Efficacy and Safety of Methoxyflurane for Treatment of Acute Traumatic Pain by EMTs during Alpine Rescue Operations: The "PainDrop" Trial

Background: Treatment of acute traumatic pain is a core task for mountain rescue services. Intravenous access, however, is often difficult, and the vast majority of missions are carried out without a physician at the scene. The spectrum of analgesics available for use by non-physician personnel is limited. Inhaled analgesics, such as methoxyflurane, might prove useful, but currently no data exist on their application by non-physicians in the alpine setting.Methods: This prospective observational alpine field study was conducted over a period of 15 months. Patients suffering traumatic injuries with moderate to severe pain (pain score ≥ 5) after downhill bike accidents in the Tyrol mountains (1,362 m to 2,666 m above sea level) were enrolled. Teams of four mountain rescue service members, one of them a trained EMT, treated the patients with 3 ml of methoxyflurane by inhaler. We measured efficacy as reduction in pain from baseline to 15 minutes after treatment on a numerical rating scale. Safety was assessed by change in vital signs or occurrence of side-effects. Sample-size calculations were based on the efficacy outcome and yielded a need for 20 patients at a power of 0.8.Results: From June 29, 2020 to September 30, 2021, a total of 20 patients (two females; mean age 37 years) were included. The mean initial pain score was 7.2 (SD 1.0) points. After 15 minutes, pain was significantly reduced by a mean of 2.9 (SD 1.4) points. No major adverse events or relevant changes in vital signs were observed.Conclusion: The use of methoxyflurane by EMTs during alpine rescue operations in our study proved to be safe and efficient. We observed no reduction in the efficacy of the inhaler device at moderate altitude.

Quantifying changes in ambient NOx, O3 and PM10 concentrations in Austria during the COVID-19 related lockdown in spring 2020

During spring 2020, unprecedented changes in local and regional emissions have occurred around the globe due to governmental restrictions associated with COVID-19. Many European countries including Austria issued partial curfews or stay-at-home order policies, which have impacted ambient air quality through reductions in non-essential transportation and energy consumption of industrial sites and work places. Here, we analyse the effect of these measures on ambient concentrations of nitrogen oxides (NO_x), ozone (O₃) and particulate matter (PM₁₀) during the first nationwide lockdown in Austria (16.03.2020 to 14.04.2020). To ensure a robust analysis, the Austrian domain is divided into four individual subsectors contingent on regional climate. For air quality analysis a novel method is applied for filtering days with comparable weather conditions during the 2020 lockdown and spring 2017 to 2019. In general, our analysis shows decreasing pollutant concentrations, although in magnitude dependent on pollutant and regional subdomain. Largest reductions are found for NO_x reaching up to −68% at traffic sites reflecting the substantial decrease in non-essential transport. Changes in the O₃ concentrations at background sites show a rather weak response to NO_x declines varying between roughly −18 to +8% for both the median and the upper tail of the distribution. Occasional site level increases in O₃ concentrations can be attributed to comparably weak titration during night-time. PM₁₀ concentrations show the smallest response among air pollutants, attributable to manifold precursor sources not affected by the lockdown measures. However, our analysis indicates also a shift of PM₁₀ distributions at traffic sites closer to distributions observed at background sites.

Usability and effectiveness of inhaled methoxyflurane for prehospital analgesia - a prospective, observational study

Background

Pain relief in the prehospital setting is often insufficient, as the administration of potent intravenous analgesic drugs is mostly reserved to physicians. In Australia, inhaled methoxyflurane has been in routine use by paramedics for decades, but experience in Central European countries is lacking. Thus, we aimed to assess whether user friendliness and effectiveness of inhaled methoxyflurane as sole analgesic match the specific capabilities of local ground and air-based EMS systems in Austria.

Methods

Observational study in adult trauma patients (e.g. dislocations, fracture or low back pain following minor trauma) with moderate to severe pain (numeric rating scale [NRS] ≥4). Included patients received a Penthrop® inhaler containing 3 mL of methoxyflurane (maximum use 30 min). When pain relief was considered insufficient (NRS reduction < 3 after 10 min), intravenous analgesics were administered by an emergency physician. The primary endpoint was effectiveness of methoxyflurane as sole analgesic for transport of patients. Secondary endpoints were user friendliness (EMS personell), time to pain relief, vital parameters, side effects, and satisfaction of patients.

Results

Median numeric pain rating was 8.0 (7.0–8.0) in 109 patients. Sufficient analgesia (reduction of NRS ≥3) was achieved by inhaled methoxyflurane alone in 67 patients (61%). The analgesic effect was progressively better with increasing age. Side effects were frequent (n = 58, 53%) but mild. User satisfaction was scored as very good when pain relief was sufficient, but fair in patients without benefit. Technical problems were observed in 16 cases (14.7%), mainly related to filling of the inhaler. In every fifth use, the fruity smell of methoxyflurane was experienced as unpleasant. No negative effects on vital signs were observed.

Conclusion

In prehospital use, inhaled methoxyflurane as sole analgesic is effective for transport of trauma patients (62%) with moderate to severe pain. Older patients benefit especially from inhaled methoxyflurane. Side effects are mild and vital parameters unaffected. Thus, inhaled methoxyflurane could be a valuable device for non-physician EMS personnel rescue services also in the central Europe region.

Influence of positive end-expiratory pressure on arterial blood pressure in mechanically ventilated trauma patients in the field: a retrospective cohort study

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 pressure < 80 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.

Implementation of Crisis-Resource-Management-based Team Training in Lower Austria

Objective

Sequelae of medical errors are a significant problem in acute care. Human-factor-based events are frequent but avoidable causes. Thus, non-technical skills are crucial. In 2008, crisis-resource-management (CRM)-based simulation training was established for the medical staff of the Lower Austria Regional Hospitals, one of the largest hospital operators in Europe.

Methods

Implementation and development of simulation training from 2008 until today are described, costs and performance data retrospectively analysed over a 10-year period. The applied methodology and organisational aspects of CRM training are highlighted. To complete the picture, activities triggered through CRM training throughout the hospitals with potential to further improve patient safety are shown.

Results

With an initial funding of €100,000 by the Landeskliniken Holding and course rates of €350 to €500, a simulation programme was established for approximately 1,900 co-workers in the acute care setting. In the past 10 years, more than 2,300 doctors and nurses took part in one of the courses, held by 14 qualified trainers. Training was held in the simulation centre as well as in hospitals. Over the time, simulation facilities have been expanded to 8 different manikins, high-fidelity ventilation and monitoring simulation. In addition, a variety of patient safety activities like implementation of critical incident reporting, OR checklists and anaesthesia briefing was accompanied by the trainer team. The total cost of the project was just under €20, 00,000.

Conclusion

Simulation-based CRM training was successfully introduced and sustainably institutionalised at the NOE LKH group of hospitals. The demand for and acceptance of the training were both excellent. The previous costs of training were relatively low; the organisational model of an independent, non-profit registered association allowed the training activities to be implemented without reducing the availability of the instructors in their clinical roles.

Computer tomographic assessment of gastric volume in major trauma patients: impact of pre-hospital airway management on gastric air

Background

Gastric dilation is frequently observed in trauma patients. However, little is known about average gastric volumes comprising food, fluids and air. Although literature suggests a relevant risk of gastric insufflation when endotracheal intubation (ETI) is required in the pre-hospital setting, this assumption is still unproven.

Methods

Primary whole body computed tomographic (CT) studies of 315 major trauma patients admitted to our Level 1 Trauma Centre Salzburg during a 7-year period were retrospectively assessed. Gastric volumes were calculated employing a CT volume rendering software. Patients intubated in the pre-hospital setting by emergency physicians (PHI, N = 245) were compared with spontaneously breathing patients requiring ETI immediately after arrival in the emergency room (ERI, N = 70).

Results

The median (range) total gastric content and air volume was 402 (26–2401) and 94 (0–1902) mL in PHI vs. 466 (59–1915) and 120 (1–997) mL in ERI patients (p = .59 and p = .35). PHI patients were more severely injured when compared with the ERI group (injury severity score (ISS) 33 (9–75) vs. 25 (9–75); p = .004). Mortality was higher in the PHI vs. ERI group (26.8% vs. 8.6%, p = .001). When PHI and ERI patients were matched for sex, age, body mass index and ISS (N = 50 per group), total gastric content and air volume was 496 (59–1915) and 119 (0–997) mL in the PHI vs. 429 (36–1726) and 121 (4–1191) mL in the ERI group (p = .85 and p = .98). Radiologic findings indicative for aspiration were observed in 8.1% of PHI vs. 4.3% of ERI patients (p = .31). Gastric air volume in patients who showed signs of aspiration was 194 (0–1355) mL vs. 98 (1–1902) mL in those without pulmonary CT findings (p = .08).

Conclusion

In major trauma patients, overall stomach volume deriving from food, fluids and air must be expected to be around 400–500 mL. Gastric dilation caused by air is common but not typically associated with pre-hospital airway management. The amount of air in the stomach seems to be associated with the risk of aspiration. Further studies, specifically addressing patients after difficult airway management situations are warranted.

Postponing intubation in spontaneously breathing major trauma patients upon emergency room admission does not impair outcome

Background

Pre-hospital emergency anaesthesia and tracheal intubation are life-saving interventions in trauma patients. However, there is evidence suggesting that the risks associated with both procedures outweigh the benefits. Thus, we assessed whether induction of anaesthesia and tracheal intubation of trauma patients can be postponed in spontaneously breathing patients until emergency room (ER) admission without increasing mortality.

Methods

Retrospective analysis of major trauma patients either intubated on-scene by an emergency medical service (EMS) physician (pre-hospital intubation, PHI) or within the first 10 min after admission at a level 1 trauma centre (emergency room intubation, ERI). Data was extracted from the German Trauma Registry, hospital patient data management and electronic clinical information system.

Results

From a total of 946 major trauma cases documented between 2010 and 2017, 294 patients matched the study inclusion criteria. Mortality rate of PHI (N = 258) vs. ERI (N = 36) patients was 26.4% vs. 16.7% (p = 0.3). After exclusion of patients with severe traumatic brain injury and/or pre-hospital cardiac arrest, mortality rate of PHI (N = 100) vs. ERI patients (N = 29) was 6% vs. 17.2%, (p = 0.07). Median on-scene time was significantly (p < 0.01) longer in PHI (30 min; IQR: 21–40) vs. ERI patients (20 min; IQR: 15–28).

Conclusions

There was no statistical difference in mortality rates of spontaneously breathing trauma patients intubated on-scene when compared with patients intubated immediately after hospital admission. Due to the retrospective study design and small case number, further studies evaluating the impact of airway management timing in sufficiently breathing trauma patients are warranted.

[Statement of the Austrian Society for Anesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) on the use of laryngeal tubes by ambulancemen and paramedics]

Due to an increasing number of severe complications reported during the prehospital application of laryngeal tubes, the Austrian Society for Anesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) is prompted to formulate a respective statement. With regard to the current training situation and the applicable laws, ÖGARI recommends to convert the "Emergency Competence for Endotracheal Intubation (NKI)" for emergency paramedics into an "Emergency Competence for Extraglottic Airway Management, (NK-EGA)". Training should include at least 40 h of theoretical instruction, hands-on training on the manikin to secure mastery of the methodology and at least 20 successful applications under clinically elective conditions in adult patients under direct medical supervision. Here, depending on local conditions, both laryngeal mask and laryngeal tube can be used. In the prehospital environment, the device must be used which has been trained as mentioned above. Only 2nd generation EGA should be used. After successful EGA placement timely cuff pressure monitoring and gastric suction should be performed. The use of an EGA by ambulance-men cannot be recommended; these have to be limited to bag-mask ventilation.

[Intensive care treatment of traumatic brain injury in multiple trauma patients : Decision making for complex pathophysiology]

Traumatic brain injury (TBI) and hemorrhagic shock due to uncontrolled bleeding are the major causes of death after severe trauma. Mortality rates are threefold higher in patients suffering from multiple injuries and additionally TBI. Factors known to impair outcome after TBI, namely hypotension, hypoxia, hypercapnia, acidosis, coagulopathy and hypothermia are aggravated by the extent and severity of extracerebral injuries. The mainstays of TBI intensive care may be, at least temporarily, contradictory to the trauma care concept for multiple trauma patients. In particular, achieving normotension in uncontrolled bleeding situations, maintenance of normocapnia in traumatic lung injury and thromboembolic prophylaxis are prone to discussion. Due to an ongoing uncertainty about the definition of normotensive blood pressure values, a cerebral perfusion pressure-guided cardiovascular management is of key importance. In contrast, there is no doubt that early goal directed coagulation management improves outcome in patients with TBI and multiple trauma. The timing of subsequent surgical interventions must be based on the development of TBI pathology; therefore, intensive care of multiple trauma patients with TBI requires an ongoing and close cooperation between intensivists and trauma surgeons in order to individualize patient care.

Landiolol in patients with septic shock resident in an intensive care unit (LANDI-SEP): study protocol for a randomized controlled trial

Background

In patients with septic shock, the presence of an elevated heart rate (HR) after fluid resuscitation marks a subgroup of patients with a particularly poor prognosis. Several studies have shown that HR control in this population is safe and can potentially improve outcomes. However, all were conducted in a single-center setting. The aim of this multicenter study is to demonstrate that administration of the highly beta1-selective and ultrashort-acting beta blocker landiolol in patients with septic shock and persistent tachycardia (HR ≥ 95 beats per minute [bpm]) is effective in reducing and maintaining HR without increasing vasopressor requirements.

Methods

A phase IV, multicenter, prospective, randomized, open-label, controlled study is being conducted. The study will enroll a total of 200 patients with septic shock as defined by The Third International Consensus Definitions for Sepsis and Septic Shock criteria and tachycardia (HR ≥ 95 bpm) despite a hemodynamic optimization period of 24–36 h. Patients are randomized (1:1) to receive either standard treatment (according to the Surviving Sepsis Campaign Guidelines 2016) and continuous landiolol infusion to reach a target HR of 80–94 bpm or standard treatment alone. The primary endpoint is HR response (HR 80–94 bpm), the maintenance thereof, and the absence of increased vasopressor requirements during the first 24 h after initiating treatment.

Discussion

Despite recent studies, the role of beta blockers in the treatment of patients with septic shock remains unclear. This study will investigate whether HR control using landiolol is safe, feasible, and effective, and further enhance the understanding of beta blockade in patients with septic shock.

Trial registration

EU Clinical Trials Register; EudraCT, 2017-002138-22. Registered on 8 August 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3024-6) contains supplementary material, which is available to authorized users.

Emergency management of patients with ST-segment elevation myocardial infarction in Eastern Austria: a descriptive quality control study

Background

Myocardial infarction is a time-critical condition and its outcome is determined by appropriate emergency care. Thus we assessed the efficacy of a supra-regional ST-segment elevation myocardial infarction (STEMI) network in Easternern Austria.

Methods

The Eastern Austrian STEMI network serves a population of approx. 766.000 inhabitants within a region of 4186 km². Established in 2007, it now comprises 20 pre-hospital emergency medical service (EMS) units (10 of these physician-staffed), 4 hospitals and 3 cardiac intervention centres. Treatment guidelines were updated in 2012 and documentation within a web-based STEMI registry became mandatory. For this retrospective qualitative control study, data from February 2012–April 2015 was assessed.

Results

A total of 416 STEMI cases were documented, and 99% were identified by EMS within 6 (4.0–8.0) minutes after arrival. Median time loss between onset of pain and EMS call was 54 (20–135) minutes; response, pre-hospital and door-to-balloon times were 14 (10–20), 46 (37–59) and 45 (32–66) minutes, respectively. When general practitioners were involved, time between onset of pain and balloon inflation significantly increased from 180 (135–254) to 218 (155–348) minutes (p < .001). A pre-hospital time < 30 min was achieved in 25.8% of all patients during the day vs. 11.6% during the night (p < .001). Three hundred forty-five patients (83%) were subjected to primary percutaneous coronary intervention (PPCI), and 6.5% were thrombolysed by EMS. Pre-hospital complication rate was 18% (witnessed cardiac arrest 7%, threatening arrhythmias 6%, cardiogenic shock 5%). Twenty-four hours and hospital mortality rate were 1.2 and 2.8%, respectively.

Discussion

Optimal patient care and subsequently outcome of STEMI is strongly determined by a short patient-decision time to call EMS and by the first medical contact to balloon time (FMCBT). Supra-regional networks are key in order to increase the efficacy and efficiency of health care. The goal of 120 min FMCBT was achieved in 78% of our patients immediately managed by EMS, thus indicating room for improvement.

Conclusion

In conclusion, results from the Eastern Austrian STEMI network shed light on the necessity of increasing patient awareness in order to minimize any time loss derived by delayed EMS calls. Involvement of family physicians resulted in prolonged FMCBT. A stronger utilization of rescue helicopters could further improve the efficacy of this supra-regional network. Nevertheless PPCI rates, time intervals and outcome rates compare well with international benchmarks.

S(+)-ketamine : Current trends in emergency and intensive care medicine

S(+)-ketamine, the pure dextrorotatory enantiomer of ketamine has been available for clinical use in analgesia and anesthesia for more than 25 years. The main effects are mediated by non-competitive inhibition of the N-methyl-D-aspartate (NMDA) receptor but S(+)-ketamine also interacts with opioid receptors, monoamine receptors, adenosine receptors and other purinergic receptors. Effects on α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors, metabotropic glutamate receptors (mGluR) and L‑type calcium chanels have also been described. S(+)-ketamine stimulates the sympathetic nerve system, making it an ideal drug for analgosedation or induction of anesthesia in instable patients. In addition, the neuroprotective properties, bronchodilatory, antihyperalgesic or antiepileptic effects provide interesting therapeutic options. In this article we discuss the numerous effects of S(+)-ketamine under pharmacological and clinical aspects especially for typical indications in emergency medicine as well as intensive care.

Success rates of pre-hospital difficult airway management: a quality control study evaluating an in-hospital training program

BACKGROUND

Competence in emergency airway management is key in order to improve patient safety and outcome. The scope of compulsory training for emergency physicians or paramedics is quite limited, especially in Austria. The purpose of this study was to review the difficult airway management performance of an emergency medical service (EMS) in a region that has implemented a more thorough training program than current regulations require, comprising 3 months of initial training and supervised emergency practice and 3 days/month of on-going in-hospital training as previously reported.

METHODS

This is a subgroup analysis of pre-hospital airway interventions performed by non-anesthesiologist EMS physicians between 2006 and 2016. The dataset is part of a retrospective quality control study performed in the ground EMS system of Wiener Neustadt, Austria. Difficult airway missions recorded in the electronic database were matched with the hospital information system and analyzed.

RESULTS

Nine hundred thirty-three of 23060 ground EMS patients (4%) required an airway intervention. In 48 cases, transient bag-mask-valve ventilation was sufficient, and 5 patients needed repositioning of a pre-existing tracheostomy cannula. Eight hundred thirty-six of 877 patients (95.3%) were successfully intubated within two attempts; in 3 patients, a supraglottic airway device was employed first line. Management of 41 patients with failed tracheal intubation comprised laryngeal tubes (n = 21), intubating laryngeal mask (n = 11), ongoing bag-mask-valve ventilation (n = 8), and crico-thyrotomy (n = 1). There was no cannot intubate/cannot ventilate situation. Blood gas analysis at admission revealed hypoxemia in 2 and/or hypercapnia in 11 cases.

CONCLUSION

During the 11-year study period, difficult airways were encountered in 5% but sufficiently managed in all patients. Thus, the training regime presented might be a feasible and beneficial model for training of non-anesthesiologist emergency physicians as well as paramedics.

Landiolol for managing post-operative atrial fibrillation

Beta-blockers are a potential option to manage peri-operative atrial fibrillation. Landiolol is a new ultra-short beta-blocker with a half-life of only 4 minutes and very high beta-1 selectivity which has been used for treatment and prevention of atrial fibrillation in pulmonary surgery and gastro-intestinal surgery. Due to its limited negative inotropic effect and high beta-1 selectivity landiolol allows for control of heart rate with minimal impact on blood pressure. Landiolol is well tolerated by the respiratory system. Additional benefits are related to the regulation of the inflammatory response and blunting of the adrenergic pathway. There is a limited number of trials with total of 61 patients undergoing lung resection or oesophagectomy who developed post-operative atrial fibrillation and were treated with landiolol. The experience with landiolol for prevention is more documented than landiolol application for treatment of post-operative atrial fibrillation. There are 9 comparative studies with a total of 450 patients administered landiolol for prevention of post-operative atrial fibrillation. The use of low dosage (5-10mcg/kg/min) is usually sufficient to rapidly control heart rate which is associated with earlier and higher rate of conversion to sinus rhythm as compared to the controls. The excellent tolerance of landiolol at lower dosage (3-5mcg/kg/min) allows to initiate prophylactic use during surgery and postoperatively. Landiolol prophylaxis is associated with reduced incidence of post-operative atrial fibrillation without triggering adverse events related to a beta-blockade.

Citicoline in severe traumatic brain injury: indications for improved outcome : A retrospective matched pair analysis from 14 Austrian trauma centers

Goal-oriented management of traumatic brain injury (TBI) can save the lives and/or improve the long-term outcome of millions of affected patients worldwide. Additionally, enhancing quality of life will save enormous socio-economic costs; however, promising TBI treatment strategies with neuroprotective agents, such as citicoline (CDP-choline), lacked evidence or produced contradictory results in clinical trials. During a prehospital TBI project to optimize early TBI care within 14 Austrian trauma centers, data on 778 TBI patients were prospectively collected. As preceding evaluations suggested a beneficial outcome in TBI patients treated at the Wiener Neustadt Hospital (WNH), we aimed to investigate the potential role of citicoline administration, solely applied in WNH, in those patients. In a retrospective subgroup analysis we compared 67 patients from WNH with citicoline administration and 67 matched patients from other Austrian centers without citicoline use. Patients with Glasgow Coma Scale score <13 on site and/or Abbreviated Injury Scale of the region "head" >2 were included. Our analysis revealed significantly reduced rates of intensive care unit (ICU) mortality (5% vs. 24%, p < 0.01), in-hospital mortality (9% vs. 24%, p = 0.035) and 6‑month mortality (13% vs. 28%, p = 0.031), as well as of unfavorable outcome (34% vs. 57%, p = 0.015) and observed vs. expected ratio for mortality (0.42 vs. 0.84) in the WNH (citicoline receivers) group. Despite the limitations of a retrospective subgroup analysis our findings suggest a possible correlation between early and consequent citicoline administration and beneficial outcomes. Therefore, we aim to set up an initiative for a prospective, multicenter randomized controlled trial with citicoline in sTBI (severe TBI) patients.

Analgosedation of adult patients with elevated intracranial pressure : Survey of current clinical practice in Austria

BACKGROUND

Analgesia and sedation are key items in intensive care. Recently published S3 guidelines specifically address treatment of patients with elevated intracranial pressure.

METHODS

The Austrian Society of Anesthesiology, Resuscitation and Intensive Care Medicine carried out an online survey of neurointensive care units in Austria in order to evaluate the current state of practice in the areas of analgosedation and delirium management in this high-risk patient group.

RESULTS

The response rate was 88%. Induction of anesthesia in patients with elevated intracranial pressure is carried out with propofol/fentanyl/rocuronium in >80% of the intensive care units (ICU), 60% use midazolam, 33.3% use esketamine, 13.3% use barbiturates and 6.7% use etomidate. For maintenance of analgosedation up to 72 h, propofol is used by 80% of the ICUs, followed by remifentanil (46.7%), sufentanil (40%) and fentanyl (6.7%). For long-term sedation, 86.7% of ICUs use midazolam, 73.3% sufentanil and 73.3% esketamine. For sedation periods longer than 7 days, 21.4% of ICUs use propofol. Reasons for discontinuing propofol are signs of rhabdomyolysis (92.9%), green urine, elevated liver enzymes (71.4% each) and elevated triglycerides (57.1%). Muscle relaxants are only used during invasive procedures. Inducing a barbiturate coma is rated as a last resort by 53.3% of respondents. The monitoring methods used are bispectral index (BIS™, 61.5% of ICUs), somatosensory-evoked potentials (SSEP, 53.8%), processed electroencephalography (EEG, 38.5%), intraparenchymal partial pressure of oxygen (pO₂, 38.5%) and microdialysis (23.1%). Sedation and analgesia are scored using the Richmond agitation and sedation score (RASS, 86.7%), sedation agitation scale (SAS, 6.7%) or numeric rating scale (NRS, 50%) and behavioral pain scale (BPS, 42.9%), visual analogue scale (VAS), critical care pain observation tool (CCPOT, each 14.3%) and verbal rating scale (VRS, 7.1%). Delirium monitoring is done using the confusion assessment method for intensive care units (CAM-ICU, 46.2%) and intensive care delirium screening checklist (ICDSC, 7.7%). Of the ICUs 46.2% do not carry out delirium monitoring.

CONCLUSION

We found good general compliance with the recommendations of the current S3 guidelines. Room for improvement exists in monitoring and the use of scores to detect delirium.

In-hospital airway management training for non-anesthesiologist EMS physicians: a descriptive quality control study

Background

Pre-hospital airway management is a major challenge for emergency medical service (EMS) personnel. Despite convincing evidence that the rescuer’s qualifications determine efficacy of tracheal intubation, in-hospital airway management training is not mandatory in Austria, and often neglected. Thus we sought to prove that airway management competence of EMS physicians can be established and maintained by a tailored training program.

Methods

In this descriptive quality control study we retrospectively evaluated all in- and pre-hospital airway cases managed by EMS physicians who underwent a structured in-hospital training program in anesthesia at General Hospital Wiener Neustadt. Data was obtained from electronic anesthesia and EMS documentation systems.

Results

From 2006 to 2016, 32 EMS physicians with 3-year post-graduate education, but without any prior experience in anesthesia were trained. Airway management proficiency was imparted in three steps: initial training, followed by an ongoing practice schedule in the operating room (OR). Median and interquartile range of number of in-hospital tracheal intubations (TIs) vs. use of supra-glottic airway devices (SGA) were 33.5 (27.5–42.5) vs. 19.0 (15.0–27.0) during initial training; 62.0 (41.8–86.5) vs. 33.5 (18.0–54.5) during the first, and 64.0 (34.5–93.8) vs. 27 (12.5–56.0) during the second year. Pre-hospitaly, every physician performed 9.0 (5.0–14.8) TIs vs. 0.0 (0.0–0.0) SGA cases during the first, and 9.0 (7.0–13.8) TIs vs. 0.0 (0.0–0.3) SGA during the second year. Use of an SGA was mandatory when TI failed after the second attempt, thus accounting for a total of 33 cases. In 8 cases, both TI and SGA failed, but bag mask ventilation was successfully performed. No critical events related to airway management were noted and overall success rate for TI with a max of 2 attempts was 95.3%.

Discussion

Number of TIs per EMS physician is low in the pre-hospital setting. A training concept that assures an additional 60+ TIs per year appears to minimize failure rates. Thus, a fixed amount of working days in anesthesia seems crucial to maintain proficiency.

Conclusions

In-hospital training programs are mandatory for non-anesthetist EMS physicians to gain competence in airway management and emergency anesthesia.Our results might be helpful when discussing the need for regulation and financing with the authorities.

Current practice in neurocritical care of patients with subarachnoid haemorrhage and severe traumatic brain injury : Results of the Austrian Neurosurvey Study

OBJECTIVES

The task force Neuroanaesthesia of the Austrian Society of Anaesthesiology, Resuscitation and Intensive Care Medicine (ÖGARI) is aiming to develop and provide recommendations in order to improve neurocritical care in Austria. Thus, a survey on neurocritical care concepts in Austria regarding intensive care of subarachnoid haemorrhage (SAH) and severe traumatic brain injury (TBI) was performed to assess the current status.

METHODS

An online internet questionnaire comprising 59 items on current concepts of SAH and TBI critical care was sent to 117 anaesthesiology departments.

RESULTS

The survey was answered by 30 (25.6 %) of the hospitals, 24 (80 %) of them treating patients with SAH and/or TBI. Data from ten SAH centres reveal that definitive care was achieved within 24 h in all hospitals; a case load >50 per year is noted in 70 % of intensive care units (ICU). In all, 50 % of departments employ written protocols for treatment. Regarding the treatment of TBI patients, 14 answers were received, indicating that 42.9 % of departments provide care for >50 patients per year. Time between arrival and CT scan is <30 min in all hospitals, and 28.6 % of departments rely on written protocols. Only 14.3 % of hospitals report about routine morbidity and mortality rounds. While the neurologic status is assessed at discharge from the ICU, there is no evaluation of 1‑year outcome.

CONCLUSIONS

Definitive care of SAH and TBI patients is achieved timely in Austria. When compared with SAH, more hospitals with lower case loads take care of TBI patients. Written guidelines and protocols at institutional level are often missing. Since routine morbidity and mortality conferences are sparse, and long-term outcome is not assessed, there is room for improvement.

Factors that may improve outcomes of early traumatic brain injury care: prospective multicenter study in Austria

Background

Existing evidence concerning the management of traumatic brain injury (TBI) patients underlines the importance of appropriate treatment strategies in both prehospital and early in-hospital care. The objectives of this study were to analyze the current state of early TBI care in Austria with its physician-based emergency medical service. Subsequently, identified areas for improvement were transformed into treatment recommendations. The proposed changes were implemented in participating emergency medical services and hospitals and evaluated for their effect.

Methods

14 Austrian centers treating TBI patients participated in the study. Between 2009 and 2012 all patients with Glasgow Coma Scale score < 13 and/or AIS head > 2 within 48 h after the accident, were enrolled. Data were collected in 2 phases: in the first phase data of 408 patients were analyzed. Based on this, a set of recommendations expected to improve outcomes was developed by the study group and implemented in participating centers. Recommendations included time factors (transport to appropriate trauma center, avoiding secondary transfer), adequate treatment strategies (prehospital fluid and airway management, anesthesia, ventilation), monitoring (pulse oximetry and blood pressure monitoring in all patients, capnography in ventilated patients) for prehospital treatment. In the emergency department focus was on first CT scan as soon as possible, short interval between CT scan and surgery and early use of thrombelastometry to optimize coagulation. Following implementation of these recommendations, data on 325 patients were collected and analyzed in phase 2. Final analysis investigated the impact of the recommendations on patient outcomes.

Results

Patients in both data collection phases showed comparable demographic and injury severity characteristics. Treatment changes, especially in terms of fluid management, monitoring and normoventilation as well as thrombelastometry measurements were implemented successfully in phase 2, and led to significant improvement of patient outcomes. Hospital mortality was reduced from 31 % to 23 %. We found a lower rate of unfavorable outcomes, a significant increase in unexpected survivors and more patients with unexpected favorable outcomes as well.

Conclusions

The results of this study clearly demonstrate that the outcomes of TBI patients can be improved with appropriate early care.

Pediatric trauma in the Austrian Alps: the epidemiology of sport-related injuries in helicopter emergency medical service

BACKGROUND/PURPOSE

We aimed to examine the epidemiological characteristics and injury patterns of pediatric trauma in helicopter emergency medical service (HEMS) caused by sports/outdoor activities in alpine environment.

METHODS

This retrospective cohort study analyzed 912 primary HEMS missions for pediatric trauma (0-14 years of age) in Austrian Alps between 1 January 2006 and 30 June 2007. Children were stratified by age into toddlers (3-5 years), children in early (6-9 years), and late school age (10-14 years).

RESULTS

The majority of pediatric sports-related trauma in alpine environment was caused by skiing (82.1%; n=749). Pediatric patients were predominately in late school age and boys (72.8%, n=664 and 61.0%, n=556, respectively) and a minority (16.0%, n=146) was severely injured. Overall, fracture (47.0%, n=429), contusion (17.9%, n=163), and traumatic brain injury (17.0%, n=155) were the most common prehospital diagnoses. The most frequent pattern of injury was related to the head/face and spine (36.3%, n=331).

CONCLUSIONS

The knowledge about epidemiological characteristics of HEMS use for injured children in alpine environment may be essential for training requirements of HEMS crews and operational considerations of HEMS providers. The incidence of head and spinal injuries requires support for initiatives to promote helmet wear and appropriate risk behavior amongst skiers and snowboarders.

The epidemiology of amputation injuries in the Austrian helicopter emergency medical service: a retrospective, nationwide cohort study

PURPOSE

Data on the epidemiological characteristics of traumatic amputations in prehospital emergency care, especially in the context of air rescue, are scarce. Therefore, we aimed to describe the epidemiology of total and subtotal amputation injuries encountered by the OEAMTC helicopter emergency medical service (HEMS) in Austria, based on an almost nationwide sample.

METHODS

We retrospectively reviewed all HEMS rescue missions flown for amputation injuries in 2009. Only primary missions were analyzed.

RESULTS

In total, 149 out of 16,100 (0.9 %) primary HEMS rescue missions were for patients suffering from amputation injuries. Among these, HEMS physicians diagnosed 63.3 % (n = 94) total and 36.9 % (n = 55) subtotal amputations, with both groups showing a predominance of male victims (male:female ratios were 8:1 and 6:1, respectively).The highest rate occurred among adults between 45 and 64 years of age (35.6 %, n = 53). The most common causes were working with a circular saw (28.9 %, n = 43) and processing wood (16.8 %, n = 25). The majority of the cases included digital amputation injuries (77.2 %, n = 115) that were mainly related to the index finger (36.2 %, n = 54). One hundred forty patients (94.0 %) showed a total GCS of more than 12. Amputations were most prevalent in rural areas (84.6 %, n = 126) and between Thursday and Saturday (55.0 %, n = 82). The replantation rate after primary air transport was low (28 %).

CONCLUSIONS

In the HEMS, amputation injuries are infrequent and mostly not life-threatening. However, HEMS crews need to maintain their focus on providing sufficient and fast primary care while facilitating rapid transport to a specialized hospital. The knowledge of the epidemiological characteristics of amputation injuries encountered in the HEMS gained in this study may be useful for educational and operational purposes.

Randomized crossover trial comparing physical strain on advanced life support providers during transportation using real-time automated feedback

BACKGROUND

Feedback devices provide verbal and visual real-time information on cardiopulmonary resuscitation (CPR) quality. Feedback devices can improve the quality of CPR during transportation. It remains unclear if feedback has an effect on the physical strain felt by providers during ongoing CPR.

OBJECTIVES

The objective was to assess the influence of real-time automated feedback on physical strain of rescuers during ongoing chest compressions in different means of transportation.

METHODS

The study was a randomized crossover trial comparing physical strain on advanced life support (ALS) providers during chest compressions using real-time automated feedback in different transport environments: 1) a moving ambulance and 2) a flying helicopter. The authors measured objective and subjective measures of physical strain and calculated the difference in the rate pressure product (RPP) after 8 minutes of external chest compressions.

RESULTS

There was no difference in the RPP (mean intraindividual difference = 21; 95% confidence interval [CI] = -1,438 to 1,480; p = 0.98) between using the feedback device versus no feedback. There was no significant interaction of vehicle type on the effect of feedback on the RPP. Feedback resulted in a significant mean perceived exertion reduction of a Borg scale score by 0.89 points (95% CI = 0.42 to 1.35; p < 0.001). For systolic and diastolic blood pressure, for serum lactate concentrations, and for the modified Nine Hole Peg Test (NHPT; measurement of fine motor skills), we found no statistically significant differences.

CONCLUSIONS

Feedback devices for CPR during transportation do not have an effect on objective components of physical strain, but decrease perceived exertion in experienced rescuers in an experimental setting.

Prehospital pediatric emergencies in Austrian helicopter emergency medical service - a nationwide, population-based cohort study

INTRODUCTION

Arguably, the most challenging emergencies encountered by emergency medical service crews involve children. Because only scant data exist about the epidemiology of pediatric emergencies in helicopter emergency medical service (HEMS) on a population level, we sought to determine the epidemiological characteristics stratified by responding area in a large nationwide sample.

METHODS

This was a retrospective cohort study including all pediatric patients (0-14 years of age) who were treated by HEMS in Austria from January 2006 to June 2007 (18 months).

RESULTS

Pediatric emergencies accounted for 2207 (8.2%) of a total of 26.850 helicopter rescue missions. Of those, 69.9% (n = 1543) were not involved in life-threatening emergencies. The rate of critical pediatric emergencies was higher in urban than in rural or alpine environment (45.2%, 38.2% and 20.3%, respectively). The most common chief complaint was trauma; the frequency of injuries ranged from 54.2% (582/1074) in rural area and 60.3% (44/73) in urban area to 91.4% (969/1060) in alpine environment. Fracture and head trauma (34.9%; 557/1595 and 26.3%; 419/1595, respectively) were the most common injuries. Advanced life support measures like tracheal intubation, cardiopulmonary resuscitation and intraosseous access were rarely performed (3.7%; n = 82, 1.9%; n = 42 and 0.9%; n = 19, respectively).

CONCLUSIONS

Pediatric emergencies in Austrian HEMS show different epidemiological characteristics in alpine, urban and rural operational environments. Because of challenges and infrequency of prehospital pediatric emergencies, HEMS crews need to maintain their skills in pediatric advanced life support and trauma care.

Equipment for pre-hospital airway management on Helicopter Emergency Medical System helicopters in central Europe

BACKGROUND

For advanced out-of-hospital airway management, skilled personnel and adequate equipment are key prerequisites. There are little data on the current availability of airway management equipment and standards of medical staff on Helicopter Emergency Medical System (HEMS) helicopters in central Europe.

METHODS

An internet search identified all HEMS helicopters in Austria, Switzerland and Luxembourg. We identified 15 HEMS helicopter bases in Switzerland, 28 in Austria and three in Luxembourg. A questionnaire was sent to all bases, asking both for the details of the clinical background and experience of participating staff, and details of airway management equipment carried routinely on board.

RESULTS

Replies were received from 14 helicopter bases in Switzerland (93%), 25 bases in Austria (89%) and all three bases in Luxembourg. Anaesthesiologists were by far the most frequent attending physicians (68-85%). All except one bases reported to have at least one alternative supraglottic airway device. All bases had capnometry and succinylcholine. All bases in the study except two in Austria had commercial pre-packed sets for a surgical airway. All helicopters were equipped with automatic ventilators, although not all were suitable for non-invasive ventilation (NIV; Switzerland: 43%, Austria: 12%, Luxembourg: 100%). Masks for NIV were rarely available in Switzerland (two bases; 14%) and in Austria (three bases; 12%), whereas all three bases in Luxembourg carried those masks.

CONCLUSION

Most HEMS helicopters carry appropriate equipment to meet the demands of modern advanced airway management in the pre-hospital setting. Further work is needed to ensure that appropriate airway equipment is carried on all HEMS helicopters.

[Vasopressin for therapy of persistent traumatic hemorrhagic shock: The VITRIS.at study]

While fluid management is established in controlled hemorrhagic shock, its use in uncontrolled hemorrhagic shock is being controversially discussed, because it may worsen bleeding. In the irreversible phase of hemorrhagic shock that was unresponsive to volume replacement, airway management and catecholamines, vasopressin was beneficial due to an increase in arterial blood pressure, shift of blood away from a subdiaphragmatic bleeding site towards the heart and brain and decrease of fluid resuscitation requirements. The purpose of this multicenter, randomized, controlled, international trial is to assess the effects of vasopressin (10 IU IV) vs. saline placebo IV (up to 3 injections at least 5 min apart) in patients with prehospital traumatic hemorrhagic shock that persists despite standard shock treatment. The study will be carried out by helicopter emergency medical service teams in Austria, Germany, Czech Republic, Portugal, the Netherlands and Switzerland. Inclusion criteria are adult trauma patients with presumed traumatic hemorrhagic shock (systolic arterial blood pressure <90 mmHg) that does not respond to the first 10 min of standard shock treatment (endotracheal intubation, fluid resuscitation and use of vasopressors) after arrival of the first emergency physician at the scene. The time window for randomization will close after 30 min of shock treatment. Exclusion criteria are terminal illness, no intravenous access, age <18 years, injury >60 min before randomization, cardiac arrest before randomization, presence of a do-not-resuscitate order, untreated tension pneumothorax, untreated cardiac tamponade, or known pregnancy. Primary study end-point is the hospital admission rate, secondary end-points are hemodynamic variables, fluid resuscitation requirements and hospital discharge rate.

Quality of closed chest compression in ambulance vehicles, flying helicopters and at the scene

CONTEXT

Transport of patients during resuscitation is a critical procedure. In both, ambulances and helicopters the quality of resuscitation is potentially hampered due to the movement of the vehicle and confined space. To date, however, no direct comparison of the quality of resuscitation at the scene, during a helicopter flight and in a moving ambulance has been made.

OBJECTIVE

Direct comparison of the quality of resuscitation at the scene, during a helicopter flight and in a moving ambulance.

DESIGN

The study was performed in July 2005 as a randomised cross-over trial comparing different environments for resuscitation.

SETTING

Medical University of Vienna.

PARTICIPANTS

Eleven European Resuscitation Council (ERC) approved health care professionals.

INTERVENTIONS

Interventions during resuscitation: (a) in a moving ambulance, (b) in a flying helicopter, were compared to those staying at the (c) scene (control). Each participant performed resuscitation in all three environments.

MAIN OUTCOME MEASURES

Quality of chest compression during resuscitation.

RESULTS

Compared to resuscitation at the scene, efficiency of chest compressions during a helicopter flight was 86% and 95% in the moving ambulance 95%. There were no differences in secondary outcomes (time without chest compression, total number of incorrect hand position relative to total compressions, and total number of incorrect pressure release relative to total compressions).

CONCLUSIONS

Resuscitation during transport is feasible and relatively efficient. There is some difference between the environments, but there is no relevant difference between helicopters and ambulances regarding the effectiveness of CPR.

Hemodynamic monitoring using PiCCO system in a 10 months old infant suffering from serious burn injury

In this study, authors present a case report of a 10 months old patient with burn injuries involving 20.5 % body surface area, grades 2a and 2b. According to the continuous monitoring of hemodynamic parameters by PiCCO (Pulsion Medical Systems, Munich, Germany), fluid therapy was successfully managed. Despite of an increasing EVLWI (extravascular lung water index) it was possible to preserve the child from lung edema and subsequent artificial lung ventilation by the early targeted therapeutic interventions. Moreover, the study analyzes the possibilities and indications of less invasive hemodynamic monitoring supplied by PiCCO in children (Tab. 2, Fig. 3, Ref. 7). Full Text (Free, PDF) www.bmj.sk.

Penile block in children, our first experience

Penile block has been in use in penile surgery as a technique for perioperative analgesia for 25 years. The authors reintroduced penile block on the Department of Paediatric Anaesthetics and Intensive Care at the University Children's Hospital in Bratislava, Slovakia in June 2004 after 8 years. This prospective open observational study presents their experience with penile block for elective penile surgery in 96 paediatric patients (Tab. 3, Ref. 14).

[Polytrauma and air rescue. A retrospective analysis of trauma care in eastern Austria exemplified by an urban trauma center]

OBJECTIVE

The aim of this study was a retrospective analysis of polytraumatized patients who were treated by a helicopter emergency medical service (HEMS) crew. This study was performed to evaluate the level of prehospital care provided for severely injured patients. Special consideration was given to treatment strategies of specific injuries which led to multiple injuries, defined as "polytrauma."

METHODS

From September 1992 to April 2001 data of 386 patients treated in the Department of Traumatology of the University of Vienna were collected. A total of 104 patients (26.9%) were transported by helicopter directly from the accident scene. This collective was analyzed demographically; relevant prehospital data such as therapeutic interventions and the early clinical course were examined.

RESULTS

The mean Injury Severity Score (ISS) was 36.9: 70 (67.3%) patients were male and 34 (32.7%) female; the median age was 36.1 years. Traffic accidents were the most frequent trauma mechanism (78.9%) followed by falls from height (17.3%). The mean period between trauma and trauma emergency room was 0.73 h; 77 (74.0%) patients were intubated and mechanically ventilated at the scene and all patients received analgosedation. The mean preclinical fluid load was 1673 ml. The mean duration of treatment in the emergency room was 53 min. The mean length of intensive care was 8.6 days and the mortality rate was 19.2% within the first 24 h.

CONCLUSION

Major trauma is an important cause for requesting a primary HEMS mission. As the results of this study show, immediate and invasive interventions at the scene lead to an improvement of vital functions at admission. For the patients' further course of treatment, the choice of a trauma center seems to be important, too.

Inspiratory oscillatory flow with a portable ventilator: a bench study

INTRODUCTION

We observed an oscillatory flow while ventilating critically ill patients with the Dräger Oxylog 3000 transport ventilator during interhospital transfer. The phenomenon occurred in paediatric patients or in adult patients with severe airway obstruction ventilated in the pressure-regulated or pressure-controlled mode. As this had not been described previously, we conducted a bench study to investigate the phenomenon.

METHODS

An Oxylog 3000 intensive care unit ventilator and a Dräger Medical Evita-4 NeoFlow intensive care unit ventilator were connected to a Dräger Medical LS800 lung simulator. Data were registered by a Datex-S5 Monitor with a D-fend flow and pressure sensor, and were analysed with a laptop using S5-Collect software. Clinical conditions were simulated using various ventilatory modes, using various ventilator settings, using different filters and endotracheal tubes, and by changing the resistance and compliance. Data were recorded for 258 combinations of patient factors and respirator settings to detect thresholds for the occurrence of the phenomenon and methods to overcome it.

RESULTS

Under conditions with high resistance in pressure-regulated ventilation with the Oxylog 3000, an oscillatory flow during inspiration produced rapid changes of the airway pressure. The phenomenon resulted in a jerky inspiration with high peak airway pressures, higher than those set on the ventilator. Reducing the inspiratory flow velocity was effective to terminate the phenomenon, but resulted in reduced tidal volumes.

CONCLUSION

Oscillatory flow with potentially harmful effects may occur during ventilation with the Dräger Oxylog 3000, especially in conditions with high resistance such as small airways in children (endotracheal tube internal diameter <6 mm) or severe obstructive lung diseases or airway diseases in adult patients.

[Emergency respirator therapy in intermediate altitude with the Ambu Matic]

Portable emergency ventilators are commonly used in a pre-hospital setting in the transport of critically ill patients also in hypobaric environments. The aim of our trial was to evaluate the influence of moderate altitude at 2700 m compared to 171 m altitude on minute ventilation and blood gas analysis in healthy volunteers during mechanical ventilation with the Ambu Matic ventilator. At 2700 m altitude, the delivered minute volume increased by 13.8%. paCO2 decreased by 9.2% (p < 0.01 for all reported changes). No statistical change in paO2 at 2700 m altitude was observed. These changes are of sufficient magnitude and importance to require monitoring of minute volume to prevent volutrauma or barotrauma.