[Trauma team activation-Who should be alerted for which patients?] / Schockraumaktivierung ­ Bei welchen Patienten alarmieren wir wen?

INTRODUCTION: It is estimated that in total almost 10 million people are injured in accidents in Germany every year, most of which are in the household milieu and leisure sector. It is estimated that of these more than 32,000 seriously injured patients are admitted to the emergency room every year. It is recommended that the decision of the prehospital treatment team or the first examiner in the hospital as to whether a potentially severely injured patient should be admitted via the emergency room of the hospital should be based on a catalogue of criteria. MATERIAL AND METHOD: Against the background of the update of the S3 guidelines on the treatment of multiple trauma/severely injured patients and on the basis of the current literature, an overview with respect to the composition of the team and the criteria for which an emergency room team is or should be activated is given. RESULTS: Alerting the emergency room team is still recommended if a certain injury pattern is present or if a prehospital intervention is necessary. The B­criteria based on the course of the accident or mechanism, which have recently been the subject of increasing criticism, have been adapted. Recommendations for geriatric patients could also be formulated. DISCUSSION: Compared to the S3 guidelines from 2016 the emergency room alarm criteria could be revised on the basis of new literature and have been included in the revised guidelines. There is no doubt that further optimization. e.g., based on prehospital algorithms or using point of care diagnostics, are possible and desirable in the future.

Survival among patients with severe high cervical spine injuries - a TraumaRegister DGU® database study.

BACKGROUND: Trauma is a significant cause of death and impairment. The Abbreviated Injury Scale (AIS) differentiates the severity of trauma and is the basis for different trauma scores and prediction models. While the majority of patients do not survive injuries which are coded with an AIS 6, there are several patients with a severe high cervical spinal cord injury that could be discharged from hospital despite the prognosis of trauma scores. We estimate that the trauma scores and prediction models miscalculate these injuries. For this reason, we evaluated these findings in a larger control group. METHODS: In a retrospective, multi-centre study, we used the data recorded in the TraumaRegister DGU® (TR-DGU) to select patients with a severe cervical spinal cord injury and an AIS of 3 to 6 between 2002 to 2015. We compared the estimated mortality rate according to the Revised Injury Severity Classification II (RISC II) score against the actual mortality rate for this group. RESULTS: Six hundred and twelve patients (0.6%) sustained a severe cervical spinal cord injury with an AIS of 6. The mean age was 57.8 ± 21.8 years and 441 (72.3%) were male. 580 (98.6%) suffered a blunt trauma, 301 patients were injured in a car accident and 29 through attempted suicide. Out of the 612 patients, 391 (63.9%) died from their injury and 170 during the first 24 h. The group had a predicted mortality rate of 81.4%, but we observed an actual mortality rate of 63.9%. CONCLUSIONS: An AIS of 6 with a complete cord syndrome above C3 as documented in the TR-DGU is survivable if patients get to the hospital alive, at which point they show a survival rate of more than 35%. Compared to the mortality prognosis based on the RISC II score, they survived much more often than expected.

[Psychological care in German intensive care units : Results of a survey among the members of the German Interdisciplinary Association for Intensive Care and Emergency Medicine]. / Psychologische Versorgung auf deutschen Intensivstationen : Ergebnisse einer Umfrage unter den Mitgliedern der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin.

BACKGROUND: Psychological care should be provided in intensive care units (ICUs) because of the proven mental symptoms of patients and relatives. Even physicians and nurses can benefit from a corresponding care structure. Knowledge is lacking whether and how psychological care for patients and relatives as well as support for staff in German ICUs is implemented. For this reason, a survey was conducted among the members of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) to gain an overview of the current structures and the need for psychological support. METHODS: The members of DIVI were invited to participate in a web-based survey. A total of 226 physicians and nurses took part in the survey. Analysis included statistics and group comparisons with Χ2 methods. RESULTS: In all care areas, psychological care of patients, relatives, and support for staff, respondents indicated a significant undersupply and expressed the need for improved care. A model which provides consular or team-integrated support based on the level of care is conceivable. DISCUSSION: The current state of psychological care in German ICUs does not cover the existing need. Consequently the development of concepts and the beginning of discussions on how appropriate psychological care can be implemented in the future is necessary.

[Algorithm for flexible decision-making in the intra-hospital management of patients with the changing requirements of the SARS-CoV-2 pandemic]. / Flexibler Entscheidungsalgorithmus zum innerklinischen stationären Patient*innen-Management unter wechselnden Anforderungen der SARS-CoV-2-Pandemie.

After the initial fulminant outbreak, the SARS-CoV­2 pandemic has now taken a more protracted course which, nevertheless, challenges hospitals in returning to a "normal" mode and in preparing for a worst-case scenario of a second wave. Not only the organization of the first contact with the patient and the admission in the emergency department but also the admission as an in-patient and the subsequent management requires both flexibility and clear directions of action for the medical personnel involved. The aim of the algorithm was to develop a structured, easy to implement and easy to follow guideline while simultaneously preserving resources. The algorithm covers some key points of decision making such as clinical signs, first contact, admission for in-patient treatment, consequences of swab and computed tomography (CT) results, and allocation and isolation measures within the hospital. The algorithm is not intended to guide diagnostics, decisions and treatment in the narrower medical sense but to provide more general instructions for the management of in-patients considering specific aspects of SARS-CoV­2.

[Optimization of criteria for activation of trauma teams : Avoidance of overtriage and undertriage]. / Optimierung der Kriterien zur Schockraumalarmierung : Vermeidung von Über- und Untertriage.

INTRODUCTION: Severely injured patients are supposed to be admitted to hospital via the trauma room. Appropriate criteria are contained in the S3 guidelines on the treatment of patients with severe/multiple injuries (S3-GL); however, some of these criteria require scarce hospital resources while the patients then often clinically present as uninjured. There are tendencies to streamline the trauma team activation criteria (TTAC); however, additional undertriage must be avoided. A study group of the emergency, intensive care medicine and treatment of the severely injured section (NIS) is in the process of optimizing the TTAC for the German trauma system. MATERIAL AND METHODS: In order to solve the objective the following multi-step approach is necessary: a) definition of patients who potentially benefit from TTA, b) verification of the definition in the TraumaRegister DGU® (TR-DGU), c) carrying out a prospective, multicenter study in order to determine overtriage and undertriage, thereby validating the activation criteria and d) revision of the current TTAC. RESULTS: This article summarizes the consensus criteria of the group assumed to be capable of identifying patients who potentially benefit from TTA. These criteria are used to test if TTA was justified in a specific case; however, as the TTCA of the S3-GL are not fully incorporated into the TR-DGU dataset and because cases must also be considered which were not subject to trauma room treatment and therefore were not included in the TR-DGU, it is necessary to perform a prospective full survey of all individuals in order to be able to measure overtriage and undertriage. CONCLUSION: Currently, the TR-DGU can only provide limited evidence on the quality of the TTAC recommended in Germany. This problem has been recognized and will be solved by conducting a prospective DGU-supported study, the results of which can be used to improve the TR-DGU dataset in order to enable further considerations on the quality of care (e. g. composition and size of the trauma team).

[Scientific impact of the TraumaRegister DGU®]. / Wissenschaftlicher Impact des TraumaRegister DGU®.

BACKGROUND: The trauma registry of the German Trauma Society (TraumaRegister DGU®) is not only a tool for quality management but also for research purposes. OBJECTIVE: Evaluation of the impact of the TraumaRegister DGU® on scientific output and patient treatment. MATERIAL AND METHODS: Analysis of publications from the TraumaRegister DGU® with respect to numbers, impact factors, journals, citations and presentations. RESULTS AND CONCLUSION: The number and impact factors of publications from the TraumaRegister DGU® rose steeply during the last 10 years and in the last 3 years consisted of 25 publications per year. More than two thirds of them were published in high quality international journals and reflect the great scientific importance. For the German speaking readership and the specific aspects of treatment of the severely injured relevant to Germany, the large number of German language articles are just as important. Independent of the impact factor publications in Deutsches Ärzteblatt, the journal with the highest circulation and Der Unfallchirurg play the most important role. A large amount of scientific information gained from the TraumaRegister DGU® has been included in treatment guidelines and structures. The register is a basic prerequisite for the TraumaNetzwerk DGU®. Since almost all severely injured patients in Germany are now included in the registry, it is possible to obtain epidemiologically reliable data of treatment and outcomes for these patient groups.

[Unplanned admission or readmission to the intensive care unit : Avoidable or fateful?] / Ungeplante Aufnahmen oder Rückverlegungen auf die Intensivstation : Vermeidbar oder schicksalhaft?

BACKGROUND: Unplanned admissions or readmissions to the intensive care unit lead to a poorer outcome and present medical, logistic and economic challenges for a clinic. How often and what are the reasons for readmission to the intensive care unit? Which strategies and guidelines to avoid readmission are recommended. MATERIAL AND METHODS: Analysis and discussion of available studies and recommendations of national and international societies. RESULTS: Many studies show that unplanned admissions and readmissions to the intensive care unit represent an independent risk factor for a poor outcome for patients. Different factors that increase the probability of readmission can be identified. Structural changes concerning the normal wards, intensive care unit or the clinic internal emergency service could positively effect readmission rates and/or patient outcome while other studies failed to show any effect of these arrangements. CONCLUSION: Patient transition from the intensive care unit to a lower level of care is a critical point of time and has to be accompanied by a high quality handover. Unstable patients on normal wards have to be identified and treated as soon as possible but effects of standardized medical emergency teams are controversial.

Intermediate care units : Recommendations on facilities and structure.

A growing number of patients with increasingly complex or specialized diseases are being treated in hospitals worldwide. The treatment requirements of some of these patients are exceeding the capacity of standard nursing units. However, the severity of these diseases or the treatment requirements for these specific clinical pictures do not always justify admission to an intensive care unit. For this reason, an increasing number of special units (intermediate care units) are being set up to offer highly specialized treatment and close monitoring, in order to fulfil an intermediate role between the standard care unit and the intensive care unit. The recommendations of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) on the personnel, capacity, equipment and structure of these units are intended to provide the framework for the setting up and operation of intermediate care units in collaboration with experts on both an evidence-based and an expert-based basis (where scientific evidence is not available). Where only minimal or indirect evidence is available, patient safety is paramount in the formulation of the recommendation.

[Choice of crystalloids in interventions and surgery]. / Auswahl von Kristalloiden bei Interventionen und Operationen.

BACKGROUND: Fluid therapy is daily routine in the perioperative setting; however, high quality guidelines are lacking. The S3-guideline Intravasal Fluid Therapy in the Adult Patient gives evidence- and consensus-based recommendations for the use of fluids in perioperative and critically ill patients. In addition to identifying hypovolemia and guiding volume replacement, the type of fluid that should be used is addressed. OBJECTIVES: The purpose of this article is to present and discuss the recommendations of the S3-guideline with respect to the choice of crystalloids in the perioperative setting. MATERIALS AND METHODS: A literature search within the scope of the guideline development was performed. RESULTS AND CONCLUSIONS: In this review the recommendations and their rationale in the perioperative setting are presented. Crystalloids are the basis of fluid therapy. Instead of isotonic saline, buffered solutions are recommended. Regarding the type of buffer (lactate, acetate, malate), no preferences based on outcome data can be made.

[Eleven years of core data set in intensive care medicine. Severity of disease and workload are increasing]. / Elf-Jahre-Kerndatensatz in der Intensivmedizin. Zunahmen von Fallschwere und Versorgungsaufwand.

BACKGROUND: In the year 2000 a working group of the German Interdisciplinary Association for Intensive Care Medicine (DIVI) defined a core data set on quality assurance for the first time. In the following years the participating intensive care units sent data to the registry on a voluntary basis and received an annual report on benchmarking data. Alterations in the quality in the field of intensive care medicine have so far only been published to a very low extent. AIM: This study analyzed the core date set of the DIVI between 2000 and 2010 in respect to changes in disease severity using the simplified acute physiology score (SAPS II), the sequential organ failure assessment (SOFA), the need for therapeutic interventions with the therapeutic intervention scoring system (TISS 28) and intensive care unit (ICU) mortality. MATERIAL AND METHODS: Inclusion criteria were participation in the registry for at least 4 years, SAPS II, SOFA, TISS28 scores available and data on ICU discharge. A standardized mortality rate (SMR) was calculated for each year. RESULTS: The mean SAPS II score including 94,398 patients increased by 0.23 points/year with a standard error (SE) of 0.02 to 26.9 ± 12 points (p < 0.001). Similarly, the SOFA score on admission to the ICU increased by 0.14 points/year (SE 0.04) to 3.4 ± 2.7 points (p < 0.001), the proportion of patients with a two organ failure doubled to 7.1 % and the number of patients dependent on ventilation increased by 13.6 % to 59.8 %. The mean time on ventilation increased by 0.17 ventilator days/year (SE 0.01, p < 0.001) to 3.1 ± 7.5 days/patient. The mean number of therapeutic interventions increased by 8.7 % to 26.3 ± 8.3 TISS 28 points/day. The mean length of stay on the ICU (4.3 ± 8 days) and the age of the patients (63.2 ± 17.0 years) remained unchanged. The readmission rate showed no significant changes between the years 2004 and 2010. The readmission rate to the ICU within 48 h after primary discharge was 3.1 % with a 95 % confidence interval (CI) of 3.0-3.3 in contrast to 1.5 % (95 % CI 1.4-1.6) for readmission to the ICU after 48 h. The length of stay in hospital before admission to the ICU decreased for patients with scheduled surgery (6.3 ± 9.7 days vs. 4.2 ± 6.9 days), increased slightly for patients with medically indicated admission to the ICU (2.4 ± 8.2 days 3.1 ± 8.6 days) and remained unchanged for patients with unscheduled admission to the ICU after surgery (4.1 ± 8.6 days). The SMR decreased between 2000 and 2004 from 0.97 to 0.72 and increased again thereafter to 0.99 (ICU mortality 8.5 %). CONCLUSION: The severity of disease on admission to the ICU, the proportion of patients on ventilation and the workload of therapeutic interventions increased between 2000 and 2010 in German ICUs but the length of stay of patients in the ICU remained unchanged. The SMR decreased until 2005 and increased thereafter to return to the initial values. The overall ICU mortality was low compared to international data.

[Diagnostic management in paediatric blunt abdominal trauma - a systematic review with metaanalysis]. / Diagnostik des stumpfen Abdominaltraumas des Kindes - ein systematisches Review mit Metaanalyse.

OBJECTIVE: The objective of this systematic review was to investigate the diagnostic management in paediatric blunt abdominal injuries. METHODS: A literature research was performed using following sources: MEDLINE, Embase and Cochrane. Where it was possible a meta-analysis was performed. Furthermore the level of evidence for all publications was assigned. RESULTS: Indicators for intraabdominal injury (IAI) were elevated liver transaminases, abnormal abdominal examinations, low systolic blood pressure, reduced haematocrit and microhematuria. Detecting IAI with focused assessment with sonography for trauma (FAST) had an overall sensitivity of 56.5 %, a specificity of 94.68 %, a positive likelihood ratio of 10.63 and a negative likelihood ratio of 0.46. The accuracy was 84.02 %. Among haemodynamically unstable children the sensitivity and specificity were 100 %. The overall prevalence of IAI and negative CT was 0.19 %. The NPV of abdominal CT for diagnosing IAI was 99.8 %. The laparotomy rate in patients with isolated intraperitoneal fluid (IIF) in one location was 3.48 % and 56.52 % in patients with IIF in more than one location. CONCLUSIONS: FAST as an isolated tool in the diagnostics after blunt abdominal injury is very uncertain, because of the modest sensitivity. Discharging children after blunt abdominal trauma with a negative abdominal CT scan seems to be safe. When IIF is detected on CT scan, it depends on the number of locations involved. If IIF is found only in 1 location, IAI is uncommon, while IIF in two or more locations results in a high laparotomy rate.

[Stingray injury--a harmless injury for surfers?]. / Der Stachelrochenstich--eine harmlose Wellenreitverletzung?

BACKGROUND: Stingray injuries with potentially lethal outcomes have been described in the medical literature, but a stingray injury to a surfer does not belong to the injuries treated daily in Germany. PATIENTS: We report on a stingray injury to a 31-year-old female with an uncommon course. RESULTS: Diagnostics of and therapy for stingray injuries are described. CONCLUSION: Stingray stings are painful injuries. In addition to the pain-relieving heat deactivation of the stingray toxin, the wound has to be cleaned to avoid secondary infection. Non-radiopaque foreign bodies should be ruled out by MRI. Stingray bites can cause severe injuries to water sportsmen and women with the need for surgical intervention.

[Cross sectional study of structural quality of German intensive care units. A reevaluation of the DIVI register]. / Querschnittstudie der Strukturqualität deutscher Intensivstationen. Eine Reevaluation der Strukturdaten des DIVI-Registers.

BACKGROUND: Effectiveness of intensive care treatment is essential to cope with increasing costs. The German national register of intensive care established by the German Interdisciplinary Association for Intensive Care Medicine (DIVI) contains basic data on the structure of intensive care units in Germany. A repeat analysis of data of the DIVI register within 8 years provides information for the development of intensive care units under different economic circumstances. METHODS: The recent data on the structure of intensive care units were obtained in 2008 and compared with the primary multicenter study from 2000. The hospitals selected were a representative sample for the whole of Germany. Data on the status of the hospital, staff and technical facilities, foundation of the hospital and the statistics of mechanically ventilated patients were analyzed. RESULTS: The technical facilities and the number of staff have improved from 2000 to 2008. A smaller availability of diagnostic procedures and staff remain in hospitals for basic treatment outside normal working hours. The average utilization of intensive care unit beds was not altered. The existence of intermediate care units did not significantly change the proportion of patients with artificial ventilation or ventilation times. The number of beds in intensive care units was unchanged as was the average number of beds in units and the number of patients treated. A relevant number of beds of intensive care units shifted towards hospitals with private foundation without changes in the overall numbers. The structure of the hospitals was comparable at both time points. CONCLUSIONS: The introduction of intermediate care units did not alter ventilation parameters of patients in 2008 compared with 2000. There is no obvious medical reason for the shift of intensive care beds towards private hospitals. The number of staff and patients varied considerably between the intensive care units. The average number of patients treated per bed was not different between the periods or between hospitals with different structures. Overall availability of medical staff and diagnostic procedures increased during the study period. An increase of availability of fully trained medical staff in intensive care medicine is desirable to increase the quality of treatment.

[Intercultural differences in the treatment of severely injured patients with poor prognosis. Using the example of a 23-year-old Chinese patient]. / Interkulturelle Differenzen bei der Behandlung von schwerstverletzten Patienten mit infauster Prognose. Beispiel eines 23-jährigen chinesischen Patienten.

Because of globalization, we are increasingly confronted with the treatment of patients from other cultures. Using the example of a 23-year-old Chinese patient, we explain the origin of the intercultural differences which developed into a conflict.Due to a bicycle accident the patient incurred an extremely severe traumatic brain injury with multiple midface fractures. The prognosis was unfavorable. Despite extensive information the family insisted on maximum therapy. This resulted in a misunderstanding among the medical team involved, because they believed that this was not in the interests of the patient. The position of the family is rooted in Chinese culture. An intensive examination might have avoided, or at least mitigated, a conflict. To summarize, it could be useful to address cultural peculiarities at an early stage when treating patients from different cultures to prevent conflicts or to be better prepared for them. Also, an Ethics Commission may be involved early for preventing or resolving a potential conflict.

Special considerations in the interpretation of plain radiographs of the cervical spine in children. A review of the literature.

INTRODUCTION: This review provides an overview of the special considerations with regard to correct diagnosis of plain radiographs of the pediatric cervical spine. Injuries to the cervical spine are rare in children. The leading trauma mechanism is motor vehicle injury. Plain radiographs are a common tool in the search for a diagnosis. Taking the growth process into account there are many differences to be found compared to the adult c-spine. Knowledge of these differences is important when working towards the correct interpretation of plain radiographs of the pediatric c-spine. METHODS: To create this review, a literature search of the electronic databases Cochrane, PubMed/MEDLINE and Embase was conducted. RESULTS: Special considerations of plain radiographs of the pediatric c-spine are presented. Biomechanical and embryology specifics have been a focus of this review. They are explained relating on the development of the c-spine. The known auxiliary lines used in the interpreting of the pediatric c-spine are reported. A selection of these auxiliary lines is shown. CONCLUSION: Knowledge of the c-spines characteristics is of major importance for every physician involved in pediatric trauma care. This could lead to not only avoiding misdiagnosis but could also lead to avoiding the overuse of computed tomography of the pediatric c-spine.

Diagnosis of cervical spine injuries in children: a systematic review.

OBJECTIVE: The objective of this systematic review was to discuss current knowledge of the diagnostic management of cervical spine (c-spine) injuries in children. METHODS: Studies dealing with this topic were collected from the following sources: MEDLINE via PubMed, Embase, and Cochrane. Where possible, a meta-analysis was performed. Furthermore, the level of evidence for all the included publications was assigned. RESULTS: The incidence of cervical spine injury (CSI) in children is rare (1.39 %). It seems that the upper c-spine is more often injured in children younger than 8 years of age. When a CSI is expected, immobilization should be performed. The best immobilization is achieved with a combination of a half-spine board, rigid collar, and tape. The literature for thoracic elevation or an occipital recess in children younger than 8 years of age is inhomogeneous. The c-spine in children can be cleared by a combination of the National Emergency X-Radiography Utilization Study (NEXUS) low-risk criteria and the Canadian C-Spine Rule. Caution is advised for nonverbal and/or unconscious children. In these children, plain radiographs should be performed. If these images are inadequate or show hints for bony injuries, a computed tomography (CT) of the c-spine should be considered. Additional views of the c-spine offer only little information for clearing the c-spine.

[Emergency trauma room management in severely and most severely injured patients. A multidisciplinary task]. / Schockraummanagement beim Schwer- und Schwerstverletzten. Eine interdisziplinäre Aufgabe.

The treatment of most severely injured patients represents a great challenge for the trauma room team. Besides the time factor, which is a crucial cornerstone of the treatment in general and of the appropriate treatment of life-threatening injuries in particular, minor injuries and non-life-threatening injuries must also be taken into account. For this task, multidisciplinary processes play a paramount role. Advanced Trauma Life Support®, Definitive Surgical Trauma Care and the European Trauma Course represent training concepts, which predefine structured diagnostic and treatment procedures. These concepts allocate the highest treatment priority to injuries that may be immediately fatal for the patient. Besides those life-threatening injuries that are commonly summarised under the term "deathly six", other minor traumas should also be assessed and treated in a structured manner as they may often considerably affect the quality of life after trauma.

[Emergency anesthesia, airway management and ventilation in major trauma. Background and key messages of the interdisciplinary S3 guidelines for major trauma patients]. / Notfallnarkose, Atemwegsmanagement und Beatmung beim Polytrauma. Hintergrund und Kernaussagen der interdisziplinären S3-Leitlinie Polytrauma.

Patients with multiple trauma presenting with apnea or a gasping breathing pattern (respiratory rate < 6/min) require prehospital endotracheal intubation (ETI) and ventilation. Additional indications are hypoxia (S(p)O(2) < 90% despite oxygen insufflation and after exclusion of tension pneumothorax), severe traumatic brain injury [Glasgow Coma Scale (GCS) < 9], trauma-associated hemodynamic instability [systolic blood pressure (SBP) < 90 mmHg] and severe chest trauma with respiratory insufficiency (respiratory rate > 29/min). The induction of anesthesia after preoxygenation is conducted as rapid sequence induction (analgesic, hypnotic drug, neuromuscular blocking agent). With the availability of ketamine as a viable alternative, the use of etomidate is not encouraged due to its side effects on adrenal function. An electrocardiogram (ECG), blood pressure measurement and pulse oximetry are needed to monitor the emergency anesthesia and the secured airway. Capnography is absolutely mandatory to confirm correct placement of the endotracheal tube and to monitor tube dislocations as well as ventilation in the prehospital and hospital setting. Because airway management is often complicated in trauma patients, alternative devices need to be available preclinical and a fiber-optic endoscope should be available within the hospital. Use of these alternative measures for airway management and ventilation should be considered at the latest after a maximum of three unsuccessful endotracheal intubation attempts. Emergency medical service (EMS) physicians should to be trained in emergency anesthesia, ETI and alternative methods of airway management on a regular basis. Within hospitals ETI, emergency anesthesia and ventilation are to be conducted by trained and experienced anesthesiologists. When a difficult airway or induction of anesthesia is expected, endotracheal intubation should be supervised or conducted by an anesthesiologist. Normoventilation should be the goal of mechanical ventilation. After arrival in the resuscitation room the ventilation will be controlled and guided with the help of arterial blood gas analyses. After temporary removal of a cervical collar, the cervical spine needs to be immobilized by means of manual in-line stabilization when securing the airway.