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Background In unconscious patients in the supine position, the loss of soft tissue tension results in obstruction of the upper airway. Unexperienced rescuers may be unable to perform efficient bag–valve–mask ventilation due to difficulties in detecting the optimal head position to open the airway. If the ventilation mask were to indicate an optimized head position to the rescuer, bag–valve–mask ventilation could possibly be optimized. Methods A digital sensor was attached to a face mask to measure the degree of head reclination. We attached this face mask to an airway trainer and sealed the mask to its face with tape; the airway trainer was connected to a test lung and ventilated in a pressure-controlled mode by a standard anesthesia machine (Pmax 10 mbar, PEEP 0 mbar, F 12/min). Its head was extended starting from the neutral position to 42 degrees in steps of 2 degrees. The primary endpoints were the correlation of preset angles and our face mask’s digitally measured head position angles. We further evaluated the tidal and minute ventilation volume depending on head reclination. Results The preset head position angles correlated significantly (R2 = 0.9895855684; PConclusion Digital head position angle measurement correctly detected the head position in this study. A signal in a face mask could be a helpful tool to indicate to first responders or relatively inexperienced rescuers the optimized head position during emergency ventilation.

Ventilation with positive end-expiratory pressure (PEEP) may result in decreased venous return to the heart and therefore decrease cardiac output. We evaluated the influence of PEEP ventilation on arterial blood pressure in the field in 296 posttraumatic intubated patients being treated by a helicopter emergency medical service in a retrospective cohort study. Initial systolic blood pressure on the scene, upon hospital admission and their mean difference were compared between patients being ventilated with no/low PEEP (0-0.3 kPa) and moderate PEEP (0.3-1 kPa). In a subgroup analysis of initially hemodynamic unstable patients (systolic blood pressure80 mmHg), systolic blood pressure was compared between patients being ventilated with no/low or moderate PEEP Further, the mean difference between initial systolic blood pressure and upon hospital admission was correlated with the chosen PEEP. Systolic arterial blood pressure of patients being ventilated with no/low PEEP improved from 105 ± 36 mmHg to 112 ± 38 mmHg, and that of patients being ventilated with moderate PEEP improved from 105 ± 38 mmHg to 119 ± 27 mmHg. In initially unstable patients being ventilated with no/low PEEP systolic blood pressure improved from initially 55 ± 36 mmHg to 78 ± 30 mmHg upon hospital admission, and in those being ventilated with moderate PEEP, the systolic blood pressure improved from 43 ± 38 mmHg to 91 ± 27 mmHg. There was no significant correlation between the chosen PEEP and the mean difference of systolic blood pressure (Pearson's correlation, r = 0.07, P = 0.17). Ventilation with moderate PEEP has no adverse effect on arterial systolic blood pressure in this cohort of trauma patients requiring mechanical ventilation. Initially unstable patients being ventilated with moderate PEEP tend to be hemodynamically more stable.

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Background In unconscious patients in supine position, loss of soft tissue tension results in obstruction of the upper airway. Unexperienced rescuers may be unable to perform efficient bag-valve mask ventilation due to difficulties to detect the optimal head position for opening the airway. If the ventilation mask indicates the rescuer an optimized head position, bag-valve mask ventilation could be possibly optimized. Methods A digital sensor was attached to the face mask to measure the degree of head reclination. We attached this face mask to an airway trainer and sealed the mask with tape on the face; the airway trainer was connected to a test lung and ventilated in pressure-controlled mode by a standard anesthesia machine (Pmax 10 mbar, PEEP 0 mbar, F 12/min). The head was extended starting from the neutral position to 42 degrees in steps of two degrees. Primary endpoints were the correlation of preset and by our face mask digitally measured head position angles. We further evaluated tidal- and minute ventilation volume depending on head reclination. Results Preset head position angles correlated significantly (R2 = 0.9895855684; PConclusion Digital head position angle measurement correctly detected head position. A signal in a face mask could indicate first responders or relatively inexperienced rescuers an optimized head position during emergency ventilation.

BackgroundOver the past years, several emergency medical service providers have introduced mechanical chest compression devices (MCDs) in their protocols for cardiopulmonary resuscitation (CPR). Especially in helicopter emergency medical systems (HEMS), which have limitations regarding loading weight and space and typically operate in rural and remote areas, whether MCDs have benefits for patients is still unknown. The aim of this study was to evaluate the use of MCDs in a large Swiss HEMS system.Materials and methodsWe conducted a retrospective observational study of all HEMS missions of Swiss Air rescue Rega between January 2014 and June 2016 with the use of an MCD (Autopulse®). Details of MCD use and patient outcome are reported from the medical operation journals and the hospitals’ discharge letters.ResultsMCDs were used in 626 HEMS missions, and 590 patients (94%) could be included. 478 (81%) were primary missions and 112 (19%) were interhospital transfers. Forty-nine of the patients in primary missions were loaded under ongoing CPR with MCDs. Of the patients loaded after return of spontaneous circulation (ROSC), 20 (7%) experienced a second CA during the flight. In interhospital transfers, 102 (91%) only needed standby use of the MCD. Five (5%) patients were loaded into the helicopter with ongoing CPR. Five (5%) patients went into CA during flight and the MCD had to be activated. A shockable cardiac arrhythmia was the only factor significantly associated with better survival in resuscitation missions using MCD (OR 0.176, 95% confidence interval 0.084 to 0.372,p ConclusionWe conclude that equipping HEMS with MCDs may be beneficial, with non-trauma patients potentially benefitting more than trauma patients.

Das Studium der Humanmedizin ist, wie viele andere Studiengange auch, eine grose Herausforderung fur die studierenden jungen Menschen. Der vorliegende Fall geht darauf ein, dass diese Herausforderung ohne Unterstutzung und Begleitung nicht fur jeden zu meistern ist und zur Uberforderung werden kann.

Was tun, wenn der Tod bereits eingetreten ist, sich aber dann plotzlich doch noch Leben zeigt, wo keines mehr hatte sein durfen? Dieser Fall zeigt, dass es in der Medizin Phanomene gibt, die man mit wissenschaftlichen Ansatzen und Forschungen noch nicht hinreichend erklaren kann.

STUDY OBJECTIVE Drugs stored in rescue helicopters may be subject to extreme environmental conditions. The aim of this study was to measure whether drugs stored under the real-life conditions of a Swiss helicopter emergency medical service (HEMS) would retain their potency over the course of 1 year. METHODS A prospective, longitudinal study measuring the temperature exposure and concentration of drugs stored on 2 rescue helicopters in Switzerland over 1 year. The study drugs included epinephrine, norepinephrine, amiodarone, midazolam, fentanyl, naloxone, rocuronium, etomidate, and ketamine. Temperatures were measured inside the medication storage bags and the crew cabins at 10-minute intervals. Drug stability was measured on a monthly basis over the course of 12 months using high-performance liquid chromatography. The medications were considered stable at a minimum remaining drug concentration of 90% of the label claim. RESULTS Temperatures ranged from -1.2 °C to 38.1 °C (29.84 °F to 100.58 °F) inside the drug storage bags. Of all the temperature measurements inside the drug storage bags, 37% lay outside the recommended storage conditions. All drugs maintained a concentration above 90% of the label claim. The observation periods for rocuronium and etomidate were shortened to 7 months because of a supply shortage of reference samples. CONCLUSION Drugs stored under the real-life conditions of Swiss HEMS are subjected to temperatures outside the manufacturer's approved storage requirements. Despite this, all drugs stored under these conditions remained stable throughout our study. Real-life stability testing could be a way to extend drug exchange intervals.

Background: Airway management is a key skill in any helicopter emergency medical service (HEMS). Successful intubation is less often than in the hospital, and alternative forms of airway management are needed more often. Methods: Retrospective observational cohort study in an anaesthesiologist-staffed HEMS in Switzerland. Patients charts from all scene calls (n=9035) that took place between June 2016 and May 2017 (12 months) were analysed. The primary outcome parameter was intubation success rate. Secondary parameters included number of patients intubated by ground-based emergency medical services, alternative devices used, and comparison of patients with and without difficulties in airway management. Results: A total of 676 patients with invasive ventilatory support were identified. Difficulties in airway management were rare, occurring in 44 (6.5%) patients, and trauma was significantly more common (59.1% vs. 38.6%, pConclusion: Despite overall high success rates for endotracheal intubation in the physician-staffed service, each physician gets little real-life experience with advanced airway management in the field, highlighting the importance of a solid basic competence such as anaesthesiology and additional training. Direct laryngoscopy is still a valuable skill and an important Plan B in difficult airway situations in which factors such as fogging, blood, bright radiation on the video laryngoscopes screen, impaired the success of video laryngoscopes intubation.

Objective We aimed to investigate the medical characteristics of helicopter hoist operations (HHO) in HEMS missions. Methods We designed a retrospective study evaluating all HHO and other human external cargo (HEC) missions performed by Swiss Air-Rescue (Rega) between January 1, 2010, and December 31, 2019. Results During the study period, 9,963 (88.7 %) HEMS missions with HHO and HEC were conducted during the day, and 1,265 (11.3 %) at night. Of the victims with time-critical injuries (NACA ≥ 4), 21.1 % (n = 400) reached the hospital within 60 min during the day, and 9.1 % (n = 18) at night. Nighttime missions, a trauma diagnosis, intubation on-site, and NACA Score ≥ 4 were independently and highly significantly associated with longer mission times (p n = 3,731, 37.5 %) while practicing recreational activities (n = 5,492, 55.1 %). In daytime HHO missions, the most common medical interventions performed were insertion of a peripheral intravenous access (n = 3,857, 38.7 %) and administration of analgesia (n = 3,121, 31.3 %). Conclusions Nearly 20 % of patients who needed to be evacuated by a hoist were severely injured, and complex and lifesaving medical interventions were necessary before the HHO procedure. Therefore, only adequately trained and experienced medical crew members should accompany HHO missions.

In intensive care medicine heat moisture exchangers are standard tools to warm and humidify ventilation gases in order to prevent temperature loss of patients or airway epithelia damage. Despite being at risk of hypothermia especially after trauma, intubated emergency medicine patients are often ventilated with dry and in winter probably cold ventilation gases. We tried to assess the amount of temperature-loss due to ventilation with cold, dry medical oxygen in comparison to ventilation with warm and humidified oxygen. We ventilated a 50-kg water-dummy representing the calorimetric capacity of a 60-kg patient over a period of 2 hours (tidal volume 6.6 mL/kg = 400 mL; respiratory rate 13/min). Our formal null-hypothesis was that there would be no differences in temperature loss in a 50 kg water-dummy between ventilation with dry oxygen at 10°C vs. ventilation with humidified oxygen at 43°C. After 2 hours the temperature in the water-dummy using cold and dry oxygen was 29.7 ± 0.1°C compared to 30.4 ± 0.1°C using warm and humidified oxygen. This difference in cooling rates between both ventilation attempts of 0.7 ± 0.1°C after 2 hours represents an increased cooling rate of ~0.35°C per hour. Ventilation with cool, dry oxygen using an automated transport ventilator resulted in a 0.35°C faster cooling rate per hour than ventilation with warm humidified oxygen in a bench model simulating calorimetric features of a 60-kg human body.

Background: Simultaneous ventilation of two patients, e.g., due to a shortage of ventilators in a pandemic, may result in hypoventilation in one patient and hyperinflation in the other patient. Methods: In a simulation of double patient ventilation using artificial lungs with equal compliances (70mL∙mbar-1), we tried to voluntarily direct gas flow to one patient by using 3D-printed y-adapters and stenosis adapters during volume-, and pressure-controlled ventilation. Subsequently, we modified the model using a special one-way valve on the limited flow side and measured in pressure-controlled ventilation with the flow sensor adjusted on either side in a second and third setup. In the last setup, we also measured with different lung compliances.Results: Volume- or pressure-controlled ventilation using standard connection tubes with the same compliance in each lung resulted in comparable minute volumes in both lungs, even if one side was obstructed to 3mm (6.6±0.2vs.6.5±0.1L for volume-controlled ventilation, p=.25 continuous severe alarm and 7.4±0.1vs.6.1±0.1L for pressure-controlled ventilation, p=.02 no alarm). In the second setup, pressure-controlled ventilation resulted at a 3mm flow limitation in minute ventilation of 9.4±0.3vs3.5±0.1L∙min-1, p=.001. In a third setup using the special one-way valve and the flow sensor on the unobstructed side, pressure-controlled ventilation resulted at a 3mm flow limitation in minute ventilation of 7.4±0.2vs3±0L∙min-1, at the compliance of 70mL∙mbar-1 for both lungs, 7.2±0vs4.1±0L∙ min-1, at the compliances of 50 vs. 70mL∙mbar-1, and 7.2±0.2vs5.7±0L∙ min-1, at the compliance of 30 vs. 70mL∙mbar-1 (all p=.001).Conclusions: Overriding a modern intensive care ventilator's safety features are possible, thereby ventilating two lungs with one ventilator simultaneously in a laboratory simulation using 3D-printed y-adapters. Directing tidal volumes in different pulmonary conditions towards one lung using 3D-printed flow limiters with diameters

Background Pain is one of the major symptoms complained about by patients in the prehospital setting, especially in the case of trauma. When there is mountainous topography, as in Switzerland, there may be a time delay between injury and arrival of professional rescuers, in particular on ski slopes. Administration of a safe opioid by first responders may improve overall treatment. We therefore assessed administration of nasal nalbuphine as an analgesic treatment for trauma patients in Switzerland. Methods This observational cohort study examined 267 patients who were treated with nasal nalbuphine by first responders in six ski resorts in Switzerland. All first responders were instructed to begin treatment by assessing the feasibility of using nalbuphine to treat pain in the patient. A treatment algorithm was developed and distributed to assure that nalbuphine was only administered following a strict protocol. Data regarding pain scores and pain reduction after administration of nalbuphine were collected on-site. Refills were handed out to the first responders with the return of each completed questionnaire. Results Nalbuphine provided effective pain relief, with the median level of pain on the numeric rating scale for pain reduced by 3 units on average, from 8 points (p p = 0.006). No major side effects were observed. Conclusion Nasal administration of nalbuphine by first responders is a presumably safe and effective noninvasive pain management strategy for acutely injured patients in the prehospital setting. This may be an alternative, especially in the case of severe pain and prolonged time between arrival of the first responders and arrival of EMS/HEMS personnel on scene.

BACKGROUND: Deranged glucose metabolism after moderate to severe trauma with either high or low concentrations of blood glucose is associated with poorer outcome. Data on prehospital blood glucose concentrations and trauma are scarce.OBJECTIVES: The primary aim was to describe the relationship between traumatic shock and prehospital blood glucose concentrations. The secondary aim was to determine the additional predictive value of prehospital blood glucose concentration for traumatic shock when compared with vital parameters alone.DESIGN: Retrospective analysis of the predefined, observational database of a nationwide Helicopter Emergency Medical Service (34 bases).SETTINGEmergency trauma patients treated by Helicopter Emergency Medical Service between 2005 and 2013 were investigated.PATIENTS: All adult trauma patients (18 years) with recorded blood glucose concentrations were enrolled.OUTCOMES: Primary outcome: upper and lower thresholds of blood glucose concentration more commonly associated with traumatic shock. Secondary outcome: additional predictive value of prehospital blood glucose concentrations when compared with vital parameters alone.RESULTS: Of 51 936 trauma patients, 20 177 were included. In total, 220 (1.1%) patients died on scene. Hypoglycaemia (blood glucose concentration 2.8 mmol l1 or less) was observed in 132 (0.7%) patients, hyperglycaemia (blood glucose concentration exceeding 15 mmol l1 ) was observed in 265 patients (1.3%). Blood glucose concentrations more than 10 mmol l1 (n ¼ 1308 (6.5%)) and 2.8 mmol l1 or less were more common in patients with traumatic shock (P < 0.0001). The Youden index for traumatic shock ((sensitivity R specificity) 1) was highest when blood glucose concentration was 3.35 mmol l1 (P < 0.001) for patients with low blood glucose concentrations and 7.75 mmol l1 (P < 0.001) for those with high blood glucose concentrations. In logistic regression analysis of patients with spontaneous circulation on scene, prehospital blood glucose concentrations (together with common vital parameters: Glasgow Coma Scale, heart rate, blood pressure, breathing frequency) significantly improved the prediction of traumatic shock in comparison with prediction by common vital parameters alone (P < 0.0001). CONCLUSION: In adult trauma patients, low and high blood glucose concentrations were more common in patients with traumatic shock. Prehospital blood glucose concentration measurements in addition to common vital parameters may help identify patients at risk of traumatic shock.

Summary The aim of this study was to analyse publication trends from the anaesthetic literature of the G-20 countries. We performed a literature search in Medline to identify articles related to anaesthetic departments published between 2001 and 2015, by specific G-20 countries according to the affiliation field of the authors, and to three time periods 2001–2005, 2006–2010 and 2011–2015. The number of articles, number of original articles (vs. reviews, editorials or correspondence), articles per million inhabitants, and citations per article were analysed. In total, 96,920 articles were published between 2001 and 2015 in 74 anaesthetic and in 4117 non-anaesthetic journals, with an increase of +104% absolute (i.e. from 23,028 in 2001–05 to 46,887 articles in 2010–15) and +85% as articles per million inhabitants. Similarly, the number of original articles increased by 21%, but the anaesthetic specialty's share of original articles (as a proportion of total articles in biomedicine) decreased from 31% in 2001–2005 to 19% in 2011–2015 (−38%). The USA published most articles (2011–15 16,016; 31% of total), second came the EU as a whole and third Japan (from 2001 to 2005) or Germany (2006–2010) until 2011–2015 when China took over the third rank. In 2011–2015, Canada published most articles per million inhabitants (68.7 articles/million inhabitants). China and India exhibited the most publication growth 11- and 9-fold, respectively, and are now among the top five countries for the number of published articles.

Background Radiation therapy (RT) of the head and neck region is often accompanied by serious side effects. Research in this area is needed to improve treatment outcomes and ameliorate therapy tolerance. Laboratory rodents are barely matching today's clinical standards in RT research. Yet domestic swine (Sus scrofa domestica) have previously proved suitable for various advanced tests in clinical research and training. We therefore investigated whether S. scrofa domestica is also appropriate for irradiation of the mandible. Study Design A common scheme for irradiation treatment of S. scrofa domestica mandibles in a split-mouth design was acquired by applying computed tomography (CT) scanning under sedation. Basing on close anatomic resemblance, a standard treatment plan comprising 2 opposed irradiation fields could be accomplished. Results RT was carried out in a clinical environment with 2 × 9 Gy. The resulting operating procedure facilitated complication-free sedation, transport, positioning, CT scanning, and effective irradiation. Conclusion Based on common standards applied for RT in humans, domestic pigs can be employed to progress RT clinical research. Due to their human-like anatomy, physiology, size, and weight, the swine model is expedient for advancing experimental RT of the head and neck area.

Mentoring is fundamentally valuable and important to students considering a path into our specialty, as well as to colleagues already in it and with ambition to advance. General principles and personal experiences are collected and described to help inform future mentors and to reinforce the value of having a mentor and the satisfaction (and work) that is associated with such a role.Detecting a latent talent among medical students or residents may be challenging but is worth the effort to develop personal careers and the specialty itself. Upon agreeing to jointly move a certain project, a professional plan is needed to improve chances of success and decrease the likelihood of frustration. Various challenges always have to be detected and solved, with the ultimate goal to guide a medical student to residency, subsequently into faculty status and preferably to lifelong collaboration.Access to a mentor is an often-cited key to choosing a specialty and the success of junior colleagues and thus the entire department. Mentoring is fundamentally valuable in providing role modeling and also in protecting the mentee from the inefficiency of learning lessons the hard way.

Several incidents of anesthesia-attributed mortality in the past were caused by misconnection of gas pipelines resulting in ventilation with pure nitrous oxide. A simple safety feature may be to “mark” nitrous oxide with a lower pressure than oxygen and room air within the hospital’s gas pipeline system. Then, any misconnection of gas pipelines could be detected by pressure differences with a manometer in the anesthesia machine. To check technical suitability, we tested maximum achievable nitrous oxide flows of an anesthesia machine at different pressures in the nitrous oxide supply line. Using decreased pressures for nitrous oxide compared to oxygen did not result in decreased nitrous oxide flows, as long as pressure in the nitrous oxide supply line was >1500 hPa. A concept of different pressures for nitrous oxide and oxygen could be used to technically differentiate between those two gases, and to avoid potentially fatal misconnections.