Emergency Anesthesia

Emergency anesthesia

Prehospital emergency anesthesia in adults

For the emergency medical services, immediate airway management, anesthesia induction and maintenance as well as adequate ventilation are essential elements of prehospital treatment.1 Although emergency anesthesia is rarely administered by the EMS provider – in only in 3-5% of call-outs – it still entails a risk.2

Therefore, emergency physicians working in the prehospital environment should have the ability to perform emergency anesthesia safely. The practical skills required for this must be learned in a clinical environment and practiced regularly. 

The challenges of prehospital emergency anesthesia are defined by the multiplicity of injury patterns, indications and patient groups. It should also be remembered that outside of the clinical environment, the traditional resources of an anesthesia setting are not available.

In 2015, the “Prehospital emergency anesthesia” team of the Scientific Working Group on Emergency Medicine of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) published the S1 guideline “Recommendations for prehospital emergency anesthesia in adults”.3

In this article, you will find a comprehensive overview of this guideline’s recommendations. WEINMANN’s MEDUMAT Standard² and MEDUVENT Standard ventilators support the implementation of the guidelines.

Indications for prehospital emergency anesthesia

The decision to administer prehospital emergency anesthesia must be made carefully and checked critically. The DGAI recommendations on prehospital airway management as well as the S3 guideline on treating cases of multiple trauma/severe injury should also be followed.

Before starting emergency anesthesia, the risks and benefits need to be carefully weighed up, taking the individual skills of the medical team into account. As the makeup of emergency teams usually changes regularly, it is important that clear procedures are defined in recommended actions and local Standard Operating Procedures (SOP).

In view of the risks of emergency anesthesia, it is essential that all team members are familiar with the process involved.

The following overview gives the indications for prehospital emergency anesthesia at a glance:

  • Unconscious patients (GCS < 9) with danger of aspiration
  • Acute respiratory insufficiency
  • Hypoxia and/or respiratory rate < 6/min or > 29/min with contraindication of non-invasive ventilation (NIV), or if NIV fails

Multiple trauma/serious trauma with one or more of the following diagnoses:

  • Hemodynamic instability, systolic BP < 90 mmHg
  • Apnea or gasping (respiratory rate < 6/min)
  • Hypoxia with SpO2 < 90% despite oxygen administration and exclusion of a tension pneumothorax
  • Traumatic brain injury with GCS < 9
  • Serious thorax trauma with respiratory insufficiency (respiratory rate > 29/min)

An exception is made for patients who are undergoing cardiopulmonary resuscitation and first require the airway to be secured. Emergency anesthesia may only be possible once spontaneous circulation has been restored.

Objectives of prehospital emergency anesthesia

The objectives of prehospital emergency anesthesia, which are essentially the same as the general objectives of anesthesia, are listed below.

  • Enabling rapid and effective securing of the airway (ensuring oxygenation by means of ventilation as well as aspiration protection using endotracheal intubation)
  • Protecting vital organ systems and avoiding secondary myocardial and cerebral damage
  • Pain therapy
  • Amnesia
  • Anxiolysis
  • Protection from stress

Factors influencing successful emergency anesthesia

According to DGAI guidelines, successful implementation depends on several factors. These include: 

  • experience, training and routine of both the emergency team as a whole and the individual team members
  • conditions at the scene (e.g., lighting, space, weather conditions)
  • transportation time and method (ground or air ambulance)
  • circumstances surrounding airway management (e.g., complications during intubation)

All of these aspects must be taken into account when carrying out emergency anesthesia so as to guarantee effective and safe emergency treatment.

The emergency team’s self-assessment of their own skills is just as important as the patient’s individual situation. Administering emergency anesthesia comes with a risk and requires a high degree of skill in administering and monitoring it, as well as in treating any complications. 

Recommended actions for prehospital emergency anesthesia

The following recommendation is based on the S1 guideline of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and is aimed at all personnel working in emergency medicine. 

It comprises measures which, according to the current state of knowledge, can ensure that emergency anesthesia is administered appropriately on patients who are in a critical condition. Individual factors such as infrastructure, local conditions, the patient’s condition, and the user’s knowledge and experience are taken into account.

The following overview lists the central points of this recommendation:

  • Critical check of the indication, taking into account patient, situation and user-related factors
  • Rapid Sequence Induction (RSI), to minimize the risk of aspiration
  • Pre-oxygenation if there is spontaneous respiration, for 3-4 minutes with 12-15 l oxygen per minute
  • Standardized preparation of anesthetic and emergency medication, plus ventilator with accessories, provision of alternative airway and monitoring instruments, including capnography (recommendation: mechanical ventilation is preferable to manual ventilation using a bag-valve mask)4
  • Standard monitoring during prehospital emergency anesthesia comprises ECG, automatic blood pressure measuring (NIBP) and pulse oximetry oxygen saturation (SpO2)
  • Capnography for checking the tube position, detecting dislocations and disconnections, plus indirect monitoring of the hemodynamics
  • Creation of two peripheral venous accesses, if possible, before inducing anesthesia

Administration and procedure for prehospital emergency anesthesia

The decision on whether to administer prehospital emergency anesthesia is only made after a thorough risk-benefit analysis, and taking into account the influencing factors mentioned above. As soon as the physician has decided to administer anesthesia, this needs to be shared with the team. 

The standard administration and procedure for prehospital emergency anesthesia, as recommended by the DGAI, comprises several steps:

  1.  Critical check of the indication for administering emergency anesthesia
  2.  Communicating the indication for emergency anesthesia to all team members
  3.  Optimizing the ambient conditions, such as correct positioning in the ambulance and the position of the patient’s head
  4.  Immediate start of pre-oxygenation if there is spontaneous breathing
  5.  Preparing the emergency anesthesia medication and the airway management equipment
  6.  Monitoring via ECG, SpO2 and automatic blood pressure measurement (NIBP) and provision of capnography
  7.  Ensuring two peripheral venous accesses with running infusion solution, if possible
  8.  Rapid Sequence Induction/Rapid Sequence Intubation (RSI): 

     - Removing the cervical spine immobilization, if applicable

     - Announcement of the anesthetic medication with active substance and dosage

     - Wait for loss of consciousness and relaxation effect

     - Airway management without intermediate ventilation and tube position check

     - Controlled ventilation (recommendation: mechanical ventilation is preferable to manual ventilation using a bag-valve mask)5

     - If applicable, stop manual in-line stabilization and apply cervical spine immobilization brace again

  9.  Continuous monitoring, including continuous capnography and correctly setting the ventilator
  10.  Maintaining and monitoring the anesthesia
  11.  Detecting and treating vital function disorders, and managing any complications

WEINMANN ventilators for successful emergency anesthesia

WEINMANN ventilators have been specially developed for use in emergency medicine. Our MEDUMAT Standard² and MEDUVENT Standard devices are equipped with the latest functions, which guarantee reliable ventilation in every emergency situation. 

Special modes of ventilation, such as RSI mode and Manual mode, provide optimal support for the induction of anesthesia. Despite their impressive performance, they are remarkably lightweight and compact, which makes them very practical for use at accident scenes, in helicopters, during transportation or in disaster medicine.

The night mode and color coding with inverted colors mean that all vital signs are easy to read in the dark without any distracting glare. At just the touch of a button, you have quick access to the various modes and can adapt them flexibly to the situation. A professional alarm system with individual setting options ensures maximum safety during treatment.

MEDUMAT Standard² 

Exclusive RSI mode for the induction of anesthesia, with functions such as: 

  • Pre-oxygenation in Demand mode 
  • Manual mode for tube position monitoring with MEDUtrigger 
  • Capnography for checking the CO₂ levels and tube position monitoring 
  • Easy switching to continuous ventilation 
  • Monitoring of ventilation parameters via pressure and flow measurement 

MEDUVENT Standard 

One of the world’s smallest turbine-driven ventilators, offering various types of use, even without an external gas supply, and equipped with functions such as:

  • Manual mode for tube position monitoring with MEDUtrigger 
  • Easy switching to continuous ventilation 
  • Monitoring of ventilation parameters via pressure and flow measurement