Anesthesia in prehospital emergencies and in the

emergency department
Patrick Braun, Volker Wenzel and Peter Paal
Department of Anesthesiology and Critical Care
Medicine, Innsbruck Medical University, Innsbruck,
Austria
Correspondence to Dr Peter Paal, DESA, EDIC,
Department of Anesthesiology and Critical Care
Medicine, Innsbruck Medical University, Anichstrasse
35, 6020 Innsbruck, Austria
Tel: +43 512 504 80448; fax: +43 512 504 22450;
e-mail: peter.paal@uki.at
Current Opinion in Anaesthesiology 2010,
23:500–506
Purpose of review
Recently, notable progress has been made in the field of anesthesia drugs and airway
management.
Recent findings
Anesthesia in prehospital emergencies and in the emergency department is reviewed
and guidelines are discussed.
Summary
Preoxygenation should be performed with high-flow oxygen delivered through a tight-
fitting face mask with a reservoir. Ketamine may be the induction agent of choice in
hemodynamically unstable patients. The rocuronium antagonist sugammadex may have
the potential to make rocuronium a first-line neuromuscular blocking agent in emergency
induction. Experienced healthcare providers may consider prehospital anesthesia
induction. Moderately experienced healthcare providers should optimize oxygenation,
hasten hospital transfer and only try to intubate a patient whose life is threatened. When
intubation fails twice, ventilation should be performed with an alternative supraglottic
airway or a bag–valve–mask device. Lesser experienced healthcare providers should
completely refrain from intubation, optimize oxygenation, hasten hospital transfer and
ventilate patients only in life-threatening circumstances with a supraglottic airway or a
bag–valve–mask device. Senior help should be sought early. In a ‘cannot ventilate-
cannot intubate’ situation, a supraglottic airway should be employed and, if ventilation is
still unsuccessful, a surgical airway should be performed. Capnography should be used
in every ventilated patient. Clinical practice is essential to retain anesthesia and airway
management skills.

Keywords
airway, anaesthesia, emergency medical services, intubation, resuscitation, ventilation

Curr Opin Anaesthesiol 23:500–506

ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
0952-7907

anesthesia drugs and airway management. Thus, the aim

Introduction
Anesthesia in emergencies may save a life in critically ill
or injured patients. However, it may also increase
mortality if not performed properly. For instance, a
patient with an acute severe respiratory insufficiency
may benefit from emergency anesthesia and ventilatory
support. However, a patient may benefit even more from
noninvasive ventilatory support with a continuous
positive airway pressure (CPAP) mask or helmet. Sim-
ilarly, a patient with a traumatic brain injury and a
Glasgow Coma Scale (GCS) score of 7 may benefit from
prehospital emergency anesthesia and intubation [1], but
outcome may also depend on factors such as transfer time
to the next hospital and airway management skills of the
attending healthcare personnel. The pros and cons of
emergency anesthesia are hotly debated. When should a
patient be intubated? Which anesthetics should be admi-
nistered? Which airway should be chosen? Recently,
impressive advances have been made in the fields of
0952-7907 ß 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
of this review is to offer a nonsystematic review on
anesthesia in prehospital emergencies and in the emer-
gency department (ED).
Indications for emergency anesthesia
In France, airway management-experienced emergency
physicians had problems in only approximately 3% of
prehospital intubations [2]. On the contrary, in Miami,
paramedics encountered intubation difficulties in
approximately 30% of patients, and were not able to
intubate 10% of patients [3]. Similarly, a study [4] in
San Francisco reported endotracheal tubes being mis-
placed esophageally or being dislocated in 15 children, 14
of whom died. As a consequence, the authors recom-
mended paramedics to refrain from intubating children.
In a German study on prehospital intubations performed
by emergency medical system (EMS) physicians with
widely varying airway management skills, a 15% rate of
DOI:10.1097/ACO.0b013e32833bc135

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

esophageally or bronchially positioned tubes was reported.
Mortality rate in patients with esophageally misplaced
tubes was 80% as compared with 20% for the overall study
cohort [5]. Recently, the Association of Anaesthetists of
Great Britain and Ireland [6] recommended prehospital
anesthesia only for appropriately trained and competent
practitioners. Studies on intubation recommendations
have provided conflicting results, mainly attributable on
variable study setting parameters such as different patient
cohorts (e.g. blunt vs. penetrating trauma), profession
groups (e.g. anesthesiologist vs. EMS physician vs. nurse
vs. paramedic), skill levels (e.g. anesthesiologist vs. general
practitioner) and hospital transfer time [2,5]. In our
opinion, the title and profession of a given rescuer are less
important than his or her skill level. For example, a
paramedic with regular clinical experience may have a
higher skill level than an EMS physician with rare airway
management practice. Recently, we have suggested a
three-level airway management skills model, which could
serve as a decision guide for a given rescuer [7]. For
instance, a highly skilled ‘gold’ level rescuer could decide
freely how to oxygenate and ventilate a patient. A moder-
ately skilled ‘silver’ level rescuer could attempt endotra-
cheal intubation twice and then switch to an alternative
supraglottic airway device or bag–valve–mask ventilation.
A less skilled ‘bronze’ level rescuer should completely
refrain from endotracheal intubation, optimize oxygen-
ation, hasten hospital transfer and employ a supraglottic
airway device or bag–valve–mask ventilation only in
patients in life-threatening situations.
Prehospital anesthesia and anesthesia in the
emergency department
The decision of whether a patient should be anesthetized
in the field or later in the ED may depend on several
parameters. Indications of prehospital anesthesia are as
follows:
(1) gold level rescuer,
(2) experienced team members,
(3) severe head trauma (GCS<9),
(4) long transport time to hospital,
(5) fast deteriorating patients, whose condition could be
stabilized with intubation (e.g. respiratory failure),
(6) good equipment including drugs and airway manage-
ment tools,
(7) safe and appropriate environment (e.g. terrain,
temperature and light).
Also, contraindications of prehospital anesthesia when
compared with anesthesia in the ED should be kept in
mind. For instance, pneumonia rate [8] and mortality [9]
may be increased with prehospital anesthesia when com-
pared with anesthesia performed in the ED. However,
study results are difficult to extrapolate from one EMS to
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Anesthesia in medical emergencies Braun et al. 501
another because of highly different structures. For
example, in an urban vs. a rural EMS, transfer time is
short; thus anesthesia may be delayed until hospital
arrival. This may be safer for a patient because both
logistics and personnel resources in the ED are better.
One new option to make tracheal intubation safer could
be a suction laryngoscope, which rendered esophageal
intubations less likely when ‘bronze’ level laryngosco-
pists were performing airway management [10].
Oxygenation and preoxygenation
To avoid oxygen desaturation during anesthesia induc-
tion, body oxygen stores should be filled up with pre-
oxygenation. Several techniques may improve preoxy-
genation. Optimally, oxygen should be applied with a
tightly fitting face mask with reservoir and high oxygen
flow (e.g. 10 l/min, Table 1) [11], approaching an inspira-
tory oxygen fraction of approximately 100% [12]. Func-
tional residual capacity may be increased with CPAP up
to 10 cmH2O [13], a sitting position [14] or elevating the
chest by 258 [15], if applicable with the hemodynamics
present and the trauma pattern. However, in hemodyna-
mically unstable patients, CPAP may destabilize circula-
tion owing to the consequences of heart–lung interaction
[16]. Also, fear and pain should be treated to decrease
excessive oxygen demand [17]. In cases of sufficient
spontaneous breathing, 3 min or eight deep breaths of
100% oxygen denitrogenize the lungs [18]. Deep breath-
ing over 1–2 min has to be considered under these
circumstances, as this maneuver is equally effective in
yielding maximal preoxygenation and extending time to
desaturation onset [19]. Efficiency of preoxygenation
may be monitored with a pulse oximetry target value
of at least 99% and an end-expiratory oxygen fraction of at
least 80%, as measured by an anesthetic monitor. Many
factors can influence preoxygenation. For instance, oxy-
gen stores may be reduced owing to lung contusion or
pneumonia in a critically ill patient, decreasing functional
residual capacity and increasing right-to-left shunt.
Additionally, hemoglobin may be critically low because
of hemorrhage. Thus, preoxygenation may be less effec-
tive in some patients, but because of increased safety
margins during endotracheal intubation, it should always
be employed. A short time to definite airway control is a
Table 1 Devices for oxygenation and preoxygenation
Oxygenation device O2 (l/min) FiO2 (%)
Nasal cannula 1–6 24–44
Face mask 8–10 40–60
Face mask with reservoir 6–10 60–100
Anesthesia bag–valve–mask device 12 50
Anesthesia bag–valve–mask 12 100
device with reservoir
Oxygen flow (l/min) and resulting inspiratory oxygen fraction (FiO2) are
given.
 502 Anesthesia outside the operating room

Table 2 Indications, side effects and doses of commonly used intravenous analgesics
Analgesic Indications Side effects Dose

Fentanyl Anesthesia induction in hemodynamically
stable patients, anesthesia maintenance
Ketamine Anesthesia induction in hemodynamically
fragile or unstable patients, anesthesia
maintenance
Sufentanil Anesthesia induction in hemodynamically
stable patients, anesthesia maintenance
Respiratory depression, cardiocirculatory
depression
Superficial anesthesia, inhibitory effect
on steroid genesis
Respiratory depression, cardiocirculatory
depression
Induction, 3–5 mg/kg; maintenance,
1–5 mg/kg as repetitive bolus
Induction, 0.5–1.0 mg/kg; maintenance,
0.5–3 mg/kg/h continuously or
0.2–0.5 mg/kg as repetitive bolus
Induction, 0.25–1.0 mg/kg; maintenance,
0.1–10 mg/kg/h continuously or
0.3–0.7 mg/kg as repetitive bolus

key factor in the prevention of a hypoxemia-related
secondary organ injury.
Drugs in emergency anesthesia
Tables 2 and 3 give an overview of commonly used
anesthetics. Administration of etomidate in critically ill
patients has been discouraged because of its inhibitory
effect on steroid genesis, even after single administration
[20,21]. Ketamine may be the drug of choice for anesthe-
sia induction in hemodynamically unstable patients [22].
Also, propofol coinduction with 0.1 mg/kg midazolam [23]
or 0.5 mg/kg ketamine [24] compared with propofol alone
may be propofol sparing, resulting in less hemodynamic
depression, which may be advantageous in hemodynami-
cally unstable patients. For analgesia during anesthesia
induction, fentanyl or sufentanil in hemodynamically
stable and ketamine in hemodynamically unstable
patients may be the agents of choice because of fast
onset and acceptable analgesic effect and duration [25].
Adding neuromuscular block to emergency anesthesia
induction is discussed controversially. Some argue
that the presence of a neuromuscular block offers the
best possible intubation condition. Others argue that,
with a neuromuscular block, an esophageally placed
endotracheal tube inevitably leads to death. Therefore,
some EMS services do not recommend administra-
tion of neuromuscular blockers when performing an
emergency anesthesia induction. Suxamethonium
(1–1.5 mg/kg) is still the most widely employed neu-
romuscular blocking agent. However, some refrain from
using this drug because of several, potentially lethal,
drawbacks such as malignant hyperthermia, hyperkale-
mia, intraocular pressure increase and muscle pain.
Recently, the rocuronium antagonist sugammadex has
been introduced into clinical practice. With a dose of
16 mg/kg sugammadex, rocuronium-induced neuromus-
cular block reversal is faster than spontaneous muscular
recovery after suxamethonium administration. Thus,
rocuronium (1.2 mg/kg) has the potential to become
the first-line neuromuscular blocking agent in emer-
gency anesthesia.
Anesthesia induction, maintenance and
monitoring
The patient should be placed in a sniffing position – with
a support beneath his head – to open the upper airway
optimally; this may be especially helpful in patients with
obesity or a stiff cervical spine. In infants, a support under
the chest may counteract the anterior head flexion caused
by the large occiput. Before anesthesia induction, a
patient should be monitored with ECG, blood pressure
(BP) measurement and pulse oximetry. The intravenous
line should be well fixed to avoid dislocation during
anesthesia induction and maintenance. Involved person-
nel should be experienced in anesthesia induction and
treatment of possible side effects. All drugs for anesthesia
and advanced life support should be ready. An emer-
gency is not an opportunity for testing new drugs or
techniques. Patients are too sick to tolerate errors by
inexperienced rescuers. Thus, drugs and techniques
should first be sufficiently tested in a controlled environ-
ment with noncritically ill or injured patients with expert

Table 3 Indications, side effects and doses of commonly used intravenous hypnotics
Hypnotic Indications Side effects Dose

Etomidate Anesthesia induction in hemodynamically
fragile or unstable patients
Midazolam Anesthesia induction in hemodynamically
fragile or unstable patients, anesthesia
maintenance
Propofol Anesthesia induction in hemodynamically
stable patients
Thiopental Anesthesia induction in hemodynamically
stable patients, status epilepticus
Superficial anesthesia, inhibitory
effect on steroid genesis
Slow onset, superficial anesthesia
Arterial hypotension
Histamine release! flush, asthma
bronchiale; tissue necrosis if
extravasation
Induction, 0.2–0.5 mg/kg
Induction, 0.1–0.4 mg/kg; maintenance,
0.03–0.2 mg/kg/h continuously or
0.03–0.2 mg/kg as repetitive bolus
Induction, 2–3 mg/kg; maintenance,
2–6 mg/kg/h continuously or
0.5–2 mg/kg as repetitive bolus
Induction, 3–7 mg/kg

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supervision before being applied in emergencies, in
particular in preclinical emergency situations.
Tracheal intubation and ventilation
Tracheal intubation is still the gold standard to secure
the airway. Flexible bronchoscopy may be an excellent
tool to intubate a patient with a known difficult airway
(Fig. 1 [26]). However, it will be hardly accessible in the
field and, for an efficient use, healthcare personnel
require more training than with other intubation tech-
niques. A suction device with a large diameter tube
should be prepared. A backward–upward–rightward
pressure or an optimal–external–laryngeal movement
maneuver may improve both laryngoscopy and tracheal
intubation [28,29]. Cricoid pressure (Sellick maneuver)
has been widely advocated to prevent reflux of gastric
content. Recently, several studies have suggested that it
does not prevent aspiration [30]. Additionally, bag–
valve–mask ventilation, laryngoscopy and tracheal intu-
bation may be hindered [31]. Therefore, applying the
Sellick maneuver universally in emergencies is not
recommended in children [32] and is still in debate in
adult patients [32]. Also, the tongue may be pushed to
the left side and not be compressed by the laryngoscope,
thus improving visibility of the vocal cords. 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 may result in lower
exchange rates with a comparable frequency of side
effects [33].
Verifying tracheal tube position
After intubation, two details guarantee correct endotra-
cheal tube position and should be checked immediately.
First, during laryngoscopy, the tube should have passed
in between the vocal cords. Second, endexpiratory carbon
dioxide should be confirmed with capnography [5]. How-
ever, during cardiac arrest or in low blood flow states,
capnography may be not reliable. In these situations,
chest auscultation, apart from visual control, may be
the best method to confirm correct tracheal tube place-
ment [34]. Bronchial intubation should be considered
with diminished compliance, unilateral ventilation
sounds and chest movements, and low oxygen saturation.
How to proceed after a failed intubation
attempt
Sometimes, intubation with one attempt is not possible;
thus bag–valve–mask ventilation should be resumed
within 30 s and efforts made to improve intubation
success. To improve upper airway patency, an orophar-
yngeal or nasopharyngeal tube may be employed. Bag–
valve–mask ventilation is sufficient if the chest rises
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Anesthesia in medical emergencies Braun et al. 503
Figure 1 Algorithm for an expected difficult airway in the field or
in the emergency room
Expected difficult airway
Yes No
Avoid anesthesia Highly experienced in
airway management?
Optimize
oxygenation No Yes
Fast transport to Consider anesthesia
hospital; if in hospital induction
call senior help
Prehospital anesthesia if In hospital awake
patient in extremis fiberoptic intubation
Adapted with permission from [26].
clearly during positive pressure ventilation and recedes
during expiration. Ventilation should be performed cau-
tiously to avoid adverse effects of excessive stomach
inflation. Recently, a stomach inflation triggered
abdominal compartment syndrome has been reported
[35,36]; venous return to the heart may diminish,
decreasing cardiac output and finally even contributing
to death. Also, gut ischemia in a patient with excessive
stomach inflation has been described [37]. If three intu-
bation attempts have failed, further attempts should be
omitted even by an experienced healthcare provider
[38]. Bag–valve–mask ventilation should be resumed
or, if not possible, ventilation should be achieved with a
supraglottic airway device [27]. Senior help should be
sought early. Some scientific societies in Europe and
North America have developed difficult airway algor-
ithms [27,39]. Similarly, EMSs should develop algor-
ithms for an expected and an unexpected difficult air-
way, adapted to local conditions and national regulatory
framework (Figs 1 and 2).
Alternative airway devices
Conventional tracheal intubation may not be feasible in
some patients despite optimal performance. In this case,
an alternative airway device may be the second best way
to intubate and ventilate a patient (Fig. 2). Established
tools for tracheal intubation are the laryngeal mask airway
(LMA) Fastrach (LMA North America, Inc., San Diego,
California, USA) [40] and the LMA Ctrach (LMA North
America, Inc.) [41], both devices allow ventilation and
intubation. The Airtraq (ProMedic, Inc., Bonita Springs,
Florida, USA) is another promising intubation device
 504 Anesthesia outside the operating room
Figure 2 Algorithm for an unexpected difficult airway in the field
or in the emergency room
Unexpected difficult airway
Optimize oxygenation
No Mask ventilation possible? Yes
Alternative Alternative
airway airway
device device
No Ventilation No
ventilation ventilation
Hospital transfer; if in Mask
Surgical airway
hospital call senior help ventilation
Adapted with permission from [26].
[42]. Supraglottic airway devices allow ventilation with-
out securing the airway. Most experience has been gath-
ered with the LMA Classic (LMA North America, Inc.)
and the LMA Proseal (LMA North America, Inc.). Inser-
tion of the LMA Classic may be easier, but the LMA
Proseal has a higher airway leakage pressure [43]. LMA
Proseal insertion may be most efficient when performed
with a laryngoscope and a gum elastic bougie [44].
Ventilation quality with the laryngeal tube suction
(LTS) is comparable to the LMA Proseal [45]. However,
the LTS requires a higher cuff pressure than the LMA
Proseal, which may cause pressure sores and macroglossia
[46]. The Combitube (Tyco-Kendall, Mansfield, Massa-
chusetts, USA) may cause mucosal injury and even life-
threatening esophageal rupture and is nowadays used less
often [47]. All mentioned airway devices, apart from the
Combitube, are recommended for training during routine
anesthesia [48].
Anesthesia maintenance and monitoring
Once the airway is secured and the patient is being
ventilated, anesthesia should be maintained until defini-
tive treatment. Thus, for transport, long-acting anes-
thetics with almost inert hemodynamic properties should
be administered (Tables 2 and 3). During transport,
continuous monitoring with ECG, automated BP
measurement, pulse oximetry and capnography should
be performed. Capnography should be employed in every
ventilated patient to achieve normocapnia. However, in a
patient with severe chest trauma, arterial partial carbon
dioxide pressure is more reliable than capnography owing
to an increased alveolor–arterial carbon dioxide pressure
gradient. Also, in a patient with severe traumatic brain
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
injury, capnography should be interpreted cautiously,
and ventilation adjusted according to arterial partial car-
bon dioxide pressure [49].
Side effects of anesthesia
Hypoxia, arterial hypotension and hypothermia with
detrimental effects on outcome are common side effects
and should be prevented. For instance, a brain-injured
patient may be at risk of hypoxia-induced and hyper-
ventilation-induced secondary brain injury [50]. Also, in
hemodynamically unstable trauma patients, ventilation
rate above 10/min and positive end-expiratory pressure
should be avoided because mortality may increase [51].
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.
Training
A patient should not suffer or die because of a healthcare
provider’s poor anesthesia and airway management capa-
bilities. A healthcare provider has to be familiar with the
locally available alternative airway devices because man-
agement of a difficult airway depends more on the
experience of the rescuer than on a given airway device.
Regular training in simulation courses and the operating
room is warranted.
Recently, the Association of Anaesthetists of Great
Britain and Ireland [6] stated that a high training
level and simple techniques are the key to successful
airway management. Healthcare personnel providing
prehospital anesthesia ‘should have the same level of
training and competence that would enable them to
provide unsupervised rapid sequence induction in the
ED’. Unfortunately, this training level may be unrealistic
in many EMSs.
Conclusion
Preoxygenation should be performed with high-flow oxy-
gen delivered through a tight-fitting face mask with a
reservoir. Ketamine may be the induction agent of choice
in hemodynamically unstable patients. The rocuronium
antagonist sugammadex may have the potential to make
rocuronium a first-line neuromuscular blocking agent in
emergency induction. Experienced healthcare providers
may consider prehospital anesthesia induction. Moder-
ately experienced healthcare providers should optimize
oxygenation, hasten hospital transfer and only try to
intubate a patient whose life is threatened. When intuba-
tion fails twice, ventilation should be performed with an
alternative supraglottic airway or a bag–valve–mask

device. Less experienced healthcare providers should
completely refrain from intubation, optimize oxygen-
ation, hasten hospital transfer and ventilate patients only
in life-threatening circumstances with a supraglottic air-
way or a bag–valve–mask device. Senior help should be
sought early. In a ‘cannot ventilate-cannot intubate’
situation, a supraglottic airway should be employed
and, if ventilation is still unsuccessful, a surgical airway
should be performed. Capnography should be used in
every ventilated patient. Clinical practice and continuous
supervised training, for example in simulation courses,
are essential to retain high-level skills in preclinical
anesthesia and airway management.
Acknowledgements
This manuscript has solely been sponsored by departmental funds.
There are no conflicts of interest.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:
 of special interest
 of outstanding interest
Additional references related to this topic can also be found in the Current
World Literature section in this issue (p. 538).
1 Winchell RJ, Hoyt DB. Endotracheal intubation in the field improves survival in
patients with severe head injury. Trauma Research and Education Foundation
of San Diego. Arch Surg 1997; 132:592–597.
2 Tentillier E, Heydenreich C, Cros AM, et al. Use of the intubating laryngeal
mask airway in emergency prehospital difficult intubation. Resuscitation
2008; 77:30–34.
3 Cobas MA, De la Pena MA, Manning R, et al. Prehospital intubations and
mortality: a level 1 trauma center perspective. Anesth Analg 2009; 109:489–
493.
4 Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric
endotracheal intubation on survival and neurological outcome: a controlled
clinical trial. JAMA 2000; 283:783–790.
5 Timmermann A, Russo SG, Eich C, et al. The out-of-hospital esophageal and
endobronchial intubations performed by emergency physicians. Anesth Analg
2007; 104:619–623.
6 The Association of Anaesthetists of Great Britain and Ireland (AAGBI). Safety
 Guideline for prehospital anaesthesia. http://www.aagbi.org/publications/
guidelines/docs/prehospital_glossy09.pdf; 2009. [Accessed 2010]
An authoritative and up-to-date discussion on prehospital anesthesia, including
some recommendations, written by the Association of Anaesthetists of Great
Britain and Ireland.
7 von Goedecke A, Herff H, Paal P, et al. Field airway management disasters.
Anesth Analg 2007; 104:481–483.
8 Ufberg JW, Bushra JS, Karras DJ, et al. Aspiration of gastric contents: associa-
tion with prehospital intubation. Am J Emerg Med 2005; 23:379–382.
9 Davis DP, Dunford JV, Poste JC, et al. The impact of hypoxia and hyperventila-
tion on outcome after paramedic rapid sequence intubation of severely head-
injured patients. J Trauma 2004; 57:1–8.
10 Mitterlechner T, Maisch S, Wetsch WA, et al. A suction laryngoscope
facilitates intubation for physicians with occasional emergency medical
service experience: a manikin study with severe simulated airway haemor-
rhage. Resuscitation 2009; 80:693–695.
11 Tanoubi I, Drolet P, Donati F. Optimizing preoxygenation in adults. Can J
 Anaesth 2009; 56:449–466.
A very good review on preoxygenation techniques, which should be read by
everyone involved in anesthesia in emergencies.
12 McGowan P, Skinner A. Preoxygenation: the importance of a good face mask
seal. Br J Anaesth 1995; 75:777–778.
13 Gander S, Frascarolo P, Suter M, et al. Positive end-expiratory pressure
during induction of general anesthesia increases duration of nonhypoxic
apnea in morbidly obese patients. Anesth Analg 2005; 100:580–584.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Anesthesia in medical emergencies Braun et al. 505
14 Altermatt FR, Munoz HR, Delfino AE, Cortinez LI. Preoxygenation in the obese
patient: effects of position on tolerance to apnoea. Br J Anaesth 2005;
95:706–709.
15 Dixon BJ, Dixon JB, Carden JR, et al. Preoxygenation is more effective in the 25
degrees head-up position than in the supine position in severely obese
patients: a randomized controlled study. Anesthesiology 2005; 102:
1110–1115.
16 Reuter DA, Goetz AE, Peter K. Assessment of volume responsiveness in
mechanically ventilated patients [article in German]. Anaesthesist 2003;
52:1005–1007; 1010–1013.
17 Mort TC. Preoxygenation in critically ill patients requiring emergency tracheal
intubation. Crit Care Med 2005; 33:2672–2675.
18 Stafford R, Benger J, Nolan J. Preoxygenation remains essential before
emergency tracheal intubation. Crit Care Med 2006; 34:1859–1860.
19 Nimmagadda U, Chiravuri SD, Salem MR, et al. Preoxygenation with tidal
volume and deep breathing techniques: the impact of duration of breathing
and fresh gas flow. Anesth Analg 2001; 92:1337–1341.
20 Jabre P, Combes X, Lapostolle F, et al. Etomidate versus ketamine for rapid
 sequence intubation in acutely ill patients: a multicentre randomised con-
trolled trial. Lancet 2009; 374:293–300.
This original article reports on adverse survival effects of a single dose of
ethomidate administered in adults. It is clearly demonstrated that ethomidate
should be avoided in critically ill adult patients.
21 den Brinker M, Hokken-Koelega AC, Hazelzet JA, et al. One single dose of
etomidate negatively influences adrenocortical performance for at least 24 h
in children with meningococcal sepsis. Intensive Care Med 2008; 34:163–
168.
22 Morris C, Perris A, Klein J, Mahoney P. Anaesthesia in haemodynamically
 compromised emergency patients: does ketamine represent the best choice
of induction agent? Anaesthesia 2009; 64:532–539.
This highly informative review discusses the pros and cons of drugs which may be
employed as anesthesia induction agents during emergencies in hemodynamically
unstable patients.
23 Win NN, Kohase H, Yoshikawa F, et al. Haemodynamic changes and heart
rate variability during midazolam–propofol co-induction. Anaesthesia 2007;
62:561–568.
24 Begec Z, Demirbilek S, Onal D, et al. Ketamine or alfentanil administration
prior to propofol anaesthesia: the effects on ProSeal laryngeal mask airway
insertion conditions and haemodynamic changes in children. Anaesthesia
2009; 64:282–286.
25 Morgan E, Mikhail M, Murray M. Clinical anesthesiology. 4th ed.; 2006.
26 Paal P, Herff H, Mitterlechner T, et al. Anaesthesia in prehospital emergencies
and in the emergency room. Resuscitation 2010; 81:148–154.
27 Practice guidelines for management of the difficult airway: an updated report
by the American Society of Anesthesiologists Task Force on Management of
the Difficult Airway. Anesthesiology 2003; 98:1269–1277.
28 Takahata O, Kubota M, Mamiya K, et al. The efficacy of the ‘BURP’ maneuver
during a difficult laryngoscopy. Anesth Analg 1997; 84:419–421.
29 Benumof JL, Cooper SD. Quantitative improvement in laryngoscopic view by
optimal external laryngeal manipulation. J Clin Anesth 1996; 8:136–140.
30 Thorn K, Thorn SE, Wattwil M. The effects of cricoid pressure, remifentanil,
and propofol on esophageal motility and the lower esophageal sphincter.
Anesth Analg 2005; 100:1200–1203.
31 Steinmann D, Priebe HJ. Cricoid pressure [article in German]. Anaesthesist
2009; 58:695–707.
32 Weiss M, Gerber AC. Induction of anaesthesia and intubation in children with
a full stomach. Time to rethink! [article in German]. Anaesthesist 2007;
56:1210–1216.
33 Weiss M, Dullenkopf A, Fischer JE, et al. Prospective randomized controlled
 multicentre trial of cuffed or uncuffed endotracheal tubes in small children. Br J
Anaesth 2009; 103:867–873.
In children, an endotracheal tube exchange rate reduction from 30 to 3% is
reported in this study by employing MicroCuff (Kimberly-Clark, Roswell, Georgia,
USA) when compared with uncuffed tubes, while having comparable side effects.
34 Takeda T, Tanigawa K, Tanaka H, et al. The assessment of three methods to
verify tracheal tube placement in the emergency setting. Resuscitation 2003;
56:153–157.
35 Paal P, Neurauter A, Loedl M, et al. Effects of stomach inflation on haemo-
dynamic and pulmonary function during spontaneous circulation in pigs.
Resuscitation 2009; 80:470–477.
36 Paal P, Neurauter A, Loedl M, et al. Effects of stomach inflation on haemo-
dynamic and pulmonary function during cardiopulmonary resuscitation in pigs.
Resuscitation 2009; 80:365–371.
 506 Anesthesia outside the operating room
37 Paal P, Schmid S, Herff H, et al. Excessive stomach inflation causing gut
ischaemia. Resuscitation 2009; 80:142.
38 Mort TC. Emergency tracheal intubation: complications associated with
repeated laryngoscopic attempts. Anesth Analg 2004; 99:607–613.
39 Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society
guidelines for management of the unanticipated difficult intubation. Anaes-
thesia 2004; 59:675–694.
40 Ferson DZ, Rosenblatt WH, Johansen MJ, et al. Use of the intubating LMA-
Fastrach in 254 patients with difficult-to-manage airways. Anesthesiology
2001; 95:1175–1181.
41 Nickel EA, Timmermann A, Roessler M, et al. Out-of-hospital airway manage-
ment with the LMA CTrach: a prospective evaluation. Resuscitation 2008;
79:212–218.
42 Maharaj CH, Costello JF, Harte BH, Laffey JG. Evaluation of the Airtraq and
Macintosh laryngoscopes in patients at increased risk for difficult tracheal
intubation. Anaesthesia 2008; 63:182–188.
43 Brimacombe J, Keller C, Boehler M, Puhringer F. Positive pressure ventilation
with the ProSeal versus classic laryngeal mask airway: a randomized, cross-
over study of healthy female patients. Anesth Analg 2001; 93:1351–1353.
44 Hohlrieder M, Brimacombe J, von Goedecke A, Keller C. Guided insertion of
the ProSeal laryngeal mask airway is superior to conventional tracheal
intubation by first-month anesthesia residents after brief manikin-only training.
Anesth Analg 2006; 103:458–462.
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
45 Gaitini LA, Vaida SJ, Somri M, et al. A randomized controlled trial comparing
the ProSeal Laryngeal Mask Airway with the Laryngeal Tube Suction in
mechanically ventilated patients. Anesthesiology 2004; 101:316–320.
46 Figueredo E, Martinez M, Pintanel T. A comparison of the ProSeal laryngeal
mask and the laryngeal tube in spontaneously breathing anesthetized pa-
tients. Anesth Analg 2003; 96:600–605.
47 Bagheri SC, Stockmaster N, Delgado G, et al. Esophageal rupture with the
use of the Combitube: report of a case and review of the literature. J Oral
Maxillofac Surg 2008; 66:1041–1044.
48 Bein B, Carstensen S, Gleim M, et al. A comparison of the proseal laryngeal
mask airway, the laryngeal tube S and the oesophageal–tracheal combitube
during routine surgical procedures. Eur J Anaesthesiol 2005; 22:341–346.
49 Davis DP, Dunford JV, Ochs M, et al. The use of quantitative end-tidal
capnometry to avoid inadvertent severe hyperventilation in patients with head
injury after paramedic rapid sequence intubation. J Trauma 2004; 56:808–
814.
50 Shafi S, Gentilello L. Prehospital endotracheal intubation and positive pres-
sure ventilation is associated with hypotension and decreased survival in
hypovolemic trauma patients: an analysis of the National Trauma Data Bank.
J Trauma 2005; 59:1140–1145.
51 Herff H, Paal P, von Goedecke A, et al. Influence of ventilation strategies on
survival in severe controlled hemorrhagic shock. Crit Care Med 2008;
36:2613–2620.