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German Prehospital Anesthesia Recommendation
PASSWORT VERGESSEN

Recently, the German Society of Anesthesiology and Critical Care Medicine dasFOAM
(DGAI) has published their rst ever Recommendation on prehospital emergency
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anesthesia. Since in Germany there is a system with both paramedics (currently 2 Search…
years of training, just now “upgraded” to 3 years) and a broad availability of
prehospital emergency physicians on rapid response vehicles and helicopters
(about 1.000 emergency vehicles in the country) often times, even complex airway Forum
management is done “in the eld”. SMACC+FOAM D-A-
CH
So – what is the DGAI recommending? Username:
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The central points in the recommendations are:

Critical scrutiny of the indication to induct prehospital anesthesia Password:

RSI with a standardized approach, standardized equipment and medications,
in-line-stabilization (if needed), capnography
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Preoxygenation via face-mask with reservoir or noninvasive ventilation (NIV)
Basic monitoring that needs to be there: ECG monitoring, automatic blood Log In
pressure, pulse oxymetry, capnography Register Lost Password
If possible two venous accesses

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Analgesie, Sedierung
Indications to induce prehospital anesthesia are: und Delirmanagement
in der Intensivmedizin
Respiratory insu ciency (hypoxemia or hyper/hypoventilation) and What do you really know
contraindication or failure of noninvasive ventilation (NIV) about coagulation at this
Reduced consciousness / neurologic de cit with risk of aspiration very moment?
Polytrauma / massive trauma with hemodynamic instability or hypoxia or in situ simulation
suspicion of traumatic brain injury with GCS <9. workshop at
#smaccDUB
Goals of prehospital anesthesia are: Learning on the Loo –
Toilet paper #2:
Amnesia Torsades de pointes
Anxiolysis EuSEM Refresher
Reduction of stress Course 7
Analgesia

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08/08/2018 German Prehospital Anesthesia Recommendation – foam-europe.org

E ective airway protection Neueste

Reduction in Oxygen consumption Kommentare
Protection of vital organs, reduction/prevention of secondary myocardial or
Martin Fandler on
cerebral damage
Pediatric dosing – table
David on Pediatric
There is a lot of emphasis on preparation, team communication and team
dosing – table
management.
Thomas Ihmann on
Pediatric dosing – table
Before starting with the “real” RSI, there needs to be the indication and team
foam-europe.org – Neue
communication. While preoxygenation is started, optimal positioning, preparation of
Netzressource | News
medications, airway alternatives, suction and capnography as well as monitoring and
Papers on Learning on
two IV-accesses are prepared. Only then RSI is started. (There is no “checklist” per
the Loo – Toilet paper
se, as it is recommended in a few of the other online available airway algorithms, e.g.
#1: Pulmonary
Sydney HEMS or EMcrit.
embolism
Martin Fandler on
In the case of cannot ventilate / cannot intubate they suggest a “forward strategy” Favorite Tool #2 –
since the option to return to spontaneous breathing is in preclinical emergency folding bougie
medicine – contrary to clinical anesthesia – mostly only a theoretical option.

Now to what I really like about this guideline – they managed to group prehospital Archives
patients into di erent scenarios and have suggestions for induction in all of them.
January 2017
Since we as prehospital emergency doctors treat such a broad range of patients, a
August 2016
“one size ts all” concept does not always apply (the only exeption being of course
June 2016
Ketamine, which I love dearly ;-)).
May 2016
April 2016
I list their recommendations here – please feel free to discuss and o er your
March 2016
opinions! By the way – they to use S-Ketamin/Ketanest here (double potency of
February 2016
Ketamine), so don’t be surprised by the seemingly low doses of Ketamine. Also, they
January 2016
suggest push-dose-pressors of 10yg of Norepinephrine given with low blood
December 2015
pressure, or via continuous infusion.
January 2015

 
Beitrags-
Massive Trauma Kategorien

Analgosedation until extrication is achieved (if needed): Select Category

Midazolam 3mg + S-Ketamin 25mg (every 10min rep bolus 10mg if needed)

Induction:
Team – Login
Midazolam 7mg OR Propofol 100mg OR Thiopental 200mg Register
+ S-Ketamin 100mg OR Fentanyl 0,2mg OR Sufentanil 20yg Log in
+ Rocuronium 70-100mg OR Succinylcholine 100mg Entries RSS
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Midazolam 3-5mg (every 20mins)
+ S-Ketamin 20mg (every 20 mins) OR Fentanyl 0,15mg (every 20 mins)
+ Rocuronium 20mg (every 20min)

Isolated traumatic brain injury, stroke, intracranial hemmorhage

Induction:
Thiopental 300mg or Propofol 140mg
+ Fentanyl 0,2mg OR Sufentanil 20yg OR S-Ketamin 100mg
+ Rocuronium 70-100mg OR Succinylcholine 70mg

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Maintenance:
Midazolam 3-5mg (every 20mins)
+ Fentanyl 0,15mg (every 20 mins)

High Risk Cardiac Patient – two cases with di erent suggestions

1.) Hypertensive pulmonary edema, hypoxemia, failure of NIV

Induction:
Fentanyl 0,2mg OR Sufentanil 20yg iv
+ Etomidate 20mg
+ Rocuronium 70-100mg OR Succinylcholine 70mg

Maintenance:
Midazolam 3-5mg (every 20mins)
+ Fentanyl 0,1mg (every 20 mins)

2.) Cardiogenic shock, hypotensive, hypoxemia

Induction:
Fentanyl 0,2mg OR Sufentanil 20yg iv
+ Midazolam 7mg
+ Rocuronium 70-100mg OR Succinylcholine 70mg

Maintenance:
Midazolam 3-5mg (every 20mins)
+ Fentanyl 0,1mg (every 20 mins)

Respiratory insu ciency

Version 1:

Induction:
Fentanyl 0,2mg OR Sufentanil 20yg iv
+ Propofol 110-160mg or Etomidate 20mg
+ Rocuronium 70-100mg OR Succinylcholine 100mg

Maintenance:
Midazolam 3-5mg (every 20mins)
+ Fentanyl 0,15mg (every 20 mins)

Version 2:

Induction:
S-Ketamin 35-100mg
+ Midazolam 7mg
+ Rocuronium 70-100mg OR Succinylcholine 100mg

Maintenance:
Midazolam 3-5mg (every 20mins)
+ S-Ketamin 20mg (every 20 mins)

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08/08/2018 German Prehospital Anesthesia Recommendation – foam-europe.org

What I think: I think this is a great step forward to standardize the prehospital airway
management in Germany. Ketamine was prominently managed, even while
some Anesthesiologists out there still seem to think of it only a “last resort medication in
trauma”. Also,the focus pre-, peri- and post-RSI communication within the team is very
well done. Some medication combinations are not what I would use, but there are very
good arguments in all the cases. Notably absent is the use apneic oxygenation. Maybe in
the next version there will be a stronger emphasis on video laryngoscopy, checklists and
even a part on prehospital procedural sedation.

But what do you think? Is this similar to what you use in the prehospital eld (or the
resus room) or do you have totally di erent regimes?

Link to the german version of the recommendations: AWMF.

This entry was posted in prehospital and tagged Airway, Analgesia, Anesthesia,
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3 thoughts on “German Prehospital Anesthesia
Recommendation”

February 9, 2016 at 5:47 pm

Great initiative! Looking forward to the future progress!
Fredrik
Granholm
@TotalResus
says:
Reply
February 9, 2016 at 10:27 pm
Thanks Fredrik! If you want to participate, feel free to write me an
email!
Martin
Fandler
says:
Reply

Pingback: [german] Online presentation and hangout – emergency airway

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