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

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Trends in Anaesthesia and Critical Care

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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

s u m m a r y
Keywords:
Airway
Anaesthesia
Resuscitation
Cardiopulmonary
Ventilation

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 tight
tting face mask connected with a reservoir. Ketamine may be the induction agent of choice in haemodynamically 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 difcult airway breoptic awake intubation should be performed.
With a not difcult airway, airway management according to the rescuers 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

2. Anaesthesia in medical emergencies - an international

perspective

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 insufciency 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 nonsystematic review on anaesthesia in pre-hospital and in-hospital
emergencies.
* Corresponding author. Tel.: 43 512 504 80390.
E-mail address: [email protected] (H. Prossliner).

In France, airway management-experienced emergency physicians had problems in only approximately 3% of pre-hospital
intubations. On the contrary, in Miami, paramedics encountered
intubation difculties 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 intubations performed by emergency medical system (EMS) physicians
with 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

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

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

management studies proved to be difcult, mainly due to varying
parameters between the studies such as different patient cohorts
(e.g. penetrating trauma vs. blunt), profession groups (e.g. paramedic 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.

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
Face mask
Face mask with reservoir
Anaesthesia bag-valve mask device
Anaesthesia bag-valve mask device
with reservoir

1e6
8e10
6e10
12
12

24e44%
40e60%
60e100%
50%
100%

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 emergency. Indications for anaesthesia induction may be:
(1) highly experienced team members
(2) not difcult 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 (GCS<9)
(6) fast deteriorating patients, whose condition could be stabilised
with intubation (e.g. respiratory failure)
Long transport times should be considered. Senior help should
be called early, in case of expected difculties, ideally before
anaesthesia induction.
Pre-hospital anaesthesia may pose a patient at a higher risk
when compared with anaesthesia induction in the hospital. For
instance, pneumonia rate11 and mortality12 may be higher with
pre-hospital anaesthesia when compared with anaesthesia performed in the ED. However, study results are difcult to extrapolate
from one EMS to another because of highly different structures. For
example, in an urban when compared to a rural EMS, transfer time
is short; thus anaesthesia induction in an urban setting may be
delayed until hospital arrival a few minutes later. Anaesthesia
induction in the hospital may be safer because of better logistics
and personnel resources in the ED.
4. Oxygenation and preoxygenation
To avoid oxygen desaturation during anaesthesia induction,
body oxygen stores should be maximised during preoxygenation.
Optimally, oxygen should be applied with a tightly tting face mask
with reservoir and high oxygen ow (e.g. 10 L min1, Table 1),
allowing an inspiratory oxygen fraction of approximately 100%.13
Functional residual capacity may be increased with continuous
positive airway pressure (CPAP) up to 10 cmH2O,14 a sitting position15 or elevating the chest by 25 ,16 if applicable with patients
haemodynamics and the trauma pattern.17 In haemodynamically
unstable patients, CPAP may destabilise circulation owing to the
consequences of heartelung interaction.18 Fear and pain should be
treated to decrease excessive oxygen demand.19 In case of sufcient
spontaneous breathing, 3 min breathing with normal tidal volume
(w500 mL) or eight deep breaths of 100% oxygen denitrogenise the
lungs.20 Efciency of preoxygenation may be monitored with
a pulse oximetry target value of at least 99% and an expiratory
endtidal oxygen fraction >80%. Many factors can negatively inuence preoxygenation. For instance, in a critically ill patient, oxygen
stores may be compromised owing to lung contusion or pneumonia, 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 prevention 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 on
steroid 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 may be used for analgesia 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 stabilising 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 unstable
patients. For analgesia during anaesthesia induction, fentanyl or
sufentanyl in haemodynamically stable and ketamine in haemodynamically 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 induction is discussed controversially. Some argue that the presence of
a neuromuscular block offers the best possible intubation condition. Others argue that, with neuromuscular block, an oesophageally placed endotracheal tube inevitably leads to death.
Therefore, some EMS services do not recommend administration of
neuromuscular blockers with anaesthesia induction. Suxamethonium (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 blocking
agent 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 snifng position e with a support beneath the head; this
may be especially helpful in patients with a stiff cervical spine or

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

111

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
Anaesthesia induction or co-induction with
propofol in haemodynamically fragile or
unstable patients, status asthamticus,
anaesthesia maintenance
Anaesthesia induction in haemodynamically
stable patients, anaesthesia maintenance

Respiratory depression
Cardiocirculatory depression
Supercial anaesthesia
Tachycardia and arterial hypertension

Induction: 3-5 (mg kg1)

Maintenance: 1-5 (mg kg1) as repetitive bolus
Induction: 0.5e1.0 (mg kg1)
Maintenance: 0.5e3 (mg kg-1 h-1) continuously
or 0.2e0.5 (mg kg1) as repetitive bolus

Respiratory depression
Cardiocirculatory depression

Induction: 0.25e1.0 (mg kg1)

Maintenance: 0.1e1 (mg kg-1 h-1) continuously
or 0.3e0.7 (mg kg1) as repetitive bolus

Ketamine

Sufentanyl

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

the anterior head exion caused by the large occiput. An intravenous line should be xed well to avoid dislocation during anaesthesia 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 haemodynamically 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.

Keep in mind that, a medical emergency is not an opportunity for testing new drugs or techniques. Emergency
patients are too sick to tolerate errors made by inexperienced rescuers

7. Fibreoptic awake intubation

With an expected difcult airway, anaesthesia induction should
be delayed until breoptic awake intubation is possible in a fully
equipped 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 analgosedated 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 capnography. 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 sufcient skills to perform endotracheal intubation safely during emergencies.31 Unfortunately, many rescuers
never acquire these skills. For example, a study in Switzerland
found that anaesthesia residents required 60 endotracheal intubations to gain a 90% success rate with endotracheal intubation
attempts.32 Thus, only highly-experienced rescuers who continuously 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, further
attempts 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 Additionally, bage valveemask ventilation, laryngoscopy and tracheal
intubation may be hindered.39,40

Table 3
Indications, 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
Anaesthesia induction in haemodynamically fragile
or unstable patients
Anaesthesia maintenance
Anaesthesia induction in haemodynamically stable
patients
Anaesthesia co-induction with ketamine or midazolam
in haemodynamically unstable patients
Anaesthesia induction in haemodynamically stable
patients
Status epilepticus

Supercial anaesthesia
Inhibitory effect on steroid genesis;
avoid in septic patients
Slow onset
Supercial anaesthesia

Induction: 0.2e0.5 (mg kg1)

Midazolam

Propofol

Thiopental

Arterial hypotension

Histamine release / ush, asthma

bronchiale
Tissue necrosis if extravasation

Induction: 0.1e0.4 (mg kg1)

Maintenance: 0.03e0.2 (mg kg-1 h-1) continuously
or 0.03e0.2 (mg kg1) as repetitive bolus
Induction: 2e3 (mg kg1)
Maintenance: 2e6 (mg kg-1 h-1) continuously
or 0.5e2 (mg kg1) as repetitive bolus
Induction: 3e7 (mg kg1)

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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 immediately. 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 considered with diminished compliance, unilateral ventilation sounds
and chest movements, and low oxygen saturation.

One should keep in mind that too many patients still die
because of failed oxygenation, mostly related to cases of
failed endotracheal intubation. Thus, in medical emergencies one of the most prioritised aims should be adequate
oxygenation instead of repeated endotracheal intubation
attempts

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 difcult airway,
a supraglottic airway device may be employed as a conduit for

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

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

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

permission of.33 DOPES: D denotes Dislocation, O obstruction, P pneumothorax,
E equipment, S stomach.

endotracheal intubation.44 A supraglottic airway device may also 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 laryngeal 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 LMA Classic (LMA North
America, Inc.) and the LMA Proseal (LMA North America, Inc.).
Insertion of the LMA Classic may be easier, but the LMA Proseal has
a 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
efcient 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 lifethreatening 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
difcult 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 device when
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 difcult airway should be developed,
based on the local possibilities and requirements (Figs. 1 and 2).

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113

10. Ventilation and anaesthesia maintenance

Acknowledgements

Ventilation should be performed cautiously to avoid adverse

effects. Gastric overdistension and subsequent vomiting and
pulmonary aspiration, as well as hyperventilation induced hypotension 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 haemodynamic 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, capnography
should be interpreted cautiously, and ventilation adjusted according 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

This manuscript has solely been sponsored by departmental

funds. There are no conicts of interest.

11. Side effects of anaesthesia

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 and hyperventilation-induced secondary brain injury.65
Also, in a haemodynamically unstable patient, a ventilation rate
above 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 reservoir. Ketamine may be the induction agent of choice in haemodynamically unstable patients. Sugammadex, a rocuronium
antagonist, may have the potential to make rocuronium a 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, 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 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 anaesthesia and airway
management skills.

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