Based on written surveys conducted during the series of workshops entitled "Invasive emergency techniques (INTECH)" the aim of this study was to characterize defined qualifications of emergency physicians and to discuss by examples whether strictly practice-oriented workshops represent a suitable means of closing the apparent gaps in training. Our data show clearly that even experienced emergency physicians indicated that they lack training in carrying out preclinical invasive emergency procedures such as chest tube, cricothyrotomy and intraosseous access. Furthermore, they are only very seldom confronted with emergency situations in which these procedures could decidedly affect the survival of a patient and which, at the same time, put them under extremely high emotional pressure. Thus, the didactic concept of continuing education workshops that are strictly practice-oriented and that focus in particular on problem areas in emergency medicine, can contribute significantly to help close the gaps in training and ensure that emergency physicians are highly qualified.

/pdf/invasive-techniques-in-emergency-medicine-i-practice-4y0xbf8n8q.pdf

[Invasive techniques in emergency medicine. I. Practice-oriented training concept to ensure adequately qualified emergency physicians].

Die intraossare Punktion ist inzwischen fester Bestandteil der padiatrischen, aber auch der adulten Notfallmedizin geworden. Die intraossare Punktion ist eine ebenso einfache wie sichere und schnelle Alternative in Situationen, bei denen dringlich ein Gefaszugang geschaffen werden muss, aber konventionell nicht oder nur zeitverzogert etabliert werden kann. Der klassische Zugang erfolgt uber die proximale Tibia mit Hilfe spezieller intraossarer Punktionskanulen. Hierbei konnen samtliche in der Notfallmedizin intravenos verabreichten Medikamente und Infusionen nahezu uneingeschrankt intraossar appliziert werden. Dosierung sowie Anschlagzeit derartig verabreichter Medikamente unterscheiden sich nicht von der intravenosen Gabe. Mit Ausnahme von Frakturen nahe der Punktionsstelle bestehen keine absoluten Kontraindikationen. Bei korrekter Anwendung und Handhabung, sind Komplikationen selten und stehen in keinem Verhaltnis zu den Vorteilen der intraossaren Punktionstechnik beim vital bedrohten Patienten.

Invasive Techniken in der Notfallmedizin

Emergency medicine measures often have to be carried out under suboptimal conditions in emergency situations and require invasive patient treatment. In the case of a fatal outcome these measures have to be evaluated at autopsy, regarding indications, correct implementation and possible complications. As well, alongside the more familiar procedures--such as endotracheal intubation, insertion of chest drains, external cardiac massage and cannulation of central and peripheral veins--there are alternative techniques being increasingly applied, that include new tools for the management of hemorrhagic shock, drug delivery and alternative airway management devices. On the one hand, all of these measures are essential for the survival and appropriate treatment of the injured and/or sick patient, but on the other hand they can damage the patient and thus contain a significant risk of both medical and forensic relevance for the patient and the physician. In the following review we provide an overview of established, new and alternative techniques for emergency airway management, administration of drugs and management of hemorrhagic shock. The aim is to facilitate the understanding and autopsy evaluation of current emergency medicine techniques.

Emergency medicine techniques and the forensic autopsy.

Cricothyrotomy is a very invasive technique to secure the airway in an emergency but is irreplacable when less invasive techniques fail or cannot be instigated under the prevailing circumstances. Various techniques have been reported which can be subdivided into anatomical-surgical preparation or puncture techniques. The preferred strategy is mostly oriented towards the departmental standard procedure which will be decided by the clinical situation. Training for each procedure can be carried out in intensive care departments, and using autopsy material or a manekin. Various methods of cricothyrotomy will be discussed here, and additionally an anatomical preparation and two puncture techniques will be demonstrated in detail.

/pdf/invasive-techniken-in-der-notfallmedizin-3eec0o82n7.pdf

Das praxisorientierte Ausbildungskonzept fur invasive Notfalltechniken (INTECH-Seminar) wird seit 2001 jahrlich mit dem Ziel angeboten, Notarzte in der Anlage von Thoraxdrainagen, eines intraossaren Zugangs und der Durchfuhrung einer Notfallkoniotomie zu trainieren. Ziel der Studie war, den Langzeiteffekt dieses Ausbildungskonzepts zu evaluieren. Die Teilnehmer der INTECH-Seminare zwischen 2001 und 2004 wurden wahrend des jeweiligen Seminars und ein 2. Mal im November 2005 mittels eines Fragebogens evaluiert bzw. reevaluiert. Von insgesamt 224 ausgebildeten Notarzten nahmen 134 nach einem durchschnittlichen Zeitintervall von 2,4±1,1 Jahren an der Reevaluation teil (Ruckantwortrate: 60%). Im Vergleich zu der initialen Evaluation (n=154) zeigte sich nach Teilnahme am INTECH-Seminar ein Anstieg in der Anzahl der durchgefuhrten intraossaren Punktionen pro Notarzt pro Jahr (0,1±0,2 vs. 0,2±0,3, p<0,001). Ein hoherer Anteil an Teilnehmern hatte in dem Zeitintervall nach dem Seminar mindestens eine intraossare Punktion durchgefuhrt (13,4 vs. 23,1%, p=0,03). Bei beiden Evaluationen gaben mehr als 92% der Befragten an, durch das INTECH-Seminar mehr personliche Sicherheit im Umgang mit invasiven Notfalltechniken erlangt zu haben. 68% der reevaluierten Notarzte gaben an, dass Hands-on-Workshops eine Grundvoraussetzung fur die notarztliche Tatigkeit seien und die Teilnahme am INTECH-Seminar als Vorbereitung auf den Ernstfall effektiver sei als die theoretische Fachkunde und die tagliche klinische Arbeit. Die Reevaluation der Teilnehmer der Heidelberger INTECH-Seminare zeigte, dass ein praxisorientiertes Training die Bereitschaft und das personliche Zutrauen hinsichtlich der Durchfuhrung von invasiven Notfalltechniken erhoht. Praxisorientiertes Training scheint eine Grundvoraussetzung fur die notarztliche Tatigkeit zu sein und konnte einen weiteren Schritt zur Optimierung der notarztlichen Versorgungsqualitat darstellen.

Praxisorientiertes Ausbildungskonzept für invasive Notfalltechniken

OBJECTIVE Should the technique of surgical cricothyroidotomy be practiced on cadavers and should it be a compulsory part of the teaching curriculum? Is it wise to use a speculum for the insertion of the endotracheal tube? What is the optimum size of the tube? METHODS A surgical cricothyroidotomy with a speculum was carried out on 30 cadavers from the Institute of Legal Medicine, Medical School Hannover. This took place as part of a official and voluntary course for students of advanced semesters, anaesthetists and emergency doctors with the subjects "cricothyroidotomy, chest drainage and venous cut-down". The surgical cricothyroidotomy without the use of a speculum was carried out on 5 cadavers by two clinicians well practiced in this technique. The elapsed time between skin incision and the insertion of the endotracheal tube was measured on all five subjects. After the course the participants were asked if they were able to carry out a cricothyroidotomy in an emergency. They were also asked whether this course should be a compulsory part of their curriculum and whether practical sessions should take place. During autopsies at the Institute of Legal Medicine the length of the ligamentum conicum was measured on 40 corpses with reclined and non-reclined heads. RESULTS The average time of storage of the cadavers was 4.2 days +/- 1.9 days. The cricothyroidotomy was possible on all 35 cadavers. In one case (3,3 %) the result was a complete rupture of the cricoid cartilage. In 5 cases (16.7 %) the horizontal incision was torn due to prising with the speculum. Difficult situations always occured when the skin incision was not exactly in the midline. The average time to place the endotracheal tube into the trachea by the surgical procedure of cricothyroidotomy was 22.4 seconds +/- 3.1 seconds (minimum 18 seconds, maximum 26 seconds). 10 % of the medical students and 50 % of the anaesthetists and emergency doctors felt they would be prepared to carry out a cricothyroidotomy in an emergency. 90 % of the students and respectively 80 % of the anaesthetists and emergency doctors stated that they would like to practice the technique on a cadaver again. Almost all participants were of the opinion that the course should be integrated as a compulsory course in a future educational curriculum. The average distance between the thyroid cartilage and the cricoid cartilage was 9.5 mm +/- 1.9 mm with non-reclined head (minimum 6 mm, maximum 14 mm) and 11.9 mm +/- 2.5 mm with reclined head (minimum 7 mm, maximum 18 mm). The average difference of distances was 2.4 mm +/- 1.2 mm (minimum 1 mm, maximum 6 mm) in reclined and non-reclined heads. CONCLUSIONS In our opinion it is highly recommended that the technique of cricothyroidotomy should be practiced on cadavers and that the course should become a compulsory part in a future educational curriculum. In addition the incision of the ligamentum conicum using dilators or a speculum is not to be recommended from the point of view of this study. The tracheal tube used in this study (reinforced wire tube, ID 6.0) was best suited for surgical cricothyroidotomy.

[Cricothyroidotomy training on cadavers - experiences in the education of medical students, anaesthetists, and emergency physicians].

Die Begutachtung moglicher arztlicher Behandlungsfehler beim anasthesiologischen Management des schwierigen oberen Atemwegs mit Intubationsproblemen kann im Einzelfall schwierig sein. Die Frage, inwieweit ein letaler Ausgang auf einen vorwerfbaren arztlichen Behandlungsfehler zuruckzufuhren ist, erfordert eine genaue Kenntnis der Literatur und die Einholung weiterer Fachgutachten. In dieser Arbeit werden klinisch anerkannte Richtlinien zum Management und Algorithmen zur Beherrschung eines unerwartet schwierigen oberen Atemwegs vorgestellt. Mithilfe dieses Instrumentariums kann der rechtsmedizinische Gutachter beurteilen, ob ein adaquates und den Richtlinien entsprechendes Management zur Beherrschung des schwierigen Atemwegs vorgenommen wurde. Dies soll nicht dazu verleiten, dieses komplexe Begutachtungsfeld ausschlieslich forensisch zu bewerten. Vielmehr wird eine Zusammenarbeit zwischen Klinikern und Rechtsmedizinern zur konkreten Beantwortung juristischer Fragen zu Behandlungsfehlervorwurfen bei schwierigen Intubationen empfohlen.

Rechtsmedizinische Begutachtung von Behandlungsfehlervorwürfen zu Todesfällen nach schwieriger Intubation

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[Cricothyroidotomy training on cadavers - experiences in the education of medical students, anaesthetists, and emergency physicians].

Rechtsmedizinische Begutachtung von Behandlungsfehlervorwürfen zu Todesfällen nach schwieriger Intubation