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cambridge university press
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© D. C. Borshoff 2011
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and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without
the written permission of Cambridge University Press.
First published 2011
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Library of Congress Cataloging-in-Publication Data
Borshoff, David, 1955–
Anaesthetic crisis manual / David Borshoff.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-521-27986-4 (Paperback.)
1. Anesthetics–Handbooks, manuals, etc. 2. Surgery–Complications–Handbooks, manuals, etc.
I. Title.
[DNLM: 1. Anesthesia–adverse effects–Handbooks. 2. Emergencies–Handbooks.
3. Intraoperative Complications–Handbooks. WO 231]
RD85.5.B67 2011
6150 .781–dc23
2011018532
ISBN 978-0-521-27986-4 Paperback
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Every effort has been made in preparing this book to provide accurate and up-to-date information
which is in accord with accepted standards and practice at the time of publication. Although
case histories are drawn from actual cases, every effort has been made to disguise the identities
of the individuals involved. Nevertheless, the authors, editors and publishers can make no
warranties that the information contained herein is totally free from error, not least because clinical
standards are constantly changing through research and regulation. The authors, editors and
publishers therefore disclaim all liability for direct or consequential damages resulting from
the use of material contained in this book. Readers are strongly advised to pay careful attention
to information provided by the manufacturer of any drugs or equipment that they plan to use.
With thanks to Irma Brayley and Associate Professor Richard Riley
Shockable Cardiac Arrest (VF/VT Adult)
Unshockable Cardiac Arrest (Asystole, PEA Adult)
Paediatric Advanced Life Support
Intraoperative Myocardial Ischaemia
Severe Intraoperative Haemorrhage
Anaphylaxis
Haemolytic Transfusion Reaction
Air Embolism
Difficult Mask Ventilation
Unanticipated Difficult Intubation
Can’t Intubate Can’t Ventilate
Laryngospasm
Elevated Airway Pressure
Severe Bronchospasm
Aspiration
Total Spinal (Obstetrics)
Post Partum Haemorrhage
Maternal Collapse
Neonatal Resuscitation – Newborn Life Support
Local Anaesthetic Toxicity
Hyperkalaemia
Malignant Hyperthermia
Terminal Event Checklist – The 10 Ts
Crisis Prevention
1
1
SHOCKABLE
CARDIAC ARREST
VF/VT Adult
1 Call for help, communicate the problem and delegate.
2 Commence compressions (100–120 per minute).
3 Secure the airway. Use 100% O2. Resume CPR.
4 SHOCK immediately defibrillator is ready. Resume CPR.
5 SHOCK at 2 minutes.* Resume CPR.
6 SHOCK at 4 minutes. Give amiodarone 300mg and
adrenaline 1mg. Resume CPR.
7 Continue to shock every 2 minutes and review reversible
causes.
8 If practical, use transthoracic ultrasound to assist diagnosis.
9 For resistant VF/VT give adrenaline 1mg every 3–5 minutes
(alternate shocks) and a further 150mg of amiodarone
followed by an infusion of 900mg over 24 hours.
10 Following ROSC, commence post resuscitation care.
Consider: Referral for urgent percutaneous intervention
Therapeutic hypothermia
Avoid: Hyperglycaemia (treat >10mmol/l)
Hyperoxaemia (keep SpO2 94–98%)
Hypercarbia
ROSC = return of spontaneous circulation
*In the USA, Australia and New Zealand, adrenaline is given after the second shock
SHOCKABLE
CARDIAC ARREST
VF/VT Adult
Delegate a staff member to call time prompts and document events. If other
members are assigned the tasks of chest compression, ventilation and monitoring
cardiac output, this will allow the team leader to review potential reversible causes.
Reversible Causes 4Hs 4Ts
Hypoxia
Hypovolaemia
Hypothermia
Hypo/hyperkalaemia
Tension
Tamponade
Thrombosis
Toxins
If using transthoracic echo, use the sub-xyphoid view.
The patient should be ventilated with 100% O2 at a rate of 10 normal tidal volume
breaths per minute – do not hyperventilate.
If the patient requires intubation, this should be performed quickly and by the most
experienced practitioner, confirmed by EtCO2 if available, and only after
compressions have commenced (CAB)*.
Emphasis is on minimally interrupted, high quality chest compressions. Aim for
any pause (rhythm analysis and shock delivery) to be <5 seconds – if using a
manual defibrillator, after rhythm assessment, continue CPR while machine
charges to minimize ‘pre-shock pause’.
Self adhesive defibrillation pads allow faster shock delivery.
Shock energy: Biphasic 200J first shock. For subsequent shocks use the same or
greater. Monophasic 360J. For children use 4J/kg.
Successive or ‘stacked’ shocks (up to 3 in a row) are reserved for witnessed VF/VT
with defibrillator pads already in place – post cardiac surgery, cardiac catheter
laboratory or the critical care environment.
Drugs are given immediately following defibrillation.
Drug dosages
Magnesium IV 1–2g over 3 minutes for Torsade de Pointes or hypomagnesaemia.
Calcium chloride 10% IV 0.2ml/kg (5ml max) for hyperkalaemia, hypocalcaemia
or overdose of Ca2þ channel blockers.
Sodium bicarbonate 1–2ml/kg 8.4% IV for hyperkalaemia and antidepressant
overdose – NOT prolonged resuscitation.
Lignocaine 1mg/kg IV if amiodarone not available.
Intraosseous is the preferred alternative route for drug administration.
* In adult cardiac arrest, the ‘ABC’ of resuscitation may be more effective if performed in the
order of ‘CAB’. That is, establishing circulation first.
2
2
UNSHOCKABLE CARDIAC
ARREST
Asystole, PEA Adult
1 Call for help, communicate the problem and delegate.
2 Commence compressions (100–120 per minute).
3 Secure the airway. Use 100% O2. Resume CPR.
4 Check ECG leads without interruption to compressions.
5 Give Adrenaline 1mg intravenously.
6 Review reversible causes-4Hs 4Ts.
7 After 2 minutes check pulse and ECG rhythm –
consider sub-xyphoid ultrasound view.
8 Continue CPR – minimize pause duration for rhythm
checks.
9 Give adrenaline 1mg every alternate cycle (3–5 min).
10
If ECG shows VF/VT convert to Shockable Cardiac
Arrest protocol see tab 1.
11
Consider cardiac pacing only in asystole when
p waves are present.
12
Following ROSC, commence post resuscitation care.
Consider: Referral for urgent percutaneous intervention
Therapeutic hypothermia
Avoid: Hyperglycaemia (treat >10mmol/l)
Hyperoxaemia (SpO2 94–98%)
Hypercarbia
UNSHOCKABLE CARDIAC
ARREST
Asystole, PEA Adult
Delegate a staff member to call time prompts and document events.
If other members are assigned the tasks of chest compression,
ventilation and monitoring cardiac output, this will allow the team
leader to review potential reversible causes (tab 1).
Minimizing pauses in CPR increases the chance of success.
Suspect hypovolaemia in PEA in the surgical setting – consider
undiagnosed haemorrhage, particularly with laparoscopic surgery.
Hypoxia should be immediately corrected with a secure airway and
ventilation using 100% O2.
Electrolytes and metabolic abnormalities can be assessed with urgent
blood chemistry – indications for magnesium and calcium are outlined
in drug dosages (tab 1) and should all be corrected.
Hyperkalaemia is treated according to the protocol - see tab 21.
Tamponade, tension pneumothorax and thromboembolic obstruction
are all difficult to diagnose without significant knowledge of clinical
history.
Ultrasound imaging provides information that may assist diagnosis – a
sub-xyphoid view obtained during the brief rhythm check is
recommended.
Aim for normovolaemia – in the absence of hypovolaemia, excessive
infusion of fluid should be avoided.
Whenever possible, confirm correct placement of airway device
with CO2 detection.
All drugs should be administered via a peripheral or central venous line.
If this is not achievable, the tibial or humeral interosseous route is used.
The tracheal route is not recommended.*
Also see notes for Shockable Cardiac Arrest – tab 1.
3
3
PAEDIATRIC ADVANCED
LIFE SUPPORT
1 Call for help, communicate the problem and delegate.
2 Commence CPR and use 100% O2.
3 Check ECG leads without interruption to
compressions.
4 Cease all vagal stimulation.
5 Give adrenaline 10mcg/kg IV or intraosseous.
6 Review reversible causes (4Hs 4Ts).
7 After 2 minutes check pulse and ECG rhythm –
consider sub-xyphoid ultrasound view.
8 Continue CPR – minimize pause duration for rhythm
checks.
9 Give adrenaline 10mcg/kg every 3–5 mins.
10
If ECG shows VF/VT convert to Shockable Cardiac
Arrest Protocol (tab 1).
11
If ROSC, commence post resuscitation care
(see adult protocol – tab 1).
ROSC ¼ return of spontaneous circulation
PAEDIATRIC ADVANCED
LIFE SUPPORT
Delegate a staff member to call time prompts and document events. If
other members are assigned the tasks of chest compression, ventilation
and monitoring cardiac output, this will allow the team leader to review
potential reversible causes (tab 1).
Excluding cardiac anaesthesia, most anaesthetic related paediatric
cardiac arrests will be aystole or PEA.
If VF or VT, follow the adult protocol - see tab 1, using drug dosages
listed below.
Hypoxia and vagal stimulation are the most frequent
reversible causes in children
For CPR, use a compression rate of 100–120/minute and a ventilation
rate of 12–20 breaths/minute.
Adrenaline 10mcg/kg is given immediately in PEA and asystole and
then every 3–5 minutes. Atropine is not recommended.
Adrenaline 10mcg/kg and amiodarone 5mg/kg are both given after
the 3rd and 5th shock in VF/VT.
Drugs should be given via intravenous or intraosseous routes
Adrenaline 100mcg/kg can be given via endotracheal tube if other
routes are unsuccessful.
Defibrillation
For manual defibrillation use a shock energy of 4J/kg.
If using an AED, a ‘paediatric attenuated adult shock energy’ should
be selected in those aged less than 8 years.
Monitor EtCO2 for both tube placement and cardiac output.
Principles of post resuscitation care are the same as adults.
Therapeutic hypothermia in the post arrest, comatose
child should be considered.
Also see notes for Adult Cardiac Arrest (tabs 1 and 2).
4
4
INTRAOPERATIVE
MYOCARDIAL ISCHAEMIA
1 Administer 100% oxygen.
2 Confirm there is adequate: ventilation
anaesthesia
analgesia
3 Control the heart rate.
If steps 1, 2 and 3 complete and patient is HYPERTENSIVE:
4 Cease stimulation
Introduce Beta Blockers
Commence GTN infusion
If steps 1, 2 and 3 complete and patient is HYPOTENSIVE:
5 Restore normovolaemia – use blood if anaemic
6 Treat inappropriate vasodilatation.
7 Control filling pressure.
8 Support contractility – consider an inodilator or
inotrope.
9 Commence GTN infusion*.
10
Consider anticoagulation, placement of IABP and
percutaneous coronary intervention.
INTRAOPERATIVE
MYOCARDIAL ISCHAEMIA
5
Treatment is based on reducing oxygen demand and increasing oxygen supply.
Heart rate: Aim for 60–80 bpm.
Use a beta blocker and additional narcotic if required.
Treat any tachyarrhythmias if necessary using amiodarone, lignocaine
or DC shock (see Shockable Cardiac Arrest for dosages).
Correct any abnormal electrolytes and anaemia.
Blood pressure: Aim for 100–120 systolic with MAP >75.
For anaesthetic induced vasodilation, carefully titrate a vasoconstrictor
avoiding any adverse increase in afterload.
Filling pressure
CPP ¼ ADP – LVEDPQ
With severe obstruction distal coronary pressure may be very low so
avoid elevated LVEDP.
*GTN will both dilate coronaries and reduce LVEDP.
Drug dosages for 70kg patient:
Dobutamine
250mg in 50ml 0.9% saline
Adrenaline
3mg in 50ml 0.9% saline
Noradrenaline
4mg in 50ml 0.9% saline
Infusions are commenced at 5ml/hr and titrated according to response. Other
diluents and dilutions are possible. See product information if necessary.
Metoprolol
Esmolol
Phenylephrine
Metaraminol
GTN
2.5 mg boluses
0.5mg/kg bolus
50–200mcg/kg/min infusion
25–50mcg bolus
0.5–1mg bolus
50mg in 50ml 0.9% saline
Commence at 3ml–5ml/hr and titrate to response.
Blood pressure may require continued support during GTN infusion
QCPP ¼Coronary Perfusion Pressure
ADP ¼Aortic Diastolic Pressure
LVEDP¼Left Ventricular End Diastolic Pressure
SEVERE INTRAOPERATIVE
HAEMORRHAGE
5
1 Call for help, communicate the problem and delegate.
2 Confirm there is surgical effort to control bleeding.
3 Switch to 100% oxygen until the crisis is resolved.
4 Use vasopressors only if necessary to maintain vital
organ perfusion.
5 Warm fluids. Warm theatre. Warm patient.
6 Insert 2 14g cannulae and consider an 8.5FG PA
sheath.
7 Contact blood bank to crossmatch blood early and
consult haematologist to plan component therapy.
8 Utilize the rapid fluid infuser and cell saver.
9 Consider antifibrinolytic agents.
10
Carefully monitor calcium levels.
11
Establish bedside monitoring: Arterial line, urinary
catheter, CVP, temperature Haemocue®,
Coagucheck® thromboelastography.
12
Follow up with laboratory testing: FBC, electrolytes,
ABGs, clotting screen.
Blood bank
Ext No. . . . . . .
Haematology Ext No. . . . . . .
ICU
Ext No. . . . . . .
SEVERE INTRAOPERATIVE
HAEMORRHAGE
Call for assistance, delegate responsibilities and communicate effectively so staff
appreciate the severity and urgency. Nominate a communicator to relay
messages between the laboratories, theatre and ICU and a runner to transport
blood samples, packed cells and component therapy.
Early delegation allows time to coordinate management, prioritize and review
possible causes.
Large bore intravenous cannulation should be delegated to suitably
experienced personnel.
If time does not permit crossmatched blood (Hb 5 or less with ongoing
bleeding), O negative or group specific should be used.
Surgical control may involve direct pressure, arterial or aortic clamping.
Consider prompting if necessary
If a senior clinician predicts large blood loss, early infusion of FFP (15ml/kg) may
prevent impending haemostatic failure and microvascular bleeding.
If fibrinogen <1g/l and PT or aPTT >1.5 x normal there is established
haemostatic failure and larger volumes of FFP will be needed. The use of
component therapy should be guided by laboratory tests, clinical experience
and consultation with haematology (see table below).
Hypocalcaemic cold patients don't clot – aggressively manage temperature
and electrolytes.
Factor rV11a is indicated in massive haemorrhage unresponsive to
conventional therapy.
Therapy
Indication
Initial dosages
FFP
PT, aPTT <1.5 normal,
fibrinogen <1g/l
15ml/kg
Cryoprecipitate
Fibrinogen <1g/l
5–10ml/kg
Prothrombinex
Massive haemorrhage
unresponsive to
conventional therapy
15mg/kg
Factor VIIa
As above
90mcg/kg
Tranexamic acid
Fibrinolysis
1gm IV over 10 min
then 1gm over 8 hrs
Platelets
Platelet count <75 109
15–20ml/kg
6
ANAPHYLAXIS
6
1 Call for help, communicate the problem and delegate.
2 Cease all likely triggers, follow the ABC guideline
and commence CPR if indicated.
3 Monitor the time, SpO2 and haemodynamics.
4 Ventilate with 100% O2 and intubate the patient if
required to maintain the airway.
5 Infuse fluids (at least 20ml/kg) and elevate the legs.
6 Give intravenous Adrenaline 1mcg/kg in bolus
doses. If cardiovascular collapse use 1mg, or 10mcg/kg
in children.
7 Insert an arterial line for monitoring and gases as
soon as possible – delegate if necessary.
8 Consider adjunctive therapy when haemodynamic
stability is established.
9 Collect blood specimens for mast cell tryptase
10
levels. Take sample during resuscitation, at 2 hours
and at 24 hours.
Prepare for transfer to Intensive Care.
ICU Ext No. . . . . . .
ANAPHYLAXIS
Signs during anaesthesia include:
CVS collapse
Bronchospasm
Erythema
Urticaria
Hypotension
Angioedema
Hypoxia
Cutaneous rash
7
Call for assistance early, communicate effectively and delegate
timekeeping and monitoring roles. Elapsed time calls may be useful in
cardiovascular collapse.
The anaesthetist should take the leadership role and coordinate
management.
Common triggers include muscle relaxant, antibiotics, latex, colloid and
chlorhexidine.
Drug dosages
IV adrenaline bolus ¼ 1mcg/kg
IM adrenaline bolus ¼ Adult 500mcg
6–12 years 300mcg
<6 years 150mcg
IV adrenaline infusion ¼ 0.1mcg/kg/min
With 3mg in 50mls dilution, mls/hr ¼ mcg/min. For an adult commence
at 7mls/hr.
Additional therapy
Aminophylline bolus up to 5mg/kg IV or IM
Hydrocortisone bolus (slow IV or IM)
>12 years. . . . . . . . . 200mg
6–12 years . . . . . . . . 100mg
6 months–6 years. . . 50mg
0–6 months. . . . . . . . 25mg
Chlorpheniramine bolus (slow IV or IM) >12 years. . . . . . . . . . .10mg
6–12 years . . . . . . . . . . 5mg
6 months–6 years. . . 2.5mg
<6 months . . . 250mcg/kg
In the unlikely event that bronchospasm does not respond to adrenaline
therapy, alternative treatment is outlined in Severe Bronchospasm - see tab 14.
HAEMOLYTIC
TRANSFUSION REACTION
1 Cease transfusion of the blood product.
7
2 Call for help, communicate the problem and delegate.
3 Follow the ABC guideline – use 100% O2.
4 Treat any bronchospasm. See tab 14.
5 Implement cardiovascular support as required.
6 Insert an arterial line and CVC for blood gas analysis
and haemodynamic monitoring.
7 Maintain urine output – use diuretic therapy.
8 Treat the developing coagulopathy – consult with
transfusion services.
9 Return all products to blood bank and take fresh
10
blood and urine samples for analysis.
ICU admission.
Blood Bank
Ext No. . . . . . .
Haemotalogy Ext No. . . . . . .
ICU
Ext No. . . . . . .
HAEMOLYTIC
TRANSFUSION REACTION
Signs in the anaesthetized patient include:
Hypotension
Tachycardia
Bronchospasm
Urticaria
Wheeze
Tachypnoea
Oedema
Hypoxia
Cola-coloured urine
Bleeding (membranes, infusion sites)
Cardiovascular collapse
Although rare, this carries significant mortality.
Staff should be informed immediately and the blood rechecked against
the patient.
More blood should be taken for further testing.
Treatment is directed towards circulatory support, alleviating
respiratory symptoms and anticipating and treating coagulopathy (see
also Anaphylaxis, Major Haemorrhage and Bronchospasm protocols).
Diuretics and inotropic support should be commenced to maintain
urine output of 0.5 to 1.5ml/kg/hr.
Treatment of any developing coagulopathy should be directed by the
coagulation profile (see table on tab 5).
All products should be returned to transfusion for further analysis.
Drug dosages
Mannitol 25%
Frusemide
Methylprednisolone
Adrenaline
Dobutamine
Noradrenaline
0.5g–1g/kg IV
0.5mg/kg IV
1–3mg/kg IV
3mg/50ml saline
(60mcg/ml)
250mg/50ml saline
(5mcg/ml)
4mg/50ml saline
(80mcg/ml)
Paediatric dose
0.05–0.5mcg/kg/min
2–20mcg/kg/min
0.02–1.0mcg/kg/min
In a 70kg adult, infusions can be commenced at 5ml/hr and then
titrated to response. Dilutions are given for syringe drivers.
8
AIR EMBOLISM
1 Call for help, communicate the problem and delegate.
2 Prevent further entrainment of air.
8
3 Flood the operative field.
4 Ventilate with 100% O2. Avoid Nitrous Oxide.
5 Place the patient in a head down, lateral position.
6 Consider the use of PEEP.
7 Aspirate the CVC. Attempt closed cardiac
massage.
8 Commence IV fluid therapy and keep hydrated.
9 Use adrenaline for haemodynamic support.
10
Consider hyperbaric oxygen therapy and
ICU admission following successful resuscitation.
ICU
Ext No. . . . . . .
Hyperbaric Chamber Ext No. . . . . . .
AIR EMBOLISM
Signs during anaesthesia include:
+SpO2
+EtCO2
Hypotension
‘Mill wheel’ murmur
Pulmonary oedema
Elevated PA pressure
Elevated CVP
Tachycardia
Bronchospasm
Cardiovascular collapse
Communicate effectively so staff appreciate the severity and urgency of the situation.
Delegate a person to call elapsed time and monitor the haemodynamic status.
Hyperventilate with 100% O2 and intubate if necessary.
The use of PEEP is controversial. Initially thought to help prevent venous air embolism it
may also increase the risk of paradoxical air embolism. Judicious use to support
oxygenation may still be appropriate.
Aspirate only if a central venous catheter or pulmonary artery catheter is in place. There
is no evidence to support emergent CVC placement.
Closed cardiac massage has been shown to break up large volumes of air in the
cardiac chambers.
Hyperbaric oxygen up to 6 hours (possibly more) following the event should be considered in
large paradoxical air embolism – a patent foramen ovale is present in 10–30% of the
population.
As little as 0.5ml of air in the coronary arteries can precipitate ventricular
fibrillation.
Drug dosages
Adult:
Adrenaline
bolus 25 to 100mcg.
Infusion of 3mg in 50ml commenced at 5ml per hour.
Note with 3mg in 50ml, rate in ml/hr = mcg/min.
Paediatric:
Adrenaline
bolus
infusion
0.1mcg/kg.
0.05–0.5mcg/kg/min.
The use of positive pressure ventilation, end tidal monitoring, central venous or pulmonary
catheters, precordial doppler and transoesophageal echo in high risk procedures can lead
to early diagnosis and treatment.
9
DIFFICULT MASK
VENTILATION
1
Call for help, communicate the problem and delegate.
2
Use high flow 100% O2.
3
Optimize ventilation attempt: head position
jaw thrust
guedel airway
dry perioral area
9
If there is no improvement is associated with rapid deflation of
reservoir bag, poor refilling, low circuit pressure and ongoing facemask
leak, go to step 4.
If there is no improvement associated with good filling of reservoir bag,
good facemask seal, high circuit pressure and difficulty emptying
reservoir bag on attempted ventilation then consider Laryngeal
Spasm (tab 12) or Elevated Airway Pressure (tab 13).
4
Consider waking the patient if appropriate.
5
Ensure adequate anaesthesia and attempt 2 LMA™
insertions.
6
Use a depolarizing muscle relaxant and intubate.
If LMA™ insertion fails.
7
If intubation is difficult and saturations permit,
continue with the difficult intubation protocol;
however time and saturations may dictate
immediate CICV protocol - see tab 11.
This is not a checklist but a guideline to regularly rehearse.
DIFFICULT MASK
VENTILATION
This protocol is based on the assumption of a recently
checked anaesthetic machine and an intact circuit with fresh
gas flow – confirmed by preoxygenating the patient and witnessing
a visible EtCO2 trace.
In practice, these conditions may not always be met. In difficult mask
ventilation when machine or circuit is suspected, removing them and
using a self-inflating resuscitator is the most time efficient method of
excluding these possibilities.
To maximise conditions consider
Head position: neck flexion head extension (‘sniffing’).
Jaw thrust: two hands forward pressure behind mandibles.
Guedel airway: opt for larger size.
Perioral area: clean off moisturizer and remove any excess airway
lubricant to allow firm grip on face and mask.
Waking the patient may be an option if factored into the anaesthetic
plan e.g. gaseous induction or gradual onset TIVA to test ventilation in
suspected difficult airway.
However, if difficulty was not anticipated and the patient received a full
anaesthetic induction dose, the anaesthetist may be committed to
securing the airway.
Ensuring adequate anaesthesia is a prerequisite for mask ventilation
and LMA™ insertion. Preserved airway reflexes and insufficient
anaesthetic depth will diminish the likelihood of success.
Time management during airway crises is vital to a positive outcome. It
can be complicated by partial ventilation, borderline saturations, the
arrival of another clinician, equipment delays, drug onset times and
fixation error. Delegating to a staff member the role of calling elapsed
time interval as well as monitoring SpO2 and EtCO2 may prevent
prolonged hypoxia.
Always preoxygenate the patient before induction if possible.
10
UNANTICIPATED
DIFFICULT INTUBATION
10
1
Call for help, communicate the problem and delegate.
2
Request difficult airway trolley.
3
Monitor the time, SpO2 and EtCO2.
4
Confirm bag and mask ventilation.
If ventilation is unsuccesful,
5
Maximize laryngeal view: neck flexion head extension
adjust cricoid pressure
attempt external manipulation
consider long or straight blade
McCoy or video laryngoscope
6
Allow up to 4 intubation attempts if SpO2 permits
7
Attempt 2 LMA™ insertions*
8
If after attempted ventilation and intubation,
SpO2 <90% with FiO2¼1
No breath sounds or chest movement
Flat EtCO2 trace then
Call CICV emergency response.
This is not a checklist but a protocol requiring regular rehearsal.
UNANTICIPATED
DIFFICULT INTUBATION
There is overlap of the ‘Difficult Mask Ventilation’ and ‘Difficult
Intubation’ protocols, as each technique uses the other as a rescue
alternative.
The following summarizes the protocols.
1. Can't bag and mask
2. Can't intubate
Options: Wake the patient if possible
Use LMA™ as rescue device
Intubate
Options: Wake the patient if possible
Bag and mask
Use LMA™ as rescue device
If none of the above options is successful, implement the CICV emergency
response.
Always delegate a timekeeper and SpO2 observer (calling elapsed time
intervals and saturations) and be aware that multiple intubation
attempts can convert a ‘can't intubate can ventilate’ to a ‘can't intubate
can't ventilate’ emergency (also known as ‘cant intubate can't
oxygenate’).
Given the variability in difficult airway scenarios, familiarity with the
decision making process and the underlying principles is a prerequisite
for safe practice.
*Trying LMA™ insertion after muscle relaxation (given for attempted
intubation) may improve rescue success rate.
Once ventilation of the lungs is established with persistent CO2
waveform, the airway can be secured by an increasing number of
techniques available. The clinician should use that which is most familiar
and likely to be successful in the particular clinical circumstance.
Always preoxygenate the patient before induction if possible.
11
CAN'T INTUBATE CAN'T
VENTILATE
Cannula Cricothyroidotomy
1
Palpate (NDH) and puncture (DH) the cricothyroid
membrane.
2
Stabilize syringe (DH) and slide cannula into
trachea (NDH).
3
Confirm position by aspirating the full length
of the syringe.
4
Attach the ventilation system to the cannula.
5
Begin cautious ventilation – 1 second inflation,
3 second pause with high pressure (jet) ventilation.
6
Confirm ventilation of lungs and exhalation through
the upper airway.
7
If unsuccessful or complications develop, proceed
immediately to surgical cricothyroidotomy.
11
Recommendations:
Choose a 14g kink resistant cannula.
Syringe size between 5 and 20ml. DAS (UK) suggests 20ml.
Review equipment on difficult airway trolley on a regular basis.
Be familiar and confident with high pressure ventilation.
Regularly rehearse the steps outlined.
Attend advanced airway workshops for hands on experience.
DH¼dominant hand
NDH¼non dominant hand
CAN'T INTUBATE CAN'T
VENTILATE
Surgical Cricothyroidotomy
If the anatomy is palpable.
1
Identify cricothyroid membrane.
2
Stab incision through skin and membrane. Enlarge
with dilator or blunt dissection (scalpel handle or
forceps).
3
Caudal traction on cricoid cartilage with tracheal
hook.
4
Insert ETT or tracheostomy tube.
5
Ventilate from a standard low pressure source.
6
Confirm ventilation with EtCO2.
Alternatively, once a horizontal stab incision is made, the scalpel
blade can be rotated caudally and with lateral pressure allowing a
space for a ventilating bougie to be passed.
If the anatomy is not palpable, a 6 to 8cm midline vertical neck
incision with blunt finger dissection to separate the strap muscles
will expose the trachea. Cannula cricothyroidotomy can then be
achieved under vision.
In all cases, once there has been successful oxygenation, early
conversion to a definitive airway is required.
CICV sometimes referred to as CICO (can't intubate can't
oxygenate).
12
LARYNGOSPASM
1
100% oxygen.
2
Cease all stimulation.
3
Remove airway devices and suction*.
4
Apply gentle CPAP with jaw thrust.
If spasm persists and desaturation continues,
12
5
Call for help, communicate the problem and delegate.
6
Deepen anaesthesia^.
7
Give suxamethonium and continue CPAP.
8
Intubate if SpO2 does not improve
9
Consider atropine 10–20mcg/kg for the treatment
of associated bradycardia.
This is a sequence to be rehearsed.
Time will not permit a checklist management approach.
LARYNGOSPASM
Although stimulating airway devices contributing to spasm should be
removed, the Guedel (oral) airway may be helpful in providing CPAP.
Call for assistance early. The situation deteriorates rapidly in children.
Delegate responsibilities clearly including ETT preparation and
suxamethonium administration.
Some paediatric anaesthetists will carry pre-drawn suxamethonium
in their pocket to reduce drug error and save time during
desaturation.
^Deepening anaesthesia is an option in adult anaesthesia.
Rapid development of hypoxia in children usually precludes this.
Spasm will ‘break’ with sufficient hypoxia and time, but predisposes to
bradycardia, cardiac arrest, regurgitation and pulmonary oedema.
These can be prevented with early intervention.
Dosage: suxamethonium 0.1 to 1mg/kg IV.
2 to 4mg/kg IMI/IO/IL.
In complete obstruction, forced inflation attempts will add to
obstruction (Fink ball/valve effect) and inflate the stomach.
Consider stomach deflation before emergence.
In a rapidly desaturating child, immediate intubation without
relaxation may be the appropriate treatment.
IO=Intraosseous.
IL=Intralingual.
13
ELEVATED AIRWAY
PRESSURE
13
1
Manually ventilate to confirm high pressure and
immediately check the airway for any obvious
change.
2
Exclude light anaesthesia and/or inadequate muscle
relaxation.
3
Perform a systematic circuit inspection.
4
If unresolved, replace the circuit with a self inflating
resuscitator connected directly to the airway device.
5
Check the position and patency of the airway.
6
Examine the patient's respiratory system and
consider calling for assistance.
7
If any doubt, replace the airway. If ventilating with
an LMA™, consider replacing with an ETT.
8
Review checklist of patient causes.
ELEVATED AIRWAY
PRESSURE
Checking muscle relaxation eliminates the most likely cause. In the
unintubated patient this is usually laryngospasm.
If eliminating inadequate relaxation does not correct the rise in
pressure, systematically working through steps 1 to 6 should determine the
problem.
While hand ventilating, check all tubes, valves, connections and
filters. Check the machine position to exclude tube kinking or
obstruction.
Once the circuit is removed and replaced with a resuscitator, the
problem is isolated to the airway device or patient.
The airway should be: assessed for position and patency.
be suctioned down its full length.
be replaced if the problem is unresolved.
A chest examination should be performed before undertaking airway
replacement.
If there is no change following these procedures (new airway
and new circuit), the problem must then be with the patient.
Consider:
Laryngospasm
Bronchospasm
Oedema
Pneumothorax
Haemothorax
Chest wall rigidity
Although calling for assistance is the last step in this sequence, it could
occur at any stage the practitioner feels appropriate.
For a review of causes see Crisis Prevention: ↑ Airway Pressure (tab 27).
14
SEVERE BRONCHOSPASM
1 Call for help, communicate the problem and delegate.
2 Hand ventilate and deepen anaesthesia.
3 Check tube placement and switch to 100% O2.
4 Utilize in-circuit salbutamol and ipatropium
bromide.
5 Monitor EtCO2 waveform and airway pressures.
6 Consider IV fluids, arterial line and serial ABGs.
14
7 Commence adrenaline or salbutamol as an
IV bolus and use infusions if indicated to maintain
stability.
8 Use a long expiratory phase, intermittent
disconnection and low pressure PEEP to reduce
hyperinflation.
9 Consider hydrocortisone, aminophylline or
magnesium as adjunctive or alternative treatment.
10
Prepare for ICU admission if required.
ICU Ext No. . . . . . .
SEVERE BRONCHOSPASM
Bronchospasm will vary in severity under anaesthesia.
Mild bronchospasm will usually respond to removal of irritants
(instrumentation and incorrect tube position), ‘in-circuit’
bronchodilators and deepening anaesthesia.
Severe bronchospasm requires more aggressive, intravenous
bronchodilator therapy.
Drug dosages
Adrenaline bolus:
0.1–1.0mcg/kg titrated to haemodynamics.
infusion: 0.1mcg/kg/min.
Note with 3mg in 50ml, rate in ml/hr = mcg/min.
Therefore commence at 7mls/hr for a 70kg man.
Use an arterial line and serial ABGs to guide management.
Salbutamol bolus:
5mcg/kg up to 2 years.
15mcg/kg up to 18 years (max 250mcg).
infusion: Start at 100mcg/kg/hr (up to 300mcg/kg/hr).
Aminophylline: Loading dose of 5 to 7mg/kg over 15 minutes.
Infusion of 0.5/kg/hr to follow.
Magnesium: 50mg/kg over 20 minutes with a max dose of 2g.
Hydrocortisone: 1–2 mg/kg IV.
IV fluids: commence therapy with 10–20ml/kg of crystalloid.
Intermittent disconnection allows CO2 escape and prevents
hyperinflation. Hand ventilation with permissive hypercapnia may also be
required to avoid the complications of high airway pressure ventilation.
Treatment can be assessed by haemodynamic parameters, airway
pressure, ABGs and the CO2 waveform. With resolution, the ‘sloping’
upward trace of EtCO2 returns to normal with the more horizontal
alveolar plateau.
15
ASPIRATION
15
1
Call for help, communicate the problem and delegate.
2
Place the patient in a head down and lateral
position.
3
Remove the airway and suction the pharynx.
4
Intubate and suction bronchial tree when airway
secured.
5
Ventilate with 100% oxygen.
6
If aspiration is severe, proceed only with emergency
surgery.
7
Empty the stomach before emergence.
8
Consider admission to ICU.
ICU Ext No. . . . . . .
ASPIRATION
How much assistance required depends on the severity and circumstances.
Immediate communication with the surgeons and delegation of tasks
(e.g. turning the patient) may limit the amount of aspiration.
Positioning the patient will depend on the type of surgery and practical
limitations.
Steps 1 to 4 should be achieved before step 5 if SpO2 permits.
Cricoid pressure can be used during intubation but NOT during active
vomiting or regurgitation.
Mild aspiration usually resolves without specific treatment.
If at 2 hours post aspiration, the patient is not symptomatic, the chest
X-ray is clear and the SpO2 is normal, ICU is not indicated.
However, if there is particulate matter, indicative of more severe
aspiration, ICU will be required.
Steroid and antibiotic therapy are NOT usually indicated in the short
term management of aspiration.
16
TOTAL SPINAL
Obstetrics
1 Call for help, communicate the problem and delegate.
2 Follow the ABC protocol.
3 Time the resuscitation and use elapsed time
prompts.
4 Intubate and ventilate with 100% O2 if respiratory
arrest.
5 Use vasopressors to maintain an adequate blood
pressure.
6 Elevate the legs and rapidly infuse IV fluids.
7 Commence CPR if there is no detectable cardiac
output.
16
8 Give atropine for associated bradycardia.
Steps 1-8 also apply to non pregnant patient.
9 Deliver the baby after 4 minutes if there is no
10
response.
Inform ICU and the neonatal unit
Cardiac Arrest
Ext No. . . . . . .
Obstetric Emergency Ext No. . . . . . .
Neonatal Unit
Ext No. . . . . . .
ICU Unit
Ext No. . . . . . .
TOTAL SPINAL
Obstetrics
Call for assistance immediately. An unconscious pregnant woman will
require many hands to manage during resuscitation.
Delegate clearly and convey the sense of urgency.
Although the steps are listed sequentially, with delegation key interventions
should be occurring simultaneously – leg elevation, fluids and vasopressors
can all occur during the securing of the airway.
The diagnosis is usually apparent – rapidly ascending numbness and
paralysis following spinal or epidural.
If not witnessed or diagnosis uncertain, see Maternal Collapse (tab 18).
The differential diagnosis includes:
Vasovagal
Haemorrhage
LA toxicity
IVC compression
Embolus
A pregnant woman is prone to reflux. Intubation is preferred but
should not exclude any other form of airway management if conditions
don't permit (cricoid pressure is recommended).
If the patient has lost consciousness, intubation can be accomplished
without an induction agent or with relaxant only.
In profound spinal blockade with an detectable cardiac output CPR should
commenced be until there is a response to fluids and vasopressors.
It should be performed in accordance with the maternal resuscitation
guidelines (see Maternal Collapse - tab 18) including emphasis on
uterine displacement, left lateral tilt and delivery of the baby.
Delivery should be considered 4 minutes after commencement of CPR
Bolus drug dosages:
Atropine
Ephedrine
Phenylephrine
Adrenaline
0.6–1.2mg
12–15mg
50–100mcg
25–50mcg
17
POST PARTUM
HAEMORRHAGE
1 Call for help, communicate the problem and delegate.
2 Administer 100% oxygen.
3 Insert 14g IV cannula 2.
4 Use crystalloid or colloid resuscitation*.
5 ‘Rub up’ the uterus or use bimanual compression.
6 Notify blood bank for crossmatch and component
therapy.
7 Consider group specific or O negative blood.
8 Notify operating theatres for immediate transfer.
9 Use oxytocics for uterine atony.
17
10
Support vital organ perfusion with vasopressors.
11
Induce general anaesthesia with RSI for surgical
control.
12
Continue with Severe Haemorrhage Protocol (tab 5).
Obstetrics
Ext No. . . . . . .
Duty anaesthetist
Ext No. . . . . . .
Blood bank
Ext No. . . . . . .
Operating Theatres Ext No. . . . . . .
POST PARTUM
HAEMORRHAGE
Blood loss is frequently underestimated and coagulopathy may be
disproportionate to blood loss.
*There is no advantage of colloid over crystalloid supported by evidence
(meta-analysis in Cochrane library favoured crystalloid).
Use normal saline or lactated Ringer's solution. . . NOT 5% dextrose.
1 litre blood loss requires 3–5 litres of crystalloid.
Uterine manoeuvres including ‘rubbing up’ the uterus or bimanual
compression can significantly slow and reduce blood loss.
FFP, platelets, cryoprecitate, antifibrinolyitics and recombinant Factor
VII and Prothrombinex may all be required.
Products should be administered initially as clinical circumstances
dictate but then guided by coagulation testing.
Life threatening haemodynamics may require the use of
uncrossmatched (O negative) or group specific blood.
Oxytocic dosages:
Oxytocin
Ergometrine
Misprostol
Carboprost
5IU slow push IV
10IU per hour infusion
500mcg IMI
400 to 1000mcg PR/SL
250mcg IMI/intrauterine
(15 minutely, max 8 doses)
Vasopressor dosage:
Ephedrine
Metaraminol
Phenylephrine
6 to 12mg bolus
1mg bolus
25–50mcg bolus
18
MATERNAL COLLAPSE
18
1
Call for help, communicate the problem and delegate.
2
Commence CPR.
Use left, cephalad uterine displacement or
max 30° tilt.
3
Intubate early and ventilate with 100% O2.
4
Establish IV access.
5
Place monitor leads and assess cardiac rhythm.
6
Follow the appropriate cardiac arrest protocol
see tab 1 and 2.
7
Treat any reversible causes.
8
Deliver baby after 4 minutes if pregnancy > 24 weeks.
9
Debrief and support the resuscitation team.
Emergency Call Ext No. . . . . . .
Obstetric team Ext No. . . . . . .
OR
Ext No. . . . . . .
Paeds
Ext No. . . . . . .
MATERNAL COLLAPSE
Key differences in maternal resuscitation are: uterine displacement
early intubation
baby delivery
Early intubation reduces aspiration risk.
Task delegation includes: Airway
Chest compression
Uterine displacement
IV insertion
Common causes (delivery less likely)
Vasovagal
High epidural/spinal block (tab 16)
LA toxicity (tab 20)
Haemorrhage (tab 17)
Hypertensive disease of pregnancy
Commence magnesium sulphate therapy for seizures
Loading dose 4g over 15 minutes (1g = 4mmol Mg)
Infusion 1g/hr for 24 hours
2g bolus if still fitting
Uncommon causes (delivery more likely)
Pulmonary embolus
Cardiac event (4Hs 4Ts, tab 1)
Uterine rupture
Cerebral event
Amniotic fluid embolus Anaphylaxis (tab 6)
A PERIMORTEM delivery pack should be kept on the resuscitation
trolley.
The most experienced clinician performs C–section with a vertical
incision (or obstetrician preference) for rapid extraction of baby.
Maternal resuscitation is a traumatic event for all concerned.
Debriefing and supportive counselling are recommended.
19
NEONATAL RESUSCITATION –
NEWBORN LIFE SUPPORT
1 Dry, warm and cover the baby to conserve heat.
2 Assess the colour, tone, breathing and heart rate.
3 Call for assistance, communicate the problem and
delegate tasks if nonvigorous or condition deteriorating.
4 Open the airway and give 5 inflation breaths.
5 Reassess heart rate (target >100bpm) and chest
movement.
6 If there is no improvement or chest movement,
reposition and repeat.
7 Visualize the pharynx, suction and intubate if
necessary.
8 If the heart rate falls below 60/min commence
chest compressions.
9 Reassess every 30 seconds and if no response
Give
19
adrenaline 10–30mcg/kg
glucose 10% 2.5ml/kg
10
In the presence of hypovolaemia, 10ml/kg of
isotonic crystalloid or O negative, CMV negative
blood can be given and repeated if necessary.
11
Continue Paediatric Advanced Life Support (tab 3)
and admit to Neonatal ICU if successful
resuscitation
Neo-natal ICU Ext No. . . . . . .
NEONATAL RESUSCITATION –
NEWBORN LIFE SUPPORT
An inflation breath is 2–3 seconds in duration and 30cm H2O
pressure – if the heart rate responds by increasing, continue to ventilate
at a rate of 30–40/min until there is adequate spontaneous ventilation.
If there is no chest movement, reposition and try airway manoeuvres to
aerate effectively include: Postioning of head (neutral)
Jaw thrust (assistance may be required)
Oropharyngeal airway (Guedel)
Laryngoscopy, suction þ/ intubation
Gentle oropharyngeal suctioning is preferred. Nasopharyngeal
suctioning has been associated with bradycardia during
resuscitation.
Endotracheal suctioning is still indicated in nonvigorous babies when
meconium is present.
The LMA™ can be used as an alternative airway device.
Colour is not a reliable indicator of SpO2 in the newborn but pallor may
indicate an acidotic or anaemic baby.
SpO2 soon after birth should be 60% increasing to >90% at
10 minutes. Room air is appropriate for the term newborn. However
if SpO2 is still unacceptable, introduce oxygen supplementation – use
oximetry for guidance.
Hyperoxaemia, particularly in preterm babies, should be avoided.
Chest compressions are given at 120/min.
Ventilation chest compression ratio should be 1:3 with a pause for
ventilation. Once intubated, the pause is no longer necessary.
Ventilation and chest compression fail to resuscitate less than 1 in
1000 babies
Adrenaline dose is 10mcg/kg but can be increased to 30mcg/kg if the
lower dose is not effective. Bicarbonate is not recommended.
Post resuscitation care should include therapeutic hypothermia if
evidence of evolving encephalopathy.
20
LOCAL ANAESTHETIC
TOXICITY
20
1
STOP giving the drug.
2
Call for help, communicate the problem and delegate.
3
Review the airway, secure if necessary with
intubation and ventilate with 100% O2.
4
Commence CPR if there is circulatory arrest.
5
Secure intravenous access and treat convulsions.
6
Follow standard arrhythmia protocols (tab 1 and 2).
7
Administer 20% intralipid intravenously.
The intralipid is kept in the . . . . . .
8
Consider cardiopulmonary bypass if readily
accessible.
Perfusion Ext No. . . . . . .
LOCAL ANAESTHETIC
TOXICITY
If there is no circulatory arrest, use conventional supportive measures
to maintain haemodynamic stability.
Delegate a staff member to monitor haemodynamic status and to call out
elapsed time (1 to 2 minutely).
Amiodarone can be used for ventricular irritability but lignocaine and
other class 1B antiarrhythmic agents should be avoided – for dosage
see tab 1. Beta blockers can also have an adverse effect through
myocardial depression and decreasing clearance of anaesthetic agent.
Advanced life support should be continued for at least one hour
because of the duration of binding to the myocardium.
Drug dosages
Anticonvulsants
Midazolam
Diazepam
Thiopentone
Propofol
0.05–0.1mg/kg
0.1–0.2 mg/kg
1mg/kg
0.5–2mg/kg
70kg patient
5–10mg
5–10mg
50mg
50–100mg
20kg patient
1–2mg
2mg
20mg
20–40mg
Intralipid regimen
Immediately: 1.5mg/kg bolus over 1 minute (100ml in adult).
Commence infusion of 15ml/kg/hr (1000ml per hour in adults).
At 5 minutes: Repeat the bolus dose and double the infusion rate if not
responding.
Allow a total of three bolus doses 5 minutes apart.
Although there are significant practical considerations, a well
rehearsed cardiac unit with bypass readily available may be
lifesaving.
21
HYPERKALAEMIA
1
Exclude any possible artifact. Repeat sample.
2
Establish cardiac monitoring and intravenous
access.
3
Cease any source of Kþ administration.
4
Hyperventilate the patient.
5
Give:
6
Consider continuous nebulized salbutamol.
7
Undertake dialysis if dangerous levels persist or
longer term control required.
8
Correct any reversible precipitating factors.
21
Calcium chloride
NaHCO3
Glucose
Insulin
HYPERKALAEMIA
Treatment is required if hyperkalaemia is considered severe (>7mmol/L)
or there are obvious ECG changes.
To exclude artifact, repeat venepuncture from a new site.
ECG changes: Peaked T waves Loss of P wave
Prolonged PR
Loss of R amplitude
Widened QRS
Sine wave pattern – asystole
Drug dosages
Adult:
Calcium chloride
Calcium gluconate
NaHCO3
50% dextrose
Insulin
5ml 10% IV slow push
10ml 10% IV slow push
50ml IV stat
25–50ml IV stat
10 units IV stat
Paediatric:
Calcium chloride
0.2ml/kg 10% IV over 5 min
(5ml max)
1ml/kg 10% IV over 3–5 mins
(10ml max)
0.5g/kg (2ml/kg)
0.1units/kg IV stat
Calcium gluconate
Glucose 25%
Insulin
Precipitating factors include:
trauma
burns
suxamethonium (burns, spinal injury, neurological disease)
malignant hyperthermia
acidosis
acute renal failure
organ reperfusion following clamp release
haemolyis/massive transfusion
medications
Avoid: suxamethonim
respiratory acidosis
Hartmann's solution
22
MALIGNANT
HYPERTHERMIA (MH)
1 Call for help, communicate the problem and delegate.
2 Request pre-prepared MH box. Use task cards.
Box is located. . . . . . .
3 Cease and remove volatile agents. Change soda lime
only if quick and easy.
4 Hyperventilate with 15l/min 100% O2 – do not
waste time changing circuit or machine.
5 Commence IV dantrolene. Use 2.5mg/kg.
6 Maintain anaesthesia – use TIVA.
7 Insert arterial line and consider CVC – do not delay
dantrolene.
8 Actively cool the patient.
9 Treat associated conditions: Hyperkalaemia
22
Acidosis
Arrhythmias
10
Maintain urine output at >2ml/min.
11
Monitor with serial ABGs, electrolytes and
temperature.
12
Admit to the ICU.
MH box is located. . . . . . .
Laboratory Ext No. . . . . . .
ICU
Ext No. . . . . . .
MALIGNANT
HYPERTHERMIA (MH)
Signs suggesting possible MH
Early
Elevated EtCO2
Masseter spasm
Tachycardia
Arrhythmias
Developing
Acidosis
Temperature rise
CVS instability arrest
Hyperkalaemia
Late
Cola-coloured urine
""CK
Coagulopathy
#SpO2
If there is a malignant hyperthermia pre-prepared ‘box’ in the hospital,
use it and follow the task card system.
If not, prioritize treatment: Dantrolene
Anaesthesia
Supportive therapy
Dantrolene requires dedicated staff to prepare. It is dissolved in sterile
water.
TIVA – use propofol TCI 4mcg/ml or 30–50ml/hr in adult.
Hyperkalaemia is treated according to protocol - see tab 21.
Diuresis is maintained using 0.5g/kg of mannitol. Aim for >2ml/kg/hr
with a pH>7.0.
Consider the treatment of acidosis with 8.4% NaHCO3 only if there is
associated hyperkalaemia.
Active cooling includes:
Intra-abdominal lavage (saline at 4 C)
Cool IV fluids
Cool sponging and ice packs
Lowering theatre temperature
Blood chemistry includes FBC, electrolytes, ABG's, CK, clotting profile
and myoglobin levels.
23
TERMINAL EVENT
CHECKLIST – THE 10 Ts
1 Tubes: airway placement, obstruction,
disconnection, constriction, disruption.
2 Torrential haemorrhage.
3 Tryptase: anaphylaxis induced cardiac arrest.
4 Terminal rhythm: primary cardiac disease.
5 Tamponade: traumatic or surgical.
6 Tension pneumothorax.
7 Thrombus: cardiac, pulmonary embolus, amniotic
fluid, air or fat embolus.
8 Toxic: drugs, electrolytes, metabolic derangement.
9 Total spinal.
10
Tumour: space occupying lesions producing "ICP.
The 10 Ts checklist may help clinicians managing an anaesthetic crisis
when the diagnosis has not been established.
23
NOTES
24
References
Association of Anaesthetists of Great Britain and Ireland Safety
Guidelines
– Management of Patient with Suspected Anaphylaxis during Anaesthesia
– Blood Transfusion and the Anaesthetist; Management of Massive
Haemorrhage
– Blood Transfusion and the Anaesthetist; Blood Component Therapy
– Checklist for Anaesthetic Equipment (2004)
– Management of a Malignant Hyperthermia Crisis (2007)
– Management of Severe Local Anaesthetic Toxicity 2 (2010)
http://www.aagbi.org/publications.htm
Resuscitation Council (UK) Guidelines, Medical Information and
Reports; Resuscitation Guidelines 2010
www.resus.org.uk
2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care Science. Circulation
2010;122(18 suppl 3).
Difficult Airway Society (UK) Guidelines
www.das.uk.com
Heard A. et al. The formulation and introduction of a ‘Can't intubate,
Can't ventilate’ algorithm into clinical practice. Anaesthesia
2009;64(6):601–8.
Allman K, McIndoe A, Wilson I. Emergencies in Anaesthesia. Oxford
University Press, 2005.
Gaba D, Fish K, Howard S. Crisis Management in Anaesthesia. Churchill
Livingstone, 1993.
For further references, please see www.cambridge.org/9780521279864
24
CRISIS
PREVENTION
Contents
15 Point Anaesthetic Machine Check .................. 25
Elevated Airway Pressure ........................................ 26
Desaturation ................................................................ 27
Hypertension................................................................ 27
Hypotension ................................................................ 28
Tachycardia .................................................................. 28
Bradycardia .................................................................. 29
Hypercapnia ................................................................ 29
Hypocapnia .................................................................. 30
Crisis Prevention Checklist...................................... 30
25
25
15 POINT ANAESTHETIC
MACHINE CHECK
1 Check the machine is switched on, uncluttered and
positioned appropriately for the operating session.
2 Check service date and be aware of any notifications
on the machine.
3 Check monitors are on with appropriate limits,
cycling times and sampling lines connected –
confirm oxygen analyzer, pulse oximeter and
capnograph are functioning.
4 ‘Tug test’ the pipeline connections.
5 Check the oxygen is connected to the machine.
6 Check there is an adequate reserve supply of O2.
7 Check other gas supplies are adequate and all
pipeline pressures are between 400–500kpa.
8 Check flow meters are operating smoothly
throughout the flow range.
15 POINT ANAESTHETIC
MACHINE CHECK
26
9 Check the antihypoxia device and O2 bypass are
correctly functioning.
10
Check vapourizers are filled, seated, not leaking
and then switched off.
11
Check the breathing circuit
12
13
14
15
configuration
connections
valves
leaks (include inner
tube if present)
Check the ventilator tube connections
pressure relief valve
disconnect alarm
settings
Check the scavenging system is
connected
correctly configured
functioning
Check the airway trolley – make sure all equipment
needed for the anaesthetic plan (and contingency
plan) is present and functioning.
Check suction, bed tilt, and confirm an alternative
means of ventilation.
*AIRWAY PRESSURE
26
Circuit
Ventilator bag switch
Ventilator setting
Obstructed or kinked circuit
Filter blockage
Circle valve malfunction
APL valve closed or stuck
O2 flush malfunction
Airway
Laryngospasm
Tube position
Tube size
Tube obstruction
Patient
Bronchospasm
Tracheal pathology
Respiratory tract tumours
Pneumothorax
Pneumoperitoneum
Chest wall rigidity
Obesity
Chest compression
Alveolar pathology: Oedema
Fibrosis
Contusion
Infection
ARDS
Most likely
Inadequate muscle relaxant
Airway position
Laryngospasm
Bag/ventilator settings
DESATURATION (#SpO2)
+Delivery of O2 to lungs
Oxygen supply – low FiO2
Apnoea
Low or inappropriate FGF
ETT in left main bronchus
Airway postion/obstruction
Laryngospasm
Brochospasm
Ventilator malfunction/setting
Circuit obstruction/disconnect
+Delivery of blood to lungs
Cardiac arrest
Cardiac failure
Anaphylaxis
Pulmonary embolism
Impaired oxygen exchange
or * A V shunt
One lung ventilation
Pulmonary oedema
Aspiration
Contusion
Atelectasis
Pneumothorax
Pneumoperitoneum
Pneumonia
Sepsis/ARDS
Artifact
Most likely
Hypothermia
Poor peripheral circulation
Probe displacement
Probe displacement
Apnoea/hypoventilation
Tube position
Laryngospasm
27
HYPERTENSION
Anaesthesia
Emergence
Inadequate depth
Inadequate analgesia
Hypoxia
Hypercarbia
Malignant hyperthermia
Drugs
Transducer height
Surgery
Tourniquet application
Aortic clamping
Carotid endarterectomy
Baroreceptor stimulation
Patient
Essential hypertension
Full bladder
Pre-eclampsia
Renal disease
Phaeochromocytoma
Thyroid storm
Raised intracranial pressure
27
28
Most likely
Intubation/emergence
Inadequate anaesthesia/analgesia
Drugs
Essential hypertension
HYPOTENSION
+Preload
+Contractility
Blood loss
Obstructed venous return
Dehydration
Capillary leak
Elevated intrathoracic pressure
Tamponade
Embolism
Patient position
Drugs (including volatile agents)
Ischaemic heart disease
Cardiomyopathy
Myocarditis
Arrhythmia
Valvular heart disease
Sudden increased afterload
+Systemic vascular resistance
Volatile agents
Narcotics
Vasodilators
Regional blockade
Sepsis
Post cardiopulmonary bypass
Neuropathy
Tourniquet release
Addison's disease
Thyroid disease
Anaphylaxis
Bone cement
Most likely
Anaesthetic agent
Narcotics
Regional blockade
Hypovolaemia
28
TACHYCARDIA
Primary causes
Ischaemic heart disease
Post cardiac surgery
Cardiomyopathy
Accessory conduction pathways
Sick sinus syndrome
Congestive heart failure
Myocarditis
Pericarditis
Valvular disease
Congenital heart disease
Secondary causes
Hypovolaemia
Anaesthetic depth
Drugs
Anxiety
Hypertension
Electrolyte abnormalities
Tamponade
Sepsis
Throtoxicosis
Lung disease
Malignant hyperthermia
28
Most likely
Anxiety
Intubation
Anaesthetic depth
Drugs
Hypovolaemia
BRADYCARDIA
Primary causes
Ischaemic heart disease
Sick sinus syndrome
Degeneration of conduction system
Valvular disease
Myocarditis
Cardiomyopathy
Post cardiac surgery
Hereditary conduction disorders
Physiological fitness
Secondary causes
Electrolyte abnormalities
Antiarrhythmic medication
Anaesthesia
Hypothyroidism
Hypothermia
Vasovagal syndrome
Increased intracranial pressure
Anaesthetic causes
Most likely
Hypoxia
Volatile agent
Muscle relaxant
Narcotic
Anticholinesterase
High spinal/epidural
Vasopressor reflex
Drug related
Vasovagal
Spinal anaesthesia
Fitness
29
HYPERCAPNIA
*Production
Endogenous
Exogenous
+Excretion
Circuit
29
Lungs
Most likely
Sepsis
Malignant hyperthermia
Thyroid storm
NLMS
Reperfusion
Bicarbonate administration
CO2 insufflation
TPN
CO2 in fresh gas flow
Exhausted soda lime
Airway obstruction
Dead space
Inadequate fresh gas flow
Valve malfunction in circuit
Incorrect ventilator settings
Spontaneous hypoventilation
Bronchospasm
Chronic airways disease
Spontaneous hypoventilation
Exhausted soda lime
Ventilator setting
Fresh gas flow setting
HYPOCAPNIA
+Production
Hypothermia
Hypothyroidism
*Excretion
Spontaneous hyperventilation
Inappropriate ventilator setting
+Transport in blood
Cardiac arrest
Severe hypotension
Anaphylaxis
Pulmonary embolus
+Transport in lungs
ETT obstruction
Incorrect airway placement
Laryngospasm
Severe bronchospasm
Sampling dilution
Disconnect
Entrainment
Inappropriate sampler placement
High fresh gas flows
NO EtCO2
Most likely
Disconnect
No sampling
No ventilation
Cardiac arrest
Hyperventilation
Inadequate tidal volume
Laryngospasm
Incorrect airway placement
Hypotension
30
CRISIS PREVENTION
CHECKLIST
1 Check the machine.
2 Know the assistant's qualifications and experience.
3 Outline the anaesthetic plan – ask for feedback
or questions.
4 Have a contingency plan – if uncertain consult with
a colleague.
5 Know the location of dantrolene, difficult airway
trolley and resuscitation trolley.
6 Confirm correct patient, procedure and side.
30
7 Be aware of any drug allergy.
8 Review airway and fasting status.
9 Check drug label and syringe.
10
Preoxygenate – check O2 is on and confirm EtCO2 trace.
11
Perform a post induction check “OCAB”
12
O xygenation
C arbon dioxide
A naesthetic agent
B lood pressure
In crisis management call for help early.
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