Trends in Anasthesia and Critical Care

8/17/2019 Trends in Anasthesia and Critical Care

1/6

REVIEW

Anaesthesia in medical emergencies

Harald Prossliner*, Patrick Braun, Peter Paal

Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria

Keywords:

Airway

Anaesthesia

Resuscitation

Cardiopulmonary

Ventilation

s u m m a r y

To provide an up-to-date review on drugs and airway management equipment required in anaesthesia

for pre-hospital and in-hospital emergencies. Current literature is reviewed and reasonable approaches

are discussed. Preoxygenation should be performed with high-ow oxygen delivered through a tighttting face mask connected with a reservoir. Ketamine may be the induction agent of choice in hae-

modynamically unstable patients. Sugammadex, a rocuronium antagonist, may have the potential to

make rocuronium the rst-line neuromuscular blocking agent in emergency induction. Experienced

healthcare providers may consider pre-hospital anaesthesia induction; lesser experienced healthcare

providers should refrain from endotracheal intubation, but optimise oxygenation, hasten hospital

transfer and ventilate patients only in life-threatening circumstances with a bagevalveemask device or

a supraglottic airway. Senior help should be sought early.

In the hospital, with an expected dif cult airway breoptic awake intubation should be performed.

With a not dif cult airway, airway management according to the rescuer’s skills should be attempted. In

a ‘cannot ventilate, cannot intubate’ situation, a supraglottic airway should be used and, if ventilation is

still unsuccessful, a surgical airway should be achieved. Capnography should be used in every ventilated

patient. Continuous clinical practice is essential to retain anaesthesia and airway management skills.

2012 Elsevier Ltd. All rights reserved.

1. Introduction

Anaesthesia in emergencies may save the life of a critically ill or

injured patient. However, it may also increase mortality if not

performed properly. For instance, a patient with an acute severe

respiratory insuf ciency may benet from emergency anaesthesia

and ventilator support. However, a patient may benet even more

from non-invasive ventilatory support with a continuous positive

airway pressure (CPAP) mask or helmet.1 Similarly, a patient with

a traumatic brain injury and a Glasgow Coma Scale (GCS) score of

seven may benet from pre-hospital emergency anaesthesia and

intubation,2 but outcome may also depend on factors such as

transfer time to the next hospital and airway management skills of the attending healthcare personnel. Pros and cons of emergency

anaesthesia are hotly debated: Which anaesthetics should be

administered? Which airway should be chosen? When should

airway management be performed? Recently, impressive advances

have been made in the elds of anaesthesia drugs and airway

management. Thus, the aim of this article is to offer a non-

systematic review on anaesthesia in pre-hospital and in-hospital

emergencies.

2. Anaesthesia in medical emergencies - an international

perspective

In France, airway management-experienced emergency physi-

cians had problems in only approximately 3% of pre-hospital

intubations. On the contrary, in Miami, paramedics encountered

intubation dif culties in approximately 30% of patients, and were

not able to intubate 10%.3 Similarly, a study4 in San Francisco

reported endotracheal tubes being misplaced oesophageally or

being dislocated in 15 children, 14 of these children died. As

a consequence, the authors recommended paramedics to refrain

from intubating children. In a German study on pre-hospital intu-

bations performed by emergency medical system (EMS) physicianswith widely varying airway management skills, a 15% rate of

oesophageally or bronchially positioned tubes was reported.

Mortality rate in patients with oesophageally misplaced tubes was

80% as compared with 20% for the overall study cohort.5 Some

argue, that a worse outcome in a number of studies is attributable

to inexperienced personnel and endotracheal intubation without

neuromuscular block.6 Recently, the Association of Anaesthetists of

Great Britain and Ireland recommended pre-hospital anaesthesia

only for appropriately trained and competent practitioners.7 An

Australian and a US-American study heated the debate when they

showed improved outcome in critically brain injured patients with* Corresponding author. Tel.: þ43 512 504 80390.

E-mail address: [email protected] (H. Prossliner).

Contents lists available at SciVerse ScienceDirect

Trends in Anaesthesia and Critical Care

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / t a c c

2210-8440/$ e see front matter 2012 Elsevier Ltd. All rights reserved.

doi:10.1016/j.tacc.2012.01.002

Trends in Anaesthesia and Critical Care 2 (2012) 109e114

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pre-hospital intubation.8,9 Comparing pre-hospital airway

management studies proved to be dif cult, mainly due to varying

parameters between the studies such as different patient cohorts

(e.g. penetrating trauma vs. blunt), profession groups (e.g. para-

medic vs. general practitioner vs. anaesthesiologist), and hospital

transfer time.5,10 Some argue that the profession of a given rescuer

is less important than the skill level. For example, a paramedic with

regular clinical experience may have a higher skill level than

a general practitioner with rare airway management practice.

3. Indications for anaesthesia induction

The decision whether a patient should be anaesthetised may

depend on several factors. Indications for pre-hospital anaesthesia

should be set more conservatively than with an in-hospital emer-

gency. Indications for anaesthesia induction may be:

(1) highly experienced team members

(2) not dif cult airway

(3) good equipment including drugs and airway management

tools at hand

(4) safe and appropriate environment (e.g. terrain, temperature

and light)(5) severe head trauma (GCS80%. Many factors can negatively inu-

ence preoxygenation. For instance, in a critically ill patient, oxygen

stores may be compromised owing to lung contusion or pneu-

monia, decreasing functional residual capacity and increasing

right-to-left shunt. Additionally, haemoglobin may be critically low

because of haemorrhage.21 Thus, preoxygenation may be less

effective in some patients, but because of increased safety margins

during anaesthesia induction, it should always be performed. A

short time to denite airway control is a key factor in the preven-

tion of a hypoxaemia-related secondary organ injury.

5. Drugs for anaesthesia induction

Table 2 and Table 3 give an overview of commonly used

anaesthetics. In critically ill patients administration of a single dose

of etomidate has been discouraged because its inhibitory effect onsteroid genesis may increase mortality even after a single injection.

On the contrary, ketamine has a broad therapeutic range, with

respiration and haemodynamics affected only to a lesser degree.

Thus, ketamine maybe used foranalgesia in patients with excessive

pain,22,23 thus potentially avoiding anaesthesia induction. If

employed for analgesia, ketamine should be co-administrated with

a longer acting sedative, e.g. midazolam. Importantly, ketamine

may be the induction agent of choice for anaesthesia induction in

haemodynamically unstable patients due to its circulation stabil-

ising proprieties.24

Also, propofol co-induction with 0.5 mg kg1 ketamine25 or

0.1 mg kg1 midazolam26 compared with propofol alone may be

propofol-sparing, resulting in less haemodynamic depression,

which may be advantageous in haemodynamically unstablepatients. For analgesia during anaesthesia induction, fentanyl or

sufentanyl in haemodynamically stable and ketamine in haemo-

dynamically unstable patients may be the agents of choice because

of fast onset and acceptable analgesic effect and duration.27

Adding neuromuscular block to emergency anaesthesia induc-

tion is discussed controversially. Some argue that the presence of

a neuromuscular block offers the best possible intubation condi-

tion. Others argue that, with neuromuscular block, an oesopha-

geally placed endotracheal tube inevitably leads to death.

Therefore, some EMS services do not recommend administration of

neuromuscular blockers with anaesthesia induction. Sux-

amethonium (1e1.5 mg kg1) is still the most widely employed

neuromuscular blocking agent, but rocuronium (1.2 mg kg1) has

the potential to become the rst-line neuromuscular blockingagent in emergency anaesthesia, because of its fast onset and its

reversibility within a few minutes when employing sugammadex

(16 mg kg1), a novel specic rocuronium antagonist. Importantly,

rapid sequence induction skills should be trained regularly in

a controlled environment under the supervision of an expert, for

example under supervision of an anaesthesiology specialist in an

operating theatre.28

6. Positioning and monitoring for anaesthesia induction and

maintenance

To open the upper airway optimally, the patient should be

placed in a snif ng positione with a support beneath the head; this

may be especially helpful in patients with a stiff cervical spine or

Table 1

Devices for oxygenation and preoxygenation. Oxygen ow (L min1) and resulting

inspiratory oxygen fraction (FiO2) are given.

Oxygenation device O2 L min1 FiO2

Nasal cannula 1e6 24e44%

Face mask 8e10 40e60%

Face mask with reservoir 6e10 60e100%

Anaesthesia bag-valve mask device 12 50%

Anaesthesia bag-valve mask devicewith reservoir

12 100%

H. Prossliner et al. / Trends in Anaesthesia and Critical Care 2 (2012) 109e114110



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obesity. In infants, a support under the shoulders may counteract

the anterior head exion caused by the large occiput. An intrave-

nous line should be xed well to avoid dislocation during anaes-

thesia induction and maintenance. Before anaesthesia induction,

a patient should be monitored with ECG, non-invasive automated

blood pressure measurement and pulse oximetry. An invasive

arterial blood measurement should be established in haemody-

namically unstable or fragile patients.29 Involved personnel should

be experienced in anaesthesia induction and treatment of possible

side effects. All drugs for anaesthesia and advanced life support

should be at hands.

7. Fibreoptic awake intubation

With an expected dif cult airway, anaesthesia induction should

be delayed until breoptic awake intubation is possible in a fullyequipped operating theatre with highly skilled personnel. Ideally,

every in-hospital emergency service should offer a 24 h service.

There are different methods for analgosedation in breoptic awake

intubation.30 Importantly, one should master one technique,

instead of using more techniques, but no technique well. The

advantage with breoptic awake intubation is that the analgose-

dated patient breathes spontaneously until the endotracheal tube is

correctly placed into the trachea; this should be veried with

bronchoscopy and appearance of endtidal carbon dioxide on cap-

nography. Anaesthesia is started only after correct endotracheal

tube placement.

8. Is endotracheal intubation the gold standard to secure the

airway?

For many years endotracheal intubation was considered the

gold standard in emergency medicine. However, increasing

evidence suggests that a high and regular case load is required to

acquire and retain suf cient skills to perform endotracheal intu-

bation safely during emergencies.31 Unfortunately, many rescuers

never acquire these skills. For example, a study in Switzerland

found that anaesthesia residents required 60 endotracheal intu-

bations to gain a 90% success rate with endotracheal intubation

attempts.32 Thus, only highly-experienced rescuers who contin-

uously practice endotracheal intubation on elective patients in

the operating theatre will be able to intubate safely in

emergencies.

Hence, in the eld a moderately experienced rescuer should

optimise oxygenation, fasten hospital transfer and if ventilation is

necessary employ bag-valve-mask ventilation or a supra-glottic

airway device; endotracheal intubation should be considered only

as a last resort. A lesser experienced rescuer should optimise

oxygenation, fasten hospital transfer and only as a last resort

employ a bag-valve-mask device or a supra-glottic airway device.33

If three endotracheal intubation attempts have failed, furtherattempts should be omitted even by an experienced healthcare

provider.34 Bagevalveemask ventilation should be resumed or, if

not possible, ventilation should be achieved with a supraglottic

airway device.35 A suction device with a large diameter tube should

be ready. A backwardeupwarderightward pressure or an

optimaleexternalelaryngeal movement36 may improve both

laryngoscopy and tracheal intubation.36,37 Recently, the cricoid

pressure (Sellick manoeuvre) has been de-emphasised as several

studies suggest that it does not prevent aspiration. 38,39 Addition-

ally, bage valveemask ventilation, laryngoscopy and tracheal

intubation may be hindered.39,40

Table 2

Indications, side effects and doses of commonly used intravenous analgetics, modied from:27

Analgetic Indications Side effects Dose

Fentanyl Anaesthesia induction in haemodynamically

stable patients, anaesthesia maintenance

Respiratory depression

Cardiocirculatory depression

Induction: 3-5 (mg kg1)

Maintenance: 1-5 (mg kg1) as repetitive bolus

Ketamine Anaesthesia induction or co-induction with

propofol in haemodynamically fragile or

unstable patients, status asthamticus,

anaesthesia maintenance

Supercial anaesthesia

Tachycardia and arterial hypertension

Induction: 0.5e1.0 (mg kg1)

Maintenance: 0.5e3 (mg kg-1 h-1) continuously

or 0.2e0.5 (mg kg1) as repetitive bolus

Sufentanyl Anaesthesia induction in haemodynamically

stable patients, anaesthesia maintenance

Respiratory depression

Cardiocirculatory depression


Maintenance: 0.1e1 (mg kg-1 h-1) continuously


Table 3Indications, side effects and doses of commonly used intravenous hypnotics, modied from:27.

Hypnotic Indications Side effects Dose

Etomidate Anaesthesia induction in haemodynamically fragile

or unstable patients

Shock states


Inhibitory effect on steroid genesis;

avoid in septic patients


Midazolam Anaesthesia induction in haemodynamically fragile

or unstable patients

Anaesthesia maintenance

Slow onset



Maintenance: 0.03e0.2 (mg kg-1 h-1) continuously


Propofol Anaesthesia induction in haemodynamically stable

patients

Anaesthesia co-induction with ketamine or midazolam

in haemodynamically unstable patients

Arterial hypotension Induction: 2e3 (mg kg1)

Maintenance: 2e6 (mg kg-1 h-1) continuously

or 0.5e2 (mg kg1) as repetitive bolus

Thiopental Anaesthesia induction in haemodynamically stable

patients

Status epilepticus

Histamine release/ ush, asthma

bronchiale

Tissue necrosis if extravasation

Induction: 3e7 (mg kg1)

Keep in mind that, a medical emergency is not an oppor-

tunity for testing new drugs or techniques. Emergencypatients are too sick to tolerate errors made by inexperi-

enced rescuers

H. Prossliner et al. / Trends in Anaesthesia and Critical Care 2 (2012) 109e114 111



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With endotracheal intubation, to optimise the visibility of the

vocal cords, the tongue should be completely pushed to the left

side. Also, to facilitate intubation, a tracheal tube should always be

equipped with a guide wire. In small children, employing a cuffed

vs. an uncuffed endotracheal tube results in lower exchange rates

with a comparable frequency of side effects.41 Cuffed tubes in

children are now also recommended in medical emergencies by the

ERC 2010 guidelines.42

After intubation, two safety maneuvers guarantee correct

endotracheal tube position and hence should be checked imme-

diately. First, during laryngoscopy, the tube should have passed

clearly in between the vocal cords. Second, end-expiratory carbon

dioxide should be conrmed with capnography.5 However, during

cardiac arrest or in low blood ow states, capnography may be not

reliable. In these situations, chest auscultation, apart from visual

laryngoscopic control, may be the best method to conrm correct

tracheal tube placement.43 Bronchial intubation should be consid-

ered with diminished compliance, unilateral ventilation sounds

and chest movements, and low oxygen saturation.

9. Alternative airway devices

For moderately skilled rescuers an alternative airway device

instead of endotracheal intubation may be the best option to

adequately oxygenate a patient (Fig. 2). With a dif cult airway,

a supraglottic airway device may be employed as a conduit for

endotracheal intubation.44 A supraglottic airway device mayalso be

employed in infants and children with a success rate >90%.45

Two interesting supraglottic airway devices which can be used

for ventilation but also for endotracheal intubation are the laryn-

geal mask airway (LMA) Fastrach (LMA North America, Inc.,

San Diego, California, USA)46 and the LMA Ctrach (LMA North

America, Inc.).47

Other supraglottic airway devices allow ventilation without

additionally securing the airway with an endotracheal tube. Most

experience has been accumulated with the LMAClassic (LMA North

America, Inc.) and the LMA Proseal (LMA North America, Inc.).

Insertion of the LMA Classic may be easier, but the LMA Proseal hasa higher airway leakage pressure.48 Consequently, if a high peak

airway pressure is required, an LMA Proseal will remain more air

tight than an LMA Classic. LMA Proseal insertion may be most

ef cient when performed with a laryngoscope and a gum elastic

bougie.49 Ventilation quality with the laryngeal tube suction (LTS)

is comparable to the LMA Proseal.50 However, the LTS requires

a higher cuff pressure than the LMA Proseal, which may cause

pressure sores and tongue swelling from venous blood ow

obstruction at the jaw level.51 The Combitube (Tyco-Kendall,

Manseld, MA, USA) may cause mucosal injury and even life-

threatening oesophageal rupture and is nowadays used less

often.52 All mentioned airway devices, apart from the Combitube,

have been recommended for airway training during routine

anaesthesia induction in the operating theatre.53

Recently, video laryngoscopy showed a higher endotracheal

intubation success than a McIntosh laryngoscope in routine and

dif cult airway scenarios.54,55 However, high acquisition costs may

be a barrier for wide adoption of these devices.

In many studies basically trained volunteers had higher success

rates ventilating the patient with a supraglottic airway devicewhen

compared to endotracheal intubation or even bag-valve mask

ventilation.56 Thus, for less skilled rescuers the time may come

when a supraglottic airway device will be the rst line technique to

ventilate a patient in a medical emergency.32,57

In every EMS regular training with standard and alternative

airway devices should be incorporated. Also, an algorithm for the

expected and unexpected dif cult airway should be developed,

based on the local possibilities and requirements (Figs. 1 and 2).

One should keep in mind that too many patients still diebecause of failed oxygenation, mostly related to cases of

failed endotracheal intubation. Thus, in medical emergen-

cies one of the most prioritised aims should be adequate

oxygenation instead of repeated endotracheal intubationattempts

Fig. 1. Management of an expected dif cult airway in the eld. Adapted from.33

D denotes Dislocation, O obstruction, P pneumothorax, E equipment, S stomach.

Fig. 2. Management of an unexpected dif cult airway in the eld. Adapted with

permission of.33 DOPES: D denotes Dislocation, O obstruction, P pneumothorax,

E equipment, S stomach.




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10. Ventilation and anaesthesia maintenance

Ventilation should be performed cautiously to avoid adverse

effects. Gastric overdistension and subsequent vomiting and

pulmonary aspiration, as well as hyperventilation induced hypo-

tension have been recognised since years.58,59 Less known is an

excessive stomach ination triggered abdominal compartment

syndrome. Indeed excessive stomach and gut ination may

compress central venous return to the heart, thereby decreasing

cardiac output and nally survival.60,61 Also, gut ischaemia in

a patient with excessive stomach ination has been described.62

Once the airway is secured and the patient is being ventilated,

anaesthesia should be maintained until denitive treatment. Thus,

for transport, long-acting anaesthetics with almost inert haemo-

dynamic properties should be administered (Table 2 and Table 3).

During transport, continuous monitoring with ECG, automated, and

if in place invasive, blood pressure measurement, pulse oximetry

and capnography should be continued. Capnography should be

used in every ventilated patient targeting for normocapnia.

However, in a patient with severe chest trauma, arterial partial

carbon dioxide pressure is more reliable than capnography owing

to an increased alveolarearterial carbon dioxide pressure gradient.

Also, in a patient with severe traumatic brain injury, capnographyshould be interpreted cautiously, and ventilation adjusted accord-

ing to arterial partial carbon dioxide pressure.63

In the operating theatre anaesthesia maintenance should be

performed with halogenated anaesthetics, as this will reduce the

risk of adverse cardio- and cerebrovascular events.64

11. Side effects of anaesthesia

Hypoxia, arterial hypotension and hypothermia with detri-

mental effects on outcome are common side effects and should be

prevented. For instance, a brain-injured patient may be at risk of

hypoxia and hyperventilation-induced secondary brain injury.65

Also, in a haemodynamically unstable patient, a ventilation rateabove 10 min1 and positive end-expiratory pressure should be

avoided as mortality may increase.66 In a ventilated patient with

a sudden drop of arterial oxygen saturation, DOPES should be

considered as causes: (tube-) Dislocation, (tube-) Obstruction,

(tension-) Pneumothorax, Equipment failure and Stomach

distension.

12. Conclusion

Preoxygenation should be performed with high-ow oxygen

delivered through a tight tting face mask connected with a reser-

voir. Ketamine may be the induction agent of choice in haemody-

namically unstable patients. Sugammadex, a rocuroniumantagonist, may have the potential to make rocuronium a rst-line

neuromuscular blocking agent in emergency induction. Experi-

enced healthcare providers may consider pre-hospital anaesthesia

induction.

Lesser experienced healthcare providers should refrain from

endotracheal intubation, optimise oxygenation, hasten hospital

transfer and ventilate patients only in life-threatening circum-

stances with a bagevalveemask device or a supraglottic airway.

Senior help should be sought early. In a ‘cannot ventilate cannot

intubate’ situation, a supraglottic airway shouldbe employed and, if

ventilation is still unsuccessful, a surgical airway should be per-

formed. Capnography should be used in every ventilated patient.

Clinical practice is essential to retain anaesthesia and airway

management skills.

Acknowledgements

This manuscript has solely been sponsored by departmental

funds. There are no conicts of interest.

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