Handlungsempfehlung für das präklinische Atemwegsmanagement^[*]

Kernaussagen

Die erfolgreiche Sicherung der Atemwege ist eine der zentralen Aufgaben in der Notfallmedizin, da ohne adäquate Oxygenierung und Ventilation alle weiteren Therapiemaßnahmen vergeblich bleiben. Das präklinische Atemwegsmanagement ist deutlich schwieriger im Vergleich zu innerklinischen Verhältnissen, da zahlreiche Faktoren erschwerend hinzukommen, die den Zustand der Patienten, die Umgebungsverhältnisse, die limitierte Ausrüstung und die individuellen Kenntnisse des medizinischen Personals betreffen.

Die tracheale Intubation (ETI) gilt nach wie vor als Goldstandard zur Sicherung der Atemwege, obwohl keine ausreichende Datenlage zur Wahl des besten Verfahrens besteht. Ebenso fehlt die Evidenz, aufgrund derer die minimale Anzahl von erfolgreichen innerklinischen Anwendungen einer spezifischen Technik und deren regelmäßige Wiederholung gefordert werden kann. Die nachfolgenden Empfehlungen basieren daher auf der Bewertung von prä- und innerklinischen Studien.

Die ETI sollte nur von denjenigen durchgeführt werden, die die Technik sicher beherrschen. Dazu sollte zum Erlernen der Technik die Durchführung von wenigstens 100 ETI und nachfolgend 10 ETI/Jahr an Patienten unter Aufsicht dokumentiert werden.

Unter präklinischen Bedingungen dürfen maximal zwei Intubationsversuche unternommen werden, die jeweils nicht länger als 30 s andauern sollten. Zwischen zwei Intubationsversuchen sollte eine Maskenbeatmung durchgeführt werden. Nach gescheiterter ETI oder bei Fehlen der geforderten Voraussetzungen sollten extraglottische Atemwege (EGA) mit maximal zwei Versuchen zur Anwendung kommen. Als Minimalvoraussetzung vor dem präklinischen Einsatz sollten 10 Anwendungen eines EGA an Patienten unter Aufsicht erfolgen und jährlich dreimalig wiederholt werden. Es sollten EGA mit Drainagekanal verwendet und eine Magensonde platziert werden. Nach erfolgloser ETI und/oder EGA-Einlage sollte die Atemwegssicherung über eine Koniotomie erfolgen. Nach durchgeführter Atemwegssicherung muss eine Kontrolle der Beatmung mittels kontinuierlicher Kapnografie erfolgen. Im Kreislaufstillstand sollte eine zweite Methode zur Erkennung einer ösophagealen Fehllage verwendet werden.

^* Beschluss des Engeren Präsidiums der DGAI vom 18.4.2012 in Frankfurt am Main

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