[Check valves : Important facts for safe use]. / Rückschlagventile : Wissenswerte Eigenschaften für die sichere Anwendung.

Patients benefit from the use of check valves when drugs with a particularly short half-life (e.g., catecholamines) are continually administered through a one-way valve or when an accidental retrograde bolus application must be prevented, as in the event of a rapid sequence induction and intubation. The lack of a check valve can prevent the administered drug from working in the intended manner resulting in potentially insufficient treatment and negative consequences for the patient. In order to ensure the highest level of patient safety while using check valves appropriate training of medical personnel is essential. In contrast, preventable dangers (e.g., infections, awareness) exist when safety measures are disregarded, including the re-use of medications, syringes or disposable materials in successive patients after having only exchanged the check valves. It is not clear how often this is practiced in German-speaking areas.

[Peripheral intravenous lines : A multifaceted topic]. / Periphere Venenverweilkanülen : Ein facettenreiches Thema.

Peripheral intravenous lines are indispensable for emergency and intensive medical care. They have a high importance, especially in the context of primary care as well as in the early stages of treatment initiation. This requires in-depth knowledge of the persons being treated. This article describes the most important aspects of the indications, puncture and fixation techniques as well as special features in terms of management and hygiene.

[Out-of-hospital airway management with a laryngeal tube or endotracheal intubation for out-of-hospital cardiac arrest : Influence on in-hospital mortality]. / Präklinisches Atemwegsmanagement mit Larynxtubus oder Endotrachealtubus bei präklinischem Herz-Kreislauf-Stillstand : Einfluss auf die Krankenhausmortalität.

BACKGROUND: Endotracheal (ET) intubation has been the gold standard in out-of-hospital airway management for a long time. Recent guidelines suggest an alternative airway management with supraglottic airway devices like the laryngeal tube (LT) especially for less experienced rescue personnel. However, scientific evidence on the prognostic impact of the laryngeal tube in the setting of cardiopulmonary resuscitation is limited. METHODS: We aimed to compare mortality outcomes in out-of-hospital cardiac arrest (OHCA) patients after preclinically initiated airway management with either ET or LT in a propensity score matched, single-center retrospective analysis. RESULTS: A total of 208 patients with OHCA were resuscitated and intubated with either ET (n = 160; 77%) or LT (n = 48; 23%) in the urban area of Frankfurt am Main, Germany, and treated thereafter on the intensive care unit of the University Hospital Frankfurt from 2006-2014. In-hospital mortality was 84% versus 85% in the ET and LT group (p = 0.86). No difference regarding in-hospital mortality has been observed between the two airway management techniques in univariate as well as in multivariate mortality analysis (HR = 0.98, 95% confidence interval [CI] 0.69-1.39; p = 0.92; adjusted HR = 1.01, 95% CI 0.76-1.56; p = 0.62). To adjust for potential confounders, propensity score matching was additionally performed resulting in a cohort of 120 matched patients in a 3:1 ratio (ET:LT). Again, survival to hospital discharge was comparable between the two patient groups (propensity-adjusted HR = 0.99, 95% CI 0.65-1.51, p = 0.97). Further, preclinical airway management with LT or ET showed no difference in mortality within first 24 h (propensity-adjusted HR = 1.02; 95% CI 0.44-2.36; p = 0.96). CONCLUSION: Preclinical airway management with LT shows similar mortality outcomes in direct comparison to intubation with ET in OHCA patients. Further randomized studies are warranted.

[Viral Infections Among the Nursing Personnel - a Survey]. / Arbeitsbedingte virale Infektionen in der Pflege ­ eine Umfrage.

BACKGROUND AND AIM: Healthcare workers (HCW) are at risk of occupational infections and can also transmit diseases to patients. The acceptance of measures to improve safety is linked to knowledge and risk awareness of HCW. The purpose of our study was to ascertain the knowledge and risk awareness of nursing staff regarding occupational infections and vaccinations as well as the frequency of needlestick injuries (NSI) in relation to the level of education. METHODS: In the context of a conference on nursing, an anonymous questionnaire was distributed to the participants. RESULTS AND CONCLUSIONS: Nursing staff had insufficient knowledge of viral occupational infections with regard to the actual hazard. At the same time, more than 60 % of the respondents rated the probability of contracting occupational infections as "pretty high" to "very high". In addition, 62.1 % of the study participants also stated that they did not feel sufficiently trained to care for patients with highly contagious or rare infectious diseases. Intensified training and awareness programs for nursing personnel are required to increase the knowledge of occupational infections.

[Preclinical duty of care during cuff pressure management]. / Präklinische Sorgfaltspflicht beim Cuffdruckmanagement.

BACKGROUND: Airway morbidity is influenced by different factors. Independent of the main emergency health problem, airway morbidity factors may exacerbate a possible poor outcome (e.g., bleeding, tongue swelling, nerve lesion). OBJECTIVES: However, insertion technique and cuff pressure management are both important for duty of care out-of-hospital emergency medicine. After securing the airway (e.g., tracheal tube or supraglottic airway device cuff), pressure measurement is necessary. MATERIALS AND METHODS: In a number of recent publications, a largely forgotten issue has come into the focus of preclinical science. This issue became particularly relevant in the admitting hospital. RESULTS: The results from the aforementioned publications show that preclinical management of cuff pressure is not taken sufficiently into consideration, resulting in possible harm to the patient. DISCUSSION: It is important and safe to use a cuff pressure device. The initial cuff pressure and if necessary corrected value should be documented.

Mechanical properties of morcellised bone graft with the addition of hydroxyapatite.

Mixtures of morcellised bone graft (MBG) and hydroxyapatite (HA) are frequently used in revision arthroplasty surgery. However, the changes in the mechanical properties from adding HA to MBG are unknown. This study used a uniaxial compression test to replicate impaction bone grafting and subsequent early postoperative weightbearing to investigate the effect of adding different proportion of HA to MBG. To achieve this aim, human MBG was subjected to increasing impaction forces and the apparent stiffness and creep for each stress level determined. Subsequently, increasing proportions porous and non porous HA were added to the MBG. The major findings were that the apparent stiffness for MBG increased and the associated creep decreased both with the application of increasing stress and with the addition of increasing proportions of HA. In conclusion, greater proportions of HA in the graft mixture improved the mechanical response compared with MBG impacted under the same force. This improvement replicated the properties of pure MBG under high axial stress. This study indicates that graft mixtures of MBG and HA can be tailormade for patients. The need for less impaction force in MBG:HA mixtures to obtain the same properties as pure MBG may decrease the risk of intraoperative fracture.

[Taking over a patient with preclinical laryngeal tube]. / Übernahme eines Patienten mit Larynxtubus aus der Präklinik.

Endotracheal intubation (ETI) is the most effective method for securing the airway. However, the practice and theory of ETI differ considerably. There is a wide gap between reality and the optimum of quality and quantity required by many specialist organizations, e.g., the European Resuscitation Council. Alternative airway devices, such as a laryngeal tube, can be useful provided the hospital staff know how the device functions and how to avoid or control complications.

[TEAM®-G (Trauma Evaluation and Management Germany). Serves as a basis for an interdisciplinary training in the emergency room]. / TEAM®-G ("Trauma Evaluation and Management Germany"). Grundlage für ein interdisziplinäres und interprofessionelles Schockraumtraining.

BACKGROUND: The implementation of ATLS® in the daily routine of trauma management in the emergency department is a challenge. This goal cannot be reached by educating ATLS® to a few team members only. In order to enforce the implementation of ATLS® in a level I trauma centre, a generic in-house training was introduced in 2009 with inter-professional integration of all specialists of the trauma team. MATERIALS AND METHODS: The TEAM® course (trauma evaluation and management concept of the American College of Surgeons) was the theoretical basis of the training. This educational program was developed for medical students and multidisciplinary team members. Prior training, a questionnaire for self-assessment was completed by n=84 team members to assess their knowledge about ATLS® principles. The hands-on training time was 90 min. N=10 members of the trauma team worked out three scenarios of multiple injured patients. These were provided as near-reality manikin simulations by a specialist trainer. After the training participants re-evaluated and analysed improvement by the training. Duration of trauma management and the number of missed injuries were analysed one year prior and one year after the training and served as a marker of the process and outcome quality of trauma care. RESULTS: Prior the training, 57% of trainees specified their knowledge related to the ATLS® can be improved. Their expectations were generally satisfied by the training. The mean time of trauma management in the ED could not be reduced one year after the training (36±16 min) compared to one year prior the training (39±18 min), however, the detection of missed injuries (5.6% vs. 3.2%, p<0.05) was significantly diminished after the training. CONCLUSION: Apart form education of ATLS® providers the inauguration of an interdisciplinary and interprofessionel team training may enhance implementation of ATLS- algorithms into daily routine.

[Reintubation using the C-MAC videolaryngoscope. Implementation in patients with difficult airways initially managed with in situ laryngeal tubes]. / Umintubation mithilfe des C-MAC-Videolaryngoskops. Durchführung bei Patienten mit schwierigem Atemweg und einliegendem Larynxtubus.

BACKGROUND: Securing the airway with supraglottic airway devices, such as a laryngeal tube, is a regular component of most difficult airway management algorithms. It is further recommended that in emergency medicine rescuers less skilled in endotracheal intubation should use supraglottic airways as a first line device. Exchanging the laryngeal tube with an endotracheal tube can be performed with video-assisted laryngoscopy as described below. MATERIAL AND METHODS: A total of 20 adult patients with airways managed using laryngeal tubes due to actual or anticipated difficult intubation underwent endotracheal intubation using the C-MAC videolaryngoscope. After deflating the cuffs of the laryngeal tube, seeking out the glottis was done by following the constructional landmarks of the laryngeal tube, considering concordance with anatomical landmarks of the human airway. In cases of failed video-assisted endotracheal intubation, the laryngeal tube that was still in situ was reinflated to re-establish ventilation of the lungs. RESULTS: In 19 out of the 20 patients the laryngeal tube could be exchanged for an endotracheal tube with the video-assisted technique described. In one patient no laryngeal structures could be identified (Cormack and Lehane grade IV) even with the C-MAC videolaryngoscope and ventilation was continued via the laryngeal tube. No complications related to the video-assisted intubation technique were observed. CONCLUSIONS: The C-MAC videolaryngoscope is a mobile system which facilitates endotracheal intubation in patients with a difficult airway and a laryngeal tube in place. It is not only possible but recommended to leave the laryngeal tube in situ as a back-up when videolaryngoscopy fails.

[Implementation of the laryngeal tube for prehospital airway management: training of 1,069 emergency physicians and paramedics]. / Implementierung des Larynxtubus im präklinischen Atemwegsmanagement: Ausbildung von 1069 Notärzten und Rettungsassistenten.

OBJECTIVE: The European Resuscitation Council recommends that only rescuers experienced and well-trained in airway management should perform endotracheal intubation. Less trained rescuers should use alternative airway devices instead. Therefore, a concept to train almost 1,100 emergency physicians (EP) and emergency medical technicians (EMT) in prehospital airway management using the disposable laryngeal tube suction (LTS-D) is presented. METHODS: In five operational areas of emergency medicine services in Germany and Switzerland all EPs and EMTs were trained in the use of the LTS-D by means of a standardized curriculum in the years 2006 and 2007. The main focus of the training was on different insertion techniques and LTS-D use in children and infants. Subsequently, all prehospital LTS-D applications from 2008 to 2010'were prospectively recorded. RESULTS: None of the 762 participating EMTs and less than 20% of the EPs had previous clinical experience with the LTS-D. After the theoretical (practical) part of the training, the participants self-assessed their personal familiarity in using the LTS-D with a median value of 8 (8) and a range of 2-10 (range 1-10) of 10 points (1: worst, 10: best). Within the 3-year follow-up period the LTS-D was used in 303 prehospital cases of which 296 were successfully managed with the device. During the first year the LTS-D was used as primary airway in more than half of the cases, i.e. without previous attempts of endotracheal intubation. In the following years such cases decreased to 40% without reaching statistical significance. However, the mean number of intubation attempts which failed before the LTS-D was used as a rescue device decreased significantly during the study period (2008: 2.2 ± 0.3; 2009: 1.6 ± 0.4; 2010: 1.7 ± 0.3). CONCLUSION: A standardized training concept enabled almost 1,100 rescuers to be trained in the use of an alternative airway device and to successfully implement the LTS-D into the prehospital airway management algorithm. Because the LTS-D recently became an accepted alternative to endotracheal intubation in difficult airway scenarios, the number of intubation attempts before considering an alternative airway device is steadily decreasing.

[Laryngeal tube II : alternative airway for children?]. / Larynxtubus II : Alternativer Atemweg bei Kindern?

Difficult airway situations both expected and unexpected, present major challenges to every anesthesiologist, especially in pediatric anesthesia. However, the integration of extraglottic airway devices, such as the laryngeal mask, into the algorithm of difficult airways has improved the handling of difficult airway situations. A device for establishing a supraglottic airway, the laryngeal tube (LT), was introduced in 1999. The LT is an extraglottic airway designed to secure a patent airway during either spontaneous breathing or controlled ventilation. The design of the device has been revised several times and a further development is the LTS II/LTS-D, which provides an additional channel for the insertion of a gastric drain tube. This article reports on the successful use of the LTS II in 12 children aged from 2 days to 6 years when endotracheal intubation, alternative mask or laryngeal mask ventilation failed. Use of the LTS II was associated with a high level of success, securing the airway when other techniques had failed. The potential advantage of the LTS II over the standard LT is an additional suction port, which allows gastric tube placement and can be used as an indirect indicator of correct placement. With a modified insertion technique using an Esmarch manoeuvre, placement was simple and fast to perform. In emergency situations when direct laryngoscopy fails or is too time-consuming the LTS II tube is recommended as an alternative device to secure the airway. As with all extraglottic airway devices, familiarity and clinical experience with the respective device and the corresponding insertion technique are essential for safe and successful use, especially in emergency situations.

[Prehospital airway management of laryngeal tubes. Should the laryngeal tube S with gastric drain tube be preferred in emergency medicine?]. / Präklinische Anwendung des Larynxtubus. Bietet der Larynxtubus S mit Magensonde Vorteile in der Notfallmedizin?

Laryngeal tubes (LT) are increasingly being used for emergency airway management. This article reports on two patients in whom out-of-hospital intubation with a single-lumen LT was associated with massive pulmonary aspiration in one patient and gastric overinflation in the other. In both cases peak inspiratory pressures exceeded the LT leak pressure of approximately 35 mbar. This resulted in gastric inflation and decreased pulmonary compliance and increased inspiratory pressure further, thereby creating a vicious circle. It is therefore recommended that laryngeal tube suction (LTS) should be used in all cases of emergency airway management and a gastric drain tube be inserted through the dedicated second lumen. Apart from gastric overinflation, incorrect LT/LTS placement must be detected and immediately corrected, e.g. in cases of difficult or impossible gastric tube placement, permanent drainage of air from the gastric tube, decreasing minute ventilation or an ascending capnography curve.

Tracheal intubation using the mobile C-MAC video laryngoscope or direct laryngoscopy for patients with a simulated difficult airway.

BACKGROUND: Several studies have shown that video laryngoscopy enhances the laryngeal view in patients with apparently normal and anticipated difficult airways. The utility of the novel, portable, battery-powered C-MAC video laryngoscope is unproven, but its design makes it potentially useful for emergency situations. We hypothesized that, in patients with a simulated difficult airway created by means of a rigid cervical immobilization collar, the rate of glottic views considered "failed" under direct laryngoscopy could be significantly reduced with the C-MAC video laryngoscope. METHODS: Following power analysis and ethical approval, 43 adults undergoing surgery under general anesthesia were studied. First, direct laryngoscopy was performed with the naked eye with and without applying external laryngeal pressure (BURP maneuver). The best-obtained view was graded by the laryngoscopist without looking at the video monitor. A second anesthesiologist, who was blinded to the laryngeal view obtained under direct laryngoscopy, graded the laryngeal view on the video monitor. A difficult airway was then created and the laryngoscopy sequence repeated. Endotracheal intubation was then attempted under video-aided visualization. RESULTS: In patients with a normal airway, the glottic view was considered as "good" in the vast majority of patients (40-43/43; 93-100%) regardless of the laryngoscopy technique used. When a difficult airway was created, the glottic view was graded as "failed" in 30/43 (70%) and 16/43 (37%) of patients under direct laryngoscopy without and with the BURP maneuver, respectively (P=0.0047). Using video laryngoscopy, significantly fewer laryngoscopic views were graded as "failed" without (14%, P<0.0001) and with the BURP maneuver (5%, P=0.0003) compared to direct laryngoscopy. Endotracheal tube placement was successful in 88% of patients with a difficult airway. CONCLUSION: The C-MAC video laryngoscope effectively enhanced the laryngeal view in patients with limited inter-incisor distance and eliminated cervical spine clearance. However, endotracheal tube placement failed in 5/43 patients despite a mostly good laryngeal view.

[Laryngeal tube suction]. / Larynxtubus Suction : Temporäres Hilfsmittel bei Notfallpatienten mit schwierigem Atemweg Temporary device for emergency patients with a difficult airway.

BACKGROUND: The difficult airway remains a challenge especially in emergencies. MATERIALS AND METHODS: The use of laryngeal tube suction in 8 cases involving difficult airways in emergencies was reviewed. RESULTS: Use of the laryngeal tube was successful in all cases to bridge patients until a secure airway was established; insertions were successful at the first attempt and classified as easy. In 6 out of 8 patients a secure airway was established by cricothyreotomy or by surgical tracheotomy while using the laryngeal tube for oxygenation and ventilation of the patient. CONCLUSION: The laryngeal tube allows rapid oxygenation in emergency patients with a difficult airway until a secure airway can be established. In cases of potentially life saving operations successful ventilation via the laryngeal tube might allow the priority of establishing a secure airway to be deferred.