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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]