Page 120 - JSOM Winter 2023

Naval Surgical Vignette – strong indication. We asked medical and military personnel of the
Cesarean Delivery Aboard a German Frigate five military hospitals, the universities of Aachen and Bonn, and
LtCol (Ret.) Christof Neuner, MD the hospital in Würselen. Furthermore, recipients of the newsletter
from the platform news-papers.eu on the internet were invited to
cesarean delivery is not commonly encountered by a trauma participate as well. Results: Fifteen percent (n=63) answered, that
Asurgeon but may be necessary during deployment. These were they had experienced this type of situation. eFONA had been per-
the circumstances during EUNAVFOR SOPHIA Naval deploy- formed by 28% of the interviewed colleagues (n=117). A total of
ment in December 2016. A cesarean delivery was urgently re- 417 people participated in the survey, of whom the biggest number
quired on board the German frigate Mecklenburg-Vorpommmern were soldiers. The average years in the profession was 13.4 years.
F218 by the on board trauma surgeon in team with an anesthetist A total of 28% (n=117) of the participants answered that they had
and the ship‘s doctor (a general practitioner). A vaginal examina- performed an eFONA at least one time. About 91% (n=378) were
tion of an estimated 28-year-old pregnant refugee was performed able to name an algorithm to solve a difficult airway. According to
in the replacement ship’s hospital (helicopter hangar) and showed the individual confidence in the skills of performing an eFONA by
a fetus in a non-vaginal-deliverable position. The normal surgical using a correct method, 76% (n=313) of the participants answered
equipment for such a procedure was not immediately available, to being able to perform this procedure. The location and mate-
but the cesarean delivery was still performed in the Misgav- rial of the cricothyrotomy set was well known in 90% (n=371).
Ladach because of the time-critical condition of the mother and Fifteen percent (n=63) answered to have experienced a situation,
fetus. A well-developed boy in appropriate weight and growth in which an eFONA would have been indicated and didn’t hap-
was delivered after about 15 minutes. The boy showed no sign of pen, retrospectively. Conclusion: Multiple approaches exist to be
cardiac action and was not spontaneously breathing therefore the prepared for the worse-case scenario of cannot ventilate, cannot
APGAR score was 0. CPR procedures were initiated right away oxygenate. Specific guidelines and algorithms exist and have been
by the anesthetist and a non-commissioned medical officer with published by leading national and international societies. In case
pediatric expertise while the mother was cared for by the trauma of unsuccessful oxygenation, including endotracheal intubation,
surgeon; exposure of the placenta and wound closure was done. establishing a supraglottic airway, or bag-valve mask ventilation,
CPR action was unsuccessful and return of spontaneous circu- an eFONA has to be performed. In total, 117 (28%) colleagues
lation was never achieved; therefore, CPR was terminated after had performed at least one eFONA. This result reflects the high
45 minutes. One year before, the first child (Sophia) was born number of military physicians and paramedics participating in the
aboard a German naval vessel (FRG Schleswig-Holstein) during survey. This amount of experience is rarely representative of that
the EUNAVFOR Mission in the Mediterranean. The ship’s doc- of the civilian setting. But the fact that 63 (15%) colleagues men-
tor offered recommendations at that time based on experiences tioned a situation in which an eFONA wasn’t performed, even
gathered during his mission. Among them was the recommenda- if it was indicated, shows that there is space for improvement.
tion to have an appropriate stock of related pharmaceuticals (e.g., CRM (crew resource management) guidelines may be an essential
oxytocin). The needed surgical equipment should be on board tool in threatening situations demanding measures like eFONA.
among the ship‘s hospital standard appliances, as stated in the By “speaking up,” cannot ventilate, cannot oxygenate situations
related standard operating procedures. That also includes a proper could be solved in more effective ways. Furthermore, terms like
environment in the form of the ship’s hospital, a 3.5MHz ultra- “failed airway” should be avoided, implying a failure of the
sound unit, a urinary bladder catheter, and appropriate surgical provider or of the entire airway team. The term “non-accessible
instruments. In lack of all four at the beginning, the cesarean de- airway” could de-stress this and should be introduced. An ideal
livery was performed in the ship’s helicopter hangar and rushed simulator to train eFONA has not been introduced, but it is man-
by the acute clinical situation of the mother and supposedly the datory to train procedures and algorithms on different types of
fetus. Taking the circumstances and the refugee’s condition into simulators and manikins to achieve mastery. There are still limita-
account, the lethal outcome for the fetus was thereby most likely tions concerning the implementation of randomized, prospective
inevitable. Nonetheless adequate training apart from the “normal studies.
trauma procedures” should be provided prior to deployment to
any surgeon who is facing deployment, especially in uncommon References
environments and circumstances. 1. https://das.uk.com/files/das2015intubation_guidelines.pdf (letzter
Aufruf 30.03.2023)
The Emergency Front of Neck Access (eFONA): 2. Law JA, Duggan LV, Asselin M, et al. Canadian Airway Focus Group
Can We Master It? updated consensus-based recommendations for management of
the difficult airway: part 1. Difficult airway management encoun-
LtCol Fabian Spies, MD tered in an unconscious patient. Mise à jour des lignes directrices
Background: Cricothyrotomy, emergency front of neck airway consensuelles pour la prise en charge des voies aériennes difficiles
access (eFONA), is the final approach to secure the airway if stan- du Canadian Airway Focus Group: 1ère partie. Prise en charge de
dard and minimally invasive procedures fail. In the prehospital voies aériennes difficiles chez un patient inconscient. Can J Anaesth.
and clinical settings, different algorithms have been introduced, 2021;68(9):1373-1404. DOI:10.1007/s12630-021-02007-0.
indicating an eFONA has to be established in case of a “cannot 3. Murphy C, Rooney SJ, Maharaj CH, Laffey JG, Harte BH. Com-
parison of three cuffed emergency percutaneous cricothyroidotomy
ventilate, cannot oxygenate” situation [1,2]. This may happen devices to conventional surgical cricothyroidotomy in a porcine
once in every 13,000–50,000 situations, in which an airway has to model. Br J Anaesth. 2011 Jan;106(1):57-64. DOI: 10.1093/bja/
be secured [3,4]. Resulting hypoxia may be fatal and is at least as- aeq294. Epub 2010 Oct 30. PMID: 21037267.
sociated with severe brain damage. Establishing a definite surgical 4. Mariappa V, Stachowski E, Balik M, Clark P, Nayyar V. Cricothy-
airway may prevent the patient from hypoxia or death [5]. Meth- roidotomy: comparison of three different techniques on a porcine
ods: In a survey (SurveyMonkey ) we allocated data concerning airway. Anaesth Intensive Care. 2009;37(6):961–7. doi: 10.1177/
®
the level of experience with eFONA, devices required, previous 0310057X0903700602. PMID: 20014603.
training, and complications among acute and emergency care pro- 5. Hamaekers AE, Henderson JJ. Equipment and strategies for emer-
viders of different backgrounds (doctors and paramedics). Fur- gency tracheal access in the adult patient. Anaesthesia. 2011
thermore, we asked about individual attitudes to and frequency of Dec;66 Suppl 2:65–80. DOI: 10.1111/j.1365-2044.2011.06936.x.
former situations, in which an eFONA wasn’t established despite PMID: 22074081.

118 | JSOM Volume 23, Edition 4 / Winter 2023