Recently, the German Society of Anesthesiology and Critical Care Medicine (DGAI) has published their first ever Recommendation on prehospital emergency anesthesia. Since in Germany there is a system with both paramedics (currently 2 years of training, just now “upgraded” to 3 years) and a broad availability of prehospital emergency physicians on rapid response vehicles and helicopters (about 1.000 emergency vehicles in the country) often times, even complex airway management is done “in the field”.

So – what is the DGAI recommending?

The central points in the recommendations are:

  • Critical scrutiny of the indication to induct prehospital anesthesia
  • RSI with a standardized approach, standardized equipment and medications, in-line-stabilization (if needed), capnography
  • Preoxygenation via face-mask with reservoir or noninvasive ventilation (NIV)
  • Basic monitoring that needs to be there: ECG monitoring, automatic blood pressure, pulse oxymetry, capnography
  • If possible two venous accesses

 

Indications to induce prehospital anesthesia are:

  • Respiratory insufficiency (hypoxemia or hyper/hypoventilation) and contraindication or failure of noninvasive ventilation (NIV)
  • Reduced consciousness / neurologic deficit with risk of aspiration
  • Polytrauma / massive trauma with hemodynamic instability or hypoxia or suspicion of traumatic brain injury with GCS <9.

Goals of prehospital anesthesia are:

  • Amnesia
  • Anxiolysis
  • Reduction of stress
  • Analgesia
  • Effective airway protection
  • Reduction in Oxygen consumption
  • Protection of vital organs, reduction/prevention of secondary myocardial or cerebral damage

There is a lot of emphasis on preparation, team communication and team management.

Before starting with the “real” RSI, there needs to be the indication and team communication. While preoxygenation is started, optimal positioning, preparation of medications, airway alternatives, suction and capnography as well as monitoring and two IV-accesses are prepared. Only then RSI is started. (There is no “checklist” per se, as it is recommended in a few of the other online available airway algorithms, e.g. Sydney HEMS or EMcrit.

In the case of cannot ventilate / cannot intubate they suggest a “forward strategy” since the option to return to spontaneous breathing is in preclinical emergency medicine – contrary to clinical anesthesia – mostly only a theoretical option.

Now to what I really like about this guideline – they managed to group prehospital patients into different scenarios and have suggestions for induction in all of them. Since we as prehospital emergency doctors treat such a broad range of patients, a “one size fits all” concept does not always apply (the only exeption being of course Ketamine, which I love dearly ;-)).

I list their recommendations here – please feel free to discuss and offer your opinions! By the way – they to use S-Ketamin/Ketanest here (double potency of Ketamine), so don’t be surprised by the seemingly low doses of Ketamine. Also, they suggest push-dose-pressors of 10yg of Norepinephrine given with low blood pressure, or via continuous infusion.

 

Massive Trauma

Analgosedation until extrication is achieved (if needed):
Midazolam 3mg + S-Ketamin 25mg (every 10min rep bolus 10mg if needed)

Induction:
Midazolam 7mg OR Propofol 100mg OR Thiopental 200mg
+ S-Ketamin 100mg OR Fentanyl 0,2mg OR Sufentanil 20yg
+ Rocuronium 70-100mg OR Succinylcholine 100mg

Maintenance:
Midazolam 3-5mg (every 20mins)
+ S-Ketamin 20mg (every 20 mins) OR Fentanyl 0,15mg (every 20 mins)
+ Rocuronium 20mg (every 20min)

Isolated traumatic brain injury, stroke, intracranial hemmorhage

Induction:
Thiopental 300mg or Propofol 140mg
+ Fentanyl 0,2mg OR Sufentanil 20yg OR S-Ketamin 100mg
+ Rocuronium 70-100mg OR Succinylcholine 70mg

Maintenance:
Midazolam 3-5mg (every 20mins)
+ Fentanyl 0,15mg (every 20 mins)

High Risk Cardiac Patient – two cases with different suggestions

1.) Hypertensive pulmonary edema, hypoxemia, failure of NIV

Induction:
Fentanyl 0,2mg OR Sufentanil 20yg iv
+ Etomidate 20mg
+ Rocuronium 70-100mg OR Succinylcholine 70mg

Maintenance:
Midazolam 3-5mg (every 20mins)
+ Fentanyl 0,1mg (every 20 mins)

2.) Cardiogenic shock, hypotensive, hypoxemia

Induction:
Fentanyl 0,2mg OR Sufentanil 20yg iv
+ Midazolam 7mg
+ Rocuronium 70-100mg OR Succinylcholine 70mg

Maintenance:
Midazolam 3-5mg (every 20mins)
+ Fentanyl 0,1mg (every 20 mins)

Respiratory insufficiency

Version 1:

Induction:
Fentanyl 0,2mg OR Sufentanil 20yg iv
+ Propofol 110-160mg or Etomidate 20mg
+ Rocuronium 70-100mg OR Succinylcholine 100mg

Maintenance:
Midazolam 3-5mg (every 20mins)
+ Fentanyl 0,15mg (every 20 mins)

Version 2:

Induction:
S-Ketamin 35-100mg
+ Midazolam 7mg
+ Rocuronium 70-100mg OR Succinylcholine 100mg

Maintenance:
Midazolam 3-5mg (every 20mins)
+ S-Ketamin 20mg (every 20 mins)

 

What I think: I think this is a great step forward to standardize the prehospital airway management in Germany. Ketamine was prominently managed, even while some Anesthesiologists out there still seem to think of it only a “last resort medication in trauma”. Also,the focus pre-, peri- and post-RSI communication within the team is very well done. Some medication combinations are not what I would use, but there are very good arguments in all the cases. Notably absent is the use apneic oxygenation. Maybe in the next version there will be a stronger emphasis on video laryngoscopy, checklists and even a part on prehospital procedural sedation.

But what do you think? Is this similar to what you use in the prehospital field (or the resus room) or do you have totally different regimes?

Link to the german version of the recommendations: AWMF.

 

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