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Adequate analgesia is one of the most important measures of emergency care in addition to treatment of vital function disorders and, if indicated, should be promptly undertaken; however, a large proportion of emergency patients receive no or only inadequate pain therapy. The numeric rating scale (NRS) is recommended for pain assessment but is not applicable to every group of patients; therefore, vital signs and body language should be included in the assessment. Pain therapy should reduce the NPRS to5 points. Ketamine and fentanyl, which have an especially rapid onset of action, and also morphine are suitable for analgesia in spontaneously breathing patients. Basic prerequisites for safe and effective analgesia by healthcare professionals are the use of adequate monitoring, the provision of well-defined emergency equipment, and the mastery of emergency procedures. In a structured competence system, paramedics and nursing personnel can perform safe and effective analgesia.

In 2003 an article on the future of prehospital emergency medicine in Germany was published in the journal Der Anaesthesist. Emergency medicine in Germany, which at that time was almost exclusively defined as prehospital emergency rescue, has evolved and now in-hospital domains have increasingly moved into the focus. At that time, the primary goal was to connect prehospital management with a smooth transition to hospital admission and further care in the hospital and to further optimize the rescue chain from the actual emergency through to causative treatment. Now after 15 years, the authors have critically assessed the development postulated in 2003 and reevaluated it. Which aspects could be developed further and become firmly established, what is still open and which questions in preclinical and clinical emergency treatment of the population will occupy us in the coming 15 years? With a critical eye to the past, the present contribution aims to capture the essential and new topics and open questions and provide a fresh perspective for the future of emergency medicine. Regulation at the state level or even lower levels of government often stand in contrast to more sweeping and economically effective approaches at the federal level. Prehospital emergency medicine in Germany is on the whole well-positioned with respect to facilities and personnel; however, as far as the economic situation and the utilization of available systems are concerned, there is still substantial room for improvement.

Terrorist attacks have become reality in Germany. The aim of this work was, after the Würzburg terrorist attack, to define quality indicators and application characteristics for rescue missions in life-threatening situations. The results can be used to record data from future missions using this template in order to make them comparable with each other.After approval of the local ethic committee, the first step was to designate a group of experts in order to define the template in a consensus process. The next step was to perform the consensus process by defining the template. An independent expert for emergency medicine and disaster management reviewed and approved the results afterwards.The expert group defined 13 categories and 158 parameters that will further serve the systematic evaluation of the rescue mission of the Würzburg terror attack. Preliminary results of this evaluation process are given in this paper; the full evaluation has not yet been completed.In this study we first describe quality indicators and parameters suitable for the German rescue system in order to evaluate rescue operations for violence caused mass casualties. There is similar international documentation, but it does not specifically focus on life-threatening operations and are not adapted to the German context.There is an important need to systematically evaluate rescue missions after mass killing incidents. In this study we report a template of parameters and quality indicators in order to systematically evaluate mass violence events. The presented template is the result of an expert consensus process and may serve as a basis for further development and research.

In 2011 the first interdisciplinary S3 guideline for the management of patients with serious injuries/trauma was published. After intensive revision and in consensus with 20 different medical societies, the updated version of the guideline was published online in September 2016. It is divided into three sections: prehospital care, emergency room management and the first operative phase. Many recommendations and explanations were updated, mostly in the prehospital care and emergency room management sections. These two sections are of special interest for anesthesiologists in field emergency physician roles or as team members or team leaders in the emergency room. The present work summarizes the changes to the current guideline and gives a brief overview of this very important work.

Blast injuries may result from a variety of causes but the biomechanical impact and pathophysiological consequences do not differ between domestic or industrial accidents or even terrorist attacks. However, this differentiation relevantly affects the tactical procedures of the rescue teams. Focusing on further detonations, top priority is given to the personal safety of all rescue workers. The rareness of blast injuries in a civilian setting results in a lack of experience on the one hand but on the other hand the complexity of blast injuries to the human body places high demands on the knowledge and skills of the entire rescue team for competent treatment. The purpose of this article is to explain the physicochemical principles of explosions and to convey tactical and medical knowledge to emergency medical services.

Fragestellung und Ziel der Studie: Ziel der Arbeit ist, durch Messung des intramuskularen Sauerstoffpartialdrucks den kritischen Bereich des pneumatischen Drucks der Antischockhose (ASH) zu definieren, ab dem sich eine Muskelischamie an der unteren Extremitat entwickelt. Bei gleichzeitiger intrakompartimenteller Druckmessung sollte neben der Gewebeoxygenation auch die auf Druck empfindlich reagierende Impulsfortleitung im N. peronaeus profundus beurteilt werden. Methodik: Bei 22 normotensiven gesunden Freiwilligen wurden mit einem ASH-Beinsegment im M. tibialis anterior Druckwerte zwischen 0 und 100 mm Hg erzeugt. Uber einen Zeitraum von bis zu 6 h erfolgte die Messung des Muskelgewebedrucks, der Sauerstoffspannung und des Muskelsummenaktionspotentials (MSAP) des N. peronaeus profundus. Ergebnisse: Ausgangsdruckwert im M. tibialis anterior im Median 12,0 mm Hg (Q25%/Q75%: 8,9/17,3), pO2: 14,8 mm Hg (Q25%/Q75%: 11,5/22,0). Ubertragung des pneumatischen Drucks zu 97,7% (Q25%/Q75%: 89,2/99,8) auf den Extremitatenmuskel. Bereits bei niedrigen ASH-Druckwerten (20–40 mm Hg) trat im Einzelfall eine schwere Hypoxie auf. Eine Reduktion des MSAP war ab einem ASH-Druck von 10 mm Hg zu beobachten. ASH-Druckwerte von 60 mm Hg (n = 6) fuhrten in 5 Fallen innerhalb von 5–20 min zum Abfall des pO2 auf pathologische Werte. Inflationsdruckwerte uber 60 mm Hg resultierten nahezu ausnahmslos in einer Anoxie des Muskels und im Verlust des MSAP. Schlusfolgerungen: Der Einsatz der ASH sollte nur mit Modellen erfolgen, bei denen der Inflationsdruck manometrisch kontrolliert werden kann. Der ASH-Einsatz erscheint dann gerechtfertigt, wenn bei einem Polytraumatisierten im schweren hamorrhagischen Schock das Risiko einer sich auch systemisch auswirkenden lokalen Gewebeischamie bewust in Kauf genommen werden mus.

The general approach to the initial resuscitation of non-trauma patients does not differ from the ABCDE approach used to evaluate severely injured patients. After initial stabilization of vital functions patients are evaluated based on the symptoms and critical care interventions are initiated as and when necessary. Adequate structural logistics and personnel organization are crucial for the treatment of non-trauma critically ill patients although there is currently a lack of clearly defined requirements. For severely injured patients there are recommendations in the S3 guidelines on treatment of multiple trauma and severely injured patients and these can be modeled according to the white paper of the German Society of Trauma Surgery (DGU). However, structured training programs similar to the advanced trauma life support (ATLS®)/European resuscitation course (ETC®) that go beyond the current scope of advanced cardiac life support training are needed. The development of an advanced critically ill life support (ACILS®) concept for non-trauma critically ill patients in the resuscitation room should be supported.

Trauma is the leading cause of death in the patient group under 40 years of age. Within the prehospital management of seriously injured trauma victims the accuracy of the field triage by emergency physicians is of utmost importance.The aim of this study was to determine the accuracy of prehospital emergency physician field triage in road traffic accident victims.The study involved a retrospective analysis and comparison of prehospital and inhospital trauma records of road traffic accident victims treated by a Helicopter Emergency Medical Service (HEMS) team and transferred to a level I trauma centre. A comparison of prehospital and inhospital diagnostic findings was carried out according to an anatomical score (AIS).Included in the analysis were 479 patients with a mean age of 37.0 ± 18.2 years, males 65.8 %, mean injury severity score (ISS) 15.5 ± 13.5, ISS 16 in 41,1 % and mortality 7.3 %. The leading causes of injury were motor vehicle accidents (56.2 %), followed by motorcycle (24.0 %) and bicycle accidents (11.6 %) as well as truck accidents (4.0 %) and pedestrian accidents (4.2 %). The most common body regions injured (AIS ≥ 3) were the chest (37 %), head (25.1 %) and lower extremities (16.7 %). A correct prehospital field triage by emergency physicians was found for injuries with an AIS ≥ 3 of the head 77 %, chest 69 %, abdomen 51 %, pelvis 49 %, extremities 70 %, neck/cervical spine 67 % and thoracic/lumbar spine 70 %. Overlooked injuries in the prehospital setting (AIS ≥ 3) comprised predominantly injuries of the trunk (chest 12.6 %, abdomen 16.9 % and pelvis 15 %). Overlooked injuries were found significantly less for the head in patients with a Glasgow Coma Score ≤ 8 on arrival at the scene (5.4 % versus 19 %, p = 0.015), for the chest in patients with a S(p)O(2) ≤ 96 % on arrival at the scene (18.1 % versus 35.5 %, p = 0.004) and for the abdomen in patients with a systolic blood pressure 90 mmHg on arrival at the scene (28.6 % versus 52.5 %, p = 0.025).Accurate field triage in seriously injured road accident victims, even by trained physicians, is difficult. This pertains especially to injuries to the abdomen and the pelvis. For the field triage a combination of anatomical and physiological criteria as well as the mechanism of injury should be used to increase accuracy.

In emergency medicine intraosseous access (IOA) has been established as an alternative to conventional intravenous access. Originally the use of IOA was strictly limited to children up to 6 years of age and to adults for cardiopulmonary resuscitation. These limitations have been relaxed and the indications for IOA have been expanded.A retrospective nationwide analysis of rescue missions by all helicopter emergency medical services of the German Automobile Club (ADAC) Air Rescue Service as well as the German Air Rescue (DRF) over a 7-year period was carried out.A total of 466,813 patients were treated during the study period and an IOA was established in 1,498 (0.32 %) patients. There was a significant increase in using an IOA from 0.1-0.5 % (p 0.05) from 2005 to 2011. Furthermore, there was an increase in using an IOA in elderly patients and in patients with lower degrees of severity according to the National Advisory Committee for Aeronautics (NACA) scales (2005-2011): decreased use of IOA in patients up to 6 years of age from 92.4 % to 19.7 % (p 0.05) and in patients with NACA grades VII/VI from 74.4 % to 46.6 % (p 0.05) and temporarily limited increase of non-indicated IOA use in patients with NACA grade III between 2008 and 2010. Furthermore, there was an increase in the number of the different drug groups used for intraosseous infusion over the study period.The current guidelines and recommendations for the use of IOA in the prehospital setting are reflected more and more in mission reality for helicopter emergency medical services.

Adequate prehospital and inhospital primary care is a decisive factor in the successful treatment of multiple trauma patients. For optimization of treatment algorithms the implementation of a medical quality management is of utmost importance. The aim of this study was to extend quality management by including data on process quality.A retrospective study of primary rescue missions of the Helicopter Emergency Medical Service (HEMS) Christoph 22 in Ulm over a period of 2.5 years was performed. In a detailed analysis of filter criteria, in which relevant deviations from the recommendations (not fulfilled in 10% of the cases) occurred, process data was included (vital data, measurements and events).In the study population (n = 298, males 71.8%, mean age 39.8 ± 21.8 years) 2 filter criteria were identified in which relevant deviations where observed: time management where prehospital treatment time ≤ 60 min in 36% of the cases was not fulfilled and circulatory management where the systolic blood pressure, detected with Riva-Rocci method (RR(sys)) ≥ 120 mmHg on hospital admission in patients with severe head trauma was not fulfilled in 45% of the cases. In patients with deviations in time management, prehospital treatment time was prolonged (75.6 ± 18.3 min versus 50.5 ± 6.7 min; p0.01) caused by a prolonged on scene attendance time (34.1 ± 22.1 min versus 20.6 ± 9.2 min; p0.01) and transport time (17.3 ± 9.4 min versus 13.3 ± 4.8 min; p0.01). In entrapment trauma prehospital treatment time was expanded (44% versus 10%; p0.01). Patients in whom circulatory management deviations were observed were more often in shock on arrival at the scene (RR(sys) ≤ 90 mmHg: 60% versus 30%; p0.01), more often hypoxemic [pulse oximeter oxygen saturation (S(p)O(2)) ≤ 90%: 36% versus 19%; p0.05] and more often sustained a trauma to the chest as well as to chest and abdomen/pelvis (69% versus 52% and 42% versus 28%, respectively; p0.05). Furthermore, the infusion volume of colloids was higher (1241 ± 810 ml versus 753 ± 359 ml; p0.05) and the combined usage of small volume resuscitation and catecholamines was more often necessary (42% versus 25%; p0.05).Including process data of prehospital mission data recording facilitates an extended medical quality management.

Intraosseous infusion has become established as a fast and safe alternative to conventional vascular access in emergency situations. Originally the use of intraosseous access was limited to children up to 6 years of age and to adults for cardiopulmonary resuscitation but this limitation has now been removed. The aim of this study was to obtain data on mission reality regarding the use of intraosseous access in the prehospital setting against the background of the expanded recommendations on the use of the intraosseous infusion.An analysis of rescue missions by all rescue helicopters of the ADAC (German Automobile Club) Air Rescue as well as the German Air Rescue Service (58 helicopter emergency medical service bases) over a 4 year period from January 2005 to December 2008 was carried out.A total of 247,454 rescue missions were carried out during the study period and in 525 patients (0.2% of the total study collective) an intraosseous access was established. There was a significant increase in the intraosseous infusion rate from 0.1% to 0.4% (p0.05). Furthermore, there was a significant increase in its use in elderly patients and in patients with lower National Advisory Committee for Aeronautics (NACA) scores (2005 vs. 2008): 92.4% vs. 42.9% of all intraosseous infusions in patients ≤ 6 years of age (p0.05) and 74.4% vs. 42.9% of all intraosseous infusions in patients with NACA score VI/VII (p0.05). The proportion of trauma patients in the total study collective was 33% and there was no significant change in the frequency of trauma cases over the study period but there was a remarkable increase of intraosseous infusions in trauma patients in the last year of the study period compared to the previous years (38% in 2008 vs. 27-30% in 2005-2007). Furthermore, there was an increase in the number of different drug groups used for intraosseous infusion over the study period.The expanded indication recommendations for the use of intraosseous infusion in the prehospital setting enter more and more mission reality in air rescue services in Germany.

The aim of this study was to examine whether it is possible to perform resuscitation according to the present European Resuscitation Council (ERC) guidelines with a modified algorithm in the case of special, e.g. military, circumstances. On international missions of the German Armed Forces a rescue team only consists of an emergency physician and a paramedic. As the German Armed Forces require the same means of medical aid for all soldiers on every type of mission worldwide the algorithm must meet the ERC requirements.In the study 20 medical teams specialized in resuscitation were examined. Of these teams 10 were from the German Armed Forces (the physician is a certified emergency physician) and 10 were civilian (the emergency physicians had up to 28 years experience). Each team was monitored as they performed resuscitation on a simulator for a period of 10 min. The patient's airway was secured by a laryngeal tube (LT) and over-the-head chest compressions were performed by the emergency physician. During resuscitation both team members held their position. In addition to comparing all results to the ERC guidelines both groups were analyzed separately and compared to each other.The median time needed for securing the airway was 17 s without any differences between the 2 groups. In 75% of the cases the time needed for successfully securing the airway on the first attempt was less than the allowed 30 s. In 5 cases (25%) the teams did not manage to successfully install the LT during the first attempt (4 failed attempts were performed by civilian teams and 1 by the military emergency teams); however, all 5 teams were successful at the second attempt. In the cases where the placement of the LT was not successful at the first attempt the time required for the final and successful placement was nevertheless less than 40 s. During the 10 min resuscitation procedure the hands-off fraction was on average 22.4%. No differences between the two groups were noted concerning the hands-off time (133.5 s for the civilian teams and 134.5 s for the teams of the German Armed Forces). The frequency of chest compressions was above the required 100/min (for the civilian teams 110/min and for the teams of the German Armed Forces 116.5/min).During military missions of the German Armed Forces there are no other options to perform resuscitation than by performing this procedure with only two rescuers. Using the algorithm in a modified way securing of the airway with an LT, the performance of over-the-head chest compressions and an effective resuscitation with advanced cardiac life support according to the ERC guidelines of 2005 are feasible even with 2 rescuers. Using the LT instead of endotracheal intubation to secure the airway particularly contributed to shortening the hands-off time.

In Germany only 2-9% of rescue missions performed by emergency physicians are pediatric emergencies. Therefore, an emergency physician has to deal with a pediatric emergency on average every 1.1-1.3 months. There are only a few studies in the literature evaluating the frequency of "invasive" techniques and procedures (e.g. vascular access, endotracheal intubation, alternative airway techniques and insertion of chest tube) in pediatric patients in the prehospital setting performed by German emergency physicians. The purpose of this study was to evaluate the frequency of these kinds of procedures in pediatric emergencies in the field of the Helicopter Emergency Medical Service (HEMS).Evaluation of pediatric emergencies (defined as18 years of age) over a 4 year period at the Helicopter Emergency Medical Service (HEMS) was carried out retrospectively.During the study period 5,826 rescue missions (4,778 primary rescue missions, 571 inter-hospital transfers and 461 others) were completed. A total of 643 (11%) pediatric emergency patients were treated by the HEMS team. Out of this pediatric study group 16.3% had an initial Glasgow Coma Score (GCS)9 and 59.3% were rated IV-VII on the National Advisory Committee of Aeronautics (NACA) scale. Within the pediatric study group children 1-5 years of age and children 14-17 years of age were predominant (29.2% and 25.8%, respectively). Regarding the whole pediatric study group trauma was predominant (57.9%). In children1 year of age and children 1-4 years of age, non-traumatic emergencies were predominant (84.2% and 56.9%, respectively), whereas in children 6-9 years of age, 10-13 years of age and 14-17 years of age, traumatic injuries were predominant (64.2%, 74.8% and 72.3%, respectively). Non-invasive standard monitoring by ECG (electrocardiogram), blood pressure (RR) and pulse oximetry (S(p)O(2)) was established in more than 75% of the pediatric patients (ECG: 77.0%, RR: 81.5%, S(p)O(2): 96.7%) and the older the children the more monitoring was established (children1 year of age: ECG: 47.4%, RR: 36.8%, S(p)O(2): 93.0% vs. children 14-17 years of age: ECG: 89.8%, RR: 98.2%, S(p)O(2): 100.0%). Regarding the whole pediatric study group, vascular access was established in 81.5% of the cases and in 2.5% of the cases as intraosseous infusion. Out of a total of 16 intraosseous infusions performed within the study period 14 (87.4%) were performed in children6 years of age. In 20.7% of the cases an endotracheal intubation was performed and in 92.5% of these cases induction of anaesthesia was necessary. The insertion of a chest tube within the study period was only necessary in 1.2% of the cases.Compared to the results of other studies the number of pediatric emergency patients with a NACA score IV-VII in this study is very high. Furthermore, the percentages of non-invasive monitoring procedures applied to the patients as well as invasive therapeutic procedures performed by the HEMS team were also high. Therefore, a special pediatric training course for emergency physicians seems to be necessary.

With the assistance of digital pen and paper technology in the field of prehospital data reporting, it seems to be possible to fulfill the requirements of "documentation" as well as the requirements of "quality management". The aim of this study was to determine the "primary documentation quality" (PDQ) of a data reporting system based on digital pen and paper technology (so-called DINO) within a helicopter emergency medical service (HEMS) over a 6-month period.The PDQ is defined as the proportion of prehospital documented data, which is primarily recorded correctly by the data reporting system. For the national uniform core dataset (so-called MIND2) the PDQ was 96.7%, for "checkbox" and "numeric data fields" the PDQ was 99.8% and 93.6%, respectively and for "vital data" the PDQ was 96.7% [heart rate (HF), measurement of blood pressure] and 84.1% [peripheral oxygen saturation (S(p)O2), end tidal carbon dioxide concentration (etCO2), oxygen administration (O2)]. For "measurements" the PDQ was 96.9% (time stamps) and 86.9% (time frames), for "drugs" the PDQ was 43.6% (drug name) and 69.8% (drug dosage) and for"placement of infusion" 42% (infusion name) and 85.3% (infusion time), respectively. The average time for the "verification process" after mission completion was 1.5+/-0.4 min/mission.The "primary documentation quality" of prehospital mission data reporting with the assistance of a digital pen and paper based documentation system (DINO) has been shown to completely fulfill the requirements of rapid and safe data documentation in actual missions, even at this early stage of development.

While fluid management is established in controlled hemorrhagic shock, its use in uncontrolled hemorrhagic shock is being controversially discussed, because it may worsen bleeding. In the irreversible phase of hemorrhagic shock that was unresponsive to volume replacement, airway management and catecholamines, vasopressin was beneficial due to an increase in arterial blood pressure, shift of blood away from a subdiaphragmatic bleeding site towards the heart and brain and decrease of fluid resuscitation requirements. The purpose of this multicenter, randomized, controlled, international trial is to assess the effects of vasopressin (10 IU IV) vs. saline placebo IV (up to 3 injections at least 5 min apart) in patients with prehospital traumatic hemorrhagic shock that persists despite standard shock treatment. The study will be carried out by helicopter emergency medical service teams in Austria, Germany, Czech Republic, Portugal, the Netherlands and Switzerland. Inclusion criteria are adult trauma patients with presumed traumatic hemorrhagic shock (systolic arterial blood pressure90 mmHg) that does not respond to the first 10 min of standard shock treatment (endotracheal intubation, fluid resuscitation and use of vasopressors) after arrival of the first emergency physician at the scene. The time window for randomization will close after 30 min of shock treatment. Exclusion criteria are terminal illness, no intravenous access, age18 years, injury60 min before randomization, cardiac arrest before randomization, presence of a do-not-resuscitate order, untreated tension pneumothorax, untreated cardiac tamponade, or known pregnancy. Primary study end-point is the hospital admission rate, secondary end-points are hemodynamic variables, fluid resuscitation requirements and hospital discharge rate.

The intraosseous puncture (IO) is a fast and safe alternative to the puncture of peripheral veins in emergency situations in childrenor =6 years of age. The purpose of this paper is to summarize 10 years of experience on the prehospital use of the IO method by the Helicopter Emergency Medical Service (HEMS) "Christoph 22", Ulm.This was a retrospective study from 1 January 1996 to 31 December 2005.Out of a total of 9,549 missions, the proportion of children was 11.1%. In 27 children (4.2% of the childrenor =6 years of age) an IO puncture was performed. Patients of the IO group were younger (1.0 vs. 3.7 years of age; p0.001) and showed a higher degree of injury severity (NACA 6 vs. 4; p0.001) compared to the total children group. In all children of the IO group (100%), the intraosseous puncture was the method of first choice to obtain access to the vascular system by the HEMS team. In 96.4% of these cases (26/27), the first IO puncture attempt was successful - in one child, a second puncture attempt was necessary. A standardized puncture technique was performed using the proximal tibia. The time required for successful placement of the IO infusion line was 60 s or less in all cases. In 37% of the cases (10/27) the IO infusion line was used for induction of general anaesthesia; dosage and onset of administered drugs were described as being equivalent to a peripheral infusion line. In all cases, the IO needle was replaced in-hospital within 2 h by a central or peripheral iv line. No complications were observed.The IO infusion technique is a simple, fast and safe alternative method for emergency access to the vascular system in childrenor =6 years of age in the prehospital setting.

Approximately 8000 patients with multiple trauma are admitted annually to an emergency room in Germany. The prognosis of these severely injured patients is influenced in particular by concomitant craniocerebral injury, an abdominal wound, or thoracic trauma. Hypoxia and hypotension subsequent to shock induced by hemorrhagic-traumatic effects are of prime importance. Preclinical management thus includes examining the injured patient, immobilizing the spine, ensuring airway patency, stabilizing cardiovascular status suitting the approach to the injury pattern, commensurate care of partial injuries, pain therapy, as well as rapid and careful transportation to the nearest qualified trauma center. Management of patients with multiple trauma poses a particular challenge to the responding team. This article in the continuing education series deals with current algorithms for preclinical management of patients with multiple injuries with particular focus on the significant factor of time.

Against the background of an ever-increasing shortage of financial support, closure of smaller hospitals and shortage of personnel in the medical branch, the necessity of the Federal emergency system is being increasingly called into question. In reality the number of missions which are relatively indicated are clearly increasing nationwide: an emergency doctor is not absolutely necessary in many situations. However, for complex emergency situations in Germany, an emergency medical system must remain an integral component of the preclinical care system in addition to the well-trained rescue service personnel. Hereby it is less important to have more emergency medical doctors, but more important to have a higher emergency medical qualification, possibly by a reduction in the density of emergency service stations. By the introduction of a ranked assistance system and the inclusion of "first responders", the time period before the arrival of the highly qualified emergency medical doctor can be bridged by qualified paramedics and general practitioners. The impulse of the legislators, assimilation of the rescue service acts, restructuring of rescue service catchment areas and the introduction of integrated demand-oriented control stations with a consequent quality management system as well as the implementation of a medical leader rescue system can reduce costs and further improve the quality of the emergency medical rescue system.

The aim of the study was a demonstration of peculiarities of two invasive airway management methods performed by anesthesiology residents as a subgroup of emergency physicians.During an airway management training seminar,2 groups including 18 anaesthesiology residents and 2 students performed a simulated emergency surgical cricothyrotomy on unfixed cadavers. The more experienced physicians in group 2 started with a puncture technique preceding a blind surgical approach. The time needed to perform each procedure and resulting complications were analyzed.The time taken ranged from 75 to 280 s (median 180 s) in group 1 and from 53 to 255 s (median 73 s) in group 2. The surgical approach caused "bleeding" in 40% (group 1) and 30% (group 2) and damage to the cartilages occurred in 20% and 30%, respectively. Punctures were performed within 10-36 s (median 25 s) and 70% were successful without complications.Puncture of the cricothyroid membrane can serve as initial emergency approach or as intermediate airway access until a surgical method is available.

The aim of the study was to assess, whether the pneumatic pressure of an antishock-trouser (AST) of 20-40 mm Hg induces a decreased oxygenation of the anterior tibial muscle and attenuates muscular response potential (MRP) of n. peronaeus profundus?Among 22 normotensive, healthy volunteers the AST were tested by applying pressure values between 0 and 100 mm Hg and measuring the intracompartmental pressure, the muscular oxygen pressure as well as the MRP by electroneurographic means within a period of 6 hours.The median initial intracompartmental pressure value of the m. tibialis anterior was 12.0 mm Hg (Q25%/Q75%: 8.9/17.3), the muscular oxygen pressure 14.8 mm Hg (Q25%/Q75%: 11.5/22.0). Transmission of the pneumatic AST-leg segment pressure to the muscle: 97.7% (Q25%/Q75%: 89.2/99.8). Already in the low AST pressure field (20-40 mm Hg) a severe hypoxia occurred in one case. A reduction of MRP was noticed at an AST pressure rate of 10 mm Hg. In 5 of 6 cases AST pressure values of 60 mm Hg led to pathological pO2-values within 5-20 minutes. Almost without exception AST-pressure rates60 mm Hg resulted in an anoxia of the muscle and loss of the MRP.We should demand that the AST are only applied with models where the pressure generated within the single segments can be controlled by pressure gauge. The application of the AST seems to be justified for polytraumatised in severe haemorrhagic shock where the risk of a local tissue ischemia with systemical consequences must deliberately be accepted.

In prehospital emergency treatment, the timely establishment of a secure vascular access, especially in infants and small children, can be difficult or even impossible. An alternative to the puncture of peripheral or central veins is intraosseous (IO) puncture However, experience with this method in prehospital emergency medicine within the Federal Republic of Germany is extremely limited at present. After intensive theoretical and practical training of our trauma anaesthesiologists, IO puncture was introduced in our rescue helicopter program "Christoph 22" as an alternative to peripheral or central venous puncture in the prehospital treatment of patients up to 6 years of age. IO puncture is indicated after a maximum of three failed peripheral venous puncture attempts. The purpose of this study was to collect data and summarise first-hand experience on the prehospital use of the IO method as well as the practicability of our prescribed IO puncture algorithm in order to subject them to critical review and evaluation.A restrospective study by the rescue helicopter service "Christoph 22" was carried out for the period 1 June 1993-31 August 1995.In a total of 1,455 primary rescue missions flown, the proportion of patientsand = 6 years of age, was 6.2% (n = 90). Ten patients in this partial collective (11.1%) were subjected to IO puncture (Fig. 3). In all of these cases (10/10), the first IO puncture attempt was successful. A standardized puncture technique was performed using the proximal tibia. The time required to successful placement of the IO infusion line wasand = 60 s in all cases. Complications, especially incorrect needle position, did not occur during the study period. Materials infused by IO infusion before hospitalisation included crystalloids (Lactated Ringer's, Päd OP) as well as colloids (hydroxyethylstarch, human albumin), adrenaline, atropine, ketamine, thiopentone, diazepam, fentanyl, succinylcholine, and vecuronium (Table 3). Prehospital induction of general anaesthesia using the IO infusion line was required by 2/10 children; dosage and onset of administered drugs was described by the trauma anaesthesiologists as being similar to that using an i.v. infusion line. Seven of the patients had been treated prior to the arrival of the rescue helicopter team by other emergency medical personnel; in all of these cases multiple peripheral and in 3 additional central venous puncture attempts had failed (duration of attempts: 10-50 min). Upon arrival of the rescue helicopter, 5 of these patients had been pulseless and non-breathing (Table 2).The IO infusion technique has proven to be a simple, fast, and safe alternative method of emergent access to the vascular system.

Trauma patients are at great risk of accidental hypothermia (body temperature [BT]36 degrees C). Hypothermia influences the functioning of all organ systems and can lead to pathological changes, which in turn additionally complicate the trauma. Furthermore, hypothermia can, e.g., by influencing blood coagulation (reduction of thrombocyte aggregation, increased fibrinolysis) have a markedly unfavourable impact upon the in-hospital surgical treatment of the trauma patient. In a prospective study involving 302 trauma patients treated during primary helicopter rescue missions over a 1-year period, we studied the following factors: (1) incidence and degree of severity of hypothermia; (2) seasonal influence; (3) possibility of individual risk groups within the study group; (4) changes in BT during the prehospital treatment phase; and (5) their consequences for emergency treatment. METHOD. BT was taken upon commencement of emergency treatment and upon release of the patient to the receiving hospital. To avoid possible damage to the patient's tympanic membrane by the thermometer probe, we excluded all patients under 16 years of age and those with an indication of an ear or temporal-bone injury. In all cases standardized patient positioning was applied. The statistical evaluation was performed utilizing descriptive presentations and the Mann-Whitney U test and chi-square test. RESULTS. During study period, a total of 302 trauma patients were treated. On 228 of these, prehospital temperature monitoring was performed (151 males and 77 females, average age 41.8 years). Because of the established criteria for exceptions and equipment malfunction, no monitoring was performed on 74 patients. Traffic accidents (69%) were the major cause of injury (Table 2), predominantly the group with NACA III (32%), followed by NACA IV (22%) and NACA V (18%) (Table 3); 27% had multi-system trauma. BT monitoring disclosed that 49.6% or almost every second trauma patient, had hypothermia. The proportion of hypothermia II degrees (BT 34 degrees-30 degrees C) versus hypothermia III degrees (BT30 degrees C) was 6.6% to 0.5%. Our statistical evaluation did not disclose any significant connection between season of the year and frequency of accidental hypothermia. Special risk factors in regard to frequency and degree of severity turned out to be "entrapment" (98.1% of patients with an entrapment trauma [ET] versus 34.5% without such; P0.001) and age (56.8% of patients65 years of age without ET and 100% with ET; P0.001) (Figs. 2, 3). No significant changes in BT were noted during the prehospital treatment phase. Clinical symptoms pointing to hypothermia or other indicators, i.e., shivering, were only noted in 4.4% of the cases where the patients BT was below normal. CONCLUSION. Based upon our findings, accidental hypothermia poses a relevant problem in the prehospital treatment of trauma patients. It is not limited to a special season of the year. The variability or total absence of definite diagnostic symptoms underlines the necessity for prehospital BT monitoring, whereby tympanic-membrane thermometry has proven to be a worthwhile method.