are ventilation after appropriate and (e.g. may be during the preoxygenation and induction with a should be for anaesthesia should be when It is to induce anaesthesia using drugs (e.g. that not respiratory the respiratory and not to a of and should not be on account of their Emergency anaesthesia for patients with respiratory Drugs for emergency anaesthesia on the a of and are in rescue drugs are for and anaesthesia, the knowledge of these their and as well as patient should be Drugs with and for emergency anaesthesia are by a a of adverse and This an overview of the drugs most to induce and emergency anaesthesia. in of critically ill or severely injured patients as well as those with unstable cardiopulmonary drugs for anaesthesia should be or to to or to has a and has the most induction in from respiratory can also to a in BP to and reduction of cerebral pressure in case of are in patients. should be taken when patients with is for sequence This only been in patients with is as an alternative to anaesthesia in cerebral blood and leads to a reduction in including in of to the therapeutic of on and the It only be by experienced to the of or alternative is to anaesthesia. is not relevant to emergency medicine. Table an overview of the most important of has a and intubation conditions are of most in of using to induce in which is as to in of intubation and may and ventilation may be Table of a of in the and the associated in (e.g. respiratory multiple in ventilation ICU higher is the of The S3 guideline on treatment of major and the of the guideline on that the of should be In to the Eastern Association for the Surgery of Trauma is the of as an induction In of and the of review does not the of especially in the and their relevant on and which has not been the authors that the of can be in of anaesthetic As a with a of a therapeutic in the treatment of and and intubation conditions and in BP during sequence can be an alternative to as a to induce and anaesthesia in trauma patients. In has a than always be with or an overview of the most important of is a that has been to induce anaesthesia in emergency medicine for many This is by a and and of anaesthesia. to ICP (e.g. in trauma patients with or of and may in patients with management to the individual is recommended as a can be to provide relevant that must be is in cases, may to and are the of in emergency anaesthesia. have different of and The of include respiratory of the and and has been to perform out-of-hospital emergency anaesthesia, are This also to the indication during and or are not recommended for anaesthesia. can be for as well as anaesthesia induction and In can also be for the patient to respiratory Table This has the for can be as a and with a syringe has not been approved for as a intubation anaesthesia. of out-of-hospital is, a in emergency on the this can be for and for induction and of anaesthesia. causes anaesthesia, which is associated with and on the the protective reflexes and spontaneous breathing are not include and which with a to and may also patients who are or difficult to reach may from and based on and a spontaneous breathing and are in most It should be from the is with considerably different The most important of are in Table those of in Table is an of sequence induction and emergency anaesthesia management. 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