Analgesia, sedation and anaesthesia in emergency care

Sedation, analgesia and emergency anaesthesia are key elements of pre-hospital emergency medical care. These measures pose a significant challenge to the whole emergency team. Pain may be eased through supportive measures (e.g. reduction of fractures, immobilisation) and verbal emotional support. In many cases however, patients will only be pain free once potent analgesics have been administered. Numerous emergency medical services in Germany permit trained and certified paramedics ("Notfallsanitater") to administer analgesics and analgosedation in accordance with standard operating procedures within the scope of job delegation. Whilst this can shorten the time to treatment especially for severe pain, it does not make the emergency physician redundant. Basic monitoring should be established as a matter of principal whenever analgosedation is administered. Provision of emergency anaesthesia is reserved for emergency physicians and includes a critical evaluation of the indication for anaesthesia, taking patient, scenario and provider-related factors into account. As a rule, rapid sequence induction (RSI; aka "crash" induction) should be used for emergency anaesthesia and should include the following points: standard monitoring, preoxygenation, standardised provisions for emergency anaesthesia (anaesthetic and emergency drugs, airway and breathing equipment), drug administration, temporary manual in-line stabilisation of the cervical spine during intubation (if required), airway management and securing of the endotracheal tube following verification of correct placement. Standard preparation for general anaesthesia includes prior accord, secure labelling of anaesthetic and emergency drugs, checking required equipment and making available alternative airway management devices. Standard monitoring for prehospital analgesia, sedation and emergency anaesthesia should include an electrocardiogram, automatic or manual measurement of blood pressure and pulse oximetry. Continuous capnography is required without exception for verification of correct endotracheal tube placement, for detection of disconnection or dislocation and for indirect haemodynamic monitoring.