Anaesthesia in prehospital emergencies and in the emergency room.
OBJECTIVE
To review anaesthesia in prehospital emergencies and in the emergency room, and to discuss guidelines for anaesthesia indication; pre-oxygenation; anaesthesia induction and drugs; airway management; anaesthesia maintenance and monitoring; side effects and training.


METHODS
A literature search in the PubMed database was performed and 87 articles were included in this non-systematic review.


CONCLUSIONS
For pre-oxygenation, high-flow oxygen should be delivered with a tight-fitting face-mask provided with a reservoir. In haemodynamically unstable patients, ketamine may be the induction agent of choice. The rocuronium antagonist sugammadex may have the potential to make rocuronium a first-line neuromuscular blocking agent in emergency induction. An experienced health-care provider may consider prehospital anaesthesia induction. A moderately experienced health-care provider should optimise oxygenation, fasten hospital transfer and only try to intubate a patient in extremis. If intubation fails twice, ventilation should be resumed with an alternative supra-glottic airway or a bag-valve-mask device. A lesser experienced health-care provider should completely refrain from intubation, optimise oxygenation, fasten hospital transfer and only in extremis ventilate with an alternative supra-glottic airway or a bag-valve-mask device. With an expected difficult airway, the patient should be intubated awake. With an unexpected difficult airway, bag-valve-mask ventilation should be resumed and an alternative supra-glottic airway device inserted. Senior help should be called early. In a "can-not-ventilate, can-not-intubate" situation an alternative airway should be tried and if unsuccessful because of severe upper airway pathology, a surgical airway should be performed. Ventilation should be monitored continuously with capnography. Clinical training is important to increase airway management skills.
Paal
Peter
P
Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria. peter.paal@uki.at
Herff
Holger
H
Mitterlechner
Thomas
T
von Goedecke
Achim
A
Brugger
Hermann
H
Lindner
Karl H
KH
Wenzel
Volker
V
D000465:Algorithms; D000758:Anesthesia / Q000379:methods; D004636:Emergency Service, Hospital; D004638:Emergency Treatment; D006801:Humans