Der Einsatz des intraossären Zugangs im präklinischen Notarztdienst: Diskrepanz zwischen Leitlinienempfehlungen und Realität!

Differences in training among prehospital emergency physicians in Germany

Background

Germany has an interdisciplinary physician-based emergency medical service. Differences in training likely lead to different levels of expertise.

Objectives

We assessed the number of manual procedures performed at the completion of training to determine level of experience of prehospital emergency physicians of different primary specialties.

Materials and methods

Immediately after passing the board examination each examinee was asked to estimate the number of performed procedures for 26 manual skills. We compared the results with recommendations and data on learning manual skills. Results are presented as mean (standard deviation).

Results

Endotracheal intubation via direct laryngoscopy was performed 1032 (739) times by anesthesiologists. Surgeons and internists performed 89 (89) and 77 (65) intubations, respectively. Intubation via video laryngoscopy was performed 79 (81) times by anesthesiologists, 11 (17) times by surgeons and 6 (11) times by internists. Surgeons had little experience in non-invasive ventilation, with 9 (19) performed procedures and had rarely used external pacemaker therapy or electrical cardioversion. In comparison, among all participants non-invasive ventilation was performed 152 (197) times, electrical cardioversion was performed 41 (103) times and an external pacemaker was used 6 (15) times. For other procedures the numbers did not markedly differ between the different specialties.

Conclusion

The number of performed procedures markedly differed for some skills between different primary specialties. Recommendations regarding a procedural volume were not always met, suggesting missing expertise for some skills. A defined number of procedures should therefore be a formal requirement to be eligible for board certification in prehospital emergency medicine.

EZ-IO(®) intraosseous device implementation in German Helicopter Emergency Medical Service

BACKGROUND

Intraosseous access (IO) is a rapid and safe alternative when peripheral venous access is difficult. Our aim was to summarize the first three years experience with the use of a semi-automatic IO device (EZ-IO(®)) in German Helicopter Emergency Medical Service (HEMS).

METHODS

Included were all patients during study period (January 2009-December 2011) requiring an IO access performed by HEMS team. Outcome variables were IO rate, IO insertion success rates, site of IO access, type of EZ-IO(®) needle set used, strategy of vascular access, procedure related problems and operator's satisfaction.

RESULTS

IO rate was 0.3% (348/120.923). Overall success rate was 99.6% with a first attempt success rate of 85.9%; there was only one failure (0.4%). There were three insertion sites: proximal tibia (87.2%), distal tibia (7.5%) and proximal humerus (5.3%). Within total study group IO was predominantly the second-line strategy (39% vs. 61%, p<0.001), but in children<7 years, in trauma cases and in cardiac arrest IO was more often first-line strategy (64% vs. 28%, p<0.001; 48% vs. 34%, p<0.032; 50% vs. 29%, p<0.002 respectively). Patients with IO access were significantly younger (41.7±28.7 vs. 56.5±24.4 years; p<0.001), more often male (63.2% vs. 57.7%; p=0.037), included more trauma cases (37.3% vs. 30.0%; p=0.003) and more often patients with a NACA-Score≥5 rating (77.0% vs. 18.6%; p<0.001). Patients who required IO access generally presented with more severely compromised vital signs associated with the need for more invasive resuscitation actions such as intubation, chest drains, CPR and defibrillation. In 93% EZ-IO(®) needle set handling was rated "good". Problems were reported in 1.6% (needle dislocation 0.8%, needle bending 0.4% and parafusion 0.4%).

CONCLUSIONS

The IO route was generally used in the most critically ill of patients. Our relatively low rate of usage would indicate that this would be compatible with the recommendations of established guidelines. The EZ-IO(®) intraosseous device proved feasible with a high success rate in adult and pediatric emergency patients in HEMS.

[Intraosseous infusion in the German Air Rescue Service : Guideline recommendations versus mission reality]

BACKGROUND

In emergency medicine intraosseous access (IOA) has been established as an alternative to conventional intravenous access. Originally the use of IOA was strictly limited to children up to 6 years of age and to adults for cardiopulmonary resuscitation. These limitations have been relaxed and the indications for IOA have been expanded.

MATERIAL AND METHODS

A retrospective nationwide analysis of rescue missions by all helicopter emergency medical services of the German Automobile Club (ADAC) Air Rescue Service as well as the German Air Rescue (DRF) over a 7-year period was carried out.

RESULTS

A total of 466,813 patients were treated during the study period and an IOA was established in 1,498 (0.32 %) patients. There was a significant increase in using an IOA from 0.1-0.5 % (p < 0.05) from 2005 to 2011. Furthermore, there was an increase in using an IOA in elderly patients and in patients with lower degrees of severity according to the National Advisory Committee for Aeronautics (NACA) scales (2005-2011): decreased use of IOA in patients up to 6 years of age from 92.4 % to 19.7 % (p < 0.05) and in patients with NACA grades VII/VI from 74.4 % to 46.6 % (p < 0.05) and temporarily limited increase of non-indicated IOA use in patients with NACA grade III between 2008 and 2010. Furthermore, there was an increase in the number of the different drug groups used for intraosseous infusion over the study period.

CONCLUSION

The current guidelines and recommendations for the use of IOA in the prehospital setting are reflected more and more in mission reality for helicopter emergency medical services.

[Use of intraosseus infusion in the German air rescue service : nationwide analysis in the time period 2005 to 2009]

BACKGROUND

Intraosseous infusion has become established as a fast and safe alternative to conventional vascular access in emergency situations. Originally the use of intraosseous access was limited to children up to 6 years of age and to adults for cardiopulmonary resuscitation but this limitation has now been removed. The aim of this study was to obtain data on mission reality regarding the use of intraosseous access in the prehospital setting against the background of the expanded recommendations on the use of the intraosseous infusion.

METHODS

An analysis of rescue missions by all rescue helicopters of the ADAC (German Automobile Club) Air Rescue as well as the German Air Rescue Service (58 helicopter emergency medical service bases) over a 4 year period from January 2005 to December 2008 was carried out.

RESULTS

A total of 247,454 rescue missions were carried out during the study period and in 525 patients (0.2% of the total study collective) an intraosseous access was established. There was a significant increase in the intraosseous infusion rate from 0.1% to 0.4% (p<0.05). Furthermore, there was a significant increase in its use in elderly patients and in patients with lower National Advisory Committee for Aeronautics (NACA) scores (2005 vs. 2008): 92.4% vs. 42.9% of all intraosseous infusions in patients  ≤ 6 years of age (p<0.05) and 74.4% vs. 42.9% of all intraosseous infusions in patients with NACA score VI/VII (p<0.05). The proportion of trauma patients in the total study collective was 33% and there was no significant change in the frequency of trauma cases over the study period but there was a remarkable increase of intraosseous infusions in trauma patients in the last year of the study period compared to the previous years (38% in 2008 vs. 27-30% in 2005-2007). Furthermore, there was an increase in the number of different drug groups used for intraosseous infusion over the study period.

CONCLUSIONS

The expanded indication recommendations for the use of intraosseous infusion in the prehospital setting enter more and more mission reality in air rescue services in Germany.