Im Jahre 1960 wurde an der Johannes Gutenberg-Universität Mainz die heutige Klinik für Anästhesiologie als Anaestoesiologieabteilung gegründet und der damals außerordentliche Professor Rudolf Frey zu ihrem Leiter berufen. 1962 wurde die Abteilung in “Institut für Anästhesiologie” umbenannt, seit 1967 besteht in Mainz das erste deutsche Ordinariat für das Fachgebiet Anästhesiologie, Durch das große Engagement von Herrn Prof. Dr. Dr. h. c. mult. Frey in der Notfall- und Rettungsmedizin etablierte sich bereits im Jahre 1964 ein regelmäßiger Notarztdienst für die Bevölkerung der Stadt Mainz und des Landkreises Mainz-Bingen. Dieser Notarztwagen, neben ähnlichen Projekten in Heidelberg und Köln, stellte in Deutschland die Versorgung der Bevölkerung durch qualifizierte Notärzte bei Patienten mit akuter Lebensbedrohung sicher. 1983 erhielt das Institut mit Prof. Dr. Dr. h. c. Wolfgang Dick eine neue Leitung; gleichzeitig wurde es in Klinik für Anästhesiologie umbenannt.

Zusammenfassung Für den Combitube ™ sind Fragen zu Anwendungsgebieten, optimaler Insertionstechnik und korrekter Positionierung bis heute nicht abschließend untersucht, die erfolgreiche Anwendung wurde jedoch in mehreren Studien und Fallberichten nachgewiesen. Ziel dieser Untersuchung war es, die Lage des Combitube ™ nach Einführung mittels unterschiedlicher Insertionstechniken durch fiberoptische Untersuchung zu analysieren. Bei 20 Patienten wurde abwechselnd laryngoskopisch (n=10) und nicht-laryngoskopisch (n=10) ein Combitube ™ eingeführt. Bei 10 Patienten erfolgte zusätzlich eine Vorbiegung des Combitube ™ (n=5 mit und n=5 ohne Laryngoskop). Nach Positionierung des Tubus erfolgte die Lagekontrolle mittels fiberoptischer Untersuchung. Bei 19 von 20 Patienten wurde der Combitube ™ erfolgreich eingeführt, Unterschiede bezüglich Insertionszeiten, Tubuslage und Schleimhautschäden zwischen laryngoskopischer und nicht-laryngoskopischer Einführung sowie mit oder ohne Vorbiegung konnten nicht festgestellt werden. Das Einführen nach Vorbiegen wurde jedoch als einfacher empfunden. Die fiberoptische Kontrolle ergab bei allen Patienten durch Schleimhaut verlegte Ventilationsperforationen, wobei im Mittel 3,7 von 8 Perforationen frei waren. Allein 9 Tuben wiesen Blutspuren auf und 15 Tuben waren nicht wie vom Hersteller angegeben positioniert. Der Combitube ™ ist zur Atemwegssicherung in Notsituationen durch Eingewiesene geeignet. Modifikationen der Ventilationsperforationen sowie der Markierungen zur richtigen Insertionstiefe sind überlegenswert. Eine Schleimhautschädigung ist gehäuft festzustellen.

Aim: Harmonization and standardization of education in: 1) risk evaluation; 2) planning; 3) medical response; 4) evaluation and debriefing; and 5) training.Format: One-year curriculum based on: 1) study via Internet; 2) research paper; 3) 3 week live-in session: lectures, debates, exercises, written and oral evaluation; 4) simulation exercises; and 5) interactive assessment through Internet.An electronic learning environment will be developed in collaboration with ARIADNE, a research and technology project focusing on the development of tools and methodologies for producing, managing and reusing computer-based, pedagogical elements and telematics supported training curricula.

Zusammenfassung Fragestellung der vorliegenden Studie war, ob die bislang immer vermutete, aber nie bewiesene Beeinflussung von Reaktionsparametern durch emotional belastete Einsatzstichworte, tatsächlich nachweisbar ist. Die Untersuchungsmethode beruhte auf der Dokumentation von Rettungsdiensteinsätzen und konsekutiver Analyse der Zeitintervalle „Ausrückzeit” und „Anfahrzeit” sowie der durchschnittlichen Fahrtgeschwindigkeit der Rettungsmittel wobei die subjektive verbale Beeinflussung durch den Leitstellendisponenten durch schriftliche Depeschenalarmierung eleminiert wurde. Insgesamt konnten 4302 Einsätze von Rettungswagen (RTW) und Notarztwagen (NAW) analysiert werden. Es zeigten sich deutlich verminderte Anfahrzeiten und Ausrückzeiten für traumatische gegenüber nicht-traumatischen Notfällen, ebenso deutlich verkürzte Ausrückzeiten und erhöhte Geschwindigkeiten für Notfälle mit Patienten der Altersgruppe 0–6 Jahre gegenüber Patienten >60 Jahren bzw. bei Einsätzen in Schulen/Kindergärten gegenüber Altenheimen. Schnellere Ausrückzeiten konnten für die Tage Montag bis Donnerstag gegenüber dem Wochenende aufgezeigt werden. Die Ergebnisse sind als Indikatoren für den Einfluß von Einsatzstichworten und Dienstbedingungen auf die Reaktionsparameter zu sehen und bedürfen aufgrund der Auswirkungen auf die organisatorische Qualität der präklinischen Notfallversorgung weiterer Evaluierung.

Zusammenfassung Außergewöhnliche Notfallsituationen in Krankenhäusern, bei denen der Bedarf an medizinischer Versorgung den tatsächlichen Bedarf bei weitem übersteigt, können nur mit Hilfe suffizienter und an die personelle und geographische Situation des jeweiligen Krankenhauses angepaßte Katastrophenschutzpläne (KSP) bewältigt werden. Ziel dieser Umfrage mit 522 teilnehmenden deutschen Krankenhäusern war, einen aktuellen Überblick über die Qualität und Verfügbarkeit von KSP zu erhalten. Dabei stellte sich heraus, daß 83,5% aller Krankenhäuser über einen KSP verfügen, welcher jedoch in 54,8% nicht zwischen der internen, das Krankenhaus unmittelbar betreffenden und externen Notfällen unterscheidet. Auch waren 22,4% der KSP nie oder nur gelegentlich überarbeitet worden, Katastrophenschutzübungen wurden in 51,2% der Krankenhäuser noch nie durchgeführt. Demgegenüber steht die Tatsache, daß bereits 14,5% aller Kliniken ihren KSP aktivieren mußten. Gemäß den Erwartungen von 51,6% der Krankenhausträger hat die Aktivierung durch die diensthabenden Assistenzärzte initiiert zu werden. Jedoch setzen nur 25,3% aller Kliniken ihre ärztlichen Mitarbeiter über den gültigen KSP in Kenntnis. Ein adäquates Management von außergewöhnlichen Notfallsituationen ist derzeit in Deutschland nicht durchgehend gewährleistet. Zur Garantierung eines suffizienten Katastrophenschutzes müssen KSP mindestens 1- bis 2mal pro Jahr überarbeitet werden, die Umsetzung des KSP muß durch regelmäßige Übungen trainiert und sichergestellt werden, jeder Plan muß auf das individuelle Krankenhaus mit spezifischen lokalen Gegebenheiten ausgerichtet sein.

The crucial factor deciding the success of cardiopulmonary resuscitation is a sufficient oxygen supply. At about 4 min after cardiac arrest, cerebral death results because of hypoxia, and cardiopulmonary resuscitation has to be started regardless of the pathogenesis of the cardiac arrest. The purpose of the study was to assess the application of guidelines for cardiopulmonary resuscitation by participants at a dental surgery congress (n = 96) and to evaluate previous knowledge in cardiopulmonary resuscitation and knowledge after instruction. The present study was based on the standards and guidelines for cardiopulmonary resuscitation issued by the American Heart Association. The group was divided into four groups of doctors experienced or inexperienced in clinical emergencies or with dummies. For the study the Skillmeter-ResusciAnne (Laerdal, Stavanger, Norway) was used, which has automatic data recording. After analysis of the individual errors, the success of new instruction was assessed. Good previous knowledge was registered, particularly with respect to checking respiration and hyperextension of the head (67.7%), primary insufflation (93.8%), closed-chest cardiac massage (99%) and correct compression rate (68.4%). The participants demonstrated post-instruction improvement in all subdivisions except in the group without practice on dummies (primary insufflation: from 94.4 to 88.9%; correct order of checking consciousness and respiration, primary insufflation, the carotid pulse and closed-chest cardiac massage: from 22.2 to 5.6%). Good results with marked improvements in the second passage were achieved in checking consciousness and the carotid pulse, closed-chest cardiac massage and correct implementation of compression. The participants were, however, found to be in need of further education and training in diagnostics and certain cardiopulmonary resuscitation measures. Knowledge should be improved concerning recognition of the emergency (42.7%), checking the carotid pulse (22.9%), the correct order of primary insufflation and closed-chest cardiac massage (9.4%), correct implementation of compression (21.8%) and ventilation (36.4%), and the correct ratio of compression and ventilation (21.9%). Regular courses should be targeted at these specific aspects.

Der limitierende Faktor für eine erfolgreiche Reanimation ist die adäquate Sauerstoffversorgung. Ca. 4 min nach Beginn des Herzstillstands tritt der Gehirntod aufgrund der Hypoxie auf. Somit sind zunächst unabhängig von der Genese des Herzstillstands sofort die Reanimationsmaßnahmen einzuleiten. Die Fragestellungen der Arbeit bestanden darin, zu zeigen, inwieweit die Richtlinien in Herz-Lungen-Wiederbelebungsmaßnahmen (HLW-Maßnahmen) von Teilnehmern eines zahnärztlichen Kongresses (n = 96) angewendet werden. Die beobachtende Studie beinhaltete die Überprüfung des Grundwissens und der praktischen Fähigkeiten vor und nach Instruktion anhand der Kriterien der American Heart Association. Eine Unterteilung in 4 Untergruppen mit/ohne Erfahrung am Patienten/an der Puppe wurde vorgenommen. Nach Durchführung einer kardiopulmonalen Reanimation ohne Anleitung an einer Puppe (Skillmeter-Resusci-Anne, Laerdal) erfolgte nach einer Fehleranalyse und Auffrischung der Kenntnisse eine erneute Durchführung der Reanimation mit erneuter Fehleranalyse. Die Ergebnisse zeigten gute Vorkenntnisse im ersten Durchgang v. a. bei der Überprüfung der Atmung und Überstrecken des Kopfs (67,7%), der Durchführung einer Primärinsufflation (93,8%), der extrathorakalen Herzmassage (99%) und der korrekten Durchführung der Kompressionsrate (68,4%). Die Testpersonen zeigten nach der Kurzschulung im 2. Durchgang bei allen Untergruppen außer der Gruppe ohne Training an der Puppe bei der Durchführung der Primärinsufflation (von 94,4 auf 88,9%) und der korrekten Durchführung der Reihenfolge der HLW-Maßnahmen (von 22,2 auf 5,6%) eine Verbesserung. Gute Ergebnisse mit deutlichen Verbesserungen im 2. Durchgang bestanden bei der Bewußtseinsüberprüfung, der Kontrolle des Karotispulses, der Handdruckmassage und der korrekten Durchführung der Kompressionen. Die Vorkenntnisse der Teilnehmer in bezug auf die Erkennung des Notfalls (42,7%), Kontrolle des Karotispulses (22,9%), einer korrekten Reihenfolge der Primärinsufflation und Herzdruckmassage (9,4%), der korrekten Durchführung der Kompression (21,8%) und Ventilation (36,4%) sowie die Einhaltung des korrekten Verhältnisses von Kompression und Ventilation (21,9%) sind jedoch verbesserungswürdig. Schlußfolgerungen sind die Einführung von Schulungen und Kursen speziell auf diesem Bereich, die regelmäßig wiederholt werden sollten.

A disaster situation for a hospital occurs when the need for medical treatment overwhelms the actual hospital treatment capacity. 1 This may be defined by numerical or situational means; the threshold must always be the result of an individual assessment of the given health care unit. A disaster situation may also be defined as the point of no return to normal standard operating procedures in a certain hospital. In case of a disaster, health care units are required to have and activate a disaster management plan (DMP). In the USA the requirements of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) are trend-setting; in European countries, regulations are normally set by state requirements or by-laws. According to the location of the disaster, it is regarded useful to discriminate the DMP for external disasters (e.g. road accident, air crash), internal disasters (e.g. fire in the hospital) and finally external disasters that have an impact on the hospital as well (e.g. earthquake, hurricane)) '2 The JCAHO requires US hospitals to have such a divided DMP; in other countries this prerequisite is only recommendedY

The light-guided intubation is based on the principle, that a light brought into the trachea results in clearly visible transcutaneous illumination, whereas no illumination can be observed if placed in the oesophagus. The Trachlight® is a recently introduced instrument incorporating a length-adjustable stylet with a removable internal wire, a source of light, a stable handle tight fixation of the tube warning device to avoid extended intubations. The study was designed to evaluate the handling, application, problems, and limitations of the method with the indications for the method, compared with conventional intubation. One hundred patients (informed consent, ethics committe approval, Mallampati I, ASA I-III) were randomly allocated to one of 2 groups (each n=50): Testgroup LGI: light-guided intubation (Trachlight®, Laerdal Comp.) Testgroup CI: conventional laryngoscopic intubation (Macintosh blade, size 3). The recorded parameters were: course and duration of intubation, complications and difficulties, changes in cardiovascular responses (20 patients in each group), postoperative incidence of sore throat and temperomandibular joint (TMJ) problems. Forty-six patients in group LGI were intubated successfully, the mean time needed was 29.9 ± 14.8 s (range: 6–61 s). In group CI 49 patients were intubated without problems, the average time needed was 24.9 ± 13.7 s. In group LGI the following positive results can be summarized (see Table 16): easy handling and application, no injury to soft tissues or teeth, always correct placement of the tube, reduced incidences of TMJ-disorders and sore throat complaints. As (serious) problems appeared in group LGI: a sufficient transillumination was only achieved after (entire) dimming of the room (<100 Lux), insufficient control over the distal end of the tube due to unfixed metal wire, unintentional switching off of the light, difficulties in drawing back the metal wire, disturbing effects caused by the warning device. Reasons for 4 unsuccessful attempts were: introduction into the oesophagus despite a supposed correct position (n=2), insufficiently clear transillumination (2 obese patients). Cardiocirculatory parameters showed no changes during the laryngeal manipulation, clear increases in heart rate and blood pressure were recorded however when pushing forward the tube into the trachea (no difference CI-LGI).Table 16: abstract 43) Intubation outcomes The light-guided intubation technique can be regarded as another technique for airway-management. The indication for the technique is for patients who are not expected to be difficult to intubate but avoids damages to soft tissue and avoids traumatizing TMJ movements. Clinical use may be limited, by the environment brightness when airway difficulty is expected, fibreoptic intubation has still to be considered to be first choice.

The Combitube® (CT), a twinlumen tube designed to provide ventilation after blind intubation, is either placed into the oesophagus or trachea. It has proved to be useful in establishing an airway during CPR and in patients with difficult airway situations. Aim of this study was to determine efficacy and safety of the CT for emergency airway management. To obtain reliable data, the CT was used during the controlled setting of elective general anaesthesia (GA). After approval of the Local Ethics Committee and informed consent, 50 patients (ASA grade I–II, Mallampati grade I) were included. Haemodynamic parameters, oxygen saturation, pCO2, ventilatory parameter complications were recorded. GA was induced with thiopentone, fentanyl, atracurium (0.5 mg kg−1) and maintained with enflurane, nitrous oxide/oxygen. For intubation the patients head remained in a neutral position and the CT was inserted blindly until the two markings on the CT were adjacent to the patients upper incisors. Ventilation was first checked with the head in the neutral position followed by a hyperextended position. All CTs were inserted within 12 to 23 s, always positioned in the oesophagus. In 47 patients a sufficient airway was established at the first attempt. In 3 applications the CT had to be withdrawn 1–2 cm from its initial position to achieve successful ventilation (obstruction of the glottic opening by the upper cuff). Better ventilation conditions were observed in all patients with the head placed in the hyperextended position compared with the neutral position. Major difficulties during ventilation occurred in 11 patients: 60 min after the initial neuromuscular blockade and beginning of positive pressure ventilation, peak pressures increased slightly, accompanied with a sound produced in the laryngeal region. Seconds later sufficient ventilation became impossible. After a repeated dose of atracurium airway pressure returned within 60 s to base-line values. Similar symptoms occurred during recovery from anaesthesia under positive pressure ventilation: sufficient ventilation could be maintained by elevating the jaw with the head in a hyperextended position. After return of spontaneous ventilation, there were no more signs of any airway obstruction. Mucosal bleeding was observed in 12 patients. There were no signs of gastric insufflation or regurgitation. The CT allowed a reliable airway to be established in all patients, but was always positioned in the oesophagus. The markings on the CT are not suitable for all patients and following the instruction manual (positioning the CT between both markings) led to airway obstruction in 3 cases. In 11 patients a closure of the vocal cords occurred due to obstruction of the glottic opening with impaired ventilation. During controlled ventilation neuromuscular blockade with a deep level of anaesthesia are necessary to prevent this complication. The CT can be regarded as an alternative airway management device during CPR or during emergency management of a difficult airway, if conventional endotracheal intubation can not be performed immediately. The immediate use of the CT may offer the possibility of prompt ventilation after blind intubation. This is the major advantage of the CT, but for safe use, frequent training is essential.

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Medical performance is subject to quality control. Continuous advanced training (CAT) and continuous medical education (CME) are essential, and quality must be checked and assured: structure (contents, organizational form, framework, term, demands on leachers), process (term of the CAT, interaction between teachers and participants) and results (satisfaction and acceptance, increased knowledge, influence on medical treatment, improvement of the success rate of medical treatment.In emergency medicine one must differentiate between the necessity for CAT (e.g., certified proof required for working as an emergency physician) and a desire for CME (the individual task of the physician). The diversity of forms for CAT/CME reflects the different individual requirements. Using the new German guidelines to obtain qualitifcation as an emergency physician, ''Fachkundenachweises Rettungsdienst'' offers measures for quality assessment and assurance can be obtained.Structure quality: The recommendations for obtaining the ''Fachkundenachweis Rettungsdienst'' which have been valid until now date from the year 1983 and were set fourth explained very differently in the individual countries medical boards. This led to problems in the comparability of the essential CAT. The quality of the structure has now been improved by establishing new minimum requirements for clinical activity, specification of particular knowledge, number-of supervised calls for the emergency car as well as participation in interdisciplinary CAT courses, dealing with general and special aspects of emergency medicine. The aim of these measures is not the (senseless) regimentation of CAT training measures, but the qualified transfer of specific medical knowledge and treatment guidelines.Process quality. On qualifying, hardly any physician has any didactic and/or rhetorical education; the physician must make a personal effort to obtain a qualification of this kind. Conventional and commonly practised forms of learning must therefore be set aside in favour of modern teaching methods (e.g. problem-orientated learning). This will lead to a better acceptance of CAT/CME measures. It is essential for the process quality that the teachers' education meets the following requirements: relevant knowledge of preclinical emergency medicine, rhetorical and didactic abilities, employment of relevant teaching techniques,, flexibility in presentation, extensive experience in emergency medicine as well as enthusiasm for high-quality education.Result quality: Questionnaires can be used to evaluate the satisfaction and acceptance of the participants, as well as their rating of individual speakers. The results are decisive for planning future CAT/CME measures. The transfer of knowledge can be estimated at the end of advanced training by questionnaire. However, this makes allowance for previous knowledge/skills and how much is forgotten. The influence of advanced training on further medical treatment can be seen in the quality of a given CAT/CME measure, but not in the success rate of medical treatment. The result desired can only be achieved by linking all system components of medical quality control and assurance. Advanced training provides a fundamental contribution to this end.

The technique of light-guided intubation is based on the principle that a source of light brought into the trachea results in clearly visible and defined transcutaneous illumination, while no illumination can be observed with the light source in the oesophagus (Fig. 1-7). The Trachlight(R) is a reintroduced instrument for this alternative intubation technique. The essential developments are: a length-adjustable stylet with a removable internal metal wire, a brighter light source, a stable handle with tight fixation of the endotracheal tube, and a time-dependent warning device to avoid extended intubations. One hundred twenty patients (Mallampati I, ASA I-III) were included in the study (conventional intubation [group KL, n=60], Trachlight(R) intubation [group TT, n=60]. The goals of the investigation were to examine the handling, application, problems, limitations, and possible indications of the method. The recorded parameters were: number of intubation attempts: course and duration of intubation; complications; and difficulties. In 40 patients (20 in each group) the indication for invasive blood pressure measurement was given due to the surgical procedure, and circulatory parameters were recorded at defined moments during the intubation course. In group KL 55 patients were intubated in the attempt, 4 on the second, and 1 on the third (mean duration 23.6 +/- 10.4 s, range 12-60 s). Complications were: unilateral intubation (3 patients), bradycardia (2), asystole (1) and soft-tissue injury (1). Of the 60 patients in group TT, 54 were intubated successfully, the mean time needed being 29.9 +/- 14.8 s (range: 6-61 s). The remaining 6 were then intubated by the conventional method. Positive results in group TT included: easy handling and application, no injury to soft tissues or teeth, and invariably correct placement of the tube. Problems included: sufficient transillumination was achieved only after (entire) dimming of the room, insufficient control over the distal end of the tube due to an unfixed metal wire, unintentional switching off of the light while with-drawing the metal wire, difficulties in withdrawing the metal wire (too strong fixation). as well as disturbing effects of the warning device (blinking of the light 30 s after switching on). Reasons for the 6 intubation failures were introduction of the instrument into the oesophagus despite a supposed correct position, impossibility of correct placement in a patient with an extremely large goiter, and insufficiently clear transillumination in 3 extremely obese patients. The cardiovascular parameters showed no changes during laryngeal manipulation; a clear rise in heart rate and blood pressure was recorded, however, when the tube was inserted into the trachea. The cardiovascular parameters during conventional intubations were similar. The light-guided intubation technique can be regarded as a further alternative for airway management, due to the described improvements of the instrument. The indication for the technique is given in patients in whom no difficulty with intubation is expected, to avoid soft tissue damage and traumatising temporomandibular joint movements. Preclinical use may be limited due to environmental brightness. In patients with expected difficult airway management, fiberoptic intubation will remain the method of choice.

Medical performance is subject to quality control. Continuous advanced training (CAT) and continuous medical education (CME) are essential, and quality must be checked and assured: structure (contents, organizational form, framework, term, demands on teachers), process (term of the CAT, interaction between teachers and participants) and results (satisfaction and acceptance, increased knowledge, influence on medical treatment, improvement of the success rate of medical treatment. In emergency medicine one must differentiate between the necessity for CAT (e.g., certified proof required for working as an emergency physician) and a desire for CME (the individual task of the physician). The diversity of forms of CAT/CME reflects the different individual requirements. Using the new German guidelines to obtain qualification as an emergency physician, "Fachkundenachweises Rettungsdienst" offers measures for quality assessment and assurance can be obtained. STRUCTURE QUALITY: The recommendations for obtaining the "Fachkundenachweis Rettungsdienst" which have been valid until now date from the year 1983 and were set fourth explained very differently in the individual countries medical boards. This led to problems in the comparability of the essential CAT. The quality of the structure has now been improved by establishing new minimum requirements for clinical activity, specification of particular knowledge, number of supervised calls for the emergency car as well as participation in interdisciplinary CAT courses, dealing with general and special aspects of emergency medicine. The aim of these measures is not the (senseless) regimentation of CAT training measures, but the qualified transfer of specific medical knowledge and treatment guidelines. PROCESS QUALITY: On qualifying, hardly any physician has any didactic and/or rhetorical education; the physician must make a personal effort to obtain a qualification of this kind. Conventional and commonly practised forms of learning must therefore be set aside in favour of modern teaching methods (e.g. problem-orientated learning). This will lead to a better acceptance of CAT/CME measures. It is essential for the process quality that the teachers' education meets the following requirements: relevant knowledge of preclinical emergency medicine, rhetorical and didactic abilities, employment of relevant teaching techniques, flexibility in presentation, extensive experience in emergency medicine as well as enthusiasm for high-quality education. RESULT QUALITY: Questionnaires can be used to evaluate the satisfaction and acceptance of the participants, as well as their rating of individual speakers. The results are decisive for planning future CAT/CME measures. The transfer of knowledge can be estimated at the end of advanced training by questionnaire. However, this makes allowance for previous knowledge/skills and how much is forgotten. The influence of advanced training on further medical treatment can be seen in the quality of a given CAT/CME measure, but not in the success rate of medical treatment. The result desired can only be achieved by linking all system components of medical quality control and assurance. Advanced training provides a fundamental contribution to this end.

Laryngoscopy causes temporary postoperative dysfunction of the temporomandibular joint (TMJ): during iatrogenic TMJ manipulation in anaesthetised patients, the TMJs have lost the protection afforded by the tone of the surrounding muscles. Thus far, the exact type and extent of TMJ movements have not been known. The purpose of this study was to develop a method to visualise and assess TMJ movements during intubation by means of electronic axiography, a diagnostic monitor of TMJ movements used in dentistry: registration of the hinge axis (HA) as an equivalent of the condylar paths on extra-oral sagittally mounted, parallel plates. The HA is individually defined in each patient by the pure, rotating TMJ movement during initial mouth opening (no farward gliding of the condyles, incisor distance up to 10 mm). The parallel plates are placed in the TMJ region in the skull-mounted plate bow; both registration tips (''drawing'' the HA tracings on the electronic plates) are connected to the mandible by a face bow, paraocclusally fixed to the teeth. The face bow is individually shaped for each patient to allow mask ventilation and free movement of the laryngoscope during intubation. HA tracings are registered and calculated for both sides independently every 24 ms with the SAM/Klett system and presented on sagittal and frontal projections. In the operating theatre, the active mouth-opening traces (MOT) are registered first and the passive endotracheal intubation traces (EIT) after induction of anaesthesia (same head position). With informed consent and approval by the ethics committee of the Landesarztekammer Rheinland-Pfalz, 40 male patients (ASA I, Mallampati I, limb surgery) were randomly allocated to four groups (n=10 each). OS: Oral intubation, suxamethonium (1.5 mg/kg); OV: Oral intubation, vecuronium (0.1 mg/kg); NS: Nasal intubation, suxamethonium (1.5 mg/kg); and NV: Nasal intubation, vecuronium (0.1 mg/kg). Intubation was performed 100 s after injection of the relaxant. Pre- and postoperatively (every 24 h over 3 days, in case of positive findings longer) recorded were: active movements of the mandible (maximal mouth opening/max. laterotrusion); dysfunction of the TMJ; and pain sensation in the TMJ (Helkimo rating).MOTs and EITs were recorded and analysed with the system described and typical EIT patterns were identified: bland, clinically uneventful intubations (n=7), massive distraction and laterotrusion of the EIT compared to the MOT (n=24), and blocked or limited TMJ movements resulting in intubation problems (n=1). With the method presented, TMJ movements could be visualised during endotracheal intubation for the first time. It can be used to assess techniques, routes, and instruments for intubation as well as to evaluate potential traumatising movements during endotracheal intubation.

The technique of light-guided intubation is based on the principle that a source of light brought into the trachea results in clearly visible and defined transcutaneous illumination, while no illumination can be observed with the light source in the oesophagus (Fig. 1-7). The Trachlight is a reintroduced instrument for this alternative intubation technique. The essential developments are: a length-adjustable stylet with a removable internal metal wire, a brighter light source, a stable handle with tight fixation of the endotracheal tube, and a time-dependent warning device to avoid extended intubations. One hundred twenty patients (Mallampati I. ASA I-III) were included in the study (conventional intubation [group KL, n = 60]. Trachlight intubation [group TT, n = 60]. The goals of the investigation were to examine the handling, application, problems, limitations, and possible indications of the method. The recorded parameters were: number of intubation attempts: course and duration of intubation; complications; and difficulties. In 40 patients (20 in each group) the indication for invasive blood pressure measurement was given due to the surgical procedure, and circulatory parameters were recorded at defined moments during the intubation course. In group KL 55 patients were intubated in the attempt, 4 on the second, and 1 on the third (mean duration 23.6 +/- 10.4 s, range 12-60 s). Complications were: unilateral intubation (3 patients), bradycardia (2), asystole (1) and soft-tissue injury (1). Of the 60 patients in group TT. 54 were intubated successfully, the mean time needed being 29.9 +/- 14.8 s (range: 6-61 s). The remaining 6 were then intubated by the conventional method. Positive results in group TT included: easy handling and application, no injury to soft tissues or teeth, and invariably correct placement of the tube. Problems included: sufficient transillumination was achieved only after (entire) dimming of the room, insufficient control over the distal end of the tube due to an unfixed metal wire, unintentional switching off of the light while with-drawing the metal wire, difficulties in withdrawing the metal wire (too strong fixation), as well as disturbing effects of the warning device (blinking of the light 30 s after switching on). Reasons for the 6 intubation failures were introduction of the instrument into the oesophagus despite a supposed correct position, impossibility of correct placement in a patient with an extremely large goiter, and insufficiently clear transillumination in 3 extremely obese patients. The cardiovascular parameters showed no changes during laryngeal manipulation; a clear rise in heart rate and blood pressure was recorded, however, when the tube was inserted into the trachea. The cardiovascular parameters during conventional intubations were similar. The light-guided intubation technique can be regarded as a further alternative for airway management, due to the described improvement of the instrument. The indication for the technique is given in patients in whom no difficulty with intubation is expected, to avoid soft tissue damage and traumatising temporomandibular joint movements. Preclinical use may be limited due to environmental brightness. In patients with expected difficult airway management, fiberoptic intubation will remain the method of choice.