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Abstract: Aims: To review anaesthesia in prehospital emergencies and in the emergency room, and to discuss guidelines for anaesthesia indication; pre-oxygenation; anaesthesia induction and drugs; airway management; anaesthesia maintenance and monitoring; side effects and training. Methods: A literature search in the PubMed database was performed and 87 articles were included in this non-systematic review. Conclusions: For pre-oxygenation, high-flow oxygen should be delivered with a tight-fitting face-mask provided with a reservoir. In haemodynamically unstable patients, ketamine may be the induction agent of choice. The rocuronium antagonist sugammadex may have the potential to make rocuronium a first-line neuromuscular blocking agent in emergency induction. An experienced health-care provider may consider prehospital anaesthesia induction. A moderately experienced health-care provider should optimise oxygenation, fasten hospital transfer and only try to intubate a patient in extremis. If intubation fails twice, ventilation should be resumed with an alternative supra-glottic airway or a bag-valve-mask device. A lesser experienced health-care provider should completely refrain from intubation, optimise oxygenation, fasten hospital transfer and only in extremis ventilate with an alternative supra-glottic airway or a bag-valve-mask device. With an expected difficult airway, the patient should be intubated awake. With an unexpected difficult airway, bag-valve-mask ventilation should be resumed and an alternative supra-glottic airway device inserted. Senior help should be called early. In a “can-not-ventilate, can-not-intubate” situation an alternative airway should be tried and if unsuccessful because of severe upper airway pathology, a surgical airway should be performed. Ventilation should be monitored continuously with capnography. Clinical training is important to increase airway management skills. [Copyright &y& Elsevier]

Abstract: Aim: Ventilation of a non-intubated emergency patient by inexperienced rescuers with a standard bag-valve device may result in high inspiratory flow rates and subsequently high airway pressures with stomach inflation. Therefore, a self-inflating bag has been developed that requires lay rescuers to blow up a single-use balloon inside an adult bag-valve device, which, in turn, displaces air within the bag towards the patient. This concept has been compared to standard adult bag-valve devices earlier in bench models but not in patients. Methods: An anaesthetist who was blinded to all monitor tracings ventilated the lungs of 40 apnoeic patients during routine anaesthesia induction either with a standard bag-valve device or with the mouth-to-bag resuscitator in a random order. Study endpoints were peak inspiratory flow rates, peak airway pressure, tidal volumes and inspiratory time. Results: Peak inspiratory flow was 40±10lmin−1 for the standard bag-valve device versus 33±13lmin−1 for the mouth-to-bag resuscitator (P <0.0001); peak airway pressure was 17±5cmH2O versus 14±5cmH2O (P <0.0001); inspiratory tidal volume was 477±133ml versus 644±248ml (P <0.001) and inspiratory time was 1.1±0.3s versus 1.9±0.6s (P <0.0001). Conclusion: Employing the mouth-to-bag resuscitator during simulated ventilation of a non-intubated patient in respiratory arrest significantly decreased peak inspiratory flow and peak airway pressure and increased inspiratory tidal volume and inspiratory times compared to a standard bag-valve device. [Copyright &y& Elsevier]

Abstract: Aims: Inexperienced health-care-providers may encounter severe problems to ventilate an unconscious child. Designing a ventilating device that could indicate how to open an upper airway correctly may be beneficial. Neutral position in young children and slight head extension in older children is recommended, although the optimal head angle is not clear. Thus, we compared effects of neutral head position and extension, measuring head-position angles and ventilation parameters. Methods: Sixty-one children scheduled for tonsillectomy were enrolled, and were ventilated with pressure-controlled ventilation after anaesthesia induction. Results: Children were divided into two groups: 1–5 years old (pre-school children, n =38) and 6–10 years old (school children, n =23). In neutral (mean±SD: 1.3±6.0) vs. head-extension position (13.2±6.0; P <0.001) in pre-school children, tidal volumes (132±44,137±49ml), peak-expiratory flow (300±90 vs. 310±100mls−1) and expiratory airway resistance (20±8 vs. 18±6cmH2Osl−1) were comparable (P =NS). In neutral (−0.4±5.4) vs. head-extension position (15.7±6.4; P <0.001) in school children, expiratory airway resistance (17±7 vs. 13±5cmH2Osl−1; P =0.048) differed, while tidal volume (224±93 vs. 230±92ml) and peak-expiratory flow (427±181 vs. 381±144mls−1) were comparable (P =NS). Conclusions: Head-extension and neutral head-position angles differed in pre-school and school children. In pre-school children, neutral head position or head extension with an angle of −1° or 13°, and in school children head extension of 16°, may be used to achieve optimal ventilation of an unprotected airway. [Copyright &y& Elsevier]

Abstract: Introduction: In a model of severe simulated upper airway haemorrhage, we compared two techniques of performing endotracheal intubation: (1) suctioning via the endotracheal tube during laryngoscopy with subsequently advancing the endotracheal tube, and (2) the standard intubation strategy with performing laryngoscopy, and performing suction with subsequently advancing the endotracheal tube. Methods: Forty-one emergency medical technicians intubated the trachea of a manikin with severe simulated airway haemorrhage using each technique in random order. Results: There was no significant difference in the number of oesophageal intubations between suctioning via the tube and the standard intubation strategy [8/41 (20%) vs. 6/41 (15%); P =0.688], but suctioning via the endotracheal tube needed significantly more time [median (IQR, CI 95%): 42 (20, 39–60) vs. 33 (15, 35–48)s; P =0.015]. Conclusions: Suctioning via the endotracheal tube showed no benefit regarding the number of oesophageal intubations and needed more time when compared to the standard intubation strategy. [Copyright &y& Elsevier]

Abstract: Background: In North America and Europe ∼150 persons are killed by avalanches every year. Methods: The International Commission for Mountain Emergency Medicine (ICAR MEDCOM) systematically developed evidence-based guidelines and an algorithm for the management of avalanche victims using a worksheet of 27 Population Intervention Comparator Outcome questions. Classification of recommendations and level of evidence are ranked using the American Heart Association system. Results and conclusions: If lethal injuries are excluded and the body is not frozen, the rescue strategy is governed by the duration of snow burial and, if not available, by the victim's core-temperature. If burial time ≤35min (or core-temperature ≥32°C) rapid extrication and standard ALS is important. If burial time >35min and core-temperature <32°C, treatment of hypothermia including gentle extrication, full body insulation, ECG and core-temperature monitoring is recommended, and advanced airway management if appropriate. Unresponsive patients presenting with vital signs should be transported to a hospital capable of active external and minimally invasive rewarming such as forced air rewarming. Patients with cardiac instability or in cardiac arrest (with a patent airway) should be transported to a hospital for extracorporeal membrane oxygenation or cardiopulmonary bypass rewarming. Patients in cardiac arrest should receive uninterrupted CPR; with asystole, CPR may be terminated (or withheld) if a patient is lethally injured or completely frozen, the airway is blocked and duration of burial >35min, serum potassium >12mmolL−1, risk to the rescuers is unacceptably high or a valid do-not-resuscitate order exists. Management should include spinal precautions and other trauma care as indicated. [Copyright &y& Elsevier]

Abstract: Introduction: We developed a suction laryngoscope, which enables simultaneous suction and laryngoscopy in cases of airway haemorrhage and evaluated its potential benefits in physicians with varying emergency medical service experience. Methods: Eighteen physicians with regular and 24 physicians with occasional emergency medical service experience intubated the trachea of a manikin with severe simulated airway haemorrhage using the suction laryngoscope and the Macintosh laryngoscope in random order. Results: In physicians with regular emergency medical service experience, there was neither a difference in time needed for intubation [median (IQR, CI 95%)]: 34 (18, 30–46) vs. 34 (22, 30–52) s; P =0.52, nor in the number of oesophageal intubations [0/18 (0%) vs. 3/18 (16.7%); P =NS] when using the suction vs. the Macintosh laryngoscope. In physicians with occasional emergency medical service experience, there was no difference in time needed for intubation [median (IQR, CI 95%)]: 42 (25, 41–57) vs. 45 (33, 41–65) s; P =0.56, but the number of oesophageal intubations was significantly lower when using the suction laryngoscope [4/24 (16.7%) vs. 12/24 (50.0%); P =0.04]. Conclusions: In a model of severe simulated airway haemorrhage, employing a suction laryngoscope significantly decreased the likelihood of oesophageal intubations in physicians with occasional emergency medical service experience. [Copyright &y& Elsevier]